san diego system transformation: implementation lessons learned, approaching the tipping point...
TRANSCRIPT
San Diego System Transformation: Implementation Lessons Learned,
Approaching the Tipping PointLauren Chin, MPH, Health Planning & Program Specialist,
Health & Human Services Agency, County of San Diego
Nora Cole, MEd, MFT, Associate Director, Mental Health Services, Family Health Centers of San Diego
Shelly Tregembo, M.A., Administrative AnalystHealth & Human Services Agency, County of San Diego
Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Session #C1bOctober 28, 201111:15 AM
Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
Need/Practice Gap & Supporting Resources
25 year mortality disparity for those with Serious Mental Illness (SMI); increased mortality is primarily due to chronic physical conditions ( heart disease, stroke, diabetes, etc) – Improved
physical health care is important for this population.
Public Specialty Behavioral Health is a scarce commodity; improved access for those who need specialty services is achieved when stable SMI are managed in a primary care
medical home rather than specialty care.
Objectives
• Describe the integration of behavioral and primary health care on site at three rural clinics.
• Describe a process for linking SMI with chronic health conditions to primary care more successfully by accelerating the eligibility process.
• Explore issues related to the transition of “stable” SMI to primary care medical home for ongoing medication monitoring and physical health care.
• Describe a system for pairing of mental health and primary care clinics by region and neighborhood for coordinated treatment and bidirectional referral
Expected Outcome
Identify resources and tools to develop or strengthen relationships between behavioral health and primary care providers; to increase capacity for mutual engagement in shared population management to meet the physical and
behavioral health care needs of the SMI population.
Live Well, San Diego!Live Well, San Diego!
San Diego CountySan Diego County
• Population: 3.2M; 4,300 sq. miles
• Urban, suburban, and rural communities
• Ethnically diverse; 68 languages
• No county-run primary care services
Complex Web of Safety Net ServicesComplex Web of Safety Net Services
Physical Health• 17 separate primary
care organizations (FQHCs / non-profit clinics)
• Approximately 100 individual primary care sites
• Children/Youth: FQHC’s and other health systems (numerous providers)
Behavioral Health
• County funded Mental Health: 61,000 clients / year
• ADS serves 12,000 clients / year
• Most services contracted to organizational providers and/or FFS (Dozens of clinics & programs)
Improved Outcomes
Informed,Activated
Patient
ProductiveInteractions
Prepared,Proactive
Practice Team
Resources and Policies
Community
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Health Care Organization
Wagner Chronic Care Model
San Diego Paired Provider Model ©San Diego Paired Provider Model ©
• Different governance & payment • Generalists and Specialists Paired/partnering
provider organizations• Continuum of care - Virtual PCMH’s• Shared management of a SINGLE population,
“owned” jointly– Bi-directional Flow (Clients and Info)– Continuous access for all BH needs
Copyright © 2011 San Diego Health and Human Services Agency
Integrated Care SystemBi-directional, seamless flow of clients and information
Integrated Care SystemBi-directional, seamless flow of clients and information
RN Care Coordinator
Behavioral Health
ConsultantBH PC
MD Only FQHC BH Program
Severity / Acuity
Recovery / Stability
Community / Peer Supports
What’s in it for Behavioral Health?– Less acute clients to FQHCs– Improve access for the most SMI– Now have partners to attend to the
physical health needs of our shared population
San Diego Paired Provider Model ©San Diego Paired Provider Model ©
Copyright © 2011 San Diego Health and Human Services Agency
What’s in it for Primary Care?• “The Triple Deliverables”
– Access for clients needing specialty MH– Consultation
»Not just for SMIs– Education of providers AND support
staff
San Diego Paired Provider Model ©San Diego Paired Provider Model ©
Copyright © 2011 San Diego Health and Human Services Agency
ICARE
Integrated Care Resources
Nora Cole, MEd, MFTFamily Health Centers of San Diego
ICAREICARE
Integrated Care Resources • Collaborative Pilot Project
– Family Health Centers of San Diego (FHCSD)
– Community Research Foundation (CRF)• Funded by County of San Diego
StaffingStaffing
• Nurse Care Coordinator • Project Manager• Peer Specialists (3)• Eligibility Specialist• Behavioral Health Consultants (3)• Alcohol and Other Drug Counselor• Data Entry/Project Support
SitesSites
• CRF:– Areta Crowell Center
• FHCSD:– North Park Family Health Center – City Heights Family Health Center – Logan Heights Family Health Center
How it WorksHow it WorksCRF Discharge Planner (DP) meets with client ready to transfer care to FHCSD
If uninsured, potential transfer is linked to CRF Eligibility Specialist (ES)
DP notifies FHCSD site Behavioral Health Consultant (BHC) of potential transfer; BHC makes initial assessment appointment
BHC schedules transfer an appointment with the Alcohol and Other Drug Counselor (AOD) for an assessment, unless AOD met with transfer at Areta Crowell
BHC makes First Appointment with Physician Champion (PC) or alternate
BHC introduces transfer to Peer Support Specialist (PSS) for support, resource information, etc.
PC refers to specialty care as needed
NOTE: Nurse Care Coordinator (NCC) out-stationed at CRF for health screening of CRF participants and facilitate link to FHCSD primary care if emergent health care issue is identified – accessible to Areta Crowell program participants regardless of transfer readiness.
Keys to SuccessKeys to Success
• Shared refinement of referral criteria• Mutually developed referral process• Well-rounded referral information packet at
transition• Availability of same day consultation by
transferring party• Expedited re-entry to CRF if needed• Regular communication
How it is working so farHow it is working so far
• Change is difficult for some; others are confident their overall health will improve
• Physicians like having a team to work with, especially the added AOD resources
• Therapists understand and value the model; occasionally feel like salespeople with those struggling with the transition
• Peers enjoy helping clear up misunderstandings about systems
Workforce IssuesWorkforce Issues
• Education• Training• Orientation to team concept• Personal beliefs about mental illness• Turf
System-Wide Integration Efforts in San Diego County
Shelly Tregembo, MA
HHSA Behavioral Health Services
Several pilots launched:
– Mental Health and Primary Care Integration Services
– East County Integrated Health Access pilot (ECIHA)
– MHSA PEI Rural Integrated Behavioral Health & Primary Care Services (SmartCare)
– MHSA Innovations- ICARE
System-wide Integration Efforts
System-wide Integration Efforts
• Mental Health and Primary Care – 7 clinic organizations– MHSA-funded– SPS, Senior Promotoras, IMPACT
• SmartCare– 3 rural clinics– MHSA PEI– behavioral health screening, evaluation,
education, short term counseling and wellness activities
Recent Developments
• Integration Summit
• Integration Institute (I2)
• Psychiatric Consultation to Primary Care (PC2)
• Low Income Health Program (LIHP)
Emerging Best Practices
• Find your champions of integration
• Employ the “right” people
• Develop MOUs and SOPs
• Deliver support to providers
The Road Ahead
• Patient-Centered Medical Homes
• 2014 and Healthcare Reform
• Outcomes-driven funding
• Accountable Care Organizations
How San Diego is Preparing
• Gaining system-wide buy-in for shared population management
• Providing Access, Consultation and Education
• Convening the first Integration Institute
Contact InformationContact Information
• Lauren Chin, [email protected]
• Nora Cole, MEd, [email protected]
• Shelly Tregembo, [email protected]
Questions
&
Discussion
Live Well, San Diego!Live Well, San Diego!
Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!