MENTAL HEALTH MENTAL HEALTH INTEGRATION INTEGRATION

PROJECTPROJECTENHANCING MENTAL HEALTH PRACTICE ENHANCING MENTAL HEALTH PRACTICE

IN PRIMARY CARE…IN PRIMARY CARE…

through improved education and through improved education and communication. communication.

Dr. Ken Casimir MD Dr. Ken Casimir MD Affinity Medical GroupAffinity Medical Group

Dr. Mark Marnocha PhD Dr. Mark Marnocha PhD UW-SMPH Family UW-SMPH Family MedicineMedicine

Dr. John Mielke MD Dr. John Mielke MD Appleton Appleton Cardiology/Community FoundationCardiology/Community Foundation

Dr. Doug Moard MD Dr. Doug Moard MD Thedacare Family Thedacare Family MedicineMedicine

Dr. Mark Rovick DO Dr. Mark Rovick DO Fox Valley Children’s Fox Valley Children’s Psychiatric/MCWPsychiatric/MCW

SettingSetting

Fox Valley region: Third largest urban Fox Valley region: Third largest urban population area in Wisconsin population area in Wisconsin

Larger Cities: Larger Cities: Oshkosh, Neenah, Menasha, Oshkosh, Neenah, Menasha, Appleton. [Green Bay]Appleton. [Green Bay]

Smaller Towns: Smaller Towns: Chilton, New London, Shawano, Chilton, New London, Shawano, Hortonvlle, Kimberly, Kaukauna, Little Chute, Hortonvlle, Kimberly, Kaukauna, Little Chute, Freedom….Freedom….

Limited Scope: contiguous communities, Limited Scope: contiguous communities, and those with linkage via health systems x and those with linkage via health systems x 2.2.

Region/Community/Practice driven rather Region/Community/Practice driven rather than state-level or discipline-specific.than state-level or discipline-specific.

Weaknesses/ThreatsWeaknesses/Threats Serious shortage of Pediatric Serious shortage of Pediatric

PsychiatryPsychiatry Inadequate Adult Psychiatry AccessInadequate Adult Psychiatry Access Nation-wide shortage of psychiatryNation-wide shortage of psychiatry Strong Family Medicine practices, Strong Family Medicine practices,

though majority not full-scope. (no though majority not full-scope. (no inpatient medicine or Ob)inpatient medicine or Ob)

Family Medicine forced to assume Family Medicine forced to assume wider scope of MH practice.wider scope of MH practice.

Strengths/OpportunitiesStrengths/Opportunities Community interests in compassion, Community interests in compassion,

education, health-care, and youth services.education, health-care, and youth services. Community Foundation w/physician voice.Community Foundation w/physician voice. Connections with MCW and UW-SMPH Connections with MCW and UW-SMPH

Medical residency and consultation Medical residency and consultation programs.programs.

Involved psychiatrists with community, Involved psychiatrists with community, primary care, and youth expertise.primary care, and youth expertise.

Community aim to improve MH access, Community aim to improve MH access, align pediatric MH resources, and upgrade align pediatric MH resources, and upgrade MH prevention.MH prevention.

Relevant LiteratureRelevant Literature

Diverse studies of upgrading MH care Diverse studies of upgrading MH care skills among primary care physicians.skills among primary care physicians.

No clear ‘gold standard’ as far as methods No clear ‘gold standard’ as far as methods with well-documented and replicated with well-documented and replicated results.results.

Recent statewide initiatives to bolster Recent statewide initiatives to bolster primary care MH care skills, notably New primary care MH care skills, notably New York, Massachusetts, Nebraska.York, Massachusetts, Nebraska.

Pediatric MH concerns increasing, eg, Pediatric MH concerns increasing, eg, ADHD overdiagnosis, proper use of ADHD overdiagnosis, proper use of atypicals, suicide prevention, emerging atypicals, suicide prevention, emerging drug use, cyber issues.drug use, cyber issues.

MHIP Task ForceMHIP Task Force 630 am meetings begun in 2011630 am meetings begun in 2011 Coffee stat and prnCoffee stat and prn Prior history of diverse connections among Prior history of diverse connections among

MHIP group members.MHIP group members. Ongoing alignments with health systems, Ongoing alignments with health systems,

community initiatives, educational resources.community initiatives, educational resources. Initial literature review.Initial literature review. Questions about regional needs & physician Questions about regional needs & physician

interest?interest? Development of mixed Quantitative/ Development of mixed Quantitative/

Qualititative semi-structured interview Qualititative semi-structured interview format.format.

Interview FormatInterview Format

11 Likert or other numeric items.11 Likert or other numeric items. 5 yes-no or other forced choice items.5 yes-no or other forced choice items. 4 open-ended questions.4 open-ended questions. Comments solicited after all items.Comments solicited after all items. Interview responses transcribed by Interview responses transcribed by

interviewers.interviewers. Numeric and content summaries by Numeric and content summaries by

1st author.1st author.

