1. Advancing Comprehensive Primary Care: Through Integrated BH Program and Community Health Teams
March 26th, 2019
Debra Hurwitz, MBA, BSN RN
Executive Director

2. Expanding Comprehensive Primary Care
The Care Transformation Collaborative of Rhode Island has a growing impact across the state, and includes:
106 primary practices, including internal medicine, family medicine, and pediatric practices.
Approximately 650,000 Rhode Islanders receive their care from one of our practices.
750 providers across our adult and pediatric practices.
Investment from every health insurance plan in Rhode Island, including private and public plans.
All Federally Qualified Health Centers in Rhode Island participate in our Collaborative
$217 million reduction in total cost of care dollars in compared to non-patient centered medical homes in Rhode Island, according to data from the state’s All-Payer Claims Database.
2019 Integrated Behavioral Health Expansion
July 2019 PCMH Kids Expansion

3. Integrated Behavioral Health
Project Goals
Goal 1: Reach higher levels of quality through universal screening
Goal 2: Increase access to brief intervention for patients with moderate depression, anxiety, SUD and co-occurring chronic conditions
Goal 3: Provide care coordination and intervention for patients with high emergency department (ED) utilization /and behavioral health condition
Goal 4: Increase patient self care management skills: chronic condition and behavioral health need
Goal 5: Determine cost savings that primary care can achieve by decreasing ED visits and inpatient hospitalization
Target Audience(s): Ten Patient Centered Medical Home (PCMH) primary care practices serving 42,000 adults

4. Funding Partners
With funding from RIF, Tufts and SIM we conducted a 3 year pilot.

5. PDSA: Universal Screening Cohort 1 & 2

6. Better Care - Lower Costs
IBH Cohorts - CTC Non-IBH
Difference of the Differences
∆ $47pmpm – Cohort 1
∆ $43pmpm – Cohort 2
Data Source: Rhode Island All Payer Claims Database

7. Qualitative Evaluation
Providers love it: “When I say how much I love having integrated behavioral health, it is that I can't imagine primary care without it. It just makes so much sense to me to have those resources all in the same place because it's so important. So I love it. I can't speak highly enough of it.” (Medical Provider) Value of deliberate screening: "I'm surprised especially with the anxiety screener that there's more out there than I knew about. I was talking to somebody yesterday. You think this wouldn't be useful information. I know the patient pretty well, and the patients, if they had an issue, I'm sure they would tell me. But it comes up on the screener." (Medical Provider) Impact on ED use: “One of the things we identified [through the program] was somebody was going to the ER almost every other day, and it was due to anxiety. So he was given tools to control that, and it actually empowered him. He felt like he had taken control of this issue. And his ER visits dropped right off. He was being seen here [at the primary care practice] more frequently, but that's okay. We'd rather he come here than go to the ER.” (Practice Coordinator)
BEHAVIORAL
Changed Header and Slide

8. Main Takeaways Integrated Behavioral Health in Primary Care Works
Improved access, patient care & reduces costs
Onsite practice facilitation by IBH subject matter experts supports culture change for successful implementation
More action is needed
APM for Integrated Behavioral Health in Primary Care
No copays for behavioral health screenings
Eliminate second copay for same day visit
Continue workforce development

9. Community Health Teams and SBIRT (Screening, Brief Intervention and Referral to Treatment) Evaluation Data to Date

10. Funding Partners for CHT
S I M

11. Our Implementation Partners
Other Key Partners
BROWN
School of Public Health

12. Expanding Care in the Neighborhoods

13. Grant Goals and Results
Goal 1: Coordinate SBIRT and CHT
SBIRT embedded on all CHTs. CHT and SBIRT partners meet monthly for data sharing and quality improvement
Goal 2: Implement SBIRT in clinical settings
SBIRT currently implemented in 25+ settings, including DOC, hospital EDs, urgent care centers, PACE, primary care and community-based settings
Goal 3: Establish and evaluate 2-3 additional CHTs serving Rhode Islanders with greatest unmet clinical needs
4 additional CHTs established; 8 teams leveraging CHT network resources and reporting data via CTC multi-payer and SIM funds
Goal 4: Establish a consolidated operations model to implement integrated health programs in a way that streamline efficiencies
Centralized resource repository, training, monitoring, best practice sharing and data collection established

