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2017 Spring Learning Series

Integrating Primary Care into Behavioral Health Settings

Healthier Washington Practice Transformation Support Hub | 2017 Spring Learning Series

The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare &

Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Integrating Primary Care in Behavioral Health Settings

Table of Contents

Unit 1: Foundational Concepts for Integration Objectives…………………………………………………………………………………………. 2

Next Steps – Learning Activities………………………………………………………… 21

Integration Plan Worksheet………………………………………………………………. 22

Identifying Process and Outcome Measures Guide……………………………. 23

Unit 2: Team Roles and Readiness for Integrating Care

Objectives…………………………………………………………………………………………. 26


Tasks for Integrated Care in Behavioral Health Settings Worksheet….. 45

Unit 3: Developing Your Clinical Workflow for Integrated Care

Objectives…………………………………………………………………………………………. 47


Team Building and Workflow Guide………………………………………………….. 69

Unit 4: Population Management - Using a Registry to Track Outcomes

Objectives…………………………………………………………………………………………. 74


Patient Tracking Spreadsheet Practice Case Scenarios………………………. 92

Unit 5: Introduction to Quality Improvement Methods

Objectives…………………………………………………………………………………………. 100

Example 1 – Measuring Blood Pressure…………………………………………….. 104

Example 2 – Measuring BMI in Adolescents………………………………………. 124 Next Steps – Learning Activities………………………………………………………… 147

PDSA Worksheet……………………………………………………………………………….. 148

Laying the FoundationIntegrating Primary Care into Behavioral HealthWebinar 1

Healthier Washington Practice Transformation Support Hub 2017 Spring Learning Series

1

• Learn how to adopt core principles ofintegrated care for behavioral health settings

• Explore opportunities for new roles andresponsibilities for integrating care

• Create workflows and a tracking tool for anintegrated care pilot

• Develop a rapid cycle QI proposal for anoutcome measure your integrated care programis working to improve

Objectives for Learning Series


2

Learning Series Structure

•Week 1: Webinar 'Laying the Foundation'•Week 2 (Self-Paced): Integration Plan, Readiness Assessment and Discussion Board

1. FoundationalConcepts forIntegration

•Week 3: Webinar 'Team Roles and Readiness for Integrating Care'•Week 4 (Self-Paced): AIMS Task List and Discussion Board•Week 5 (Self-Paced): AIMS Task List and Discussion Board

2. Team Roles andReadiness for

Integrating Care

•Week 6 : Webinar 'Developing your Clinical Workflow for Integrated Care'•Week 7 (Self-Paced): Develop Screening & Treatment Workflow and Discussion Board•Week 8 (Self-Paced): Develop Screening & Treatment Workflow and Discussion Board

3. DevelopingYour ClinicalWorkflow for

Integrated Care

•Week 9: Webinar 'Using a Registry to Track Outcomes'•Week 10 (Self-Paced): Registry Activity and Discussion Board•Week 11 (Self-Paced): Registry Activity and Discussion Board

4. PopulationManagement:

Using a Registry to Track Outcomes

•Week 12: Webinar 'Introduction to Quality Improvement Methods'•Week 13 (Self-Paced): QI Activity and Discussion Board•Week 14: PDSA Sharing and Facilitated Discussion

5. Introduction toQuality Improvement

Methods


3

From: Premature Mortality Among Adults With Schizophrenia in the United StatesJAMA Psychiatry. 2015;72(12):1172-1181. doi:10.1001/jamapsychiatry.2015.1737

• Adult MedicaidBeneficiaries Diagnosedwith Schizophrenia

• 10 Common Causes ofDeath by Age Group(2001-2007)

• Standardized MortalityRatios : 2 to > 10

• No change from 2006NASMHPD report

Why Integrate Care for CBHC clients?


4

Most Premature Mortality Due to CVD

• Life expectancy is15 years shorter

• CVD accounts for60% of prematuredeaths amongpersons withserious mentalillnesses

• Every CVD risk factor is more than twice as commonCorrell CU, et al. Psychiatr Serv. 2010 Sep;61(9):892‐8.https://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.htmlhttps://www.cdc.gov/nchs/products/databriefs/db133.htmhttps://www.niddk.nih.gov/health‐information/health‐statistics/Pages/overweight‐obesity‐statistics.aspxhttps://www.cdc.gov/cholesterol/facts.htm


5

https://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html

https://www.cdc.gov/nchs/products/databriefs/db133.htm

https://www.niddk.nih.gov/health%E2%80%90information/health%E2%80%90statistics/Pages/overweight%E2%80%90obesity%E2%80%90statistics.aspx

https://www.cdc.gov/cholesterol/facts.htm

Health Behavior Interventions1

• Lifestyle modification; 30-40% lose weight

• Smoking cessationpharmacotherapy; 40%quit2

Medical Care Management3

• Health education• Care coordination• Track treatment

Behavioral Health Home4

Evidence-based Interventions

1McGinty EE et al Schizophr Bull. 2016 Jan;42(1):96-124; 2Tsoi DT, et.al. Cochrane Database Syst Rev 2013 Feb 28; 2; 3Druss BG, AN J Psychiatry; 2010; 167(2): 151-159; 4Druss BG, et al. Am J Psychiatry 2017; 174(3): 246-255


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Jha P, et al. N Engl J Med 2013; 368: 341-350

• Overall mortality among smokers(of both sexes) is 3 times as highas those who have never smoked

• Smokers lose, on average, adecade of life

• Cessation before the age of 40reduces risk of death by 90%

Smoking and Mortality


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• Cochrane review—(34 RCTs)• Bupropion

– End of treatment (vs placebo)• 7 trials (n=340)• RR= 3.03 (95% CI= 1.69-5.42)

– 6 months• 5 trials (n= 214)• RR= 2.78 (95% CI = 1.02-7.58)

• Varenicline– End of treatment (vs placebo)

• 2 trials (n=137)• RR= 4.74 (95% CI= 1.34-16.71)

– 6 months• 1 trial (n= 128)• RR= 5.06 (95% CI = 0.67-38.24)

Summary of Evidence: Medication

Tsoi DT, et.al. Cochrane Database Syst Rev 2013 Feb 28; 2: CD007253 Barboza JL et al. Expert Opin Pharmacother. 2016 Aug;17(11):1483-96.


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• Cochrane review (n=34 studies)– Some support for contingency management,

but unclear long-term benefit

• Systematic review of combination treatment2

– 123 RCTs, >60,000 patients– Best evidence for varenicline and behavioral

treatment

Summary of Evidence: Behavioral Interventions

1. Tsoi DT, et.al. Cochrane Database Syst Rev 2013 Feb 28; 2: CD0072532. Windle SB, et al. Am J Prev Med. 2016 Sep 8. pii: S0749-3797(16)30278-1.


