1. Behavioral Health/Pediatric Primary Care Integration at Geisinger: Year 1 Implementation & Evaluation Shelley Hosterman, PhD Paul Kettlewell, PhD Christine Chew, PhD Tawnya Meadows, PhD Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session #D3 October 28, 2011 3:30 PM

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap & Supporting Resources Parents often bring their children to primary care physicians first (Smith, Rost, & Kashner, 1995) 15% to 21% of primary care visits are for behavioral health concerns (Kelleher, Childs, Wasserman, McInerny, Nutting, Gardner, 1997; Lavigne, Gibbons, Arend, Rosenbaum, Binns, Christoffel, 1999; Williams, Klinepeter, Palmes et al., 2004). During 50% to 80% of child health care visits, parents or physicians raise concerns of behavioral or psychosocial issues (Cassidy & Jellinek 1998; Fries et al., 1993; Sharp, Pantell, Murphy, & Lewis, 1992).

4. Need/Practice Gap & Supporting Resources Problems with seeking behavioral health services from PCP: Increased number of medical visits Increased time spent with the physician Lost revenue if a patient takes more time than scheduled Lower reimbursement rate for mental health issues Limited training in mental health treatment (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy, 1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)

5. Need/Practice Gap & Supporting Resources Problems with seeking behavioral health services from PCP: Decreased number of patients seen Increased risk of physician burnout Unsatisfied patients Increased impairment in patient health and functioning Increased use of acute and emergency care (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy, 1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)

6. Objectives Understand the collaborative development process with the Geisinger Health Plan & Pediatric Partners Describe Geisinger’s pilot model Describe program evaluation plans for this project Review baseline data for the program

7. Agenda Developing the model – Process & Supports Details of pilot model Program evaluation & research Baseline data & future directions

8. Development: Previous System Outpatient mental health services, inpatient psychiatric unit, & consultation/liason in major hospital 3 pediatric psychs, 1 family therapist, 1 psychiatrist, 3 pre-doctoral interns, & 2 postdoc fellows Serving all children/adolescent in 5 counties, all patients with Geisinger PCPs, specialty patients Concerns with system: Waitlists, no shows, patient travel, caseloads, problems recruiting psychiatrist

9. Development: Model Prototype Munroe-Meyer Institute – Inspiration for our model University of Nebraska Medical Center; Omaha, NE http://www.unmc.edu/mmi/behavioral/ Joseph H. Evans, Ph.D. Director, Psychology Department Rachel Valleley, Ph.D. Outreach Behavior Health Clinics Coordinator

10. Development: Model Prototype Behavioral health services in primary care 23 outreach clinics across Nebraska Reaching underserved, rural populations Co-located & collaborative clinics Interns/postdocs trained in the setting Education for PCPs Frequent contacts regarding referrals Research & program evaluation Promising outcomes – Discussed later

11. Development: Our System Geisinger Health System - Integrated health network Serves 43 counties; 20,000 sq miles; 2.6 million people Nearly 60 community practice sites across the state System-wide electronic medical record Geisinger Health Plan – Among nation’s largest rural HMOs (270,000 members)

12. Development: Marketing Change Step 1: Approached psychiatry administration (10/09) Response – Excellent concept, but no way to proceed within budget Step 2a: Presentation at psychiatry grand rounds (2/10) Response – Excellent concept Possibility #1 – Private donor looking for a way to support mental health of children/adolescents 2b: Private meetings & additional presentation to private donor secured substantial gift

13. Development: Marketing Change Step 3: Presentation to Pediatric Grand Rounds (03/10) Response – Pediatrics enthused & many requested Step 4: Presentation to Geisinger Health Plan (Spring ‘10) Summary – Model offers better care, may save money, & carve out model of payment does not make sense Response – We agree, what should we do? Key message – They believe is better care & will support if we can break even or save money

14. Development: GHP Proposal Monthly planning meetings with GHP administration Data review process: Medical expenses for pediatric patients with ≥1 BH visit double those of comparison patients Key cost differences: Outpatient, pharmacy, & ED Potential for cost off-set? Outcome: GHP funded pilot project & program evaluation

15. Development: GHP Proposal Proposal objectives: 1.Improve quality of behavioral health care 2.Reduce medical expenses & utilization of patients with BH concerns 3.Increase physician, parent, & patient satisfaction with service model & delivery 4.Expand PCP knowledge of BH assessment & intervention 5.Improve access, adherence, efficiency, & integrity of BH services & intervention

16. Development: Task Force Key stakeholders Review problems & solutions in our system & state Information gathering & review of other models Focus on partnership, collaboration, & consultation to help children & adolescents Electronic survey of primary care providers

