1. Suzanne Daub, LCSW | Jaspreet Brar, MD, PhD October 14, 2016
Optimizing the Health of Individuals with Serious Mental Illness: The Behavioral Health Home Plus Model
Suzanne Daub, LCSW | Jaspreet Brar, MD, PhD
October 14, 2016

2. You must include ONE of the statements above for this session.
Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships during the past 12 months.
You must include ONE of the statements above for this session.
CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message.
The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community.
Collaborative Family Healthcare Association 12th Annual Conference

3. Learning Objectives At the conclusion of this session, the participant will be able to:
Articulate the need for and describe the key components of an effective behavioral health home model such as Behavioral Health Home Plus.
Describe wellness coaching as a strategy to effect clinical and health outcomes.
Describe preliminary results of a learning collaborative approach used to spread the model across 50+ sites in PA.
Include the behavioral learning objectives you identified for this session
Collaborative Family Healthcare Association 12th Annual Conference

4. Bibliography / Reference
Anderson, G. (2010). Chronic Care: Making the Case for Ongoing Care. Princeton, NJ: Robert Wood Johnson Foundation.
Bartels, S. J. (2004). Caring for the whole person: integrated health care for older adults with severe mental illness and medical comorbidity. Journal of the American Geriatrics Society, 52(12 Suppl), S249–S257.
Goff, D. C. (2007). Integrating general health care in private community psychiatry practice. The Journal of Clinical Psychiatry, 68 (Suppl 4), 49–54.
Nasrallah, H. A., Meyer, J. M., Goff, D. C., et al., (2006). Low rates of treatment for hypertension, dyslipidemia and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophrenia Research, 86(1–3), 15–22.
Surles, R. C., Blanch, A. K., Shern, D. L., Donahue, S. A. (1992). Case management as a strategy for systems change. Health Affairs, 11(1), 151–163.
Continuing education approval now requires that each presentation include five references within the last 5 years.
Please list at least FIVE (5) references for this presentation that are no older than 5 years.
Without these references, your session may NOT be approved for CE credit.
Collaborative Family Healthcare Association 12th Annual Conference

5. Learning Assessment A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation.
This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.
Collaborative Family Healthcare Association 12th Annual Conference

6. Community Care Part of the UPMC Health System
Covers approximately 950,000 HealthChoices members across 39 of Pennsylvania’s 67 counties
Implement a wide variety of innovative programs in the area of integrated behavioral and physical health

7. Counties Served by Community Care
Erie
Warren
Susquehanna
McKean
Potter
Tioga
Bradford
Pike
Crawford
Wayne
Forest
Wyoming
Cameron
Sullivan
Lackawanna
Venango
Elk
Lycoming
Pike
Mercer
Clinton
Jefferson
Luzerne
Clarion
Columbia
Monroe
Lawrence
Clearfield
Centre
Montour
Union
Butler
Carbon
Armstrong
Northumberland
Snyder
Northampton
Beaver
Mifflin
Schuylkill
Lehigh
Indiana
Juniata
Allegheny
Blair
Berks
Perry
Dauphin
Bucks
Cambria
Lebanon
Huntingdon
Westmoreland
Montgomery
Washington
Cumberland
Lancaster
Bedford
Fayette
Chester
Somerset
Franklin
York
Philadelphia
Greene
Fulton
Adams
Delaware

8. Behavioral Health Home Plus
Comprehensive model designed by Community Care Behavioral Health, county and consumer stakeholder groups.
Model incorporates wellness nurse, wellness coach, stratified risk registry, self management tool kits, learning collaborative, fidelity tool.
Model is spread using the IHI’s Break Through Learning Collaborative
Model of Awarded 2016 Recognition of Excellence in Wellness in SAMHSA’s Program to Achieve Wellness.
The core agency activities include:
Managing the risk stratified registry provided by Community Care.
Conducting a comprehensive health assessment with each person identified with “high needs” on the registry.
Addressing lapses in clinical care, preventive screening, and history of significant traumatic stress exposure contributing to health concerns.
Establishing a reciprocal and collaborative relationship with primary care and specialty medical providers.
Engaging people in recovery in ongoing wellness coaching

