Punch/Counter Punch: Biopsy of a Successful Integrated Care Program


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Perspectives from Primary Care and Psychiatry

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  • Medicaid contract / MI Mental Health Code / “Shall” waitlist / Full MH capitation and risk
  • Case management / addressing issues stemming from poverty - The wheel house of Community Mental Health
  • Eg. PHQ-9, GAD-7, Audit-C, MDQ, etc
  • Person-centered; Defined population; EBPs; Measurement-based; Treat to target approach Our philosophy is the social worker needs to become part of the primary care team- not an alternative track of service The social worker must create an environment of engagement for the primary care team Regular communication with primary care providers is important A social worker who “actively hangs out” Success has come after we learned that you must have the right person in this role
  • Your typical PCP – broke and living on a park bench
  • Broaden and deepen knowledge base
  • Punch/Counter Punch: Biopsy of a Successful Integrated Care Program

    1. 1. Punch / Counter-Punch: Biopsy of a SuccessfulIntegrated Care Program Perspectives from Primary Care and Psychiatry Timothy Florence, MD Ray Rion, MD April 25, 2012
    2. 2. Pre-partnership Era
    3. 3. Goals for Today Discuss key elements of a successful integrated care partnership Mind the Gap – avoiding potential pitfalls and overcoming barriers Review roles of professional staff
    4. 4. What is a partnership?
    5. 5. What is a partnership?
    6. 6. There are many kinds ofpartnerships
    7. 7. PartnershipA voluntary collaborative agreementbetween two or more parties in whichparticipants agree to work together toachieve a common purpose orundertake a specific task and to sharerisks, responsibilities, resources,competencies and benefits.
    8. 8. The Local “Public Option”
    9. 9. Guide Posts of Policy and Practice  Serve persons with serious mental illness, developmental disabilities and severe emotional disturbances  Provide integrated medical and behavioral healthcare through health homes  Michigan Mental Health Code  Medicaid regulations
    10. 10. Difficult Choices Greatest Good for the Greatest Number VsServing the Least Well Off
    11. 11. Why Partner with Primary Care? Mental health consumers are less likely to receive care for chronic physical health conditions than the general population Serious mental illness is associated with increased morbidity and mortality due to general medical conditions
    12. 12. Why Partner with Primary Care? Individuals with serious mental illness served by our public mental health system die 25 years earlier than the general population.  NASMHPD 2006 Chronic conditions receive episodic care Prevent disease progression Enhance self management/patient activation  Modify modifiable risk factors
    13. 13. WCHO Frequency of Multimorbidity Nearly three out of every four consumers has 2 + concurrent chronic conditionsMental Illness, Developmental Disabilities, Substance Use Disorder, Asthma, Emphysema,Bronchitis, Heart Disease, Diabetes, Hepatitis, Hypertension, Cholesterol, Chronic Pain.
    14. 14. WCHO Disease Management Consumers with Serious Mental Illness 1 in 3 dual- 1 in 4 dual- eligibles have eligibles have triad triad of SMI/HTN/ of SMI/HTN/ Dyslipedemia Diabetes
    15. 15. WCHO Disease Management Consumers with Developmental Disabilities Nearly 1 in 2 1 in 3 dual- dual-eligibles eligibles have have triad of DD/ triad of DD/HTN/ HTN/ Diabetes Dyslipidemia
    16. 16. Packard Health
    17. 17. Packard Health A private, tax exempt Family Practice Eight PCPs (5 MD, 3 NP), health educator, and administrative and office staff The population  8000 patients / 19,000 annual visits  Provide care regardless of insurance status/sliding fee  65% uninsured/capitated county plan (WHP)/Medicaid/Medicare  35% conventionally insured or pay market rates
    18. 18. Packard Health 2012:A Community Partnership for Care Combines primary care, mental health care, health promotion, and disease management programs in one comprehensive family practice setting. Establish ongoing relationships with our patients to help each individual achieve his/her fullest health potential.
    19. 19. Prevalence of Psychiatric Disorders inPrimary Care Patients Mauksch et al, JFP 2001
    20. 20. Impact ofCumulative Social Disadvantage Mortality is increased by:  Lack of adequate housing  Lower income  Poor social cohesion  Limited education  Multi-morbidity Housing, income, and social relatedness are treatments
    21. 21. Why Integrate Care? The medical model isnecessary but not sufficient to bend the curve
    22. 22. Integrated Health Care “Reunification in practice of mind and body” Health care model in which “physical health” and “mental health” clinicians partner to manage health conditions Shift away from disease-focused system to a person-centered system Single treatment plan focused on what patients/consumers need
    23. 23. Core Environmental Factors For Successful Integration Recognize that the population exists in the practice Consciously decide how the practice will address behavioral healthcare integration Establish a learning environment Leadership, both administrative and clinical Understand the capacity of the practice to provide integrated care Individual characteristics and roles of the primary care providers and mental health professionals
    24. 24. Recognize That the Population Exists In the Practice Know, acknowledge and accept that the target population exists in the practice  Already committed to your patients If the perception is that it doesn’t exist:  Provide evidence that it does  Implement simple screening tools to demonstrate presence of behavioral health conditions and/or needs
    25. 25. Packard Health Collaborative Care The Reality  The Plan  Many patients with  To create access to significant mental mental health services health conditions –  To reduce most not meeting fragmentation of CMH criteria services for vulnerable  Primary care patients providers  To utilize existing prescribing for resources more complex patients effectively to achieve who have no improvements in primary mental health status health provider  CSTS “graduates”
