All in the Family

All in the Family: The Benefits and Challenges of Collaborative Health Care Models
Peter S. Martin, MD, MPHMarilyn Griffin, MD Catherine Krasnik, MD, PhD
62nd Institute on Psychiatric Services
October 15, 2010

Disclosure Statement
Drs. Martin, Griffin, and Krasnik are all APA Public Psychiatry Fellows, sponsored by Bristol Myers-Squibb

Workshop Objectives
Describe the current system of health care and how this leads to difficulties in integrating primary care with mental health needs.
Identify models of integrative health care and discuss the similarities and differences that exist between these models.
Distinguish between the integrative models when applied to adult versus pediatric populations.
Discuss how the overall health care models between the United States and Canada lend unique benefits and challenges to the integration of health care.

Access to Slides
Viewable slideshow: http://www.slideshare.net/collaborativecare/
all-in-the-family
Downloadable PDF:
http://sites.google.com/site/
collaborativecaremodels

Collaborative Care: Where It Is, Where It’s Been, and Where It Can Go
Peter S. Martin, MD, MPH
Child and Adolescent Psychiatry Fellow
University of Rochester

Outline
Review of current coordination
Discussion of collaboration versus integration
Review of different collaborative care models
Highlight the medical home model and examine how it can be utilized in mental health

Current State of Coordination

Why Change the Current System?
Heavy burden
Mental health and physical health interwoven
Large treatment gap for mental disorders
Primary care settings could offer enhanced access for mental health services
Reduced stigma
Cost-effective for treating common disorders (?)
Good outcomes when integration occurs (?)
Funk, M. and G. Ivbijaro, eds. Integrating Mental Health into Primary Care: A Global Perspective.

Why Change the Current System?
Poor outcomes
Aggravated players
Wasted time
Poor compensation for work already being done
Improve screening to encourage primary prevention

Conceptual Models
Even this is complicated!

Conceptual Models
Provider-centered

Conceptual Models for ProvidersTraditional

Conceptual Models for ProvidersCoordinated Care

Conceptual Models for ProvidersCo-Location

Conceptual Models for ProvidersCo-Location in Reverse

Conceptual Models for ProvidersIntegrated Care

Levels of Integration
BASIC
On-site
CLOSE
Fully
Integrated
MINIMAL
BASIC
at a Distance
CLOSE
Partly
Integrated
Collaboration Continuum
Doherty, W. The Why’s and Levels of Collaborative Family Health Care.

Conceptual Models
Patient-centered

The Four Quadrant Clinical Integration Model
Quadrant II
↑ BH
↓ PH
Quadrant IV
↑ BH
↑ PH
Behavioral Health Risk/Status
Quadrant III
↓ BH
↑ PH
Quadrant I
↓ BH
↓ PH
Physical Health Risk/Status
Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices

Quadrant I
PCP:
Uses standard BH screening tools, practice guidelines
Prescribes psychotropic
Access to BH consultation for med mgmt
BH:
Provide formal/informal consultation and triage
Brief treatment services
Referral to community/educational resources
Health risk education

Quadrant III
PCP:
Works with medical specialists/ disease managers to manage physical health issues
Uses standard BH screening tools, practice guidelines
BH:
Provide formal/informal consultation and triage
Brief treatment services
Referral to community/educational resources
Health risk education

Quadrant II
PCP:
Provides primary care services and collaborates with the specialty BH providers
BH:
Provide BH assessment and arrange for/deliver specialty BH services
Assure case management (housing, community supports)
Assure access to health care
Create a primary care communication approach that assures coordinated service planning

Quadrant IV
PCP:
Works with medical specialists/ disease managers to manage physical health issues
Collaborate with the BH system
BH:
Provide BH assessment and arrange for/deliver specialty BH services
Assure case management (housing, community supports)
Assure access to health care
Collaborate at high level with healthcare system team

Where does the medical home model fit with different collaborative care approaches?

