Integration from a PBHCI Grantee Perspective- DuPage County Health Department By Mr. Knorr

-And turn, for the moment,
to Jason Knorr, who’s joined us from
DuPage County Health Department, sharing experiences
in their efforts to build primary care into behavioral health settings.
Jason? -Perfect. Good morning.
Hopefully, you can hear me fine. If not, let me know. Thank you for the introduction
and providing me with this opportunity
to present today. DuPage County Health Department was a Cohort V
4-year PBHCI grantee, which concluded
on September 30, 2016. It’s rewarding to see
the effort and expansion of integrated-care
practices and policies as this work has proven
effective here in DuPage. I will start my presentation
by giving you a picture of what DuPage County
Health Department provides for the community followed
by practical examples of our model,
procedures, policy ideas, engagement tools, outcomes, lessons learned
and sustaining practices with our work post-grants. I hope you’ll walk away
with some ideas to help you on your integrated-care
adventure path. Next slide…
Oh, you already got it, perfect. DuPage County is
the second-largest-populated collar county
outside of Cook County, which is home to Chicago. DuPage County is home to
approximately 920,000 residents. We have six public
health centers located within DuPage County. The picture circled on the right
is our new Community Center. It opened September 2015. The Community Center houses
our 24-hour crisis unit, 12 respite beds,
psychosocial rehab, or formerly known as that, and also National Alliance
for Mental Illness. So NAMI has also moved
into the building with us. We have approximately 218
behavioral health staff and serve 7,000
unduplicated clients, both children and adults. Our range of services
includes psychiatric, adult outpatient programs,
residential services including group homes, apartment programs,
villas, transitional housing, child and adolescent
services in crisis. Next slide, please. When we first started
our grant project, we developed several
slide-show trainings. We called our program MYCARE, and the graphics depict
our health, home and partnership between
DuPage County Health Department and our primary
care partner, VNA Health Care. VNA Health Care is the Federal
Qualified Health Care Center that operates
from several locations in Will County, Kane County, and at the beginning
of our grant, they expanded services
into DuPage County. Next slide, please. Our FQHC partner offered primary
care clinics 2 days a week, totaling 12 hours. This was a co-located model in our Wheaton
Public Health Center. It made for a one-stop shop
at this location, also offered additional
public health services such as benefiting
dental, adult health clinics, TB clinics and so on. Our primary care partners
provided acute care, chronic-disease management,
follow-up and lab work. An average visit ran from 15
to 20 minutes with 30 minutes for new patients, and at times,
this would increase based on the complexity
of our patients. VNA Health Care brought all the
medical equipment and supplies. They staffed the clinic with five Advanced
Practitioner Nurses to provide services
for our PVHCI target clients. DuPage County was invested
in developing the integrated-care
model on the right in order to help our target
population of clients with serious mental illness whom are at risk of having
chronic health issues and substance use to access
the services they need. The model was very important
during the grants, and it still is. It kept our project teams
directed and grounded during development
of procedures, programs as well
as operationally. The client, or you,
in the center of the model, the effort is put on wrapping
the client with the support and services they need to
improve their whole health, functioning and overall
satisfaction with life. The first level of wing
of support around the client contains
the MYCARE coordinator and a consumer specialist. The MYCARE coordinators
or lead staff, they were like the lead-care
manager and clinical experts. I would emphasize providing
care coordination. These positions also developed
and operated our wellness and clinical programming. These were licensed staff
with backgrounds in mental illness
and substance abuse, so we went with
higher-caliber staff to do this work. From screening tools
and assessments, we begin to work
around the wheel with the client to identify
what is in place and what is missing in their
individual care plans, kind of like a warm
hand-off concept. So a client in behavioral
health is identified without having primary care, so we would link them
to an appointment with VNA Health Care. MYCARE coordinators worked
in these primary care clinics and would meet the clients
after their visit to review recommendations
from labs, from the treatment plan. They would complete screenings
like the PHQ-9 or the Assist practice-motivational
