BH Integration: from the ordinary to the extraordinary Beverly Hammerstrom MPCA Conference Traverse City, Michigan Septemb...
Overview <ul><li>History  </li></ul><ul><li>Define the problem today </li></ul><ul><li>Why now? </li></ul><ul><li>Exactly ...
Let’s first look at insurance……. <ul><li>Group health insurance first offered in 1910 by Montgomery Ward </li></ul><ul><li...
Federal Health Insurance Policies <ul><li>By early 1960’s clamor began for federal health insurance policies, primarily to...
How did physical and mental health become separated? <ul><li>50 years ago – most people with mental illness were living in...
Promises Made; Promises Broken <ul><li>Money was intended to follow consumers into the community programs </li></ul><ul><l...
Shift in state’s directions <ul><li>Decreasing revenues have led to a shift in direction to maximize federal dollars and d...
Just How Big is the Problem <ul><li>Nearly 44 million Americans (26% of the population) experience a mental health problem...
What does this mean for Primary Health Care Providers? <ul><li>More and more needing behavioral health services are seekin...
Prevalence of Psychiatric Disorders in Low-income PC Patients 7% 10% Eating Disorder 7% 17% Alcohol Abuse 11% 36% Anxiety ...
More facts……….. <ul><li>70-80% of all psychotropic medications are prescribed within primary care settings, sometimes inap...
Compliance Issues <ul><li>As few as 1 in 4 patients referred to specialty MH or CD make the first appointment </li></ul><u...
Untreated/Under-treated Patients <ul><li>Over-utilize medical services </li></ul><ul><ul><li>Visit physician twice as ofte...
Why Patients Seek Mental Health Services in Primary Care Settings <ul><li>Limited access to specialty service providers </...
Primary Care Concurs <ul><li>Committee on the Future of Primary Care </li></ul><ul><ul><li>The committee recommends the re...
Prevalence of Psychiatric Disorders in Low-income PC Patients  7% 10% Eating Disorder 7% 17% Alcohol Abuse 11% 36% Anxiety...
Low-income Patients with Psychiatric Dx <ul><li>35% saw their PCP in the past 3 months </li></ul><ul><li>90% of low-income...
Morbidity and Mortality Rates <ul><li>People with serious mental illness  are dying nearly three decades earlier (on avera...
Recommendations……. <ul><li>Promote Coordinated and Integrated mental Health and Physical Health Care for Persons with SMI ...
And……… <ul><li>Adopt a Policy that Mental Health and Physical Healthcare should be Integrated </li></ul><ul><li>Implement ...
New Freedom Commission <ul><li>Chapter on Integration in the Final Report as well as several Action Agenda activities rela...
Why Now? <ul><li>“ Research demonstrates that mental health is key to overall physical health.  Therefore, improving servi...
The Recommendation……. <ul><li>“Commission suggests that collaborative care models should be widely implemented in primary ...
Goal #5: <ul><li>The Commission recommends that Medicare, Medicaid, and the Department of Veterans Affairs, and other Fede...
Changes at the Federal Level <ul><li>Omnibus Budget Reconciliation Acts (OBRA) of 1987 and 1989 expanded Medicare and Medi...
And……….. <ul><li>PIN 2004-05 – Medicaid funding for BH in FQHC’s </li></ul><ul><li>All new FQHC applications must include ...
Michigan Task Force Concurs <ul><li>Mental health and physical health should be more integrated…….. </li></ul><ul><li>An i...
Goal #5 <ul><li>“Coordinate the delivery of mental health services by both federally qualified health clinics and communit...
NCCBH Goals for Integration <ul><li>Every provider of public BH services assures assessment of health status as well as me...
NCCBH Goals continued…….. <ul><li>The safety net population in every community served by providers of public BH services a...
What is Integrated Care? <ul><li>Not simply placing a MH specialist inside a medical setting </li></ul><ul><li>Medically o...
Integrated care……… <ul><li>Includes a treatment plan containing behavioral and medical elements rather than two separate t...
Elements of BH Integration <ul><li>Financial or structural integration does not assure clinical integration </li></ul><ul>...
Benefits of Integration <ul><li>Improved detection of behavioral health disorders </li></ul><ul><li>Significant increase i...
More benefits…….. <ul><li>Improved consumer and provider satisfaction </li></ul><ul><li>Improved PCP skills in medication ...
And it saves money…….. <ul><li>More cost effective treatment </li></ul><ul><li>Can reduce overall cost and reduce over-uti...
Oahu Study……… <ul><li>126,000 patients </li></ul><ul><li>40% reduction of costs by a sample of high utilizers </li></ul><u...
McDonnell-Douglas Corp. 1989 <ul><li>Provided in-house counseling for substance abuse, depression, family problems for emp...
PCP prefer integrated care: PRISM-E Study of Elderly <ul><li>Better communication between PCP and MHP (93%) </li></ul><ul>...
