Integrating Behavioral Health and Primary Care Indian Health System Readiness Curriculum

1
Integrating Behavioral Health and Primary
CareIndian Health SystemReadiness Curriculum

• Ann M. Lewis, CEO
• CareSouth Carolina
• Ann.lewis_at_caresouth-carolina.com

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Objectives

• To describe current perspectives on Why
  Integrate
• To present an array of considerations for those
  centers interested in integration.
• To present a review of the various models for
  behavioral health and primary care integration,
  discussing strengths and weaknesses.
• To describe the core clinical functions of
  integration
• To share experiences of CareSouth Carolina and
  other team examples with integration within the
  framework of the Care Model

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Why Integrate Behavioral Health and Primary Care?

• Surgeon Generals Report on Mental Health in 1999
  acknowledged the crucial role of primary care
  in provision of mental health care
• The Presidents New Freedom Commission on Mental
  Health (2003) promoted integration
• Secretarys National Advisory Committee on Rural
  Health and Human Services (2004) and Institute of
  Medicine (2005) call for integration

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Benefits of Integrated Care

• Seamless for the Patient improves patient
  satisfaction
• Immediate Access (no referral out)
• Reduces Stigma
• Improves Access for MH expertise
• Immediate Curbside Consultation
• Extends Behavioral Change Expertise into the
  Primary Care Center for improved management of
  chronic conditions (DM,CVD)
• Improves medical productivity, access and flow
• Contributes to the improvement of medical
  clinical outcomes and functional outcomes
• Depending on state reimbursement structures,
  behavioral health services can have a positive
  fiscal impact on the center.

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Common Barriers and Myths (to get over.quickly)

• Our patients do not want to address depression or
  mental health.
• It is understandable that our patients are
  depressed or mentally unhealthy.
• We do not have the right staff or support, if we
  ask, we open Pandoras Box
• It will cost too much.
• Our patients need help with social and economic
  issues, not mental health or depression.

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Considerations If youre thinking about
integration

• How clinical, administrative, and operational
  functions will be integrated
• How community and market factors affect
  integration
• What mental health conditions are likely to be
  seen in the centers patient population and in
  the community?
• Will services be provided only to center patients
  or open to new patients from the community?

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Considerations.

• What types of behavioral health conditions and
  levels of acuity will be treated within the
  service?
• What referral sources are available for patients
  with needs beyond the capacity of the centers
  services?
• What level (model) of integration is desired?
• What is the comfort level of the existing PCPs?

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Considerations.

• What administrative, information, and support
  systems are needed? Billing, registry,
  appointment.
• What are the resources and constraints within the
  community and state.
• What are the state licensing requirements for
  mental health staff?
• Consider MH clinicians abilities to engage
  patients and work well with PCPs. It is
  different from private practice and CMHC models.
• What are the state reimbursement structures? For
  Medicaid, for managed care, for private
  insurance?
• What is the pharmaceutical availability for the
  center? For indigent and uninsured patients?

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Models of Integration

• Diversification provided on-site directly with
  Centers own mental health staff
• Linkage / Co-location provided on-site by
  non-Center staff health worker
• Referral provided off site by non-Center staff
  under formal arrangement
• Enhancement train primary care practitioners to
  provide mental health services on site.

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Diversification Model

• Gives the center control over how behavioral
  health services are provided
• Ability to provide services to indigent and
  uninsured
• Reduction of stigma
• Improved patient satisfaction
• Improve likelihood of continuing treatment
• Reducing time demands on PC staff improving PC
  productivity
• Integrated medical record with BH tab facilitates
  patient care planning
• Allows for PC team collaboration in real time

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Wind River Behavioral Health Department

• 4 Psychologists (one unfilled)
• 1 Counselor
• 2 Social Workers
• 1 Consulting Psychiatrist

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2007 Top BH Patient Concerns
Other Emotional Reactions 13
Alcohol Related 25
Post-Traumatic Stress 9
Depression 22
Social Services 31
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2007 Most Frequent Behavioral Health Primary
Diagnoses