interviewing. They would even walk clients
over to dental for an exam. They would also educate
and engage clients in one of several wellness
groups we ran to address nutrition, diabetes,
smoking cessation, chronic pain self-management,
substance use and trauma. So we used this model
as a reference with clients when they started with us and ongoing
throughout treatment. It’s just a nice visual to help
people see what we could offer. Next slide, please. To enroll clients into the
health home during the grant, we developed a system
to engage new clients to the Health Department as well as existing
clients in our services. New patients came directly
from our intake by use of screening tools and further comprehensive
assessments. Once a client was identified
as needing additional services like primary care
or dental, psychiatric or wellness, from our previous model, we ordered these services during
the treatment-plan process. Next slide. I mentioned looking
at internal clients for integrated-care services. It was very important
to us to allow access into these services, so we created a report from our electronic
medical record. This report was used to alert
us about potential clients that were already
receiving services. It was also used to assist staff in cultivating more enrollments
into the project. This report pulls specific data
from our assessments to help identify clients
with medical issues, tobacco use, dental needs, substance use, kind of a marketing
tool for staff at other locations
to apply more strategy by intervening
with our clients. MYCARE coordinators also used
this report to identify clients in need of services and were able to do outreach. The report is sorted by
primary location, primary staff, and this particular
report was also sent to the behavioral
health supervisors so that they could engage
their staff during supervision about the health
needs of their client they might not be addressing. So really, there’s no wrong door to find clients
with integrated-care needs and no wrong door
to get an in to these services. Next slide, please. During enrollment, in addition to behavioral
health information, we also collected
physical health measures. So these were performed
at baseline during quarterly check-ins and 6-month reviews
to measure client progress. These health indicators
were required during the grant, and collecting these values
assist us to evaluate outcomes, direct our interventions, and they also demonstrated
tangible improvement to patients
and the treating staff. Next slide, please. I was talking about
those wellness programs. This is a slide
from one of them. It was the NEW-R
or Nutrition and Exercise for Wellness and Recovery. It’s a wellness program
we implemented, and over time, developing reports
that demonstrate client progress
with health indicators from not only
integrated services but, more specifically,
as a result of attending our wellness programming, helped clients
and staff see progress. This is a bigger-picture
look at cumulative weight loss by quarter. When issues with weight,
waist circumference, BMI, blood pressure and cholesterol
are considered at risk, clients would be referred
to this program. It’s facilitated by
behavioral health staff and a registered dietitian. We’ve sustained this 8-week
group to date and facilitate this program at four of our public
health centers. Next slide, please. Excuse me. Measuring decrease in E.R. usage
and hospitalization for mental-health issues
is valuable data. I probably don’t need
to tell you that. We demonstrated a decrease
in clients accessing both E.R. and hospitalization
when clients were enrolled in our
integrated-services program. Next slide, please. Actually, these next three
slides really demonstrate some outcome data. Having an evaluator or a data
analyst is a must-have when embarking
on integrated-care projects. Benchmarking outcomes is another
marketing strategy and helpful to see how your services
match up to other local or national organizations
doing similar work. This slide uses data from
the National Outcome Measures, or NOMS, one of the tools
we were required to do with our grant clients, and it shows improvement
with us compared to other Illinois
PBHCI grantees. Next slide, please. I talked about dental before. This is just a slide
I threw in there to show some of the access we — How were we able
to get clients over to dental? Many of our clients
just had not seen dentists, were not interested
in seeing dentists. So we really had a lot
of success in clinic when people would be
talking about having pain in their mouth,
bleeding gums and just, you know, hadn’t had a checkup, we were able to just walk them
right over to dental. And the dental staff
over there knew who we were and that this was part
of the program, and they were fantastic at getting people in
for treatments and exams. It was really
neat to see. All right.