17. Development: PCP Survey Most common problems ADHD (77%) Obesity (72%) Depression (57%) Anxiety (47%) Disruptive Behavior (44%) Most want training/assistance ADHD (45%) Disruptive Behavior (43%) Anxiety (32%) Obesity (29%), Depression (26%) Eating Disorders (26%)

18. Development: PCP Survey Barriers to service: No local resources (94%) Getting appt (55%) Insurance issues (46%) Travel for families (35%) No time to address (24%) No training (20%) Patient Follow (11%) No collaboration (11%) Desired Models: On-site services (76%) Training in assessment & diagnosis (65%) Medication consults (64%) Screening tools (49%)

19. Development: Task Force Follow-up interviews with primary care: Additional input Assess site specific enthusiasm, barriers, and % GHP Identified three sites  Presented to CPSL Three goals: 1.Behavioral health providers on-site in PCP sites 2.Support PCPs with screening tools & training 3.Case consultation with child/adolescent psychiatrist

20. Clinic Structure: Team Planning Team planning meetings – Psych & PCPs, office staff Shadowing PCPs Billing discussions REACH Institute training – PCPs & Psych’s together – Focus on screening & psychopharm

21. Clinic Structure: Services Report templates: Concise, completed during visit, structured for brief review Clinician schedules: 1 psychologist + 1 psychology fellow 75 min evals, 45 min returns 75% scheduled – Always available to PCP Warm hand-offs & consultations: Join visits, education, pass patients on, simple recommendations, immediate eval Tracking details

22. Clinic Structure: Services Handouts – Common for psychologists & PCPs Crisis evaluations as needed Communication – Medical record & constant contact Ongoing training for PCP’s Monthly case conferences Presentations on request Relationship building – Join clinic community

23. Clinic Structure: Services Common screening tools Anticipate high-volume issues ADHD evaluations Weight management DBC groups Psychiatry consultation – Case review & phone consultation Electronic screening tools – Results directly in medical record

24. Clinic Structure: Services Brief Case Examples

25. Program Evaluation: Key Domains Satisfaction PCP comfort/knowledge in assessment & intervention Quality of life Clinically significant symptoms Medication use Utilization data Clinic efficiency data Quality of Care v. Practice Standards

26. Program Evaluation: Tools & Predictions Satisfaction: Pre & Post questionnaires for parents & PCPs Includes: Convenience, time to first appointment, Stigma/Comfort Communication with PCP Perceived Benefit Predict increased satisfaction relative to traditional model Comfort and Knowledge: Physician survey Pre & post training, pre-integration, & yearly Predict increases across each measurement

27. Program Evaluation: Tools & Predictions Quality of Life: Peds QL-4 Pre & post intervention School questionnaire – attendance, performance Predict improved QOL & school attendance Predict match results from other CBT outcome studies Clinical symptoms: Target behavior ratings 5 point Likert Scale at every session Dual purpose - research outcomes & tracking treatment goals Most immediate/likely measure of change Predict steady reductions across course of treatment

28. Program Evaluation: Tools & Predictions Medication use Chart review – Pre and post integration, per diagnosis Predictions – More appropriate use (sufficient trials, monitoring change, appropriate match to symptoms) Utilization data: Chart Review # Medical visits: Frequency PCP visits reduced pre v. post Specialist visits: Frequency reduced pre v. post Time to first visit – Reduced delay between physician referral & assessment vs. traditional model in our system Out of network – Pre & post insurance company data. Predict reduced out of network

29. Program Evaluation: Tools & Predictions Efficiency data Time study: Pre, yearly, post Code: Medical, Beh, & Med/Beh visits Appointment duration: no change on medical appointments, less time on behavioral & med/beh Cost savings & cost effectiveness: Pre, yearly, post Predict increase in overall clinic revenue, reduced PMPM cost for patients with BH issues Quality of Care Identify AAP standards of care Chart review assessing adherence with standards

30. Time Study Data Table 1 Minutes Spent Per Visit Type of Concern Percent of Total Visit Types Observed (N) Mean Medical 30114.04 Behavioral 1013.60 Medical and Behavioral 3412.99

31. Results

32. Referral to Pediatric Psychology 2.9% of all patients observed were referred to peds psych 28% of those diagnosed with a psychological disorder were referred to peds psych

33. Baseline data: Referrals & Handoffs ConsultsWarm Handoffs New Appointments Return Appointments Crisis Clinic 119162339 0 Clinic 2233159366 Clinic 3381431353 Total 80611131109

34. Learning Assessment Questions?

35. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!

36. Contact Information Shelley J. Hosterman, PhD sjhosterman@geisinger.edu References available upon request