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• Longer duration (24weeks)

• Manualized

• Combined educationand activity

• Both nutrition andphysical exercise

• Evidence-based (proveneffective by RCTs)

Behavioral Weight Loss Interventions

Most Likely Effective Less Likely Effective

• Briefer durationinterventions

• General wellness orhealth promotioneducation-only

• Non-intensive,unstructured, or non-manualizedinterventions

Bartels S, et al. SAMHSA-HRSA Center for Integrated Health Solutions, 2012


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• Patient Population– Adults with Severe Mental Illness

• New Team Member Roles– Primary Care Consultants– Primary Care RN Care Managers

• Annual Metabolic Screening

• Diabetes Education and Treatment

• Pay for Performance (Missouri example)– Half of Quality Performance Measures are Medical– Half of Medication Adherence Measures are Medical

Behavioral Health Homes


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• SAMHSA Primary Behavioral Health CareIntegration (PBHCI) Grantees– National Demonstration Program (2009-

present)– 100 CMHCs– 4-year projects– Outcomes1: mean reduction in cholesterol

and LDL

• HOME Study2

– Randomized controlled study (n= 447)– BHH improved quality of care for persons

with SMI and CVD risk factors

Evidence for Behavioral Health Homes

1. Scharf DM, et.al. Psychiatr Serv. 2016 Nov 1;67(11):1226-12322. Druss BG, et al. Am J Psychiatry 2017; 174(3): 246-255;


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Principles for Evidence-Based Integration in Behavioral Health and Primary Care

Team-Based and Client-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.

Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for every patient. Treatments are actively changed until clinical goals are achieved.

Population-Based A defined group of clients is tracked in a registry so that no one “falls through the cracks.”

Used with permission from the University of Washington AIMS Center


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Client-Centered Team: Behavioral Health Home

PCP

PsychiatristCare

Manager/ Registry

Patient

Mental Health Center

Primary Care

Case Manager



14

KEY= RN= Psychiatrist

Refer to PCP for diabetes

treatment

Check weight, blood pressure, smoking status & order metabolic labs

Yes No

Weigh at next visit

Counsel

Re-evaluate medications

Repeat BP Check BP at next

visit

Yes No Yes No

Offer treatment

NoYes

Yes No

Re-evaluate medications

Measurement-Based Care Workflow Example

A1c > 5.7%

A1c > 6.5%?

BP > 140/90?

Smoker? BMI > 25?

Annual screen

Yes No

Check BP at next

visit

Refer to PCP for

HTN treatment

BP still > 140/90?

Counsel

Screen at next visit



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Case Number

Active in Care Management

Date Primary Physician RMHC PsychiatristNext Psychiatrist

Appt Date

Standard monitoring labs last done BMI LDL HbA1c

Fasting plasma glucose

Diastolic BP

Next PCP appt

Next case

manager contact due

3/18/2011 Ramirez 5.1.15 6/12/2014 32 152 6.9 121 102 3.12.15 4.1.153/5/2012 No PCP 9/11/20135/15/2014 RHC12/2/2014 Dr Ramirez5/21/2014 Dr. Sanchez 7/17/2014

Dr. Sandival4/19/2012 Dr. Przeniczny5/21/2014 Dr. Simantarkis MISSING6/27/2012 Dr. Carter 11/3/20145/21/2014 MISSING2/23/2011 Dr. Vavilala 7/16/20144/5/2011 Dr. Vavilala 2/25/20148/15/2012 Dr. Girn5/21/2014 NP Snezana MISSING

Population-Based Care: Registry Example



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Lay the foundation

Plan for practice change

Train team in new roles

Launch new

workflowSustain

Implementation Timeline


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• What are your goals for this program?

• Who will the program serve (target population)

• How will you know the program is working– What process measures?– What outcomes will be tracked, when and how?

• What are some strengths of your organization thatwill support this work?

• What challenges do you anticipate in this work?

Making an Integration Plan


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• Where is your organization now?– Leadership– Behavioral health case managers– Psychiatric prescribers– Others

• Who do you think you still need to convince?

Cultivate Organizational Buy-In


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Maine Health Access Foundation (MeHAF) Self-Assessment

Site Readiness Assessment


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• Engage your core integration team– Weekly meetings

• Complete activities for Unit 1: Lay the Foundation– Develop an integration plan– Cultivate organizational buy-in– Complete a readiness assessment

Next Steps – Learning Activities


21

The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and

Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and

do not necessarily represent the official views of HHS or any of its agencies.

Integration Plan

Program Name:

What are your goals (short- and long-term) for this program?

Who will the program serve? Identify a target population.

How will you know the program is working? Process and outcome measures, intervals, and targets.

What will be some of the strengths your organization will bring? What will be some of the challenges?

Used with permission of University of Washington AIMS Center. Originally developed by A. Ratzliff, MD, PhD and J. Unützer, MD, MPH, MA

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The Healthier Washington Practice Transformation

Support Hub

Bi-Directional Integration Spring Learning Series: Behavioral Health Track Measures

Process Measures Choose at least one

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Definition: The percentage of clients 3-17 years of age who had a visit with a PCP and who had evidence of the following during the measurement year: (1) BMI percentile documentation; (2) counseling for nutrition; and (3) counseling for physical activity. Report three separate rates.

Numerator: Clients who had BMI percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year.

Denominator: Clients age 3-17 years of age with a visit with a PCP in the measurement year.

Exclusion: Clients who were pregnant during the measurement year.

Source: NCQA (HEDIS), NQF 0024, WA State Common Measure Set 2017

Adult Body Mass Index Assessment

Definition: The percentage of clients 18-74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.

Numerator: Clients 18-74 years of age with a BMI documented during the measurement year or the year prior to the measurement year.

Denominator: Clients age 18-74 years of age with a visit in the past two years.

Source: NCQA (HEDIS), WA State Common Measure Set 2017

Comprehensive Diabetes Care: HbA1c Testing

Definition: The percentage of clients 18-75 years of age with diabetes (type 1 and type 2) who had an HbA1c test during the measurement year.

Numerator: Clients who had an HbA1c test performed during the measurement year.

Denominator: Clients age 18-75 years of age with a visit in the last year.

Exclusion: Clients who do not have a diagnosis of diabetes in the measurement year, or the year prior to the measurement year or have a diagnosis of gestational diabetes or steroid-induced diabetes.


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The Healthier Washington Practice

Transformation Support Hub

Outcome Measures

Choose at least one

Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Definition: Percentage of clients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement year.

Numerator: Clients whose most recent HbA1c level (performed during the measurement period) is > 9.0% or is missing a result or the test was not done during the measurement year.

Denominator: Clients 18 - 75 years of age with diabetes with a visit during the measurement year.

Exclusion: Clients who do not have a diagnosis of diabetes in the measurement year, or the year prior to the measurement year or have a diagnosis of gestational diabetes or steroid-induced diabetes.


Controlling High Blood Pressure

Definition: The percentage of clients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was controlled during the measurement year.

Numerator: Clients ages 18 to 59 as of the end of the measurement year whose BP was <140/90, ages 60 to 85 as of the end of the measurement year with a diagnosis of diabetes and whose BP was <140/90, or ages 60 to 85 as of the end of the measurement year, not with a diagnosis of diabetes with BP of <140/90.