9. Why have behavioral health homes?
As a group, individuals with SMI have high rates of premature death, dying as much as 15 to 25 years younger than the general population largely due to modifiable lifestyle choices.
Key contributors:
Modifiable lifestyle choices and behaviors
Negative metabolic effects of atypical antipsychotic medication
higher rates of undiagnosed, untreated, or poorly treated medical illnesses
Difficulties obtaining routine preventive and primary care.
The existing behavioral health system can be enhanced to support good health outcomes for individuals with SMI/SUD

10. What’s the ultimate goal?
Help individuals with SMI take a more active role in their own health and health care
Build provider capacity to sustain and spread the Behavioral Health Home model with high quality

11. The Learning Collaborative
Support for successful implementation of the Behavioral Health Home Model across the state
Create an agency-wide culture of wellness
Learning Collaborative process
Build on Milestones (Detailed steps for successful implementation)
PDSA Cycles (Process for quality improvement)
Monitor outcome and process aims
Learn from each other

12. Wellness Coaching
Develop a Wellness Narrative highlighting strengths, struggles, accountability, turning points, accomplishments
Assess The Eight Dimensions of Wellness
Explore strengths, needs and desires to change in the physical dimension
Health Education on common risk factors: weight, nutrition, smoking, physical inactivity, stress
Wellness Planning Tool -- SMART Goal
Self-management toolkit
Track progress on member portal
Create an agency-wide culture of wellness:

13. Learning Collaborative Aims
Process Aim 1: Wellness. By September 2015, 80% of all individuals presenting with complex needs will have completed the wellness planning tool.
Process Aim 2: Assessment: By September 2015, 80% of all individuals presenting with complex needs will have completed a health assessment.
Outcome Aim: Involvement: By September 2015, 80% of individuals engaged in BHHPE will report being highly involved (rated a 9 or 10) in working with their behavioral health service provider on physical health and wellness as measured by a 10-point involvement question.

14. Provider-Reported Rating of Progress
PRE Q1 Q2 Q3 Q4
1.0
1.5 50
2.0 40
2.5 20
3.0 10 60
3.5
4.0 30
4.5
100
5.0
Rating:
Definition:
1.0
Charter and team established
3.0
Modest improvement
1.5
Planning for the project
3.5
Improvement
2.0
Activity, but no changes
4.0
Significant improvement
2.5
Changes tested, but no improvement
4.5
Sustainable improvement
5.0
Outstanding sustainable results

15. Collaborative Wellness Process Aim

16. Collaborative Assessment Process Aim

17. Collaborative Involvement Outcome Aim

18. The Wellness Outcome Online Tool!
The Wellness Outcomes Online Tool (WOOT!) gathers information on individuals’ wellness goals as well as a self-assessment of overall physical and behavioral wellness
Provider and individual complete together every 6 months
This report is a summary of information gathered from the Secure Portal to August 9, 2015
The information pertains to each individual’s first survey completion
747 surveys received from 513 unique individuals across 10 contracted entities

19. Wellness Area: Importance
Please complete for each area:
How important is this area to you?
(select one response for each area)
Not at all
A little
Some
Quite a bit
A lot
Diet and Nutrition
17 (3.4)
46 (9.3)
106 (21.5)
131 (26.5)
194 (39.3)
Physical Activity
26 (5.3)
57 (11.7)
116 (23.8)
130 (26.6)
159 (32.6)
Sleep/ Rest
25 (5.2)
44 (9.1)
92 (19.0)
145 (29.9)
179 (36.9)
Relaxation/ Stress Management
19 (3.9)
40 (8.3)
114 (23.6)
141 (29.1)
170 (35.1)
Medical Care/ Screening
27 (5.6)
33 (6.8)
86 (17.8)
123 (25.4)
215 (44.4)
Smoking Cessation
196 (43.0)
58 (12.7)
65 (14.3)
52 (11.4)
85 (18.6)
Taking Medications Effectively
36 (7.5)
26 (5.4)
66 (13.7)
124 (25.7)
231 (47.8)
Habits and Routines
57 (12.5)
43 (9.4)
112 (24.6)
132 (28.9)

