Integrating Mental Health into Primary Care: Sustainable Partnerships

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Integrating Mental Health into Primary Care
Sustainable Partnerships

• Jane Hamel-Lambert, MBA, PhD
• Karen Montgomery-Reagan, DO, FAAP, FACOP
• Sherry Shamblin, PCC-S
• Dawn Murray, DO
• March 20, 2009

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Overview

• IPAC A Rural Health Network
• Integration Efforts
• Developmental Screening and Surveillance
• Co-Locating Mental Health in Primary Care
• Co-Location Interagency Partnerships
• University Medical Associates, Inc
• Tri-County Mental Health Counseling Services
• Family Healthcare, Inc.

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Introductions

• Jane Hamel-Lambert, MBA, PhD
• President, IPAC Department of Family Medicine,
  Ohio Universitys College of Osteopathic Medicine
• Karen Montgomery-Reagan, DO, FAAP, FACOP
• Chair, Pediatrics, Ohio University College of
  Osteopathic Medicine University Medical
  Associates, Inc.
• Sherry Shamblin, PCC-S
• Early Childhood Mental Health Consultant,
  Clinical Supervisor, Tri-County Mental Health
  Counseling Services, Inc.
• Dawn Murray, DO
• Medical Director, Family Healthcare, Inc.

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Integrating Professionals for Appalachian
Children
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IPAC A Rural Health Network

• Interdisciplinary collaboration hinges on
  interagency cooperation
• MHPSA.
• Retention/recruitment
• Thank you to Office of Rural Health Policy (P10
  RH06775, D06RH07920)

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Integration Goals

• Adoption of routine developmental surveillance
• Improves early identification
• Alternative to wait and see
• Co-location of Mental Health Providers
• Improves access
• Improves quality through care coordination
• Improves patient outcomes
• Developing common language

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AAP guideline

• Developmental Surveillance and Screening
  Algorithm
• 9, 18, 30 months give screening tool
• If at risk, refer for further evaluation
• http//www.medicalhomeinfo.org/Screening/DPIP20Fo
  llow20Up.html

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Adoption of the Ages and Stages Questionnaires

• ASQ ASQSE
• Childcare programs
• Primary care settings
• Shift away from clinical impressions (watch and
  listen) to using formal parent-completed, normed
  screening tool.
• Reassurance and Risk

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SCREENS

• ASQ Screens 5 Domains
• Communication
• Gross Motor
• Fine Motor
• Problem solving
• Personal-social
• ASQSE
• Social-Emotional development

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Why ASQ Tools?

• CHEAP!
• ASQ 3 (May 2009) 249 and ASQSE 149.00
• Low cost alternativeannual cost of 25-50 for
  following children
• Permission granted to photocopy

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Quick and Easy

• Utility Parent satisfaction survey (N731)
  (publisher data)
• How long did it take to complete the
  questionnaire?
• 70 Less than 10 minutes
• 28 10-20 minutes
• 2 More than 20 minutes
• It was easy to understand the questions?
• 97 Easy
• 3 Sometimes
• 0 Not easy

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Accurate ASQ

•  
• Normative sample of over 8000 questionnaires,
  high reliability (gt 90), internal consistency,
  sensitivity, and specificity
• See www.brookespublishing.com for ASQ Users
  Guide Technical Report for complete psychometric
  data.

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Parent Report ASQ Research

• As accurate as formal measures for identifying
  cognitive delay (Glascoe, 1989, 1990 Pulsifer,
  1994)
• As accurate as formal measures for identifying
  language delay (Tomblin, 1987)
• As accurate as formal measures for identifying
  symptoms of ADHD and school related problems
  (Mulhern, 1994)
• More accurate than Denver for predicting
  school-age learning problems (Diamond, 1987)

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Physicians trust it

• Catches kid earlier than she may have
• Opens up conversations with parents regarding
  observations
• Monitoring
• Billable
• Generate Revenue

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Billing

• CPT Code 96110 (limited evaluation)
• E/M Modifier 25 Significant Separately
  Identifiable Evaluation and Management Service by
  the Same Physician or the Same Day of the
  Procedure or Other Service
• Document administration, interpretation (normal,
  abnormal, parent discussion and referral/action)
• Medicaid Relative Value (staff admin) 13.64
  (2005)

