#TEAMUPsymposium

Transforming andExpandingAccess toMental Health Care in

UrbanPediatrics

Implementation Challenges and Solutions:

Improvement Strategies to Guide Your Implementation

of Core BHI Clinical Workflows

Anita Morris, MSN, FNP-BCDirector of Practice Transformation

TEAM UP for Children, Boston Medical Center

Charlotte Vieira, MPHImplementation Manager

TEAM UP for Children, Boston Medical Center

#TEAMUPsymposium

Transforming andExpandingAccess toMental Health Care in

UrbanPediatrics

Expert Panel

Jane Marie Dolan, MDTEAM UP Clinical Champion

Lead Pediatrician and Assistant CMO OB/GYN and Pediatrics Brockton Neighborhood Health Center

Marsha IlusTEAM UP Community Health WorkerBrockton Neighborhood Health Center

Huy Nguyen, MDTEAM UP Clinical Champion

Chief Medical Officer, DotHouse Health

Lara Jackson, MPHPractice Transformation Director

DotHouse Health

Michael Tang, MD, MBATEAM UP Clinical Champion

Chief Behavioral Health Officer, The Dimock Center

#TEAMUPsymposium

Presenter Disclosure

3

The presenters in this session do not have anything to disclose with regard to commercial

interests and do not plan on discussing unlabeled/investigational uses of a commercial

product.

#TEAMUPsymposium

Agenda

• Welcome and introductions

• Universal Screening with the SWYC: Brockton Neighborhood Health Center

• Systems Re-design to Support Universal Screening: DotHouse Health

• Specialty BH and SDoH Care as Primary Care: The Dimock Center

• Discussion

4

#TEAMUPsymposium

How did we get here from there?

5

Figuring out what we were trying to do…

Vision, Aim, Guiding

Principles

Figuring out how to do it!

Model Development Framework

Organizing ourselves

Practice Transformation

Framework

Using a data-driven QI framework

Failure Modes and Effects

Analysis

Co-developing a sustainable

model

TEAM UP Transformation

Model

Evaluation

data &

reports

Experiential

learning

from the CHCs

#TEAMUPsymposium

Guiding Principles

6

Family-Centered, Community-Connected Care

• Care for children by caring for families.• Develop services that respond to the needs and preferences of families served by the health centers.• Promote connections for families to link to already-existing services in the surrounding community.

Stepped Care Model

• Use a model of care that encompasses interventions aimed at prevention, treatment, and coordination of care for behavioral health within the primary care setting.

• Provide the appropriate level of care based on symptoms and patient readiness.• Create a process for monitoring treatment progress and step up/down care accordingly.

Build Capacity• Build capacity within primary care to address the behavioral health of children and families in a clinical

model that is sustainable and replicable. • Build workforce knowledge and skills through the Learning Community.

Team-Based Care

• Integrate behavioral and primary healthcare within the pediatric setting and create a culture such that everyone feels a part of the care team.

• Optimize the expertise of the interdisciplinary care team to enable every team member to provide therapeutic interventions appropriate to their role and scope.

• Ensure all team members are empowered to work at the top of their scope of practice.

Population Health Approach

• Create an integrated culture within pediatrics that is founded on reliable workflows within a consistent, integrated system of care.

• Develop registries to monitor special populations beyond visit-based care and outreach/engage patients in addressing care needs.

Continuous Quality Improvement Framework

• Use data and experience to guide clinical practice transformation, improve patient retention, improve positive outcomes, and decrease the burden on primary care providers.

• Adopt evidence-based care and share best practices.

Create and Strengthen a Sustainable Integrated Care Model (added 11/2019)

• Co-develop a sustainable model for pediatric integrated behavioral health care through consensus-building and shared decision-making across the TEAM UP Community.

• Ensure the TEAM UP model includes a common framework of core components and a customizable implementation strategy that is responsive to local environments.

• Create a feedback loop between implementation and evaluation findings and activities to continuously refine the model and build the field of knowledge in integrated care.

