evaluating the integrated approach to chronic care management

Evaluating the integrated approach to chronic care management

Ryan [email protected]

Cherry Street Health Serviceswww.CherryHealth.org

Michigan Primary Care Association Webinar 3/13/12

Cherry Street Health Services (CSHS)

Not-for-profit 501(c)(3) federally qualified health center (FQHC)

Established in 1988 Based in Grand Rapids with health

centers in Kent and Montcalm counties Served over 50,000 individuals in 2010

CSHS Merger

On October 1, 2011 CSHS merged with two behavioral health organizations Touchstone Innovare Proaction Behavioral Health Alliance

Touchstone Innovare

Private, non-profit, 501(c)(3) corporation formed in 1998

Outpatient Services for individuals with serious psychiatric conditions: Psychiatry Therapy Case Management Psychosocial rehabiliation

Served 2,900 clients in 2010

Proaction Behavioral Health Alliance

Private, non-profit 501(c)(3) corporation originally established in 1968 as Project Rehab

Services: Residential treatment for correctional systems Outpatient counseling Substance use treatment Wellness & Prevention programs Employee Assistance Program

Approximately 176,000 outpatient encounters and 56,700 residential days per year

The new Cherry Street Health Services

Largest not-for-profit FQHC in Michigan Over 800 employees Now provides a wide array of services to

the community New vision:

“One person. One place. One Solution.”

Focus on integration of physical, mental, and psychiatric care.

Heart of the City Health Center

Hallmark of “One Person. One Place. One Solution” motto

One location for all of a patient’s health needs Adult Medical Clinic Pediatric Clinic Vision Clinic Dental Clinic Counseling Center Case Management and Psychiatry Patient Services Patient Centered Health Home

Durham Clinic

One of the seven different clinics located in the Heart of the City Health Center

Opened October 3rd Integrated behavioral/medical health

clinic Focus is on erasing that distinction

Using the Patient Centered Medical Home Model We hope to become a certified PCMH

Durham Clinic – Mission

Purpose – “To help individuals manager their chronic

health conditions, so their conditions do not interfere with how they want to lead their lives”

Durham Clinic – MissionChronic Care

Focus on chronic health conditions Any health condition that requires

continued follow-up treatment, adjustment, or review

Designed to simultaneously address multiple chronic health conditions, some of which are psychiatric

Integration across all chronic health conditions

Behavioral/Physical - irrelevant

Durham Clinic – MissionPatient Activation

Get the patient involved in their health care An educated patient is an empowered patient

Walking side-by-side No more “Do as I tell you” paradigm Stages of Change and Motivational Interviewing

Changing how we view patient progress Stop thinking in terms of “resistance” and “non-compliance” Rather, patients are “pre-contemplative” or “under-activated”

Recognizing that patients always do their best given their experiences and environments

It is the provider’s task to help patients make different choices, to become informed and activated.

Draws out intrinsic motivation, rather than pouring in

Durham Clinic – MissionLessen Impact of Illness

Goal: Reduce symptoms, ameliorate illness But this isn’t always 100% possible

Freedom to live how they choose Minimize hindrances from conditions

From “managing the person” to “managing the illness”

Durham Clinic – Who we areOur Patients

A mix of clients from Touchstone and previous Cherry Street patients

Total population will be around 600 patients Approx. 250 from Touchstone

Serious mental illness Most with one or more comorbidities Transferred directly from case management team

to Durham in October Most referred by case manager

Approx. 350 from existing CSHS patients and new referrals

Durham Clinic – Who We Are Clinical Staff

2 Internal Medicine Physicians (1 FTE) 1 Psychiatrist (0.5 FTE) 6 Health Coaches 1 Nurse 1 Medical Assistant 2 Case Managers

Durham Clinic – What We DoProviders

Provider Roles Physician, psychiatrist, nurse, medical assistant

Similar to a regular practice with one exception: They practice within the framework of an integrated team

Case Managers Goal planning Connect patient with community resources “Manage the illness, not the individual” framework

Health Coaches Licensed social workers with Master’s of Social Work degrees

(LMSW) Help patients to become informed and activated Provide primary interventions when appropriate

E.g. Counseling support

Durham Clinic – What We DoHealth Coaching

Tools: Licensed outpatient therapists

CBT, DBT, etc. Extensive education in a multitude of

chronic conditions (e.g. HTN, diabetes) Trained in Motivational Interviewing

Work alongside the patient to gain insight into illness and develop strategies for positive change

Durham Clinic – What We DoCoordination of Care

Morning meetings All clinicians meet to discuss patients coming in that day Coordinated strategic planning

One electronic health record Providers working together -> Chart becomes a complete,

holistic view of medical history One treatment plan

All conditions treated together The internist’s plan is the psychiatrist’s plan is the health

coach’s plan…because they worked together to develop it No PCP gatekeeper or mandated hand-offs

Everyone sees internist, health coach, nurse One person. One place. One solution.

Durham ClinicOrigins - IDT

Development of Durham “Integrated Development Team” (IDT)

Pilot program “Mini-Durham” 22 patients Smaller staff 06/2010 – 10/2011

EvaluationOrigins – Pilot Study

Pilot study design 13 IDT patients Methods:

Surveys Patient activation, health status, symptoms, etc.

Focus Groups Staff Patient

Outcomes: Quantitative data (surveys) not yet analyzed Qualitative data showed us:

Clinical improvements Study improvements Confirmed: We can do this. We need to do this.

