Behavioral Health Integration in the Mount Sinai Health System: Opioid Treatment and Primary Care

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1 Behavioral Health Integration in the Mount Sinai Health System: Opioid Treatment and Primary Care HANYS Behavioral Health SWAT October 4, 2017 Sabina Lim MD, MPH Vice President and Chief of Strategy, Behavioral Health Mount Sinai Health System

2 Outline Overview of MSHS and Behavioral Health Integration Focus on OTP and Primary Care Integration Successes and Challenges Acknowledgements 2

3 Mount Sinai Health System Overview Integrated health care system with 7 hospitals and 45+ ambulatory practices in NYC, Westchester and Long Island Behavioral Health Services: Based out of Manhattan campuses (Mount Sinai Hospital, Mount Sinai St. Luke s, Mount Sinai West, Mount Sinai Beth Israel) Over 350 inpatient psych, detox, and rehab beds 3 CPEPs and 1 Psych ED; 2 Mobile Crisis Teams, 12 Ext. Obs Beds Full spectrum of ambulatory and community BH services across age span MH Clinic child/adolescent/adult PHP (and IOP) ACT Team Child CSPOA and Home-Based Waiver SUD Clinic and Rehab Amb Detox OTPs Integrated Behavioral Health Services 3

4 Integrated Behavioral Health Services Diverse spectrum of integrated BH and PC and specialty services across the age span Available at 5 of 7 hospitals Ranges from co-located consultation to more advanced integrated models First major site with distinct goal of an advanced integrated model was at Mount Sinai Hospital Internal Medicine implementation began

5 Integrated Behavioral Health Services BH in PC 7 sites: 4 with primarily Adult Depression Care Management, and 1 with several tracks (MSH IMA) MSH IMA: Distinct Tracks/Programs with deep clinical and organizational integration of BH and PC Depression Care Management Full Article 31 services (moderate-severe depression/anxiety and other BH diagnoses) High-Risk sub-clinic integrated care with psychiatrist and High-Risk team PCPs and care managers SUD services: Buprenorphine; New PCP with Addiction Medicine Fellowship hired Most Common Diagnoses: MDD Adjustment Disorder related to medical dx or recent loss PTSD GAD SUD: less commonly identified but likely underestimated Exception: MSH IMA 5

6 Mount Sinai Beth Israel OTPs Overview 6 physical locations in Manhattan and Brooklyn 6,000 patient capacity, active patients generally in 5,500 5,900 range Two distinct tracks of physical health care integration: Primary Care Hepatitis C screening and coordinated care 6

7 Primary Care in Mount Sinai Beth Israel OTP Primary care in the MSBI OTP on 125th street began on September 1 st 2015 Primary care is provided to any OTP patient who is willing to choose us as their primary care provider Primary Care is provided by a Physician Assistant and Attending Physician Distinct space and program: Primary Care Unit 7

8 Primary Care in OTP High-Level Operations Workflow of seamless care incorporating primary care, behavioral health and social work Patients interested in primary care are directly escorted to PCU via Warm Hand Off and warm referral Patients are seen by appointment and as walk-in visits Patients are reminded about their appointment during their visit to OTP by their counselors and nursing staff USPSTF screening guidelines are utilized to provide a quality standard of primary care Total number of patients enrolled in PCU to date: 163 8

9 Primary Care in OTP Services Annual physicals, routine follow-up and urgent care Immunizations and other preventative care Onsite treatment is available for acute physical health conditions: Diabetes mellitus: blood glucose level checks, insulin, glucagon available for immediate treatment of hyper- and hypoglycemia Hypertension: Nifedipine IR available for acute hypertension COPD/asthma: Nebulizer treatments for acute asthma exacerbations Acute and Chronic Pain: non-opioid pain treatment with NSAIDS and acetaminophen provided onsite for pain management Onsite treatment has helped with avoiding ER/ Urgent Care visits 9

10 Primary Care in OTP Common Conditions Most Common Conditions: DM, Hypertension, Obesity Diagnoses Treated Total Abnormal laboratory findings 81 Mental and behavioral disorders 59 Endocrine, nutritional and metabolic diseases 54 Diseases of the musculoskeletal system and connective tissue 51 Infectious and parasitic diseases 47 Diseases of the circulatory system 42 Diseases of the digestive system 24 Diseases of the respiratory system 20 * Patients may have been treated for multiple diagnoses 10

11 Hepatitis C Care in OTP MSBI OTPs have developed a collaborative onsite and referral coordination process for patients with Hepatitis C Collaboration with Division of General Internal Medicine REACH Program (Respectful and Equitable Access to Comprehensive Healthcare Program) All patients in MSBI OTPs screened for Hepatitis C If positive: Hepatology team for treatment of HCV infection on site weekly to enroll and provide linkage to care Each primary-care patient is seen by clinic Social Worker on initial visit for depression and anxiety screening (PHQ-9 and GAD-7) Health Home representatives are on site to ensure patient engagement and adherence 69 patients enrolled in HH Direct coordination of care with Hepatology services across MSHS 11

12 Hepatitis C Care in OTP Total number of patients referred from across BI OTP sites 2017 YTD=258 Treatment Status of New BI OTP Referrals, 11/1/2016 6/30/2017: Treatment Status Total SVR 12 0 Completed treatment, pending SVR 14 Currently ontreatment 25 About to start treatment 7 Waiting for medication approval 10 In treatment work up 23 Transferred to another clinic 12 Not viremic; treatment not indicated 14 Lost follow up 23 Total Linked to Care

13 General Challenges of Primary Care in OTPs Space Cultural issues reflection of historical silos in health care services: Patient apprehension that if pain is a physical ailment, analgesics will not be prescribed Patient perception that OTP medical staff can t or shouldn t manage physical health issues Unique clinical issues of reverse integration General challenges of any health clinic service: No Shows despite high level of warm handoff and coordination General administrative workflows Operational/Billing/Reimbursement-related technical and micro-level requirements 13

14 Successes the Patient Perspective From OTP Patients: Understanding, caring and non-judgmental staff Respect of person and staff that is friendly and always try to help Convenient location Walk-in appointments are available The doctor explains and educates about illness and medications 14

15 Acknowledgements Mount Sinai Beth Israel OTP Leadership: Dr. Ruy Tio, Medical Director of the MSBI OTPs Dr. Rakhsan Chida, East 125 th Street OTP & PCU Attending Physician Joanne Ellison, East 125 th St PCU Physician Assistant Glorice Sanders, MSBI OTP Associate Director Reginald Jospitre, MSBI OTP Operations Director Teri Friedman, MSBI OTP Administrator Dr. Michael Fiori, MSBI Division Director of Addictions Dr. Grant Mitchell, MSBI Chair of Psychiatry Mount Sinai Health System Division of General Internal Medicine REACH Program: Dr. Jeff Weiss 15