Hypothesis: <ul><li>Better identification of behavioral health needs and better targeting and managing of treatment to tho...
Getting there is not a “walk in the park” <ul><li>Financial Barriers </li></ul><ul><ul><li>Not reimbursed for collaborativ...
The Great Cultural Divide…….. <ul><li>Primary Care Docs </li></ul><ul><ul><li>10-15 minute blocks </li></ul></ul><ul><ul><...
Training………… <ul><li>Most primary care physicians receive little training in psychiatry </li></ul><ul><li>Most psychiatric...
Barriers Identified by Michigan FQHC’s <ul><li>Funds to employ staff </li></ul><ul><li>Limited availability of behavioral ...
Three World View: Three Languages <ul><li>Clinical </li></ul><ul><ul><li>“Achievement” of health goals </li></ul></ul><ul>...
Minkoff’s View  (Medical Director of Choate Integrated Behavioral Care, Woburn, MA) <ul><li>Clinical integration </li></ul...
Balance clinical integration with….. <ul><li>Programmatic integration </li></ul><ul><li>Structural integration </li></ul><...
And……….. <ul><li>Fiscal integration </li></ul><ul><ul><li>Mental health and primary care services under a common funding s...
Doherty’s FIVE LEVELS OF COLLABORATION Doherty’s Five Levels,  FULLY INTEGRATED ELECTRONIC HEALTH RECORD; NEED-TO-KNOW ACC...
Bureau of Primary Health Care Model……….. <ul><li>Model I </li></ul><ul><ul><li>Referral Relationship </li></ul></ul><ul><l...
A very basic on-site integrated model <ul><li>Physicians remain in charge of patient’s physical health </li></ul><ul><li>M...
Collaboration – Contact & Communication <ul><li>Therapists read medical charts and notes </li></ul><ul><li>Physicians read...
Continuum of Integration BH specialists primary care team members +++++ Integrated Care On-site/shared cases With BH speci...
Components of an Integrated Model <ul><li>Behavioral Health Triage  </li></ul><ul><li>Comprehensive Behavioral Health Asse...
On-site Behavioral Health Treatment <ul><li>May include an array of services </li></ul><ul><ul><li>Individual, group, fami...
Referrals <ul><li>Internal referral back to PCP or other BH staff </li></ul><ul><li>External referral to specialty BH prov...
Care monitoring <ul><li>Chronic psychiatric conditions that can be managed effectively in PC setting </li></ul><ul><ul><li...
Cherokee Health Systems <ul><li>Both a community health clinic and a community mental health provider in Tennessee </li></...
Cherokee’s Patient Base <ul><li>40,000 in 2001 </li></ul><ul><ul><li>44% sought primary health care </li></ul></ul><ul><ul...
Core Objective = Integration <ul><li>Entire staff is committed </li></ul><ul><li>All staff (accounting, front-line, suppor...
And……… <ul><li>Cherokee offers 12-month, 2000-hour internships to provide “an intensive and diverse clinical training expe...
According to Cherokee…….. <ul><li>……….placement of a behaviorist on each primary care team is crucial to their mission to ...
Next steps………. <ul><li>Determine where you are on the continuum of care and where you want to be </li></ul><ul><ul><li>Mig...
Don’t reinvent the wheel…. <ul><li>Lots of model programs that have proven successful </li></ul><ul><li>Look at them, but ...
Washtenaw County WCHO <ul><li>Delonis Homeless Shelter </li></ul><ul><ul><li>Small health clinic open 35 hrs. per week </l...
National Models That Already Exist <ul><li>MacArthur </li></ul><ul><li>IMPACT </li></ul><ul><li>RWJ Depression Disparities...
A rose by any other name…. <ul><li>If you’ve seen one integrated care program, you’ve seen one integrated care program </l...
Look for ways to partner…. <ul><li>Shared staffing arrangements </li></ul><ul><li>Shared services </li></ul><ul><li>Don’t ...
Look for funding opportunities <ul><li>HRSA Grants </li></ul><ul><li>Foundations </li></ul><ul><ul><li>RWJF </li></ul></ul...
Legislation may be needed…. <ul><li>Reimbursement codes  </li></ul><ul><ul><li>Federal </li></ul></ul><ul><ul><li>state </...
What’s on the Horizon……… <ul><li>National Learning Collaboratives </li></ul><ul><li>National Learning Communities </li></u...
“ There is no try; only do.”  Yoda Thank you.
