Behavioral Health/Pediatric Primary Care Integration at Geisinger:

Year 1 Implementation & EvaluationShelley Hosterman, PhD

Paul Kettlewell, PhDChristine Chew, PhD

Tawnya Meadows, PhD

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #D3October 28, 20113:30 PM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

• Parents often bring their children to primary care physicians first (Smith, Rost, & Kashner, 1995)

• 15% to 21% of primary care visits are for behavioral

health concerns (Kelleher, Childs, Wasserman, McInerny, Nutting, Gardner, 1997; Lavigne, Gibbons, Arend, Rosenbaum, Binns, Christoffel, 1999; Williams, Klinepeter, Palmes et al., 2004).

• During 50% to 80% of child health care visits, parents or physicians raise concerns of behavioral or psychosocial issues (Cassidy & Jellinek 1998; Fries et al., 1993; Sharp, Pantell, Murphy, & Lewis, 1992).

Need/Practice Gap & Supporting Resources

Problems with seeking behavioral health services from PCP:

• Increased number of medical visits

• Increased time spent with the physician

• Lost revenue if a patient takes more time than scheduled

• Lower reimbursement rate for mental health issues

• Limited training in mental health treatment (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy,

1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)

Need/Practice Gap & Supporting Resources

Problems with seeking behavioral health services from PCP:

• Decreased number of patients seen

• Increased risk of physician burnout

• Unsatisfied patients

• Increased impairment in patient health and functioning

• Increased use of acute and emergency care (Connor, McLaughlin, Jeffers-Terry, O’Brien, Stille, Young, & Antonelli, 2006; deGruy,

1997; Leaf, Owens, Levelthal, Forsyth, Vaden-Kiernan, Epstein, Riley, & Horwitz, 2004; Strosahl, 2002; Young, Klap, Sherbourne, & Wells, 2001)

Objectives

• Understand the collaborative development process with the Geisinger Health Plan & Pediatric Partners

• Describe Geisinger’s pilot model

• Describe program evaluation plans for this project

• Review baseline data for the program

Agenda

• Developing the model – Process & Supports

• Details of pilot model

• Program evaluation & research

• Baseline data & future directions

Development: Previous System

• Outpatient mental health services, inpatient psychiatric unit, & consultation/liason in major hospital

• 3 pediatric psychs, 1 family therapist, 1 psychiatrist, 3 pre-doctoral interns, & 2 postdoc fellows

• Serving all children/adolescent in 5 counties, all patients with Geisinger PCPs, specialty patients

• Concerns with system: Waitlists, no shows, patient travel, caseloads, problems recruiting psychiatrist

Development: Model Prototype

Munroe-Meyer Institute – Inspiration for our modelUniversity of Nebraska Medical Center; Omaha, NE

http://www.unmc.edu/mmi/behavioral/

Joseph H. Evans, Ph.D. Director, Psychology DepartmentRachel Valleley, Ph.D.Outreach Behavior Health Clinics Coordinator

Development: Model Prototype

• Behavioral health services in primary care

• 23 outreach clinics across Nebraska

• Reaching underserved, rural populations

• Co-located & collaborative clinics

• Interns/postdocs trained in the setting

• Education for PCPs• Frequent contacts

regarding referrals• Research & program

evaluation• Promising outcomes –

Discussed later

Development: Our System

Geisinger Health System - •Integrated health network•Serves 43 counties; 20,000 sq miles; 2.6 million people•Nearly 60 community practice sites across the state•System-wide electronic medical record

•Geisinger Health Plan – Among nation’s largest rural HMOs (270,000 members)

Development: Marketing Change

Step 1: Approached psychiatry administration (10/09)•Response – Excellent concept, but no way to proceed within budget

Step 2a: Presentation at psychiatry grand rounds (2/10)•Response – Excellent concept•Possibility #1 – Private donor looking for a way to support mental health of children/adolescents•2b: Private meetings & additional presentation to private donor secured substantial gift

Development: Marketing Change

Step 3: Presentation to Pediatric Grand Rounds (03/10)•Response – Pediatrics enthused & many requested

Step 4: Presentation to Geisinger Health Plan (Spring ‘10)•Summary – Model offers better care, may save money, & carve out model of payment does not make sense•Response – We agree, what should we do?•Key message – They believe is better care & will support if we can break even or save money

Development: GHP Proposal

Monthly planning meetings with GHP administration

Data review process:•Medical expenses for pediatric patients with ≥1 BH visit double those of comparison patients•Key cost differences: Outpatient, pharmacy, & ED•Potential for cost off-set?