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Generalizability

• Depression for adults PHQ -9
• Patient Health Questionnaires
• Improves identification
• Tool for communication

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• Co-location of Mental Health Providers in Primary
  Care

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University Medical Associates, Inc

• UMA is a multispecialty group dedicated to
  serving southeastern Ohio. Affiliated with Ohio
  University College of Osteopathic Medicine
• Karen Montgomery-Reagan, DO, FACOP, FAAP

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Motivation for Co-Location Program

• Practice Group has a need for mental health
  services
• Difficulty with referrals seems like a black
  hole..
• Making appointment calls
• CMHC required in person to schedule appointment
• Families need access to service
• Waiting for appointments
• Communication
• Did they go, what was the dx, were they
  discharged from care?
• What was the Primary Doc role?

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Family Benefits

• Clients familiar with surroundings and
  comfortable with office staff/patients
• Ease of scheduling for patient and physicians
• Referral sheet to reception
• Families provided intake paperwork
• Appointment scheduled right then and there
• Parents/patients more willing to try mental
  health services provided at our office

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Family Quotes

• Patient Ive tried counseling before
• I have individuals that will fit your
  personality (choice)
• I will speak with the provider individually
• If it doesnt work, I have other avenues
• Patient If you think this person will help, I
  will give it a try
• Patient How soon? It always take so long to get
  it

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Physician Benefits

• Physicians find mental health a benefit for their
  patients
• Physician have direct contact with provider
• Curbside consults, guides diagnostics, treatment
  planning
• Communication easy on site, no phone message
• Dont wait until its a disaster---crisis
• Appointment info is charted
• I know if they are going and continuing care
• Physicians are able to directly discuss cases
  with the mental health professional on site

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Infrastructure

• Scheduling
• On site facilitates follow through
• Sooner access is easier to negotiate
• Office Space
• Location matters
• Shape, size and absence of medical gear
• Private practitioner vs CMH clinicians
• MH Practitioner Billing
• Providers are doing their own billing
• Record Keeping
• Doc charts have mental health progress note

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Real Numbers

• Three Providers
• 2 ½ days of service combined
• Numbers of Families
• 78 families have been provided service
• Numbers of Visits
• Over 250 appointments (Jan08/May08)
• No Show rates
• Medicaid (approx 29) NS rate gt than privately
  insured NS rate (approx 10 12)

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Tri-County Mental Health and Counseling Services,
Inc.

• TCMH-CS is a licensed Community Mental Health
  Center serving four counties in southeastern Ohio

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Components of the Community Mental Health System
that Impacted Our Co-Location Efforts
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Recovery Model vs. Medical Model
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Recovery Model

• Focuses on resiliency while reducing symptoms
• All people have strengths to overcome challenges
• Individuals are the experts in their experiences
  so have the voice and choice in services
• Values unconditional acceptance of the individual

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Implications of Differences in Practice Models

• Professional Culture
• Patient/Client
• Implications for Assessment/ Diagnosis
• Organizational Structure
• Physical Office Space
• Communication

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Practitioner Work Style

• Consultation
• Info goes back and forth
• Physician manages case
• Mental health
• Has time efficiencies

• Collaboration
• Fuse ideas
• Jointly develop treatment plan
• our patient
• Time to develop relationship
• Build in communication strategies

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Billing and Paperwork Procedures

• Medicaid/Insurance
• Medicaid match
• Reimbursement by insurer, by who is delivering
  services
• Electing to serve
• Modifying structure of intake paperwork and
  documentation
• Difficult to merge systems even when there is
  duplication because of ODMH requirements

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Evaluate Your Practice Needs

• Age
• Family Care versus Pediatric Practice
• Payee source
• Mental Health Needs

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Laying a Good Foundation

• Choose the right mental health partner for your
  practice
• Build a working relationship
• Build time for communication/interaction
• Be prepared to develop joint vision and goals for
  the partnership

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Family Healthcare, Inc

• Behavioral Health Integration a work in progress
• Dawn Murray, DO

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MISSION of FHI (Family Healthcare, Inc.)