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MPCA Integrating Behavioral Health Project

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MPCA Integrating Behavioral Health Project

  1. 1. BH Integration: from the ordinary to the extraordinary Beverly Hammerstrom MPCA Conference Traverse City, Michigan September 17, 2007
  2. 2. Overview <ul><li>History </li></ul><ul><li>Define the problem today </li></ul><ul><li>Why now? </li></ul><ul><li>Exactly do we mean by integrated care? </li></ul><ul><li>Examples of models </li></ul><ul><li>Next steps </li></ul>
  3. 3. Let’s first look at insurance……. <ul><li>Group health insurance first offered in 1910 by Montgomery Ward </li></ul><ul><li>Became readily available in the US in the late 1930’s </li></ul><ul><ul><li>Prior to this primarily offered on lives, houses, cars, etc. </li></ul></ul><ul><ul><li>Covered only catastrophic losses </li></ul></ul><ul><ul><ul><li>In-patient, emergency room </li></ul></ul></ul><ul><li>Employer-sponsored health insurance became popular in the 1950’s after the IRS ruled it was a tax-deductible business expense </li></ul><ul><li>1960 – Private Sector (75%); Public Sector (25%); but most private sector plans did not cover MH (carve outs) </li></ul>
  4. 4. Federal Health Insurance Policies <ul><li>By early 1960’s clamor began for federal health insurance policies, primarily to aid poor and elderly </li></ul><ul><ul><li>Medicare </li></ul></ul><ul><ul><li>Medicaid </li></ul></ul><ul><li>By end of 1960’s – federal share = 40% </li></ul>
  5. 5. How did physical and mental health become separated? <ul><li>50 years ago – most people with mental illness were living in asylums </li></ul><ul><ul><li>more than 20,000 people in Michigan were living in state or county-operated facilities </li></ul></ul><ul><li>1960’s – due to efforts of John Kennedy and advances in medicine thinking began to change </li></ul><ul><li>Michigan PA 258 of 1974 – “tipping point” from institutional care to community-based system </li></ul><ul><li>1980-1990 – reduced by 50% number of people living in tax-funded institutions </li></ul><ul><li>Today only less than 2000 patients in state facilities </li></ul>
  6. 6. Promises Made; Promises Broken <ul><li>Money was intended to follow consumers into the community programs </li></ul><ul><li>Employer-paid insurance had no reason to pick up the bill; most didn’t </li></ul><ul><li>Operating two systems – state & community; never enough money to fund both </li></ul><ul><li>Community-based mental health system has ALWAYS been under funded </li></ul>
  7. 7. Shift in state’s directions <ul><li>Decreasing revenues have led to a shift in direction to maximize federal dollars and draw down more Medicaid match funds </li></ul><ul><li>Incentives put in place in 1995 to encourage CMH’s to become authorities; froze county match </li></ul><ul><li>Most treated in county-based systems today for mental illness are Medicaid </li></ul><ul><ul><li>Few general fund dollars available to treat other populations </li></ul></ul><ul><ul><li>Guidelines specify they must treat the most severe first </li></ul></ul>
  8. 8. Just How Big is the Problem <ul><li>Nearly 44 million Americans (26% of the population) experience a mental health problem annually </li></ul><ul><li>Only 5% of those suffering from a mental health problem receive treatment from a mental health professional </li></ul><ul><li>Community Mental Health Centers (CMHC) are not required to serve the uninsured population </li></ul>
  9. 9. What does this mean for Primary Health Care Providers? <ul><li>More and more needing behavioral health services are seeking it through primary care providers </li></ul><ul><li>95% seek treatment from a family physician – many for physical complaints </li></ul><ul><ul><li>92% of all elderly patients receive MH care from PCP </li></ul></ul><ul><ul><li>90% of most common complaints have no organic basis </li></ul></ul><ul><li>70% of federally-funded health centers report on-site mental health treatment and counseling; 50% provide substance abuse treatment and counseling (2003) </li></ul>
  10. 10. Prevalence of Psychiatric Disorders in Low-income PC Patients 7% 10% Eating Disorder 7% 17% Alcohol Abuse 11% 36% Anxiety Disorder 16% 33% Mood Disorder 28% 51% At least one psych DX General PC Low-income Disorder
  11. 11. More facts……….. <ul><li>70-80% of all psychotropic medications are prescribed within primary care settings, sometimes inappropriately </li></ul><ul><ul><li>67% of psychoactive agents prescribed by PCP </li></ul></ul><ul><ul><li>80% of antidepressants prescribed by PCP </li></ul></ul><ul><li>About ½ the time, mental health problems go undetected in primary care settings </li></ul><ul><li>Even when diagnosed, these problems tend to be under-treated </li></ul><ul><ul><li>MH outcomes in primary care patients only slightly better than spontaneous recovery </li></ul></ul>
