Downloaded 13 times
Uploaded byCHC Connecticut
Behavioral Health Staff in Integrated Care Settings | The Vital Role of Collaboration Across Teams: Expand the Impact of Your Care
The document discusses the vital role of collaboration among behavioral health staff in integrated care settings to improve patient outcomes in primary care. It emphasizes the need for interdisciplinary teamwork involving psychiatry, psychology, and nursing to effectively address behavioral health issues within complex patient populations. The community health center aims to enhance behavioral health services through education, training, and the implementation of innovative approaches like telehealth.
More Related Content
Similar to Behavioral Health Staff in Integrated Care Settings | The Vital Role of Collaboration Across Teams: Expand the Impact of Your Care
More from CHC Connecticut
Behavioral Health Staff in Integrated Care Settings | The Vital Role of Collaboration Across Teams: Expand the Impact of Your Care
- 1. Behavioral Health Staffin Integrated Care Settings The Vital Role of Collaboration Across Teams: Expand the Impact of Your Care May 6th, 2019
- 2. Expert Panelists Tichianaa Armah,MD • Medical Director, Psychiatry • VP of Behavioral Health Chelsea McIntosh, PsyD • On Site Behavioral Health Director Nicole Scalora, BSN, RN • Staff Nurse
- 3. Disclosure • With respectto the following presentation, there has been no relevant (direct or indirect) financial relationship between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which would be considered a conflict of interest. • The views expressed in this presentation are those of the presenters and may not reflect official policy of Community Health Center, Inc. and its Weitzman Institute. • We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation (not FDA approved) and any limitations on the information hat we present, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.
- 4. Get the MostOut of Your Zoom Experience • Use the Q&A Button to submit questions! • Live tweet us at @CHCworkforceNCA • Recording and slides are available after the presentation on our website within one week • View past webinars at www.chc1.com/nca
- 5. Learning Objectives 1. Gaina broader perspective on the scope and role of the behavioral health workforce in primary care 2. Understand how health center teams can effectively utilize the role of psychiatry and psychology within the interdisciplinary team 3. Learn concrete ways that psychology, psychiatry and nursing can collaborate across disciplines to provide quality care to complex patient populations
- 6. CHC Profile: Foundingyear: 1972 Over 200 service sites Patients/year: 100,000 6
- 7. The Weitzman Instituteworks to improve primary care and its delivery to medically underserved and special populations through research, innovation, and the education and training of health professionals. Weitzman Institute 7
- 8. The Community HealthCenter, Inc. and its Weitzman Institute provides education, information, and training to interested health centers on: Transforming Teams • National Webinars on the team based care model • Invited participation in Learning Collaboratives to launch team based care at your health center Training the Next Generation • National Webinar series on developing Nurse Practitioner and Clinical Psychology residency programs and successfully hosting health profession students in health centers • Invited participation in Learning Collaborative to implement these programs at health center
- 9. • Nearly 1in 5 US residents is struggling with behavioral health (BH) problems • An estimated 43% to 60% of individuals with BH conditions are receiving treatment solely in primary care settings • Researchers estimate between 30% and 80% of all primary care visits are driven at least in part by BH issues. Increasingly, integrated BH is seen as an expectation of primary care. Landscape Blasi PR, Cromp D, McDonald S, Hsu C, Coleman K, Flinter M, Wagner E. Approaches to Behavioral Health Integration at High Performing Primary Care Practices. J Am Board Fam Med. Sept-Oct 2018: 31(5): 691-701.
