Behavioral Health Integration in Primary Care 1

HACKLEY COMMUNITY CARE CENTER (HCCC) CEDRIC H. SCOTT, LLP,CAC-R Behavioral Health Integration into Primary Care

HCCC’s Demographics
Located in Muskegon Heights, MI
We have 140 employees
6 Physicians
7 Physician Assistants
3 Nurse Mid-wives
2 LLP
1 MSW
2 BSW
Dental

HCCC’s Demographics Con’t
Over 15,000 clients
20% uninsured
60% medicaid
10% medicare
9% private
More than 841 depression disorder patients

Five Levels of Integration
Level 1 -Minimal Collaboration
Level 2 - Basic Collaboration at a Distance
Level 3 - Basic Collaboration On-Site
Level 4 - Close Collaboration in a Partly Integrated System
Level 5 - Close Collaboration in a Fully Integrated System

Level 1- Minimal Collaboration
Description: Mental Health and other health care professionals work in separate facilities, have separate systems, and rarely communicate about cases.
Where practiced: Most private practices and agencies.

Level 1 Con‘t
Handles adequately: Cases with routine medical or psychosocial problems that have little biopsychosocial interplay and few management difficulties.
Handles inadequately: Cases that are refractory to treatment or have significant biopsychosocial interplay.

Level 2 – Basic Collaboration at a Distance
Description: Providers have separate systems at separate sites, but engage in periodic communication about shared patients, mostly through telephone and letters. All communication is driven by specific patient issues.
Where practiced: Settings where there are active referral linkages across facilities.

Level 2 Con’t
Handles adequately: Cases with moderated biopsychosocial interplay, for example, a patient with diabetes and depression where the management of both problems proceeds reasonably well.
Handles inadequately: Cases with significant biopsychosocial interplay, especially when the medical or mental health management is not satisfactory to one of the parties.

Level 3 – Basic Collaboration On-Site
Description: Mental health and other health care professionals have separate systems but share the same facility. As in Levels one and two, medical physicians have considerably more power and influence over case management decisions than the other professionals, who may resent this.

Level 3 Con’t
Where practiced: HMO settings and rehabilitation centers where collaboration is facilitated by proximity, but where there is no systemic approach to collaboration and where misunderstandings are common.

Level 3 Con’t
Handles adequately: Cases with moderate biopsychosocial interplay that require occasional face-to-face interactions between providers to coordinate complex treatment plans.
Handles inadequately: Cases with significant biopsychosocial interplay, especially those with ongoing and challenging management problems.

Level 4 – Close Collaboration in a Partly Integrated System
Description: Mental health and other health care professionals share the same sites and have some systems in common, such as scheduling or charting.
Where practiced: Some HMOs, rehabilitation centers, and hospice centers that have worked systematically at team building. Also some family practice training programs.

Level 4 Con’t
Handles adequately: Cases with significant biopsychosocial interplay and management complications.
Handles inadequately: Complex cases with multiple providers and multiple larger systems involvement, especially when there is the potential for tension and conflicting agendas among providers or triangling on the part of the patient or family.

Level 5 – Close Collaboration in a Fully Integrated System
Description: Mental health and other health care professionals share the same sites, the same vision, and the same systems in a seamless web of biopsychosocial services.
Where practiced: Some hospice centers and other special training and clinical settings.

Level 5 Con’t
Handles adequately: The most difficult and complex biopsychosocial cases with challenging management problems.
Handles inadequately: Cases where the resources of the health care team are insufficient or where breakdowns occur in the collaboration with larger service systems.

Hackley Community Care Center Integrated BH
Providers refer patients
Realtime visits
Consulting with providers
Shared decision making/tx
Mental health reimbursement barriers
Outside referrals
Barriers
Reimbursement
Parity

HCCC’s Programs
School-based health programs
Substance abuse treatment
Pain management
Behavioral health care screening tools

References
Five Levels of Primary care/behavorial Healthcare Collaboration
William J. Doherty, University of Minnesota
Susan H. McDaniel, Ph.D., University of Rochester
Macaran A. Baird, M.D., HealthPartners, Minneapolis, MN
Behavioral Healthcare Tomorrow , October, 1996, 25-28.

