retaining & strengthening the primary care workforce · osa screen medication review and...
TRANSCRIPT
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Retaining & Strengthening the Primary Care Workforce
Community Health InstituteMay 16, 2018
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Mind and Body Wellness Clinic
(Obesity Management Project)
Gvantsa Didebulidze, MD
Brockton Neighborhood Health Center
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Obesity in Primary Care Setting
High prevalence globally especially in medically
underserved areas
Lack of patient awareness about its detrimental
effects on health
Often neglected as a medical condition
Lack of supporting services to assure proper
follow up.
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Multidisciplinary Approach for Obesity
Management
We based our project based on Guidelines(2013) for management of Overweight and Obese in Adults published by OS/ACC/AHA task force.
Our team was completed by Nutritionist, Behavioral Health Clinician, Community Health Worker, NP and physician.
Curriculum was created for biweekly group visits and biweekly telephone encounters for a follow up
Each group visit covered topics related to Comprehensive lifestyle intervention.
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Criteria for Patient Selection
BMI >30 with or w/o Comorbidities
Motivated patients willing to make a change were referred by internal referral system
CHW provided screening by phone questionnaire to assess willingness and readiness to attend sessions
1. In the past month, have you been trying to lose weight?
2. Are willing to enroll in a group weekly visits that that involves visit s every 2 weeks in a group setting and follow up phone calls every 2 weeks for 3-6 months?
3. What time would work for you AM vs PM hours?
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Our Goal
Educating our patients about
healthy weight and lifestyle
Realistic expectations: even 3-
5% of total body weight loss
can improve overall wellbeing
and underlying comorbidities
Understanding and revealing
factors and barriers affecting
weight management
Prescribe a calorie restricted diet based on the patients’ preference and health status.
“Obesity” Unhealthy weight as a complex chronic disease
Determinants of Obesity-genetics, lifestyle, medications, sleep and stress
Treatment- Comprehensive lifestyle intervention and other treatment options
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Team Member Roles
RD
Learning about food groups
Plate model
Importance of breakfast
Learning how to read labels
and making smart choices
during food shopping
Low budget healthy eating
Challenging situations
Eating at fast food restaurants
Portion management
Simulated menu cases
Food shopping with dietician
Group activities: like making your own snack during group visits
Food diaries
One on one visits with RD
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CHW
Point of contact for enrolled patients
Patient assessment for specific needs and barriers to attend group visits
like lack of transportation, housing etc
Weekly phone call reminders about upcoming group visit appointments
BHC
Chart reviews and assessment for underlying mental health comorbidities
Connecting patients in need to MHD
Motivational interviewing
Stress management
Using behavioral strategies to assist our patients in adherence to prescribed
diet, exercise and overall lifestyle changes.
Mindfulness and self care
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MD/NP roles
Chart review/medical history/weight history
OSA screen
Medication review and identification of weight promoting agents
Assessing comorbidities
Obtaining (A1C, TSH, Lipid profile) if not done within 12 months
Prescribing physical activity based on each individual patients n
Assessing patients for adjuvant therapy (weight loss medications) and bariatric surgery.
Interactive learning through clinical vignettes
Open discussions and Q&A
Developing curriculum and hand outs for each session, including behavioral health tips, Nutritional guide, medical facts and physical activity guidelines.
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About Pilot
March 5th-May 14th
About 20 English speaking
patients were selected
Age 19-59
BMI 32-51
Attendance 1-5 sessions
* Weight change +3lbs, O and
-4 lbs.
Almost 100 % admitted to be stressed
>40% had known mental health condition
* >40% had medical co-morbidity
* 3 patients were diagnosed with night eating syndrome and Bulimia Nervosa
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Future of Mind & Body Wellness Clinic
• After Pilot clinic will be open throughout health center
• Sessions will be available in different languages (Haitian Creole, Cape Verdean Creole and Portuguese)
• Clinic will be self-sustainable as encounters are billable.