- 10. Health Center BehavioralHealth Accomplishments Health centers have long been at the forefront of treating behavioral health in the United States Nearly 90% of health centers providing mental health services https://bphc.hrsa.gov/qualityimprovement/clinicalquality/behavioralhealth/index.html
- 11. UDS 2017 Health Center’s Complex Patient Population SelectedMental Health and Substance Use Conditions Number of Patients with Diagnosis Alcohol related disorders 317,518 Other substance related disorders (excluding tobacco use disorders) 485,992 Tobacco use disorder 1,182,710 Depression and other mood disorders 2,284,818 (8%) Anxiety disorders including PTSD 2,026,904 (7%) Attention deficit and disruptive behavior disorders 520,573 Other mental disorders, excluding drug or alcohol dependence 1,520,311 Total 8,338,826 (30%) https://bphc.hrsa.gov/uds/datacenter.aspx
- 12. https://bphc.hrsa.gov/uds/datacenter.aspx UDS 2017 Data Staffingand Utilization FTEs Ratio: Total Behavioral Health Provider FTEs/Total Patients Ratio: Total Psychologist & Psychiatrist FTEs/Total Patients 1 / 2,552 1 / 16,753
- 14. Benefit of Collaborationon Patient Care Patient Example Patient prescribed medications by the psychiatrist Due to housing instability, RN established a voluntary medication plan Patient recommended for therapy and group Connected patient with community resources
- 16. 16 Warm Hand Offs(WHOs): Proactive and Reactive Medical initiated warm hand-off and behavioral health initiated warm hand-off • Reactive: Initiated by medical provider (e.g. medical screenings) • Proactive: Initiated by BH provider based on dashboard • BH diagnosis and no BH visits • Health related diagnoses that can impact emotional health • e.g. opioid prescription, chronic pain diagnosis, nicotine use diagnosis) • High risk patient can be a client with a PHQ score over 15 (moderately severe)
- 17. Initial Assessment/Ongoing Treatment Psychodiagnostic assessment Assess nature of symptoms Create plan for treatment identifying goals for care Treatment plan Treatment modalities: Individual, family, group treatment Referral for psychiatric consult Referral to community supports/higher level of care as needed Therapy
- 18. Group therapy offersadditional services to patients who may have common needs. Common Group Types: • Shared behavioral health diagnoses (e.g. depression, trauma) • Medical diagnosis impacting emotional health (e.g. smoking, chronic pain) • Medication assisted treatment Group Therapy All of these and more can create referrals for in house services and serve to better integrated care between medical and behavioral health.
- 20. Direct Assessment • Evaluation • DiagnosticClarity Treatment • Individual Appointments • Group Therapy • WHO Education • Patient education (including medications) Indirect Assessment • Diagnostic Clarity Treatment • Consultation • Curb-side Education • Provider Grand Rounds • Staff Learning sessions Psychiatry
- 21. Health centers haveincreasingly recognized the potential for telehealth, in its various forms, to address service and access gaps resulting from mental health shortages • eConsults • Telepsychiatry Expanding Telehealth to Improve Behavioral Health Access
- 23. Medical Screening There aremany pathways to Behavioral Health care, one of the most robust and reliable is regular screening in medical visits. Nurses and MAs can screen for multiple conditions including • Substance use/SBIRT (DAST, AUDIT-C, CRAFFT, CAGE) • Depression (PHQ-2/9) • Intimate Partner Violence (HITS, HARK) • Patient Symptom Checklist-17 • MCHAT • ACES • Others that you may determine All of these identify patients who may be in need of support from Behavioral Health
- 24.
- 25. Role of Nursing NursingVisits/Co-Visit with BH (in-between provider visit surveillance) • Routine prescription monitoring programs (PMP) Checks (delegate status) • Medication Reconciliation • Side Effect Surveillance • Random/Routine Toxicology • Controlled Substance Agreement Review/Signing Engaging Teams
- 26. Panel Management • Monitorlabs • High risk meds/controlled substances Education • Examples: Smoking cessation, contraceptive counseling, Narcan use, etc. Care Coordination • Medication assistance: compliance, refills • Coordination with community providers Top of Licensure Collaboration Between Psychology, Psychiatry & Nursing
- 27. Integrating BH servicesinto primary care can enhance access to treatment for mental health and substance use issues reduce costs, improve patient experiences of care, and improve patient outcomes. Through BH integration, primary care practices can identify and address patients’ physical health, mental health, health behavioral, substance use, life stressors, and barriers to wellness. Blasi PR, Cromp D, McDonald S, Hsu C, Coleman K, Flinter M, Wagner E. Approaches to Behavioral Health Integration at High Performing Primary Care Practices. J Am Board Fam Med. Sept-Oct 2018: 31(5): 691-701.
