Behavioral Health Integration in Primary Care 1


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Clinical presentation at 2009 MPCA Annual Conference.

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Behavioral Health Integration in Primary Care 1

  1. 1. HACKLEY COMMUNITY CARE CENTER (HCCC) CEDRIC H. SCOTT, LLP,CAC-R Behavioral Health Integration into Primary Care
  2. 2. HCCC’s Demographics <ul><li>Located in Muskegon Heights, MI </li></ul><ul><li>We have 140 employees </li></ul><ul><li>6 Physicians </li></ul><ul><li>7 Physician Assistants </li></ul><ul><li>3 Nurse Mid-wives </li></ul><ul><li>2 LLP </li></ul><ul><li>1 MSW </li></ul><ul><li>2 BSW </li></ul><ul><li>Dental </li></ul>
  3. 3. HCCC’s Demographics Con’t <ul><li>Over 15,000 clients </li></ul><ul><li>20% uninsured </li></ul><ul><li>60% medicaid </li></ul><ul><li>10% medicare </li></ul><ul><li>9% private </li></ul><ul><li>More than 841 depression disorder patients </li></ul>
  4. 4. Five Levels of Integration <ul><li>Level 1 -Minimal Collaboration </li></ul><ul><li>Level 2 - Basic Collaboration at a Distance </li></ul><ul><li>Level 3 - Basic Collaboration On-Site </li></ul><ul><li>Level 4 - Close Collaboration in a Partly Integrated System </li></ul><ul><li>Level 5 - Close Collaboration in a Fully Integrated System </li></ul>
  5. 5. Level 1- Minimal Collaboration <ul><li>Description: Mental Health and other health care professionals work in separate facilities, have separate systems, and rarely communicate about cases. </li></ul><ul><li>Where practiced: Most private practices and agencies. </li></ul>
  6. 6. Level 1 Con‘t <ul><li>Handles adequately: Cases with routine medical or psychosocial problems that have little biopsychosocial interplay and few management difficulties. </li></ul><ul><li>Handles inadequately: Cases that are refractory to treatment or have significant biopsychosocial interplay. </li></ul>
  7. 7. Level 2 – Basic Collaboration at a Distance <ul><li>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. </li></ul><ul><li>Where practiced: Settings where there are active referral linkages across facilities. </li></ul>
  8. 8. Level 2 Con’t <ul><li>Handles adequately: Cases with moderated biopsychosocial interplay, for example, a patient with diabetes and depression where the management of both problems proceeds reasonably well. </li></ul><ul><li>Handles inadequately: Cases with significant biopsychosocial interplay, especially when the medical or mental health management is not satisfactory to one of the parties. </li></ul>
  9. 9. Level 3 – Basic Collaboration On-Site <ul><li>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. </li></ul>
  10. 10. Level 3 Con’t <ul><li>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. </li></ul>
  11. 11. Level 3 Con’t <ul><li>Handles adequately: Cases with moderate biopsychosocial interplay that require occasional face-to-face interactions between providers to coordinate complex treatment plans. </li></ul><ul><li>Handles inadequately: Cases with significant biopsychosocial interplay, especially those with ongoing and challenging management problems. </li></ul>
  12. 12. Level 4 – Close Collaboration in a Partly Integrated System <ul><li>Description: Mental health and other health care professionals share the same sites and have some systems in common, such as scheduling or charting. </li></ul><ul><li>Where practiced: Some HMOs, rehabilitation centers, and hospice centers that have worked systematically at team building. Also some family practice training programs. </li></ul>
  13. 13. Level 4 Con’t <ul><li>Handles adequately: Cases with significant biopsychosocial interplay and management complications. </li></ul><ul><li>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. </li></ul>
  14. 14. Level 5 – Close Collaboration in a Fully Integrated System <ul><li>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. </li></ul><ul><li>Where practiced: Some hospice centers and other special training and clinical settings. </li></ul>
  15. 15. Level 5 Con’t <ul><li>Handles adequately: The most difficult and complex biopsychosocial cases with challenging management problems. </li></ul><ul><li>Handles inadequately: Cases where the resources of the health care team are insufficient or where breakdowns occur in the collaboration with larger service systems. </li></ul>
  16. 16. Hackley Community Care Center Integrated BH <ul><li>Providers refer patients </li></ul><ul><li>Realtime visits </li></ul><ul><li>Consulting with providers </li></ul><ul><li>Shared decision making/tx </li></ul><ul><li>Mental health reimbursement barriers </li></ul><ul><li>Outside referrals </li></ul><ul><li>Barriers </li></ul><ul><ul><li>Reimbursement </li></ul></ul><ul><ul><li>Parity </li></ul></ul>
  17. 17. HCCC’s Programs <ul><li>School-based health programs </li></ul><ul><li>Substance abuse treatment </li></ul><ul><li>Pain management </li></ul><ul><li>Behavioral health care screening tools </li></ul>