#TEAMUPsymposium

Define a unifying Framework

Articulate and agree upon an inclusive, common framework through Steering Committee meetings

Establish a Starting Point

Analyze the baseline performance and priorities for each health center

Innovate, Observe, Evaluate & Share

Share our experience and outcomes in Practice Transformation meetings

Iterate & Focus In

Assess the impact and define what contributes to improved outcomes at each health center

Finalize Core Components

Finalize TEAM UP model components at Steering Committee meetings

Model Development Framework

#TEAMUPsymposium

Practice Transformation Framework

Stepped Care ModelUniversal Screening Wellness & Prevention Treatment in Primary Care

Basic

Need

s

Pare

ntal

Issue

s

SWYC

Pre

ve

ntio

n

In

te

rve

ntio

ns

In

te

nsive

C

ase

Ma

na

ge

me

nt

Ba

sic N

ee

ds

Su

pp

ort

Me

dica

lS

ocia

l

Wo

rk

&

D

ise

ase

Ma

na

ge

me

nt

Fo

cu

se

d

In

te

rve

ntio

ns b

y

Prim

ary C

are

Te

am

In

itia

l E

nga

ge

me

nt

& E

va

lu

atio

n b

y

BH

Te

am

Brie

f In

te

rve

ntio

n

by B

H Te

am

Re

asse

ssm

en

t

Lin

ks to

S

pe

cia

lty

Ca

re

Special PopulationsEarly Childhood - Foundational Stepped Care

Hig

h R

isk

P

re

na

ta

l –

Po

stp

artu

m

Tra

nsitio

n

He

alth

y P

are

ntin

g &

En

ro

llm

en

t

Tra

ck

in

g E

arly

In

te

rve

ntio

n

Re

fe

rra

ls

Ea

rly C

hild

ho

od

Old

er A

do

le

sce

nt

De

pre

ssio

n &

An

xie

ty

Atte

ntio

nD

eficit

Diso

rd

er

Au

tism

S

pe

ctru

m

Diso

rd

er

Su

bsta

nce

U

se

Tra

um

a

Cu

ltu

re

& La

ng

ua

ge

Operational WorkflowsCare Team: Scope

of Roles

Care Team: Staffing

Levels

System-Wide Workflows

BH

Cs

CH

W&

F

P

PC

Ps

Nu

rse

s &

M

As

BH

Cs

CH

W &

F

P

PC

Ps

Nu

rse

s &

M

As

Co

din

g, B

illin

g,

Re

im

bu

rse

me

nt, &

Su

sta

in

ab

ility

Co

mm

un

ity &

Fa

mily E

nga

ge

me

nt

Tra

um

a-In

fo

rm

ed

En

viro

nm

en

t

Cu

ltu

ra

l

Co

mp

ete

nce

&

Re

pre

se

nta

tio

n

8

#TEAMUPsymposium

Universal Screening Workflow

Warm Hand-off Workflow

Process Mapping

RNs huddle and look at upcoming schedule the night before; if there is a child who is coming in for BH concern

or who practice is concerned about, RN writes in EMR Comment section to flag medical team

START: Family/patient arrives at

clinic

Patient Roomed by MA who gives family screening packet***SWYC, MCHAT, PSC, PHQ, PSC-Y,

Basic Needs

Pen and paper screener

PCP scores and enters score into

ECW

Paper screening instruments also to

to RN station to get entered into

Excel by FP

Family Partner does second

check of screenersPositive?

Phone encounter to PCP or BH

PCP discusses with pt to assess needs and preferences

Screen +/concerns?

Regular WCC visit

Identified needs?

Parent declines services

PCP or Family Partner followup

PCP and onsite BH/CHW talk in real time

On site BH/ CHW evaluation ~30 minute assessment with result

d/w PCPAlready in services

Get record release after release of information signed;

outreach and consultationdone by access clinician/

medical SWReferral for onsite services; next appt

intake in ~ one week; Vanderbilts may be sent home

Community BH services*

Home for Little Wanderers; CSI; Family

Services, South Bay*to community based on

language preference, transportation, need for

in home or school therapy

School based therapy

For parental needs: to Dimock

BH if parent patient; sometimes Family Navigator

Intake visit (may be with different

person than warm handoff);

screeners may be done (PSC17;

CBCL)

Patient comes for intake?

