1. ACC Program Best Practices & Clinical Transformation Meeting Wednesday, February 27, 2013 5:00 - 7:30 PM

2. ACC Program Best Practices and Clinical Transformation Meeting Agenda Adjourn 5:00 PMRefreshments 5:15 PMIntegrating Behavioral Health into Primary Care Practice Deb Parsons, MD Medical Director, Region 3 5:30 PMA Roadmap : Pediatric Primary Care and Behavioral Health Services Integration Lydia M. Prado, PhD; Yvette Buxton, MD; Dawn Wilson-Davenport, PhD; and Rachel Lund, LCSW The Mental Health Center of Denver RMYC/MHCD Behavioral Health Integration: Provider Perspectives Lori Cohn and Kim White, MD Rocky Mountain Youth Clinics Yvette Buxton, MD and Rachel Lund, LCSW Mental Health Center of Denver Additional Perspectives 7:30 PMAdjourn

3. Upcoming Region 3 & 5 Meetings of Interest  March 20th: Information and Operations Meeting, NEW TIME! 1:00 pm - 3:00 pm  Colorado Access, Denver Highlands (Clock Tower) Building, 1st floor, 10065 E. Harvard Ave., Denver, CO 80231  May 7th: Colorado Access Performance Improvement Advisory (Medical and Behavioral Quality Improvement) Committee Meeting, 6:00 pm - 8:00 pm  Colorado Access, Denver Highlands (Clock Tower) Building, 6th floor, 10065 E. Harvard Ave., Denver, CO 80231  May 22nd: Best Practices and Clinical Transformation Group, 5:00 pm - 7:30 pm  Colorado Access, Denver Highlands (Clock Tower) Building, 1st floor, 10065 E. Harvard Ave., Denver, CO 80231

4. Meeting Resources on VC3  Meeting Webpage  http://vccc.co/index.php/2-27-2013-acc-bpct-meeting http://vccc.co/index.php/2-27-2013-acc-bpct-meeting  Videos of tonight’s presentations  Downloadable presentations  Opportunity to blog about tonight’s topic  Past Meetings  November 28, 2012  http://vccc.co/index.php/11-28-2012-acc-bpct-meeting http://vccc.co/index.php/11-28-2012-acc-bpct-meeting  August 29, 2012  http://vccc.co/index.php/8-29-2012-acc-bpct-meeting http://vccc.co/index.php/8-29-2012-acc-bpct-meeting

5. Best Practices and Clinical Transformation Group Mission, Vision, and Values Mission:To align with IHI’s Triple Aim of improving health outcomes and patient experiences of care while controlling the costs of care. RCCO 3 & 5 will focus on 3 cost areas by:  Reducing unnecessary ED utilization,  Reducing unnecessary hospital readmission,  Reducing unnecessary high cost imaging. Vision: For everyone to have the right care at the right time from the right provider. Values: Clinical transformation is ‘patient-centric’; clinical transformation is ‘provider-led’; clinical transformation nets ‘value.’

6.  Endorse and support the “Tenets of Engagement.”  Collect, analyze, interpret and act on individual and collective data.  Contribute to the Best Practices and Clinical Transformation Group through demonstrations, presentations and adoption of best practices.  Communicate with RCCO partners, learn from PCMP efforts, and educate and inspire colleagues through regular use of the VC3, the web-based RCCO Virtual Community for Collaborative Care.”  Mobilize the ‘will for change’ through community engagement Best Practices and Clinical Transformation Group Goals & Strategies

7.  We are a Sharing and Learning community…with shared vision, shared values and shared aims.  We are leaders and we lead the improvement efforts.  We are committed to change even if it is not comfortable.  We move from ‘mine’ to ‘ours’ as our incentives become aligned.  Our culture is based on relationships that are trusting, respectful, open-minded, mutually supportive and non-competing.  We believe that information that transforms care should not be proprietary.  We engage in healthy dialogue such that the status quo is challenged and new ideas are respectfully and critically analyzed. Best Practices and Clinical Transformation Group Tenets of Engagement

8.  Our focus is on the whole patient.  The patients’ perspective is the most important perspective to consider.  Priority is given to relationships between providers and patients and we help these thrive.  We endeavor to expand and build collaborative relationships between all stakeholders including but not limited to primary care, specialty care, mental health, hospitals, long term care, payers.  We embrace the concept of ‘team’, and include patients and community members on the team.  We will build a ‘think tank’ or ‘clearing house’ for best practices in transforming care. Best Practices and Clinical Transformation Group Tenets of Engagement Continued

