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Integrated Care Challenges in a Public Health Setting

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Safety net for indigent care in Buncombe County, (150,000 people) ... adapted from presentation in 2006 by Susan Mims, Buncombe County Medical Director ... – PowerPoint PPT presentation

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Title: Integrated Care Challenges in a Public Health Setting


1
Integrated Care Challenges in a Public Health
Setting
  • Collaborative Family Healthcare Association
  • 10th Annual Conference
  • Denver, CO Nov.
    7, 2008
  • Ashley Lester, LCSW Stephen Snow, PhD, LPC
  • Integrated Care Clinicians
  • Buncombe County Health Center
  • RHA Health Services, Inc.
  • Asheville, N.C. 28801

2
Introductions
  • Ashley
  • LCSW, University of Denver, 1996
  • Integrated Care, RHA/BCHC Primary Care Clinic
  • Bilingual (Spanish/English) Therapist
  • Certified Yoga Teacher
  • Steve
  • PhD, Counseling, UNC Charlotte, 2005
  • Private practice (family violence/complex trauma)
  • Integrated Care, RHA/BCHC Primary Care Clinic
  • Executive Director, CFHA
  • Previous careers journalism, telecommunications

3
Overview
  • Introduction
  • Overview of BCHCs population
  • Integrated care interventions
  • Challenges and creative responses
  • Case examples
  • Final comments and questions
  • Resources

4
Buncombe County Health Center
  • 36,000-40,000 patient visits annually
  • 12 medical clinicians
  • 3 integrated care clinicians
  • Safety net for indigent care in Buncombe County,
    (150,000 people)
  • 1 of 2 primary care clinics out of 100 Health
    Departments in NC (county funded)

5
Our Beginnings
  • Duke Depression Grant
  • 5 full time integrated care clinicians
  • Budget cuts, county contracted out positions

6
RHA Health Services, Inc.
  • RHA Behavioral health established in 1995
    not-for-profit company serving people with mental
    illness, substance abuse, and developmental
    disabilities.
  • RHA Health Services and RHA Howells provide
    residential, vocational, and educational programs
    for more than 1500 infants, children,
    adolescents, and adults in North Carolina and
    Tennessee
  • More than 700 employees deliver a wide variety of
    care, from community support to intensive in-home
    and crisis management.
  • 200 million in revenue 23 million in free
    services

7
Clinic Population
  • 13 latino (adult) 54 latino (child)
  • Latino population has increased 210 in past 10
    years
  • .01 Ukrainian/Russian speaking
  • .002 Other languages
  • 11 African American
  • 76.9 Caucasian

8
Public Health Population
  • Largely indigent, some homeless, little money,
    little education, disorganized, chaotic lives
  • uninsured
  • medicaid/medicare
  • insured - other

9
Low-Income Patients
  • Living in poverty is a health risk. The stresses
    of the lives of people in poverty take a greater
    toll on their bodies than is true for people with
    adequate financial resources.
  • Low-income and underserved populations are less
    likely than the general public to accept a mental
    health definition of their problem. If they do
    accept a referral for mental health services,
    they have much greater difficulty with travel and
    scheduling.

10
Low-Income Patients
  • Garrison, et. al., (1992), in a study in
    Springfield, MA, found that while low income
    patients have higher levels of psychosocial
    needs, medical providers are less likely to
    address psychosocial needs in this population
    than in more affluent populations.
  • Lower institutional trust, clinicians lack of
    assertive treatment.
  • Physicians were more likely to try to deal with
    parents concerns if the payment type was
    anything except Medicaid and more likely to try
    to refer Medicaid patients to specialty mental
    health services.
  • Garrison, W., Bailey, E., Garb, J. Ecker, B.
    (1992). Interactions between parents and
    pediatric primary care physicians about
    children's mental health.  Hospital Community
    Psychiatry 43 489-493.

