The All-Inclusive Health and Social Services Team A Pilot Next-Step to Scaled Housing First A Collaboration of the William K. Warren Foundation and The Mental Health Association Oklahoma Erik R. Vanderlip, MD MPH Assistant Professor OU School of Community Medicine
Jacki Sauter, LPN Licensed Practical Nurse Mental Health Association Oklahoma
Whitney Phillips, PA-C Michael Brose, MSW Faculty Chief Executive Officer Mental Health Association Oklahoma OU School of Community Medicine
Click to edit
Programmatic Context •Target population housed in permanent supported housing •People who are formally homeless •People affected by serious, untreated mental illness, addiction and trauma •Historic absence of mental health and physical health care, regardless of benefits
Cedars Apartments
Brighton Park Apartments
Sheridan Point
Baltimore Apartments
Walker Hall Apartments
Altamont Apartments
The Bradstone Apartments
Indianapolis Apartments
Terrace View Apartments
Belle Arms Apartments
Ranch Acres Manor
Charan Apartments
The Ritz Apartments
Velda Rose Apartments
Abbey Road Apartments
Autumn Ridge Apartments
Yale Apartments
Pheasant Run Apartments
Lewiston Apartments
31st Plaza
Collaboration With Private Philanthropy •Data is essential, but the story is the story •Timing is everything •Pubic funding vs. private funding (or both) •Development of dialogue •Working with philanthropy to make a difference •Community Health and Wellness Program
The Structure of the Program •Forty hours per week physician assistant •Four hours per week psychiatric consultation •Four hours per week primary care •Independent 3rd party program evaluation •Full integration of recovery model and medical model of care
Care for Complex Populations Prepared by: Erik R. Vanderlip MD MPH for the Mental Health Association of Oklahoma January 11, 2016
whole.
health
sociological
psychological
biological
health housing
substance use
legal vocation/income clothing
behavioral cognitive/interpersonal
food security
medical
genetic
health housing
legal
substance use
MHAO
vocation/income clothing
behavioral cognitive/interpersonal
food security
medical medical
genetic genetic
health housing
legal
substance use
MHAO
vocation/income clothing
behavioral cognitive/interpersonal
food security
medical
genetic
health housing
legal
substance use
MHAO
vocation/income clothing
behavioral cognitive/interpersonal
food security
medical
genetic
health housing
legal
substance use
MHAO
vocation/income clothing
behavioral cognitive/interpersonal
food security
medical
genetic
health housing
legal
substance use
MHAO
vocation/income
behavioral
clothing Is there a role for physician/prescriber consultation? cognitive/interpersonal food security
medical
$
genetic
direct provision of care
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). JAMA. 288(14), 1775–9.
Iterations of the Chronic Care Model: “Collaborative Care” 1995
2001
2010
“CC”
IMPACT
TEAMcare
The evolution of collaborative care to envelop multiple chronic conditions.
2010
“Core Principles of Effective Collaborative Care” Patient-Centered Care Teams • Team-based care: effective collaboration between PCPs and Behavioral Health Providers.
Population-Based Care • Patients tracked in a registry: no one ‘falls through the cracks’.
Measurement-Based “Treat to Target” • Measurable treatment goals clearly defined and tracked for each patient • Treatments are actively changed until the clinical goals are achieved – “treat to target”
Evidence-Based Care • Treatments used are ‘evidence-based’ • Pharmacology, brief psychotherapeutic interventions, models http://uwaims.org and Whitebird et al, AJMC, 2014.
39
Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). JAMA. 288(14), 1775–9.
health housing
legal
substance use
MHAO
vocation/income
behavioral
clothing Is there a role for physician/prescriber consultation? cognitive/interpersonal food security
medical
$
genetic
direct provision of care
Chronic Care Management and Prevention
Episodic Care
Chronic General Health Consultant
Urgent Care
Care Principal Care Manager
Patient
ER
Manager Hospital/I CU Specialist X
Specialist Y
Ideally: 3 Components
Chronic Care Management and Prevention
Episodic Care
1. Urgent Care
MHAO Pilot Patient Prescriber Consultation Medicine/Psy chiatric
ER
Hospital/I CU
Chronic Care Management and Prevention
Episodic Care
1. Urgent Care
MHAO Pilot Patient Prescriber Consultation Medicine/Psy chiatric
2. HIE Coordination: Patient ID, Outcomes
ER
Hospital/I CU
Chronic Care Management and Prevention
Episodic Care
1.
3.