• Visits
• Depressive disorder 236
• Family Circumstances 201
• Adjustment disorder (mixed emotions and
  conduct) 176
• Bereavement 155
• Post-traumatic stress disorder 145
• Adjustment disorder with anxiety/depression 141
  
• Alcohol dependence (in remission) 122

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Behavioral Medicine

• Falls under Medical Services, integrated into
  Primary Care
• I provide immediate preventive medicine and/or
• risk reduction interventions to patients
  (15/30/45)
• If indicated, BH referrals are made or B.Med
  patients scheduled
• Motivational interviewing is the primary tool
• Currently only at Fort Washakie, will spread to
  AHC

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Most Frequent Behavioral Medicine Secondary
Diagnoses

• Stress-Related Physiological Response Affecting a
  Medical Condition (316)
• Pain Disorder Assoc. w/Psych. Factors a Medical
  Condition (307.89)
• Maladaptive Behaviors Affecting a Med. Condition
  (316)
• Hx of Past Non-compliance, Hazard to Health
  (V15.81)
• Other Psychological Stress (Difficulty Coping)
  (V62.89)

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2007 Top B. Med. Patient Concerns
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Linkage / Co-location Model

• Contracts with local mental health centers or
  private providers
• Issues of changes in local or state funding
• Issues of providing care to indigent and
  uninsured patients
• Issues of support structures appointment
  scheduling, billing, office space, medical record
  documentation, interaction with PC team.

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Referral Model

• More frequently used to supplement the
  Diversification Model
• Addresses the need for care that is beyond the
  capacity of centers mental health staff.
• Center must address tracking and follow-up,
  expectations of reporting from specialist

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Enhancement Model

• Typically used to supplement the Diversification
  Model
• Improves the capacity of the PCP to work as part
  of an integrated team.
• Requires targeted training, usually for
  medication management
• When used as stand alone model
• Has significant detrimental impact on provider
  productivity
• Requires targeted training for assessment and
  counseling treatment

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Core Clinical Functions of Integration

• Integrative Activities
• Patient screening / assessment using
  standardized, evidence based tool (PHQ9) may be
  done by PCP team, BH staff, other
• Initial Engagement Brief introduction to BH
  staff for evaluation of immediate needs.
  Engaging the patient improves likelihood of
  further treatment. Responding to questions from
  patient and staff
• Maintaining walk in slots for same day access.
  Consider 15/45 minute schedule
• Coordination with the PCP team
• Follow up and tracking

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Core Clinical Functions of Integration, continued

• Direct Care Services
• Medication management by PCP
• Counseling and therapy services, individual,
  family, group by mental health staff
• Begin TX within 2 weeks for non-emergency
  problems
• Psychiatric consultation / referral- phone,
  telemedicine, appointments

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Lets talk about specific team experiences with
behavioral health integration specific to the
components of the Care Model

• CareSouth Carolina
• South Central Foundation
• Gerald Ignace
• Eastern Aleutian Tribes
• Cherokee
• Any others????? (Wind River)

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Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Productive Interactions through effective asset
based partnering over time
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
Patient Driven
Coordinated
Timely and Efficient
Evidence-based and Safe
Improved achievement of patient and community
goals
Wagner, E. et al
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CSC Integrated Behavioral HealthHealthcare
Organization

• CSC has been engaged with integrated BH and PC
  for over 15 years.
• Division of Behavioral Health is at the top
  management level in organizational structure.
• Behavioral Health services are part of the
  strategic plan, healthcare plan, business plan
  and performance improvement plan.
• Senior Leadership supports integrated behavioral
  health with the will, the ideas and the execution
  necessary to insure integration.
• Behavioral Health has specific system level
  performance process and outcome measures.