• The Mission of Family Healthcare, Inc. is to
  provide access to high quality, affordable,
  healthcare to everyone without discrimination.
• All Community Health Centers have a similar
  mission.

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Family Healthcare, Inc

• FQHC (federally Qualified Health Center)
• Six sites in six counties in Southeastern Ohio
• Behavioral health considered a core service,
  provided on site or through referral agreement
• Investigated many models of behavioral
  health/primary care integration.
• IPAC (Integrating Professionals for Appalachian
  Children) involvement was springboard for our
  current journey.

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FQHC

• Federally Qualified Health Centers AKA Community
  Health Centers
• Receive 330 grant from federal government which
  provides for uninsured care. (For FHI, this is
  about 20 of budget)
• Sliding fee scale based on income
• Accept most insurances including medicaid (and
  Medicaid HMOs), medicare.
• Enhanced reimbursement through medicaid and
  medicare.
• Considered safety net providers
• FTCA malpractice coverage
• Different funding stream than Community Mental
  Health centers

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Behavioral Health/Primary care Integration models
in FQHCs

• Referral Agreements with Private Psychiatrists or
  Community Mental Health Centers (no integration)
• Complete in house Mental Health program with
  psychologists, social workers, and psychiatrists
  as FQHC employees.
• In house Behavioral Health Program with Clinical
  psychologists, LISWs, counselors under
  supervision of PCPs
• FQHC contracting with Community Mental Health
  Agency for mental health personnel
• All possible combinations of these.

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IPAC-Colocated Providers

• Involvement in IPAC allowed more collaboration
  between agencies for ideas to develop.
• We started with the original plan of a Tri County
  counselor in one of our sites.
• Quickly saw limitations of this arrangement
• Only available for kids. Not as many kids as
  predicted. Bigger need for adult services. Better
  if billing is through FQHC due to another funding
  stream.
• Began contract with Tri County, but still kept
  IPAC involvement

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Behavioral Health/Primary Care model

• LISW can triage for PCPs which increases
  everyones efficiency
• LISW will keep people for counseling at FQHC and
  work with PCP to address goals to enhance medical
  outcomes.
• If patient is outside of PCP scope for mental
  health issues, LISW can start intake paper work,
  make psychiatric referral and expedite patient
  care. She can continue counseling at FQHC with
  support from PCP. This is very important given
  the long wait times we sometimes have for
  psychiatrists, especially in rural areas. We can
  keep people from falling through the cracks.

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Concerns

• Competition for patients/clients
• Supervision
• Reimbursement
• Integration

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Win-Win

• At a time when Mental Health funding is being
  cut, it is good to have other revenue streams.
  By contracting for services of the LISW, she
  actually increased her productivity at the Mental
  Health Center. FHI is breaking even on the deal,
  and getting excellent services for our patients.

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Next Steps

• We are working on streamlining our communication
  between the PCP and the LISW.
• Developing a protocol and system to triage more
  urgent psyche referrals into the Mental Health
  Center.
• We are planning to spread to our other sites.
• Continuously communicating between Community
  Mental Health center, and providers to foster
  trust, and better integrate our cultures for
  improved access to quality healthcare for all
  patients.

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CoLocation toward Integration

• Shift referring my clients to jointly taking
  care of families
• Co-Learning
• Understanding diagnostic paradigms
• Understanding professional biases
• MH builds medical knowledge Doc gains mental
  health knowledge
• Communication Goals
• Shared language
• Participation in routine meetings
• Access to medical charts

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Lessons Learned

• Health delivery system dichotomizes MH and Health
• Carve out billings
• Different govt oversight agencies (ODH, ODMH)
  Mission and mandates
• Diagnostic tools are different
• Philosophies of care
• Communication nourishes partnerships
• Tensions teach
• Build the relationships

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Questions and Answers
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Contact Information

• Jane Hamel-Lambert
• hamel-lj_at_ohio.edu
• Karen Montgomery-Reagan
• montgomeryreagan_at_oucom.ohiou.edu
• Sherry Shamblin
• sshamblin_at_tcmhcs.org
• Dawn Murray
• murraydoc_at_yahoo.com