• We are exploring opportunities to acquire space for exercise studio
• We are working on development of support group using Social Media to engage enrolled patients in group activities and information sharing.
• Our clinic has success history with organizing cooking and diabetes groups, before we didn’t have any recourses for our obese patients, our clinic is the first initiative with this perspective.
• Main Challenge - High no show rate
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Thank You!
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Massachusetts League of Community Health Centers’ Annual Community Health Institute
Wednesday, May 16, 2018
Sea Crest Hotel , Falmouth , Massachusetts
Brent A. Fryling MD
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Objectives:Background, history, and mission of Lynn
Community Health Center
The need for treatment of Hepatitis C
Project description: Access To Hepatitis C Testing, Treatment, and Cure at the Commnunity Health Center
Lessons learned
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Background, History, Mission
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Background, History, Mission Began as storefront
mental health counseling center in 1971
Now providing over 280,000 patient visits to over 60,000 patients
Services in primary care, OB/Gyn, complex addictions, behavioral health and dental
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Hepatitis C – the need for treatment
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Hepatitis C – The need for treatment
WHO estimates 170 million (3%) of the world population is infected with Hepatitis C
Highest infection rates in Egypt
Lowest infection rates in Sweden
In USA, CDC estimates 2.7 – 3.9 million people infected with Hepatitis C.
People born from 1940 – 1965 have highest incidence rates
25,000 people die of cirrhosis and chronic liver disease each year
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Hepatitis C – The Need for Treatment
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Hepatitis C – The Need for Treatment
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Hepatitis C – The Need for Treatment
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Hepatitis C – The Need for Treatment
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Hepatitis C – The Need for Treatment
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Hepatitis C – The Need for Treatment
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Massachusetts League of Community Health Centers’ Grant has allowed Lynn
Community Health Center to respond to the call to treat and cure Hepatitis C
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The Project-Data
-Champions
-CME
-Address Obstacles
-Sustainability
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The Project:Data-Hepatitis C diagnosis and viral load check = 1437
-- Hepatitis C patients treated:
- 2015-2016 21
- 2016 – 2017 81
- 2017 – 2018 98
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The Project: Hepatitis C Champions
Hanna Haptu - Pearl team
Clark Van Den Bergh -Blue team
Sara Nakhal - Purple team
Marianne Bauer –Sunflower team
James Nicholson –Orange Team
Brent Fryling - Green Team
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The Project: Hepatitis C Champions
For 6 months provided 3 hours each week dedicated Hepatitis C time to each champion
Included every other week Hepatitis C case conference
At first hours used for data and CME, later used for patient care
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The Project: CMETwo CME sessions presented by Dr Camilla Graham, BIDMC
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The Project: CME
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The Project: CME
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The Project: Obstacles
-Provider time away from patient care hours
-Prior authorization process
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The Project: ObstaclesProvider time:
Schedulers were able to reserve Hepatitis C slots and then fill with other patients if not needed
Scripts written were a help to our pharmacy and therefore the bottom line of the health center as well
Prior Authorization:
-Staff PharmD has been able to utilize time of pharmacy students to streamline prior authorization process for providers
--Hep C “smart phrases” helpful for prior authorization process.
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The Project: Sustainability-When grant ends, the only thing that will change is the protected hepatitis C time.
-Providers are keeping gained knowledge and experience
-Organization is keeping gained knowledge and experience
-Many staff involved in grant work were not supported by the grant so their work continues
-This grant has truly “primed the pump” for hepatitis C treatment
and cure at Lynn Community Health
Center.
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Lessons Learned
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Lessons Learned
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Acupuncture & Community
Health in 2018
Jiani Guo DO
Charles River
Community Health
5/16/18
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What Is Acupuncture?
Meridian
Qi
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The Origins of Acupuncture
Earliest Evidence of Acupuncture and Meridians:
East- Huang Di Nei Jing (Yellow Emperor’s Inner Classic)compiled during 1st century BC and early 1st century AD
West- Otzi the 5300 year-old mummified Iceman from the Austrian Alps had numerous tattoos, with about 80% that coincided with acupuncture meridian lines
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Acupuncture Points or Tattoos?