  12. 12. Compliance Issues <ul><li>As few as 1 in 4 patients referred to specialty MH or CD make the first appointment </li></ul><ul><ul><li>Nationally = 45-75% </li></ul></ul><ul><ul><li>“no shows” from 5-15% at first integrated clinic in Washtenaw County </li></ul></ul><ul><li>50-56% non-adherence to psychoactive medications within first 4 weeks </li></ul>
  13. 13. Untreated/Under-treated Patients <ul><li>Over-utilize medical services </li></ul><ul><ul><li>Visit physician twice as often as those receiving appropriate care </li></ul></ul><ul><ul><li>Seek treatment in emergency rooms when in crisis </li></ul></ul><ul><ul><li>People with persistent depression have annual adjusted medical costs 70% higher than those without depression </li></ul></ul>
  14. 14. Why Patients Seek Mental Health Services in Primary Care Settings <ul><li>Limited access to specialty service providers </li></ul><ul><li>Lack of adequate insurance coverage </li></ul><ul><li>Cultural beliefs </li></ul><ul><li>Eligibility requirements for public mental health services </li></ul><ul><li>Trust their own physician </li></ul><ul><li>Stigma </li></ul>
  15. 15. Primary Care Concurs <ul><li>Committee on the Future of Primary Care </li></ul><ul><ul><li>The committee recommends the reduction of financial and organizational disincentives for the expanded role of primary care in the provision of mental health services. It further recommends the development and evaluation of collaborative care models that integrate primary care and mental health services more effectively. These models should involve both primary care clinicians and mental health professionals. </li></ul></ul>
  16. 16. Prevalence of Psychiatric Disorders in Low-income PC Patients 7% 10% Eating Disorder 7% 17% Alcohol Abuse 11% 36% Anxiety Disorder 16% 33% Mood Disorder 28% 51% At least One Psychiatric Dx General PC Population Low-income Patients Psychiatric Disorder
  17. 17. Low-income Patients with Psychiatric Dx <ul><li>35% saw their PCP in the past 3 months </li></ul><ul><li>90% of low-income patients with psychiatric Dx preferred integrated care </li></ul>
  18. 18. Morbidity and Mortality Rates <ul><li>People with serious mental illness are dying nearly three decades earlier (on average) than general population </li></ul><ul><ul><li>High prevalence of obesity, diabetes and cardiovascular disease </li></ul></ul><ul><li>Newer medications for bipolar disorder and schizophrenia can exacerbate metabolic risks </li></ul><ul><ul><li>BH Providers less likely to screen and monitor regularly </li></ul></ul>
  19. 19. Recommendations……. <ul><li>Promote Coordinated and Integrated mental Health and Physical Health Care for Persons with SMI </li></ul><ul><ul><li>Promote integration of general health and mental health records </li></ul></ul><ul><ul><li>Revise laws and policies to support communication between providers </li></ul></ul>
  20. 20. And……… <ul><li>Adopt a Policy that Mental Health and Physical Healthcare should be Integrated </li></ul><ul><li>Implement Care Coordinated Models </li></ul><ul><li>Assure financing methods for service improvements. Include reimbursement for coordination activities, case management…….. </li></ul><ul><li>Establish rates adequate to assure access to primary care by persons with SMI </li></ul>
  21. 21. New Freedom Commission <ul><li>Chapter on Integration in the Final Report as well as several Action Agenda activities related to integration </li></ul><ul><li>Recommended development of a comprehensive state plan across all mental health activities that should include a requirement to address primary care integration issues </li></ul>
  22. 22. Why Now? <ul><li>“ Research demonstrates that mental health is key to overall physical health. Therefore, improving services for individuals with mental illness requires close attention to how mental health care and general medical care interact. While mental health and physical health are clearly connected, a chasm exists between the mental health and general health care systems in financing and practice. </li></ul>
  23. 23. The Recommendation……. <ul><li>“Commission suggests that collaborative care models should be widely implemented in primary health care settings and reimbursed by public and private insurance.” </li></ul>
  24. 24. Goal #5: <ul><li>The Commission recommends that Medicare, Medicaid, and the Department of Veterans Affairs, and other Federal and State-sponsored health insurance programs and private insurers identify and consider payment for core components of evidence-based collaborative care including: case management, disease management, supervision of case managers, consultations to primary care providers by qualified mental health specialists that do not involve face-to-face contact with clients </li></ul>
