Project

1. Integration of Primary and Behavioral
Care In Eastern Tennessee

2. Plan of Action
We are going to provide strategic guidance and performance
improvement solutions - actionable insights and analytics,
technology platforms, consulting expertise and IT
development services for healthcare.
We are going to outline our approach to addressing the
compatibility issues between two different systems of clinical
documentation as well as the discussion of the ongoing
challenges and our rigorous solution.

3. Tennessee: Demographics

4. Demographics

5. Eastern Tennessee
Eastern Tennessee is the most populous and most densely populated. At the
2010 census it had 2,327,859 inhabitants living in its 33 counties, which have a
combined land area of 13,558.27 square miles. Its population was 37.25% of the
state's total, and its land area is 32.90% of the state's land area. Its population
density was 156.33 inhabitants per square mile.

6. Eastern Tennessee

7. Access to Healthcare
Top Community Health Needs
#1 Nutrition/Obesity/Fitness
#2 After Hours Access
#3 Substance Abuse
#4 Mental Illness
#5 Diabetes
#6 Cancer
#7 Tobacco Use

8. Poor Nutrition
Poor nutrition was ranked as the #1 health priority
While there were positive comments regarding programs, such as, Go Red, Boys
and Girls Club, organized youth sports leagues and Zumba, many respondents
would like to see a greater variety in free and low cost exercise options including,
club membership, city parks, bike and walking paths
One individual wrote on the survey, “Many residents can’t afford the exercise
programs.”, “We need a place for kids to ride their bikes.”, “Each city needs a
public swimming pool.”, “Our community needs more health fairs.”

9. Sources
Newspaper ads
Literature
Television ads
Internet
Direct Mailings
Radio ads
Billboards
Health Fairs
Lifestyle changes are seen as one of the best indicators toward improving the
health of the population. Not smoking, improved physical exercise, and a better
diet, could increase quality of life and longevity

10. Eastern Tennessee Statistics
Obesity Rates
➔ 69% of the Total Population
Physical Activity – Percent Reporting No Physical Activity
➔ 29% of Total Population
High Blood Pressure
➔ 33% of Total Population
Diabetes
➔ 10% of Total Population

11. After Hour Access to Healthcare
After Hours Access to Care was ranked as the #2 health priority
61% Ranked accessibility as good
23% Ranked accessibility as fair
14% Ranked accessibility as poor
2% Ranked accessibility as unknown
Some specific comments regarding accessibility to care included, “Accessibility is
adequate if you can afford it.”, “Accessibility is good unless specialty care is
needed.”, “Care is very accessible.”, “There are not enough doctors in town.”, and
“Need more health care clinics for faster service.”

12. The two most commonly cited reasons for self limiting of access to care were
identified as:
1. Lack of any or adequate insurance coverage (affordability – including
medications)
2. Geographic – Travel distance too far or no transportation source at all

13. Access to Healthcare
● Lack of access to health care for the underinsured and the uninsured has
been and will continue to be an issue in the future
● Individuals have limited options for obtaining health insurance
● It is also anticipated that health care costs in the United States will continue to
spiral upward.
● It is unknown how the State of Tennessee, which is experiencing budget
constraints, will be able to pay its share of the Medicaid expense as the
demand for insurance coverage increases.
● At the local level, more individuals will have difficulty paying for health care
and will delay getting needed care which may mean that when they finally
obtain care the condition may be more serious and thus, costly.

14. Some additional comments regarding access to care include:
“The public needs to be more informed about the services currently available in
the county.”
“The county needs more early am and late pm clinic hours.”
“Need to expand the Health Department hours.”
“Need more transportation options.”
“Need health insurance options.”
“Wait times are too long in the provider offices. Need more providers.”
“Provider offices need better customer service skills.”
“Need more providers who are committed to keeping patients well.”

