In this episode we hear the second half of the conversation with Franklin County Public Health Director, Scott LaVigne, in which he shares his views on the role of properly addressing behavioral health, providing a positive patient experience, and the importance of partnerships, and how these elements, and others, work together in order for his team to provide holistic care for patients.

I want to go back a little bit to something you mentioned earlier. So we talked, you talked about the needs-based care, what I call the contextualized care and Medicaid is very focused on serving the whole patient, right, which includes some of those social determinants of health. And, and we've talked about access and access to behavioral health is really important. How's Franklin County Health Partner Department partnering or attempting to partner with other agencies to address these needs?

Well, one of the things that when I first came down here that that I just said we really needed to do was get our medical staff. And by that I mean everyone from the person that greets somebody when they walk in the door and checks them in to the person that works through everything with their, their claims and submitting and all the financial pieces of all that interaction from start to finish and everything in between that we had a trauma informed and, and with a focus on integrating behavioral health and, and behavioral health is a broad term. I should probably break that down because it's used a lot in different contexts. I don't look at it as a way of, of sanitizing mental health. So I look at it as a collection of mental health and substance use disorder and, and really what we wanted to focus on here and it and it goes to the social or social determinants of health. We wanted to focus on the whole patient, not just one aspect of that patient. I know I don't think I've ever heard of patients say that they felt their life was better because they met all their HEDIS metrics.

Me either, by the way.

But what, what we did and what I, I did do almost immediately was we purchased an outcome measurement tool because I knew that one of the things that we want to do is we didn't want somebody to have all their screenings done, you know, meet all those metrics like that on the healthcare side, but have housing insecurity and be living in domestic violence and to have substance abuse and mental health problems. Because I know as a mental health provider and a substance abuse provider in my background history that most of the people that show up in emergency rooms with preventable emergency room presentations are people that have mental health and substance use disorders and other things on board or have experience childhood trauma. So we knew that if we didn't look at that whole picture and integrate that in, we were going to have a hard time doing that. So we pulled an outcome measurement tool from behavioral health. It's called the DLA 20 and it, it focuses on 20 areas of a human's existence. And we wanted to make sure that if somebody experienced a good positive health outcomes, that translated into all these other areas as well. And that became our outcome measurement tool. So that was a big piece of what we focused on. Let's see. The other thing I mentioned already was we wanted to do more screening. We, you know, we do screenings routinely as a health department. We have to spend more time with patients because of our funding than providers in the community do. That is a blessing because we have budgeted time to take into account all of what we need to do, and that fits very nicely with a more holistic approach. So it really wasn't causing us to suffer a lot in the volume department. And we focused all our efforts. And I told everybody here, you know, one of the things we want to focus on is the equation of value. And yeah, you got to have a certain amount of volume to make that equation work. But I want to knock it out of the park on outcomes and provider and patient satisfaction. If I can knock it out of the park on those three things, I don't have to worry as much about volume and that includes the services we provide. So, you know, we talked earlier about mental health and behavioral health and you know, we want to and are in the process this year of finally being able to bring somebody in to our clinic clinics to be able to do that ongoing work. Our goal is to make it so that we can keep a lot of those patients here because they're coming here and being able to keep them coming here while they're getting treatment for what can be a well-managed mental health issue. That frees up a community mental health provider to be able to do work that only they can do. You know, I don't want to work with somebody because we don't have the expertise to manage atypical antipsychotics, but the community does. Likewise, the community shouldn't have to be working with somebody who's well managed, you know, on a frontline antidepressant. So. So, yeah, we've really come a long way in that department. The other thing is as a health department, when it comes to looking at the social determinants of health, we are looking, we have a variety of services at the health department in our building that other providers don't have access to. You know, in addition to we have a family planning clinic, an STI clinic, we have immunization clinics, we have access to a WIC program, we have care management for at risk children and high risk pregnancies. Those care managers go into our clinics to meet with patients and we don't duplicate Tier 3 care management. So we've got that all there and we're one of only a handful of health departments in the entire state of North Carolina that still delivers a home health service. And that is really important to us because we are not only targeted, we are pursuing delivering service to the Medicaid population. And so we have an ability to deliver a soup to nuts kind of more than that FQHC could when it comes to home health, our ability to do that service. So we're pretty close to an FQHC, but not quite.

That's great. You, you just went through a whole list of, of wonderful programs and, and services that you guys provide. And I would, I could listen for an hour to you talking about those and ask questions about those. But I, I want to shift gears a little bit. Chess has a large variety of, of different client types and as we've been working with you guys, you obviously being a, a health department and, and focusing on the Medicaid population is something that we feel strongly is, is really important and have been really enjoyed our relationship with Franklin County Health Department. And you guys have been a, a client that has used our the CHESS care management platform and recently went to the full care management delegation. Can you talk a little bit about that decision and why you guys made that decision?