  25. 25. Changes at the Federal Level <ul><li>Omnibus Budget Reconciliation Acts (OBRA) of 1987 and 1989 expanded Medicare and Medicaid reimbursements to include clinical psychologists and master’s level social workers practicing in rural areas </li></ul><ul><li>HRSA has provided grant funding to FQHC’s to increase behavioral health staff (no longer available) </li></ul>
  26. 26. And……….. <ul><li>PIN 2004-05 – Medicaid funding for BH in FQHC’s </li></ul><ul><li>All new FQHC applications must include </li></ul><ul><li>HRSA is offering grant funds for Developing Integrated Networks in rural areas and for developing networks </li></ul>
  27. 27. Michigan Task Force Concurs <ul><li>Mental health and physical health should be more integrated…….. </li></ul><ul><li>An ideal system is integrated; for consumers entering a confusing array of services, there is no wrong door. </li></ul><ul><li>Develop specific sustainable models of collaboration at the state and local levels maximizing resources earmarked for providing mental health services. </li></ul>
  28. 28. Goal #5 <ul><li>“Coordinate the delivery of mental health services by both federally qualified health clinics and community mental health programs.” </li></ul><ul><li>The writing’s on the wall, folks! </li></ul><ul><li>and it’s the right thing to do </li></ul>
  29. 29. NCCBH Goals for Integration <ul><li>Every provider of public BH services assures assessment of health status as well as mental status and has specific protocols in place for medically monitoring all consumers receiving second generation antipsychotic medications. An integral part of their service for consumers is to assure that each person is connected to a primary care medical home and there are specific mechanisms between the BH and PCP for coordination of services. </li></ul>
  30. 30. NCCBH Goals continued…….. <ul><li>The safety net population in every community served by providers of public BH services and by CHC’s has seamless access to both BH and physical health care. There is a strong working partnership among these providers, with roles defined, referral protocols in place and cross-placement of clinical staff. </li></ul>
  31. 31. What is Integrated Care? <ul><li>Not simply placing a MH specialist inside a medical setting </li></ul><ul><li>Medically oriented; pace fits with the ecology of the medical setting </li></ul><ul><li>Covers problems not typically seen in specialty mental health care </li></ul><ul><li>Focuses on population management and on supporting and enhancing the PCP who leads the integrated care team </li></ul>
  32. 32. Integrated care……… <ul><li>Includes a treatment plan containing behavioral and medical elements rather than two separate treatment plans </li></ul><ul><li>Is a health care model in which physical health and mental health clinicians partner to manage the treatment of mental health disorders in the primary setting </li></ul>
  33. 33. Elements of BH Integration <ul><li>Financial or structural integration does not assure clinical integration </li></ul><ul><li>Clinical integration helps focus on what consumers need </li></ul><ul><li>Public sector efforts focused on financial integration (carve-ins) have had limited success </li></ul><ul><li>Clinical integration requires financial and structural supports </li></ul><ul><li>Public sector financing is a major barrier to achieving clinical integration in most settings </li></ul>
  34. 34. Benefits of Integration <ul><li>Improved detection of behavioral health disorders </li></ul><ul><li>Significant increase in patients receiving recommended care and positive clinical outcome </li></ul><ul><li>Higher levels of patient adherence to treatment </li></ul><ul><li>Better clinical outcome than by treatment in either sector alone </li></ul>
  35. 35. More benefits…….. <ul><li>Improved consumer and provider satisfaction </li></ul><ul><li>Improved PCP skills in medication prescription practices </li></ul><ul><li>Increased confidence in PCP in managing BH conditions </li></ul>
  36. 36. And it saves money…….. <ul><li>More cost effective treatment </li></ul><ul><li>Can reduce overall cost and reduce over-utilization of the medical system </li></ul><ul><li>Between 20 and 40% of total medical care cost savings </li></ul><ul><li>Up to 70% saved in treating older Americans </li></ul>
  37. 37. Oahu Study……… <ul><li>126,000 patients </li></ul><ul><li>40% reduction of costs by a sample of high utilizers </li></ul><ul><li>Reduced medical utilization by 21% </li></ul>
