This webinar will provide an overview of the evaluation study being done at the Durham Clinic, an integrated health home run by Cherry Street Health Services in Grand Rapids, Michigan. The study seeks to determine whether the delivery of health care through a multi-disciplinary team using the chronic care management model delivers better symptom management and reduced impact of the
illness on patients’ desired functioning.
VIP Call Girls Tirunelveli Aaradhya 8250192130 Independent Escort Service Tir...
Evaluating the Integrated Approach to Chronic Care Management
1. Michigan Primary Care Association Webinar
3/13/12
Evaluating the integrated
approach to chronic care
management
Ryan Kielbasa
RyanKielbasa@CherryHealth.com
Cherry Street Health Services
www.CherryHealth.org
2. Cherry Street Health Services
(CSHS)
Not-for-profit 501(c)(3) federally qualified
health center (FQHC)
Established in 1988
Based in Grand Rapids with health centers in
Kent and Montcalm counties
Served over 50,000 individuals in 2010
3. CSHS Merger
On October 1, 2011 CSHS merged with two
behavioral health organizations
Touchstone Innovare
Proaction Behavioral Health Alliance
4. Touchstone Innovare
Private, non-profit, 501(c)(3) corporation
formed in 1998
Outpatient Services for individuals with serious
psychiatric conditions:
Psychiatry
Therapy
Case Management
Psychosocial rehabiliation
Served 2,900 clients in 2010
5. Proaction Behavioral Health
Alliance
Private, non-profit 501(c)(3) corporation originally
established in 1968 as Project Rehab
Services:
Residential treatment for correctional systems
Outpatient counseling
Substance use treatment
Wellness & Prevention programs
Employee Assistance Program
Approximately 176,000 outpatient encounters and
56,700 residential days per year
6. The new Cherry Street Health
Services
Largest not-for-profit FQHC in Michigan
Over 800 employees
Now provides a wide array of services to the
community
New vision:
“One person. One place. One Solution.”
Focus on integration of
physical, mental, and psychiatric care.
7. Heart of the City Health Center
Hallmark of “One Person. One Place. One
Solution” motto
One location for all of a patient’s health needs
Adult Medical Clinic
Pediatric Clinic
Vision Clinic
Dental Clinic
Counseling Center
Case Management and Psychiatry
Patient Services
Patient Centered Health Home
8. Durham Clinic
One of the seven different clinics located in the
Heart of the City Health Center
Opened October 3rd
Integrated behavioral/medical health clinic
Focus is on erasing that distinction
Using the Patient Centered Medical Home
Model
We hope to become a certified PCMH
9. Durham Clinic – Mission
Purpose –
“To help individuals manager their chronic health
conditions, so their conditions do not interfere
with how they want to lead their lives”
10. Durham Clinic – Mission
Chronic Care
Focus on chronic health conditions
Any health condition that requires continued
follow-up treatment, adjustment, or review
Designed to simultaneously address multiple
chronic health conditions, some of which are
psychiatric
Integration across all chronic health conditions
Behavioral/Physical - irrelevant
11.
12. Durham Clinic – Mission
Patient Activation
Get the patient involved in their health care
An educated patient is an empowered patient
Walking side-by-side
No more “Do as I tell you” paradigm
Stages of Change and Motivational Interviewing
Changing how we view patient progress
Stop thinking in terms of “resistance” and “non-compliance”
Rather, patients are “pre-contemplative” or “under-activated”
Recognizing that patients always do their best given their
experiences and environments
It is the provider’s task to help patients make different
choices, to become informed and activated.