Denominator: Clients 18-85 years of age with at least one encounter with a hypertension diagnosis on or before the midpoint of the measurement year.

Exclusion: Clients who are diagnosed with End Stage Renal Disease, who were pregnant during the measurement year or who had an encounter in a non-acute inpatient setting during the measurement year.


Sources: Washington Common Measure Set:

https://www.hca.wa.gov/assets/program/2016.12.20.Common-Measure-Set-Health-Care-Quality-Cost-Approved.pdf

National Quality Forum:http://www.qualityforum.org/Measures_Reports_Tools.aspx

National Committee for Quality Assurance:http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017

The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.


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http://www.qualityforum.org/Measures_Reports_Tools.aspx

http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017

http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2017

Team Roles and Readiness for Integrated Care Integrating Primary Care into Behavioral HealthWebinar 2


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Webinar objectives: • Review readiness assessment and integration plan.

Discuss challenges and opportunities forintegration

• Define team member roles and responsibilities forintegrated care in a BHA setting

• Explore opportunities for new roles andresponsibilities in a fully integrated model of care

• Discuss the next steps for team building

Learning activity after webinar:• Complete the task list as a team

Learning Objectives


26

• Part of our mission – to care for vulnerablepopulation

• No one else is doing it

• Opportunity for frequent touches

• Possible payoff in overall medical spend

• As well as opportunity for improvement inquality of life for our clientele, before it is toolate!

Improving Health Outcomes in A Seriously Mentally Ill Population


27

• Access to staff, resources, funds, andprimary care partners highly variable

• No center in Washington has access to anadequate stream of funding to cover thiscompletely

How To Approach Change in Your Site?


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• How high a priority is this for theorganization?

• Is this a cardinal activity for a communityhealth organization? If not, why not?

• Are there resources that can be shifted, if you“have to?”

Changing Priorities: Easy For Me To Say!


29

Client-Centered Team: Behavioral Health Home

PCP

PsychiatristCare

Manager/ Registry

Patient


Primary Care

Case Manager



30

• Screening function

• Psychiatrist function

• Care management function

• Registry function

• PCP function

Care Functions


31

• Some means of gathering data:– Vital signs– Lab data– Smoking status

• How can you do this?– Medical assistant or nurse in BHA setting– Data from primary care partner– Clipboards

Screening Function


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• Review and interpret physical health data

• Clarify history

• Exam

• Synthesize and plan

• Prescribe (minimize risk)

• Communicate with PCP – form letters?

• Communicate with care management

Psychiatrist Function


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Care Management Functions per Parks

• Care Coordination• Managing Transitions of Care• Health Promotion• Referral to Community Services


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• The place in the system where the client andthe system treating the client are mostimpacted

• Most of the other functions exist in order to getthe care manager where they need to be, whenthey need to be there

The Care Manager Is The Business End of The Stick


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Multiple staff can perform these functions and have different strengths/limitations:

– Behavioral health case managers• Used to coordinating care, interfacing with the

outside world• Less medical background

– Nurses• More medical background• [Sometimes] less comfort with SMI population• More expensive!

– Peers• The benefit of lived experience• Less medical background

How To Deploy Staff To Perform Care Management Functions


36

Integration of Care in BH Needs Someone To Drive the Registry

PCP

PsychiatristCare

Manager/ Registry

Patient


Primary Care

Case Manager



37

• Permits tracking, treatment to target ofphysical conditions

• Does involve double entry

• Doesn’t have to be impossibly complicated

• Someone has to do it, but it doesn’t have tobe a doctor or a nurse

• Oversight of the registry is different – airtraffic controller function

• A function, not a person

Registry Function


38

Registry Example



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• Medical management• Collaboration with BH team• Teaching, monitoring of patients

• Almost never in your organization• Often requires a lot of effort on care manager’s

side to get what is needed from the PCP

PCP Function


40

• Medical assistants are less expensive than nurses [thoughturn over faster]

• Funding workarounds

• Partner with an FQHC

• Choose a small group to cut your teeth on

• Don’t overreach and try to cure the $3M man

• Get data – improvements can be invisible to the naked eyeand staff can become demoralized

• Do things in groups – if the staff is asking EVERYONE aboutsmoking, it gets to be automatic

• Proximity matters – if people rub elbows, not so manymeetings need to be scheduled

• Phone calls are quicker than trips

Brainstorming About Ways to Coordinate Care on a Budget


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• Identify and engage clients

• Primary care assessment, planning andtreatment

• Treatment outcomes: track and adjusttreatment

• Provide effective program support

Team Building Worksheets


42

Addressing The Tasks in a BH Setting: Assessing Gaps


43

• Complete the AIMS Center Integration Task List



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Tasks for Integrated Primary Care in Mental Health Settings Are we doing this task now? If yes, Who is doing it? If no, who should do this

task? How should this task be

tracked? Screening Yes No Screen for Medical Problems : Office-Based Measurement (e.g. Weight, BMI, Blood pressure)

Screen for Medical Problems : Lab Measurements (e.g. HbA1C; Lipids) Screen for Health Behavior Risk: smoking, substance use, physical activity Assess where patient receives primary care Follow-up of Screening and Treatment Yes No Diagnose Medical Conditions that Need Treatment Client Education about treatment options for chronic medical conditions Prescribe Medications for Chronic Medical conditions Health Behavior Change Counseling: Smoking Cessation Health Behavior Change Counseling: Weight Management/Nutrition Health Behavior Change Counseling: Increase Physical Activity/Exercise Facilitate Referral and Coordination with Specialty Medical Care Identify Clients who Need Medical Care Management Care Coordination Yes No Obtain ROI to share information with PCP Share clinical information with PCP Track Treatment Outcomes Yes No Track Treatment Engagement & Adherence of Medical Care using Registry Reach out to Clients who are Non-adherent or Disengaged from Medical Care

Track Office-Based Measurement (e.g. Weight, BP) Track Lab Measurements (e.g. HbA1C) Track Behavioral Health Measures Track Medication Side Effects & Concerns Track Outcome of Referrals Assess Need for Changes in Treatment Facilitate Changes in Treatment if Not Improving Conduct Caseload-Focused Primary Care Consultation

Used with permission from University of Washington AIMS Center


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Develop Your Clinical Workflow for Integrated Care Integrating Primary Care into Behavioral HealthWebinar 3


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Webinar objectives: • Review the task summary worksheets and discuss

the challenges that arose for teams.• Understand how to translate new tasks for physical

health monitoring into an integrated care workflow.• Apply this workflow redesign process to

participants’ clinical teams workflow.

Learning activity after webinar:• Complete the workflow guide and develop a

process map.

Learning Objectives


47

Task Summary Worksheet Review

• Tasks for screening for chronic medicalconditions and monitoring outcomes

• Supports reporting of Medicaid TransformationProject demonstration outcomes

• Breaks down into phases of clinical care, eachwith a workflow

• Goal is to identify– Tasks that are not currently being done– Tasks that need improvement


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• Common understanding of work

• Focus on the process not the people

• Clear visual definition of current workflow

• Illuminate improvement opportunities byclarifying unnecessary work

• Identify metrics to measure improvement

Process Mapping

45


49

• Who is involved?