    26. 26. Consciously Decide How the Practice Will Address Healthcare Integration Refer to outside providers Provide onsite comprehensive care  Continuum of integration
    27. 27. The Synergy PACKARD CSTS  Patients with  Establishment of complex needs primary mental health  Trust relationship provider with primary  Coordination of health provider treatment and services  More appropriate use of provider time•Use of multidisciplinary team to improve health outcomes•Blending organizational resources to improve access to care
    28. 28. Staffing the Packard Partnership A full time behavioral health specialist (LMSW) on site and a ½ day per week of psychiatry Disease management nurse Joint supervision & oversight of the program by Packard, CSTS and WCHO
    29. 29. Establishing a Learning Environment Support innovation and creativity Support education and team learning and training Model personal mastery Talk about vision Support systems thinking If it doesn’t exist -  Identify leadership and create it through an organizational development plan
    30. 30. “Strangers in the Night” Most primary care providers receive little behavioral health training Psychiatrists receive limited training in outpatient management of chronic medical conditions Primary care providers and psychiatrists generally receive no significant training in collaborative, integrated practice arrangements
    31. 31. The Great Cultural Divide… Primary Care Docs  Psychiatrists  10-15 minute blocks  30-60 minute sessions  Deal directly with  Time with consumers other physicians considered sacrosanct  Find it difficult to deal  Team decision model with interdisciplinary  Behavioral health records team are long and complex  Medical records  Contain goals and objectives short, concise  Variety of provided services; summaries of the may be re-evaluated over diagnosis, treatment time and outcome  Contain consumer input  Language = patients  Language = clients or consumers
    32. 32. Learning Environment Critical to Overcoming Barriers Collaboration across two different cultures  Inertia, resistance Provider factors  Comfort level, mind/body dichotomy, stigma Space  Not incorporated into facilities planning Systems issues  Funding streams, payment systems, billing  Informatics  Documentation, integrated medical record
    33. 33. Leadership Administrative Leadership  Identify a champion who won’t give up  Barrier buster activities Clinical Leadership  Identify a provider with a commitment to the model If it doesn’t exist  Identify an opinion leader or two and convince them of the viability  Get them trained and have them start using it  Organizational leadership development program
    34. 34. Capacity of the Practice Infrastructure  Technology  Space or capacity to share  Reception staff Dedication to integrated healthcare Collegiality If it doesn’t exist  Identify barriers and determine how to and when to create breakthroughs  Add to organizational development plan
    35. 35. Individual Characteristics of Integrated Care Staff General Characteristics  Collegial  Flexible (comfort zone, roles, space)  Autonomous  Multitasking ability and tolerance  Practicality (Common sense biopsy)  Assertive  Clear understanding of what CAN be done
    36. 36. Medical Provider Characteristics Primary Care Providers  Differences in training (Internal Medicine vs. Family Practice vs. others) Psychiatrists  Community psychiatry focus  The Generalist / Teacher
    37. 37. Roles of the Behavioral Heath Specialist Direct service provider Consultant to both psychiatrist and primary care providers “Speak truth to power”  Allow and accept recommendations from non-medical professionals Community liaison
    38. 38. Roles of theBehavioral Health Specialist Linchpin / Mortar Liaison between PCP and psychiatrist Triage officer, crisis manager Joint sessions (“co-visits”) with PCP staff “Curbside” consultant Bridge care between PCP and CMH Provide ongoing follow up for psychiatrist Manager of psychiatry time Brief treatments and case management
    39. 39. Role of the Psychiatrist Educator, Clinician and Liaison  Curbsides  Co-visits  Consultation  Co-management  Clinical Teaching  Case conferences  Community bridging
    40. 40. OutreachSuccess depends upon it O utreach is a profound manifestation of unconditional positive regard offered towards a stranger.
    41. 41. Psychiatric Outreach: Starting Where the PCP Is Bring the door to the PCP  Meet where he/she is, literally and figuratively  Different PCPs => Different stages of change Service must meet perceived needs  PCPs don’t care how much you know until they know you will help  Offer service, be concrete, actively listen  Be always available and become indispensable Remember Maslow  Motivational enhancement of PCP  See one, do one, teach one
    42. 42. EngagementCentral to all work with primary care providers E ngagement is a process of relational discovery between two or more people. It is characterized by mutual respect, shared responsibility, and commitment towards positive change.
    43. 43. PCP Engagement As Empowerment Have perception of poor access to and communication from psychiatry Opportunity to “do with” Have appreciation of PCPs’ strengths Building of trust and relationships are key Work from stance of consensus rather than coercion or isolation Cultivate change together Facilitate recovery from days of split treatment, practice silos and the mind/body dichotomy
    44. 44. In Summary
    45. 45. Core Factors For Successful Integration Recognize that the population exists in the practice  Already committed to your patients Consciously decide how the practice will address behavioral healthcare integration  Make a plan Establish a learning environment  Change is a process  Develop a process that supports change
    46. 46. Core Factors For Successful Integration Leadership, both administrative and clinical  Transform the culture as well as the process Understand the capacity of the practice to provide integrated care  Grow, but know your limits Individual characteristics of the primary care providers and mental health professionals  Get the right people on the bus
    47. 47. Core Factors For Successful Integration The role of the psychiatrist and behavioral health specialist  Adapt to the patient and provider needs  Make yourself indispensable
    48. 48. Thank you