BH therapist calls

On site therapy (brief or long term with licensed MH

professional based on family need)

with PSC17 monitoring

Early Intervention

Offsite referral (release of

information sought as above for �already in therapy�)

If need for psychotropic

meds, to be sent to psychiatry

Note: MCPAP not used now that

onsite child psychiatry

Therapy ends based on:

improvement on PSC17, provider

assessment, family preference

Onsite psychiatry

Needs?

NoYes

Yes

DIMOCK Process Map- 11/2017

No

Yes

Brief Intervention

9

#TEAMUPsymposium

Failure Modes and Effects Analysis – Warm Hand-off

Failure Modes

Failure Causes Likelihood of

Occurrence(1-10)

Likelihood of

Detection(1-10)

Severity(1-10)

Risk Profile

Number (RPN)

Actions to Reduce Occurrence of Failure

Family (parent or child) declines services

-Family can’t wait-Family is not interested-in therapy somewhere else-Cultural concerns-Concern with CPS

3.50 2.75 6.00 57.75 • Schedule follow up appointments at times when BHC is available if family could not wait

BH clinician is unavailable

-In trainings and meetings-With another scheduled patient-Another warm hand-off-Sundays/early morning-Not long enough coverage hours-Out sick or on vacation-Misunderstanding that someone is available-Not there in time, too slow

3.75 3.00 4.75 53.44

Interpreter not available w/ language concordance

-No provider interpreter-Don’t want to work with provider -Interpreter not in office yet or at lunch-Cultural discordance-Need for multilingual BH staff

4.25 2.25 5.25 50.20 • Review and encourage use of language line when necessary

• Research availability of services in the area that are available in required language to provide to families

RN sends patient home by mistake

-Busy clinic and space issues-Lab pharmacy-Multiple warm hand-offs confusion who went in what room -Miscommunication regarding next steps

1.50 4.75 4.00 28.50 • Review workflow for WHO (who checks in with who before a patient leaves)

• Identify manner to communicate which patients BHCs have seen

10

#TEAMUPsymposium

Core Clinical Workflows

Model Component Clinical Workflow Sequencing

Strengthen Families & Promote Healthy Development

Prenatal-Postpartum Transition Support

Healthy Parenting Support

Enhance Screening for Behavioral and Social Needs Enhanced Universal Screening

Provide Access to Integrated Behavioral Health Care

PCP BH Plan

Warm Hand-off to BHC

Warm Hand-off to CHW

Symptom Tracking

BHC BH Plan

Bridge Connections to Specialty Services

Early Intervention (EI) Tracking

Clinical Pathways for Special Populations

Access to Specialty Care

11

1st 2nd Throughout

#TEAMUPsymposium

Universal Screening with the SWYC:Brockton Neighborhood Health Center

Jane Marie Dolan, MDTEAM UP Clinical Champion

Lead Pediatrician and Assistant CMO OB/GYN and Pediatrics Brockton Neighborhood Health Center

Marsha IlusTEAM UP Community Health WorkerBrockton Neighborhood Health Center

#TEAMUPsymposium

Brockton Neighborhood Health Center

13

Patient Ethnicity – 2018

1.52% 2.95%1.65%

2.73%

32.61%

17.52%

10.80%

1.87%0.28%

10.27%

0.60%10.01%

2.54%0.60% 1.69%

2.36%

Central AmericaSouth AmericaCarribeanAfricaCape VerdeHaitiBrazilAsianNative AmericanAfrican Americanamerican multiAmerican whitePuerto RicomultiPortugalother

MOST GROWTHCape VerdeHaitiBrazilPortugalPeruNigeria

#TEAMUPsymposium

Brockton Neighborhood Health Center

14

0.34% 1.98%

76.57%

7.70%

0.75%1.95%

10.71%

Native AmericanAsianBlackHispanic--all racesmore than 1 raceunknownwhite

Patient Race – Sept. 2019

#TEAMUPsymposium

Brockton Neighborhood Health Center

15

48%

51%

54%

56%

40%

50%

60%PATIENTS NEEDING INTERPRETERS (UDS)

