PHLN: Behavioral Health Integration

Axis Community Health

PHLNYear2ProjectAim MeasuresforSuccess

AxisCommunityHealth

Tohavetheabilityto:•  Trackpatientscoresthroughouttreatment•  Examinedatatoidentifypatientswhose

depressionisnotimproving•  Adjusttreatmentasneeded•  Measureimprovements

Developregistrytoidentifypatientsw/:•  1+BehavioralHealthVisit(6monthlookback)•  Diagnosisofdepression•  PHQ-9scoreof15orabove

Reportgeneratedforthepast3consecutivemonths.

OurTeam•  Quality Enhancement / Data Analytics

o  Amit Pabla, MHAo  Afsheen Islam, MHA

•  Behavioral Health Leado  Dr. Jennifer Penney

•  Consulting Psychiatristo  Dr. Jerry Ngo

•  Integrated Behavioral Health Providerso  16 licensed providers at 4 locations

ChangesTestedby:

•  DiscoveringnewEpicReportingcapabilitiesasofJanuary2019

•  BrainstormingnewopportunitiesandlimitationswithDr.Raney

•  UtilizingaworkgroupwithourConsultingPsychiatrists

•  Determiningwhatdataismostbeneficialfortheteam

Implementedbyadding:•  PHQ-9scorechangesmonthtomonthforpatientsin

treatment

•  Quickidentifierstodeterminewhetherapatient’sscorehasworsenedorimproved

•  Addedcurrentpsychotropicmedicationtothereportinordertoidentifyanyimpacttoscoreasmedicationisadjusted

•  Providedreporttoprovidersinitially,andlatertoconsultingpsychiatristalso

•  One-on-onemeetingsbetweentheconsultingpsychiatristandthetreatingBHprovider

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DataCollected:•  ReportingPeriod:4/1/19to9/30/19•  15behavioralhealthproviders•  207patients•  115patientswithonly1PHQ-9Score•  92patientswith2ormorePHQ-9Scores

•  59patientswhosescoreimproved(by1-19points)•  16improvedby50%ormore•  43improvedbylessthan50%

•  26patientswhosescoreworsened(by1-20points)•  7patientswhosescorewasconstant

DataResulted:•  ByidentifyingpatientswhosePHQ-9scoresweregettingworse

andadjustingtheirtreatmentplansaccordingly

UsingDataforImprovement

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UtilizedourCoach,Dr.Raney,tofocusonaspecificsubsetofouroverallbehavioralhealthpatientpopulationandlearnfrombestpractices(e.g.AIMSInstitute).

CollaboratedwithOCHINReportingAnalyststodiscusswaystoinnovatereporttomaximizeuseofkeyperformanceindicators.

Discusseddatawithprovidersduringstaffmeetingstodeterminetrackingwhichvariablesweremostuseful.

UtilizedourConsultingPsychiatristtoadvocateforchangeintreatment-discusstherapeuticstrategywiththerapists,andmedicationinterventionwithPCPs.

StrategiesforSuccess

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EpicResources:

OCHINReportAnalysts

DepressionRegistry

KeyTools&Resources

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CCIResources:

CoachDr.Raney

IBHAffinityGroups

AxisResources:

IBHTeam

ConsultingPsychiatrist

QualityEnhancementTeam

NextSteps

•  Pullmoregeneraldata:

•  PHQ-9&DepressionDiagnosis

•  NoIBHvisitsinthepastyear

•  Psychotropicmedication,ifprescribed

*Patientswithhighscoreswillbeoutreachedbyourcarecoordinatorssothatwecangetthemconnectedwithtreatment.

•  Automatereportsonamonthlybasis

•  Organizeandauto-distributetoaninternaldrivemonthly,reviewedbyIBHmanagementanddispersedtostaff.

•  Consultingpsychiatristnowhasstandingmeetingtimestodiscussresultswiththerapists(consultingpsychiatristpositionisfundedthroughthecounty).

•  Feedbackcanbegivendirectlytopatients.ProvidershavebeentrainedonusinggraphicscreeningreportsonEPIC.

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Spreading Sustaining

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AlargeportionofourIBHpatientsreceivepsychiatrictreatmentoutsideofourorganization,therefore,itisdifficulttoconnectwiththeseprovidersinordertoinfluencechangestomedication.

Providerstendtobecomeoverwhelmedbythedataandthiscanleadtounder-utilization.We’dliketobeabletodevelopanautomatedprocesstoidentifyonlyclinicallysignificantchange,orlackofchangeinscores.

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CurrentChallenges