Primary and Behavioral Care Integration West Texas Centers April 16, 2014

Primary and Behavioral Care Integration

West Texas Centers

April 16, 2014

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Blending Behavioral Health Into Primary Care at Cherokee Health Systems

National Register of Health Service Providers In Psychology, Fall 2007.

A Tale of Two Systems: A Look at State Efforts to Integrate Primary Care and Behavioral Health in Safety Net Settings National Academy for State Health Policy, May 2010.

Integrated Care UpdateCareIntegra, February 2007.

Evolving Models of Behavioral Health Integration in Primary CareMillibank Memorial

Fund, 2010 Report.

Integrating Mental Health Treatment into the Patient Centered Medical Home AHRQ, June 2010.

Integrating Behavioral and Primary CareCommunity Health Forum, Oct.

2005.How Healthcare Reform Can End The Step-Child Status of Primary Care and Behavioral Health Behavioral Health Central, Jan. 2010.

Can Primary Care Docs and Behavioral Specialists Work Together? Behavioral Healthcare Tomorrow, April 2004.

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“Integration” is Today’s Hot Topic

The Integration Stampede

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When it comes to the health and well-being, it is Important to understand that mental health is part of overall health.NAMI

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“Integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served.”

INTEGRATED CARE: WHAT IS IT?

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“Integration is in response to the fragmentation of health care. As individuals we are not fragmented, we are whole people. The current health care system does not recognize this. Integration is trying to fix a big problem, which is that we have two separate systems that take care of our health. Integration is a game changer for health care.”

– Benjamin Miller, Psy.D., assistant professor, Department ofFamily Medicine, University of Colorado School of Medicine

INTEGRATED CARE: WHAT IS IT?

Psychotherapy, which was offered as a prepaid benefit, was studied as a method to reduce primary care visits while also more properly (and less expensively) addressing the problem at hand.

Studies revealed that by participating in brief psychotherapy, medical utilization reduced by 65%.

History

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In the early 1960s, Kaiser Permanente, an early Health Maintenance Organization (HMO), uncovered that 60% of physician visits were either individuals who were somatizing stress or whose physical condition was exacerbated by emotional factors.

These findings prompted Kaiser to explore various strategies to better manage psychosocial complaints, with ultimate goal of cost reduction.

Maine Rural Health Research Center

The First Generation of “Integration”Awakening interest in collaborationPreferential referral relationshipFormalized screening proceduresSpecialty consultationDisease managementCircuit ridingContracted providers or servicesCo-location of services

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Easier access to care because of a critical shortage of mental healthproviders, especially in rural communities.

Care provided in a primary care setting may be covered by insurancepolicies that do not include mental health care coverage.

Individuals may feel more comfortable in a primary care setting because of stigma associated with seeking care in a mental health care setting.

Why seek behavioral health services in the primary care setting?

9NAMI

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Improved adherence totreatment.Greater convenience and

satisfaction for patients.

Increased likelihood thatpatients follow through withreferral for mental healthservices and supports.

Decreased wait times between mental health referrals and initial appointments.

Decreased use of unneeded medical and emergency services.

Increased attention to the treatment preferences of the individual.

Reported Integrated Care Benefits

NAMI

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People with mental health conditions are at risk for physical health problems that deteriorate their quality of life and lead to premature death. The risk is especially high for people with serious mental illness (SMI) such as schizophrenia, bipolar disorder, and major depression.

Persons with Serious Mental Illness

Connections to Morbidity and Mortality

National Association of State Mental Health Program Directors

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• Medical conditions such as cardiovascular, pulmonary, and infectious diseases account for 60% of premature deaths among people with schizophrenia.

• People with SMI have higher rates of risk factors that put them at increased risk of illness and death, including smoking, alcohol consumption, poor nutrition, and unsafe sexual behavior. For example, 75% of individuals with addictions or mental illness smoke cigarettes compared with 23% of the general population.



National Association of State Mental Health Program Directors

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• Second-generation antipsychotic drugs are associated with weight gain, diabetes, high cholesterol, insulin resistance, and metabolic syndrome.



• People with SMI undergo fewer routine preventive services, have lower rates of cardiovascular procedures, and have inadequate diabetes care.