- 28.
- 29. Visit our NationalLearning Library Contact us at nca@chc1.com www.chc1.com/nca
- 30. Resource Highlights National LearningLibrary www.chc1.com/nca December 13th | Behavioral Health Workforce Development: Training Across the Various Behavioral Health Disciplines Video Slides February 15 | Taking Team-Based Care to the Next Level Video Slides February 22 | Advancing the Practice of RNs and Behavioral Health Providers Video Slides February 27| The Vital Role of Behavioral Health: Effective Integration in a Model of Team Based Care Slides
Editor's Notes
- #2 Amanda I would prefer to use the picture here see from our facebook.
- #3 Amanda-
- #4 Amanda
- #5 Amanda
- #6 Amanda
- #7 Amanda-
- #8 Amanda-
- #9 Amanda-
- #10 Armah -Thank you Amanda! -I want to first applaud the efforts of all of you joining today. Because your agencies are either providing behavioral health services currently or would like to do so. So, you already recognize the importance of this work so you may already know that -Nearly 1 in 5 US residents is suffering from behavioral health conditions. - & About Half of these individuals are estimated to be receiving treatment solely in Primary Care settings -Now, you would be hard pressed to find any provider, family medicine, internal medicine, or pediatric, who does not feel that most of their patients need behavioral health services because of the tremendous impact of mental illness on their patients’ physical health and the providers ability to help patients with their physical complaints. -& beyond the anecdotal reports of medical providers, researchers estimate anywhere from between 30 and 80% of all primary care visits are driven at least in part by behavioral health concerns. -So it should be no surprise that behavioral health is increasingly seen as an expectation of primary care.
- #11 Armah -But this is not new, Health centers have long been at the forefront of treating behavioral health conditions in the United States with nearly 90% of health centers providing mental health services https://bphc.hrsa.gov/qualityimprovement/clinicalquality/behavioralhealth/index.html
- #12 Armah -The UDS or Uniform Data System is a standardized performance reporting system that provides information about health centers and similar agencies each year. -The data gives us a window to some of the BH diagnoses that are being reported from health centers, which are listed here, and your can imagine that not every pt with a diagnosis is captured here. -So all of this demonstrates that while the need is high, the specialized workforce to meet the demand is limited.
- #13 Armah For that, we look to more National UDS data. If you look only at psychiatrist and licensed clinical psychologist, the FTE to patient ratio is about 1 for every 17,000 patients. Even if you add LCSW's, LMFT's, LPCs, LMHCs, and all the other behavioral health providers, the ratio is still incredibly high (1 for every ~2500 patients . Ratios are better for medical providers, and it demonstrates just why we need to work together between behavioral health and medical to support these patients with significant behavioral health needs. So before diving into the model of how we work together in an integrated team we want to take a moment to paint a picture with one recent high-risk patient case that demonstrates how the reach of the behavioral health can be extended for patients with complex needs.
- #14 Armah- But this is actually a microcosm of the full team and as you can imagine there are others involved in his care who are not in this room. -This graphic provides an overview of how we leverage having a highly skilled integrated team to comprehensively address the combined needs of our patients with a focus on how addressing behavioral health issues fits into the framework. -Today, we will touch on some of the components of what you see here under behavioral health and nursing but go into greater detail about all the elements of this slide in past webinars, which we would encourage you to find in our national learning library. -We use this model because we acknowledge, as the case we shared demonstrates, that medical illness, mental illness, substance use, and socioeconomic challenges, add layers of complexity to providing the best quality of care. -So next we are going to dive into the pathway we use to address the whole patient, and as you hear it think about how you might use it or some variation of it, based on the framework of your agency. to further explain the pathway we use, I turn it over to my wonderful teammate and fearless local leader, Dr. McIntosh
- #15 Everyone---As a group, discuss as a group each step to show how you used collaboration to monitor and support one high-risk patient. Chelsea begins- In through medical Seen for therapy Referred to psych for medication management Tichianaa- -Pt already on medication regimen but not getting better (severe depression and homicidal ideation) -but engaged in therapy for the first time. -complication (EtOH precontemplative, med nonadherence) -medication adherence conversations, once recognizing the importance and some improvement when taking medication, decided on nurse order to dive deeper into the problem in a more meaningful way by referring to RN. Nicole Decided on in office prepour due to housing status Some improvements seen Chelsea- came in ready for detox and rehab referred to Nicole for more work connecting with and transferring care up to higher level Tichianaa- this case is one of many but does really highlight how we were able to rally behind a patient from a multidisciplinary approach to support the patient to reach goals and improve outcomes.