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Auricular Acupuncture
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Possible Complications● Pneumothorax
● Visceral Complication: pneumoperitoneum, hemothorax, cardiac tamponade, and penetration of the kidney and bladder.
● Local inflammation, bacterial abscesses, and chondritis from needling points on the ear.
● Minor sensory impairment from penetrating peripheral nerves
● Infections
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Is there a Role for Acupuncture in American Healthcare Today?
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The Acupuncture Evidence Project
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Can Acupuncture benefit Community Health patients?
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Can Acupuncture help our Community Health Centers?
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$$Cost-Effectiveness$$
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Grant Project Summary
● Medical Acupuncture For Physicians Course (Helms
Medical Institute): 300 CME hours
● Helms vs. Harvard
● Acupuncture for Primary Care and for Pain
Management.
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Sustainability Plans
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Challenges/BarriersInsurance Coverage
Cultural Misconceptions
Needle-shock!
Pregnant Patients
Pediatrics
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References
● https://www.ibtimes.co.uk/new-tattoos-found-otzi-iceman-support-prehistoric-acupuncture-theory-1485224
● http://blogs.discovermagazine.com/d-brief/2015/01/30/scientists-mapped-otzi-icemans-61-tattoos/#.WuvDYi-ZORs
● Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Medical Acupuncture Publishers. 1st Edition. 1995
● McDonald J, Janz S. The Acupuncture Evidence Project: A Comparative Literature Review (Revised Edition). Brisbane: Australian Acupuncture and Chinese Medicine Association Ltd. 2017
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D A N A S . R U B I N M D , M S W
D O T H O U S E H E A L T H
P E D I A T R I C I A N / C H I L D P S Y C H I A T R I S T
B O S T O N U N I V E R S I T Y S C H O O L O F M E D I C I N E
C L I N I C A L A S S O C I A T E P R O F E S S O R O F P E D I A T R I C S A N D C H I L D P S Y C H I A T R Y
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Our Medical Home: DotHouse Health Fields Corner, Dorchester, MA
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Project Goal: Improve Care for Children with Attention Deficit Disorder (ADHD)
ADHD and Collaborative Care
ACCT: ADHD Collaborative Care Team
Quality Improvement
Based on NCQA* ADHD quality measures, created database for children with ADHD, ages 6-12 yo
Professional Development/Education
*National Committee for Quality Assurance
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ADHD Collaborative Care Team(ACCT)
LCSW – D. Meji-Tejeda
Case Manager – Maria Ortiz
Pediatric Nursing Staff
Pediatric providers
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ACCT Algorithm Visit 1 Visit 2 Visit 3 – follow up in < 30 days
PCP
ADHD /BHI Clinician
Pedi triage nurse: Consultation only
Case Manager
BH= Outpatient BH at DotHouse health; BHI= ADHD Behavioral health integration clinician: EMR referral with some capacity for on site visits: CBHI: Child Behavioral health initiative referrals
1. Call family to remind
about need for refills
and face to face
appointments.
2. Facilitate 504
accommodations
with family and
school
3. IEP as needed
4. Make other referrals
as needed
Family
presents
with
concern
about ADHD
1.Vanderbilt screen 2. Release for school 3. EMR /live
ADHD referral
for BHI clinician
Referral for
outpatient BH or
Case management
for CBHI services.