Background of Medical Home Concept
1967: The American Academy of Pediatrics (AAP) introduced the medical home concept
Referring to a central location for archiving a child’s medical record
2002: AAP policy statement expanded the medical home concept to include these operational characteristics:
Accessible, Continuous, Comprehensive, Family-centered, Coordinated, Compassionate, Culturally effective care
2004: The American Academy of Family Physicians (AAFP) developed own model for improving patient care called the “medical home”
2006: The American College of Physicians (ACP) developed own model for improving patient care called the “advanced medical home”
2007: The ACP, AAFP, AAP, and AOA release the Joint Principles of the Patient-Centered Medical Home
National Center for Medical Home Implementation

Joint Principles of the Patient-Centered Medical Home
Personal physician
Physician directed medical practice
Whole person orientation
Care is coordinated and/or integrated
Enhanced access
Quality and Safety
Payment

NCQA Standards
Access and communication
Patient tracking and registry functions
Care management
Patient self-management support
Electronic prescribing
Test tracking
Referral tracking
Performance reporting and improvement
Advanced electronic communications
West Virginia Bureau for Public Health. Medical Home NCQA Standards.

Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home.

Quadrant I
Psychiatric Consultation

Quadrant III
Psychiatric Consultation

Quadrant II
Outstationed medical nurse practitioner/ physician at behavioral health site

Quadrant IV
• Outstationed medical nurse practitioner/ physician at behavioral health site
• Nurse care manager at behavioral health site

“Mental Health Home”
Not necessarily a new service
Can take existing services and coordinate with a core set of principles
Enhanced care and coordination of care
Integration of primary and preventative services
Use of evidence-based practices and continuous quality improvement
Adoption of recovery principles
Family and community outreach
Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.”`

Differences from existing other medical home models
Primary coordinator may not be a physician
Psychiatry is not typically seen as a primary care discipline
Enhanced care
Targets those with SPMI
Emphasizes a focused, chronic-care disease management model
Ideal: Co-location and integration of primary and behavioral health care
Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.”`

Potential Pitfalls
Who is the coordinator – physician vs. NP/PA vs. another care coordinator
Is the PCP the best coordinator in all cases – maybe instead specialist
Difficult for small practices to take on extra workload
Difficulty with getting families involved (easier to do with children vs. adults)
Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today.

Remaining Challenges
Financing
Policy and regulation
Workforce
Information sharing
Need for greater research relating to the costs, cost offsets and health outcomes of patient-centered healthcare home models for the population with serious mental illnesses.
Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home

Take Home Points
Large continuum of care
No one-size-fits-all model
Flexibility is required
Challenging work
Economics cannot be ignored
Patient-centered focus should not be lost

Pilot Projects of Interest
Cherokee Health Systems (Tennessee)
Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND) (Minnesota)
Intermountain Healthcare (Utah and Idaho)
The U.S. Air Force Behavioral Health Optimization Project (Nationwide)
Buncombe County Health Center (North Carolina)
South Cove Community Health Center (SCCHC) (Boston)
PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly)
IMPACT (Improving Mood: Promoting Access to Collaborative Treatment)
PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial)
RESPECT-D (Reengineering Systems for Primary Care Treatment of Depression)

Suggested Resources
Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf
Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009.
Pautler, K., and M.-A. Gagne. 2005. Annotated Bibliography of Collaborative Mental Health Care. Mississauga, ON: Canadian Collaborative Mental Health Initiative. http://www.ccmhi.ca/en/products/documents/03_AnnotatedBibliography_EN.pdf
Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatric Services. 2009;60:528–533. http://ps.psychiatryonline.org/cgi/reprint/60/4/528

Additional ResourcesMedical Home
http://www.medicalhomeinfo.org/
Center for Medical Home Improvement
http://www.medicalhomeimprovement.org/
NCQA
http://www.ncqa.org/tabid/631/Default.aspx

Hopeful Outcome
Quadrant II
↑ BH
↓ PH
Quadrant IV
↑ BH
↑ PH
Quadrant III
↓ BH
↑ PH
Quadrant I
↓ BH
↓ PH

Children Are Not Small Adults:Collaborative health care from the Child and Adolescent Psychiatry and Pediatric Perspective
Marilyn Griffin, MD, PGY 5
Triple Board Program
University of Pittsburgh Medical Center
Western Psychiatric Institute and Clinic
2009-2011 APA Public Psychiatry Fellow
APA IPS October 15, 2010

Outline
The need for collaborative care in the Pediatric setting
The medical home – revisited
Child and Family Counseling Center
Other models
Moving forward

Kids have needs too…
≈ 1 in 5 children in US with diagnosable mental health disorder
≈ 80% if mentally ill children are not identified or treated
Suicide is the 3rd leading cause death in 10-24 yo
Pediatric mental health problems often identified at primary care visits
Comorbidity and complex interactions between mental and physical health

The children are our future
Opportunity to create patient and family centered system in a familiar setting
Mental Illness is the 2nd leading cause of disability and premature mortality in the U.S.
Burden of untreated mental illness on various systems of care

The children are our future, cont.
Source: Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (2009 pg 246). Adapted from Eisenberg and Neighbors (2007).

Medical Home- revisited

Medical Home – revisited, cont.
1967 AAP introduced the medical home concept
2002-2006 expanded definitions of medical home and creation of other models
2007 AAFP, AAP, ACP, AOA, developed: Joint Principles of the Patient-Centered Medical Home

Medical Home – revisited, cont.
Unique opportunity to engage in services without stigma
Appropriate level of care in familiar environment
Benefit for patients and families by improving access to specialty care

Child and Family Counseling Center(CFCC)
Pittsburgh, PA

Child and Family Counseling Center (CFCC)
Based on medical home model
Unmet behavioral health service need
Provide evaluation and treatment:
Mood disorders
Anxiety disorders
Attention-deficit and disruptive behavior disorders
Adjustment disorders
http://www.chp.edu/CHP/counseling

CFCC Partnership
Children’s Community Pediatrics
Children’s Hospital of Pittsburgh
Western Psychiatric Institute and Clinic

CFCC: Children’s Community Pediatrics
110 Pediatricians
Several mid-level providers
19 practices
28 offices
8 counties
http://www.cc-peds.net/main/index.shtm

CFCC: Children’s Hospital of Pittsburgh
Only children’s hospital serving Western PA
Level 1 Pediatric Trauma Center
One of 8 pediatric hospitals in US named to:
U.S. News & World Report's Honor Roll of America’s
“Best Children’s Hospitals”
for 2010–2011
http://www.chp.edu/CHP/Home

CFCC: Western Psychiatric Institute and Clinic
Largest psychiatric facility in Western PA
Serves over 25,000 patients and families/yr
Full continuum of services including 24 hour psychiatric emergency room
Residency training site for Triple Board Program and Family Practice/Psychiatry Program
http://www.upmc.com/HospitalsFacilities/Hospitals/wpic/Pages/default.aspx

CFCC Partnership Mission Statement
“ …a collaborative effort between pediatricians, licensed clinical social workers, psychologists and psychiatrists to provide timely access to high-quality, empirically-supported behavioral health assessments, behavioral interventions , and psychiatric interventions to children and families in an integrated model of care provided within the pediatric primary care office.”

Communication is the key

CFCC: 2007 Pilot Project
BH specialist in 1 CCP office 2 days/week (therapist, child & adolescent psychiatrist)
Referral indications and exclusions identified
Clinical treatment protocol outlined
Training sessions for all staff
Centralized registration and billing
Electronic Medical Records

Pediatrician identifies
behavioral health needs
Collaborative Care Team
Routine Care in theOffice
Psychiatric Facility/ED
Moderate to severe Symptoms/Impairment
ADHD/Need for family treatment
ADHD/Comorbid anxiety mood sx
Anxiety/phobia/OCD
Chronic illness
Depression/mood sx
Defiance/opposition
Disordered eating
Encopresis/enuresis
Grief/Loss
Parent management training
Immediate/Safety Issues
Suicidality
Homocidality
Severe substance abuse
Violence
CYF report
Safety concerns
Mild symptoms/mild impairment
ADHD managed by meds within practice
Mild adjustment issues
Mild anxiety or depression
Parenting/child development education
Family support
Referral to Behavioral Health
Therapist for assessment and
possible treatment
Pediatrician refers to Emergency Dept.
or appropriate community agency
Managed by the Pediatrician
Non-behavioral concerns are not
referred to behavioral provider:
Custody Issues
CYF/child welfare issues
Learning/school evals
Financial/housing, etc.
If no symptoms resolution or specialized
care required (bipolar disorder, psychosis, etc.)
Referral to child psychiatrist
Pediatrician refers to appropriate
community agency
Therapists/psychologist collaborate
with psychiatrist and pediatrician
G.Crum/A.Schlesinger 5-13-08

CFCC: Beyond the Pilot
2 Child and Adolescent Psychiatrists
2 Triple Board trained Physicians
Therapists at 14 different locations
Non CCP patients seen at central location (Pine Center, Wexford Office)

CFCC: Beyond the Pilot, cont.
> 1500 patients seen since Aug 2008
Ave approx 600 visits/month
Approx 10% no show rate
80% diagnoses = anxiety, depression, or ADHD
Comorbidity
Depressive & Anxiety d/o
Anxiety d/o & ADHD

CFCC: Strategies for Success
Buy in by all invested parties
Monthly meetings
Provide staff with appropriate tools/support
Centralized billing

Communication is the key
Office Managers
Nurses
Operations
Scheduling Staff
Front desk
Triage Staff
Families

Other models
http://www.aap.org/mentalhealth/mh3co.html
St. Cloud, MN: CentraCare Integrative Behavioral HealthCare Initiative
Salt Lake City, UT: University Health Care Neurobehavior Healthy Outcomes Medical Excellence (HOME) Program

Moving forward: What’s next?
Systemic changes
Prevention
Mental health screen
Support for providers
New methods of financing
Health Care Reform
Innovative educational method
Health care provider training
Workforce incentives

Systemic changes: Prevention

Systemic changes: Prevention, cont.
Source: Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (2009, pg 155).

“It is easier to build strong children than to repair broken men.”
Frederick Douglass

Systemic changes: Prevention, cont.
Community Transformation Grants: Sec 4201
Authorizes competitive grants for programs promoting health and prevention
Community Health Workforce Grants: Sec 5313
Authorizes grants to positive health behaviors and outcomes
http://www.thenationalcouncil.org/galleries/policy-file/HC%20Reform%20Bill%20Update-April%207.pdf

Systemic changes: Mental Health Screen
Component of routine care under 2010 health reform legislation
Various free online resources
www.teenscreen.org
www.pediatricmedhome.org

Systemic change: Support for providers
AAP Task Force on Mental Health
AAP toolkit: http://www.aap.org/pcorss/demos/mht.html
AAP IMPACT
http://www.aap.org/mentalhealth

Financing: Health Reform
Medicaid Medical Home Pilot: Sec 2703
authorizes up to $25 million to help states plan and implement projects
Medicaid Accountable Care Organization Pilot Program: Sec 2706
Will allow pediatric providers to receive recognition & payment as ACOs

Financing: Health Reform, cont.
Co-location of Primary and Specialty Care in Community-Based Behavioral Health: Sec 5604
Authorization of $50 million in grants for co-location of coordinated & integrated services

Innovative Educational Methods: Healthcare provider training
Prevention training standards & programs
Medical and graduate medical education curriculum changes
Johns Hopkins Pediatric Residency Training Program

Innovative Educational Methods: Workforce incentives
Training for behavioral health specialists: Sec 5306
HHS secretary to grant awards to improve training programs
Loan Repayment for Pediatric Behavioral Health Specialists in Underserved Areas: Sec 5203
Authorizes funds for loan repayment if serve in underserved areas
Educating Primary Care Providers About Behavioral Health: Sec 5405
Authorizes funds for Primary Care Extension Program

So what does this all mean?
There is a huge need to provide comprehensive integrative collaborative care for the pediatric population
Health homes facilitate an organized platform to deliver care
Finances, communities and workforce are the foundations for health homes

THANK
YOU
Chicago, IL.

INTEGRATING MENTAL HEALTH SERVICES INTO PRIMARY CARE: A Canadian Example
Catherine Krasnik MD, PhD
APA/BMS Public Psychiatry Fellow
Department of Psychiatry and Behavioural Neurosciences
McMaster University, Hamilton, ON, CANADA
Ontario, Canada

Objectives
The Canadian context
Family Health Teams
Why did our program start
Integrating mental health services in primary care
How better collaboration can assist with challenges facing our health care systems
Redesigning systems to optimize benefits

10 Provinces and 3 Territories
9,900,000 sq. kms
33 million people
Federal Government
Provinces responsible for health care (13 health care delivery systems)
Canada Health Act defined principles to guide the entire system (1964) -Universality, Portability, Publicly Administered, Comprehensive, Accessible
Almost all health services are publicly funded (10.1% of GDP)
Canada

What’s included in Canadian Medicare?
Covers physician services and hospital-based care
Emergency care available to everyone
Wait times for specialty appointments and procedures
Mental health care
Preventive care
Physicians paid to do prevention counseling (this varies by province)
*drug coverage is not included unless you have third party insurance or are on social welfare
*allied health professionals not included (e.g. psychologists, unless part of mental health clinic)

Role of Primary Care
First point of contact with the health care system
Often cradle to grave
81 % of population see their family physician annually
Initiates referrals to specialists
Comprehensive, integrated around the clock care
Co-ordinates information about patients care
Provides a variety of specialized services
Average practice size – 2,200
7.5 - 10% have no family physician
Common elements but also variation
between provincial models

Home of Problem Based Learning
Home of Evidence Based Medicine
Melius est Urinam Facere quam Amovere!

Family Health Teams (FHTs)
171 FHTs funded in 4 waves across Ontario
Various stages of implementation
31 more to be funded in next 12 months
Currently involve over 25% of comprehensive care family physicians in Ontario
2-25 physicians (largest 130 – Hamilton FHT)
Rostered populations - Funded by capitation
Team based care

Family Health Teams
Family Physician(s)
Nurse
Nurse Practitioner
Social Worker/Mental Health Counsellor
Dietitian
Pharmacist
Health Educator
Family health care
Emphasize health promotion and illness prevention
Emphasize self-management
Care co-ordination/system navigation
Linked with other community and health services
Mental health is a key part of the work of FHTs

Recognised the role primary care is already playing, often without support
Why did our program start?
Challenges in addressing mental health issues in primary care
Problems in the relationships with mental health services

Poor communication between family medicine and mental health services
Difficulty in accessing timely psychiatric consultation
Recurrent problems between Mental Health and Primary Care Services
Mental health service intake procedures cumbersome and inefficient
General lack of support and respect for the FP as a mental health caregiver

Redesigning Systems of Care
Better management and obtaining better outcomes require changes in the way systems of care are organized, both within and between systems.

Redesigning Mental Health Systems of Care
Three Steps:
Rethinking the role of primary care within the system
Looking at how mental health services can complement/support this role
Redesigning systems of care to optimize the potential collaboration can offer

The potential role of Primary Care
Early detection
Initiation of treatment
Monitoring and follow-up
Co-ordination and continuity of care
Referral and system navigation
Family interventions

Three Steps:
Redesigning systems of care to optimize the potential collaboration can offer

Goals of better collaboration
Improve access to care and reduce wait times
Increase system capacity – use current resources differently / more efficiently
Enhance the experience for the person receiving care
Improve co-ordination of care

Integrating mental health services within primary care
A solution

Hamilton Family Health Team
80 practices
105 sites
148 family physicians
340,000 patients
70% of the population of Hamilton
Hamilton FHT

Hamilton Family Health Team
80 practices
105 sites
148 family physicians
340,000 patients
70% of the population of Hamilton
HFHT
Staff Ratios: HFHT MHP
Co-ordinated by a central program team
Other pilot programs:
children’s mental health,
addictions,
depression chronic disease management,
1:1 peer support for depression

Central Program Team
Problem solving
Liaison with practices
Liaison with Ontario MOHLTC (funder)
Recruitment
Staff preparation/continuing education
Re (allocation) of resources
Co-ordination/mgmt
Needs assessments
Direction
Guidelines
Evaluation
Facilitation

Initial Program Goals
1994
1. To increase accessibility to mental health care for primary care patients
2. To expand the range of mental health services delivered in primary care
3. To strengthen linkages between primary care and mental health / community programs.
4. To increase family physicians’ skills and comfort in handling mental health problems.
2010
1. To improve the mental health of the populations being served
2. To enhance the experience of seeking / receiving care
3. To improve system efficiencies

How does the program work?
See any case/any age (3-98)
Criterion is family physician is looking for help
Emphasis on short-term care
Specialists integrated within primary care
Indirect, as well as direct service
Emphasis on education
Charting integrated
Shared care model
Stepped model of care

Role of the Counselor

The Psychiatrist: A TYPICAL HALF DAY
Direct Patient Care
consultations (2-3/half day)
follow-up (1-6/half day)
Indirect Patient Care (3-4+ per half day)
- Family physicians
Counselors
See patients 1-2 times for stabilization/initiate meds
Assist with referrals into mental health system
Great experience for learners; education

To assist the Psychiatrist
Family physician prescribes
Morning huddle
Available to FP / counselor – but not patients - when out of the practice
Funding by a sessional fee which also covers non-billable activities and paperwork (letters)
Meet as a group 2 monthly

Role of Family Physician
Remains involved
Ongoing care
More likely to investigate a problem
Better supported in a shared care model
Still sees the majority of mental health problems
Increases the range of cases they can manage
Prescribes

Specific skills the family physician can use
Motivational Interviewing
List of patients with a specific problem
Meet to discuss cases
Telephone backup
Self-Help Manual
PHQ – 9 (Patient Health Questionnaire)

Use of a Self-Help Manual
Dan Bilsker – Simon Fraser University
Anti-depressant skills workbook
Positive coping with health conditions
www.comh.ca/pchc/

Stepped Care using the PHQ-9

Does it work?
Data from the program evaluation

Referrals – 2007 (148 FPs)
Total Referrals: 7064
Age

PRIMARY REFERRAL PROBLEM TO THE COUNSELORS
% of Referrals

REASON FOR REFERRAL TO THE PSYCHIATRIST
% of Referrals

PRIMARY DIAGNOSIS BY THE PSYCHIATRIST
% of Referrals

Referrals to the Psychiatric System
Program Started
Program Expanded

Referrals to Mental Health Services (first 13 practices – 45 physicians)

Satisfaction
Family Physician
-With the counselor 90%
-With the psychiatrist 90%
-With the program 92%
Psychiatrist 90%
Counselor 92%
CSQ 91%
Average score on V.S.Q. was 4.5 / 5
Each item meets or exceeds AAGH benchmarks
Provider Satisfaction
Consumer Satisfaction

Lessons Learned

Benefits
Primary Care Physician
Mental Health System
Ready access to MH services
Access to underserviced areas
Regular communication with Psychiatrist
Feel supported; continuum of care
More comfortable being seen in family practice; less stigma
Shorter wait times
Services used more efficiently
Referrals triaged therefore more likely appropriate for services being requested
Patient can be discharged earlier from inpatient and outpatient care knowing F/U is available
Overall increase in system capacity
Consumer

Key Drivers of Success

We had added an innovation to systemsthat weren’t always performing well – now we had to change the way the system functioned to support the innovation.

Three Steps:
Redesigning systems of care to optimize the potential collaboration can offer – changing processes of care

Redesigning the Program
Population Focus
Examples
Phone visits
Email visits
Email messages
Develop registries
Proactive care
Patient goals and plans
Routine phone calls after treatment ends
Planned visits
Can be delivered in different ways

Redesigning the Program
Increase System Capacity
Child / Addiction Programs
Co-ordinator Coach
Moving from direct service model
Indirect consultations
Telephone advice
Training mental health staff

Summary
Many things that mental health services can do differently
Integrating mental health services in primary care has the potential to improve outcomes and enhance the experience of seeking / receiving care
These initiatives need to be supported by system redesign to optimize their potential
If that can be accomplished it leads to better mental health outcomes, better care and more efficient use of resources

“My own knowledge and comfort with mental
illness has significantly increased
It is no longer an area of uncertainty and doubt, but
a discipline which has begun to fall into place and
gives great satisfaction and reward.”
Family Physician in the Program

We would not be where we are today without the help of those from yesterday

AcknowledgementCollaborative Care: Where It Is, Where It’s Been, and Where It Can Go
Dennis Bertram, MD, MPH, ScD
Linda Pessar, MD
Kim Griswold, MD, MPH
Patricia Pastore, NP
Cynthia Pristach, MD
Seung-Kyoo Park, MD
YogeshBakhai, MD
Michael Scharf, MD
All the APA Public Psychiatry Fellows and Leaders

AcknowledgementsChildren Are Not Small Adults: Collaborative health care from the Child and Adolescent Psychiatry and Pediatric Perspective
Child and Family Counseling Center
Abigail Schlesinger, MD
Kenneth Thompson, MD
Roberto Ortiz-Aguayo, MD
Jennifer Dee
Gretchen Crum, LCSW

AcknowledgementsIntegrating Health Services Into Primary Care: A Canadian Example
Dr. Nick Kates
Professor, Associate Member, Department of Family Medicine Director of Programs, Hamilton Family Health Teams
Provincial Lead, QIIP (Quality Improvement and Innovation Partnership)
Dr. Harriet MacMillan
Professor, Psychiatry & Behavioural Neurosciences and Pediatrics
David R. (Dan) Offord Chair in Child Studies Associate Member, Clinical Epidemiology & Biostatistics 
APA Fellowship
Nancy Delanoche
Dr. Jules Ranz

Acknowledgements
All the fellows in the APA Public Psychiatry Fellowship
Nancy Delonche
Jules Ranz, MD

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Doherty, W. The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine. 1995;13(3–4):275–81.
Funk, M. and G. Ivbijaro, eds. Integrating Mental Health into Primary Care: A Global Perspective. Geneva, Switzerland: World Health Organization and London, UK: World Organization of Family Doctors. 2008.
Homer, CJ et al. Medical home 2009: What it is, where we were, and where we are today. Pediatric Annals. 2009;38(9): 483-490,2009
Kirschner, N and Barr, M. Specialists/subspecialists and the patient-centered medical home. Chest. 2010;137(1):200-204.
Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices. National Council for Community Behavioral Healthcare. 2006.
Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009.
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West Virginia Bureau for Public Health. Medical Home NCQA Standards. Accessed at
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Images:
http://www.spiegel.de/img/0,1020,899997,00.jpg
http://gavindo.com/images/Partnership-Program-.jpg
http://fellowshipofminds.files.wordpress.com/2010/04/medical-symbol-chrome.jpg
http://upload.wikimedia.org/wikipedia/commons/b/b5/Greek_uc_psi.jpg
ReferencesCollaborative Care: Where It Is, Where It’s Been, and Where It Can Go

ReferencesChildren Are Not Small Adults: Collaborative health care from the Child and Adolescent Psychiatry and Pediatric Perspective
AACAP Committee on Health Care Access and Economics, AAP Task Force on Mental Health. Improving Mental Health Services in Primary Care. Pediatrics Volume 123, Number 4: 1248-1251, April 2009
American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Available at: http://www.medicalhomeinfo.org/Joint%20Statement.pdf.
Goinik A, et al. Medical Homes for Children with Autism: A Physician Survey. Pediatrics Volume 123, Number 3: 966-971, March 2009
Horowitz L.M, Ballard ED, Pao M. Suicide screening in schools, primary care and emergency departments. Current Opinion in Pediatrics. 2009; 21 (5): 620-627
Lake, Raymond. How academic psychiatry can better prepare students for their future patients. Part I: the failure to recognize depression and risk for suicide in primary care; problem identification, responsibility, and solutions. Behav Med. 2008 Fall;34(3):95-100.
Merikangas KR, He J, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication-adolescent Supplement (NCS-A). JAACAP . 2010; 49 (10): 980-989
O'Connell ME, Boat T, Warner KE. Preventing Mental, Emotional, and Behavioral Disorders Among Young People:
Progress and Possibilities. The National Academies Press 2009.
Policy Statement- The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care. Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Pediatrics Volume 124, Number 1:410-417,July 2009
www.teenscreen.org
www.thenationalcouncil.org

ReferencesIntegrating Health Services Into Primary Care: A Canadian Example
Kates, N. Integrating Mental Health Services into Primary Care: The Hamilton FHT Mental Health Program. in Collaborative Medicine Case Studies. New York: 2008 pp. 71-82. Available at: www.springerlink.com/content/r8536r96x7h85780/
Kates, N. et al. Integrating mental health services within primary care: A Canadian Program. General Hospital Psychiatry Volume 19, Issue 5, September 1997, p 324-332.
Kates, N. et al. Integrating mental health service into primary care: Lessons learnt. Families, Systems & HealthVolume 19, Issue 1, Spring 2001, p 5-12.
Canadian Collaborative Mental Health Initiative (CCMHI), http://www.ccmhi.ca/en/index.html
Kates, N. et al. Sharing Care: The Psychiatrist in the family physician’s office. Canadian Journal of Psychiatry Volume 42, November 1997.
The Evolution of Collaborative Mental Health care: A Shared Vision for the Future. Prepared by the Collaborative Working Group of the Canadian Psychiatric Association and the College of Family Physicians of Canada on Shared Mental Health Care July 12th, 2010.

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all-in-the-family
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Contact Information:
Peter Martin: peter_martin@urmc.rochester.edu
Marilyn Griffin: griffinm3@upmc.edu
Catherine Krasnik: krasnice@mcmaster.ca

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