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Integrated Primary & Behavioral Healthcare

What is it and how will I know when I get there?

Deb HroudaCenter for Evidence Based Practices Case Western Reserve University, Cleveland, Ohio

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United States International

• California (CA) • Colorado (CO)• Georgia (GA)• Hawaii (HI)• Illinois (IL)• Indiana (IN)• Iowa (IA)• Kentucky (KY)• Louisiana (LA)

• Maine (ME)• Maryland (MD)• Michigan (MI) • Minnesota (MN)• Missouri (MO) • New Jersey (NJ)• New Mexico (NM) • New York (NY)• North Carolina (NC)

• North Dakota (ND)• Ohio (OH)• Pennsylvania (PA)• South Dakota (SD)• Vermont (VT) • Washington (WA) • West Virginia (WV)• Wisconsin (WI)

• Australia• Canada• England • The Netherlands• Norway

CEBP Customers• Policymakers; leaders of state and regional authorities;

service organizations; hospitals; health clinics; and technical-assistance organizations

• Ohio, 25 other states and five countries

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Goals for today• Discuss why integrated care is so important• Review models of integration and

implementation• Convey importance of measuring

implementation outcomes• Review Integrated Treatment Tool developed

by CEBP• Meet your needs / answer your questions

Integrated Primary and Behavioral Health Care

Why?

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Recent data from several states have found that people with severe and persistent mental illness

(SMI) die, on average,

25 years earlier

than the general population

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Reasons for Morbidity and Mortality• Genetic link between BH and other d/os• Inadequate/non-existent health care (access?)

– Fewer routine preventive services (Druss 2002)Fewer routine preventive services (Druss 2002)– Worse diabetes care (Desai 2002, Frayne 2006)Worse diabetes care (Desai 2002, Frayne 2006)– Lower rates of cardiovascular procedures (Druss 2000)Lower rates of cardiovascular procedures (Druss 2000)

• Side effects of medications• Smoking • Poor nutrition• Inadequate/non-existent physical activity

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Morbidity and Mortalityis largely due to

• Preventable medical conditions– Cardiovascular disease, diabetes, metabolic syndrome

• High prevalence of modifiable risk factors– Smoking, obesity, diet, exercise, substance use, infectious

diseases, delayed/no well-care, medication and symptom management/monitoring

• For people with SPMI, there is an epidemic within a National epidemic

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SPMI alone may be a health risk factor

• Patient factorsPatient factors, e.g.: amotivation, fearfulness, , e.g.: amotivation, fearfulness, homelessness, victimization/trauma, resources, homelessness, victimization/trauma, resources, advocacy, unemployment, incarceration, social advocacy, unemployment, incarceration, social instability, and IV drug useinstability, and IV drug use

• Provider factorsProvider factors: Comfort level and attitude of : Comfort level and attitude of healthcare providers, coordination between mental healthcare providers, coordination between mental health and general health care, stigmahealth and general health care, stigma

• System factorsSystem factors: Funding, fragmentation: Funding, fragmentation

Integrated Primary and Behavioral Health Care

What does this mean?

Integrating Care

Levels of “Integrated” Care• Nothing• Parallel care___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___

• “Facilitated” screening and referral• Co-location of care/Partnerships• In-house / Single Provider / Integrated care

– Genuinely Integrated Care

Need: Coordination, Collaboration, & Communication

(Co-habitation ≠ Collaboration)

Integrated Primary and Behavioral Health Care

How will we know when we get there?

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Implementation Approach (the CEBP Way)

• Assess readiness– Identify Organization’s Stage of Change

• Baseline status (fidelity where applicable)• Action plan• Consultation and training• Ongoing outcomes monitoring

– Implementation/Process – program-level– Intervention – participant-level

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Steps to Creating an Implementation Measure

• See if a model exists (or can be adapted)• Literature review• Feedback from the field• Identify model principles/components• Define components and incremental steps• Expert consensus• Field testing• Refinement based on feedback

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Existing models of integrating PC/BH

• Few with direct focus on SMI• Direction is BH into PC• BH is seen as “specialty care”• PC physician “directs” care• Psychiatry is typically “consult” (sometimes

without seeing the patient)

Integrated Treatment Tool“ITT”

A Tool to Evaluate the Integration of Primary and Behavioral Health Care

CENTER FOR EVIDENCE BASED PRACTICES AT

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Integrated Treatment Tool

“ITT”

• 30 Items• Each item:

–Definition –Gradations toward theoretical ideal

(rating 1 – 5)

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Integrated Treatment Tool

“ITT”

• Organizational

• Treatment

• Care Coordination/Management

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Organizational CharacteristicsO1. Org. Philosophy O2. Org. Policies and

Procedures O3. Integrated HITO4. Multi-Disciplinary

Health Care ApproachO5. Interdisciplinary

CommunicationO6. Care ManagerO7. Peer Supports

O8. Org.-Wide TrainingO9. Clinical Supervision, Guidance & MonitoringO10. CQIO11. Pt-Centered ApproachO12. Pt Access & SchedulingO13. Executive Leadership Team Involvement O14. Integrated Approach

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Treatment CharacteristicsT1. Comprehensive IdentificationT2. Holistic Integrated Care PlanT3. Integrated Stage-Appropriate TreatmentT4. OutreachT5. Stepped CareT6. Use of Motivational Interventions T7. Self-Management Skill DevelopmentT8. Pharmacological Approaches T9. Involvement of Social Support Network

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Care Coordination/Management Characteristics

C1. Activities, Elements, and DomainsC2. Laboratory and Test Tracking C3. Referral Facilitation and TrackingC4. Medication ReconciliationC5. Reminders C6. Transitions between settings/levels of careC7. Assessing effectiveness/quality of care rcvd

Questions…?

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Deb Hrouda, MSSA, LISW-SDirector of Quality Improvement

Center for Evidence-Based Practices (CEBP)Case Western Reserve University10900 Euclid AvenueCleveland, Ohio 44106-7169 debra.hrouda@case.edu