THE WORK OF INTEGRATION: A PRACTICE PERSPECTIVE Melinda Davis, PhD, CCRP Kristen Dillon, MD Emma Gilchrist, MPH Stephanie Kirchner, MSPH, RD Beth Sommers, MPH, CPHQ Liz Waddell, PhD Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # C5b Saturday, October 17, 2015

Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Learning Assessment A question and answer period will be conducted at the end of this presentation.

Learning Objectives At the conclusion of this session, participants will be able to: Describe the continuum of integration in primary care and how practice facilitation supports practice redesign. Discuss the clinical, operational and financial elements required to evaluate, implement and sustain the integration of primary care and behavioral health. Discuss the role primary care leadership may play in advancing efforts to integrate behavioral health.

Audience Assessment What is your orienting perspective? Primary Care Clinician Behavioral Health Clinician Integrated Care Specialist Research Faculty/Staff Other What is your level of experience with integrated care? Novice Intermediate Expert

Session Overview InteGREAT Project Overview (10 min) Location Objectives Tools Clinician/Practice Facilitator Panel (20 min) Practicing Clinician/Health System Leadership Practice Facilitator National Viewpoint Questions & Answers/Learning Assessment (10 min)

InteGREAT: Building Capacity for Integrated Behavioral Health & Primary Care

Project Location

InteGREAT Project (June 2014 – May 2015): Project Aims: 1. Build partnerships among practices that are interested in integration. 2. Collaborate with practices to create the foundation for integration (clinically, operationally, and financially). 3. Provide technical assistance (via practice facilitation) as practices initiate their integrated initiatives. Overarching Goal: To assist practices in the PacificSource Community Solutions Columbia Gorge CCO in the development of capacity for integrating behavioral health and primary care.

Dimensions of integrated care

The “range” of integrated services Miller, B. F., Brown Levey, S. M., Payne-Murphy, J. C., & Kwan, B. M. (2014). Outlining the scope of behavioral health practice in integrated primary care: Dispelling the myth of the one-trick mental health pony. Families, Systems, & Health, 32(3), 338.

1) Build Partnerships Build a relationship between PacificSource CCO, OHSU, and UCD partners Work collaboratively with 4 primary care clinics and 1 behavioral health agency identified by Integrated Care Work Team (ICWT) Serve majority of OHP clients/patients in the region Interested in integration Mentors/resources for other clinics in the region Foster development of learning ecosystem across the CCO with a focus on “honest discussions” in the ICWT

2) Utilize tools to create the foundation for successful integration Clinically Clinical Quality Measures Reporting Assessment Minimal Data Set Operationally Practice Information Form Comprehensive Primary Care Monitor or Health Home Monitor Workflow Development Financially Cost Assessment of Collaborative Healthcare (CoACH) Cost Tool

3) Provide technical assistance via practice facilitation Practice Facilitation: the provision of onsite and virtual support to primary care practices and other health care settings to redesign clinical processes and improve clinical outcomes for individual patients and the overall population of patients served. Practice Facilitator: Specially trained individuals who assist primary care clinicians in research and quality improvement projects. Distinguished from consultants through specialized training, broad scope of practice, and a long-term relationships with an organization, its providers and its patients.

Panelists Kristen Dillon, MD Director, PacificSource Columbia Gorge CCO Family Physician, Columbia Gorge Family Medicine Beth Sommers, MPH Practice Enhancement Research Coordinator Oregon Rural Practice-based Research Network, Oregon Health & Science University Stephanie Kirchner, MSPH, RD Practice Transformation Program Manager University of Colorado, Department of Family Medicine

What did your practice experience during InteGREAT? Potential Probes What’s is your practice structure and who do you serve? Why did you (or your practice) want to participate in InteGREAT? What were the practice’s goals around integrating behavioral health? Who in your practice was involved in the work of InteGREAT? What did they do? How was your practice’s experience similar/different from the other participating sites? Other panel members, additional thoughts or comments?

Characteristics of Participating Primary Care Practices at Baseline* *These four practices care for >75% of the regions Medicaid population

Comprehensive Primary Care Monitor Baseline Responses to BHI Section (includes 4 primary care practices) Average Score (Self Report) Our practice has a shared vision for BHI that everyone understandsX Our practice has identified BH conditions for focused quality improvement X A system has been implemented to screen for patient BH issuesX We have reliable registry data to identify and manage specific populations of patients with BH concerns X Our patients have easy access to comprehensive, coordinated BH services in our own clinic or with community partners X Protocols and work flows have been implemented for effective handoffs to and follow up with our BH providers X A BH professional has been fully integrated into patient care in our practice X Our practice’s business model supports the consistent delivery of integrated behavioral and medical services X Personalized patient care plans are shared between BH and primary care providers X

As the practice facilitator for InteGREAT, what did you do? Potential Probes How did your role vary based on practice structure/experience with integrated care? What practice characteristics made it “easier” to help practices progress? Understanding of “integrated care” Health Information Technology Capacity (and infrastructure) Quality Improvement experience How did practice expectations marry up with what was accomplished during the InteGREAT project? Other panel members, additional thoughts or comments?