2015 2016 2017 2018

#TEAMUPsymposium

Brockton Neighborhood Health Center

16

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

TOTAL pedi adult senior

10.09%

14.94%

8.12%

13.58%

7.16% 6.60%6.61%

12.33%

2.61%

6.27%

1.01%

5.31%

PATIENTS BY AGE2016-2019

% changes

16-17 17-18 18-19

#TEAMUPsymposium

Brockton Neighborhood Health Center

17

6281 6910 6667 6944 6955 72778237

9364

11394

1485115728 16089

1753618533 18665

2000021482 22166 22569

23050

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

.B

Pediatrics Visits by Fiscal Year2019 and 2020 are revenue only

2020

#TEAMUPsymposium

Clinical Champion Perspective

• Background

• Implementation

• Process and workflow of current pilot

18

#TEAMUPsymposium

CHW Perspective

• Language capacity

• Cultural humility

• Time efficiency of having CHW administer SWYC

• Advantage of CHWs administering SWYC

19

#TEAMUPsymposium

Challenges

• Space

• Volume of surveys administered (100-150 a week)

• Time delays with Interpreter Services

20

#TEAMUPsymposium

Proposed Solutions…

• Booth for privacy

• Training MAs

• Monitor and coordinate warm handoffs

• Continue to learn and adjust for cultural and linguistic needs

…Future plans and sustainability

21

#TEAMUPsymposium

Systems Re-design to Support Universal Screening:

DotHouse Health

Huy Nguyen, MDTEAM UP Clinical Champion

Chief Medical Officer, DotHouse Health

Lara Jackson, MPHPractice Transformation Director

DotHouse Health

#TEAMUPsymposium

DotHouse Health: At a Glance

23

Insurance Coverage:Coverage PercentPublic 62%

Private 32%

Uninsured 6%

Race/Ethnicity Percent Asian 38%Black or African American 31%White/Caucasian 14%Hispanic/Latino 17%

Race/Ethnicity:

Source: DotHouse Health UDS 2018

20,010Unique patients in 2018

of patients live at or below 200% of the federal poverty level*

*$40,560/year or $3,463/month for a family of 3

90%of patients live in Dorchester. Another 16% live in Randolph, Quincy, Mattapan, Roxbury, or Hyde Park

62%

51%of patients are best served in a language other than English

#TEAMUPsymposium

DotHouse Health: At a Glance

24

Age distribution of patients

< 19 years old

0

1000

2000

3000

4000

5000

6000

13-18 years

5-12 years

<5 years

% of patients < 19 years old with selected dx

ADHD 7.1 %

Conduct Disorder 6.3 %

Depression 5.2 %

Anxiety 3.8 %

Adjustment Disorder 6.1 %

PTSD 1 %

Substance Use Disorder

0.4 %

Autism Spectrum Disorder

2.3 %

Source: DotHouse Health UDS 2018

have one or more psychiatric dx

18.5%

have dx of Developmental Delay, Learning Disability, School Problem, School Phobia, School Avoidance, Social Problem in School

3.6%

#TEAMUPsymposium

DotHouse Universal Screening

25

<2018• PEDS: 5-65 months

– M-CHAT 16-30 months

• WeCare: 0-5 years• PSC-17: 6-12 years• PHQ2 + CRAFFT:

13-17 years– Reflex to PHQ9

for positive PHQ2• PHQ2 + SBIRT:

>=18 years– Reflex to PHQ9

for positive PHQ2

2019• SWYC: 0-71 months• PSC-17: 6-12 years• PHQ2 + CRAFFT:

13-17 years– Reflex to PHQ9

for positive PHQ2• PHQ2 + SBIRT:

>=18 years– Reflex to PHQ9

for positive PHQ2• THRIVE: All ages

2020+• SWYC: 0-59 months• PSC-17: 5-11 years• PCS-17 Y +

CRAFFT: 12-18 years– Reflex to PHQ9

for positive internalizing

• PHQ2 + SBIRT: >=19 years– Reflex to PHQ9

for positive PHQ2• THRIVE: All ages

#TEAMUPsymposium

Success Drivers

• Borrowing from design thinking• Gathering insights• Reframing• Identifying design principles