  18. 18. References <ul><li>Five Levels of Primary care/behavorial Healthcare Collaboration </li></ul><ul><ul><li>William J. Doherty, University of Minnesota </li></ul></ul><ul><ul><li>Susan H. McDaniel, Ph.D., University of Rochester </li></ul></ul><ul><ul><li>Macaran A. Baird, M.D., HealthPartners, Minneapolis, MN </li></ul></ul><ul><ul><li>Behavioral Healthcare Tomorrow , October, 1996, 25-28. </li></ul></ul>
  19. 19. References Con’t <ul><li>Integration of Mental Health/Substance Abuse and Primary Care </li></ul><ul><li>Minnesota Evidence-based Practice Center, Minneapolis, Minnesota </li></ul>
  20. 20. Muskegon Family Care Behavioral Health Services Gwen Williams, LMSW [email_address]
  21. 21. Why BH in Primary Care? <ul><li>Depression - 25% of primary care visits </li></ul><ul><li>50% of depressed patients receive all care for depression in primary care </li></ul><ul><li>Detection and correct diagnosis often not identified </li></ul><ul><li>Antidepressants used at lower intensity </li></ul><ul><li>1/3 of patients stop antidepressant in first 30 days </li></ul><ul><li>Only 50% of patients referred to specialty MH complete more than one visit </li></ul>
  22. 22. History of BH at MFC <ul><li>MFC started as a small DO Family Practice Residency clinic then got CHC look-alike in 1996. </li></ul><ul><li>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. </li></ul>
  23. 23. History of BH at MFC, cont. <ul><li>Began billing for services in 1998 </li></ul><ul><li>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. </li></ul><ul><li>Joined Depression Collaborative and began using MSW Interns as well as a clinic counselor for depression care management. </li></ul>
  24. 24. Current Staffing <ul><li>2 full-time MSW Therapists (1 at each site) providing half-hour billable visits, fully scheduled </li></ul><ul><li>2 part-time MSW Therapists (paid on per-visit model) providing billable visits </li></ul><ul><li>2 full-time master’s level Clinic Counselors who provide care management for depression and ADHD follow-up </li></ul><ul><li>3 Social Work Interns (2 BSW, 1 MSW) who provide ADHD assistance, depression care management and resource referrals </li></ul>
  25. 25. Services Provided <ul><li>1,373 mental health encounters 2003 up to 4,280 mental health encounters 2008 </li></ul><ul><li>11,500 significant phone, mail and face-to-face encounters provided by Clinic Counselors in last year </li></ul>
  26. 26. Existing Challenges / Gaps <ul><li>Substance Abuse Services (SBIRT pilot) </li></ul><ul><li>Real-time consult, making full use of H-Code billing </li></ul><ul><li>Psychiatric consult / services </li></ul><ul><li>Communication / coordination with CMH </li></ul>
  27. 27. Community Mental Health Services of Muskegon County Integrated Health Care Initiative
  28. 28. The Problem <ul><li>“ 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.” </li></ul>Cynthia M. Watson, M.D.
  29. 29. Why Should We Be Concerned? <ul><li>Individuals with serious mental illness served by our public mental health systems die, on average, 25 years earlier than the general population. </li></ul><ul><li>NASMHPD 2006 </li></ul>
  30. 30. Maine Study Results: Comparison of Health Disorders Between SMI & Non-SMI Groups
  31. 31. 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
  32. 32. Benefits of Medical Home Model <ul><li>Improved access to care </li></ul><ul><li>Stigma reduction </li></ul><ul><li>Less resistance to referrals </li></ul><ul><li>Better communication </li></ul><ul><li>Adaptations made to factor in the impact of mental illness on disease management </li></ul><ul><li>Primary care provider education </li></ul><ul><li>Insights into clinical, structural, funding models </li></ul><ul><li>May improve medical outcomes and lead to medical cost offset </li></ul>
  33. 33. Accomplishments <ul><li>Providing one time Psychiatric Consultation </li></ul><ul><li>Establishing a Medical Home </li></ul><ul><li>Increased collaboration with the Federally Qualified Health Centers </li></ul><ul><li>Providing CMH staff with training regarding medical conditions </li></ul><ul><li>Beginning the planning process to co-locate staff </li></ul>
  34. 34. Accomplishments <ul><li>Received a planning grant to assist with coordination / integration </li></ul><ul><li>Memorandum of Understanding with the Federally Qualified Health Clinics </li></ul><ul><li>“ 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”. </li></ul>
  35. 35. Accomplishments <ul><li>Collaboration with a local Pediatric Practice to assure there is a coordinated effort in providing care for children receiving services </li></ul><ul><li>Increasing the presence of CMH staff in the emergency rooms, hospitals, and doctor’s office to advocate for improved coordination of health care </li></ul>
  36. 36. National Wellness Summit Wellness Pledge <ul><li>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.   </li></ul><ul><li>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. </li></ul>
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