Physician Survey Physician Survey InformationInformation

MHIPMHIP 21 semi-structured face-to-face interviews 21 semi-structured face-to-face interviews 12 female / 9 male regional physicians 12 female / 9 male regional physicians Snowball/Convenience SampleSnowball/Convenience Sample MD/DO mixMD/DO mix Most Early-Middle career Most Early-Middle career (3-20 years post (3-20 years post

residency)residency) 17 Family Medicine, 3 Pediatrics, 1 Internal 17 Family Medicine, 3 Pediatrics, 1 Internal

MedicineMedicine 8 Affinity; 7 Thedacare; 2 Kaukauna Clinic; 8 Affinity; 7 Thedacare; 2 Kaukauna Clinic;

1 each FCCHC, PCA, UW, Independent1 each FCCHC, PCA, UW, Independent From Appleton, Chilton, Greenville, From Appleton, Chilton, Greenville,

Kaukauna, New London, Oshkosh, Kaukauna, New London, Oshkosh, Shawano, WaupacaShawano, Waupaca

General Numerical General Numerical FindingsFindings

57% do not feel proficient caring 57% do not feel proficient caring for MH problems.for MH problems.

67% do not feel counseling is 67% do not feel counseling is sufficiently accessible.sufficiently accessible.

Only 29% identify an MD partner Only 29% identify an MD partner w/special interests in MH care.w/special interests in MH care.

Only 20% find MH care Only 20% find MH care reimbursement to be a problem.reimbursement to be a problem.

Physician Views about Physician Views about MH MH ChangesChanges

BAD NEWS =BAD NEWS = “ “More PsychiatristsMore Psychiatrists” is most needed ” is most needed change, but least practical.change, but least practical.

GOOD NEWS =GOOD NEWS = “ “More PCP trainingMore PCP training” is 2” is 2ndnd most needed most needed change, and the most practical. change, and the most practical.

“ “More CounselingMore Counseling” is moderate in need ” is moderate in need and practicality.and practicality.

“ “Reimbursement ChangeReimbursement Change” is least ” is least needed, and 2needed, and 2ndnd least practical. least practical.

Need for MH ChangesNeed for MH Changes5 change areas rated from 5 change areas rated from 44 = ‘Great Need’ to = ‘Great Need’ to 11 = ‘Minimal Need’ = ‘Minimal Need’

3.95

3.453.28

3.17

2.65

1

2

3

4

MorePsychiatry

PhysicianTraining

MoreCounseling

CommunityEducation

ReimbursementChanges

Practicality of MH Practicality of MH ChangesChanges

5 change areas rated from 5 change areas rated from 44 = ‘Highly’ to = ‘Highly’ to 11 = ‘Minimally’ Practical = ‘Minimally’ Practical

3 2.95 2.87

1.651.38

1

2

3

4

PhysicianTraining

CommunityEducation

MoreCounseling

ReimbursementChanges

MorePsychiatry

Physician Interest in MH Physician Interest in MH TrainingTraining

95%95% indicated they are either “ indicated they are either “Very Very amenable - Sign me upamenable - Sign me up” or else ” or else ““Interested-Have some questionsInterested-Have some questions.”.”

Only 1 MD (later career) not interested!Only 1 MD (later career) not interested! Only Only 24%24% (5 Physicians) said they need (5 Physicians) said they need

any compensation for such training.any compensation for such training. EXTENSIVE ideas from physicians for EXTENSIVE ideas from physicians for

training content, AND for in-depth group training content, AND for in-depth group training face-to-face with primary care training face-to-face with primary care peers and psychiatry / MH resource peers and psychiatry / MH resource people.people.

Interview Content Interview Content SummariesSummaries

Mental Health Care Concerns: Mental Health Care Concerns: Lack Lack of communication w/psychiatry; poor of communication w/psychiatry; poor access to general MH resources; access to general MH resources; access to psychiatry; resources access to psychiatry; resources unfamiliarity.unfamiliarity.

Suggested Training Areas: Suggested Training Areas: Refractory depression; Younger Refractory depression; Younger children; Bipolar; Schizophrenia; children; Bipolar; Schizophrenia; Suicide; ADHD; Managing meds; Suicide; ADHD; Managing meds; Algorithms for treatment, diagnosis; Algorithms for treatment, diagnosis; Listening/counseling.Listening/counseling.

Initial MHIP ConclusionsInitial MHIP Conclusions

Additional psychiatric training is Additional psychiatric training is clearly identified by PCPs as both clearly identified by PCPs as both necessary and practicalnecessary and practical

95% of surveyed PCPs were either 95% of surveyed PCPs were either “interested” or “very interested” in “interested” or “very interested” in structured psychiatry CME training structured psychiatry CME training

Only 24% of surveyed PCPs Only 24% of surveyed PCPs identified a need for reimbursement identified a need for reimbursement for CME timefor CME time

Conclusions (continued)Conclusions (continued)

PCPs identify their relationships with PCPs identify their relationships with psychiatrists as less than satisfactorypsychiatrists as less than satisfactory

Communication regarding available Communication regarding available mental health resources is inadequatemental health resources is inadequate

Improvement of MD-MD relationships, Improvement of MD-MD relationships, along with readily accessible network along with readily accessible network re: available resources is essentialre: available resources is essential

Current status of projectCurrent status of project Community FundingCommunity Funding Initial curriculum per ASCP, with augmentation Initial curriculum per ASCP, with augmentation

prnprn 9 monthly evening sessions9 monthly evening sessions Emphasis on complex cases, minimal basic Emphasis on complex cases, minimal basic

review, and current evidence/practice updatesreview, and current evidence/practice updates 2.5 hours with dinner2.5 hours with dinner ~50 registrants; including NPs and ~50 registrants; including NPs and

students/residents. Future iterations may students/residents. Future iterations may include office staff involved in MH case include office staff involved in MH case managementmanagement

Session eval forms; pretest and posttest Session eval forms; pretest and posttest assessment of comfort with aspects of complex assessment of comfort with aspects of complex OP MH care.OP MH care.