1. SENIOR IBH Practice facilitator, CTC-RI
Integrated Behavioral Health Transformation in Rhode Island: How the smallest State plans to make the biggest changes
Date: June 26, 2018
Nelly burdette, psyD Debra Hurwitz, MBA, BSN, RN
Director, IBH, PCHC Executive Director, CTC-RI
SENIOR IBH Practice facilitator, CTC-RI

2. Funding Partners

3. Overview CTC-RI Background IBH Pilots in Primary Care
Quality and Cost Data
Lessons Learned
Challenges
Opportunities

4. CTC-RI Sets the Stage in RI

5. From humble beginnings
First Successful Quasi-Experimental/Pretest-Posttest study (2017) implementing IBH in Twelve PCMHs with the aid of practice facilitation

6. Training the Next Generation
Funded by RIF, RIC for 3 practice facilitators to be trained specifically within IBH in Primary Care
6 month training
Didactic and Experiential
3 additional PCMH sites to receive practice facilitation through trainees over 1 year period
Includes psychology, social work and marriage and family therapy trainees
Represents the first training of its’ kind in the country

7. IBH in Primary Care Pilot
10 PCMHs selected to implement
Universal Screening of depression, anxiety and substance use in primary care for all patients > 18 across two years
Rescreening within 6 months if positive at baseline
Onsite IBH providers offer evidence-based treatment
Range of FQHCs, private group practices and academic settings
Three PDSAs
Increase screening rates of depression (90%), anxiety (70%) , and substance use (70%)
High ED utilization with behavioral health
Population health focus within behavioral health

8. PHQ-9
Purpose: dual purpose 9 item depression scale that can establish provisional depression diagnosis and grade depressive symptom severity
Target Population: Adults age 18 and over
Evidence: Validated for measuring depression severity; detecting and monitoring depression in primary care settings 4
Estimated Time: 2-5 min
Administered by: Patient (self-report), Provider, Telephonically
Intended Settings: Primary Care

9. PHQ 9 in Practice

10. GAD-7 Estimated Time: 2-5 minutes
Purpose :evaluate for presence and severity of anxiety in general practice, as well as monitoring change across time 7
Target Population: Adults age 18 and over
Evidence 1: Panic Disorder Sensitivity: 74% Specificity: 81%
Social Anxiety Disorder - Sensitivity: 72% Specificity: 80%
PTSD - Sensitivity: 66% Specificity: 81%
Estimated Time: 2-5 minutes
Administered by: Self-Report
Intended Settings: Primary Care
Sensitivity: True Positive Rate or in other words, probability of testing positive when disease present (So 26% chance of being missed for Panic Disorder)
Specificity: True Negative Rate or in other words, individuals who are disease-free are correctly identified (So 19% chance of false-positive or being disease free but not indicated as such)

11. Copyright © 2015 American Medical Association. All rights reserved.
From: A Brief Measure for Assessing Generalized Anxiety Disorder:  The GAD-7
Arch Intern Med. 2006;166(10): doi: /archinte
Date of download: 12/29/2015
Copyright © 2015 American Medical Association. All rights reserved.

12. CAGE-AID
Purpose: Assesses likelihood and severity of alcohol and drug use; modified from CAGE
Target Population: Adults aged 18 years and older
Evidence: One or more yes responses has sensitivity of and specificity of 0.77; Two of more yes responses has sensitivity of 0.70 and
Estimated Time: 1 minute
Length: 4 yes/no questions
Intended Settings: Primary care

13. CAGE-AID in Practice

14. PDSA: Universal Screening Cohort 1

15. PDSA: Universal Screening Cohort 2

16. PDSA: High-Risk ED Utilization & IBH
How can behavioral health impact high-risk ED utilization?
NCM/IBH Co-visits led to reduction in ED visits from prior to intervention to 0.7 post intervention.
75% of patients in sample of 12 did not return to the ED after IBH intervention
Education about urgent care, same day sick visits
NCM and IBH connected for first time at many sites

17. Year 2 is not really second year
More like data point 2
Data point 2 only first 3 months of 2017
Measurement year: Year 1 – 1/1/ /31/ Year 2 – 4/1/2016-3/31/2017

18. Nearly $100 PMPM difference between CTC Comparison and IBH Cohort 1
Nearly $100 PMPM difference between CTC Comparison and IBH Cohort 1 *statistically significantly lower total cost of care  than comparison
Cohort 2 still mid way through final year
Measurement year: Year 1 – 1/1/ /31/ Year 2 – 4/1/2016-3/31/2017

19. PDSA: Population Health
How can behavioral health be better utilized within chronic disease management in primary care?
Diabetes and Depression Classes
Women’s Cardiovascular Health Classes
Chronic Pain and Mood Classes
Hypertension and Yoga Classes