15. Substance Abuse
Substance Abuse was ranked as the #3 health priority
It is recognized that smoking contributes to many health diseases; that alcohol and drug
abuse may affect brain development in the adolescent and young adult; and that the
younger an individual is when he or she starts to drink, the higher the chances are he
or she will have alcohol‐related problems later in life
Lack of resources for people seeking treatment; lack of enforcement of existing laws; lack
of education in schools about alcohol and other drugs
There is a general lack of services available for substance abusers and no detoxification
facility. It is limited to social services and NA meetings
One of many comments received from survey respondents, “alcohol is the major drug
problem, and should be viewed as such...”

16. Access to Healthcare

17. Deslaurier Associates recognizes that:
General health of the population is poor.
We need to come up with more health related education.
There is nowhere for students to go in the summer while parents are working.
Each town needs bike trails and a public swimming pool.
We to educate community and provide free diet counseling
Health insurance cost is too high.
There needs to be a plan for moving forward into the future which would include
plans to recruit businesses and quality services.
We need to come up with adequate resources and measurable indicators

18. Eastern Tennessee: HIPAA LAWS
HIPAA is the federal Health Insurance Portability and Accountability Act
of 1996. The primary goal of the law is to make it easier for people to
keep insurance, protect the confidentiality and security of healthcare
information and help the healthcare industry control administrative costs

19. HIPAA LAWS
Health care providers must keep all patient records strictly confidential and must
have written policies in place to limit the use and disclosure of medical
records, even if patient information is de-identified.
Provider may not sell or disclose a patient’s name or address, unless the
disclosure is made to a government agency or a third party board for
utilization, case management or peer review purposes. Patient information
can be disclosed in response to a court ordered subpoena, or if requested by
the Office of Inspector General.
These requirements apply not simply to practitioners, but to hospitals, nursing
homes, ambulatory surgical centers, dentistry practices, health maintenance
organizations, and laboratories as well.
Besides traditional patient medical records, Tennessee requires that additional
patient information that is disclosed to the state or third-parties be kept

20. Overview of Health Problems: TN vs VA
In 2014, Tennessee ranked 45th and Virginia ranked 21st out of 50 states for
overall health outcomes. Both states had high rates of adult obesity, cancer
deaths, infant mortality, and diabetes. Though Virginia’s overall ranking is
moderately low, the health outcomes in Southwest Virginia counties, where
MSHA’s facilities are located, resembles those of Tennessee. After compiling the
various sources of information, the top health priorities were identified for the
communities that each of the MSHA hospitals serve. This effort has determined
the top health priorities identified in Washington County, TN to include substance
and prescription drug abuse, smoking, obesity/diabetes/physical activity and
cardiovascular disease. There are certainly a number of other health challenges in
this community, but these rise to the top based on this assessment.
MSHA - Mountain States Health Alliance

21. Behavioral Health:Eastern Tennessee
- Behavioral Health is a branch of interdisciplinary health which focuses on the
reciprocal relationship between the holistic view of human behavior and the
well-being of the body as a whole entity. Behavioral Health are issues that
can have a different outcome by changing "behavior".
- For example, giving up smoking can lessen the health problems or illnesses
associated with cigarettes such as COPD and emphysema.
- Poor Mental Health is 33% compared to the national average of 34.9%.
Reporting but not receiving treatment for Alcohol Abuse is 5.6% compared to
the national average of 6.6%. These are just some examples how how the
demographics can help exacerbate conditions that can be treated with
professional guidance.

23. Behavioral Health: Problems and Solutions
Child and Youth Indicators
1. Nonmedical Use of Prescription Drug ( 20%)
Adult Indicators
1. Any Mental Illness in person 26+ yo ( 20%)
2. Any Mental Illness in person 18+ yo ( 22%)
3. Suicide Deaths (All ages) ( 15%)
4. Primary Opioids Prescription (23%)
5. Pregnant Women Opioid Prescriptions (35%)
6. Alcohol Abuse in person 18+ yo ( 34%)
Solution:
Network with other community agencies to
increase internal awareness of services already
available in the community and to develop a
community based action plan as appropriate.
Focus on community based Adult and Youth
education. Introduce mHealth based
interventions that do not require constant wi-fi
signals.