14. Community Health Team Model – an extension of primary care
Use care management processes to address
Physical health needs
Behavioral health/SUD needs
Health education needs
Social determinants of health needs
Community Health Team
Community-Based Licensed Behavioral Health Professional
(At least one)
SBIRT Screener
(At least one)
Community Health Worker (CHW)
(At least two)
Community-Based Specialty Consultants or Referrals
(Pharmacy, Nutrition, Legal)

15. SBIRT Overview
Five-year grant from the Substance Abuse and Mental Health Services Administration (SAMHSA)
Seeks to normalize screening for and conversing about substance use disorders
Helps Rhode Island address the ongoing opioid epidemic
Enhances CHTs with an evidence-based tool

16. CHT Clients Served Demographics Age (years) Mean = 54 (sd=17)
Range 18-96
Gender
60% Female/38% Male
English not 1st language
35%
Hispanic
13%
Non-White
39%
N=271 collected from 7 CHTs between 10/1/18-1/31/19

17. Community Health Teams Insurance Coverage 10/1/18-12/31/18
# of Patients Served
Percent
Commercial
 397
29.3%
Medicare
 170
12.6%
Medicaid
 739
54.6%
No Insurance 47
3.5%

18. 90% of CHT Patients had at least 1 SDOH need at Intake
Housing
38%
Finance
Transportation
34%
Food Insecurity
28%
Caregiver Support
13%
Interpersonal Violence
14%
N=271 collected from 7 CHTs between 10/1/18-1/31/19

19. CHT Patients at Intake Quality of Life Measure
CHT clients report poor functioning over half the days of each month
(N=231)
CDC Health-Related Quality of Life Measure Poor functioning due to Physical and/or Mental Health days/30 days (sd=11.2)

20. Wellbeing – Present + Future
“Please imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you.”
Present Life Evaluation
“On which step of the ladder would you say you personally feel you stand at this time?”
Thriving
Struggling
Suffering 5
3 Wellbeing Groups
> 7 – Thriving
- Struggling
< 4 - Suffering
Based on the Cantril Self-Anchoring Striving Scale (Cantril, 1965) & GALLUP Polls
Future Life Evaluation
“On which step of the ladder do you think you will stand about five years from now?”
Cantril Self-Anchoring Striving Scale (Cantril, 1965) & GALLUP

21. 95% of CHT Patients at Intake are Struggling or Suffering
95% Suffering or Struggling

22. Pre-Post Changes in Health Risk 43% decrease
This is data from 3 CHTs (SCH, BVCHC, FSRI) from the Risk Triage Tool. These data were from clients served in 2018
43% decrease in RTT score, intake to discharge – 7 months in care

23. Changes in Anxiety and Depression
Data is from only 1 CHT (SCH). Patients served in 2018
GAD7
PHQ9
28% decrease in GAD7 score, intake to discharge, *p<.0001
31% decrease in PHQ9 score, intake to discharge, *p<.0001

24. SBIRT 6-month follow ups show a significant decrease in use
The grant requires that we follow up with 10% of all positive screens 6 months later. Follow up rates show about a 50% decrease in the # of days using substances in the past month.

25. Preliminary Results show decrease in patient costs
Early results from Brown University matched comparison study show a decrease in total cost of care for CHT enrollees. Small sample size makes the results not statistically significant. Additional data from Thundermist being added to the analysis.