Vision for Integrated Care in the Gorge SettingBaseline modelThe Vision Independent practice Limited referrals and consultation with specialty mental health, MD as mental health provider Add 1 FTE LCSW Main activities: Warm Handoffs; Transfer PCP and MA Brief Therapy time Affiliated practice 1 Co-located mental health services (therapy) Increase BHC and Counselor FTE Main activities: More time for Warm Handoffs and Brief Therapy Affiliated practice 2 Referrals and coordination of care with specialty mental health in affiliated practice 1 Add 1 FTE LCSW Main activities: Transfer Secondary Screening, Warm Handoffs, Brief Therapy, Care Management Community Health Center Co-located mental health services (therapy) provided by community mental health center Increase to 1 FTE LCSW Main activities: More time for Warm Hand offs and Brief Therapy; Add Population Management Community Mental Health Center Limited referrals and consultation with primary care Become Behavioral Health Home, with coordinated, co-located primary care and ancillary support services

What role does leadership play in supporting these kinds of changes in primary care practices? Potential Probes What challenges did you/your practice experience? What successes did you/your practice experience? What type of leadership is required at the practice level? At the health system level? Are these similar or different? Other panel members, additional thoughts or comments?

Describe your work in Colorado and nationally to support integrated care, how was the experience in InteGREAT similar/different? Potential Probes How was the inteGREAT structure similar/different to other projects, what impact does this have on the practice/practice facilitator relations? What recommendations do you have for others locally and nationally based on what you’ve observed? Other panel members, additional thoughts or comments?

Group Discussion/Learning Assessment What did you hear that resonates with or counters your experience? What additional questions do you have of the panel? How might you apply what you heard today in your own setting?

Lessons Learned Integration is a Developmental Process Using the same words, but not with the same meaning Pre/post assessments of behavioral health integration may not have changed, but understanding did: “Even when we scored the same over time, our vision and understanding of the questions have changed, such that we’ve framed up where we are/ want to go.” “We are not where we were, but we are not where we want to be.”

Lessons Learned, continued Electronic Health Records (EHRs) not up to snuff with data tracking for common behavioral health conditions. Able to track: Screening results (e.g., PHQ for depression, smoking) = Yes, Partial Follow-up plan for patients with a positive screen = Partial, No Patient’s improvement over time = No Practices need additional help with templates, queries, reporting (and space to use data to inform quality improvement process)

Lessons Learned, continued Overall impression: Participating primary care practices have vision for integrated care Coach Cost Tool indicates service addition would be cost saving/cost neutral

Bibliography / References 1. Davis M, Balasubramanian BA, Waller E, Miller BF, Green LA, Cohen DJ. Integrating Behavioral and Physical Health Care in the Real World: Early Lessons from Advancing Care Together. J Am Board Fam Med. 2013:26(5): Dickinson WP, Miller BF. Comprehensiveness and continuity of care and the inseparability of mental and behavioral health from the patient-centered medical home. Families, Systems & Health. 2010;28(4): Brown-Levey S, Miller BF, deGruy FV. Behavioral health integration: an essential element of population-based healthcare redesign. Translational Behavioral Medicine. 2012: Kessler R, Stafford D, Messier R. The problem of integrating behavioral health in the medical home and the questions it leads to. Journal of Clinical Psychology in Medical Settings. 2009;16(1):4– Cohen DJ, Davis MM, Hall JD, Gilchrist EC, Miller BF. A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration: Observations From Exemplary Sites. Rockville, MD: Agency for Healthcare Research and Quality. March See also the hot off the press JABFM September-October 2015; 28 (Supplement) that highlights findings from two projects: Advancing Care Together and the study on Professional Practices and Core Competencies for Developing a Workforce for Integrated Care. Table of Contents Available at:

OHSU/Oregon Rural Practice-based Research Network (ORPRN) Project Team Melinda Davis, PhD: Research Assistant Professor, Department of Family Medicine; Director of Community Engaged Research, ORPRN Beth Sommers, MPH, CPHQ: Practice Facilitator Elizabeth Waddell, PhD: Project Manager/Co-Investigator. Assistant Professor Public Health & Preventive Medicine, ORPRN

University of Colorado Denver, Department of Family Medicine Benjamin Miller, PsyD, Assistant Professor Stephanie Kirchner, MSPH, Practice Facilitation Program Manager Emma Gilchrist, MPH, Integrated Healthcare Project Manager

Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!