The Evolution of Integrated Care at Kaiser Permanente Colorado: Challenges and Opportunities Arne Beck, PhD Director of Quality Improvement & Strategic Re search, Kaiser Permanente Colorado Joanne Whalen, PsyD Behavioral Medicine Specialist, Kaiser Permanente Colorado Jo Anne Doherty, MS, RN, APN Director of Mental Health, Kaiser Permanente Colorado Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session #D5a Friday, October 11, 2013 or Saturday, October 12, 2013

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

Objectives Describe integrated care programs at KPCO. Understand issues related to implementing integrated care at KPCO, including clinician roles, work flows, and use of electronic medical records data for population management and clinical trial recruitment. Discuss the variety of integrated care models used in KPCO for primary care and for specific populations.

Behavioral Medicine Specialist (BMS) Program Business case for BMS Currently 11 BMS clinicians serving KPCO primary care clinics BMS involvement with population based programs and specialty care

BMS Program Evaluation Evaluating reach and impact of BMS program through grant from the Colorado Health Foundation – qualitative data from BMS via online diary entries and patient feedback – tracking of BMS data from EMR on visits, assessments, and referrals over time from start of BMS introduction to clinic. Visit stats Primary care provider survey of value of BMS services

How Has BMS Changed Clinical Practice? Qualitative Feedback PCPs note that with BMS in their medical practice, they will screen for depression and anxiety on "all their patients“… Rationale is that with BMS in the clinic to address these issues, they are not afraid to look for these. I can obtain an immediate consultation without waiting, so I manage my patients better, and it’s a more efficient use of Behavioral Health services and my time. I made very few referrals to BH before, so having the BMS here has increased the number of patients seen for BH issues and access to BH has increased. I can offload BH issues to the BMS, otherwise I’d be putting these patients on prescriptions.

How Has BMS Changed Clinical Practice? Qualitative Feedback It gives the BH department a face and a name, so it’s great for parents when I need to refer their child to BH. We do the PHQ-9 screen on the phone, and can schedule patients whom we know have anxiety or depression for appointments when the BMS is available. It’s helped with outreach to patients both before and after and increased the compliance rate of those referred to BH who actually go. We have a better BH capture rate.

Patient Feedback "I want to thank you from the bottom of my heart for giving me the opportunity to see the BMS. She has been such a supportive, warm, caring person who distills the information I give her and makes sense of how I can navigate my emotional landscape. She has been a pillow for my worrisome and sad mind. I always feel safe with her, and her kind attention to my issues. She is equally a pillar of common sense and strength during the Bereavement Group that I attend each month I will be forever grateful to you, her and Kaiser for providing this service of counseling for those of us who grieve the loss of a spouse or dear family member."

Primary Care Provider Survey: BMS functions Adding The Most Value to Clinical Practice average rankN curbside consults (2.67) help PCP with CD patients (2.50)2.508 help PCP decide about medication options (2.44)2.449 help clarify BH diagnosis (2.15) see patients same day (2.13) outreach difficult-to-reach patients (2.00)2.006 help refer patients to BH or Medicaid providers (1.98) manage patients with straightforward BH concerns (1.95) manage complex patients (1.71) manage patients in crisis (1.64)1.6475

Care of Physical, Mental, And Substance Use Syndromes (COMPASS) CMMI-funded innovation involves integrated care for patients with depression and poorly controlled diabetes or heart disease. Care managers, behavioral health clinicians, and primary care teams provide collaborative care to improve patient outcomes and reduce risk for hospital admission.

Early Lessons with COMPASS COMPASS fills gap for complex patients with chronic illness and high psychosocial needs Use of EMR to identify and outreach patients and as virtual integration tool Engagement with primary care and care management teams to promote COMPASS referrals Phone-based BH interventions Provider and patient feedback

Prevention And Treatment Of Perinatal Depression Use of Edinburgh Postnatal Depression Scale (EPDS) – EPDS screening process during pregnancy, 2 week well visit, and 6 week postpartum follow up services (BMS, homecare, referral to BH). – improving pediatrician comfort in dealing with positive screens. Staying well - mindfulness and pregnancy study – mindfulness based cognitive therapy groups for pregnant women at risk for depression relapse – sooner identification, intervention and treatment of active symptoms – help reduce risk of post partum depression

Prevention And Treatment of Perinatal Depression Pilot testing mindful mood balance (MMB) web program for pregnant women at risk for relapse

Prevention and Treatment of Perinatal Depression Active Involved Moms (AIM) for wellness – telephonic behavioral activation (BA) for women who screen positive for depression in pregnancy, provided by trained nurse practitioners. – randomized trial at 4 sites (Kaiser Colorado, Kaiser Georgia, Group Health Cooperative in Seattle, and HealthPartners in Minneapolis) comparing BA to usual care for perinatal depression. – outcomes being analyzed include changes in depression symptoms and quality of life over 6 months after study enrollment.

Other Integrated Care Programs at Kaiser Colorado Depression care management Tele-psychiatry Pilot programs (operational or research) – screening for risky substance use in primary care (SBIRT) – using electronic PHQ9 item 9 data to predict suicide risk and developing interventions for these patients – using EMR data to identify first episode psychosis for early intervention

Issues Related To Implementing Integrated Care At KPCO Clinician roles Referrals, making seamless care transitions Scope of practice (is it therapy or coaching?) Work flows, incorporating EMR as integration tool Short vs. longer term patient management Importance of case conferences for complex patients

Issues Related To Implementing Integrated Care At KPCO use of electronic medical records data and other technologies for population management and clinical trial recruitment (Big Data) How to coordinate multiple integrated care efforts/programs across KPCO – Providing right care when and where the patient needs it

Learning Assessment Audience Question & Answer

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