26. AGENCY CHT Case Study: 2018, Q3
Male in his 50’s, immigrated from Liberia during the civil war. Experiencing chronic headaches and vertigo past 3 years. Symptoms caused him to lose job and stop driving. Many ED and specialist visits, no progress on treating/identifying cause of symptoms– pt. very frustrated. PCP wants him to go to psych, he refuses. No income, homeless-couch surfing, limited English literacy, kids in Africa rely on him financially.
Risk Drivers
Triage Score: 22
Insurance: NHP Medicaid
Utilization:
14 ED Visits
Audiologist, Otolaryngologist, Gastroenterologist, 2 ENT’s, Neurologist, LICSW, Several Radiology visit.
Health Conditions/Literacy:
Chronic Headaches/Vertigo, very frustrated over failure to find effective tx.
Care Coordination:
PCP trying to figure out cause of Headaches/Vertigo, will not see psychiatrist
Social/Emotional Support:
Support from tight knit immigrant community. Children in Africa, Girl friend out state. Very spiritual.
Functional Limitations:
Can’t drive or work, English second language, stopped school after 4th grade, very limited English literacy.
Psycho-Social Factors:
Financial: No income. Lost job due to symptoms, exhausted unemployment and TDI
Family: Stressed over inability to send money to support children in Africa, causing conflict
Housing: Homeless, couch surfing
Transportation: Walks to destinations
Behavioral Health: PTSD, Depression
Intervention
Outcomes
Utilization: Frequent PCP visits
Health Conditions/Literacy: Health Coaching, Sinus surgery- no improvement reported post surgery, insurance would not cover Mayo clinic, saw faith healer in Africa
Care Coordination: Coaching to appointments and follow PCP recommendations
Social/Emotional Support: Very frequent visit and calls with CHW
Functional Limitations: Regularly go through mail and documents with CHW, referred to GED classes
Psycho-Social Factors:
Family: Coached to focus on what he can control
Housing: Assistance applying for subsidized housing
Transportation: Taught how to use Logisticare
Financial: Guided though SSDI process, lawyer referral
Behavioral Health: Coached to partial hospitalization
Current Triage Score: 11
Utilization: 2 ER visits in 2018, none for headache/dizziness
Health Conditions/Literacy:
Following PCP recommendations, going to acupuncture, reports improvement in symptoms.
Care Coordination: Going to appointments
Social/Emotional Support: Still checks in regularly with CHW and engaged with immigrant community.
Functional Limitations: started driving again, enrolled in GED class over the summer.
Psycho-Social Factors:
Financial: Got SSDI on appeal
Family: Paid for daughters’ school tuition, eased strain with family
Housing: On list for public housing, has good priority standing
Transportation: Starting to drive again, uses Logisticare as needed.
Behavioral Health: Much improvement in mood.

27. Patients Say CHT Helped Them Acquire:
Whatever was needed:
“I pleaded with the electric company. ‘My mom will die without her oxygen. What am I supposed to do?’ And they're like, ‘Not our problem.’ So I called [CHT staff]. I was basically panicking. And she was like, ‘Nope, just let me handle it.’ And she just called them, and twenty minutes later the guy was right back -- turned it right back on.”
Psychological and substance abuse counseling
“[CHT staff person] just called all kinds of therapists until she could find one that had an opening that would take me because they're all, ‘Oh we're not taking new clients.’”
Food
Clothing
Furniture
Medical equipment
Correctly sized wheelchair
Nutrition information
Adult day care
Parenting classes
CNA
Legal representation
Affordable medication
Safer, nicer housing
Transportation
Medical information
Medical appointments
Benefits
Resources for family members
Utilities payment assistance

28. Next Steps
CHT
Promoting a multi-payer, statewide network that would serve a public utility by being payer blind
Working with EOHHS and AEs to determine how CHTs can help AEs and Medicaid meet requirements for:
* managing risk
* avoiding duplication of care coordination efforts
* addressing BH and SDOH
SBIRT
- Funding SBIRT through 2021 via SAMHSA grant opportunity
Embedding ‘Train the Trainers’ into organizations doing SBIRT
Connection on OHIC Integrating BH Workgroup
Continuation of SBIRT Training and Resource Center under SOR

29. Questions