Draws out intrinsic motivation, rather than pouring in
13. Durham Clinic – Mission
Lessen Impact of Illness
Goal: Reduce symptoms, ameliorate illness
But this isn’t always 100% possible
Freedom to live how they choose
Minimize hindrances from conditions
From “managing the person” to “managing the
illness”
14. Durham Clinic – Who we are
Our Patients
A mix of clients from Touchstone and previous
Cherry Street patients
Total population will be around 600 patients
Approx. 250 from Touchstone
Serious mental illness
Most with one or more comorbidities
Transferred directly from case management team to
Durham in October
Most referred by case manager
Approx.350 from existing CSHS patients and
new referrals
15. Durham Clinic – Who We Are
Clinical Staff
2 Internal Medicine Physicians (1 FTE)
1 Psychiatrist (0.5 FTE)
6 Health Coaches
1 Nurse
1 Medical Assistant
2 Case Managers
16. Durham Clinic – What We Do
Providers
Provider Roles
Physician, psychiatrist, nurse, medical assistant
Similar to a regular practice with one exception:
They practice within the framework of an integrated team
Case Managers
Goal planning
Connect patient with community resources
“Manage the illness, not the individual” framework
Health Coaches
Licensed social workers with Master’s of Social Work degrees
(LMSW)
Help patients to become informed and activated
Provide primary interventions when appropriate
E.g. Counseling support
17. Durham Clinic – What We Do
Health Coaching
Tools:
Licensed outpatient therapists
CBT, DBT, etc.
Extensive education in a multitude of chronic
conditions (e.g. HTN, diabetes)
Trained in Motivational Interviewing
Work alongside the patient to gain insight into
illness and develop strategies for positive
change
18. Durham Clinic – What We Do
Coordination of Care
Morning meetings
All clinicians meet to discuss patients coming in that day
Coordinated strategic planning
One electronic health record
Providers working together -> Chart becomes a
complete, holistic view of medical history
One treatment plan
All conditions treated together
The internist’s plan is the psychiatrist’s plan is the health
coach’s plan…because they worked together to develop it
No PCP gatekeeper or mandated hand-offs
Everyone sees internist, health coach, nurse
One person. One place. One solution.
19. Durham Clinic
Origins - IDT
Development of Durham
“Integrated Development Team” (IDT)
Pilotprogram
“Mini-Durham”
22 patients
Smaller staff
06/2010 – 10/2011
20. Evaluation
Origins – Pilot Study
Pilot study design
13 IDT patients
Methods:
Surveys
Patient activation, health status, symptoms, etc.
Focus Groups
Staff
Patient
Outcomes:
Quantitative data (surveys) not yet analyzed
Qualitative data showed us:
Clinical improvements
Study improvements
Confirmed: We can do this. We need to do this.
21. CIT Evaluation
Chronic Illness Treatment: An Integrated Approach
(CIT) is:
A quasi-experimental study design
Set to last for three years
Approved through the Michigan Department of Community
Health Institutional Review board
Three key questions:
1. Is it more effective to treat all of a person’s chronic
health conditions together versus separately?
2. Does the integrated model incur less health care costs
than treatment as usual?
3. Does health coaching for chronic health conditions
increase treatment adherence?
22. CIT Evaluation
Methods - Participants
Population
All over 18 years of age
One or more chronic health condition
Patient at Durham Clinic or HOTC Adult Medical
Both are Cherry Street clinics
Sample
600-1200 participants
300-600 in treatment group (Durham)
300-600 in comparison group (HOTC Adult)
Race, ethnicity and gender of participants is expected to be representative of the
current patient population
Voluntary
Patients do not need to participate in the study in order to receive care at either clinic.
Participation in study does not affect care in any way.
Data collection
Health, claims, and survey data
Survey data collected every 6 months
23. CIT Evaluation
Methods - Measures
Health data
Blood pressure (each visit)
Body Mass Index (BMI) (each visit)
Substance Use History (each visit)
HbA1c (each physician visit – for participants with diabetes)
Glycated Hemoglobin – Average amount of sugar in blood
over last few months
Lipid Panel (screen and annually)
Total cholesterol
LDL “bad cholesterol”
HDL “good cholesterol”
Triglycerides
24. CIT Evaluation
Methods - Measures
Service Utilization data
Frequency and cost of services received during
the study and 6 months prior
Cherry Street, Touchstone, Proaction data
Insurance claims data:
Emergency department visits
Hospital admissions (psychiatric and general)
Number of no shows
Length of inpatient stays
Have not began capturing this data yet
25. CIT Evaluation
Methods - Measures
Survey Data
English and Spanish versions
Validated, industry standard questionnaires:
PHQ-9 (Depression)
GAD-7 (Anxiety)
CGI-SCH (Psychosis)
BPI (Pain)
CAGE-AID (Substance use disorder)
EQ-5D (Perceived Health Status)
PAM-13 (Patient Activation)
26. CIT Evaluation
Methods - Measures
Patient Health Questionnaire
• General Anxiety Disorder 7-
9-item (PHQ-9) item (GAD-7)
Screen for depression as well Originally to diagnose
as monitor and assess GAD, but also works well as
severity screener for panic, social
“Over the last 2 weeks how anxiety, and PTSD (Source:
PHQScreeners)
often have you been bothered
by any of the following “Over the last 2 weeks how
problems?” often have you been bothered
by any of the following
• Ex. “Little interest or pleasure in
doing things” problems?”
