1. Integrating Behavioral Health

2. Wallowa County Patient Activation Project Partners Winding Waters Medical Clinic Wallowa Valley Center for Wellness Northeast Oregon Network Services Added Nurse Care Manager (Certified Diabetic Educator) Behavioral Health Coach Project period 11/1/13 through 10/31/16 Small Practice Quality Improvement Grant

3. Patient Characteristics Who has diseases or disease risk factors? How are they identified? Who has insurance? Does insurance status affect referral? Who accesses BHC services? Once patients access services do they continue?

4. Patients by Age. N=441

5. Patients by Payer. N=441

6. Patients by Referral Status 58% 17 % 22% 2.4%

7. Avg. Visits by Age Cohort. N=349

8. Patients with >1 BHC visit. N-=349 N=7 N=32 N=85 N=16 N=14 N=81 N=73 N=41

10. FU vs. no FU by Payer

11. FU vs. no FU by Age Cohort N=21 N=22 N= 34 N=12

12. FU vs. no FU by DX/Risk Factor N=111

13. How do we evaluate if we impact outcomes? BMI Blood pressure HgbA1c CAHPS Surveys

14. Improving Quality Indicators

15. RN Care Manager and Behavioral Health Coach in Action

17. Effects of BHC on BMI 60% of obese patients lost weight Average decrease in BMI was 0.8 for all patients There seemed to be a “tipping point” after 7 visits PRIMARY PREVENTION

20. Effects of program on BP Average blood pressure decreased by 2 points for all patients, 2.5 points for patients with HTN Went from 56% patients at target to 65.5% of patients at target (<140/90) Goal is >70% of patients at target

23. Effects of the program on diabetes control HgbA1c at goal increased from 64% to 74% LDL at goal increased from 54% to 61%

24. How do we change standard work to support this work? Staff education/engagement Show the data

25. Patients w at least 1 FU visit

30. All Patients

31. Patient Satisfaction Data

40. Stages of Integration

41. Questions? Janet Graham MA – Behavioral Health Coach janet@windingwatersclinic.org Keli Christman – Operations Officer keli@windingwatersclinic.org Liz Powers MD – Clinician drpowers@windingwatersclinic.org

42. EXTRA SLIDES (Not used)

43. Avg Change BMI; >1 visit# of Patients Avg Change BMI; no visits# of Patients <= 17 years-0.3560.352 18 - 34 years-1.1542-0.3211 35 - 49 years-0.65420.3610 50 - 64 years-0.9998013 65 - 74 years-0.7261-0.336 75+ years-0.9323-0.432

44. BMI Change Comparison Patients w no FU visits N=55 Mean BMI change: -.05 Min. BMI change: - 2.63 Max BMI change: 4.08 Patients w at least 1 FU visit N=331 Mean BMI change: -.88 Min. BMI change: - 7.82 Max BMI change: 5.5

47. SBP and DBP Change Comparison Patients w no FU visit N=56 Mean Change in SBP:.678 Min. SBP Change: -34 Max. SBP Change: 27 Mean DBP Change:.232 Min. DBP Change: -17 Max. DBP Change: 20 Patients w at least 1 FU visit N=332 Mean Change in SBP: - 1.80 Min. SBP Change: -101 Max SBP: 41 Mean DBP Change: -1.34 Min. DBP Change: -37 Max. DBP Change: 42

48. Tobacco Cessation Offered