20. Evaluation Results
Site self-assessment utilizing Maine Health Access Foundation Integration Initiative
18 domains measured by self-report across three time periods (baseline, midpoint - 1 year, completion- 2 years)
9 Patient and family centered dimensions
9 Organizational dimensions

21. Funding sources showed greatest change
Top 5 largest changes across all domains on MeHAF and both cohorts yielded three common areas of change…in order of largest change
1) Funding

22. Patient/family involvement next largest change
2nd largest change: patient/family involvement in care plan

23. Screening integration next largest change
3rd largest: Screening rates consistently occurring for BH

24. Qualitative Evaluation
Engaged leadership & ownership across all organizational levels
Practice facilitation makes a difference
EHRs can help or hinder but are critical
Communication in real-time between care teams by any means possible
Parity among IBH and Primary Care
Operational changes

25. Lessons Learned
Engaged leadership & ownership across all organizational levels support IBH success
-Designated IBH leader with
authority
-Previous and/or current
training or IBH experience
-Demonstrated success
processes in place through
data extraction
-Senior leadership demonstrated support

26. Lessons Learned Practice facilitation makes a difference
-Monthly meetings with practice facilitator provides focus and maintains momentum
-Practice facilitator’s expertise
-PDSA’s addressed all common issues across settings, including E- H-R, workflows, and getting support staff involved
-Focusing on reducing ED visits with IBH brought in Nurse Care Managers and “got everyone’s attention”
-Focusing on chronic health issues, such as diabetes, from an IBH perspective helped establish the medical relevancy of IBH

27. Lessons Learned EHRs can help or hinder but are critical
-Serve many functions within IBH including:
repository for screening data
tracking and reporting outcomes
communication mechanism
-Ultimately not set up to be supportive of IBH within primary care
-Modifications to EHRs take time, money and impact entire organization

28. Lessons Learned
4) Communication in real-time between care teams by any means possible
-Huddles and pre-visit planning are critical to IBH communication
-Close proximity of exam rooms to IBH provider enhances communication significantly
-Electronic communication or real-time messaging through E- H-R very helpful to ensure warm hand-offs occur

29. Lessons Learned 5) Parity among IBH and Primary Care
-Payment for IBH services can disincentive patients to obtain care overall
-Coordinating a medical visit with an IBH visit sounds good in theory, but paying for two co-pays can be prohibitive
-IBH providers can bill enough to cover their salaries in most cases, as long as there are sufficient patients on the IBH panel

30. Lessons Learned 5) Operational changes
-Creation of medical and leadership champions
-Cultural shifts in support of IBH across all roles
-Efficient systems change for:
-warm hand-offs
-IBH screening
-information exchange
-IBH workflows for short-term interventions

31. Challenges

32. Challenges Leadership and Ownership Practice Facilitation and PDSAs
Staff Turnover
Lack of ownership
Practice Facilitation and PDSAs
Moving too quickly into PDSA before basics covered
EHRs
Not set up to support IBH in primary care
Data monitoring, tracking and outcome management within IBH

33. Challenges Culture and Communication Payment and Sustainability
Pressure to bill can inhibit communication
Unbillable tasks
Payment and Sustainability
Double co-pay when there is a medical visit
High specialty co-pay

34. Opportunities Psychiatry in Primary Care
Project ECHO
Adult-based version of Pedi PRN
Training IBH Practice Facilitators
Collaboration with local universities
Web-based and online expansion
Alternative Payment for IBH
SIM currently conducting a review for PMPM within IBH in primary care
Billing codes for IBH Care Coordination
Change takes time
Governor Ramondo has sponsored S2540/H7806 bills
Requires insurance companies to consider behavioral health counseling and medication visits as primary care services = copay would be same
BCBSRI will start implementation on 1/1/2019

35. Opportunities Workforce Evidence-based treatment guidelines
Trained IBH providers/providers interested in learning IBH
Bilingual providers
Evidence-based treatment guidelines
Post-screening for depression, anxiety and substance use
Implementation of evidence-based treatment guidelines

36. The dream vs the reality

37. References
1. Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., Falloon, K., Hatcher, S. (2010). Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in Primary Care Population. Annals of Family Medicine, 8 (4):
2. Brown, R.L. and Rounds, L.A. (1995). Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisconsin Medical Journal, 94(3):
4. Kroenke K, Spitzer R. (2002). The PHQ-9: A New Depression Diagnostic and Severity Measure. Psychiatry Annals. 32:
7. Spitzer RL, Kroenke K, Williams JW, Löwe B. (2006). A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Archives Internal Medicine. 166(10):

38. Questions Nelly Burdette, Psy.D Debra Hurwitz, MBA, BSN, RN
Lead, IBH Practice Facilitator, CTC-RI Executive Director, CTC-RI
Director of Integrated Behavioral Health, PCHC