Models of Mental Health Integration for Rural Health Clinics
2014 MOBILE HEALTH CLINICS ASSOCIATION FORUM- …€¦ · MOBILE HEALTH CLINICS ASSOCIATION FORUM-...
Transcript of 2014 MOBILE HEALTH CLINICS ASSOCIATION FORUM- …€¦ · MOBILE HEALTH CLINICS ASSOCIATION FORUM-...
MOBILE HEALTH CLINICS ASSOCIATION
FORUM- SAVANNAH GEORGIA
2014
THE FIVE PILLARS OF
HEALTH: USING MOBILE
HEALTH TO LEAD THE
MOVEMENT
Maria G. Aramburu, MD, FAAP
Division of Community Pediatrics
MedStar Georgetown University Hospital
Washington D.C
OBJECTIVES
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• Introduce the five pillars of health as an innovative model of healthcare delivery to at-risk children and their families
• Introduce the potential synergy of these five components to the promote wellness for our patients
• Review quality improvement projects in the mobile health setting
• Identify the successes and barriers to care integration in community based services
• Capture the unique opportunities for mobile health care as a platform for change in the evolving healthcare environment
DIVISION OF COMMUNITY PEDIATRICS
Our mission is based on the belief that every child, regardless of his/her financial means, deserves
high-quality,
comprehensive,
continuous care,
delivered in a respectful, caring and family centered environment—a “wellness home.”
KMMC
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KIDS MOBILE MEDICAL CLINIC/
RONALD MCDONALD CARE MOBILE
Comprehensive medical services to children and adolescents birth through 21 years old
Provided over 55,000 patients visits since 1992.
Currently providing an average of 1600 patient visits per year
Six sites in wards 4, 5, 6, and 7 of Washington DC, serving six public housing communities, two public high schools and a homeless shelter for families
Mobile unit goes out 4 days per week
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HISTORY
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1992
• Georgetown University Medical Center opened the first pediatric mobile program in the District of Columbia
• Target population: children in low income communities who were uninsured
2000
• MedStar Health purchased the clinical enterprise of GUMC and program was reestablished as Georgetown University Hospital Kids Mobile Medical Clinic
• The 1997 Authorization of State Health Insurance Program created an insurance safety net for children in the District of Columbia. This addressed a financial barrier to health care access.
• Many neighborhoods in Washington DC Wards 6,7,8 continued to be designated Health Professional Shortage areas thus creating geographic barriers to accessing health care for children
2005
• First Licensing agreement with RMHC Global Inc, Ronald McDonald House Charities of Greater Washington and MedStar Georgetown University Hospital for the Ronald McDonald Care Mobile at MGUH
• First clinic in the MedStar Health System to adopt the Electronic Health Record to improve documentation and efficiency
MGUH- KIDS MOBILE MEDICAL CLINIC
RONALD MCDONALD CARE MOBILE
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The program may evolve, but the mission stays the same:
To remove the barriers to health care for childrenand families of the Greater Washington Regionliving in or near poverty by delivering health andwellness services directly in their neighborhoodsat no direct cost to their parents or caregivers.
MGUH- KIDS MOBILE MEDICAL CLINIC
RONALD MCDONALD CARE MOBILE
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IMPLEMENTATION PROCESS
ASSESSMENT IMPLEMENTATION
Where are the gaps in wellness in our population
• What do our patients say?
• What local data is available?
• What are the national trends?
What services can we provide to fill these gaps in wellness?
• Evaluate current initiatives in place locally and nationally
• Evaluate our current capacity for services
• Evaluate opportunities for new programming.
Process planning
• Structure and development
Program development,
• Staffing and training
Implementation of services
• Service delivery
• Documentation of Services in the Electronic Health record
• Billing and Coding processes
• Referrals and Care Coordination
Outcomes and Evaluation
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PILLAR # 1
PHYSICAL HEALTH
PHYSICAL HEALTH-SERVICES PROVIDED
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• School/Sports/Camp/Daycare Physicals• Sick/Periodic Care• Hearing/Vision Screenings• Immunizations• Laboratory Studies• Tuberculosis Testing• Ophthalmology Exams• Specialty Referrals and Care Coordination• 24 hour On-call coverage• On-site Pharmacy
PHYSICAL HEALTH QI- ASSESSMENT
IMMUNIZATIONS We know:
There has been a greater than 92% decline in cases and a 99% or greater decline in deaths due to diseases prevented by vaccines recommended before 1980 for diphtheria, mumps, pertussis, and tetanus.