Source: Kathol and Gatteau – Healing Mind and Body, 2007

10%

33%57%

Americans Suffering From a Diagnosable Behavioral Disorder

Treatment fromBehavioralSpecialistsTreatment fromPrimary CareProviderUntreated

14National Association of State Mental Health Program

Why Behavioral Health Practice in the Primary Care Context

What Does the Research Show About Integration? Improvement in depression remission rates: from 42% to

71% (Katon et. al., 1996)

Improved self management skills for patients with chronic conditions (Kent & Gordon, 1998)

Better clinical outcome than by treatment in either sector alone (McGruder et. al., 1988)

Improved consumer and provider satisfaction (Robinson et. al., 2000)

High level of patient adherence and retention in treatment (Mynors-Wallace et. al., 2000)

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Integration vs. Co-LocationIntegrated Care Co-Located Mental

HealthEmbedded member of

primary care teamPatient contact via

hand offVerbal communication

predominateBrief, aperiodic

interventionsFlexible scheduleGeneralist orientationBehavior medicine

scope

Ancillary service provider

Patient contact via referral

Written communicationpredominate

Regular schedule of sessions

Fixed scheduleSpecialty orientationPsychiatric disorders

scope 16

Key Operational Differences Between Primary Care and

Behavioral Health

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Cultural DifferencesLanguage Differences for $200

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U.D.S.a. What is a Urine Drug Screen?b. What is a Uniform Data

System?c. What is All of the Above?

Cultural DifferencesClinical Delivery Space

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© 2012 Cherokee Health Systems

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Typical Behavioral Health Care Services in Primary Care

Triage/Liaison Behavioral Health

Consultation Behavioral Health Follow-Up Adherence Enhancement Relapse Prevention Behavioral Medicine Consultative Co-Management Group-based interventions Conjoint Consultation On-Demand Medication

Consultation Care Management

Psychiatric Consultation PCP Consultation School/Agency Consultation Prevention Telephone Consultation

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Serious Considerations for Integrations

Values/MissionCultures/PurposesInvolvements/affiliations Transparencies/BoardsFinding champions/understanding the

challengesLearning curve (simplicity to complexity)

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Administrative Team Meetings• Meet Weekly, not Weakly• Transparency is Vital

• Shared Objectives – Work Toward Full Integration

• Creating a Process, Not a Destination – You’re in it for the Long Haul!

Leveraging the Relationship

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• What are you good at?

• What talents, resources can you bring?

• Can we disagree, debate, interact and share – and move forward?

Supporting the Partnership

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• Your relationship frames your agreement, not the other way around.

• Champions

• Meet, talk, socialize, publicize

Peanut Butter & Jelly…the perfect model for integration

• On their own, they’re fine, together they’re better

• You wouldn’t want to separate them once joined

• Just a matter of finding the “bread” to hold it together!

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Important Questions For Executive Management

Who from the senior executive team is going to champion integrated care?

What resources are we going to need to do integrated care?

How much are those resources going to cost us?

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Silos exist in how primary care and mental health care are delivered that impede effective communication and collaboration.

Lack of training, education and comfort in addressing mental health issues in primary care and other health issues in mental health care settings.

Limited time to effectively address mental health issues in primarycare.

Limited referral sources for mental health care that impact thewillingness of primary care providers to screen and to raise concerns about mental health.

Challenges to Integration

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Concerns with strict confidentiality and privacy laws and the sharingof mental health information between providers. Reimbursement concerns, especially for primary care providersproviding mental health care, and concerns that time spent on carecollaboration and consultation is often not reimbursed. Lack of funding sources to create the infrastructure that is neededfor integrated care, including training staff, electronic health recordsystems, finding the right integrated care model that fits the needs ofthe community and costs to get the care model up and running.

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ALMOST Billable Services• Consultation…Patient Not Present–Hallway conversations between providers–Telephone Consult w/Psychiatrist

• Multi-Disciplinary Treatment Team Meetings–Difficult Cases–Case Studies & Training

• Real-Time Provider Access–Telepsychiatry–Primary Care

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Spreading Costs…

Location Overhead◦Front Office Staff◦Clinical Records◦Telephone◦Lab work◦On-Call

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Corporate Overhead–Management– Clinical Leadership– Technology Support– Purchasing– Facilities


Placing a VALUE on Integrated Care Can Be Hard to Do

• Reduced ER Utilization• Reduced Inpatient Admissions• Reduced Specialty Referrals• Increased Patient Satisfaction• Increased Primary Care Utilization• Improved Outcomes

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Change Management

Bottom Line: Managing significant change is a messy business! 33

“I like change, as long as it doesn’t affect me.” Anonymous Physician

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Questions ?Landon Sturdivant, MPA, LBSW

Chief Operating OfficerWest Texas Centers

[email protected]

Documents

Primary and Behavioral Care Integration West Texas Centers April 16, 2014