© 2010 NC Center of Excellence for Integrated Care icarenc.org 1 1 NC Center of Excellence for Integrated Care: Advocates for Practice Change Regina Dickens, Ed.D., LCSW Maria Dover, MS, LMFT

© 2010 NC Center of Excellence for Integrated Care icarenc.org 2 CJ Peek, PhD What is our history?

© 2010 NC Center of Excellence for Integrated Care icarenc.org 3 The North Carolina Center of Excellence for Integrated Care builds on the work of a Foundation- sponsored program, The ICARE Partnership, which pioneered the integration of care in primary care practices between 2006 and 2010 through a broad inter-agency, multi-disciplinary partnership.

© 2010 NC Center of Excellence for Integrated Care icarenc.org 4 Rene Descarte (1641) Philosopher & mathematician Commonly given credit for establishing separate domains for the physical and mental-- and the philosophical basis for the "mind-body split". CJ Peek, PhD

© 2010 NC Center of Excellence for Integrated Care icarenc.org 5 “Integrated Care” is an effort to better match or blend clinical services to the realities that patients and their clinicians face daily.” Medical Care Behavioral Health Care A legacy of separate and parallel systems A forced choice between: Two kinds of problems Two kinds of clinicians Two kinds of clinics Two kinds of treatments Two kinds of insurance CJ Peek, PhD

© 2010 NC Center of Excellence for Integrated Care icarenc.org 6 Why the system doesn’t work…

© 2010 NC Center of Excellence for Integrated Care icarenc.org 7 Common clinical presentations don’t stay neatly in those medical or BH boxes Behavioral / psychosocial is part of medical care 70% of all PC visits have psychosocial drivers 50% of all BH care is done by PCP’s 67% of all psychoactive drugs prescribed by PCP’s Referral to BH/CD hard to navigate; often doesn’t connect CJ Peek, PhD

© 2010 NC Center of Excellence for Integrated Care icarenc.org 8 Untreated Depression = More Healthcare Use Depressed patients use 3 times more healthcare services Depressed patients have 7 times more emergency visits Depression is associated with longer hospital stays

© 2010 NC Center of Excellence for Integrated Care icarenc.org 9 Trauma associated with Intoxicant Use: In 2005, up to 60% of US trauma center patients tested positive for one or more intoxicants Of these 1 in 4 had a second drug and alcohol related injury in the same year. Maier, 2009

© 2010 NC Center of Excellence for Integrated Care icarenc.org 10 NC primary care providers (PCPs) and behavioral health providers agree that: There is difficulty finding a referral for publicly or uninsured patients There are few opportunities to develop relationships with primary care providers There is a huge benefit to community psychiatrists being available for consultation and establishing a working relationship with the PCPs.

© 2010 NC Center of Excellence for Integrated Care icarenc.org 11 One Solution is Integrated Primary Care Integrated primary care is a service that 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 A definition…

© 2010 NC Center of Excellence for Integrated Care icarenc.org 12 A look at integrated care…

© 2010 NC Center of Excellence for Integrated Care icarenc.org 13 Patient Centered Care includes: INTERNAL COLLABORATION OPERATIONAL CLINICAL FINANCIAL - quality care - patient driven -systems -organization -process improvement - coding - billing - reimbursement

© 2010 NC Center of Excellence for Integrated Care icarenc.org 14 Patients Medical Records Nurses and medical assistants Receptionists Psychiatrists Behavioral Health Therapists Physician ON-SITE Integrated Care Team All supported by common chart, documentation standards, billing procedures, and clinic management system NP’s PA’s

© 2010 NC Center of Excellence for Integrated Care icarenc.org 15 Integrated Care Program Nurse screens clients at establish care and annual appointments Physician sees client and validates screening Physician introduces client and therapist Physician and therapist provide team approach for coordinated care ▪Screening ▪Assessment ▪Brief supportive counseling ▪Therapy ▪Case management ▪Medication monitoring ▪Coordinated team care Behavioral Health Services integrated with Primary Health Care:

© 2010 NC Center of Excellence for Integrated Care icarenc.org 16 Integrated Care Works Randomized Control Trials demonstrate: More effective medication treatment Reduced depression severity Improved general health status Decreased disability Better occupational function Improved patient satisfaction Cost-effectiveness

© 2010 NC Center of Excellence for Integrated Care icarenc.org 17 Our Current Projects

© 2010 NC Center of Excellence for Integrated Care icarenc.org 18 CHIPRA: A Quality Demonstration Grant The CHIPRA statute mandates the ‘experimentation’ and ‘evaluation’ of several promising ideas related to improving the quality of children’s healthcare. Slide by Stacy Warren