20. Wellness Area: Goals and Progress
Please complete for each area:
Do you have a current goal in this area?
If this area is a goal for you, how would you rate your progress in the past month (select one response for areas specified as goals)
Not at all
A little
Some
Quite a bit
A lot
Diet and Nutrition
No: 318 (64.9)
Yes: 165 (33.7)
36 (22.2)
33 (20.4)
49 (30.2)
29 (17.9)
15 (9.3)
Physical Activity
No: 347 (70.5)
Yes: 138 (28.0)
20 (14.6)
27 (19.7)
42 (30.7)
32 (23.4)
16 (11.7)
Sleep/ Rest
No: 400 (82.6)
Yes: 81 (16.7)
21 (26.6)
19 (24.1)
12 (15.2)
8 (10.1)
Relaxation/ Stress Management
No: 380 (79.0)
Yes: 99 (20.6)
15 (15.5)
19 (19.6)
36 (37.1)
20 (20.6)
7 (7.2)
Medical Care/ Screening
No: 359 (73.6)
Yes: 120 (24.6)
11 (9.2)
12 (10.1)
38 (31.9)
27 (22.7)
31 (26.1)
Smoking Cessation
No: 413 (85.3)
Yes: 61 (12.6)
19 (32.2)
13 (22.0)
7 (11.9)
10 (16.9)
Taking Medications Effectively
No: 392 (80.8)
Yes: 82 (16.9)
4 (4.9)
8 (9.9)
19 (23.5)
22 (27.2)
28 (34.6)
Habits and Routines
No: 410 (86.1)
Yes: 59 (12.4)
7(12.1)
12 (20.7)
18 (31.0)
9 (15.5)

21. PCP and Dentist Visits 0-6 months ago n (%) 7 months – 1 year ago
0-6 months ago
n (%)
7 months – 1 year ago
1-5 years ago
>5 years ago
PCP
447 (88.9)
40 (8.0)
13 (2.6)
3 (0.6)
Dentist
169 (34.1)
109 (22.0)
147 (29.7)
70 (14.1)

22. Challenges Staff felt overwhelmed at the start of the LC
Understand the mission of the collaboration
Define roles for members on the QIT
Hard to collect and organize data and information over multiple sites
Collaboration with physical health providers takes work
Wellness is sometimes difficult to promote in a crisis driven community
Fragmented efforts don’t work

23. Positive Feedback & Observations
Learning the value of the process is the most important benefit of the LC
The LC is good for moving teams from day to day activities to quality improvement visionaries
The PDSA provides a helpful structure and helps to identify needs
Staff appreciated the value of collaboration with physical health providers and communicating with physical health providers got easier over time. “We learned better ways to communicate with physical health providers”
Routine meetings of the QIT are important (Drill large tasks down into small, actionable steps)
LC resulted in a better understanding of the relationship between physical and behavioral health
Hot button issues can be tied back to psychotropic medications and risk which link back to the PCP and why monitoring is important
Get buy-in from staff by talking about the goals of the effort
Share data and progress with staff
Link to the PCP for diagnoses
Attend the PCP visit; learn about inhalers, insulin injections, etc
Collaboration between team members is important
Collaboration with the local clinic is helpful
If you need physical health information, it’s better to just show up rather than make an appointment
Maintain the strategies that are working
Ask the physical health provider for a little bit of information just to open the lines of communication, ex, date of last physical
Having a team member on the QIT is helpful
The ‘why’ is important when participating in a LC

24. Summary
Engagement and participation in the Behavioral Health Homes is high
Teams are completing Milestones at the same rate and most activities are completed successfully
Most agencies have met goal on Process Aims
Progress is being made toward meeting our Outcome Aims
Melody

25. Questions ?

26. Session Evaluation
Please complete and return the evaluation form before leaving this session. Thank you!
This should be the last slide of your presentation
Collaborative Family Healthcare Association 12th Annual Conference