Linking Behavioral Health and Primary Care

1
Linking Behavioral Health and Primary Care

• David Pollack, M.D.,
• Medical Director
• Office of Mental Health and
• Addiction Services

2
Critical Issues in MH-PC Interface

• Assessment and prevention methodologies
• Access and availability of MHPs
• Communication issues
• Confidentiality
• Quality and outcome measures
• Costs of collaboration/integration
• Model for BH integration into PC

3
Assessment/Prevention Methodologies

• Importance of comprehensive diagnostic
  evaluations
• Importance of identifying MHCD problems in PC
  settings
• Assessment tools need for validity, user
  friendliness, and ease of interpretation
• MH conditions associated with PC settings mood,
  anxiety, eating, somatoform AD disorders

4
Assessment/Prevention Methodologies

• PRIME-MD PHQ
• 27-Item patient questionnaire (PHQ 9 items)
• Evaluates mood, anxiety, somatization, alcohol
• Focused clinical interview can follow
• DSM IV-PC
• 1995 adaptation of DSM to PCP needs
• Simplified, emphasizes PCP-relevant Dx
• Summarizes diagnostic process in algorithms

5
Access Availability of MHPs

• PCPs often frustrated in their attempts to refer
  MH patients
• Retool MH intake processes, to identify different
  levels of need in order to provide sufficient
  service capacity
• Importance of on-site consultation and
  integration with PCPs

6
Communication Issues

• Process of sending receiving communications is
  difficult can interfere with service provision
• Need for timely information exchange in both
  directions
• Excessive requirements can encumber
  communications and treatment

7
Confidentiality

• Balance need for information exchange vs. need
  for patient protection
• Critical information physical exam and MSE
  findings, treatment plans, meds, lab results
• Formal and informal confidentiality agreements
• PCP awareness of sensitivity of MH information

8
Quality Measures

• Access to services and encounter data
• Impact on service utilization (medical offset)
• Improved identification rates of BH conditions
• Direct and indirect clinical outcomes
• Satisfaction of the participants

9
Collaboration/Integration Costs and Obstacles

• Service systems should support MH-PC
  collaboration
• Consultation and co-location positions essential,
  not marginal
• Costs of integration factored into capitation or
  case rates
• Include other supports, e.g., fax, data
  management, documentation, telemedicine

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Model for BH Integration

• Non-specific to accommodate variations in
  resources, needs, community context
• Preliminary tasks/questions
• Components of the model
• Behavioral health staffing

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Preliminary Tasks/Questions

• Complete an environmental scan
• Determine the programs filter
• Establish administrative and clinical leadership
  buy-in
• Decide whether to rent or own the BH staff

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Components of the Model

• Triage
• Comprehensive assessment
• On-site treatment
• Referral
• Consultation
• Care monitoring condition management

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Staffing the Model

• Mental health professional (Masters or higher)
• Psychiatric provider
• Non-mental health personnel trained to provide
  specific support functions

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Clinician Characteristics

• Match primary care pace and style
• Respect cultural differences
• Be FLEXIBLE

• Communication skills
• Consultant skills
• Team Player
• Be visible and available
•  

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Clinician Skills

• Knowledge of Integrated Care Model
• Strong traditional clinical skills
• Bio-psycho-social model of health

• Brief, creative, and effective treatment
• Evidence-based Treatment
• Prevention and Patient Education

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Interface Staff Recommendations

• Experience with seriously mentally ill
• Motivated to do brief psychotherapy
• Experience with triage and holds
• Curious interested in medication and medical
  illness, labs etc.
• Collaborative style
• Strong organizational skills

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Skills continued

• Flexible
• Thrive in a challenging environment
• Computer competent
• Adaptable to work in the public sector
• Understands the impact of stigma on profession
  and client
• Bi-lingual

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Chronic Care Model
Community
Organization of Health Care
Patient/Family
Provider
ClinicalInformationSystems
Delivery System Design
Decision Support
Self-Management Support
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Self-Management Tasks

• Use effective self-management tools
• Set and document self-management goals
• Train others on how to help pts w/ goals
• F/u and monitor goals
• Use group visits to support self-management
• Utilize community supports when possible
• Adapt approaches to culture/age factors

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Decision Support Tasks

• Provide evidence-based tx guidelines
• Provide skill oriented interactive training
• Link to key providers and specialists
• Educate pts about tx guidelines

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Clinical Information System Tasks

• Establish a patient registry
• Develop process for data entry, data integrity,
  and maintenance of the registry
• Use registry to generate reminders and
  care-planning tools
• Use registry to provide feedback to providers and
  other team members

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Delivery System Design Tasks

• Identify depressed pts during visits for other
  purposes
• Use registry to review care and plan visits
• Care coordination
• Assign duties to various members of team
• Make sure repeat assessment (PHQ), f/u and
  outreach functions are assigned

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Organization of Health Care Tasks

• Make improving chronic care part of
  organizations mission/goals
• Get leadership support
• Integrate chronic care model into QI efforts

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Community Tasks

• Link to community resources for defrayed med
  costs, education, and materials
• Encourage involvement in community education
  classes and support groups
• Raise community awareness
• Provide a list of community resources to pts,
  family, staff

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Useful Websites

• www.healthdisparities.net/ Depression_Apr2002.pdf
• www.depression-primarycare.org