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Jane Hamel-Lambert, MBA, PhD Karen Montgomery-Reagan, DO, FAAP, FACOP Sherry Shamblin, PCC-S Dawn Murray, DO March 20, 2009. Integrating Mental Health into Primary Care: Sustainable Partnerships. Overview. IPAC: A Rural Health Network Integration Efforts - PowerPoint PPT Presentation
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Jane Hamel-Lambert, MBA, PhD
Karen Montgomery-Reagan, DO, FAAP, FACOP
Sherry Shamblin, PCC-S
Dawn Murray, DO
March 20, 2009
Overview
IPAC: A Rural Health Network Integration Efforts
Developmental Screening and SurveillanceCo-Locating Mental Health in Primary Care
Co-Location Interagency PartnershipsUniversity Medical Associates, IncTri-County Mental Health & Counseling ServicesFamily Healthcare, Inc.
Introductions Jane Hamel-Lambert, MBA, PhD
President, IPAC; Department of Family Medicine, Ohio University’s College of Osteopathic Medicine
Karen Montgomery-Reagan, DO, FAAP, FACOPChair, Pediatrics, Ohio University College of
Osteopathic Medicine; University Medical Associates, Inc.
Sherry Shamblin, PCC-SEarly Childhood Mental Health Consultant, Clinical
Supervisor, Tri-County Mental Health & Counseling Services, Inc.
Dawn Murray, DOMedical Director, Family Healthcare, Inc.
Integrating Professionals for Appalachian Children
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)
Integration Goals
Adoption of routine developmental surveillanceImproves early identification Alternative to “wait and see”
Co-location of Mental Health ProvidersImproves accessImproves quality through care coordination
Improves patient outcomes Developing common language
AAP guideline
Developmental Surveillance and Screening Algorithm9, 18, 30 months give screening tool If at risk, refer for further evaluation
http://www.medicalhomeinfo.org/Screening/DPIP%20Follow%20Up.html
Adoption of the Ages and Stages Questionnaires
ASQ & ASQ:SE
Childcare programs Primary care settings
Shift away from clinical impressions (watch and listen) to using formal parent-completed, normed screening tool.
Reassurance and Risk
SCREENS ASQ Screens 5 Domains• Communication• Gross Motor• Fine Motor• Problem solving• Personal-social
ASQ:SE• Social-Emotional development
Why ASQ Tools?
CHEAP!CHEAP! ASQ – 3 (May 2009) … $249 and
ASQ:SE… $149.00
Low cost alternative—annual cost of $25-50 for following children
Permission granted to photocopy
Quick and Easy
Utility Parent satisfaction survey (N=731) (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
Accurate: ASQ
Normative sample of over 8000
questionnaires, high reliability (> 90%), internal consistency, sensitivity, and specificity
See www.brookespublishing.com for ASQ User’s Guide Technical Report for complete psychometric data.
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)
Physicians trust it
Catches kid earlier than she may have Opens up conversations with parents
regarding observations Monitoring
Billable Generate Revenue
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)
Generalizability
Depression for adults: PHQ -9Patient Health Questionnaires
Improves identification Tool for communication
Co-location of Mental Health Providers in Primary Care
UMA is a multispecialty group dedicated to serving southeastern Ohio. Affiliated with Ohio University College of Osteopathic Medicine
Karen Montgomery-Reagan, DO, FACOP, FAAP
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?
Family Benefits Clients familiar with surroundings and
comfortable with office staff/patients Ease of scheduling for patient and
physiciansReferral sheet to receptionFamilies provided intake paperwork Appointment scheduled right then and there
Parents/patients more willing to try mental health services provided at our office
Family Quotes
Patient: I’ve tried counseling before I have individuals that will fit your personality…
(choice)I will speak with the provider individuallyIf it doesn’t 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
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 messageDon’t wait until it’s 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
Infrastructure Scheduling
On site facilitates follow throughSooner access is easier to negotiate
Office SpaceLocation mattersShape, 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
Real Numbers Three Providers
2 ½ days of service combined
Numbers of Families 78 families have been provided service
Numbers of VisitsOver 250 appointments (Jan08/May08)
No Show ratesMedicaid (approx 29%) NS rate > than
privately insured NS rate (approx 10 – 12%)
TCMH-CS is a licensed Community Mental Health Center serving four counties in southeastern Ohio
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
Implications of Differences in Practice Models
Professional Culture Patient/Client Implications for Assessment/ Diagnosis Organizational Structure Physical Office Space Communication
Practitioner Work Style Consultation
Info goes back and forth
Physician manages case
Mental health
Has time efficiencies
CollaborationFuse ideasJointly develop
treatment plan “our” patient
Time to develop relationship
Build in communication strategies
Billing and Paperwork Procedures Medicaid/Insurance
Medicaid matchReimbursement by insurer, by who is
delivering servicesElecting to serve
Modifying structure of intake paperwork and documentation
Difficult to merge systems even when there is duplication because of ODMH requirements
Evaluate Your Practice Needs Age Family Care versus Pediatric Practice Payee source Mental Health Needs
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
Behavioral Health Integration …a work in progress
Dawn Murray, DO
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.
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.
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 HMO’s), medicare. Enhanced reimbursement through medicaid and
medicare. Considered safety net providers FTCA malpractice coverage Different funding stream than Community Mental
Health centers
Behavioral Health/Primary care Integration models in FQHC’s 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, LISW’s, counselors under supervision of PCP’s
FQHC contracting with Community Mental Health Agency for mental health personnel
All possible combinations of these.
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
Behavioral Health/Primary Care model LISW can triage for PCP’s which increases
everyone’s 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.
Concerns
Competition for patients/clients Supervision Reimbursement Integration
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.
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.
CoLocation toward Integration Shift referring “my clients” to jointly taking care of
families Co-Learning
Understanding diagnostic paradigmsUnderstanding professional biases MH builds medical knowledge; Doc gains mental
health knowledge Communication Goals
Shared languageParticipation in routine meetings Access to medical charts
Lessons Learned Health delivery system dichotomizes MH and
HealthCarve out billingsDifferent govt oversight agencies (ODH, ODMH);
Mission and mandatesDiagnostic tools are differentPhilosophies of care
Communication nourishes partnerships Tensions teach Build the relationships
Contact Information
Jane Hamel-Lambert [email protected]
Karen [email protected]
Sherry Shamblin [email protected]
Dawn Murray [email protected]