1. “Integrated Care Clinic”: Full Integration of Behavioral Health in a Family Medicine Residency Clinic
Jerica Berge, PhD, MPH, LMFT; Lisa Trump, MS, LAMFT; Stephanie Trudeau, MS, LAMFT; Andrew Slattengren, DO; Michele Mandrich, MSW; Priscilla O’Neil, RN; Michael Wootten, MD

2. Disclosures Speaker & Faculty Disclosures
The speakers and faculty disclose no relevant financial relationship or interest with a proprietary entity producing health care goods or services.
This program does not include any discussion or
demonstration of any pharmaceuticals or medical devices
that are not approved by the Food and Drug Administration
(FDA) or that are considered
“off-label.”

3. Objectives
1. Describe how the ICC was strategically planned and carried out in a family medicine residency program.
2. Describe specific components of the Integrated Care Clinic, how components were measured and initial feasibility results.
3. Identify how integration of behavioral health is occurring at other respective clinics, lessons learned from the process, and next steps in transformations.

4. Need for Integrated Care Clinic?
“Integrated Care” a buzz word
Limited research on what components to include
Warm Handoffs; Hallway Consult; SSRI
Need triggers to “get BH in the room”
Point-of-Care Interventions
Integrated Care Clinic (ICC)

5. Transformation to ICC Need to change overall BH structure Therapy ICC
High No Show Rates
Long Waiting Lists
Need More Appointment Times
ICC
Need Coverage Entire Week to Really Make ICC Valuable and Efficient

6. Buy-in from Clinic and Program
Clinic Manager
Residency Director
Residents
Staff
Behavioral Health Providers
Pharmacy

7. Typical Weekly Schedule
Two behavioral health providers available at any given time, every day across the entire week
ICC
Therapy

8. Monday
Tuesday
Wednesday
Thursday
Friday
AM Clinic
Therapy
ICC
PM Clinic

9. Research Components of ICC and Therapy
We are clinicians and researchers
Develop research components into all projects/changes in BH
All ICC components have a research component including feasibility and initial effectiveness

10. Therapy Changes

11. Therapy 60 minute Diagnostic Assessments 30 minute Follow-up visits
Provide individual, couples, family therapy
Group visits: Prenatal group, Hmong depression group

12. Logistics Creating Templates in Flowcast EPIC templates
BHV (Behavioral Health Visit)
BIC (Behavioral Health Integrated Care Clinic)
Ability to schedule spontaneously
Freeze and Thaw for follow-up appointments

13. Initial Results of Therapy Change
Baseline: 6 months prior to change
Total mean=28 billed appointments per month (out of 166 total arrived appointments over 6 months)
7 per therapist per month
About 1.5 per half day
Follow-up: 6 months after change
Total mean=75 billed appointments per month (out of 451 arrived appointments)
19 per therapist per month
About 3.75 per half day

14. Initial Results of Therapy Change Cont.
Implementation of 30 minute appointments resulted in a 110% increase in patient arrivals (predicted probability; statistically significant p < 0.001)
Arrived
No Show
Probability Arrival
Probability No Show
Pre-
166
335
33%
67%
Post-
451
180
71%
29%

15. Integrated Care Clinic (ICC)

16. ICC Components—“Triggers”
Warm Hand-offs
TCM visits
Postpartum Depression Screening and point-of-care interventions
Paired visits

17. Warm Handoffs

18. Warm Handoff
Initiated by providers
Behavioral health needs of patient
Immediate
Future appointment

19. Warm Handoff Standard Work
MD/DO Provider informs patient of “holistic” care provided at Broadway Family Medicine
Provider finds BH in precepting room or overhead pages BH
MD/DO introduces BH provider to patient and indicates how BH will help them
Can turn into a “point-of-care intervention”; billable
White board at cube indicating who is on ICC for each half-day; overhead page important!

20. Initial Results of Warm Handoffs
Frequency of Warm Handoffs in the First 6 Months After Implementing the Change
Total complete = 294 (49 per month; about 2.5 per day)
Total appointments scheduled = 220 (75%)
Total appointments arrived = 132 (60%)

21. Transition of Care Meetings (TCM)

22. TCM Visits Transition of Care Meetings (from hospital to outpatient)
To reduce unnecessary hospitalizations and <30-day post-discharge hospital readmissions
Must occur 1 week after discharge
Integrated team visit with:
MD/DO provider
Behavioral health
Pharmacy
Adjust the visit structure as needed
Can result in a Point-of-Care Intervention; billable