• Intentionally going for a ‘big’ change• Aligning communications and training• Practice-wide ‘go-live’ day

26

#TEAMUPsymposium

Success Drivers

• Ease of use• Form and job aide design and location• Appropriate assignment of decision points

• Data, data, data• Identification and feedback on failure points• ‘Proving’ the gains

27

#TEAMUPsymposium

Workflow Tracking

28

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

% Screeners completed @ WCC's per Week

SWYC

PSC-17

PHQ2/CRAFFT

#TEAMUPsymposium

SWYC Scoring QA

29

Total forms reviewed 153

Issue # % of total

Incorrect 'Age at Evaluation' 37 24%Incorrect Developmental Milestones interpretation 19 12%Incorrect or Missing Developmental Milestones score 15 10%Incorrect or Missing PPSCS score 7 5%Incorrect or Missing POSI score 7 5%Incorrect or Missing Inflexibility score 6 4%Incorrect or Missing Irritability score 5 3%Wrong Form given 3 2%Incorrect or Missing Routines score 3 2%

#TEAMUPsymposium

Challenges

• Suboptimal EHR build for SWYC• Scoring• Reporting

• The 15-minute visit

• Patient barriers• Language, literacy, engagement

30

#TEAMUPsymposium

Challenges

• Cultivating a team approach while reinforcing distinct workflows for individual roles

• Cultivating a positive work environment while discussing and improving failure points

• Frequent changes + ancillary staff + turnover = breakdowns

31

#TEAMUPsymposium

Moving Forward

• EHR improvements• Easier scoring• Meaningful reports

• Dashboards

• Standardized training

• Making meaning –The ‘why?’ and ‘what happens after?’

32

#TEAMUPsymposium

Specialty BH and SDoH Care as Primary Care:

The Dimock CenterMichael Tang, MD, MBA

TEAM UP Clinical ChampionChief Behavioral Health Officer, The Dimock Center

#TEAMUPsymposium

SAMHSA-HRSA: Standard Framework for Levels of Integrated Healthcare

Value of integrating “specialty” behavioral health care for BH and social needs care

Specialty BH and SDoH Care as Primary Care

Heath 2013

Level 7?Merged Primary Care and

Specialty BH Practice

SPECIALTY BH INTEGRATED

#TEAMUPsymposium

Comparison

35

Level 6 and below Level 7• Brief interventions • Brief interventions & Long-

Term care• Still long waits to “refer out” • No “referral out”: rapid access

to specialty care• Integrated BHCs at times not

available• “Slack”: Long-term clinicians

can also act as BHCs• Not financially sustainable • Financially sustaining• Grant dependent • New standard of care

#TEAMUPsymposium

1.0 FTE Social Worker10 Resource Volunteers

Chief Executive Officer

Chief Behavioral Health OfficerChief Medical Officer

Pediatric Clinic Director

Pediatric Behavioral Health Clinic Director

MEDICAL:2.6 FTE MD Pediatricians2.0 FTE Nurse PractitionerNursesMedical Assistants

1.0 FTE Social Worker

1.0 FTE Access Therapist3.0 FTE Behavioral Health Clinicians10 Resource Volunteers

BEHAVIORAL HEALTH:1.0 FTE Access Therapist4.0 FTE Behavioral Health Clinicians0.3 FTE Child Psychiatrist0.1 FTE Accountable Care Managers

3.0 FTE Behavioral Health Clinicians

Pre 19952010Now

Level 3

1996

Level 4Level 6 (“7”)

SOCIAL DETERMINANTS:2.0 FTE Community Health Workers1.0 FTE Resource Specialist2.5 FTE Volunteers

Biopsychosocial Care1:1:1 Ratio

Medical to Behavioral Health to SDoH Providers

Level 7 Integration at Dimock: Transforming an Organization

#TEAMUPsymposium

Need identified by a patient, PCP or universal screen

(e.g. SWYC)

PCP initiates warm handoff to the

Access Therapist

Access Therapist assesses and

triages

Diagnostic intake

Long-Term Behavioral Health

Therapy, in the same clinic

Psychiatry, if indicated

Brief Intervention, if indicated

Key:

Assessment

Treatment

Level 1Level 4Level 5Level 6 (“7”)

Long-term Substance Use

Disorder Therapy, in the same clinic

Level 3

Access to Behavioral Health Care

#TEAMUPsymposium

Need identified by a patient, PCP or universal SDOH

screen (incl. SWYC)

PCP initiates warm handoff to the

CHWCHW assesses and

triages

Intake and Open Case (in SDoH

software)Longer-Term Care Rapid Resource

Referral

Need MetClose Case

Key:

Assessment

Treatment

Access to SDOH Care

#TEAMUPsymposium

Warm Handoff BHBehavioral Health Intake45 min BH Therapy

BH Referral Process

#TEAMUPsymposium

Warm Handoff CHWCHW Follow-up

SDoH Referral Process

#TEAMUPsymposium

Integrated “Referrals”

#TEAMUPsymposium

Access to BH Care Data

• Rapid access to BH care:

• Time to Warm Handoff• Median 0 days and 76% success rate

• Time to Intake• Median 7 days and 67% success rate

• Time to Long-Term Therapy• Median 14 days and 81% success rate

42

#TEAMUPsymposium 43

Health Leads MassHealth Flexible Services Learning Symposium 2019

Social Needs Screening Process

Start: Patient

check-in at front desk

Patient completes

screen

Paper screen given to routine physical patients

Provider reviews the screen & enters in EHR

Provider reviews results

with patient

Consider Community

Health Worker (CHW) Referral

Positive screen?

Paper screen placed in bin

CHW reviews bin for missed

screens

Case opened in SDoHsoftware

End

Yes

No

Screening Rate

Screen Positive Rate

Referrals to CHWs

SDoHReferral Metrics

= what we’re measuring

Access to SDoH Rate

#TEAMUPsymposium

Social Determinants of Health

• Universal screening for basic needs• SDoH software allows tracking of needs & outcomes

44

Median: 109

0

25

50

75

100

125

150

6/17

7/17

8/17

9/1710

/1711

/1712

/17 1/18

2/18

3/18

4/18

5/18

6/18

7/18

8/18

9/1810

/1811

/1812

/18 1/19

2/19

3/19

4/19

5/19

6/19

7/19

# Ef

fect

ive

Ref

erra

ls

Month Need Closed

Dimock Patient Resource Center: Effective ReferralsTotal Median: Success Equipped RRR

#TEAMUPsymposium

“Effectiveness” Measure

45

Median: 109

0

25

50

75

100

125

150

6/17

7/17

8/17

9/1710

/1711

/1712

/17 1/18

2/18

3/18

4/18

5/18

6/18

7/18

8/18

9/1810

/1811

/1812

/18 1/19

2/19

3/19

4/19

5/19

6/19

7/19

# Ef

fect

ive

Ref

erra

ls

Month Need Closed

Dimock Patient Resource Center: Effective ReferralsTotal Median: Success Equipped RRR

Closure Type Description

Success The desk and client have met the need as defined in the Scope of Services

Equipped Client’s need is not yet met, but they feel equipped to proceed without further follow-up

Rapid Resource Referral

Information is provided to client with no follow-up (i.e. info sheet)

Disconnection Client no longer wants to work on this need because need met elsewhere OR not a priority for client OR client did not respond after 3 contact attempts within 30 days

Failure No resource exists to meet client’s needs OR desk did not attempt to contact client for at least 30 days

MassHealth Flexible Services Learning Symposium 2019

#TEAMUPsymposium

Implications for the Field

• Key design elements and drivers of success

• Optimization of IT systems

• Use of data to drive decision-making

• Early identification of failure points

• Time and processes for piloting and adaptation

• QI methodology to drive change, e.g. FMEA, PDSA, etc.

46

#TEAMUPsymposium

Funding Acknowledgment

47

IMPLEMENTATION AND EVALUATION PARTNER

FUNDERS HEALTH CENTERS

All activities within the TEAM UP for Children initiative are made possible through the contributions of the TEAM UP partners. Funding for the TEAM UP for Children initiative is provided by the Richard and Susan Smith Family Foundation, The Klarman Family Foundation, and the Robert Wood Johnson Foundation.