  38. 38. McDonnell-Douglas Corp. 1989 <ul><li>Provided in-house counseling for substance abuse, depression, family problems for employees – 20,000/4 years </li></ul><ul><li>Lowered health care cost of not only employees but also dependants </li></ul><ul><li>34-44% reduction in absences </li></ul><ul><li>60-80% lower attrition rate </li></ul><ul><li>Saved $4 in health, absences, and attrition for every $1 spent </li></ul>
  39. 39. PCP prefer integrated care: PRISM-E Study of Elderly <ul><li>Better communication between PCP and MHP (93%) </li></ul><ul><li>Less stigma for patients (93%) </li></ul><ul><li>Better coordination of care (92%) </li></ul><ul><li>Better care of depression (64%) </li></ul><ul><li>Better care of anxiety (76%) </li></ul><ul><li>Better care of alcohol problems (66%) </li></ul>
  40. 40. Hypothesis: <ul><li>Better identification of behavioral health needs and better targeting and managing of treatment to those needs using collaboration will lead to more cost-effective treatment, higher compliance and better patient outcomes. </li></ul><ul><li>It should be a slam dunk…… </li></ul>
  41. 41. Getting there is not a “walk in the park” <ul><li>Financial Barriers </li></ul><ul><ul><li>Not reimbursed for collaborative work </li></ul></ul><ul><ul><li>Revenue silos </li></ul></ul><ul><ul><li>Billing requirements; record-keeping regulations </li></ul></ul><ul><li>Firewalls in communication systems </li></ul><ul><li>Legal landmines </li></ul><ul><li>Stigma and discrimination associated with mental health problems </li></ul><ul><li>Lack of resources </li></ul><ul><ul><li>Human (providers; staff) </li></ul></ul><ul><ul><li>Funding </li></ul></ul><ul><ul><li>Time/Space </li></ul></ul><ul><ul><li>Interest </li></ul></ul><ul><ul><li>Proper tools </li></ul></ul><ul><li>Language and Cultural Differences </li></ul>
  42. 42. The Great Cultural Divide…….. <ul><li>Primary Care Docs </li></ul><ul><ul><li>10-15 minute blocks </li></ul></ul><ul><ul><li>Deal one-on-one w/other physicians </li></ul></ul><ul><ul><ul><li>Find it difficult to deal with interdisciplinary team </li></ul></ul></ul><ul><ul><li>Medical records short, concise summaries of the diagnosis, treatment and outcome </li></ul></ul><ul><ul><li>Language = patients </li></ul></ul><ul><li>Psychiatrists </li></ul><ul><ul><li>Language = clients or consumers </li></ul></ul><ul><ul><li>45-60 minute sessions </li></ul></ul><ul><ul><ul><li>Time with consumers considered sacrosanct </li></ul></ul></ul><ul><ul><li>Behavioral health records are long and complex </li></ul></ul><ul><ul><ul><li>Contain goals and objectives </li></ul></ul></ul><ul><ul><ul><li>Variety of provided services; may be re-evaluated over time </li></ul></ul></ul><ul><ul><ul><li>Contain consumer input </li></ul></ul></ul>
  43. 43. Training………… <ul><li>Most primary care physicians receive little training in psychiatry </li></ul><ul><li>Most psychiatric specialty training does not provide much training in primary care issues </li></ul><ul><li>Neither receives significant training in collaborative, integrated practices arrangements </li></ul>
  44. 44. Barriers Identified by Michigan FQHC’s <ul><li>Funds to employ staff </li></ul><ul><li>Limited availability of behavioral health providers </li></ul><ul><li>Limited space and staff </li></ul><ul><li>Staff resistance </li></ul><ul><li>Ownership of medical records; HIPPA </li></ul><ul><li>Sharing of revenue sources </li></ul>
  45. 45. Three World View: Three Languages <ul><li>Clinical </li></ul><ul><ul><li>“Achievement” of health goals </li></ul></ul><ul><ul><li>Goal of care = quality </li></ul></ul><ul><li>Financial </li></ul><ul><ul><li>Bottom line </li></ul></ul><ul><ul><li>Price/value </li></ul></ul><ul><li>Structural/Operational </li></ul><ul><ul><li>Productivity </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul>
  46. 46. Minkoff’s View (Medical Director of Choate Integrated Behavioral Care, Woburn, MA) <ul><li>Clinical integration </li></ul><ul><ul><li>Dually trained clinicians or interdisciplinary teams </li></ul></ul><ul><li>Clinical practice integration </li></ul><ul><ul><li>Formal collaboration and consultation mechanisms, required screening practices, collaboration practices built into service protocols </li></ul></ul>
  47. 47. Balance clinical integration with….. <ul><li>Programmatic integration </li></ul><ul><li>Structural integration </li></ul><ul><ul><li>Behavioral and primary care services under a common administrative authority which can create standards for collaboration and clinical integration </li></ul></ul><ul><li>Physical integration </li></ul><ul><ul><li>Co-location of services in either direction </li></ul></ul>
  48. 48. And……….. <ul><li>Fiscal integration </li></ul><ul><ul><li>Mental health and primary care services under a common funding stream which can be utilized to promote any of the other’s activities </li></ul></ul>