I think I alluded to it earlier, we've had an evolution here and a lot of it is based on our patients and a lot of it is based on the reality of reporting. So we started off wanting to do the whole package, delivering our own care management, including the data ingestion and the reporting back to the prepaid health plans. We realized fairly quickly that the reporting mechanisms, we didn't have the IT infrastructure for that. It was cumbersome. It required, you know, a lot of staff time to do that. And you know, I reached out to a PHP and said, Hey, we're having trouble with this. And, and they actually gave me a couple of suggestions and, and we pursued you have after we checked out several and we've been very happy with it. So we started off with, with CHESS primarily providing just the data management part of it. And, and, and also being able to put our care management tools and being able to use that to report out. We were doing good work, but getting that to the prepaid health plans was cumbersome. And so that was the first transition. And then after a while when we realized that we were having a hard time reaching out to especially the high utilization folks, you know, and when we did, most of them were preferring to just have interaction on the phone and not come in. That got us rethinking what we were doing and whether or not we needed to devote resources to having a full-time employee doing that particular function. And so we began exploring that with CHESS and actually it was your an entity before and so we're happy to work with chess and that entity. And basically, it's been a wonderful, a wonderful experience. Again, being able to reach out to those patients that we don't have as patients, I should say, people that are attributed to us, many of whom are showing up in emergency rooms. And when I look at prepaid health plans, we have monthly meetings with most of them and we review, you know, opportunities for improvement. And a lot of the people that show up on those opportunities for improvement are people that are not active patients of ours. So that has been a huge plus and being able to have somebody who's dedicated to that and nothing else, but that has been a benefit, absolutely a very strong benefit.

That's great. What one of the things that Scott, that we really pride ourselves on that maybe is a little different, some other folks that that do similar work is we really try to partner and have a collaboration with the folks who are utilizing our services. Can you talk a little bit about how you've seen that and what does, what does collaboration look like with the chest care management team from your perspective?

Well, that has been, that has evolved also in the beginning it was, it was wonderful because we had someone that participated in all of our meetings with the prepaid health plans. And you know, to keep that in perspective, we went from as my, as my chief biller is, is wants to remind me regularly and that's who was calling by the way, as my chief biller is want to remind me. We went from one payer to five and each one has a list of priorities and a list of meetings and a list of for everything. And so you know, that takes up a lot of time. And so CHESS provides that, you know, the tells the story about those individual patients. I could not free up the person that was doing care management to participate in those. I didn't have the ability to do that and CHESS is able to do that. So that that was a big plus and those meetings are incredibly helpful. It really gives, it tells the story for the prepaid health plans who are looking at claims data, which very often does not tell the story, especially with lags and claims and all the things that go along with that. So that's been a huge collaboration. The other thing is we've opened up our access to our electronic medical record and being able to look at the care plans on your platform and your folks being able to look at ours. You've been able to find for example, phone numbers that we had that the prepaid health plans didn't and that CHESS didn't. And we had those. And so they were able to use those to reach out and contact people that were missing in action. So that's been a huge ability. And again, as I mentioned, our access to the CHESS platform has been incredibly helpful, been a strong provider for us in meetings with the, with the, the prepaid health plans and I can't say enough about that.

That's great to hear. We, we love to hear that and we've really thoroughly enjoyed the relationship and the collaboration as well. Scott, we've talked about a lot of things here, but what, what is an important question that I've not asked you about today?

Well, there, there have been some barriers to advanced medical home Tier 3 care management and you know we've identified a number of them. One I've already mentioned is we move from 1 to 5 payers and that's taking up a significant amount of time. The other thing relates to claims data and I alluded to that earlier. Claims data doesn't always paint the actual picture and especially for us as a health department, our electronic record and CPT2 codes, which are the main way that a lot of these value based metrics show up for the prepaid health plans and how we can “Close” care gaps, you know those have had issues for us. We do all of the services that are described there, but not all of them get coded and not all of them get them get reported. And that's been a barrier example. We do the PHQ 9, which is a test as a screen tool for affective disorder and, and, but we don't do a code for reading that test result. So we don't meet that metrics, which means that we don't do it. So that kind of creates these mirage gaps in care, you know, because it is the system is blind to that. So that's, that's been something that we've, we've noticed has been problematic. The value-based incentives, the care gaps that I alluded to and some of the value-based incentives as a health department and philosophically as a provider, I, I don't like downside risk. I'm not a big fan. I don't like claw backs. So I like to have something to shoot for and that feels better when we get it and I know that it's not going anywhere. So we're only upside risk. But you know, again, we're too small in a lot of respects to receive a lot of those upside risk value-based kind of incentives. So that's been somewhat problematic. And one of the things that we've noticed is with all of these prepaid health plans, they all have patient incentives and you could fill a book with all of the patient incentives that are available to patients for following up on all this stuff. And there is no way that anybody on my staff can keep track of all that stuff. And so, you know, we've had conversations with CHESS about, hey, can you guys focus in on that because I know that that's going to improve. I mean, gift cards, you know, just unbelievable things and not for insignificant amounts for patients to follow through with care and, you know, that's a win win for everybody. So that's been something that, you know, I think we didn't really think about when we first started doing this. And my providers like what do you mean they can get that? I'm like, yeah, I only found out about it, but listening to the prepaid health plan. So, yeah, that's been a big thing.

Well, Scott, tremendous work from you, your team at Franklin County Health Department. We are excited about continuing to collaborate with you guys and want to say thank you for joining us on the Move to Value podcast.

Great. It's been a pleasure to be here.