2. Foundation
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We will be reviewing:
• Erie Family Health Centers & H3 West
population overview
• H3 West program goals
• Insightful learnings
• Program challenges
• Moving forward post-grant
2
3. Foundation
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Erie Family Health Centers
75,000
medical, dental, behavioral
health patients
150+
zip codes
13 sites
>90%
Low-income
29%
Uninsured
60%
Medicaid
45%
Non-English
speaking
47%
Under 18
62%
Female
H3 West Population
84%
Medicaid or
uninsured
48%
5-13 y.o.
37%
Under 5 y.o.
15%
14-18 y.o.
47%
Spanish-speaking
caregivers
85%
Hispanic/
Latino
4. Foundation
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H3 West Program Goals
Improve the well-being of children by:
1. Achieve a fully integrated system that expands
access to both primary & behavioral health services
in partnership with community mental health center
2. Promote shared training between providers that
increases staff comfort with integrated care
3. Establish an integrated care model that can be
sustained and replicated financially, functionally and
situationally
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5. Foundation
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Pt is
registered
Pt status
changed to
“Registration
Complete”
MA
takes Pt
to check
vitals
MA hands
Pt/family
screener
(ASQ-SE, PSC-35
Y, PSC-35 P,
TESI),
Pt completes
screener
MA brings Pt to
exam room and
pulls orange &
green flag
BHC/IHA
scores
screener,
enters results
in EMR (data
recorded)
PCP sees Pt
and provides
primary care
Negative Screen
BHC/IHA verbally notifies provider
BHC determines:
- Type of issue
- Severity/Risk
factors
- Readiness
PSC, APA DSM-IV
Criteria, CGAS
BHC Visit
Results
Brief
interventiont
1
Internal/
External
Referral2
Crisis4
C4 or
other
Hand-
off3
Pt/
Family
not
ready
BHC hands
Pt/family follow-
up appt slip
MA completes
post visit
activities (labs,
immunization,
vision, etc.)
Pt completes
follow-up
activities,
schedules
follow-up visit
and checks out
PCP/BHC completes
progress
notes/charting in
EMR (data recorded)
Lessons Learned: Positive Impact
H3 Screening Workflow
1 Brief MH Intervention Workflow pg. 3 2 IHA workflow pg. 4 3 Referral to Specialty Care Workflow pg. 5 4 Crisis Intervention Workflow pg.6
Did the screener
result in a
positive score?
NO
Did patient, parent,
or provider express
concern?
NO
Pt arrives
YES
YES
BHC provides
Pt/family with H3
flyer, briefly
describes services
Warm hand-off BHC
enters exam room,
provides Pt/family
H3 flyer, and
explains services
Pt/family accepts
H3 services?
YES
NO
BHC notes Pt/family
declined services in
chart. Pt will be
screened at next
well-child visit
6. Foundation
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Lessons Learned: Positive Impact
• PSC Screening - Despite low rate of positive scores (~10%)
• Destigmatized behavioral health
• Encouraged future engagement if patient was not ready
• Warm hand offs drove slightly greater patient engagement than
+screeners/overrides – 35% vs. 25%
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July 2016 - December 2018
# of BHC visits Warm Hand Off Positive Screen/Override
# of patients % utilization # of patients % utilization
0 630 55.2% 1200 66.0%
1 184 16.1% 252 13.9%
2 94 8.2% 108 5.9%
3 76 6.7% 84 4.6%
4 49 4.3% 54 3.0%
5 37 3.2% 38 2.1%
6 23 2.0% 26 1.4%
7 19 1.7% 15 0.8%
8 12 1.1% 20 1.1%
>8 17 1.5% 20 1.1%
TOTAL 1141 1817
7. Foundation
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• Less than 10% of patients
required/requested long-term therapy
• Over 1/3 of patients needed school-
advocacy support and/or IEPs -
Integrated Health Associate was key role
• Developed ADHD guidelines and crisis
protocols for providers
• Service availability in the evenings is a
MUST!
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Lessons Learned: Positive Impact
8. Foundation
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Lessons Learned: Challenges
• Screenings – ASQ-SE
• Very time consuming for caregiver and staff with very low yield
• Limited specialty BH/psychiatry resources city-wide
• FQHCs unable to bill for case management support
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• C4 transition in Year 2
• BHC employment transition from
C4 Erie
• Lost direct access to long-term
treatment services
• Impacted billing opportunities
9. Foundation
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Moving Forward
9
Brief intervention in-house
Long-term/specialty referrals to
community MH partner
Brief, long-term, psych treatment in-
house;
Cook County BH Consortium
BHCs = 3
Full-time Pediatrics
BHCs = 4
Full-time Peds/Adults/OB
ILCHF - funded
Reimbursement + Philanthropic
Continue identifying & maximizing
FQHC BH billing opportunities
Screening tools:
0-5 yrs: ASQ-SE
6-17yrs: PSC-P & PSC-Y
2-3 providers/day
Screening tools:
0-5 yrs: Resource flyer
6-17yrs: PSC-P & PSC-Y
AIM: Universal - all providers
Integrated Health Associate:
Case management support
Unable to sustain –
Non-billable service in FQHC
Mission
Motivated by the belief that healthcare is a human right, we provide high quality, affordable care to support healthier people, families, and communities.
Vision
All people living their healthiest lives.
Here are some of our numbers
Our 700 employees – from the communities we serve
Care for 72k patients through 300K visits
At 13 sites spanning 150 zip codes
And we’ve been dedicated to caring for people in need for more than 60 years
Erie cares for all patients regardless of age, where they live, insurance or immigration status, or the ability to pay.