  49. 49. Doherty’s FIVE LEVELS OF COLLABORATION Doherty’s Five Levels, FULLY INTEGRATED ELECTRONIC HEALTH RECORD; NEED-TO-KNOW ACCESS FOR ALL PRACTITIONERS SHARED ALLEGIANCE TO BIOPSYCHOSOCIAL SYSTEMS PARADIGM NO COMMON LAN-GUAGE OR UNDER-STANDING OF OTHERS’ CULTURE LITTLE UNDERSTAND-ING OF OTHERS’ CULTURE SHARED VISION BASIC APPRECIA-TION OF OTHERS’ ROLE & CULLTURE APPRECIATION OF OTHERS’ ROLES LITTLE SHARED RESPONSIBILITY LIMITED COMMUNICATION REGULAR COLLABORATIVE TEAM MEETINGS SOME DATA SHARING BUT SEPARATE DATA SETS NO SYSTEMIC APPROACH TO COLLABORATION LINE STAFF WORK TOGETHER ON SOME CASES SEPARATE DATA SYSTEMS; LIMITED SHARING INTEGRATED FUNDING WITH RE-SOURCES SHARED ACROSS NEEDS; MAXIMIZATION OF BILLING AND SUPPORT STAFF SEPARATE FUNDING WITH SHARED ON-SITE EXPENSES; SHARED STAFFING & INFRASTRUCTURE COSTS PRIMARY CARE PHYSICIAN WORKS WITH CLINICIAN ON SITE RATHER THAN PSYCHIATRIST SEPARATE FUND-ING SYSTEMS SEPARATE FUND- ING SYSTEMS; NO RESOURCE SHARING SAME SYSTEMS; SEAMLESS; ONE TREATMENT PLAN; ON-GOING CONSULTATION COORDINATED TREATMENT PLAN; REGULAR FACE-TO-FACE INTERACTION TWO PHYSICIANS; TWO TREATMENT PLANS; SOME INTERACTION DUE TO PROXIMITY OCCASIONAL PLAN SHARING; SEPARATE & DISTINCT SERVICES SEPARATE AND DISTINCT TREATMENT PLAN AND SERVICES ONE FRONT DOOR; SHARED SITE; ONE VISIT FOR ALL NEEDS SHARED SITES SHARED FACILITY; MAY SHARE RECEPTION AREA TWO FRONT DOORS; SEPARATE FACILITIES TWO FRONT DOORS; SEPARATE FACILITIES CLOSE-FULLY INTEGRATED CLOSE-PARTLY INTEGRATED BASIC ON SITE BASIC AT DISTANCE BASIC
  50. 50. Bureau of Primary Health Care Model……….. <ul><li>Model I </li></ul><ul><ul><li>Referral Relationship </li></ul></ul><ul><li>Model II </li></ul><ul><ul><li>Co-location </li></ul></ul><ul><ul><li>Teams working separately </li></ul></ul><ul><li>Model III </li></ul><ul><ul><li>On-site; shared cases between BH and PCP </li></ul></ul><ul><li>Model IV </li></ul><ul><ul><li>Integrated Care; BH specialist an active member of primary care team </li></ul></ul>
  51. 51. A very basic on-site integrated model <ul><li>Physicians remain in charge of patient’s physical health </li></ul><ul><li>Mental health professionals assess for mental illnesses and link clients with appropriate services </li></ul><ul><li>Co-location provides “single point of entry” </li></ul>
  52. 52. Collaboration – Contact & Communication <ul><li>Therapists read medical charts and notes </li></ul><ul><li>Physicians read therapy notes </li></ul><ul><li>Providers talk in the hallway </li></ul><ul><li>Physicians join therapy sessions </li></ul><ul><li>Therapists join medical sessions </li></ul><ul><li>Conjoint family meetings </li></ul><ul><li>Unified treatment team working to best assist patient in physical and mental care </li></ul>
  53. 53. Continuum of Integration BH specialists primary care team members +++++ Integrated Care On-site/shared cases With BH specialist +++ Collaborative Care On-site BH Unit but Separate Team ++ Co-location Preferred Provider Some info exchange + Referral Relationship Traditional BH Specialty Model -- Separate Location and Mission Attributes Desirability Model
  54. 54. Components of an Integrated Model <ul><li>Behavioral Health Triage </li></ul><ul><li>Comprehensive Behavioral Health Assessment </li></ul><ul><li>On-site Behavioral Health Treatment </li></ul><ul><li>Referral </li></ul><ul><li>Consultation </li></ul><ul><li>Care monitoring and chronic disease management protocols </li></ul>
  55. 55. On-site Behavioral Health Treatment <ul><li>May include an array of services </li></ul><ul><ul><li>Individual, group, family counseling </li></ul></ul><ul><ul><li>Psychotherapy </li></ul></ul><ul><ul><li>Psychopharmacological assessment and treatment </li></ul></ul><ul><li>Limited by available behavioral health staffing and budgetary capacity </li></ul>
  56. 56. Referrals <ul><li>Internal referral back to PCP or other BH staff </li></ul><ul><li>External referral to specialty BH providers </li></ul><ul><li>Other social service components </li></ul><ul><ul><li>Housing </li></ul></ul><ul><ul><li>Employment </li></ul></ul>
  57. 57. Care monitoring <ul><li>Chronic psychiatric conditions that can be managed effectively in PC setting </li></ul><ul><ul><li>Less complicated cases of depression </li></ul></ul><ul><li>Chronic health problems that are result of or complicated by co-morbid psychiatric conditions </li></ul><ul><ul><li>Difficulty adjusting to diabetes or cancer </li></ul></ul>
  58. 58. Cherokee Health Systems <ul><li>Both a community health clinic and a community mental health provider in Tennessee </li></ul><ul><li>Opened its first co-located, integrated primary care and behavioral health clinic in 1984 </li></ul><ul><li>Today Cherokee has 21 sites </li></ul>
