Dr. Lynn is a DBH and a relatively new member of the Patient-Centered Medical Home team in a busy, but small urban primary care clinic. Dr. Lynn has been working in the clinic for 9 months as the first and only Behavioral Health Consultant. She took great care to establish herself with the team. From the office administrator to the four PCP’s, four nurses and the nutritionist. Dr Lynn educated the team about the importance of integrated behavioral health and demonstrated the value of the hallway hand-off. Over the past few months the team gained increased understanding, confidence and interest in referring patients with appropriate problems – poor medication adherence, difficulty making and maintaining changes in nutrition and physical activity, depression and anxiety co-morbid with medical disease.
Dr. Lynn wanted to take it to the next level. She wanted to put into practice the lessons learned in her DBH program and implement a population health management program. She decided to implement a combined depression and substance use disorder screening program using the PHQ-9 and the AUDIT. Further, she would use the new reimbursement codes for both SBIRT screening and for patients at high risk, the new chronic disease care management codes. Dr. Lynn decided that she would start a new stress management group for depressed patients. Patients who met criteria for “sub-threshold” depression as well as DSM-V depression would meet criteria for assessment and treatment. She would also start an education and behavior change group for substance use disorder for patients with mild to moderate severity substance abuse based on the AUDIT. Consistent with the SBIRT model she would refer patients with severe substance abuse to a local specialty substance abuse clinic. After patients were stabilized she planned to conduct telephonic follow-up and educate patients on the use of internet and smart phone APP behavior change resources.
Dr. Lynn spent several months planning this new population health management program. She was excited about the opportunity to achieve the triple aim. By identifying and treating patients she would improve the patient experience of care. By using a population health management program she would improve the population of the entire clinic population of at-risk depressed and substance abuse patients in the clinic. She knew that these patients had higher utilization and associated costs and was confident that with appropriate treatment clinical outcomes would improve, hospital and ED utilization would decrease and she would achieve the goal of Return on Investment. Dr. Lynn made a series of great presentations to the clinic leadership, clinical team and administrative staff. She sold the package and sealed the deal.
The new program was launched on a Monday. By Wednesday, there was chaos in the clinic! The screens were administered and automatically scored on the clinic ipad at patient check-in with the help of the office assistant. The PCP’s and nurses reviewed the results of the screen and made the hallway hand-off to Dr. Lynn. So far, so good, things were going swimmingly. However…it turns out that about 25% of all patients each day were screening positive based on the cut-off scores. Between the 4 PCP’s who saw an average of 25 patients per day, a total of 25 patients were being referred to Dr. Lynn. By luck of the draw, many of the patients were identified around the same time, so Dr. Lynn was faced with each of the PCP’s approaching her for a warm hand-off only to find that she already had 1 patient in her office and 1-2 more in the waiting room.
Dr. Lynn was overwhelmed. She had planned to use the 5 A’s model to engage and develop treatment plans with patients using a brief intervention model that required 30 minutes. She did not plan on a backlog of patients in the waiting room and not enough time in the day to see all of them. The office administrator started to notice grumpy faces on patients waiting and was soon fielding questions and complaints from waiting patients. The PCP’s were getting annoyed that the hallway hand-off model that worked so well up to this point suddenly seemed broken and led to frustration. The nurses were empathic and wanted to help but really had not significant training or experience in brief interventions for depression or substance abuse.
Exasperated, Dr. Lynn pulled the plug on the program by Friday morning. The team was relieved and felt bad that the program didn’t work, and they still had confidence in Dr. Lynn for doing the same type of work she had been doing before the new program. Dr. Lynn was disappointed, frustrated…and tired! But she was trained in quality improvement and Lean, and she was determined to both evaluate what went wrong AND how to re-launch the program but with modifications based on the lessons learned.
For your discussion board, discuss what you would do to re-launch a population health management program after this episode of chaos in the clinic. What would you do differently? How would the population health management program be changed to avoid the chaos? How would you re-engage the team and get them to give you a second chance? What quality improvement or Lean strategies and techniques might you utilize in order to better plan the program?
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