23. TCM Standard Work Nurse schedules visit with patient w/in 1 week
Patient told it will be a team visit with multiple providers to give them best care
Patient scheduled with all three providers in EPIC; individual notes written by all team members
All providers do a chart review prior to visit
Gather any resources that may be given to patient
Huddle between team providers the day of the visit; 10-15minutes before
Create agenda

24. TCM Standard Work Cont. During Visit: Medical provider introduces team
Explains roles of each team member: “Holistic Care”
Shared Agenda Setting: “Do we have the right people in the room?”
Each provider checks in with the patient
Anticipate each other to increase flow of visit; collaborative
Physical exam (MD/DO only)
Sometimes behavioral health or pharmacy will come back in for additional visit/point-of-care intervention
Patient Satisfaction survey given by Nurse or BH

25. Common Diagnoses Seen Diabetes
Cardiovascular Disease/Myocardial Infarction
Asthma
Anxiety—panic attacks
Depression, Suicide Attempt
Sometime acute visits
E.g., Kidney stone—still ask about stress pre- post- hospitalization

26. Initial Results of TCM Total hospital discharges 353 TCM visits 191
TCM visits with BH 84 (44%)

27. Initial Results of TCM Readmission Rates TCM 16/191 = 8.4%
TCM with BH 6/84 = 7.1%

28. Initial Results of TCM Provider Satisfaction (9mo vs baseline)
During my usual clinic shifts, I am able to have Behavioral Health see a patient during the visit if needed.
67% agree (baseline 54%)

29. Initial Results of TCM Provider Satisfaction (9mo vs baseline)
Having Behavioral Health see a patient during a TCM (Hospital Follow-up) visit improves patient care.
85% agree (baseline 70%)

30. Initial Results of TCM Provider Satisfaction (9mo vs baseline)
I find the recommendations from Behavioral Health helpful in caring for my patients.
90% agree (baseline 83%)

31. Initial Results of TCM Patient Satisfaction
I feel that having providers other than my doctor see me today was helpful
N=24 responses – 1 N/A
20 agree
3 somewhat agree

32. Postpartum Depression (PPD)

33. Postpartum Depression
Postpartum depression screening of mothers during well-child visits with children 6 months and younger
Low rate of mothers coming to their postpartum appointments
PHQ-9 score >10
Can turn into Point-of-Care Intervention with behavioral health; billable

34. Postpartum depression Standard Work
Well Child Check 6 months or younger
MA’s give mom PHQ-9
PHQ-9 10 or greater
Resident follows protocol on pink form
Pages BH for point-of-care intervention

35. Postpartum Depression
Provider acts on PPD screen
0-4: Educate on post partum depression
5-9: Support, educate, follow up in one month
10-14: Support patient, point-of-care intervention with BH, consider antidepressant
15-19: Point-of-care intervention with BH, consider antidepressant, consider postpartum care coordination
20 >: Point-of-care intervention with BH, postpartum care coordination, initiate antidepressant, follow closely

36. PPD Data Total WCC 36 49 33 59 Negative Screen 22 31 29 24 45
November
December
January
February
March
Total WCC 36 49 33 59
Negative Screen 22 31 29 24 45
Positive Screen 10 9 7 8
Warm Hand Off 1 4 2
Therapy

37. Results of PPD Cont. Incidence: Point-of-Care Interventions:
Currently close to a 20% positive PPD rate (> 10 on PHQ-9)
Point-of-Care Interventions:
23% of patients that scored >10 had point-of-care interventions completed

39.
Obesity prevention messages for children and families at Broadway
Delivered to all children ages 2-18 years old
5 = Five or more fruits and vegetables/day
2 = Less than two hours of screen time/day
1 = At least one hour of physical activity/day
0 = No sugar-sweetened beverages/day

40. Standard Work
Behavioral health provider goes in to WCC before, after, or with MD/DO provider
EPIC—Embed a note within physicians notes
Use phone encounters to track follow-up
RedCap data capture system for tracking research component

41. Initial Results
Number of conversations during well-child visits in the first 6 months: 471
Average number of WCCs
per day: 4-5
August and September months: 10-15
Difficult in terms of feasibility

42. Broadway Family Medicine 5-2-1-0 Data
No goal set, n=1; 0.2%
  Message N
Total = 471
% of Total
5 or More Fruits & Vegetables
100
21%
2 Hours or Less of Screen Time
149
32%
1 Hour or More of Active Play 28 6%
0 Sugary Drinks
193
41%

43. 5-2-1-0 Community Measures Report

44. Lessons Learned Just try!! Support from all levels
Communication and presentations

45. What are you doing?
Successes
Challenges