24. Primary Care: Eastern Tennessee
-Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first
contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the
"undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or
diagnosis.
- This also includes Women’s Health, Internal Health, Pediatrics and Geriatrics.
- According to a survey done by Avalere health, Nearly 1 in 5 Tennesseans live without adequate access
to healthcare. Adding to that the top health issues being faced such as Health care-associated
infections,Heart disease and stroke,HIV, Motor vehicle injury, Nutrition, physical activity and obesity,
Prescription drug overdose,teen pregnancy and Tobacco use.

25. Primary Care: Problems and Solutions
Most Requested Additional Services by
Residents:
1. Cardiology
2. Urgent Care Clinic – Adult and Pediatric-
preferable with reduced or free services
3. Oncology
4. Mental Health Services
5. 24 Hour-Pharmacy
6. More oncology services so patients who
are very sick do not have to travel out of
the county for treatment.
Solution:
Increase awareness of the availability of
specialty providers already practicing within
counties of Eastern Tennessee. Continue to
provide high quality care in an efficient manner
to all patients who present to the ED regardless
of the level of complaint or ability to pay.
Sponsor community based fitness projects. This
may also include introducing telehealth solutions
that allow for monthly check ins via skype or
other HIPAA approved interfaces. Focusing on
collaboration between Primary care and Mental
Health resources to make patients feel at ease.

26. Why integrate Primary and Behavioral
Health?
- Physical, Mental and Social challenges are interrelated for today’s patients.
- In the intervening years, evidence has continued to mount that having two,
mostly independent systems of care leads to worse health outcomes and
higher total spending, particularly for patients with comorbid physical and
behavioral health conditions ranging from depression and anxiety, which often
accompany physical health conditions, to substance abuse and more serious
and persistent mental illnesses.
- In spite of this, behavioral healthcare is mostly separated from the primary
care system—a practice that the Institute of Medicine concluded nearly 20
years ago was leading to inferior care.

27. Problems with Integration
1. Different Operating Systems
2. Different OS Versions
3. Different Browsers
4. Different Java Requirements
5. Time Inefficiencies
6. Provider Unawareness of newest clinical info
7. Increase provider frustration
8. Creation of shortcuts leads to data breaches

28. Different Operating Systems + Different OS Versions
Differing operating systems restricts hardware
use and the use of medical devices that may
have the potential to improve productivity.
-During moments of crisis or emergency it is
hazardous to have a systems that are not
adequately integrated.
Challenges: billing friendly EHR, data migration,
and training
-One example of differing OS versions is recent
technology versus older or outdated technology.
-Differing versions affect many necessary and
useful functions

29. Time Inefficiencies + Different Java Requirements
-While two systems are integrated it often
becomes more difficult to locate data than it
would have if the systems stood alone.
The difficulty of finding specific information
among the combined integration and the
vastness of lines of data.
-Data that is expanding faster than it can be
monitored and maintained.
-Problems with conflicting JREs and JDKs if the
version stamps are outside of each other’s
range
-incorrect cross compilation when methods are
being translated into byte code
-May result in a runtime error

30. Differing Browser Versions + Unawareness of Newest
Clinical Info
Web based applications are totally different
from windows applications. A web application
can be opened in any browser by the end user.
The integrated system can provide care
providers with its ability to compile and filter
through patient info and recommend treatment
options.
-Clinical Decision Support
Lack of awareness concerning changes to
clinical info decreases patient confidence in the
care that is being provided to them.

31. Provider Frustration + Creation of
Shortcuts
All of these factors and others combined cause
provider frustration, issues with integration
waste time, waste provider time, make the
provider inefficient, and can affect patient
interactions and health outcomes.
Users create shortcuts that put data at risk.
Such as writing passwords on paper, writing
information that is in the OS on paper, taking
notes on paper rather than in secure location or
documentation application in a computer,
leaving files, profiles, or browsers open.

