How Can Primary Care Teams Meet Patients' Medical and Behavioral Health Needs? Early Results from a 12-Month Quality Improvement Collaborative Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session #F4a October 17, 2015 Mara Laderman, MSPH Senior Research Associate, Institute for Healthcare Improvement Wendy Bradley, LPC, CAADC Behavioral Health Integration and Community Engagement Team Lead, Ampersand Health

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

Learning Objectives At the conclusion of this session, the participant will be able to: Learn about the methodology behind quality improvement collaboratives and how they can bring about results in process and outcome measures related to integrated care. Discuss how several diverse primary care practices have implemented key changes relative to team- based, integrated care. Describe early results from a 12-month quality improvement collaborative designed to create high performing primary care teams to address patients' medical and behavioral needs.

Bibliography / Reference 1. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; Available on 2. MacColl Center for Health Care Innovation. Primary Care Team Guide Available from: Laderman M. Behavioral Health Integration: A Key Component of the Triple Aim. Population Health Management. 2015;18(5): Laderman M & Mate K. Integrating Behavioral Health into Primary Care: A Challenging but Necessary Step. Healthcare Executive, Mar/April 2014, Laderman, M. & Mate, K. Integrating Behavioral Health and Primary Care. IHI Innovation Report. Cambridge, MA: Institute for Healthcare Improvement, 2014.

Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

Today’s Agenda Collaborative structure, background, and aims Measurement and evaluation Content framework Results to date Challenges and next steps

Have you participated in a collaborative? What was your experience? P7P7

Collaborative Structure, Background, and Aims

Select Topic (Develop Mission) Planning Group Develop Framework & Changes Participants ( Teams) Prework LS 1 P S AD P S AD LS 3 LS 2 Supports Phone Conferences Extranet Visits Assessments Sponsors Monthly Team Reports Dissemination Publications, Congress, etc. AD P S Expert Meeting AP1AP2 AP3* LS – Learning Session AP – Action Period *AP3 – continue reporting data as needed to document success Holding the Gains IHI Breakthrough Series (6 to 18 Months Time Frame)

The content and approach of this Collaborative is based on: 1) IHI’s system-level approach to integrating behavioral health and primary care 2) The MacColl Center for Health Care Innovation’s work on Primary Care Teams: Learning from Effective Ambulatory Practices (PCT-LEAP), funded by RWJF. PCT-LEAP involved careful study of exemplary primary care practices across the US.

Collaborative Participants 32 participating organizations: 19 FQHCs, including 7 Indian Health Service sites 10 health systems 1 ACO 1 VA system site 11

Methodology: Science of Improvement W. Edwards Deming API’s Model for Improvement

Collaborative Aim Participating organizations will redefine the composition and roles of primary care, building highly functional, multidisciplinary teams that are fully equipped to address the physical and behavioral care needs of their population. P13

Collaborative Objectives: within 12 months… Assess and segment the population served to understand medical and behavioral needs, identify barriers to better health, and target interventions to be tested. Optimize primary care team composition, roles, and activities to support integrated medical and behavioral health care (inclusive of mental health, substance abuse conditions, and healthy behaviors). Identify and implement an approach to integration that best meets the needs of the patient populations served, the primary care team, and the organization. Improve medical and behavioral health integration and care experience. Identify appropriate financial models, including quality contracts, global payment models, and grants to fund this transition. Develop plan to scale up & sustain the model that’s been developed and tested. 14

Measurement and Evaluation P15 Participants will collect, report, and share qualitative and quantitative data monthly to analyze and identify opportunities for improvement on measures relating to: Patient Experience Screening and Follow-up Health Team functionality Health care costs

P16

Content: Change Package 17

Pre-work/Onboarding Modified version of PCMH-A (Empanelment, Leadership, and QI Capacity) with resources and asynchronous learning opportunities available to those needing any remediation or a refresher. Baseline data collection on processes, population served, and people on the workforce. Assessment of current status and readiness for integration Assessments of team functionality and satisfaction Recommended readings 18

Content Framework Components Focus of collaborative work: Team-Based Relationships Integrated Behavioral Health and Primary Care Person and Family Centered Care Care Coordination Sustainable Business Model Should have in place at the outset: Committed and Engaged Leadership Quality Improvement Capacity Empanelment 19 Adapted from the Safety Net Medical Home: Wagner EH et al. The changes involved in patient- centered medical home transformation. Prim Care. Jun 2012;39(2):

Integrated Behavioral Health and Primary Care 20 Collect key information to guide program direction, staffing, and determine approach to integration. Develop reliable operations and processes to support integrated care. Make the business case for integration. Redesign care delivery using the core principles of integrated care.

BHI core components 1. Define the behavioral health needs you need and want to address. 2. Choose a behavioral health integration approach. 3. Identify how to make the business case for integration. 4. Select the behavioral health providers and organizations with whom to collaborate. 5. Develop and train the workforce. 6. Develop a process for how patients will access behavioral health care. 7. Redesign clinical and operational workflows. 8. Track patient and integration program outcomes. 9. Enhance the capacity to provide evidence-based care. 21

P22 Topics covered – BHI only Clinical Depression screening and follow up Brief interventions Clinical pathways – vertical and horizontal integration Case examples Operational Different approaches to integration Roles, competencies, and training needs of a behavioral health specialist Hiring and onboarding BHCs Redesigning clinical and operational workflows Confidentiality, health information technology, and documentation Financial Making the business case for integrated care More details on financing and payment

Sample Results to Date

Results to date P24

Results to date P25

What has gone well? 100% of teams have completed pre-work assessments. High team engagement on calls and in completing assignments. High leadership engagement. Strong understanding of integration. Participants have been very generous in sharing with other teams. A majority are on the right track and are setting themselves up for success. Participants have worked through many of the issues around confidentiality, EHRs, and resistance to brief interventions P26

Challenges Curriculum planning for a year of very complex work. Pre-work, aim setting, and population selection took longer than expected. Needed to spend more time on foundation building – team creation, culture change Inconsistent data reporting from many teams. Teams at varying levels of readiness and experience with content and quality improvement methods. Buy-in to collaborative learning approach. Continuing perception that integration is a side project. We have had to adjust our expectations for the pace of change. P27

Lessons for setting up collaboratives Topic scoping – complexity and specificity. Teams should be at similar levels of readiness with leadership, culture change, and quality improvement capability. Set clear expectations for participation and data reporting. Explicit structure and sequencing of content. In-person vs. virtual learning. Participants need to be able to contact each other (listserv). P28

Conclusions Quality improvement collaboratives can effectively bring disparate organizations with shared goals together to learn from expert faculty and from each other. Pros and cons of narrowing topic for a collaborative (BHI vs. team-based primary care). Challenging to find a balance between direction and flexibility when teaching how to implement integration for different types of organizations. Expecting changes in health status within 12 months is likely unrealistic for most organizations who are just starting out. P29

Questions? P30

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