Smallpox has been eradicated worldwide.
Declines were 80% or greater for cases and deaths of most vaccine-preventable diseases targeted since 1980 including hepatitis A, acute hepatitis B, Hib, and varicella. Declines in cases and deaths of invasive S pneumoniae were 34% and 25%, respectively.
DC Immunization Registry noted our immunization compliance at below 70%
Yet…
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DC- VFC PROGRAM- IMMUNIZATION STATISTICS
School coverage rates are bellow the target of
98%
NIS series is bellow 76% which had been
achieved in the past
High missed opportunities illustrated by gaps in
NIS coverage for selected vaccines ( HPV)
ALL VISIT IMMUNIZATION PROGRAM
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NOT A NEW IDEA…JUST A NEW IDEA FOR US
IMMUNIZATIONS
PROGRAM IMPLEMENTATION
Process Planning
Addressing Logistical challenges Two rooms
Increased time to pull records for either nurse or coordinator from DC Registry
Increased time to record immunizations in EHR
Increased time to give immunizations
Delay in patient throughout
Increased ordering demand for vaccines
Potential increased cost of private vaccine stock for uninsured
But it’s the right thing to do…
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IMPLEMENTATION
Screening for vaccine delay at every visit
Determining eligibility for VFC program
Reviewing patients before visits to ensure
adequate stock of vaccines
Increasing vaccine education to our patients
Adequate staff training and ongoing education
Elimination of missed opportunities to
vaccinate
IMMUNIZATIONS- OUTCOMES
Before May 2013
Approximately 63% of our visits included immunizations
Between May 2013 and May 2014
Instituted All Visit Immunization Program
40% sick visits were either due or overdue and got
immunized
Increase immunization compliance:
Increase from approximately 63% to 92% of patients
were up to date at the end of their visit
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PHYSICAL HEALTH ---------ASTHMA
INITIATIVE
Chronic lung disease that affects 7.0 million children (aged< 18 years)1 in the United States (U.S.), regardless of age, sex, race, or ethnicity.
Although the exact cause of asthma is unknown and it cannot be cured, it can be controlled with self-management education, appropriate medical care, and avoiding exposure to environmental triggers
ASTHMA INITIATIVE- ASSESSMENT
DC PREVALENCE OF ASTHMAPERCENTAGE OF CHILDREN WITH UNCONTROLLED ASTHMA
In 2008, an estimated
13,981 children in the
District of Columbia had
asthma.
- Child lifetime asthma
prevalence was 18.4%
- Child current asthma
prevalence was 12.6%.
EV
ALU
ATIO
N-N
ATIO
NA
L
TR
EN
DS
ASTHMA IN CHILDREN- INTERVENTION
PROGRAM
Reach out to patients with asthma: Schedule asthma control visits
Asthma action plans for every asthma patient
With EMR additions: Evaluation of severity at well- check visits
Self evaluation questionnaires between visits
Enhanced “Asthma Action Plan” visits
Providing medication and spacers to uninsured patients
Pillar #2
ORAL HEALTH
ORAL HEALTH
NEEDS ASSESSMENT
Previous research has established the effectiveness of fluoride varnish, applied 2 to 4 times per year, is effective in preventing dental caries among children. A meta-analysis of 3 studies found a 33% reduction in decayed, missing and filled primary-tooth surfaces.
Early childhood caries experience negative consequences such as pain, difficulty eating and sleeping, and diminished quality of life
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ORAL HEALTH
PROGRAM INTERVENTION
Fluoride Varnish
Program-
Ages 6 months to 3 years
10 months
Oral Health Assessment
Program
4 years to 21 years
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ORAL HEALTH
IMPLEMENTATION PROCESS
Process planning:
Establishing workflow in an already limited space
Finding a partner to work with for referrals
Program Development:
Training providers (physicians and nurses) on Fluoride varnish application through an online and in person training developed by DC Chapter of the American Academy of Pediatrics
Creating a guide for oral health services in primary care for ages 6m-3y and another for 4y-21y
Developing education materials for parents
Revising encounter forms in the electronic medical record to document services
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ORAL HEALTH
IMPLEMENTATION PROCESS CONT’D
Additional Implementation considerations:
DC Medicaid began reimbursing for Fluoride Varnish from 6months to 3 years.