32. Our Solution
Implement the protocol within the Four Quadrant Clinical Integration Model
Execute a Primary Care Behavioral Health Integration Model
Enact a Vendor Neutral Archive System
Achieve HL7 Status
Follow a Digital Imaging Adoption Model, perform training and a needs
assessment

33. To address the issues in Tennessee currently in
Primary Care and Behavioral Care, we used The Four
Quadrant Clinical Integration Model:
● The Four Quadrant Clinical Model was developed
by the National Council for Community
Behavioral Healthcare.
● Model is representative of clinical service delivery
based on the assessment of behavioral health
and physical health risk
● Eastern Tennessee has high BH and PH
risk/status, so we choose a fully integrated
Mental Health/Substance Abuse Program to
address set Behavioral and Primary Health
issues.

34. Primary Care Behavioral Health Integration Model
A Primary Care Behavioral Health Model includes:
Warm Handoffs
“Curbside” Consultations
Service Delivery - patient interaction, case management, decrease number of
no shows and increase skill coaching
A close collaboration in a fully integrated system - the primary care provider and
behavioral care provider are apart of the same team.

35. Vendor Neutral Archive System
A Vendor Neutral Archive System is technology used by healthcare
professionals that stores data in standard format and interface which makes
the data accessible through different communication systems.
VNA uses neutrality to resolve workflow challenges, adheres to open standards
which allows a VNA to manage large volumes of information.
VNA handles the data at a fast speed and you can set the importance of data
In short, A VNA can bring behavioral health and primary care information into
one central database.

36. HL7 Status
HL7 Status also known as Health Level Seven International is a set of standards and definitions in order to
exchange and develop electronic health records. We are making sure that after integration of two different
systems, that these standards are met.
Some of the main standards are:
HL7 Version 2, query language that enables health providers to send messages about health data
Clinical Document Architecture that allows exchange of clinical documents such as discharge
summaries and progress notes
Fast Health Interoperability Resources - Exchange language that allows interoperable healthcare
applications faster and easier to write

37. Digital Imaging Adoption Model (DIAM)
In a report done in 2015, 80% of
physicians use an EHR, the average
engagement time is 3.3 hours a day.
HIMSS and the European Society of
Radiology revealed this eight stage
model in order to improve healthcare
and patient outcomes.
The eight stages have compliance goals
and you can specialize in different
focus areas
The model helps take a viewer first
approach instead of a data first
approach.

38. Purpose of DIAM
Leadership and guidance
Identify infrastructure or workflow gaps
Monitor technological process overtime
Create a roadmap for future investments
Learn from peers by sharing best
practices
Push market via digital strategy in order
to improve health outcomes.

39. Training + Needs Assessment
Training is crucial in order make sure the workforce can meet the demands and specification of the newly
integrated system. Training is crucial to prevent provider frustration and to keep key stakeholders up to
date in current processes.
An example of a training program that we will look to follow comes from the National Naval Medical Center
in Maryland for training their interns:
Start an integrated service
Manage acute assessments and interventions
Population Health Intervention
Use the train the trainer approach
Having employees do a forced needs assessment will allow the company to identify additional needs of
training/education needed for their employees

40. Conclusion
Deslaurier Associates recognizes the need for integrating behavioral health and
primary health services together. Individually, we recognize the problems of the
community in regards to primary care and behavioral health care. Our solution
creates a vendor neutral archive system which causes both care units to work in a
fully integrated system; it eliminates the technical issues that typically arise with
integration. With consistent monitoring, training and key involvement of
stakeholders, we believe the integration process can be an easy one and
beneficial.

41. References
http://ruralhealthlink.org/News/FeaturedArticles/TabId/94/ArtMID/778/ArticleID/51/The-Integration-of-Behavioral-Health-and-Primary-Care-Services.aspx
http://www.sweetwaterhospital.org/CHNA.pdf
http://searchhealthit.techtarget.com/definition/Vendor-neutral-archive-VNA
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698882/
https://www.tn.gov/health/topic/hipaa
http://www.milbank.org/wp-content/uploads/2016/04/EvolvingCare.pdf
http://www.auntminnie.com/index.aspx?sec=eba&sub=eml&pag=dis&ItemID=114401
Implementing a clinical information management strategy. James Gatson, July 12, 2016
The Digital Divide in the post-EHR Adoption Era, Scott Hessen
http://www.cdc.gov/brfss/