References Con’t
Integration of Mental Health/Substance Abuse and Primary Care
Minnesota Evidence-based Practice Center, Minneapolis, Minnesota

Muskegon Family Care Behavioral Health Services Gwen Williams, LMSW [email_address]

Why BH in Primary Care?
Depression - 25% of primary care visits
50% of depressed patients receive all care for depression in primary care
Detection and correct diagnosis often not identified
Antidepressants used at lower intensity
1/3 of patients stop antidepressant in first 30 days
Only 50% of patients referred to specialty MH complete more than one visit

History of BH at MFC
MFC started as a small DO Family Practice Residency clinic then got CHC look-alike in 1996.
MSW hired as Behavioral Science Educator and began providing counseling services as well as teaching residents and evaluating their skills in communication and relationship development.

History of BH at MFC, cont.
Began billing for services in 1998
Completed a pro forma to expand services, and contracted with outside mental health agency to provide part-time therapists at 2 sites, with model of half hour billed visits.
Joined Depression Collaborative and began using MSW Interns as well as a clinic counselor for depression care management.

Current Staffing
2 full-time MSW Therapists (1 at each site) providing half-hour billable visits, fully scheduled
2 part-time MSW Therapists (paid on per-visit model) providing billable visits
2 full-time master’s level Clinic Counselors who provide care management for depression and ADHD follow-up
3 Social Work Interns (2 BSW, 1 MSW) who provide ADHD assistance, depression care management and resource referrals

Services Provided
1,373 mental health encounters 2003 up to 4,280 mental health encounters 2008
11,500 significant phone, mail and face-to-face encounters provided by Clinic Counselors in last year

Existing Challenges / Gaps
Substance Abuse Services (SBIRT pilot)
Real-time consult, making full use of H-Code billing
Psychiatric consult / services
Communication / coordination with CMH

Community Mental Health Services of Muskegon County Integrated Health Care Initiative

The Problem
“ Our minds and our bodies are always together in our lives, except when we enter the health care system. There they are often separated, and totally distinct specialties take over.”
Cynthia M. Watson, M.D. thepfizerjournal.com

Why Should We Be Concerned?
Individuals with serious mental illness served by our public mental health systems die, on average, 25 years earlier than the general population.
NASMHPD 2006

Maine Study Results: Comparison of Health Disorders Between SMI & Non-SMI Groups

Four Quadrant Integration Model Low High Quadrant I BH low, PH low Quadrant III BH low, PH high Quadrant II BH high, PH low Quadrant IV BH high, PH high Physical Health Risk/ Status Low High CMH or PCP Medical Home PCP Medical Home PCP Medical Home CMH and PCP Co-managed Care

Benefits of Medical Home Model
Improved access to care
Stigma reduction
Less resistance to referrals
Better communication
Adaptations made to factor in the impact of mental illness on disease management
Primary care provider education
Insights into clinical, structural, funding models
May improve medical outcomes and lead to medical cost offset

Accomplishments
Providing one time Psychiatric Consultation
Establishing a Medical Home
Increased collaboration with the Federally Qualified Health Centers
Providing CMH staff with training regarding medical conditions
Beginning the planning process to co-locate staff

Accomplishments
Received a planning grant to assist with coordination / integration
Memorandum of Understanding with the Federally Qualified Health Clinics
“ All parties recognize that multiple barriers currently exist in the health care systems that prevent individuals from accessing care and continuing the type of care they require to improve their health and functioning”.

Accomplishments
Collaboration with a local Pediatric Practice to assure there is a coordinated effort in providing care for children receiving services
Increasing the presence of CMH staff in the emergency rooms, hospitals, and doctor’s office to advocate for improved coordination of health care

National Wellness Summit Wellness Pledge
We Envision: a future in which people with mental illnesses pursue optimal health, happiness, recovery, and a full and satisfying life in the community via access to a range of effective services, supports, and resources.
We pledge: to promote wellness for people with mental illnesses by taking action to prevent and reduce early mortality by 10 years over the next 10 year time period.

Behavioral Health Integration in Primary Care 1

by MPCA

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