1. Call family with general information about ADHD and confirm follow up appt 2. Call school for feedback including previous testing and Vanderbilt 3. Remind family about follow up Appointment and enter data for Vanderbilts prior to next visit 4. BH and CBHI referrals as needed 5. Consult with Pediatric nursing and /or provider with specific medication questions
1. Vanderbilt forms + observations to determine DSM5 diagnosis of ADHD 2. Medication for ADHD prescribed 3. Route chart to ADHD BHI 4. If other concerns consider specific screens, such as SCARED, MFQ, PHQ9 Adol (>12 y.o.) and BH referral
1. Call family to see if any questions 2. Call in 2 weeks to confirm family has picked and starting medications 3. Confirm apt for 1 month check 4. Call to remind about 1 month apt 5. If medications or medical questions refer to ADHD nurse 6. Facilitate 504 letter to school and educate (re: process)
1. Follow up with families who have questions 2. Support ADHD Clinician Re: information about medications for medical issues
1. Check for improvement 2. Monitor side effects 3. Resend Vanderbilts once on stable dose 4. Monitor wt, ht and bp and pulse 5. Make referrals as appropriate
Refer to CBHI services
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Example of ACCT coordinator work flow
Encounter #1
Call family and send introduction letter
Family has Vanderbilt forms for school
Enter Vanderbilt scores in EPIC
School consent signed
Contact school for forms and past evaluations
Follow up appointment made
Questions about ADHD, diagnostic process, medications , educational supports
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Provider Work Flow ChangesNEW: Internal referral for ADHD care coordinator
Epic based workflow for ADHD
Vanderbilt forms for assessment of ADHD
Letters to request school support for students ( 504 plan and IEP )
Coming soon: AAP toolkit handouts for parents Toolkit
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Insurance Based ADHD Quality Measures
DHH database with NCQA specifications to monitor compliance Measure 1: Percentage of patients 6-12 years old on medication who had a follow up visit after 1st prescription within 30 days: 43%
Measure 2: Percentage of patients 6-12 years old on medications who had 2 follow up visits in the following 270 days after first visit follow up visit: 100%
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Is NCQA measure best way to monitor quality care for our patients ?
Data is a “snap shot” of our performance over year Number of patients who qualify is VERY small (M1= 16 , M2= 5) Difficult to get true picture of our practice Hard to assess practice changes with interventions
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Quality Improvement: Practice Database
Data includes children with ADHD diagnosis in problem list and in medical visits, Ages 6-12 years old Ethnicity
Date of first Diagnosis
Date of first prescriptions and last prescription
Initial and follow up visits for ADHD
Intervals between visits
Providers
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How Are We Doing at Baseline?
Stratified ADHD group to those actively on medication247 children ages 6-12 with ADHD
95 currently prescribed medications in last 3 months
Measured Interval in days from first prescription to first follow up visit
NCQA goal is less than or equal to 30 days
Median interval in days: 45
Plan to track this interval with addition of ACCT protocol.
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Challenges and Lessons Learned
Database
Many steps to translate NCQA measure
Defining cases and meaningful measure of ‘good’ care challenging
Data has brought to light other concerns, such as problems with tracking children with ADHD or ADHD concerns if they are NOT on medications
Staffing
Set up team including nursing and case management; within 1 month, 2 members of staff left
Shifted resources to add Global Health Intern for help with data management and expand conference opportunities to staff
Reconfigured staffing to utilize newly hired BHI provider with both case management and clinical experience
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2017 2018
Today
Sep Oct Nov Dec 2018 Feb Mar Apr May Jun
Cherokee Conference Sep 15
Cherokee Conference staffJun 22
Hire Global Health Fellow Feb 1
Hire LCSW for BHI and Care coordinator Feb 2
PIC- ongoing QI project at DHHMay 25
Go LIVE Apr 2
Provider education - Baseline ADHD data and project
Dec 14
Provider education - Diagnosis of ADHD and treatment
Mar 15
Provider education - PMT - BMC psychologist