Next slide, please. This slide’s information came
from quarterly internal reports shared within our agency
and with SAMHSA. It contains health-indicator
outcomes and progression of reassessment status, which shows some
of the growth. This improvement over
12 months occurred from client participation in our integrated
care and programming. Next slide, please. Many of our grant clients
have trauma histories, and I know that’s a topic
that is out and about, a common-form care. But with this trauma
histories and substance use, we started facilitating
Seeking Safety groups to support the needs
of our clients. Like most of the groups
and wellness programming, we developed these
strategic decisions based on the data we collected
from our client populations and all of our assessments. This report is a great
educational tool for staff, clients and stakeholders
showing outcomes and worth, helps change culture. This report includes
descriptions of the program, a chart on attendance,
different outcome measures during the 12 weeks
or over the 12 weeks, and what you don’t see
are client comments and staff observations about participants. But this really paints
a good picture of what the program is about, and these were
tools we developed from all of
our wellness programs and things that we developed and was just a nice
educational tool. Some of the client comments
on this one, I’ll just share. One of them was, “The group
was helpful as an open door for me to share my pain, although it took a few weeks
for me to adjust. Thank you.” Another client, and I add
these on the report as well, “This group opened up my eyes
to the fact that I have PTSD. Thanks to this group,
I have been able to talk about the abuse I’ve suffered at the hands
of my former stepfather. This feels like such a relief to be able to get years
of feeling out in the open,” so a great, wonderful group. We still run this one as well. It’s this one that we sustained,
and we’re running it at three of our public
health centers. Next slide.
Sorry. I’m talking a little fast here. Sustaining practices. So I have
a number of things here, but I really have to commend
our executive leadership team. They have taken charge
of integrated care and continue to invest
in this approach as well as helping
to drive culture, change within the agency. This consistency is not easy, specifically with our
particular state funding issues, competing priorities
among divisions and our many commitments
to the community. Integrated care is a regular
topic here in our annual reports for the agency
with our board of directors, manager update meetings and within
our organizational structure. It’s really from the top
down and the bottom up, so we’ve come a long way and still have
a long way to go, but the primary
care partnership, number two there, AMITA, the one that we had with VNA Health Care was successful. However, our business
models didn’t align. More so, the peer matches
were more often than not hindering enrollment. It ended up being difficult
to keep those clinics full towards the end. To help this, we opened
their clinics up to all DuPage County
Health Department clients, including some of
our refugee program clients being served on-site. This helped but still wasn’t
enough to sustain. So during the third year
of our grant, we had started a new partnership
with AMITA Health, and our business
models were very similar. They see our behavioral
health clients as well as prenatal clients
from our WIC programs. These clinics have been
full since we started, and we have begun
discussing expanding the clinic hours
and even locations. Number three, we, you know,
we had set out another RFP. We have other locations. We want to have more
partnerships with primary care, so we are moving forward
with trying to have those
partnerships happen. Number four, programming. We started with
several wellness programs, but we’ve really sustained
three in the end, and that decision was
supported by leadership. We kept the evidence-based
groups that bring in revenue and demonstrated
successful outcomes. And, you know, we got
to choose your battles. Pick your priorities and where you’re going to put
your energy into it. So being able to sustain
the three, I was pretty proud of that, also fits with
our triple-aim approach. Number five,
Integrated Systems Managers. We’re not sure
if you’ve heard of that title, but it’s a new title,
and it’s my new title. So part of the structure
was an organizational change. They developed positions called
Integrated Systems Managers, and we oversee, at the various
public health centers, we manage and oversee behavioral
health, community health, environmental health
and front-office operations. So we are the liaisons
to the primary care partners in our locations, and we focus on integrating
our systems on-site between divisions
and within the community. So they’re works in progress,
but it was a real investment, I think, from the agency
to realize, “Hey, we need to keep somebody at the helm of this
integrated care,” and now they have
more people to do it, which makes me pretty happy. Six and seven is a project
I currently manage. In essence, we have continued
to collect health indicators, evaluate these values,
educate clients and staff. We intervene.