© 2010 NC Center of Excellence for Integrated Care icarenc.org 19 Needs of America’s Children American children experience worse health and higher levels of mortality than do children from most other developed nations and receive recommended care only 42% of the time UNICEF, The State of World’s Children, 2009 (visited April 10,2009 Mangione-Smith R, Decristofaro A, Setodji C, Keesey Jl, Adams The Quality of Care Received by Children and Adolescents in the US. Pediatric Academy Societies, E-PAS2006:59: Slide by Stacy Warren

© 2010 NC Center of Excellence for Integrated Care icarenc.org 20 Medicaid Enrollees on the Rise In 2009, 60 million people were on Medicaid and over half of them were under in every 4 American children are on Medicaid Approximately 31% of NC children are on Medicaid Slide by Stacy Warren

© 2010 NC Center of Excellence for Integrated Care icarenc.org 21 Center for Medicare and Medicaid Services (CMS) is committed to demonstrating improvement in Medicaid/CHIP systems through: The synthesis of data and activities from diverse Medicaid/CHIP systems Providing Technical Assistance to States Tracking improvement using metrics This includes addressing health care disparities, long term health care needs supports and services and builds on the synergy and coordination of efforts with public health agencies, education and mental health care systems to improve the health care outcomes for children. Slide by Stacy Warren

© 2010 NC Center of Excellence for Integrated Care icarenc.org 22 CHIPRA Categories: A - Experiment with and evaluate the use of new and existing measures of quality for children B – promote the use of health information technology (HIT) for the delivery of care for children C – evaluate provider-based models to improve the delivery of care D – demonstrate the impact of model pediatric EHRs (electronic health records) E – creating targeted models to demonstrate their impact on health, quality and cost.

© 2010 NC Center of Excellence for Integrated Care icarenc.org 23 Category A Core Measures NC will use its Community Care infrastructure to implement and evaluate the use of the new set of 24 quality measures identified by AHRQ and CMS. NC will expand upon the current data collection system to incorporate the core set of children’s health measures and will work with local practices on the implementation, feedback and the meaningful use of the quality information for improvements in performance.

© 2010 NC Center of Excellence for Integrated Care icarenc.org 24 CHIPRA Category A Measures Update Categories for the 24 Core Measures –Prenatal, Immunizations, Screening, Well Child Visits, Dental, Availability, Upper respiratory, ED, Inpatient Safety, Asthma, ADHD, Mental Health, Diabetes, Family Experience Unique to North Carolina –EPSDT Report Card, Dental Varnishing, MCHAT, Adolescent and School Age Screening, Obesity, Foster Care Kids Linked to a Medical Home Reporting Timeline –Reporting a subset of the measures annually to CMS as of 12/2011 and quarterly to practices starting 6/2011

© 2010 NC Center of Excellence for Integrated Care icarenc.org Core Measures Three stages of progress…. We’re currently reporting on 8 of the 24 core measures requested by CMS through the IC. We’re attempting to report on an additional 8 of the 24 core measures using paid claims. Working with DMA, SCHS and Vital Records to capture the remaining eight measures. Potential roadblocks… The identification of current sources for PICU/NICU data CAHPS is only reported once every three years Transition from old to new systems makes data collection problematic..immunizations and birth certificate data It’s difficult to identify CHIP recipients in the claims system

© 2010 NC Center of Excellence for Integrated Care icarenc.org 26 New Measures EPSDT Report Card – Lead, vision, well visits, developmental screening, autism Dental Varnishing –Pediatric preventive measure from IC Reports X 3 –MCHAT, School Age Screen, Adolescent Screen Obesity –Follow up for clients with an obesity diagnosis Foster Care –Kids Linked to a Medical Home

© 2010 NC Center of Excellence for Integrated Care icarenc.org 27 Quality Improvement Quality Improvement will focus on… MeasureDescription #7Weight assessment for children/adolescents #8Screening for social/emotional development #10 - #12Well Child Visits for 15 months, 3-6 years and 12 – 21 years #18ED Utilization Unique to North Carolina:Dental fluoride varnish, Follow-up for obesity, MCHAT, School Age and Adolescent Screening

© 2010 NC Center of Excellence for Integrated Care icarenc.org 28 Reporting Reporting to CMS through CHIP Annual Reporting Template (CARTS) system Reporting to practices through Provider Portal

