Heal the Patient Not the Symptoms Michael Israel

Heal the Patient, Not the Symptoms -Michael Israel, MD Chief Medical Officer, Bluestem Health

Conflicts �None

Objectives �Review where medicine has been �Look at where medicine is going �Understand different integrated models �Discuss implementation of integration �Discuss potential problems with integration �Discuss why integration is integral in patient care

Objectives “Take the time to DEFINE the bottom line! What outcome do you desire? ”

Medicine – The Old Ages �Fee for service � 46 y/o M with DM and an a 1 c 12 (goal <7) �Diet, exercise, start meds � Return visit shows a 1 c 11. 9 � NON-COMPLIANT ? Fired �Quality took a back seat

How do we fix this? �Increase the importance of Quality Measures �Add bonuses? � 46 y/o M with DM and a 1 c 12 (goal <7) �Found out they have bipolar, anxiety, hx of sexual abuse, high risk sexual behavior, smokes 2 packs of cigarettes daily, drinks 1 pint of whiskey nightly, can not “afford” 4 dollar meds – not taking meds regularly

WHAT JUST HAPPENED? !? ! � 10 -15 min appt for a DM check �Went from 1 dx 8 dx �I AM NEVER DOING THAT AGAIN!!! �Physician Burnout

Why Should We Do It Again? �Better Care, Better Care!!!! �If we don’t, who will? �Undected and untreated/undertreated �Decreased access to mental health �Stigma �Decreased life expectancy, otherwise �Increased cost to health care, otherwise

How do we fix this? �Decrease patient panels and increase appointment times �Not enough primary care physicians in the WORLD �Join Accountable Care Organizations/Managed Care Organizations (ACOs/MCOs) �Integrated Care

What is Integrated Care? �Integration of services in which providers work together through shared services to achieve a common goal �Specifically for today’s talk: integration of primary care providers and mental health care providers and patients working together on a patient-centered approach �Vertical vs Horizontal Integration of care

Focused Integrated Care �Organizational Integration vs Organizational coordination

What did we do about it? �Bluestem Health partnered with Lutheran Family Services ~ 2014 �Started with Health 360 – mix of organizational coordination and integration �~2016 added behavioralists to other locations and psychiatry on board

2017 “Take the time to DEFINE the bottom line! What outcome do you desire? ”

2017 -Present �Overhauled scheduling process �Took 2 days of the entire staff in April to train on the Cherokee Model of Integrated Care

Current Flow PCP BHC Psych

2017 -Present �Added appropriate and visible staffing �Defined Roles �PCP �BHC �Psych �Patient �Defined Expectations of all providers – primary care and behavioral health �Get the right people on the bus

2017 – Present �Incorporated behavioral health into our provider meeting. �Monthly Goals �Monthly Progress Reports Quarterly �Continuous reassessments �Emphasis on QA department

Pitfalls?

Pitfalls we Avoided �Part of our mission statement �“To be a trusted resource for excellent medical, dental and behavioral health services” �Integrated Space �Diminished Language Barriers

Pitfalls we Avoided �EHR Usage and scheduling �Reimbursements (kind of)

Pitfalls we did not Avoid �Hard to teach and old dog new tricks �Timing to see patients and hold-ups in the rooms �Didn’t use psych appropriately

Pitfalls we did not Avoid �Reimbursement (Kind of) �Enough BHCs �Excessive dependence

Outcomes � 2016 calendar year– ranked low-800 s/~1381 in UDS data �Childhood Immunizations �Cervical Cancer Screening �Colorectal Cancer Screening �Depression and follow-up Screening �Patients with controlled HTN �Patients with DM with an a 1 c > 9 or no testing that year

Outcomes April 2017 • Childhood Immunizations Ø 39% • Cervical Cancer Screening Ø 31% • Colorectal Cancer Screening Ø 18% • Depression and follow-up Screening Ø 64% August 2019 • Childhood Immunizations Ø 45% • Cervical Cancer Screening Ø 49% • Colorectal Cancer Screening Ø 48% • Depression and follow-up Screening Ø 91%

Outcomes April 2017 • Patients with controlled HTN Ø 59% • Patients with DM with an a 1 c > 9 or no testing that year Ø 47% August 2019 • Patients with controlled HTN Ø 67% • Patients with DM with an a 1 c > 9 or no testing that year Ø 28%

Outcomes � 2018 Calendar year – ranked mid-100 s/~1381 in UDS data �About 650 spot jump

Upcoming Outcomes �We have added SBIRT trainings and are piloting different ways to implement these trainings and how to measure outcomes

Conclusion �We have to recognize that mental health stability is critical in overall well-being �We can not continue to practice the old way if are truly expecting change �Integration is not a one-size fits all and is continuously fluid, but can result in better outcomes towards healing the patient as a whole

Conclusion “Take the time to DEFINE the bottom line! What outcome do you desire? ”

Questions? ? ?

Bibliography �https: //insights. ovid. com/medicalcare/mcar/2011/06/000/understanding-excess-mortality-persons -mental/11/00005650 �https: //medcitynews. com/2018/09/vertical-integration-inhealthcare/? rf=1 �https: //www. kingsfund. org. uk/sites/default/files/field_pu blication_file/integrated-care-summary-chris-ham-sep 11. pdf �https: //www. integration. samhsa. gov/about-us/what-isintegrated-care �https: //www. integration. samhsa. gov/aboutus/CIHS_Integration_101_FINAL. pdf �https: //insights. ovid. com/medicalcare/mcar/2011/06/000/understanding-excess-mortality-persons -mental/11/00005650

Bibliography �https: //thehealthcareblog. com/blog/2014/04/25/theway-forward-for-integrated-care-what-weve-learnedfrom-horizontal-and-vertical-integration-ofphysicians/ �https: //www. cherokeehealth. com/patientservices/adult-primary-behavioral-care �https: //www. ruralhealthinfo. org/toolkits/servicesintegration/2/primary-care-behavioral-health �https: //www. healthviewx. com/fqhc-statistics-growthregion-performance-and-revenue-federally-qualifiedhealth-centers-across-usa/