• How is it done?

• What are the steps?

– Identify current workflow

– Design future state (ideal) workflow

• What is the final product?

Workflow Redesign 101


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The Process Map Tells the Story

• Sequence of tasks

• Involvement of people

• Use of documents, systems and othersources of information


51

Components of a Process Map

Start & EndPoint

Action StepsDecisions

Direction flow


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Checkpoint: Current Workflow

• Think about your currentworkflow around metabolicmonitoring…

• How well are prescribersdoing this now?

• What are the majorchallenges to trackingthese outcomes in a timelyway—AND adjustingtreatment?


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• Process mapping “ideal” testable workflow

• Identify simple metrics

– To see if things are heading in the right direction

– Identify potential unintended consequences

• Future state mapping ends with an action plan/tasklist with three components:

– Task

– Responsible Party

– Timeline

Development of the Future State


54

• Behavioral Health Agency that has served childrenand adults for past 25 years– 6,000 patients a year

• Staffing– 3 FT psychiatric prescribers– Clinic nurse– Case management service– 2 clinic admins

• No primary care partner per se, but 35% of patientsseen in a family medicine practice in thecommunity

Example CBHC


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Integration Plan Example


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Task List Example


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Task List Example (Cont’d)


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• Decision: Track BMI in high-risk population– new prescriptions of atypical

antipsychotic medication, or– patients new to us on atypical

antipsychotic medication

• Follow ADA-APA guidelines for monitoring.

Building Workflow for Tracking


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ADA-APA workgroup. Diabetes Care 2004; 27: 596-601.

BL 4 wks

8 wks

12 wks

q 3mo

q 1Yr

PMH / Family Hx X XWeight (BMI) X X X X XWaist Circumference X X

Blood Pressure X X XFasting glucose X X XFasting lipids X X X

ADA-APA Guidelines


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• Patients on SGA are high risk and metabolicoutcomes should be monitored

• How identify a subgroup to track?– Review of administrative data– Review of prescriber caseloads– Start with new SGA prescriptions– Start with new clients

Deciding on the Starting Point


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How Do We Screen


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How Do We Screen (Cont’d)


63

How Does Prescriber Use and Respond to Information?


64

Tracking Treatment Outcomes


65

Care Coordination and Treatment


66

Big Picture: How Do We Act on Data to Improve Care?


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• Complete the Workflow Guide• Create a Process Map of your clinical Screening

and Treatment Workflow



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The project described was supported by Funding Opportunity Number CMS‐1G1‐14‐001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.


Agency Name: Date: Screening WorkflowTasks for Integrated Care in Community Behavioral Health Settings

WHO Name, Discipline

HOW Process (Including Hand‐offs) & communication methods (e.g., telephone, mail)

WHEN In terms of patient flow and time constraints

WHERE Clinic? Partner agency? External referral?

Screen for Chronic Medical Conditions: Office‐Based Measurement (e.g. Weight, BMI, Blood Pressure)

Screen for Chronic Medical Conditions: Lab Measurements (e.g. HbA1C, Lipids)

Screen for Health Behavior Risk: Smoking, Substance Use, Physical Activity, Nutrition

Verify Where Patient Receives Primary Care

Organization‐Level Changes ☐Staff Hires

☐Staff Training

☐Clinical Supervision

☐Administrative Supervision

☐Other Resources needed:

Notes:

Refer to this completed guide when creating a process map for your clinical workflow.

The project described was supported by Funding Opportunity Number CMS‐1G1‐14‐001 from the U.S. Departmentof Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.


Follow‐Up of Screening: Treatment Workflow Tasks for Integrated Care in Community Behavioral Health Settings





Diagnose Medical Conditions that Need Treatment

Client Education about Treatment Options for Chronic Medical Conditions

Prescribe Medications for Chronic Medical Conditions

Health Behavior Change Counseling: Smoking Cessation

Health Behavior Change Counseling: Weight Management/Nutrition

Health Behavior Change Counseling: Increase Physical Activity/Exercise

Identify Clients who Need Medical Care Management


☐Staff Training




Notes:

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Care Coordination Tasks for Integrated Care in Community Behavioral Health Settings





Obtain ROI to Share Information with PCP

Share Clinical Information with PCP

Obtain Medication and Lab Data from PCP and Make Available in BH EMR

Coordinate PCP Appointments (e.g., Patient Reminders, Communication with PCP Office, Prior Authorizations]

Coordinate With Other Providers (e.g., pharmacy, medical equipment, specialty medical care)


☐Staff Training




Notes:

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Track Treatment Outcomes Tasks for Integrated Care in Community Behavioral Health Settings





Track Engagement in Primary Care & Outreach to Those Not Engaged

Track Adherence to Medical Treatment

Track Office‐Based Measurement (e.g. Weight, BP)

Track Lab Measurements (e.g. HbA1C)

Track Behavioral Health Measures

Track Medication Side Effects & Concerns

Track Outcome of Referrals

Assess Need for Changes in Treatment and Facilitate Changes, if Not Improving

Conduct Caseload‐Focused Primary Care Consultation


☐Staff Training




Notes:

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Population Management: Using a Registry to Track Outcomes

Integrating Primary Care into Behavioral HealthWebinar 4


73

Webinar objectives:

• Understand the principles of population health managementand how they apply to community behavioral healthworkflows

• Understand how to use a registry to provide measurement-based care

• Discuss the pros and cons of different registry options

Learning activity after webinar:

• Practice population health management with a sampleregistry

Learning Objectives


74

Principles for Evidence-Based Integration in Behavioral Health and Primary Care

Team-Based and Client-Centered Primary care and behavioral health providers collaborate effectively, using shared care plans.

Measurement-Based Treatment to Target Measurable treatment goals clearly defined and tracked for every patient. Treatments are actively changed until clinical goals are achieved.

Population-Based A defined group of clients is tracked in a registry so that no one “falls through the cracks.”



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• Population Health– The health outcomes of a group of individuals,

including the distribution of such outcomeswithin the group

• Population Care– Design, delivery, coordination, and payment of

high-quality health care services to manage theTriple Aim for a population using the bestresources available within a health care system

Population Health Management

www.ihi.org


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http://www.ihi.org

“Involves the systematic use of symptom rating scales to drive clinical decision making.”

Measurement-Based Care

https://www.thekennedyforum.org/news/measurement-based-care-issue-brief


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https://www.thekennedyforum.org/news/measurement-based-care-issue-brief

• Measurable treatment goals (“targets”) are defined

• Patients monitored using clinical measures orvalidated clinical rating scales (PHQ-9, GAD-7)– Standardized monitoring schedules based on

treatment guidelines

• Results of scales and other patient measurestracked in a registry

• Treatment results regularly evaluated andtreatment is adjusted until target goals achieved

Measurement-Based Care


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• Track population-based care

• Track progress at individual, caseload, andpopulation level

• Facilitate efficient, systematic case review

• Prompt treatment to target

• Provide timely reminders

• Provide decision support

Registry Requirements



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• Data collection integrated into clinical workflow.Standard protocol for data collection at prescribervisit. Who and where recorded?

