Behavioral Health Systems Lecture

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Behavioral Health Systems Lecture

  1. 1. Behavioral Health and Primary Care David Eisenman MD and John Luo MD Departments of Medicine and Psychiatry
  2. 2. Behavioral Health and Primary Care <ul><li>Understand barriers to integration of behavioral health and primary care </li></ul><ul><li>Implications in caring for patients </li></ul><ul><li>Steps to improve care </li></ul>
  3. 3. Barriers between Primary Care and Behavioral Health <ul><li>Historical </li></ul><ul><li>Conceptual </li></ul><ul><li>Patient </li></ul><ul><li>Provider </li></ul><ul><li>Practice </li></ul><ul><li>Health Plan </li></ul><ul><li>Population/Community/Policy </li></ul>
  4. 4. Conceptual Issues: Primary Care vs. Mental Health Specialties <ul><li>Different perspectives </li></ul><ul><ul><li>Majority of literature comes from specialty (and often tertiary) care settings </li></ul></ul><ul><ul><li>Diagnostic systems such as DSM-IV often seen as too complex and specialty-focused </li></ul></ul><ul><li>Need to adapt strategies and approaches to the primary care setting (e.g., problem vs. DSM focus) </li></ul><ul><li>Linkages between and among various systems (SUD, social services, consumer directed) , etc.) </li></ul>
  5. 5. Provider Barriers <ul><li>Time </li></ul><ul><li>Interest </li></ul><ul><li>Tools </li></ul><ul><li>Training </li></ul>
  6. 6. Practices Issues <ul><li>Organization does not enhance patient-provider interactions & promote successful outcomes </li></ul><ul><ul><li>Who is responsible for care? </li></ul></ul><ul><ul><ul><li>Limited communication and teamwork between primary care and mental health specialties </li></ul></ul></ul><ul><ul><li>How should care be provided? </li></ul></ul><ul><ul><ul><li>Consultative? Collaborative? Integrated? </li></ul></ul></ul><ul><ul><li>When should care be provided? </li></ul></ul><ul><ul><ul><li>Lack of longitudinal focus </li></ul></ul></ul>
  7. 7. WHO Responsibility for Care PCP BHS <ul><li>Assessment/diagnosis </li></ul><ul><li>Evaluate preferences </li></ul><ul><li>Initiation of referral </li></ul><ul><li>Initiation of medication </li></ul><ul><li>Psychoeducaton/Counseling </li></ul><ul><li>Longitudinal follow-up/monitoring </li></ul><ul><li>Medication follow-up (including labs) </li></ul><ul><li>2nd level or adjunctive medications </li></ul><ul><li>Link with community resources </li></ul>
  8. 8. Referral Consultative Care Collaborative Care Integrated Team Independent Autonomous (PCP) Autonomous (MHS) How
  9. 9. When Continuing Care Short-term Management Diagnosis/ Assessment Risk Factor Identification/ Prevention
  10. 10. Plan Barriers <ul><li>Separation by carve-out </li></ul><ul><li>Practitioner affiliation/communication/incentives </li></ul><ul><li>Confidentiality/HIPAA </li></ul>
  11. 11. Health Plans Money Flow and and Communication No risk Health Plan A. Indemnity Model Mental Health Plan B. Carve-out Model No Shared Risk Primary Care Provider Mental Health Specialist Legend Primary Care Provider Mental Health Specialist High communication Low communication Money Flow
  12. 12. Primary Care Tasks <ul><li>Assessment/diagnosis </li></ul><ul><li>Intervention/management </li></ul><ul><li>Communication with patient </li></ul><ul><li>Communication with mental health specialist </li></ul><ul><li>Develop strategies that are: </li></ul><ul><ul><li>Patient specific </li></ul></ul><ul><ul><li>Problem focused </li></ul></ul><ul><ul><li>Time phase sensitive </li></ul></ul><ul><ul><li>Sector/role relevant </li></ul></ul><ul><ul><li>Developmentally appropriate </li></ul></ul>
  13. 13. “ Systems of care that force the separation of “mental” from “physical” problems consign the clinicians in each area of this dichotomy to a misconceived and incomplete clinical reality that produces duplication of effort, data, and ensures that the patient cannot be completely understood” Institute of Medicine, 1996

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