We refer. We provide services
that our clients need, and, you know, I’ll explain
a little bit more about that one, too. Next slide, please. This is one of several flyers
from our campaign with AMITA. We are active in this
relationship with primary care and have more
of an integrated model versus the co-located model we practiced
with our first partner. We started talking to AMITA,
like I’d mentioned, during our third year
of our PBHCI grant, and many of our outcome reports and those things
I was showing you before, those tools helped communicate
our value to AMITA. And we expanded services
for pregnant mothers, prenatal care. This is also a population
we serve in our community-health
programs, thus giving these patients
that one-stop shop, again, for primary care, WIC, family case
management and also, when screened and a need,
behavioral health services. So it’s a way to, you know,
integrate services in-house and make sure people are really
getting the services that they need. Next slide. So procedures six and seven
that I referenced is this
Health Indicator Project. So collecting
the health indicators is a sustaining practice for us. We now do this at the time of a patient’s
psychiatric evaluation. So we picked a certain place
to do this, more specifically. The work flow involves
having an RN, Registered Nurse, or a Certified Medical
Assistant collect vitals including waist circumference,
which we still do. They use a standard
order for blood work and triage the patient’s
mental health and physical health issues with the prescriber the same day and before the evaluation. The doctors love it. We added collection in the PHQ-9
screening tool with the client. They receive that
at the front desk. The prescriber receives
the tool to use as a reference and a consideration
for major depressive diagnosis during the psychiatric
evaluation. During this process,
we collect, evaluate, refer and provide treatment
or support based on health-indicator values,
chronic health issues as well as behavioral
health symptoms, substance use
and trauma history. The prescriber makes referrals
electronically and from triage with the nurse. This data is tracked. Like, they put it right
into the electronic record. It’s tracked, and then we also
have trained staff follow up with the clients to engage
and enroll in the programs that the prescriber
has referred them to. Then patients are enrolled
in the referred programs, or care coordination
is provided. So ideally, the therapist,
the RN, the CMA, the prescriber
and the outreach staff all engage and encourage clients
to enroll in wellness. So again, no wrong way,
no wrong door. We really work hard to do this. So the system is great,
a really good thing that we’ve kept moving forward, and the doctors are learning
more efficiently to make sure that they’re marking
the correct boxes. So part of that was
doing education directly with the prescribers, and we’ve done that formally
and informally, and there’s, again,
no wrong way to help them
make the referrals that they need
to be making. And when somebody does
a follow-up call, we learn that the patients
really like it. They’re like,
“So we’ll set you.” Somebody sees a psychiatrist
for an evaluation, and that week, they get
a phone call, and they’ll say, “Hey. I’m calling on behalf
of Dr. Pennepacker. You know, he suggested
and referred you into our new R program. I’m calling you today
to tell you about that and help you get
registered and enrolled.” It’s really helped
with our enrollment, so it’s a real neat thing
that we’re doing. Next slide, please. So moving forward,
this is an older slide, I think, that carries less weight here
than it did in the past. It’s that white elephant
in our room, right, or should I say “our
behavioral-health therapy room.” We are starting to talk about health indicators
and health disparities. We have been doing this
with increasing commitment every year,
and for this, I am grateful. This work is culture changing, not only from a behavioral
health perspective, but we’ve learned that
discussing weight is hard. It’s not just us
that struggle with this. We have champions at
every location and have adopted and practice whole-health care. Client treatment plans are
shifting from just mental health to addressing mental health, physical health
and substance use, good stuff. Next slide, please. You know, some of
the challenges, I think I’ve touched base
on some of these, and you may run
into the same ones, but these days,
we’re all doing more with less. It’s just part
of the times, right? Integrated care must
remain a priority, and when new procedures
or practices are implemented, they need to be supported,
monitored and managed. And I would say that’s,
you know, one of those challenges
is really making sure you put the energy
into continuing to manage and be part of that operation because when you’re
involved in it, you really see who’s doing what and what they need in order
to do a better job. Billing, I’m looking forward
to seeing how our state defines billing activities that support
integrated-care practices. I’m not quite sure how that’s
all going to work yet, but I am hopeful. Next slide. Knew then what I know now, so what is one piece
of start-up advice? Keep your foot on the gas. Keep all stakeholders
in the loop with your work. Have regularly scheduled
checkpoints, time lines. Integrated systems and care
requires staff participation from all occupations
involved and the areas to get involved and participate in projects. This is how you find champions, and this leads
the culture change. You need front-desk staff,
RDs, dietitians, medical assistants,
accountants, consumers. See, everybody really needs
to be at the table when you’re developing
this work and these programs. Keep regular communication
with your primary care partners, administration
and direct-care staff. It’s important for leaders,
managers, staff and clients to have consistent formal and informal check-ins. People change positions
regularly. That was, you know, when we
worked with VNA Health Care, they did. Their leadership changed over,
and we had several providers, and it just, you know,
it kept you on your game because you had to
continually educate and explain
what you’re doing here. And that wasn’t a bad thing,
but just being aware that people’s positions change and staying on top of your work. So for that, I would
recommend use those with project-management
backgrounds and skill sets to develop
your programs. You need a project manager,
for sure. Keep sustainability and
continuous quality improvement a theme throughout your work, and I think that’s… Next slide. …that might be all my stuff. -Jason, Alex here. That was terrific.