– Weight/ BMI– Blood pressure– Labs

• Outside lab results called to attention of prescriberor PCP, as necessary

• During course of treatment, BMI regularly trackedand 12-week labs obtained

Measurement-Based Care in Practice


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• Care team must have readily available data onpatient status and outcomes to drive changesin treatment– In any measurement-based model, it is

difficult to achieve improvement in outcomeswithout regular review of data

• Workflow should prompt this– For example in a Behavioral Health Home,

the PCP consultant uses registry data toprioritize patients for case review andtreatment adjustments

Actionable Data in a Registry


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• When: Weekly, 60-90 minute sessions

• Who: Medical care manager, PCP consultant

• How: in-person or by phone– Registry & EHR must be available to both

• Goal: monitor entire caseload over time– review all patients on caseload in one session– only priority patients over several sessions

Systematic Case/Data Review


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Example: How to Use a RegistryIntegrating Outcomes into the Clinical Workflow

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• Excel Spreadsheet + EHR– AIMS Patient Tracking Template

• Build into EHR or Care Management System– EPIC

• Healthy Planet• Reporting workbench

Examples of Registries


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• Reflect on your experiences tracking behavioralhealth outcomes? What did you use to track?

• EHR?• Web-based population management software?• Excel?

• Reflect on your experiences using a registry fortracking physical health measures?

• Reflect on your experiences using symptom ratingscales? How did you track these at the individual,case and population level?

Checkpoint


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• Many healthcare organizations investing significantresources

• Thus far, few successes, numerous failures, manywar stories

» Epic Healthy Planet» Epic Pre-Healthy Planet» Valant Behavioral Health HER

• Approach with caution!

Registry Functions Built into EHR


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FunctionalityPatient

Tracking Spreadsheet

Customized EMR

Registry

Legal medical record

Used for billing

Tracks progress at individual patient level

Tracks population-based care Varies

Tracks progress at caseload level Varies

Facilitates psychiatric consultation and systematic case review Varies

Prompts treat to target strategies Varies

Provides decision support Varies

Cues Care Manager outreach Varies

Aggregates data across multi-Institutional projects

Comparing Registry Tools


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• 52 y/o man with historyof major depressivedisorder andhypertension

• Lives alone, volunteers atYMCA

• BMI = 33 kg/ m2; BP =153/ 94

• Smokes 1.5 ppd• PHQ-9 = 4

• Eats at KFC most days;6 Dr. Peppers daily

Case Example

• Medications– Mirtazapine 15 mg at

night– Amitriptyline 150 mg

at night– Bupropion SR 100 mg

daily– HCTZ 25 mg daily

• ASA 81 mg daily• Labs

– A1c = 8.5%– TC = 240; HDL = 30


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AIMS Center Patient Tracking Spreadsheet: “Patient Tracking” Tab


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AIMS Center Patient Tracking Spreadsheet: “Caseload Overview” Tab


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• Discuss Registry Options with your IntegrationTeam

• Review Case Example Scenarios



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Most Important Things to Know About the Patient Tracking Spreadsheet

1. The PRIMARY purpose of the registry is to help you support the clinical work of theteam. The Patient Tracking Spreadsheet is designed to serve YOU. If you feel like you’re serving the registry, something is wrong and we can help. Let us know! We can show you how to use the registry so that it serves you and helps you with your job.

2. The registry works best when you use it every day throughout the day.The registry can help you quickly and easily see who is getting better, who is not, and who needscontact. The registry can only help if you use it every day alongside your electronic health record.

3. The registry helps guide patient contacts.The registry facilitates patient contacts (phone or in person) with a patient by reminding you when afollow-up contact is due.

Patient Tracking Spreadsheet Exercises

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Getting Started

The following scenario is designed to help you learn how to use the Patient Tracking Spreadsheet to facilitate management of high-quality evidence-based medical care in a behavioral health setting.

Checklists at the end of each section indicate Patient Tracking Spreadsheet skills learned.

To get started, please open the Patient Tracking Spreadsheet, and make sure you click “Enable Editing” and “Enable Content” in the yellow bar at the top of the page.

This scenario is meant to be used in conjunction with the Patient Tracking Spreadsheet Template Quick Start Guide, which contains further instructions for each column on the spreadsheet.

We recommend that you read each scenario first, and then enter applicable information into the spreadsheet. After you have entered the information, use the checklists at the end of each section to ensure you have included the appropriate pieces of information.

As a team, discuss what steps you would take with the client in each scenario. Remember to think about actionable steps and follow-up with the client and not just entering the data!

Benny, Case #12345

Initial Contact 6/1/2016: Benny is a 52 year-old white male with history of treatment resistant Major Depressive Disorder and hypertension. Benny has lived alone in a subsidized housing apartment complex for the last 15 years, and has been relatively stable. He does not work, but contributes some to the local YMCA as a front-desk greeter three days a week.

Benny likes to watch old reruns of classic black and white TV shows when he’s not at the YMCA. He also smokes about 1.5 packs-per-day (PPD). He primarily eats out fast food from a KFC about a block away, but Ben brings him some fresh food every once in a while to stock in his refrigerator. He drinks about 6 Dr. Peppers a day too. Benny’s BMI is 33 kg/m2.

In May, Benny went to the hospital for some chest pain. A workup at that time ruled out a heart attack, and your team received the discharge paperwork from an overnight stay indicating the ER thought he had anxiety.

Benny has seen Dr. John for his primary care for the past 15 years since his housing stabilized. He usually sees Dr. John about once every 6 months, but missed his last appointment and has not seen Dr. John since he was in the hospital.

Benny saw the psychiatrist, Dr. Speedy and care manager, Kate, to enroll in services on June 1st.

Benny’s medications as of June 1st include: 1. Mirtazapine 15 mg once daily2. Amitriptyline 150 mg once nightly


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3. Bupropion SR 100 mg twice daily4. Hydrochlorothiazide 25 mg once daily5. Daily Aspirin, 81 mg

Practice the Following Registry Skills: □ Enter all possible new patient information fields□ Enter all known contacts and dates□ Enter all known measurements□ Enter the action plan you would take as the care team for Benny

Benny Follow-up Contact 7/20/2016 Benny was admitted again for chest pain and was found to have had a heart attack. Benny’s blood pressure upon discharge on July 10th was 153/94 mm Hg, HbA1c was 8.5%, and his BMI was 33 kg/m2. On discharge, he was prescribed three new medications in addition to his other medications:

1. Metoprolol 50 mg twice daily2. Metformin 500 mg twice daily3. Atorvastatin 20 mg daily

Benny has not gone to see his PCP since you met with him in June.

Registry Skills: □Update contact information□Update care manager contact date□Update measurements□Update and add any new action plans

Benny Care Coordination 7/28/2016 You call Benny and ask if he has scheduled his medical appointment. He lets you know he has an appointment on August 10th! In addition you place a request for his medical records from Dr. John.

Registry Skills: □Update care manager contact date□Update PCP upcoming appointment date□Update and add any new action plans

Benny Follow-up Contact 8/16/2016 Benny is in for an appointment with Dr. Speedy and you have a chance to briefly meet him. Benny saw Dr. John on August 10th and his blood pressure was 138/88. Benny has been taking his medications more consistently, and began an exercise program with approval from Dr. John at the YMCA. He is able to cut back a little more on his smokes with the help of a nicotine patch.


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Registry Skills: □Update care manager, PCP and psychiatrist contact dates□Update measurements□Update and add any new action plans

Case Load Review 11/20/2016 You are reviewing your case load and realizing that Benny’s last PCP appointment was in August 2016 and his PCP asked that he return in 3 months. You follow-up with Benny by phone and make a note that you want to see him the next time he is in to see his psychiatrist.

Registry Skills: □Review the caseload overview page for last contact information and BP measurement□Update contact date□Update and add any new action plans


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Getting Started

The following scenario is designed to help you learn how to use the Patient Tracking Spreadsheet to facilitate management of high-quality evidence-based medical care in a behavioral health setting.

Checklists at the end of each section indicate Patient Tracking Spreadsheet skills learned.

To get started, please open the Patient Tracking Spreadsheet, and make sure you click “Enable Editing” and “Enable Content” in the yellow bar at the top of the page.

This scenario is meant to be used in conjunction with the Patient Tracking Spreadsheet Template Quick Start Guide, which contains further instructions for each column on the spreadsheet.

We recommend that you read each scenario first, and then enter applicable information into the spreadsheet. After you have entered the information, use the checklists at the end of each section to ensure you have included the appropriate pieces of information.

As a team, discuss what steps you would take with the client in each scenario. Remember to think about actionable steps and follow-up with the client and not just entering the data!

Justin, Case #678910

Initial Contact 4/15/2016: Justin is a 16 year old high school student who lives with his mom and dad and his little sister, Delphina. He enjoys skateboarding and drawing. A couple of times he has been in trouble for graffiti, but nothing serious. He enjoys art class at school, but otherwise just passes.

He was hospitalized last year after a suicide attempt by cutting his wrist, and at that time was diagnosed with bipolar depression. It took months for his depression to respond, and he eventually stabilized on medications including lithium 600 mg twice daily and quetiapine (Seroquel) 600 mg at bedtime. He and his family also see a therapist at the mental health center, who he likes, though he is often reluctant to take time to go to the appointments.

He has been able to return to the 10th grade, though not doing quite as well as he was before, and some of his friends were freaked out by his suicide attempt, and don’t really hang out with him anymore.

He has been adherent with his meds for the most part, except when he and his parents both forget, which happens especially on the weekend, when he sleeps in.

His psychiatrist, Dr. Woods, has been seeing him regularly, every 2 or 3 weeks and at today’s appointment his PHQ-9 was 8. He is 5’6” and his weight 160 Ibs.


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Practice the Following Registry Skills: □ Enter all possible new patient information fields□ Enter all known contacts and dates□ Enter all known measurements□ Enter the action plan you would take as the care team for Justin

Justin Follow-up Contact 6/1/2016 Dr. Woods saw Justin today. His PHQ-9 was now 10. And his weight had increased by 30lbs in six months to 180 lbs [BMI of 29.1 – in the overweight range, and not far from the “obese” threshold of 30.]

Justin feels hungry all the time, and sometimes gets up in the middle of the night to eat leftovers or ice cream. He is somewhat embarrassed about how heavy he has become, his friends tease him about it, and he is sure that this makes him unattractive to girls. Skateboarding is not as easy as it used to be, and he needs more breaks.

Dr. Woods has talked with Justin about “eating healthier”, and his mom has tried to feed him more fruits and vegetables, but he has felt unable to control his appetite.

As part of routine monitoring of his medications, Dr. Woods checked laboratory tests, including fasting serum glucose, which came back 82, in the normal range, and a lipid profile, which did not: total cholesterol 205, LDL 160, HDL 39.

Practice the Following Registry Skills: □ Enter all known contacts and dates□ Enter all known measurements□ Enter the action plan you would take as the care team for Justin

Justin Follow-up Contact 6/15/2016 On his return appointment with Dr. Woods, she discussed reviewed laboratory and physical findings and her concerns about his weight and his lipid profile, and educated Justin and his family about cardiovascular risk.

They made the following plan:

1. Pediatric appointment for Justin with Dr. Smith2. Dr. Woods to consult with pediatrician3. Consider change in psychiatric meds4. Exercise plan5. Diet plan


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Practice the Following Registry Skills: □ Enter all possible new patient information fields□ Enter all known contacts and dates□ Enter the action plans you would take as the care team for Justin

Justin Care Coordination Call 6/22/2016 The behavioral health care manager gives Justin a call to find out if he made an appointment with his PCP, Dr. Smith. He has an appointment on 7/20/2016. In addition the behavioral health care manager shared information about a community center in his area that has hour during the winter for a free open swim. They made a plan to start trying to exercise more with swimming.

Practice the Following Registry Skills: □ Enter all known contacts and dates□ Enter the action plans you would take as the care team for Justin

Case Load Review 9/2016 You are reviewing the case load and realize that the last communication that you had with Justin was in June. You follow-up with him to see if he made it to his PCP appointment and started swimming.

Registry Skills: □Review the caseload overview page for last contact information and BP measurement□Update contact date□Update and add any new action plans



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Introduction to Quality Improvement Methods Integrating Primary Care into Behavioral HealthWebinar 5


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Webinar objectives: • Discuss experiences completing registry case

activities.• Describe quality improvement principles to be applied

in a BHA setting.• Describe the rapid cycle improvement strategy and

the steps of a PDSA.• Give an example of a PDSA in a BH setting.• Identify next steps for PDSA sharing and discussion.

Learning activity after webinar:• Develop a rapid-cycle PDSA related to the measure you

are working to improve.

Learning Objectives


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More than half of the care delivered in U.S. is not consistent with evidence-based guidelines

– McGlynn, et al. N Engl J Med, 348 (2003):2635-45.

QI Methodology developed in other industries and applies to medicine

– Most of chronic disease management is protocol-driven; process standardization assures:

• Consistent quality• Lowest possible cost

– Chronic illness represents majority of diseaseburden

Why Use Quality Improvement Methodology in Medicine at All?