© 2010 NC Center of Excellence for Integrated Care icarenc.org 29 Category C--CHIPRA ‘Connect ’ NC will strengthen the medical home for children and youth with special health care needs (CYSHCN) by testing and evaluating provider-led, community-based models that will identify, treat and coordinate the care of CYSHCN, particularly children with developmental, behavioral and /or mental health disorders Slide by Stacy Warren

© 2010 NC Center of Excellence for Integrated Care icarenc.org 30 CHIPRA Connect  Demonstrate a provider-based model of care for CYSHCN by testing and evaluating provider-led, community- based models  Practices will utilize the AAP Mental Health Toolkit  Emphasis on linkages and reliable communication systems

© 2010 NC Center of Excellence for Integrated Care icarenc.org 31 CHIPRA CONNECT PROJECT Learning Collaborative for Cohort I begins PCMH Certification Medical Home Learning Collaborative for Cohort II begins Obesity Oral Health PCP Pre-Work Mental Health Toolkit Obesity Oral Health Risk Stratification Tool

© 2010 NC Center of Excellence for Integrated Care icarenc.org 32 Cohort 1 Participants Community Care of the Sandhills Dr. Masoud Ahdieh ABC Pediatrics Sandhills Pediatrics Harnett County Health Department AccessCare Goldsboro Pediatrics Community Care Plan of Eastern Carolina Washington Pediatrics Surf Pediatrics Northwest Community Care Network Surry County Health and Nutrition Center Kids Count Pediatrics Westgate Pediatrics Robinhood Pediatrics

© 2010 NC Center of Excellence for Integrated Care icarenc.org 33 Each strategy will propel quality improvement both independently and in concert with the other strategies A Quality Measures C Medical Home Measures enable ongoing, flexible tracking of Medical Home Impact Medical Homes provide data on feasibility, cost and value of measures EHR supports Medical Home implement quality care EHR enables will enable efficiencies and timely tracking and meaningful use of quality measures Measures inform and evaluate impact of EHR Medical Homes will drive service-oriented, quality EHR development D Pediatric Electronic Health Record Slide by Stacy Warren

© 2010 NC Center of Excellence for Integrated Care icarenc.org 34 Category D-Pediatric Electronic Health Record Existing EHR systems often do not optimally support the provision of health care to children. The goal of Category D is to develop a model EHR Format for children, demonstrate that it can be readily used, and package it in a way that facilitates broad incorporation into EHR systems. NC, through its Community Care program, will work closely with the NC Regional Extension Center (REC) in the implementation of the model Electronic Health Record for Children (EHR). PEHR consultants in all 14 Networks will work with providers/medical homes interested in implementing the model PEHR.

© 2010 NC Center of Excellence for Integrated Care icarenc.org 35 How do we implement practice change?

© 2010 NC Center of Excellence for Integrated Care icarenc.org 36 Steps to Practice Change Identify and Convene stakeholder groups to: –Design/update needs assessments for each targeted practice group –Identify current and emerging evidenced based best practice models –Set quality assurance/ model fidelity measures for targeted practice areas –Monitor the process –Identify ways to improve family involvement in healthcare

© 2010 NC Center of Excellence for Integrated Care icarenc.org 37 Steps for Practice Change (continued) Establish learning collaboratives Establish a cadre of experts to deliver training and TA Establish Evaluation Protocols with outside Evaluator to monitor Center of Excellence goals and outcomes Establish procedures to monitor lessons learned and adjust for needed changes on a quarterly basis

© 2010 NC Center of Excellence for Integrated Care icarenc.org 38 How Can Families Be More Involved?

© 2010 NC Center of Excellence for Integrated Care icarenc.org 39 The Medical Home Family Index Purpose: to better understand how families of children and youth with special healthcare needs view the services they receive from their PCP. As a practice moves to become a ‘Medical Home’ it is important to capture how the family perceives those efforts and where there is room for improvement. Ex. of question: I am asked by our PCP how my child’s condition affects our family (impact on siblings, the time my child’s care takes, lost sleep, extra expenses, etc). Survey is provided in both English and Spanish.

© 2010 NC Center of Excellence for Integrated Care icarenc.org 40 CHIPRA TEAM Dr. Marian Earls, Physician Champion Stacy Warren, Project Director (919) Janie Shivar, Category A Clinical Coordinator (919) Marla Satterfield, CHIPRA Connect Pediatric Program Manager (919) Maria Dover, CHIPRA Connect Clinical Coordinator (919) Kern Eason, Category D Pediatric EHR Consultant (919)

© 2010 NC Center of Excellence for Integrated Care icarenc.org 41