CIT Evaluation

Chronic Illness Treatment: An Integrated Approach (CIT) is: A quasi-experimental study design Set to last for three years Approved through the Michigan Department of

Community Health Institutional Review board Three key questions:

1. Is it more effective to treat all of a person’s chronic health conditions together versus separately?

2. Does the integrated model incur less health care costs than treatment as usual?

3. Does health coaching for chronic health conditions increase treatment adherence?

CIT EvaluationMethods - Participants

Population All over 18 years of age One or more chronic health condition Patient at Durham Clinic or HOTC Adult Medical

Both are Cherry Street clinics Sample

600-1200 participants 300-600 in treatment group (Durham) 300-600 in comparison group (HOTC Adult)

Race, ethnicity and gender of participants is expected to be representative of the current patient population

Voluntary Patients do not need to participate in the study in order to receive care at either

clinic. Participation in study does not affect care in any way. Data collection

Health, claims, and survey data Survey data collected every 6 months

CIT EvaluationMethods - Measures

Health data Blood pressure (each visit)

Body Mass Index (BMI) (each visit)

Substance Use History (each visit)

HbA1c (each physician visit – for participants with diabetes)

Glycated Hemoglobin – Average amount of sugar in blood over last few months

Lipid Panel (screen and annually)

Total cholesterol LDL “bad cholesterol” HDL “good cholesterol” Triglycerides


Service Utilization data Frequency and cost of services received

during the study and 6 months prior Cherry Street, Touchstone, Proaction data Insurance claims data:

Emergency department visits Hospital admissions (psychiatric and general) Number of no shows Length of inpatient stays

Have not began capturing this data yet


Survey Data English and Spanish versions Validated, industry standard questionnaires:

PHQ-9 (Depression) GAD-7 (Anxiety) CGI-SCH (Psychosis) BPI (Pain) CAGE-AID (Substance use disorder) EQ-5D (Perceived Health Status) PAM-13 (Patient Activation)


Originally to diagnose GAD, but also works well as screener for panic, social anxiety, and PTSD (Source: PHQScreeners)

“Over the last 2 weeks how often have you been bothered by any of the following problems?”• Ex. “Trouble relaxing”

Not at all Several days More than half the days Nearly every day

•Patient Health Questionnaire 9-item (PHQ-9)

General Anxiety Disorder 7-item (GAD-7)

Screen for depression as well as monitor and assess severity

“Over the last 2 weeks how often have you been bothered by any of the following problems?”• Ex. “Little interest or pleasure

in doing things” Not at all Several days More than half the days Nearly every day

http://www.phqscreeners.com/instructions/instructions.pdf


Illness severity and degree of improvement in schizophrenia

Assesses symptom groups Positive Negative Cognitive Depressive

Filled out by psychiatrist following clinical interview

Chronic pain Assesses:

Level of pain Relief from

treatment Interference with

activity

Clinical Global Impression Scale – Schizophrenia (CGI-SCH) Brief Pain Inventory (BPI)


Screen for alcohol and drug abuse

Four questions: Cut down use Annoyed by criticism Guilty about use Eye-opener

Widely validated for identifying alcohol abuse Score of 2+ Eye-opener

Health outcome/health status Descriptive profile:

Mobility Self-Care Usual Activities Pain/Discomfort Anxiety/Depression

Patient’s perceived health state 0-100 “thermometer”

CAGE-AID EQ-5D


Patient Activation Measure 13 Item (PAM-13) Knowledge, skill, and confidence of

managing one’s own health (Patient Activation)

Goes along with Stages of Change model 13 statements

“I know what each of my prescribed medications do”

Four level Likert-type scale Disagree Strongly | Disagree | Agree | Agree

Strongly N/A

CIT EvaluationMethods - Analysis

Data will be analyzed at the end of the 3 year data collection period Analysis of variance (ANOVA)

Group x Time

Expected Results

Baseline

t1 t2 t3 t4 t5 t60

0.51

1.52

2.53

3.54

4.55

TreatmentCompar-ison

• If the Durham Clinic is successful, we will see a significant interaction between group and time.

• I.e. As time progresses, we expect to see the two groups differ in their outcomes – where positive outcomes are greater in the treatment group.

• Significant time effect likely since patients in both groups are getting some form of care.

• Group effect unlikely – We do not anticipate that the groups will differ in their baseline measures

So what?

If the data shows that Durham works: Expand! 2nd floor behavioral health wings Peds? And beyond…

Strengths and Limitations/ChallengesHeart of the City Health Center

Treatment/Comparison groups in same building Convenient!

Comparison group was initially off-site Lower need for study staff

Increased recruitment potential Providers work in both clinics

Internists Patients switching from one clinic to another

Dropped from study

Strengths and Limitations/ChallengesSimultaneous Evaluation and Clinic development

Growing pains – not everything goes as planned Serious delays with the evaluation

Logistics – not everything was planned Study was designed before we moved into HOTC;

difficult to plane where/how surveys would be administered, etc.

Tailor evaluation to specifically measure target improvement areas Unbiased: The study was designed before we knew

our clinical strengths/weaknesses. Keeps us honest.

Strengths and Limitations/ChallengesMerger and Organization

Logistics Changing regulatory (e.g. IRB) documents

Ti Cherry Street Comparison site switch

Delay Large pool of patients

Durham not possible without it CSHS executive administration

VERY open to progress and research Existing research department

Durham study independent of research department but provided consultation and resources we otherwise wouldn’t have had

Questions?

evaluating the integrated approach to chronic care management

Health & Medicine