  59. 59. Cherokee’s Patient Base <ul><li>40,000 in 2001 </li></ul><ul><ul><li>44% sought primary health care </li></ul></ul><ul><ul><li>56% sought behavioral health services </li></ul></ul><ul><ul><li>57% of population is Medicaid reimbursed on a capitation basis </li></ul></ul><ul><ul><li>12% are covered by Medicare </li></ul></ul><ul><ul><li>9% covered by federal and state grants </li></ul></ul>
  60. 60. Core Objective = Integration <ul><li>Entire staff is committed </li></ul><ul><li>All staff (accounting, front-line, supporting) are considered essential players in providing integrated care </li></ul><ul><li>Weekly case management meeting </li></ul><ul><li>include the entire clinical staff </li></ul><ul><li>Primary care providers are paid for time required for collaboration </li></ul>
  61. 61. And……… <ul><li>Cherokee offers 12-month, 2000-hour internships to provide “an intensive and diverse clinical training experience within a community health setting” </li></ul>
  62. 62. According to Cherokee…….. <ul><li>……….placement of a behaviorist on each primary care team is crucial to their mission to help ensure that the patients will get the appropriate behavioral care prescribed and recommended. </li></ul>
  63. 63. Next steps………. <ul><li>Determine where you are on the continuum of care and where you want to be </li></ul><ul><ul><li>Might require a stepped approach </li></ul></ul><ul><ul><li>Might be different at each location </li></ul></ul><ul><ul><li>Will depend upon resources available </li></ul></ul><ul><ul><ul><li>Staff, space, time, funding </li></ul></ul></ul>
  64. 64. Don’t reinvent the wheel…. <ul><li>Lots of model programs that have proven successful </li></ul><ul><li>Look at them, but then tweak them to meet the individual needs of your center </li></ul>
  65. 65. Washtenaw County WCHO <ul><li>Delonis Homeless Shelter </li></ul><ul><ul><li>Small health clinic open 35 hrs. per week </li></ul></ul><ul><li>Nurse Practitioner Clinic </li></ul><ul><ul><li>Services to consumers at CMH facility, including smoking cessation classes </li></ul></ul><ul><li>Packard Community Clinic </li></ul><ul><ul><li>Full-time MSW and 4 hrs. of psychiatric time per week </li></ul></ul><ul><li>Ypsilanti Family Practice </li></ul><ul><ul><li>½ day per week adult and child psychiatrist on site for consultation and resident training </li></ul></ul><ul><li>Corner Health Center </li></ul><ul><ul><li>Mental health staffing at center for persons 12-21 and children </li></ul></ul>
  66. 66. National Models That Already Exist <ul><li>MacArthur </li></ul><ul><li>IMPACT </li></ul><ul><li>RWJ Depression Disparities </li></ul><ul><li>BPHC Health Disparities Program </li></ul><ul><li>Washtenaw County Michigan Model </li></ul><ul><li>Cherokee Health Systems - Tennessee </li></ul>
  67. 67. A rose by any other name…. <ul><li>If you’ve seen one integrated care program, you’ve seen one integrated care program </li></ul><ul><li>Each program should be designed to address the needs in the community and be consistent with the mission and objectives of primary care </li></ul><ul><li>Different models lead to different costs and outcomes </li></ul>
  68. 68. Look for ways to partner…. <ul><li>Shared staffing arrangements </li></ul><ul><li>Shared services </li></ul><ul><li>Don’t overlook opportunities through telemedicine </li></ul><ul><li>Opportunities to co-locate </li></ul><ul><ul><li>Three Rivers Health </li></ul></ul><ul><ul><li>St. Joseph CMH </li></ul></ul><ul><ul><li>Dental practice </li></ul></ul>
  69. 69. Look for funding opportunities <ul><li>HRSA Grants </li></ul><ul><li>Foundations </li></ul><ul><ul><li>RWJF </li></ul></ul><ul><ul><li>Hogg Foundation </li></ul></ul><ul><li>Funding CMH Staff at Primary Care Clinics </li></ul><ul><ul><li>When the number of shared consumers is >40 (average case load size at CMH), and existing CMH professional and 5 hours of psychiatric time can be allocated to that clinic for the provision of on-site mental health services </li></ul></ul>
  70. 70. Legislation may be needed…. <ul><li>Reimbursement codes </li></ul><ul><ul><li>Federal </li></ul></ul><ul><ul><li>state </li></ul></ul><ul><li>Insurance Laws </li></ul><ul><li>Public/Mental Health Code Changes </li></ul><ul><ul><li>Allow for partnerships/shared funding streams </li></ul></ul><ul><li>Governance </li></ul><ul><li>It’s not impossible……. </li></ul>
  71. 71. What’s on the Horizon……… <ul><li>National Learning Collaboratives </li></ul><ul><li>National Learning Communities </li></ul><ul><ul><li>National Council for Community Behavioral Healthcare </li></ul></ul><ul><li>Statewide Learning Communities </li></ul><ul><li>Statewide Pilot Projects </li></ul><ul><li>Local Ideas </li></ul>
  72. 72. “ There is no try; only do.” Yoda Thank you.

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