- #16 Chelsea-- Intend--- showing the patient path from medical to therapy to psychiatry Intake always happens through medical Referred to BH Referred for medication medicine
- #17 WHOs -Reduce no shows for initial appointment -Brief -Issues can be resolved in the single visit Chelsea- Intent--- Quick recap of the way that patients get from medical to BH
- #18 Chelsea-
- #19 Chelsea-
- #20 Chelsea-- Intend--- showing the patient path from medical to therapy to psychiatry Intake always happens through medical Referred to BH Referred for medication medicine
- #21 Armah- A typical day for a psychiatry provider, may get started off with a question from a PCP, or FNP resident, before I even take off my coat or switch out of my driving shoes when I reach our Pod which is a shared space for the entire integrated team where we are all stationed between patients. example- pt on a med not doing well, No name diagnosis, medications or even referrals. What we would call a curbside Might need more details- consult -may ask Or initiated through EHR from the start. exploring the chart after being approached with a specific question from the Medical Provider and then making treatment recommendations based upon the information about the patient still without actually seeing the patient. Not only does that give guidance for the individual patient but it also serves to educate the provider on how to approach similar cases which is largely how they learned their craft in training, problem based scenarios, connected to patients, that stick. Some of those cursides and consults may result in the recommendation that I see them. Then… individual, or coordinated WHO visit- especially for those who are skeptical about BH in general and psychiatry. Ow without warning but where there is a need - For this to work it needs to be fluid and requires providers who are all flexible, last week I came into a session before the PCP, as the mother of patient began to yell at the Medical assistant to deescalate the situation and help her to be able to articulate how she could get her needs met in a more appropriate manner, and to help to then debrief with the staff on handling these situations in the future. Another way more patients can be reached or greater time allotted to them is through groups. And In some cases there may be groups psychiatry may also run based on their own interest in therapy and pt population needs, psychiatry have run suboxone groups or mindfulness, perhaps groups for patients on other medications like clozaril., for 5 years or more I have co-lead a group with the nutritionist, focused on mindfulness based meditation, mindful eating, and nutrition. The title of this slide is psychiatry providers To be clear, Primary care providers are prescribing the majority of psychotropic medications but of Behavioral health providers the individuals who can take on these tasks can vary from state to state. Psychiatrist, either MDs or DO's, psychiatric mental health nurse practitioners, & Physician Assistants nationwide, are the majority of the BH providers providing medication management in integrated settings. -Along with that, psychologist, are also allowed to prescribe and 5 states with varied limitations depending on the state as well, which you would need to know (Iowa, Idaho, Illinois, New Mexico, and Louisiana, as well as in the Public Health Service, the Indian Health Service, the U.S. military, and Guam. -Now you should make yourselves aware, if you are not already, of any restrictions on PMHNPs or PAs in your state for providing these services, and the level of supervision or collaboration required with physicians, as they vary throughout the country. -Pharmacists PharmDs are also a resource that many are beginning to turn to for recommendations as they comb the literature for the most up to date research on how medications compare and interactions with other medications or particular conditions. ______________________________________________________________________________________ Notes to consider: However, the highest impact for agencies may be in providing education for the more prevalent group of family medicine, internal medicine, and pediatric providers through formal and informal education in the form of consults, and curbsides, grand rounds which does not be counted by number of visits or even number of consults because…. The information learned through one consult or curbside will impact far more patients down the line than could ever be be counted.
