1. IT TAKES A VILLAGE: BUILDING AN INTEGRATED MEDICAL HOME SUPPORTED BY AN INTEGRATED MEDICAL NEIGHBORHOOD Kimberly Walter, PhD Cheryl Wright (Becky Peterson, RMA) 1

2. Seminar Objectives: 2 1. Discuss the process of building an integrated practice in a model that accounts for limited staffing and budget. 2. Describe the benefits of integration to both patient care and resident learning. 3. Identify potential community resources available for expanding into you medical neighborhood.

3. Who are we?  9-9-9 community based residency program  18 Faculty  24 staff members  3 Billing/coders  Diabetic Educator  70 total employees in our clinic

5. Our patients 5  We are the “mission in motion” for St. Anthony North Hospital  Approx 30% speak Spanish and about 5% of those need a translator  Insurance:  46% Medicaid  15% Medicare  19% Self Pay

6. Goals for Integrated Care 6  Additional Behavioral Health Staff and expanded curriculum  Improved patient outcomes  Data collection  Community collaboration for additional modalities  Improved resident physician knowledge/skills

7. Integration of Behavioral/Mental Health 7  Colorado Health Foundation Grant provided funding to hire a 1.0 FTE psychologist for a 2 year duration.  Goals for psychologist included  Rewriting behavioral science curriculum  Didactic teaching  Direct patient care  Precepting with residents  Co-appointments with residents and patients (combined educational and patient care)

8. Traditional Model (April 2011 – Jan 2012) 8  Direct Patient Care:  Psychologist had set clinic days and appointment slots (4 half days per week)  Patient appointments were 1 hour each  Residents could refer patients to see psychologist Communication about referral highly encouraged but not always received  Precepting  Available in precepting room approx 3 half days per week or in office in faculty hall by request

9. Traditional Model (April 2011 – Jan 2012) 9  Co-appointments  Residents were required to schedule 1 co-appointment with psychologist during FCM rotation  Additional co-appointments available upon request  Didactic Teaching  Noon conferences  1 st Thursday teaching block  Resident teaching days  Nursing Home Rounds

10. Limitations of Traditional Model  Residents had limited access to precepting and no consistency on availability (hit or miss)  Residents did not take ownership of “blind referral”  No educational gain from “blind referral”  EMR limitations provided huge communication barriers

11. Limitations of Traditional Model 11  Patients not receiving referrals or care in timely manner  Delay in prescriptions or medication management  High no show rate  Due to lack of explanation from residents  Patient barriers (time, transportation, etc)

12. “Open Access” Model (Feb 2012 – Present) 12  Shifted focus to “Point of Care” or “One stop shopping” type of model  Psychologist located in clinic and available for time of service needs

13. “Open Access” Model (Feb 2012 – Present) 13  Direct Patient Care:  Psychologist available to see patient while here for medical appointment  Residents could stay in room with patients and psychologist (educational piece) or move on to next patient (increased efficiency)  Precepting  Available in clinic located office for questions/consultation

14. 14  Co-appointments  Residents still required to schedule 1 co-appointment with psychologist during FCM rotations  Additional co-appointments highly utilized  Didactic Teaching  Noon conferences  1 st Thursday teaching block  Resident teaching days  Nursing Home Rounds “Open Access” Model (Feb 2012 – Present)

15. Benefits to “Open Access” Model 15  Increased accessibility to MH services for patients  Timely MH services, triage, and referral  Immediate communication to PCP  Better medication management  Increased learning opportunities for residents  More patient centered

16. Limitations to “Open Access” Model 16  Only one psychologist for 41 providers  If psychologist is not in clinic (off site, meetings, etc) no services are available.  Only triage type intervention available  Lost ability to provide on site brief counseling

17. Traditional Model April – Dec 2011 17

18. “Open Access” Model Jan – Aug 2012 18

19. # Patients receiving direct intervention 19

20. # Patients receiving indirect intervention (precepted) 20

21. "No show" rate (% of scheduled appts) 21

22. # Co-Appointments with PCP and PhD 22

23. Expanding Behavioral/Mental Health Integration  Care Managers/ Care Coordinators  Where & How to start?  AmeriCorps Volunteers The Boomers Program

24. What is AmeriCorps?  AmeriCorps members address critical needs in communities all across America. As an AmeriCorps member, you can:  Tutor and mentor disadvantaged youth  Fight illiteracy  Improve health services  Build affordable housing  Teach computer skills  Clean parks and streams  Manage or operate after-school programs  Help communities respond to disasters  Build organizational capacity

25. What is AmeriCorps? 25  Boomers Leading Change in Health was part of a larger, national movement created to provide Adults 50+ with meaningful volunteer opportunities.  These were adults who had been in the work force and understood work ethic and were educated, and responsible.

26. The Boomers Program 26  Training in:  Patient Navigation  Communication  Ethics  Health Literacy  Poverty and its impact on healthcare  Health promotion  HIPAA

27. Care Coordinators 1 st Project  Diabetic Registry  Up date  Gather base line data  Who hadn’t been seen in over 6 months?  Phone calls  Post cards sent to get lab work and appointments

34. Other benefits of the AmeriCorps Volunteers  In addition to their work with the registry they became involved with DM group visits.  They had begun a chart review of all COPD patients to assess if/when most recent pulmonary studies were preformed.  They gave educated, honest feed back which was invaluable to our process

35. Presentation Title – Date (month #, ####) 35  Collaboration with Community Reach (Adams County Mental Health)  In negotiations for over 1 year! Goal:  1 Full time BHP employed by Community Reach and located in our clinic More hands to provide “Open Access” Model Brief counseling available Liaison to Community Reach for additional services Access to Mental Health Records Expanding Behavioral/Mental Health Integration: Integrated Neighborhood

36. 36  Collaboration with Tri-County Health Department  Referral site for TCHD’s Peak Wellness Program  Motherhood Matters (Perinatal counseling and mental health services for pregnant women)  Chronic disease self management and lifestyle intervention classes  Cooking Matters

37. Cooking Matters  Cooking Matters is a groundbreaking nutrition education program that helps families help themselves by teaching them how to prepare low cost healthy meals.

38. Cooking Matters for Adults teaches low-income adults (primarily adults with children) how to prepare and shop sensibly for healthy meals on a limited budget. Cooking Matters for Kids engages kids ages 8 to 12 in learning about healthy eating and provides simple nutritious recipes that children can prepare themselves. Cooking Matters for Families teaches school-age children (ages 6 to 12) and their parents about healthy eating as a family and the importance of working together to plan and prepare healthy meals on a budget. Cooking Matters for Teens teaches teens how to make healthy food choices, meals and snacks for themselves, their families and friends.

39. What next?  Hired NP to coordinate care of hospital discharge patients to outpatient clinic  Wrote and received a grant based on the data we have obtained to hire one full time Care Coordinator  Requesting additional year for one full time AmeriCorps Boomer Volunteer  Currently using student volunteers from CU to help sustain the work our AmeriCorps volunteers started.

40. Who are we?  9-9-9 community based residency program  18 Faculty  24 staff members  3 Billing/coders  Diabetic Educator  70 total employees in our clinic

41. Who we Are.  9-9-9 community based residency program  18 Faculty  24 staff members  3 Billing/coders  Diabetic Educator  85 total employees in our clinic  Psychologist  2 Care Coordinators  8 Student Volunteers  NP – Hospital Patient Care Coordination  On site Community Mental Health  Referral site for Tri-County Health Department

42. St Anthony North Family Medicine Residency * Integrated Medical Home * Integrated Medical Neighborhood