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Other Team ExperiencesHealthcare Organization

• Where is Behavioral Health in the organizational
  structure?
• Is Behavioral Health addressed in organization
  strategic plan?
• What are some examples of Senior Leader support
  for Behavioral Health?
• Does the organization have Behavioral Health
  performance measures?

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CSC Integrated Behavioral HealthCommunity

• Collaborate with and support local Community
  Mental Health Centers devastated by state budget
  cuts
• Relationship with DJJ to provide mental health
  care for DJJ adolescents
• Parenting classes for DSS/CPS families
• Mental health care for geriatric patients of long
  term care facilities
• Relationship with Pee Dee Coalition for
  depression treatment for domestic violence
  patients
• Depression treatment for HIV/AIDS patients in
  Ryan White program
• Relationship with McLeod RMC Inpatient Behavioral
  Health facility for inpatient referrals.
• Affiliation with local hospital psychiatric
  geriatric unit and psychiatrist

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Other Team ExperiencesCommunity

• What are some examples of community relationships
  your team has established?
• What are some examples of community issues that
  impact integration plans?

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CSC Integrated Behavioral HealthDelivery
System Design

• LMSWs and LBSWs at every site (14), employed by
  CSC
• Behavioral Health staff consists of MSW and BSW
  team, providing stepped clinical counseling
  integrated into primary care
• Designed appointment systems to support the needs
  of our patients including follow-up activities
  and multiple appointments on same day
  max-packing, 15 / 45 minute rule)
• Nurses triage all patients for red flag
  depression statements, and initiate PHQ
• Telephone visits for follow-up and care
  management
• Primary care mental health assessment
  treatment in addition to specialty mental health
  care
• Co-location of clinical counselors and primary
  care providers in the same building, down the hall

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Other Team ExperiencesDelivery System Design

• What is your current staffing for behavioral
  health?
• Where are behavioral health staff physically
  located?
• What is the scope of behavioral health services
  provided?

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CSC Integrated Behavioral HealthDecision Support

• ARHQ Guidelines for Depression Management
• PHQ 9 Symptom checklist for Depression Assessment
• Psychopharmacology training for all providers and
  counselors, nurses and social workers
• DSM IV training for all Behavioral Health staff
• Evidence based problem-solving therapy

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Other Team ExperiencesDecision Support

• What are your guidelines, tools, or other
  resources for decision support.
• Does your team use a specific model for problem
  solving?

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CSC Integrated Behavioral HealthClinical
Information System

• Use a Registry (PECS data management system) to
  track, report and trigger follow-up dates for
  improved depression care
• Mental Health notes are integrated into primary
  care medical record (tab separation)
• Data is reported monthly on a Virtual Office.
• Data is discussed at site meetings, quarterly
  staff and provider meetings.
• All data is unblinded.

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Other Team ExperiencesClinical Information System

• How does your team manage both individual and
  population based information?
• How is behavioral health information documented
  in the medical record?

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CSC Integrated Behavioral HealthSelf-Management

• CSC Depression management handbook which includes
  education and action plan
• Staff trained on self-management goal setting
• Individualized self management goal setting
  implemented
• Medication monitoring and measurement

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Other Team ExperiencesSelf Management

• How does your team accomplish self management
  support?
• Does your team monitor patient medication and/or
  treatment?

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CareSouth Carolina Performance Measures For
Depression Management
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Other Team Experiences and Examples of
measurement and outcomes

• What does your team measure?
• What are some examples of your team performance?
  Outcomes?

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References

• D. Lambert, J. Gale(2006). Integrating primary
  care and mental health current practices in
  rural community health centers. Kansas city, MO
  National Rural Health Association
• Shekar, S. (2003), March24. Update from the
  BPHC Remarks to the NACHC. http//ftp.hrsa.gov
  .newsroom/NACHC2003.pdf
• Proser, M and Cox, L (2004). Health Centers
  Role in Addressing the Behavioral Health Needs of
  the Medically Underserved. NCAHC. Special
  topics Issue Brief 8. Sept. Washington, DC