1. Bi-Directional care integration Work Group
Kyle Roesler, program manager
july 31, 2018

2. Welcome and Introduction
Introduce yourself: Name and Organization
WELCOME

3. Agenda Mention pre-meeting updates Cowlitz Family Health Center
Dian Cooper, CEO
Implementation Plan
Indicators to Track Progress
Psychiatric Consultation Opportunity
AIMS Center Bi-Directional Care Integration training program
Next Steps

4. Cowlitz Family Health Center Behavioral Health Integration

5. Cowlitz Comprehensive Health Care
Unique partnership of 3 nonprofits to provide integrated care – together we served over 50% of the low income population in Cowlitz County
Cowlitz Family Health Center – primary care outpatient
Columbia Wellness – specialty mental health outpatient
Drug Abuse Prevention Center – residential and outpatient substance use disorder treatment

6. Goals Improved access to care; easier to navigate
Reduction of stigma associated with mental illness
Better communication
More focused and streamlined referral process
Improved matching of service to expertise
More efficient use of limited resources
Provider education (learning from each other)
Insights into clinical, structural, funding models
Improved customer service and job satisfaction
improve medical outcomes, reduce health disparities, and lead to medical cost offset

7. What Worked Well Standardized screening tools used in primary care
Behavioral Health Consultants and Psychiatric Nurse Practitioners added to the primary care team
Patients able to access Psych ARNP at primary care clinic
Referral and warm hand-off work flow between organizations improved
Patient services and satisfaction improved
Provider and team satisfaction improved

8. What didn’t Work as Well
More patients screened positive for behavioral health conditions but not ready to accept treatment
Patients were still lost between agencies
Patients dropped out of treatment
Integration of substance use disorder services
Original goal of 3-way merger of the organizations never occurred

9. Projects and Studies that Supported the Alliance
Integrated Comprehensive Intervention and Support Project (ICISP) – 2006
National Council for Behavioral Health Primary Care Collaborative Health Project
Health Systems Resource Grant, State of Washington, Department of Health
Health Systems Resource Grant, State of Washington, Department of Health – 2007
Re-thinking Care Initiative -2009

10. History 2004: CCH Concept is Born 2004: Business Associate Agreements
2004: Memorandum of Understanding
2007: Strategic Alliance
2011: Merger Evaluation
2012: No Merger-Strengthened Alliance

11. Cowlitz Family Health Care and Drug Abuse Prevention Center Merger
CFHC started SBIRT screening in 2011
CFHC and DAPC began operating as an integrated organization in 2014
Integrated Boards of Directors and Merged in 2015
CFHC incorporated outpatient and residential substance use disorder treatment services to our service lines
Columbia Wellness- stand-a-lone with strong inter- agency referral process

12. Substance Use Disorder Continuum of Services
SBIRT in primary care
Adult outpatient SUD assessment and treatment
Adult residential intensive treatment
Pregnant and Parenting Women long term residential treatment for pregnant and parenting women and their children
Parent Child Assistance Program intensive case management for pregnant and parenting women and their children
Phoenix House permanent supportive housing for pregnant and parenting women and their children
Harm Reduction Program (SSP-Syringe Services Pgm)
Medication Assisted Treatment

13. CFHC Integrated Care Today
CFHC is a level 3 patient centered medical home – behavioral health staff are part of the care team
Primary care patients are screened annually or more often if needed (AUDIT, DAST, PHQ, GAD, SBIRT)
Behavioral Health Consultants take warm hand-offs and provide brief treatment
Psychiatric nurse practitioners provide medication management and consultation
Substance use disorder staff take referrals and provide treatment
Harm reduction program includes syringe services, access to substance use disorder and MAT services, primary care and family planning services

14. ? Questions ?
Dian Cooper
(360)

15. Implementation Plan Due October 1, 2018 Key deliverable for CPAA
Requires specific implementation information
As an ACH, we have to submit a project implementation plan that is due October 1st. This is a key deliverable for CPAA to receive funding for year 2 of the Transformation, and will contain more specific information about the project work be implemented in the region. The HCA needs to understand our milestones, individual work steps, outcomes, how we are going to work with partnering providers, and our timeline for completing action steps and milestones. We are actively working on this right now. There is a detailed workbook and narrative portion to the plan. It will take a substantial amount of time to get right.

16. Key Indicators to Measure Implementation
What are the key indicators used by the ACH to measure implementation progress by partnering providers?
Patient-centered team care
Population-based care
Measurement-based treatment to target
Evidence-based care
Accountable care
Review Measures Handout
One of element of our plan is understanding key indicators to measure project implementation. Over the next few years, we have to measure progress for organizations either integrating primary care or behavioral health. The way I’ve been thinking about measuring progress is relying more on these 5 core principles of collaborative care, rather than a specific model. So, under each of these principles is a number of qualitative and quantitative indicators that I want us to review and consider.

17. Psychiatric Consultation
Supports collaborative care team through regular consultation
Advises prescribing medical provider
Caseload review (registry)
Treatment adjustments
Consultation notes
Questions
How can he access their registry for consultation and would he also access the partnering provider’s EHR? Might take some time to set up.
MAT and OUD potential
Looking for around 15 hours per week of psych consultation in CoCM, starting in Nov-Dec
Currently in community-based integrated care fellowship at UW
Only interested in consultation at this point
Preference would be to work in CoCM involving MAT
Next steps
Invite to a work group
Develop proposed cost of contracting
Is anyone interested in this?

18. Psychiatric Consultation Opportunity
Psychiatrist in SW WA looking to fill psych consultation role
Currently in Community-Based Integrated Care Fellowship at UW
Preference to work in CoCM involving MAT and addiction medicine
Questions
How can he access their registry for consultation and would he also access the partnering provider’s EHR? Might take some time to set up.
MAT and OUD potential
Looking for around 15 hours per week of psych consultation in CoCM, starting in Nov-Dec
Currently in community-based integrated care fellowship at UW
Only interested in consultation at this point
Preference would be to work in CoCM involving MAT
Next steps
Invite to a work group
Develop proposed cost of contracting
Is anyone interested in this?

19. AIMS Center Care Integration Training Program
One year program but variable depending on practice readiness factors
Three phases
1. Planning for whole person care
2. In-person training for integration
3. Virtual coaching and additional training
CE credits
Phase 2: in person
Problem Solving Treatment and Behavioral Activation
Training website

20. Enrollment Process Identify point of contact for training program
Identify team members to participate in training program
Participate in group phone call with CPAA/AIMS Center (optional)
Complete CPAA/AIMS Center Commitment Form/packet
Partners are grouped by organization type and start time
AIMS Center will send out welcome letter/ and confirm POCs
Gain access to AIMS Center training website
Training program begins

21. UW AIMS Center – Summer 2018 Webinars

22. Summary and Next Steps Next steps Next meeting is August 28
Register for UW AIMS Center webinar series