It is suggested that you view these sides in two modes for different purposes: In “edit mode” to read the accompanying notes and have a better sense of the discussion In “play mode” to be able to view the ”Word Salad” Video shown at the beginning, developed to capture the experience of working in the field during this period. When in play mode, click the video icon twice and it will open up.

Word Salad Video Video developed by Kevin Pardo Sunnyvale, California Click onto ‘Word Salad when in ‘PLAY’ Mode to view video This was developed to share the experience of most of us during this period of rapid change with a bombardment of new concepts and demands

Pay for Performance (P4P) Infrastructure: HR, Quality Improvement, IT, Space, and Training Pay for Performance (P4P) Infrastructure: HR, Quality Improvement, IT, Space, and Training Specialty care, Including BH with Parity Community and resources including employment, housing & ‘connectivity’ Hospitals, Nursing homes, Rehab Triple AIM: Cross Silo 3 Dimensional Measures QUALTY OUTCOMES, COST AND EXPERIENCE OF CARE Triple AIM: Cross Silo 3 Dimensional Measures QUALTY OUTCOMES, COST AND EXPERIENCE OF CARE Part II

6 Out of home placement Social Emotional Developmental Delays Untreated Addiction & mental Illness (Behavioral illness ) Disruption of family as “developmental” Environment Repeated Trauma Soc/Emotional Difficulties Depression, Aggression Early Pregnancy CMH Learning Disabilities School failure – Drop out Gang Activity Use of alcohol/drugs to medicate underlying problems “In utero” exposure to alcohol and drugs – multiple sequelae Part II

Mental HealthAddictions Primary Care Chronic, complex conditions and costs Acute and crisis ‘system’ overload Transinstitutional shifts into homelessness and justice system Demoralization 7 Reimbursement for volume and procedures Infrastructure: HR, IT, telecomm, space planning, training, quality assurance Reimbursement for volume and procedures Infrastructure: HR, IT, telecomm, space planning, training, quality assurance Part II

W HOLE - PERSON CENTERED CARE PAY-FOR-PERFORMANCE (P4P) TRIPLE AIM – CROSS-SILO 3 DIMENSIONAL MEASURES INTEGRATED DESIGN, FLOW & INFO USE with IT TO SUPPORT INFRASTRUCTURE HUMAN RESOURCES QUALITY IMPROVEMENT TELECOM SPACE WITH RAPID CYCLE FEEDBACK TRAINING Part III

BEHAVIORAL HEALTH 2 nd floor PRIMARY CARE 1 st Floor Integrated Primary Care team (IPC) Referrals IMPROVED HEALTH AND BEHAVIORAL HEALTH OUTCOMES Joint conferencing -- evolution of sub specialty workforce Health guide outreach Ancillary Services Consumer & Family Advisory Panel Johanna Ferman, M.D. Director Behavioral Health AmCare Contra Costa County DHS FQHC and MH Funding streams and same day services Part III

INITIAL VISIT W/INTEGRATED TEAM Annual H & P (Gather data/prior records/ancillary testing) INITIAL VISIT W/INTEGRATED TEAM Annual H & P (Gather data/prior records/ancillary testing) Second Visit for highest risk health concerns Partnership Planning-consumer and support system and IPC Team Second Visit for highest risk health concerns Partnership Planning-consumer and support system and IPC Team Urgent Care Group- Education Group- Education Stabilization, reversal of acute or chronic illness Stabilization, reversal of acute or chronic illness Referral Referral Problem list with brief Plan Ancillary testing (labs, EKG, etc.) Conference (multi-disciplinary; reconciliation and integration of data) TRUST Formation of relationship as health partners Return visits PRN Eventual movement to Health Center for follow-up Initiation of data base through existing IT Johanna Ferman, M.D. Director Behavioral Health AmCare Contra Costa County DHS Part III

PC MH SUD NPO Pharmacy Functions crossing IT apps Quality Practice Transformation Strict HIPAA compliance Management incl follow-up Reimbursement SeeingMANY Seeing ONE Part III

Information on human relationship AND as well as procedures Information on human relationship AND as well as procedures Central to recovery and chronic care work Central to recovery and chronic care work Careful attention to what information is collected Careful attention to what information is collected Must be conceptualized -- part of design Must be conceptualized -- part of design A function that an informed and concerned management A function that an informed and concerned management brings to the table, NOT of the IT system itself brings to the table, NOT of the IT system itself Part III

TRIPLE AIM’sPerformanceMeasures – TRIPLE AIM’s 3 dimensional Performance Measures – quality, cost and experience of care – can be readily accessed and used at all levels quality, cost and experience of care – can be readily accessed and used at all levels Interoperability to achieve ‘data fluidity’ Interoperability to achieve ‘data fluidity’ Articulate aspects of care that depend on human relationships Articulate aspects of care that depend on human relationships Access ONE individual health record Access ONE individual health record Access and trend MANY individual records/populations Access and trend MANY individual records/populations Readily available information supports ‘teachable moments’ Readily available information supports ‘teachable moments’ Supports entire team in taking ownership Supports entire team in taking ownership Readily provides feedback on evidence-based guidelines from people in a dynamic Readily provides feedback on evidence-based guidelines from people in a dynamic rapidly evolving field rapidly evolving field Part III

Part IV

Role of leadership valuing & making room for ‘creative time’ moving towards pay-for-performance (P4P) identifying organization and staff strengths and weaknesses and building internal expertise targeting greatest area of need removing obstacles, support for champions wise investment in information technology due to planning on design, flow and info use

Part IV Role of Champions Deep knowledge of evolving field: standard bearers and developers Passion for innovation – working ‘out of the box’ Desire to build team/s & create skill base for new practice/s Interdisciplinary Role of other staff and community partners Maintenance of effort – keeping the ship moving forward Continued learning within existing system Cooperation with change efforts being piloted Second generation adapters

Part I: By way of introduction In the midst of barrage, remembering who we are Identifying strengths within the sector to move forward Part II: Whole Person Care as the central driver, the heart, of health reform Part III:Pillars of Support and Sustenance special reference to design and the use of information Part IV: A Change Process

Contact information: Please feel free to contact me on-line or with a call should you desire clarification on this material or have any further questions or comments. Johanna Ferman, M.D. Integrushealth.com (under ‘contact us) or Cell: