Integrated Care at The Providence Center 2014 Presented by: Nelly Burdette, PsyD Director of Integrated Care The Providence Center

Rhode Island’s largest community mental health organization with an annual budget of $42 million. In 2013, we served 12,777 people with services provided statewide through 14 service locations in Providence, Burrillville, Cranston, Pawtucket, and Warwick, and 13 client residences in Providence. 5 main service divisions Adult (SPMI and Health Home) Child and Family Wellness, Employment and Education Residential Services Crisis Care Background TPC’s main administrative offices and adult outpatient services on North Main Street in Providence.

TPC Demographics Gender 54% Male 46% Female Age 0-3: 1% 4-8: 5% 9-12: 5% 13-18: 12% 19-34: 21% 35-50: 29% 51-64: 22% 65+: 5% Race and Ethnicity White: 43% Latino: 21% Other/Unknown: 18% Black: 13% Native American: 3% Asian: 2% Primary Reimbursement Medicaid UBH: 19% Medicaid NHP: 17% Medicare: 14% Medicaid: 16% BCBS: 5% Uninsured: 4% Private: 2%

TPC Primary Diagnoses Most common across TPC (n=7501) Depression:26% Adjustment D/o: 11% Schizophrenia: 10% Mood Disorder: 9% ADHD: 8% Most common across Health Home (n=1878) Schizophrenia 33% Depression: 27% Bipolar: 13% Mood Disorder: 12% Adjustment D/o: 7%

CMHC and FQHC Collaboration Models Behavioral Health embedded in medical Psychologist within FQHC Health Home Team within FQHC Primary care embedded in behavioral health Medical nurse care managers within CMHC (SAMHSA PBHCI Grant) FQHC embedded within CMHC

Goals of models Behavioral Health within Primary Care Setting Increase awareness of behavioral health care issues for both provider and patient Increase access to behavioral health screening and intervention Improve chronic disease management

Behavioral health within PC Part-time psychologist at largest PCHC site Specially trained in integrated care within a primary care setting Referrals comprised of a combination of traditional mental health and chronic disease lifestyle management Model based on 30-minute triage/CBT interventions averaging 3-6 visits per patient, mostly triage and referral

Behavioral health within PC Providence Community Health Centers at Prairie Avenue Collaboration Outpatient child and adult practice embedded within PCHC with bilingual therapist and bilingual child/adult psychiatrist New Health Home currently piloting

Diagnostic Rankings Top three behavioral health diagnoses within FQHC Prairie) Male & Female > 18 y/o 1.Depressive Disorder NOS 2.Recurrent Depression 3.Anxiety Disorder NOS Male & Female > 18 y/o 1. Diabetes, Type 2 2. Hyperlipidemia 3. Hypertension Top three physical health diagnoses within embedded medical center of CMHC NM)

Goals of models Primary Care within Mental Health Setting Improve morbidity and mortality of consumers with mental illness and addictions Decrease barriers to access to physical health care for consumers with behavioral health issues Improve health literacy for both providers and clients

Primary care in behavioral health Providence Community Health Centers at North Main Street Opened June 2011 Physician, nurse, medical assistant & health center director TPC-employed integrated care manager with a health literacy focus

“We are partners in health.” “We treat complex patients who have complex problems, many of whom have not sought health care for a long time. I talk with my patients about about understanding what they have to do to get healthy and how I can support them.” -Dr. Tariq Malik, M.D., M.P.H., primary care physician at Providence Community Health Centers at North Main

Personal trainers who are also trained case managers Individualized fitness and healthy lifestyle assessment performed by the health mentor for every participant Fitness plan, including eating, exercise, and health promotion Weekly individual meetings with a health mentor to participate in fitness activities from walking to gym attendance Assistance with access to fitness resources Opportunities for group exercise and healthy eating education

Primary care in behavioral health SAMHSA funded PBHCI Grant Awarded in 2010, 4 year grant Emphasis placed on embedding medical nurse care managers in Home Health SPMI Teams Education and triage related to management of chronic disease, greater access to primary care PHQ9, AUDIT, Stanford Self-Efficacy, Self-Rated Abilities for Health Practices and SF-36 administered Baseline, then every 3 months until one year completion, physical health measures including, BMI, Weight Loss, Blood Pressure, HbA1c, HDL, LDL and Triglycerides

PBHCI Results Hospitalization Utilization  Psych hospitalization and psych ER use significantly decreased  Medical hospitalizations and medical ER visits increased.  All types of hospitalizations showed a net decrease (156 days less net) Psych Hosp (n=132): 428 days to 256 days Med Hosp (n=132): 105 days to 146 days SU Hosp (n=133): 49 days to 24 days Psych ER (n=134): 72 times to 33 times Med ER (n=134): 135 times to 196 times SU ER (n=130): 14 times to 3 times

Cost Savings (n=350) Psych Hospitalization 428 days to 256 days = $122,120 savings National average $710 per day 2 Psych ER 72 times to 33 times = $27,300 savings National average $700 per day 1 SU Hospitalization 49 days to 24 days = $24,250 savings National average $970 per day 2 TOTAL $173,670 savings for 350 individuals designated as SPMI

Self-Efficacy (Stanford)  Clients belief that they can communicate with physicians, manage disease in general, manage symptoms of disease, increase nutritional abilities, improve psychological well-being has significantly improved over one year with nurse care coordination. PBHCI Results Communicate with physicians From 7.67 to 7.98 (p=.050) Manage disease in general From 6.51 to 6.76 (p=.052) Manage symptoms From 5.61 to 5.92 (p=.033) Nutrition abilitiesFrom to (p=.012) Psychological Well-being From to (p=.003) Total self-efficacy From to (p=.038) Health practices From to (p<.001)

Physical Health Measures  Statistically significant improvements over the course of one year in the below lab values  Drawbacks: lab data difficult to obtain and as a result n quite small PBHCI Results HgbA1c (n=35 to 13 to 14):9.4 to 8.7 to 7.6 (p=.032) TC (n=78 to 26 to 23):231 to 205 to 199 (p<.001) LDL (n=58 to 18 to 18):154 to 123 to 128 (p<.001) Triglycerides (n=56 to 21 to 26):300 to 306 to 248 (p=.017) BP Systolic (n=56 to 41 to 47): to to (p<.001) BP Diastolic (n=56 to 41 to 47):80.5 to 78 to 79.4 (p<.001) Waist Circumference in cm (249 to 163 to 193): 116 to 114 to 113 (p<.001)

Subjective Health (SF-36)  Every aspect of health perceived to have statistically significantly improved over the course of the year, except bodily pain and health perception. PBHCI Results General MH54.77 to (p<.001) Physical Functioning58.57 to (p<.001) Role Limitations (MH)44.1 to 57.8 (p<.001) Role Limitations (PH)51.32 to (p=.027) Social Functioning61.11 to (p<.001) Vitality42.8 to (p=.001)

PBHCI Results If alcohol screening (AUDIT) initially at-risk (>8) AT BASELINE, there was a statistically significant decrease in risk after one year of nurse care management participation Mean scores from to 9.43 to This is a significant decrease at p<.001. (n=40 to 23 to 20) If depression screening (PHQ-9) initially in the moderate range (>10) AT BASELINE (n=158), there was a statistically significant reduction over the course of one year. Mean: to to (p<.001)

Weight change descriptives for BMI>30 at baseline: PBHCI Results: BMI 6 Months12 Months Lost weight78 (49%)101 (54%) No change19 (12%)22 (12%) Gained weight62 (39%)64 (34%) Lost 5% weight33 (21%)48 (26%) Lost <5%/Gained <5%109 (69%)108 (58%) Gained 5% weight17 (11%)31 (17%)  BMI (200 to 152 to 186): 38.5 to 37.1 to 36.9 (p=.003)

Integrated care coordinator meets with SPMI (Health Home) patient a few minutes prior to physician entering the room to: assist pt in focusing on the top 3 issues he/she would like addressed today review logistics of PC: prepare pt about length of appt, any longer than anticipated wait times, etc. review pt’s mood, new stressors and any emotional issues that could be impacting physical health At the same time, physician reviews an interagency form: includes pt’s mental health diagnoses, psychiatric medications and any relevant notes from mental health team Health Literacy: Before the Medical Visit

Integrated care coordinator stays with pt for the length of exam to: be a witness to the points of difficulty between pt and physician provide support to the physician should the pt experience difficulty communicating provide support to the pt should pt experience difficulty understanding medical concepts or recommendations Health Literacy: During the Medical Visit

Health Literacy: After the medical visit

Bottom Line Integrated care must be infused into the core mission, values and commitment of an organization to be successful. There is no right way to integrate, but there are known strategies that are evidence-based Addressing the integrated care needs of the SPMI population is a challenge, but is no longer optional.

Citations 1.Stranges, E. (Thomson Reuters), Levit, K. (Thomson Reuters), Stocks, C. (Agency for Healthcare Research and Quality) and Santora, P. (Substance Abuse and Mental Health Services Administration). State Variation in Inpatient Hospitalizations for Mental Health and Substance Abuse Conditions, 20022008. HCUP Statistical Brief #117. June Agency for Healthcare Research and Quality, Rockville, MD. us.ahrq.gov/reports/statbriefs/sb117.pdf 2.Russo, C. A. (Thomson Healthcare), Hambrick, M. M. (AHRQ), and Owens, P. L. (AHRQ). Hospital Stays Related to Depression, HCUP Statistical Brief #40. November Agency for Healthcare Research and Quality, Rockville, MD.

Contact Information Nelly Burdette, PsyD Director of Integrated Care The Providence Center 530 North Main St Providence, RI Direct Office: 401/