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• Three questions– What are we trying to accomplish?– How will we know a change is an

improvement?– What changes are likely to result in

improvement?• Rapid Process Improvement Cycles:

Plan/Do/Study/Act• Spread

The IHI Model for Improvement


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• Usually we jump to solutions

• Solutions entail change, which threatens thestatus quo

• It is very easy to think of reasons to resistchange, particularly when the goal isn’t clear

• Without a clear goal and measurable outcomesimprovement efforts bog down in resistance

Simple – Effective – Very Difficult


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• Problem statement: Mortality of mental healthpatients in the Medicaid population is 1.5 – 4times higher than matched controls

• This excess mortality is driven by:– Cardiovascular disease– Cancer– Chronic respiratory disease– Diabetes

Example 1 Applying this to Behavioral Health


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• Mental illness interferes with treatment of chronicillness

• Chronic illnesses frequently makes mentaldisorders worse

• Improving outcomes requires collaboration• Standardized processes required on both sides

– Medicine: recognize and address behavioralhealth issues effectively

– Behavioral Health: recognize and address chronicillness effectively

– Coordinated evidence-based care plans

Example 1Chronic Diseases Straddle both Disciplines


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Question 1: What are we trying to accomplish?

• Define a the target population – that meanshaving a list of every patient in the population

• Define a “standard of care” supported bymedical evidence

• Translate that standard of care into specific“care gaps” to be closed

Example 1Applying the Model for Improvement


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Example 1Caseload: Role of Registry

Registry

Advantages:• One person controls data entry

and reporting• Without an EHR analytics it’s

the only option• May be best fit for “case load”

concept in behavioral health

Disadvantages:• Separate data entry• People not in registry are

overlooked• Multiple registries are

cumbersome

Caseload data managed in the registry

New Patients

Patients finishing therapy


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Example 1Consider Blood Pressure Control

• Easy to measure – must be done right• Cardiovascular disease: greatest threat

to mental health patients• Hypertension: most powerful risk factor

for cardiovascular disease• Controllable with medication• Shared management solutions create

structure for collaboration– Between medicine & behavioral

health– With community resources


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• Define the target population: Adults > age 18receiving mental health care at our facility

• Define a standard of care:– Every adult patient of the clinic will have blood

pressure measured at each visit– The blood pressure for that visit will be

documented in the registry– If BP > 140/90, a standardized process will be

followed to hand the patient off to the medicalservice for management

Example 1What Are We Trying to Accomplish?


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Example 1 The Standard Defines the Care Gaps

People in target population: Active

patients we are managing

People whose BP was measured at

last visit

People with elevated blood pressure

People handed off to PCP for management

Process Care Gap 1

Process Care Gap 2

Clinical Care Gap


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A change that closes a care gap is an improvement• The percent of patients with a blood pressure

recorded at last visit• Percent of patients with BP > 140/90 for whom a

handoff to Medicine was initiated• Percent of patients handed off to Medicine for

whom the handoff was completed• Percent of patients with elevated BP

Example 1 How Will We Know a Change is an Improvement?


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Example 1Run Charts Make Gap Closure Visible

0

10

20

30

40

50

60

70

80

90

100

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 5th Qtr 6th Qtr

Clinic

Goal

Percent of patient with standard of care met


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Co-managing blood pressure means adding a few tasks to the workflow

• Gather information: Measure blood pressure onevery patient

• Decide: Make a decision as to whether it is normalelevated

• Act: Every patient with elevated blood pressure willleave with a plan for treatment in primary care

Example 1 What Changes are Likely to Result in an Improvement?


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Example 1Workflow: Patient Sees Therapist

Work to be inserted into this workflow1. Gather the information to make a decision2. Make a decision based on the information3. Act on decision

Things to decide:1. What are the tasks we want to do?2. Who will do each task?3. Where in the workflow will it be done?4. What will that person need to do the task?


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Example 1Future State Workflow

Care Gap 1 - Gather Information: Clinical Assistant takes and documents Blood Pressure; informs Clinician if elevated

Decide: Use protocol to initiate handoff for BP management and

informs Clinical Assistant

Care Gap 2 - Act: Clinical Assistant arranges

appointment with primary care according to protocol


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Task Who When

Purchase BP Machine

Designate individual to take BP

Train clinical assistant in proper BP measurement

Set up data entry field in registry for BP

Establish referral agreements for Pts without PCP

Train front desk to identify PCP at check-in

Set up order for referral to PCP

Example 1Tasks to Complete before Testing


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• Plan out every step of future state• Pick a team eager to make it work• Test it in a single practice, with a

single patient, a single day• What worked? What didn’t?• Modify it to make it work better• Test it again, expand to more

patients, more teams

Example 1Rapid Process Improvement Cycles

Plan

DoStudy

Act


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Example 1Repeated Use of the PDSA Cycle

The future state you planned

The future state as it

evolved using rapid process improvement

A PS D

A PS D


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Example 1Run Chart for Care Gap 1: Measuring Blood Pressure

0

10

20

30

40

50

60

70

80

90

100


Clinic

GoalStart taking BP at check in for Therapist appts

Spread to all patients

Large influx of new Medicaid

enrollees

Additional staffing to accommodate expanded Pt load

Front desk configuration change to make workspace

more efficient

Percent of Adults patients with BP reading at last visit


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• Information is gathered to make decisions andcarry out effective actions

• Take the BP correctly to avoid false positiveelevation

• If elevated repeat after resting quietly for 5minutes and use second reading

• If still elevated, it requires action

Example 1Using Clinical Information to Make Clinical Decisions


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• Set up a referral agreement with at least oneprimary care clinic

• Develop a protocol for acting on elevated BP– RN in BH clinic can take handoff, schedule follow

up, and provide educational support– Find out who patient’s PCP is and help patient

schedule an appointment– If patient has no PCP refer to clinic using

prearranged referral protocol– Referral tracking to assure patient keeps

appointment

Example 1Protocols Facilitate Action


121

• What are we trying to accomplish?– Every patient whose BP is > 140/90 will receive a

medical evaluation according to standardprotocol

• Contact PCP office if patient has one• Refer to partner PCP practice if no PCP

• How will we know a change is an improvement?– Document blood pressure in the registry– Document handoff to PCP in registry– Verify handoff completed

Example 1PDSA Cycle for Care Gap 2


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• Use Lean thinking to identify waste– Verify name of PCP at check in

– If BP is elevated on second reading, have theperson taking BP set up handoff to PCP

– Make appointment with PCP before patientleaves BH office to improve keeping appointment

• Ask the people doing the work, what would maketheir jobs easier

Example 1Tactics for Identifying Changes That Should Result in Improvement


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• Obesity & depression prevalence in youth:– Depression: 2% in children; 4 – 8% in adolescents– Overweight increase from 14% to 17% since 1990s

• Emerging pattern of links between the two– Correlation is strongest in females– Similar presentation:

• Sleep disorder• Sedentary behavior• Increased appetite• Negative self-image

• Side effects of antidepressants– For each antidepressant prescribed 15% experience

increased appetite– 50% of children receiving anti-psychotic for first time have

a weight gain of 7% in the first 12 week.

Example 2What is the Problem?