Thank you. It was a great complement
to the previous presentation. We have some very good
questions coming in, and what strikes me
about the questions is how they are so appropriate for either direction
of integration. It’s amazing. You could ask the same
questions, I think, in primary care here
about the challenges that they face in bringing
in behavioral health services. So one of the questions
that comes up often that’s been asked
is about workforce and sustaining your workforce as you build this
new approach to care. Did you experience
some workforce turnover as you built
your integrated approach, particularly nurses
and psychiatrists? And how have you addressed
that over time? -I will do my best to answer
any of these questions, and feel free
to reach me personally, and if I can elaborate, I will. But you know, it wasn’t
as much workforce change because the same,
original people that started doing
this are all here, and they’ve actually
gotten spread out to the other sites
to take a more critical role in implementing integrated care and to be, like, a point person. So as far as on our side, the health department staff
have been the same. Primary care, I mean,
we changed partnerships completely and are now
working with AMITA. And they have
a residency program. It’s working really well. They have a preceptor,
and then they will bring their, like, I think,
their fourth-year doctors in that do all of the primary
care for our patients. But they sit and they have
a clinical staffing. One of the original
MYCARE coordinators is part of that clinic and the clinics
that we’re developing, so they’re a key piece. I think, yeah,
workforce can change, but, you know, having the job, we redeveloped
our job descriptions. The MYCARE coordinators
are also now called integrated
care counselors, so they have
a new job description that really spells out a lot more of detailed
what their job is and part of that
being a culture changer and a person that will lead
these primary care clinics, have a smaller case load. So I don’t know
if that’s answering your question 100%, but I would say, no, we haven’t
had a lot of turnover. -Yeah.
Jason, thank you very much. One other question,
before we transition, has to do with
your referral process and ways in which you’re
engaging the individuals and their families
in that process. Are you using peer
support in any way? -Yes.
We have consumer. Some of the wellness groups that are run are out
of our community center, and we do use
our peer-support specialists as well to engage clients. Yes.
So we do have that as a part. A lot of the engagement
just into the actual programs is now coming from the doctors,
the prescribers, the nurses, the primary clinician
that’s working with them. So again, we have
multiple people that bring up the needs of the clients
during their treatment. -You know, I’m going to offer
the last question to our colleagues
at Stanley Street. And it has to do with one
of the really interesting moments
in building integration when you go with
an open-access approach. And for Stanley Street,
what was that like, and how did you assure that you would have
a soft landing with your workforce as you went open access? -Well, I don’t know
if we had a soft landing, and we did have
some people who tried it and didn’t like it and moved on and brought in some people that were enthusiastic
about the model. So it is a total shift
from what we think. But, you know, I can say,
through our studies, through the Blue
Cross Foundation, through the NOMS, it really has made
a tremendous difference in the clients that we see. And before we go,
I just want to give a plug. If people want to learn
more about this, and we are now having patients
be able to text us, e-mail us, online forum
or live chat through And they can see
our triage center and see a little bit
about how this works.

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