11
Clinic Population
  • Most common issues presented
  • Lethargy, headaches, chest pain, chronic pain,
    etc.
  • Translates into
  • Depression
  • Anxiety/panic
  • PTSD
  • Substance Abuse
  • Complex trauma
  • Unresolved grief
  • Physical / sexual trauma
  • Bipolar disorder
  • Personality disorder
  • Somatized disorders

12
Integrated Care Interventions
  • Triage
  • Short-term therapy
  • Telephone counseling
  • Clinical case management
  • Psychiatric consultation
  • Follow up clinic visits
  • Groups

13
Triage
  • When medical clinician suspects mental health
    issue, therapist is paged.
  • Assessment
  • time avg. 20 minutes
  • BHQ
  • Differential diagnosis
  • Risk for self-harm or harm to others
  • Motivational interviewing, stages of change,
    psychoeducation
  • Referral out or follow-up with integrated care
    clinician
  • Ruling out resources
  • Eligibility for speciality mental health system
  • Advocacy
  • Concrete needs
  • Challenge NC Mental Health Reform

14
September 2008 Triages
  • Unduplicated PT Count 170
  • Total of PT Visits 362
  • Total of Triages 101
  • Total hours in Svc. Del. 250.2 (15,025 minutes
    in direct contact)
  • Average Productivity 78.3

15
2007-2008 Contacts
16
Behavioral Health Questionnaire (BHQ)
  • One-page, two-sided brief assessment
    questionnaire.
  • Depression questions
  • Nine weighted questions, including SI/HI
  • CAGE
  • Four-question Substance Abuse measure
  • Bipolar questions
  • Mania, irritability, problems because of periods
    of hyper-alertness
  • Anxiety questions
  • General immediate symptoms
  • Domestic/family violence questions
  • Still to be designed

17
Options After Triage
  • Short-term (_at_ 8 sessions/meetings) therapy
  • Phone counseling
  • Clinical case management
  • Follow up while in clinic

18
Examples/Cases
  • L.S. Bipolar-disordered/dually diagnosed woman
  • J.H. Depressed man with chronic illnesses
    (depression, COPD, diabetes)
  • S.H. Woman with trauma, anxiety, depression and
    unresolved grief
  • J.S. Chronic back pain, depression, Hep C,
    med-seeking behavior

19
Institutional Challenges
  • North Carolina mental health reform in chaos
  • Rising numbers of uninsured adds stress to system
  • Lack of therapy guidelines (evidence-based)
  • Legal barriers to communication among providers
  • Organizational and professional culture
    differences between PC and BH
  • Clinical and fiscal separation of physical and
    mental health care
  • -- adapted from presentation in 2006 by Susan
    Mims, Buncombe County Medical Director

20
With Challenges, Creative Responses
  • Psychiatric consultation
  • Groups specifically stress reduction
  • Close professional relationships w/ therapists in
    private practice
  • Connections in community w/ Spanish speaking
    providers
  • Education for clinicians
  • Do not bill

21
Final Comments
  • This model has some significant benefits,
    especially creative flexibility.
  • This model also has some significant limitations,
    including limited referral options.
  • All in all, the model is additive and still
    developing.

22
A Few Resources
  • Books
  • Blount, A. (1998). Integrated primary care The
    future of medical and mental health
    collaboration. Norton New York
  • Gatchel, R Oordt, M. (2003). Clinical health
    psychology and primary care Practical advice and
    clinical guidance for successful collaboration
    American Psychological Association Washington,
    D.C.
  • Web sites
  • http//www.integratedprimarycare.com/
  • http//www.primarycareshrink.com
  • http//www.mahec.net/ic/
  • http//www.thenationalcouncil.org/

23
A Few More Resources
  • www.depression-primarycare.org The MacArther
    Foundation
  • Institute for Healthcare Improvement (IHI)
    www.ihi.org/collaboratives
  • RWJ Project Depression in Primary Care
    www.wpic.pitt.edu/dppc
  • National Council for Community Behavioral
    Heathcare www.nccbh.org/html/learn/primary.htm
  • Developmental Behavioral Pediatrics Online
    www.dbpeds.org
  • http//cartesiansolutions.com ( Financial
    information)
  • http//www.cfha.net
  • http//www.parc.net.au
  • http//www.shared-care.ca
  • http//www.behavioral-health-integration.com/news.
    php
  • http//www.shepscenter.unc.edu/index.html
  • http//www.icarenc.org/

24
The End
  • Thanks for listening. For a free copy of this
    presentation
  • CFHA Members http//www.cfha.org
  • Non-members
  • http//www.commcure.com/cfha1108.ppt
  • Please provide credit for any material you use.
    For more information on this and other trainings,
    workshops and consultations, please go to
    www.commcure.com.
  • Contact us at
  • Ashley ashley.lester_at_buncombecounty.org
    828-250-5340
  • Steve ssnow_at_rhanet.org 828-250-5254
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