Not at all • Ex. “Trouble relaxing”
Several days Not at all
More than half the days Several days
Nearly every day More than half the days
Nearly every day
27. CIT Evaluation
Methods - Measures
Clinical Global Impression
Scale – Schizophrenia (CGI- Brief Pain Inventory (BPI)
SCH)
Illness severity and Chronic pain
degree of improvement
in schizophrenia Assesses:
Assesses symptom Level of pain
groups
Positive Relief from
Negative treatment
Cognitive Interference with
Depressive
activity
Filled out by
psychiatrist following
clinical interview
28. CIT Evaluation
Methods - Measures
CAGE-AID EQ-5D
Screen for alcohol and Health outcome/health
drug abuse status
Four questions: Descriptive profile:
Cut down use Mobility
Annoyed by criticism Self-Care
Guilty about use Usual Activities
Eye-opener Pain/Discomfort
Widely validated for Anxiety/Depression
identifying alcohol abuse Patient’s perceived
Score of 2+ health state
Eye-opener 0-100 “thermometer”
29. CIT Evaluation
Methods - Measures
Patient Activation Measure 13 Item (PAM-13)
Knowledge, skill, and confidence of managing
one’s own health (Patient Activation)
Goes along with Stages of Change model
13 statements
“I
know what each of my prescribed medications do”
Four level Likert-type scale
Disagree Strongly | Disagree | Agree | Agree Strongly
N/A
30. CIT Evaluation
Methods - Analysis
Data will be analyzed at the end of the 3 year
data collection period
Analysis of variance (ANOVA)
Group x Time
31. Expected Results
5 • If the Durham Clinic is
4.5 successful, we will see a
4 significant interaction between
group and time.
3.5
3 • I.e. As time progresses, we
2.5 expect to see the two groups
Treatment
2 differ in their outcomes –
1.5 where positive outcomes are
Compariso
1 n greater in the treatment
group.
0.5
0 • Significant time effect likely
since patients in both groups
t6
t1
t2
t3
t4
t5
Baseline
are getting some form of care.
• Group effect unlikely – We do
not anticipate that the groups
will differ in their baseline
32. So what?
If the data shows that Durham works: Expand!
2ndfloor behavioral health wings
Peds?
And beyond…
33. Strengths and
Limitations/Challenges
Heart of the City Health Center
Treatment/Comparison groups in same
building
Convenient!
Comparison group was initially off-site
Lower need for study staff
Increased recruitment potential
Providers work in both clinics
Internists
Patients switching from one clinic to another
Dropped from study
34. Strengths and
Limitations/Challenges
Simultaneous Evaluation and Clinic development
Growing pains – not everything goes as
planned
Serious delays with the evaluation
Logistics – not everything was planned
Studywas designed before we moved into
HOTC; difficult to plane where/how surveys would
be administered, etc.
Tailor evaluation to specifically measure target
improvement areas
Unbiased: The study was designed before we
knew our clinical strengths/weaknesses. Keeps
us honest.
35. Strengths and
Limitations/Challenges
Merger and Organization
Logistics
Changing regulatory (e.g. IRB) documents
Ti Cherry Street
Comparison site switch
Delay
Large pool of patients
Durham not possible without it
CSHS executive administration
VERY open to progress and research
Existing research department
Durham study independent of research department but
provided consultation and resources we otherwise wouldn’t
have had