Mobile Outreach
MHAO Pilot Patient Prescriber Consultation Medicine/Psy chiatric
2. HIE Coordination: Patient ID, Outcomes
ER
ICU
Episodic Care
Chronic Care Management and Prevention
Mobile Outreach MHAO Pilot
ER
Consultants
ICU HIE Coordination: Patient ID, Outcomes
PCMH
Outcome Type
Detail
Source
Timeline to when available
Implementation
Recruitment and Hiring of Key Staff
n/a
0-3 mos
Implementation
Mobile Clinic Operational (contracts in n/a place, schedule constructed, staff hired, equipment secured)
0-3 mos
Process
Number of On-Site Mobile Clinics
Mobile Clinic Schedule
3-12 mos
Process
Number of On-Site Patients Seen
Mobile Clinic Utilization Record, Initial Visit Form
3-12 mos
Process
Demographics of Patients Receiving On-Site Care Complaints Addressed in Mobile Clinic
Mobile Clinic Initial Visit Form
3-12 mos
Process Process
Process Utilization, Healthcare Utilization, Healthcare
Number of Patient Enrolled in Care Team, Target 5-15/mo. Starting month 3-6 Demographics of Care Team Population *Baseline ER Visits 12 months prior to enrollment Number of ER visits post-enrollment
Mobile Clinic Initial and Follow-up 3-12 mos Visit Forms Care Team Registry 3-12 mos
Care Team Registry
3-12 mos
MyHealth HIE
3-12 mos
MyHealth HIE
3-12 mos
Utilization, Healthcare
*Number of inpatient hospitalizations, baseline 12 mos prior to enrollment
MyHealth HIE
3-12 mos
Utilization, Healthcare
Number of inpatient hospitalizations post-enrollment
MyHealth HIE
3-12 mos
Clinical
Percent of Patients on Intervention Team with uncontrolled hypertension
MyHealth HIE
3-12 mos
Clinical
Percent of Patients on Intervention team MyHealth HIE with uncontrolled diabetes
3-12 mos
Clinical
Percent of Patients on Intervention team MyHealth HIE, team registry eligible for statin therapy but not receiving it
3-12 mos
Clinical
Percent of Patients on Intervention Team with uncontrolled depression (PHQ-9)
3-12 mos
MyHealth HIE, team registry
Outcomes Tracking HIE Linkages
Patient Referral
Team Infrastructure Development
MHAO Community Treatment Team Timeline to Implementation, 2015-2016 Mid-Level Hiring/Recruitment
Mid-Level Provision of Care
Physician Consultant Recruitment/Contracting
Physician Consulting
Pt Referral Standardized, Outreach and Education
Patient Recruitment and Enrollment
Prep, Supplies, Schedule, Institutional Agreements for Use
Mobile Clinic Mobilized
Data Arrangements, Standardization, EMR Integration
Data Monitoring, Implementation and Quality Improvement Assistance, Pilot Reporting Month 0
Timeline Not To Scale
Outcomes Tracking and Reporting to Team for Referral and Management
Month 3-6
Month 6-12
Month 12-15 Month 15
BL
Patient 1
BP BL
Patient 2 BP
BL
Patient 3 BL
Patient 4 BL
Patient 5 BL
Month 0 Timeline Not To Scale
Month 3-6
Patient 6 Month 6-12
Month 12-15
T0 Patient 1
BP
Patient 2 BP Patient 3 Patient 4 Patient 5 Patient 6 Month 0 Timeline Not To Scale
Month 3-6
Month 6-12
Month 12-15
Patients Screened VS Patients Enrolled Refused, 8, 6%
Enrolled, 15, 11%
Negative for DM, HTN, Statin, 12, 9% Not in Program Housing, 2, 2%
PACT Team, 7, 5%
PHQ9 < 10, 66, 50%
Engaged with Existing Services, 23, 17%
Initial Findings Blood Pressure 160 150 140 130 120 110 100 90 80 70 60
147 130 119 91 83 79
Baseline
1 Month (N=14)
Systolic Blood Pressure Average
3 Months (N=11)
Diastolic Blood Pressure Average
Initial Findings PHQ9 18 16
15.8
14 12 10 7.4
8
8.5
6 4 2
0 Baseline
1 Month Average
PHQ9
3 Month Average
Initial Findings HbA1c 10
9.8
9.5 9 8.5
8.5 8 7.5
Baseline
3 Month Average HbA1c
Case #1 • Enrollee #6 • Enrollment Date : 4/22/2016 • 57 YO Caucasian M with PMH significant for hypertension, diabetes, depression and anxiety—all untreated for over one year due to lack of insurance and income. • Initial Values (untreated) –Blood pressure: 160/89 –A1C: 13.0% –PHQ 9 Score: 19
Case #1: Enrollee #6 (cont'd) •Current Values—treated –Blood pressure: 133/84 –A1C (diabetes): 9.4 –PHQ 9 score (depression): 4
Case #2 • Enrollee #8 • Enrollment Date: 6/7/2016 • 65 YO Caucasian F with PMH significant for hypertension, GERD, alcoholism, depression—sporadic treatment for hypertension, depression and GERD—inconsistent follow up with former primary care physician • Initial Values—with sporadic treatment • Blood pressure: 162/98 • PHQ 9 score (Depression): 22
Case # 2/Enrollee #8 (cont'd) •Current Values—treated –Blood pressure: 110/76 –PHQ 9 score (Depression): 7
Barriers •consistent access to medications/payment •labs •transportation •active substance use •strict enrollment criteria
Next Steps •financial support for medications and labs •creative solutions for transportation dilemma •continue to actively partner with community resources •establish participant graduation guidelines •Critically appraise enrollment criteria
Questions?
The All-Inclusive Health and Social Services Team A Pilot Next-Step to Scaled Housing First A Collaboration of the William K. Warren Foundation and The Mental Health Association Oklahoma Erik R. Vanderlip, MD MPH Assistant Professor OU School of Community Medicine
Jacki Sauter, LPN Licensed Practical Nurse Mental Health Association Oklahoma
Whitney Phillips, PA-C Michael Brose, MSW Faculty Chief Executive Officer Mental Health Association Oklahoma OU School of Community Medicine