Outcome: GHP funded pilot project & program evaluation

Development: GHP Proposal

Proposal objectives:1.Improve quality of behavioral health care2.Reduce medical expenses & utilization of patients with BH concerns3.Increase physician, parent, & patient satisfaction with service model & delivery4.Expand PCP knowledge of BH assessment & intervention5.Improve access, adherence, efficiency, & integrity of BH services & intervention

Development: Task Force• Key stakeholders

• Review problems & solutions in our system & state

• Information gathering & review of other models

• Focus on partnership, collaboration, & consultation to help children & adolescents

• Electronic survey of primary care providers

Development: PCP Survey

Most common problems

• ADHD (77%)• Obesity (72%)• Depression (57%)• Anxiety (47%)• Disruptive Behavior

(44%)

Most want training/assistance

• ADHD (45%)• Disruptive Behavior

(43%)• Anxiety (32%)• Obesity (29%),• Depression (26%)• Eating Disorders (26%)

Development: PCP Survey

Barriers to service:• No local resources (94%)• Getting appt (55%)• Insurance issues (46%)• Travel for families (35%)• No time to address (24%)• No training (20%)• Patient Follow (11%)• No collaboration (11%)

Desired Models:• On-site services (76%)• Training in assessment &

diagnosis (65%)• Medication consults (64%)• Screening tools (49%)

Development: Task Force

Follow-up interviews with primary care:•Additional input•Assess site specific enthusiasm, barriers, and % GHP•Identified three sites Presented to CPSL

Three goals:1.Behavioral health providers on-site in PCP sites2.Support PCPs with screening tools & training3.Case consultation with child/adolescent psychiatrist

Clinic Structure: Team Planning

• Team planning meetings – Psych & PCPs, office staff

• Shadowing PCPs

• Billing discussions

• REACH Institute training – PCPs & Psych’s together– Focus on screening & psychopharm

Clinic Structure: Services

Report templates: Concise, completed during visit, structured for brief review

Clinician schedules: 1 psychologist + 1 psychology fellow•75 min evals, 45 min returns•75% scheduled – Always available to PCP

Warm hand-offs & consultations:•Join visits, education, pass patients on, simple recommendations, immediate eval•Tracking details

Clinic Structure: ServicesHandouts – Common for psychologists & PCPs

Crisis evaluations as needed

Communication – Medical record & constant contact

Ongoing training for PCP’s•Monthly case conferences•Presentations on request

Relationship building – Join clinic community

Clinic Structure: ServicesCommon screening tools

Anticipate high-volume issues•ADHD evaluations•Weight management•DBC groups

Psychiatry consultation – Case review & phone consultation

Electronic screening tools – Results directly in medical record

Clinic Structure: Services

Brief Case Examples

Program Evaluation: Key Domains

• Satisfaction

• PCP comfort/knowledge in assessment & intervention

• Quality of life

• Clinically significant symptoms

• Medication use

• Utilization data

• Clinic efficiency data

• Quality of Care v. Practice Standards

Program Evaluation: Tools & PredictionsSatisfaction: Pre & Post questionnaires for parents & PCPsIncludes: •Convenience, time to first appointment, Stigma/Comfort•Communication with PCP•Perceived BenefitPredict increased satisfaction relative to traditional model

Comfort and Knowledge: Physician survey•Pre & post training, pre-integration, & yearlyPredict increases across each measurement

Program Evaluation: Tools & PredictionsQuality of Life: Peds QL-4•Pre & post intervention•School questionnaire – attendance, performance•Predict improved QOL & school attendance•Predict match results from other CBT outcome studies

Clinical symptoms: Target behavior ratings•5 point Likert Scale at every session•Dual purpose - research outcomes & tracking treatment goals•Most immediate/likely measure of change•Predict steady reductions across course of treatment

Program Evaluation: Tools & PredictionsMedication use•Chart review – Pre and post integration, per diagnosis•Predictions – More appropriate use (sufficient trials, monitoring change, appropriate match to symptoms)

Utilization data: Chart Review•# Medical visits: Frequency PCP visits reduced pre v. post•Specialist visits: Frequency reduced pre v. post •Time to first visit – Reduced delay between physician referral & assessment vs. traditional model in our system•Out of network – Pre & post insurance company data. Predict reduced out of network

Program Evaluation: Tools & Predictions

Efficiency data•Time study: Pre, yearly, post•Code: Medical, Beh, & Med/Beh visits• Appointment duration: no change on medical appointments,

less time on behavioral & med/behCost savings & cost effectiveness: Pre, yearly, post•Predict increase in overall clinic revenue, reduced PMPM cost for patients with BH issuesQuality of Care•Identify AAP standards of care•Chart review assessing adherence with standards

Time Study Data

Table 1

Minutes Spent Per Visit

Type of Concern

Percent of Total Visit Types Observed

(N)

Mean

Medical 301 14.04

Behavioral 10 13.60

Medical and Behavioral

34 12.99

ResultsPercentage

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Referral to Pediatric Psychology

• 2.9% of all patients observed were referred to peds psych

• 28% of those diagnosed with a psychological disorder were referred to peds psych

Baseline data: Referrals & HandoffsConsults Warm

HandoffsNew Appointments

Return Appointments

Crisis

Clinic 1 19 16 23 39 0

Clinic 2 23 31 59 36 6

Clinic 3 38 14 31 35 3

Total80 61 113 110 9

Learning Assessment

Questions?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Contact Information

Shelley J. Hosterman, PhDsjhosterman@geisinger.edu

References available upon request