phln: behavioral health integration · changes tested by: • discovering new epic reporting...
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PHLN: Behavioral Health Integration
Axis Community Health
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PHLNYear2ProjectAim MeasuresforSuccess
AxisCommunityHealth
Tohavetheabilityto:• Trackpatientscoresthroughouttreatment• Examinedatatoidentifypatientswhose
depressionisnotimproving• Adjusttreatmentasneeded• Measureimprovements
Developregistrytoidentifypatientsw/:• 1+BehavioralHealthVisit(6monthlookback)• Diagnosisofdepression• PHQ-9scoreof15orabove
Reportgeneratedforthepast3consecutivemonths.
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OurTeam• Quality Enhancement / Data Analytics
o Amit Pabla, MHAo Afsheen Islam, MHA
• Behavioral Health Leado Dr. Jennifer Penney
• Consulting Psychiatristo Dr. Jerry Ngo
• Integrated Behavioral Health Providerso 16 licensed providers at 4 locations
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ChangesTestedby:
• DiscoveringnewEpicReportingcapabilitiesasofJanuary2019
• BrainstormingnewopportunitiesandlimitationswithDr.Raney
• UtilizingaworkgroupwithourConsultingPsychiatrists
• Determiningwhatdataismostbeneficialfortheteam
Implementedbyadding:• PHQ-9scorechangesmonthtomonthforpatientsin
treatment
• Quickidentifierstodeterminewhetherapatient’sscorehasworsenedorimproved
• Addedcurrentpsychotropicmedicationtothereportinordertoidentifyanyimpacttoscoreasmedicationisadjusted
• Providedreporttoprovidersinitially,andlatertoconsultingpsychiatristalso
• One-on-onemeetingsbetweentheconsultingpsychiatristandthetreatingBHprovider
CENTER FOR CARE INNOVATIONS | 4
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DataCollected:• ReportingPeriod:4/1/19to9/30/19• 15behavioralhealthproviders• 207patients• 115patientswithonly1PHQ-9Score• 92patientswith2ormorePHQ-9Scores
• 59patientswhosescoreimproved(by1-19points)• 16improvedby50%ormore• 43improvedbylessthan50%
• 26patientswhosescoreworsened(by1-20points)• 7patientswhosescorewasconstant
DataResulted:• ByidentifyingpatientswhosePHQ-9scoresweregettingworse
andadjustingtheirtreatmentplansaccordingly
UsingDataforImprovement
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UtilizedourCoach,Dr.Raney,tofocusonaspecificsubsetofouroverallbehavioralhealthpatientpopulationandlearnfrombestpractices(e.g.AIMSInstitute).
CollaboratedwithOCHINReportingAnalyststodiscusswaystoinnovatereporttomaximizeuseofkeyperformanceindicators.
Discusseddatawithprovidersduringstaffmeetingstodeterminetrackingwhichvariablesweremostuseful.
UtilizedourConsultingPsychiatristtoadvocateforchangeintreatment-discusstherapeuticstrategywiththerapists,andmedicationinterventionwithPCPs.
StrategiesforSuccess
CENTER FOR CARE INNOVATIONS | 6
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EpicResources:
OCHINReportAnalysts
DepressionRegistry
KeyTools&Resources
CENTER FOR CARE INNOVATIONS | 7
CCIResources:
CoachDr.Raney
IBHAffinityGroups
AxisResources:
IBHTeam
ConsultingPsychiatrist
QualityEnhancementTeam
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NextSteps
• Pullmoregeneraldata:
• PHQ-9&DepressionDiagnosis
• NoIBHvisitsinthepastyear
• Psychotropicmedication,ifprescribed
*Patientswithhighscoreswillbeoutreachedbyourcarecoordinatorssothatwecangetthemconnectedwithtreatment.
• Automatereportsonamonthlybasis
• Organizeandauto-distributetoaninternaldrivemonthly,reviewedbyIBHmanagementanddispersedtostaff.
• Consultingpsychiatristnowhasstandingmeetingtimestodiscussresultswiththerapists(consultingpsychiatristpositionisfundedthroughthecounty).
• Feedbackcanbegivendirectlytopatients.ProvidershavebeentrainedonusinggraphicscreeningreportsonEPIC.
CENTER FOR CARE INNOVATIONS | 8
Spreading Sustaining
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AlargeportionofourIBHpatientsreceivepsychiatrictreatmentoutsideofourorganization,therefore,itisdifficulttoconnectwiththeseprovidersinordertoinfluencechangestomedication.
Providerstendtobecomeoverwhelmedbythedataandthiscanleadtounder-utilization.We’dliketobeabletodevelopanautomatedprocesstoidentifyonlyclinicallysignificantchange,orlackofchangeinscores.
CENTER FOR CARE INNOVATIONS | 9
CurrentChallenges