- Identifying appropriate billing and ICD-9 codes to use
Ordering and paying for supplies upfront
Developing a system for tracking referrals to outside partner
Setting goals and proposed patient outcomes:
Children between 6mo to 3 years seen for a well visit will receive fluoride varnish application as part of the comprehensive well child exam
Children between 4yr and 21y will receive an oral health exam as part of the comprehensive well child exam
Increase early identification of dental caries in the primary care setting
Ensure that all children seen for prevention services have a dental home AND have had a preventive visit in the last 6 months
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PARENT EDUCATION
ELECTRONIC RECORDING
BILLING/CODING
REFERRAL PROCESS
ORAL HEALTH:EXPECTED OUTCOMES
HOW DO YOU MEASURE WHAT YOU DO?
Data Collection:Can we create a closed loop
system? We can use the EHR or Radar
for tracking structured data Number of referrals and the
outcome
Number of children provided the fluoride varnish
Risk Factors
Protective Factors
Disease indicators
Sharing of information between partners
Can we then estimate the reduction in early childhood caries we expect to see in this population?
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PILLAR # 3
NUTRITIONAL HEALTH
NUTRITION SERVICES
ASSESSING THE NEED
2011 study- cost of medical care for obesity-
related illnesses-$190 billion annually
2001 study-obese people had 67 percent
higher chance of suffering from conditions
like diabetes than similar normal weight
individuals.
Nearly 1 in 5 children under the age of 6,
either overweight or obese
23% Children in Washington DC are
overweight, with the vast majority coming
from wards 5,6,7,8
Health professionals are on the front line to
address this but… 34
PROGRAM IMPLEMENTATION
Process planning:
Reviewed all patients between June 2012 and December 2013
to identify patients with BMI either overweight >85th%ile or Obese >95th%ile
Identified any other co-morbid or chronic conditions
PHYSICIAN LED FOCUS GROUP FOR PARENTS
Data collection: barriers, enabling factors, and participants’ knowledge of nutrition with the hope of influencing future intervention design
CREATION OF PARTNERSHIPS
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EXPLORING OUR PATIENTS NEEDS-NUTRITION
1%
1%
18%
19%61%
Age Distribution of Patients with
Overweight or Obesity
0 to 3
3 to 6
6 to 10
10 to 13
13 and above
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Presence of Dx of
Obesity/Overweight
Had Dx 42.1%
Did not have Dx
57.9%
EXPLORING OUR PATIENTS NEEDS-NUTRITION
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5
10
15
20
25
30
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40
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PROGRAM DEVELOPMENT
Train faculty, staff, students and residents on
use of Motivational Interviewing for behavior
change
Create encounter form in the electronic
medical record to document weight
management plan
Establish routine follow up visits
Telemedicine Nutrition Visits Pilot
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NUTRITION
PROGRAM IMPLEMENTATION
Implementation:
PHASE I : NUTRITION CLINIC
Phase II: implementation of a comprehensive nutrition and physical activity program that addresses knowledge and access to fresh fruits and vegetables for the family and community.
Setting goals and proposed patient outcomes:
Improved understanding of the link between diet and health
Increased physical activity
More effective and educated consumers
Motivating change in patients
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PILLAR # 4
MENTAL HEALTH
MENTAL HEALTH –
ASSESSING THE NEED
AAP policy statement in 2009 Recognized the uniqueness of the primary care clinician’s role: Building resilience in all children
Promoting healthy lifestyles
preventing or mitigating mental health and substance abuse problems
identifying risk factors and emerging mental health problems in children and their families and
partnering with families, schools, agencies, and mental health specialists to plan assessment and care
In July 1st 2013 – DC Medicaid Managed Care Organizations are required to ensure annual mental health screening using approved screening tools
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MENTAL HEALTH
PROGRAM INTERVENTION
Establish Screening as
a Standard of Care and
Best Practices in
Pediatrics Mobile Care
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CHILDHOOD MENTAL HEALTH-ASSESSMENT
Importance of screening for developmental, social emotional and potential mental health problems as early as possible
Reasons to screen AAP Guidelines
DC medical Community Commitment
Access to services
Mental Health-Preschool Children Prevalence
Any anxiety-9.4%
ADHD-2-5.7%
Depression-2.1%
Any emotional disorder-10.5%
Any behavioral disorder-9%
Any disorder-16.2%
Pervasive Developmental Disorders-1/125 4year olds
MENTAL HEALTH
PROGRAM IMPLEMENTATION
Process planning:
Review Literature
Assessment of ways to implement and score tools in time efficient manner
Chart Audit initially throughout the Pediatrics Department
Establishing a referral network within the team and identifying outside providers that fit our patients needs
Program Development
Department wide implementation of universal screening
Staff training and pilot implementation of screening process (learning collaborative webinars and on-site training from pediatric psychiatry providers)
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MENTAL HEALTH- IMPLEMENTATION
All visits 1-3 year olds : Ages and Stages Questionnaire- Social Emotional
Component
MCHAT
All visits 4-11 year olds : Strengths and Difficulties Questionnaire –parent
report
All Visits 11-18 year olds: Strengths and Difficulties Questionnaire self report
All visits 18-21 year olds: PHQ-9 Adolescent
MENTAL HEALTH
PROCESS IMPLEMENTATION
Implementation:
Evaluation of billing and coding for mental health screening
Developing a system for tracking referrals to outside partner
Assess implementation of tool, report of result, referral of patient and billing for services used in visit
Evaluation and outcomes
Early identification of mental health conditions Chart Audit of pre and post implementation of screening tools in
well child visits
Improved emotional markers for our patients
Increased # of visits with a mental health management plan
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PILLAR #5
SOCIAL DETERMINANTS OF HEALTH
SOCIAL DETERMINANTS OF HEALTH: ASSESSING THE NEED
Social determinants of health are conditions in the environment in which people are born, live, learn, work, play and age that affect their health, functioning, and quality of life outcomes
Recognizing the social determinants of health in a primary care setting helps to explore how programs, practices and policies affect the individual, family, and community.