Mar 28
MGH ADHD conference Mar 4
Pediatric Academic Society -QI conference May 4
Care coordinator - changed positions
Jan 8
Nurse left Health Center
Jan 15
Internal referrals unable to be accessed by LCSW
Apr 3
Sep 7 - Jun 1100%ADHD data
Sep 7 - Jun 195%NCQA
Sep 5 - Jun 190%ACCT Protocol
Nov 16 - Jun 1ACCT Workflow
Jan 8 - May 2960%Patient Education
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Education and Professional Development
Patient education:
• AAP ADHD toolkit license
• Phone or face to face contact with ACCT care coordinator
Professional development:
• Cherokee conference/training Behavioral Health Integration
• Academic Pediatric Association: Quality improvement
• MGH-ADHD Across the Lifespan= Psychopharmacology
DHH Staff Education
• Lunchtime seminars: Diagnosis of ADHD, Parent management training and ADHD Medication Management
• Staff offered opportunity to attend Cherokee Health systems Behavioral Health Integration training
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Next Steps….Project will continue in the form of Quality Improvement Project Goal of decreasing time from first prescription to follow up visit with
provider by 20%InterventionACCT protocol –Go Live : May 1 Run database monthly to track changes EducationContinue staff education for psychosocial and psychopharmacological treatment Continue to develop patient education material around ADHD and school
advocacy
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Special Thanks
Bethel Aklilu, MPH; Global Health Fellow at DotHouse Heatlh
Huy Nguyen, MD; CMO , DotHouse Health
Emily Feinberg, ScD,CPNP; PCP , DotHouse Health and Associate Professor , BU School of Public Health
Digna Mejia-Tejada and Maria Ortiz: the backbone of our clinical support to families
Rima Klevsky, Do Quyen Pham– IT/Quality Improvement DotHouse Health
Mass League of Community Health Centers for support for improving the care of children in their Medical Homes
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Michael Tang, MD
Adult Psychiatrist, Child Psychiatrist and Pediatrician
Clinical Director of Behavioral Health Integration
The Dimock Center
Massachusetts League of Community Health Centers
Special Projects Grant Presentation
May 16, 2018
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1. Screen for depression
2. Screen for social determinants of health
3. Integrate our Substance Use Disorder Outpatient Clinic
4. Manage inpatient psychiatric hospital notifications
5. Design a Behavioral Health Care Manager role
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• Team includes:• Chief Medical Officer
• Psychiatrist / Associate Clinical Director
• Social Worker / Program Manager
• 4 Community Health Workers
• Nurse Care Manager
• Primary care providers, Nurses, Medical Assistants, Behavioral Health clinicians
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Provider #1 Provider #2 added All Providers
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Over the past 10 months: 354 patients seen 3,000+ visits Moved onto EHR More access, less stigma
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MBHP manually compiles
CHC psychiatric admissions
into a spreadsheet
MBHP sends spreadsheets
via secure server to Dimock
forwarding emails
DimockIntegrated Therapists
receive emails and
login to secure server
Therapists call inpatient
units and follow-up on admissions
and discharges
• Insurance company (MBHP) notifying Dimock in real-time about inpatient psychiatric admissions
• During pilot: 44 total admits (including 30 adults)
• Developing workflows:
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Reviewed charts of 99 high-risk patients
Designed workflows; began 1st pilot
Hired Behavioral Health Care Manager
Began 2nd pilot February 2018
Outreached to 13 BH patients, conducted intakes with 6 patients and completed care plans
Intensity: 29 contacts, including 13 face-to-face integrated visits
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Adult Medicine Clinic Director
MEDICAL:
5.0 FTE MD Internists
1.0 FTE Nurse Practitioner
Nurses
Medical Assistants
BEHAVIORAL HEALTH:
1.2 FTE Access Therapists
4.0 FTE BH Clinicians
3.0 FTE Substance Use Disorder Clinicians
1.1 FTE Psychiatrists
2.0 FTE MAT Team
RESOURCE SUPPORT:
3.0 FTE Resource
Specialists
CARE MANAGEMENT
TEAM:
1.0 FTE NP
1.0 FTE Integrated Behavioral Health
Care Manager
1.0 FTE Community
Health Worker
Screening for depression & social needsInpatient psychiatric notifications
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Questions?