9. Integrating Behavioral Health into Primary Care Practice  Deb Parsons, MD Medical Director, Region 3

10. Integrating Behavioral Health into Primary Care Practice  MH conditions result in disproportionate bad outcomes in physical health  Acute and chronic medical disease can initiate a MH illness or exacerbate one

13. Diagnostic Codes included in “Mental Health” Condition  Attention Deficit / Hyperactivity Disorder  Bi - Polar Disorder  Chronic Stress and Anxiety Diagnoses  Conduct, Impulse Control, and Other Disruptive Behavior Disorders  Depression  Depressive and Other Psychoses  Eating Disorder  Major Personality Disorders  Schizophrenia

14. Diagnostic codes included in M1 conditions and masked in the data  Alcohol a/or Drug Services  Alcohol a/or Drug Training  Alcohol a/or Drug Screening  Alcohol a/or Drug Assessment  Alcohol a/or Drug Prevention  Alcohol a/or Drug Hotline  Alcohol a/or drug Halfway House, Per Diem  Alcohol/drug Abuse Svc Nos  Alcohol a/or Drug Intervention  Alcohol a/or Drug Outreach  Alcohol/drug Screening  Alcohol/drug Service 15 Min, 30 min, etc.  Alcohol/drugTx Program, Per hr; pr diem  Assay Of Amphetamines  Assay Of Barbiturates  Assay Of Benzodiazepines  Assay Of Breath Ethanol  Assay Of Cocaine  Assay Of Dihydrocodeinone  Assay Of Dihydromorphinone  Assay Of Ethanol  Assay Of Methadone  Assay Of Opiates  Assay For Phencyclidine  Pt Education Noc Individ  Family/couple Counseling  Day Treatment For Individual  Treatment Plan Development  Pt Edu Re Alcohol Drinking Done  Pt Screened For Inj Drug Use  Pt Tlk Psych & Rx Opd Addiction  Pt Talk Psychsoc&rx Oh Dpnd  Ambulatory Setting Substance  Program Intake Assessment  Eval Self-Assess Depression  Child Sitting Services  Drug Confirmation  Drug Screen Qualitate/multi  Test For Chlorohydrocarbons  Chromotography Quant Sing  Quantitative Assay Drug

16. Lydia M. Prado, PhD Yvette Buxton, MD Dawn Wilson- Davenport, PhD Rachel Lund, LCSW The Mental Health Center of Denver A ROADMAP : PEDIATRIC PRIMARY CARE AND BEHAVIORAL HEALTH SERVICES INTEGRATION

17.  Consultation  Co-Location  Case Management Driven Models  Integrated Service Models Primary care has behavioral health specialists, embedded in their practice, who can assess and work with children and families, providing promotion, prevention, early intervention and treatment services in partnership with the primary care provider/s. SERVICE INTEGRATION APPROACHES

18.  “One of the best indicators of risk for emergence of mental illness in the future is the presence of parental or caretaker concern about a particular child’s behavior. Primary care offices can screen for risk by routinely inquiring about parental concern. The prevention of mental illness and physical disorders and the promotion of mental health and physical health are inseparable.” National Research Council and Institute of Medicine (2009) WHY INTEGRATE?

19. “Integrated primary care combines medical and behavioral health services to more fully address the spectrum of problems that patients bring to their primary medical care providers. It allows patients to feel that, for almost any problem, they have come to the right place.” Alexander Blount, Ed.D., Director, Center for Integrated Primary Care WHY INTEGRATE?

20.  Primary Care: Client population/demographics Staffing patterns Specific concerns/mental health needs Payer sources EMR provider What are the primary goals of primary care/behavioral health integration? Who are the champions for service integration? How will this model be funded?  Behavioral Health: Services available Staff allocations How can behavioral health be most helpful? ASSESSING FEASIBILITY: INITIAL DISCUSSIONS

21.  Practice Management (screening, well visits, scheduled consultations, unscheduled consultations, therapy)  Credentialing  Scheduling/practice pace  Consent to treatment/mandatory disclosure  Modifications to the electronic medical record  Documentation  To bill or not to bill  Outcomes measurement  Sustainability ADDRESSING SYSTEMS AND PRACTICE CHANGES

22.  Role clarification  Documentation/Coding/Confidentiality  Billing (Who, what, when, how)  Contracting  Hiring  Onboarding  Reporting and supervisory relationships  Ongoing communication, check-in meetings  Outcomes: care outcomes, cost outcomes, data capture; patient, provider, family perspectives? ADDRESSING THE DETAILS