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• Depression and childhood obesity appear linked• Improving outcomes requires collaboration• Standardized processes required on both sides

– Medicine: recognize and address depressioneffectively

– Behavioral Health: recognize and addresschildhood obesity effectively

– Coordinated care plans

Example 2Childhood Obesity Straddles both Disciplines


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Question 1: What are we trying to accomplish? • Define a the target population – that means

having a list of every patient in the population

• Define a “standard of care” supported bymedical evidence

• Translate that standard of care into specific“care gaps” to be closed

Example 2Applying the Model for Improvement


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Example 2Caseload: Role of Registry

Registry

Advantages:• One person controls data entry

and reporting• Without an EHR analytics it’s

the only option• May be best fit for “case load”

concept in behavioral health

Disadvantages:• Separate data entry• People not in registry are

overlooked• Multiple registries are

cumbersome

Caseload data managed in the registry

New Patients

Patients finishing therapy


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Example 2Consider Body Mass Index (BMI)

• Weigh & Height are easy tomeasure

• Shared management solutionscreate structure for collaboration– Between medicine & behavioral

health– With community resources

• Nutrition counseling• Opportunities for exercise• School-based programs


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• Define the target population: Youth receivingdepression care at this facility

• Define a standard of care:– Every child or adolescent will have height

and weight measured at each visit– The calculated BMI for that visit will be

documented in the registry– If BMI is > 30, or between 25 & 30 and

increasing, a standard process will befollowed to hand the patient off to themedical service for evaluation & management

Example 2What are We Trying to Accomplish?


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Example 2The Standard Defines the Care Gaps

Target population: Young people we

are managing

Young people whose BMI was measured at last visit

Young people with elevated BMI

Young people handed off to PCP for management

Process Care Gap 1

Process Care Gap 2

Clinical Care Gap


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A change that closes a care gap is an improvement• The percent of patients with a BMI was

documented at last visit• Percent of patients with BMI > 30 for whom a

handoff to Medicine was initiated• Percent of patients handed off to Medicine for

whom the handoff was completed• Percent of patients with elevated BMI

Example 2How Will We Know a Change is an Improvement?


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Example 2Run Charts Make Gap Closure Visible

0

10

20

30

40

50

60

70

80

90

100


Clinic

Goal

Percent of patient with standard of care met


132

Co-managing obesity means adding a few tasks to the workflow• Gather information: Measure height and weight

on every patient • Decide: Make a decision as to whether BMI

meet threshold for action• Act: Every patient with elevated or increasing

will leave with a plan for involving primary care

Example 2What Changes are Likely to Result in an Improvement?


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Example 2Workflow: Patient Sees Therapist

Work to be inserted into this workflow1. Gather the information to make a decision2. Make a decision based on the information3. Act on decision

Things to decide:1. What are the tasks we want to do?2. Who will do each task?3. Where in the workflow will it be done?4. What will that person need to do the task?


134

Example 2Future State Workflow

Care Gap 1 - Gather Information: Clinical Assistant gets height and weight and documents it; informs

Clinician if BMI elevated

Decide: Use protocol to initiate handoff for weight management and informs Clinical Assistant

Care Gap 2 - Act: Clinical Assistant arranges

appointment with primary care according to protocol


135

Task Who When

Purchase scale and height measurement device

Designate individual to measure height & weight

Assure EHR calculates BMI from height & weight

Train clinical assistant in technique & scripting

Set up data entry field in registry for height & weight

Establish referral agreements for Pts without PCP

Train front desk to identify PCP at check-in

Set up order for referral to PCP

Example 2Tasks to Complete before Testing


136

• Plan out every step of future state• Pick a team eager to make it work• Test it in a single practice, with a

single patient, a single day• What worked? What didn’t?• Modify it to make it work better• Test it again, expand to more

patients, more teams

Example 2Rapid Process Improvement Cycles

Plan

DoStudy

Act


137

Example 2Repeated Use of the PDSA Cycle

The future state you planned

The future state as it

evolved using rapid processimprovement

A PS D

A PS D


138

Example 2Run Chart for Care Gap 1: Measuring Body Mass Index

0

10

20

30

40

50

60

70

80

90

100


Clinic

GoalStart taking ht & wt at check in for Therapist appts

Spread to all patients

Large influx of new Medicaid

enrollees

Additional staffing to accommodate expanded Pt load

Front desk configuration change to make workspace

more efficient

Percent of Adults patients with BMI reading at last visit


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• Young people are highly sensitive to bodyimage

• Essential to get expert guidance on scripting– How to approach checking weight– What to say if BMI is > 30 or increasing– How to respond if patient refuses or

becomes emotionally upset

Example 2Scripting and Messaging is Essential


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• Set up a referral agreement with at least oneprimary care clinic– Find out what resources primary care has for

managing obesity in children and adolescents• Develop a protocol for acting on elevated BMI

– RN in BH clinic can take handoff, schedule follow up,and provide educational support

– Find out who patient’s PCP is and help patientschedule an appointment

– If patient has no PCP refer to clinic using prearrangedreferral protocol

– Referral tracking to assure patient keepsappointment

Example 2Protocols Facilitate Action


141

• What are we trying to accomplish?– Every patient whose BMI is > 30, or between

25 – 30 and increasing will receive a medicalevaluation according to standard protocol• Contact PCP office if patient has one• Refer to partner PCP practice if no PCP

• How will we know a change is an improvement?– Document BMI in the registry– Document handoff to PCP in registry– Verify handoff completed

Example 2PDSA Cycle for Care Gap 2


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• Use Lean thinking to identify waste– Verify name of PCP at check in– Make appointment with PCP before patient

leaves BH office to improve keepingappointment

• Ask the people doing the work, what wouldmake their jobs easier

Example 2Tactics for Identifying Changes That Should Result in Improvement


143

Components of Successful Change Management

Knoster, T., Villa R., & Thousand, J. (2000) A framework for thinking about systems change.


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• Use the PDSA Worksheet to implement PDSAs



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PDSA Worksheet Page 1 of 2

PDSA Worksheet

Complete Page 1 of the worksheet when planning your Plan-Do-Study-Act (PDSA) cycle. Multiple PDSAs can be designed in support of a single Aim.

AIM STATEMENT (Measurable goal, with a target date)

___________________________________________________________

___________________________________________________________ Today’s Date: _____________________

___________________________________________________________ PDSA Cycle #: ____________________

___________________________________________________________________________________________________

PLANWhat will you try? _________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

When? ___________________________________________________________________________________________

Who will be involved?

Team: ____________________________________________________________________________________________

Patients: _________________________________________________________________________________________

What do you predict will happen? __________________________________________________________________

___________________________________________________________________________________________________

How will you evaluate how it went? ________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Who will collect the evaluation data? _______________________________________________________________

What do you need to do to get ready? ______________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

PDSA Worksheet Page 2 of 2

Complete Page 2 of the worksheet during your test and its follow-up assessment.

Today’s Date: ________________________

DOWhat actually happened? __________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

STUDYWhat did you learn? ______________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

How did the results compare to your predictions? ___________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

ACTHow will you adapt, accept, or abandon? ___________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

www.QualisHealthMedicare.org/PDSA

Adapted by Qualis Health from materials developed by the Institute for Healthcare Improvement and prepared under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. ID/WA-C10-QH-916-09-12

Used with permission from Qualis Health.

http://www.QualisHealthMedicare.org/PDSA

Thank you


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