We know that we can provide good health services and promote healthy lifestyles
If we don’t address some of the other disparities or access issues our patients were experiencing: they will not achieve their optimal health status
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SOCIAL DETERMINANTS OF HEALTH
PROGRAM IMPLEMENTATION Social work services support the creation of a social
and physical environment that promotes good
health for all
Since 1997 the mobile program has employed a full
time social worker as part of the integrated care
model. With the family, the social worker examines:
The availability of resources to meet the daily
needs of the family (housing , food, clothing
Access to health care services (including
mental health services)
Access and quality of education
Availability of community-based resource to
support safe and appropriate recreational and
leisure activities
Exposure to crime and violence (community
and in the home)
Social support
Socioeconomic condition49
SOCIAL DETERMINANTS OF HEALTH
PROGRAM IMPLEMENTATION
Social work services on the care mobile aims to emulate the medical home model and ensures:
children receive a continuum of care to help resolve their problems and make positive life changes
that limited resources are being maximized
that care is managed and coordinated effectively and efficiently for the most complex needs of children and adolescents
that ‘silos’ of care are removed to create a coordinated system
that educational resources are available for both patients, providers and community members to improve understanding of the impact of conditions on an individual’s psychosocial functioning.
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SOCIAL DETERMINANTS OF HEALTH-
EXPECTED OUTCOMES
Using collected data, in addition to pre-assessment and post-assessment instruments, measure the successful attainment of desired outcomes which include:
A reduction of symptoms
A return to previous levels of functioning
Attainment of necessary resources
Increase understanding for people to make good decisions about their health.
Connecting families to resources that enhance quality of life
This enables us to evaluate our program intervention strategies and make appropriate adjustments to best meet the needs of our patients.
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KEY CONSIDERATIONS FOR COLLECTING DATA
AND EVALUATING EFFECTIVENESS
Practice Management Information System
Electronic Medical Record
RADAR
DC Immunization Registry
Manual data collection
Surveys
Standardized tools
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THE FIVE PILLARS OF HEALTH
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An inter-professional model that focuses on care delivery that supports wellness in all five areas:
• Physical Health
• Mental health
• Oral Health
• Nutritional Health
• Social Determinants of health
Using data and patient outcomes we expect to measure
and evaluate the synergistic effect of addressing all areas
in sync to improve patient well being
IS THERE PROOF OF A SYNERGY IN
IMPLEMENTING THE FIVE PILLARS OF HEALTH
USING MOBILE HEALTH?
Not yet, but, the conversation is beginning…
Healthy People 2020 includes Health-Related quality of
life (HRQoL) indicators to measure impact of health
status on quality of life
Patient reported Outcomes Measurement Information system
(PROMIS) Global health measures
Well-being measures- assess the positive evolution of the
individuals daily lives, the quality of their emotions, relations,
and resilience
Participation measures- reflect the individuals’ assessment of
the impact of their health on their current environment
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SUMMARY
Mobile health can be synergistic.
We aim to prevent disease and therefore
create: Wellness
A holistic approach to health will lead to health
Outcomes measures are essential to measure
if we are being effective
Constant growth is an essential component to
our commitment to excellence
THANKS
QUESTIONS?