1. Date: May 11, 2018 Nelly burdette, psyD LEAD, IBH Practice facilitator
What’s integrated care got to do with it? Looking back and forward in primary care for Rhode Island
Date: May 11, 2018
Nelly burdette, psyD
LEAD, IBH Practice facilitator

2. Funding Partners

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

4. What’s integration got to do with it?

5. Studies show mental health has a lot to do with it
Source: Corso, Cost of treating chronic health condition without the mental health condition costs more Per Health and Human Services Data from

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

7. 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

8. 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
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

9. Cohort 1 (blue) February 2016 Cohort 2 (yellow) November 2016
10 Practicing Sites
Cohort 1 (blue) February Cohort 2 (yellow) November 2016
Associates in Primary Care
East Bay Community Action Program (Newport and E. Providence)
Providence Community Health Centers (Chaffee)
Women’s Medicine Collaborative
Tri-Town Community Action Program
Wood River Health Center
Coastal Hillside Family Medicine
Providence Community Health Centers (Prairie)
Providence Community Health Centers (Capitol Hill)
University Medicine

10. PDSA: Universal Screening Cohort 1

11. PDSA: Universal Screening Cohort 2

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

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

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

20. Qualitative Evaluation
Engaged leadership & ownership across all organizational levels support IBH success
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

21. Lessons Learned

22. Lessons Learned Standardize the Universal Screening process
Self-administered
Completed by patient on laminated sheets, on-line
Verbally administered by medical assistant , entered directly into EHR
Linked to a Preventative Services reminder in EHR
Support staff need to recognize during huddle or pre-visit planning
If screening is negative, no need to rescreen for one year *unless clinically determined by provider

23. Lessons Learned Train and Re-Train the Care Team
Emphasize the reasons why we screen for IBH conditions
Emphasize the medical assistant’s crucial role on team
Never miss an opportunity to screen for IBH conditions

24. Proactively expect and address concerns before they takes root
Lessons Learned
Anticipate the naysayers…
“We shouldn’t screen because…”
- too busy already or it’s a sick visit
- Don’t want to open up a can of worms
- I’ll have to deal with the consequences
Proactively expect and address concerns before they takes root

25. Lessons Learned Sustainability Change takes time
Huddles/Interdisciplinary Care Conferences
Increased Productivity = encompassing Primary Care pace
Within 2 years, most sites financially sustainable
Change takes time
Governor 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

26. Challenges

27. Challenges Financial and Billing Culture and Training
Mostly occurs in specialty model of care
Only face-to-face codes based on time can consistently be used and reimbursed
Culture and Training
Medical Culture vs IBH Culture
NCM relationship to IBH
Specialty Behavioral Health Referrals
Psychiatry wait-lists
Communicating between Specialty MH and Primary Care

28. 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

29. 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

30. The dream vs the reality

31. Questions Nelly Burdette, Psy.D Lead, IBH Practice Facilitator, CTC-RI
Director of Integrated Behavioral Health, PCHC