23.  How is it going for patients, providers, behavioral health consultant, front desk staff?  What’s working?  What can be improved?  Is the infrastructure supporting data, outcome and billing requirements?  Are we able to do what we set out to do? FEEDBACK LOOPS

24.  Clinical Practice  Practice Management Skills  Consultation Skills  Documentation Skills  Team Performance Skills  Administrative Skills THE BEHAVIORAL HEALTH CONSULTANT: CORE COMPETENCIES

25. + Rocky Mountain Youth Clinics: Lori Cohn, Director of Social Services and Kim White, Pediatrician Mental Health Center of Denver: Yvette Buxton, Psychiatrist and Rachel Lund, Clinical Social Worker RMYC/MHCD Behavioral Health Integration: Provider Perspectives

26. + What is the impact for the medical providers? “Health is a state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.” World Health Organization, 1946  Increased confidence to bring up issues  Increased confidence discussing issues  Strong belief that families will get the help they need  Increased understanding of how to identify BH issues  More time to address medical problems  Greater ease for patients  Reduced excuses not to engage  Trust by association  Truly feel that services are comprehensive  Tremendous benefit of intervention in the moment  Less “burdened"

27. + Provider collaboration/intervention case studies

28. + C is an 11 year old boy  Mom contacted the clinic after a friend of the family committed suicide  Mom expressed concern that C seemed very sad  In clinic BH provider completed an assessment  Determined he was likely experiencing normal grief process  Intervention included drawing pictures about his feelings; he reported a positive effect  Upon return to the clinic; -sadness was improved -expressed understanding about how future events could also make him sad -should that happen, he acknowledged the ability to implement coping strategies

29. + R is a teen boy  History of anxiety symptoms of ruminative thoughts/fears that impact functioning at home and school  Trouble falling asleep secondary to these worries & poor academics secondary to difficulty focusing  Several therapeutic sessions with BH provider focused on cognitive/behavioral techniques to address anxiety symptoms  Patient and father very engaged in this therapy  Some improvement, but symptoms continued to significantly impact home and school functioning  Child psychiatrist asked to evaluate patient; generalized anxiety disorder diagnosed  By history, also concern of long-standing attention deficit disorder -diagnosed  Additionally, client diagnosed with tic disorder, present for several years, with moderately severe facial tics.  Patient started on Tenex and work with BH provider continues  Combination of therapies resulted in greatly reduced anxiety, resolution of insomnia, improved focus and school functioning, and minimal decrease in facial tics  To further address tic disorder-recommendation of neurology consult

30. + L and A are 7 and 8 year old sisters  Both have some medical concerns and are acting out at home  Mom struggles with managing their behavior, getting them to go to sleep and to wake up Behavioral Health Intervention:  discussed some strategies  assessment of the situation revealed complex family issues  determined they needed services beyond what could be managed in the clinic  facilitated connection to MHC  medical and BH providers consult regularly about this families issues; as they continued to struggle with academic and mental health follow through  Primary care is greatest point of consistency and support

31. + M is a 16 year old girl  Presents in clinic with request for pediatrician to take on prescribing of psychiatric medications  Recently discharged from the hospital on antidepressant  Ongoing treatment with outside MH therapist, no current outpatient psychiatric care.  Medical provider asked child psychiatrist to join appointment  Patient revealed that she had increased suicidal ideations and showed providers her arms with dozens of cuts upon them  Psychiatrist coordinated with outside therapist and hospital for readmission

32. + D is a 7 year old boy  Clinic visit centered around discussion of behavior problems at school  Difficulty sitting still, impulsive and behind in school work  Also active at home but doing better with mom and grandma involved and concerned  Discussed some strategies which they tried but without significant improvement  Complete assessments; including Vanderbilt(s)  Positive for ADHD and ruled out other concerns  Discussed intervention strategies including medication  Consultation with medical provider resulting in joint session with family  Decision to try a small dose of meds.  D has improved greatly BH and medical providers continue joint meetings for follow up and support

33. + “I have learned that success is to be measured not so much by the position that one has reached in life as by the obstacles which he has had to overcome while trying to succeed.” ~Booker T. Washington

34. Additional Perspectives

35. Adjourn  Next ACC Program Best Practices and Clinical Transformation Meeting  May 22, 2013  5:00 pm - 7:30 pm