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.

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

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