- #22 Armah- Because not all are able to have psychiatry on-site I will take a moment to discuss these alternative options for integration as well. In the last slide I talked about consults inhouse, and if you are unfamiliar with eConsults they can be provided for Psychiatry in much the same way. -Electronic consults in the form of secure messages sent by PCPs or therapists to experts in the field outside the agency asking clinical questions primarily for medication recommendations on specific cases. -The psychiatry provider has access to the notes and relevant labs or testing from the chart arranged by the referral coordinator. Then within 24 hours the PCP has their clinical question answered and can also apply that acquired knowledge to other similar clinical cases. Many patients and agencies are now looking to telepsychiatry and psychiatry providers are interested in providing these services for patients and agencies. Using secure video services to bring the care to the patients in the building, such as for rural environments where the number of psychiatry providers is low, or even right into the patient’s home. We are looking to implement it now for our school based clinics to meet some of the logistical needs there. In a similar vein, of growing the reach of BH providers, if you do have psychiatry staff on site but likely in limited supply, registered nurses (RNs) can see and coordinate care between psychiatry visits, to help support the patient population with their BH needs. And to talk more about that, I will pass along to our RN extraordinaire and 2018 nightingale award recipient, Nicole.
- #23 Nicole—highlight that this is where we are in the pathway, at nursing. You have already seen the slide and gone through
- #24 Nicole One of the most prominent ways patients are referred to BH from Medical is through routine screenings during their medical appointments. Common questionnaires that tip providers for further evaluation include substance abuse, depression and domestic violence screenings.
- #25 Nicole As stated earlier, one of the ways patients are commonly found to have BH needs are through routine screenings. The planned care dashboard alerts staff (nurses and MAs) when a patient is due for a routine screening so this can be performed at that days medical appointment. These screenings are mostly done annually but have varying timelines
- #26 Nicole- The role of the nurse in our agency is to assist both medical and behavioral health. One of the most common ways I support BH is through nursing visits. Nurses have their own independent schedule where following protocols, standing orders and directed orders, we can assist our patients and providers outside of their other appointments. Every patient on a controlled substance agrees to a controlled substance contract or agreement which entails routine substance monitoring and drug testing for patient safety. This is a common visit for nurses where they collect a drug screen from the patient, provided education on medication safety and check in on their status, potential side effects, potential substance abuse, and more, and report back concerns to the provider. Often nurses help BH providers through medication reconciliation visits, side effect surveillance and education when starting new medication, routine medication prepours, EKGs prior to medication initiation, medication counts, and much more.
- #27 Nicole- Nurses are encouraged and expected to work at the top of their licensure to provide patients with outstanding care coordination. We do this often outside of the visits I had discussed. I work with BH providers greatly in panel management, with one of the most frequently items being monitoring of high risk medications, such as clozapine and suboxone, and ofcourse controlled substances. With provider orders, I will track clozapine prescribed patient’s CBCs, ensuring that the lab is ordered appropriately, that the patient completes the lab when needed, and that the pharmacy receives the ANC in appropriate timeframe in order for timely dispensal of medication. With suboxone patients, I will ensure they are attending their required visits, performing the orders routine drug screening, that the suboxone is present in the screen, track refills, ensure that contracts are up to date, and much more. Many time BH therapists seek assistance with medical education as patients frequently come to them with concerns. I’ll work with therapists to coordinate visits to education patients on smoking cessation and resources, sex education, narcan administration and more. Many patients become overwhelmed with multiple medications for their chronic conditions and will request medication prepours and help with coordination refills. I have done both voluntary medication assistance where the patient requests and ordered medication assistance where the provider obligates the patient to tracking and coordination. This includes frequent pharmacy coordination, such as keeping up on refills and coordinating med deliveries to pt’s houses and to the office. Additionally, I coordinate with community providers such as specialists, IOPs, inpatient psych units, visiting nurse services and much much more. With VNS, with provider orders, I initiate services and receive and relay information with visiting nurses. I am the liason between VNs and prescribers and help communicate between them often.
- #28 Picture here of the pod with us all in it would be great here Armah So, if you could not tell Nicole could go on and on about the many ways in which this team coordinates care and the strength of our integrated approach. And there are many more cases we could share with you with varying degrees of complexity, that highlight the impact of integration, within this microcosm of the integrated team. It is our hope that through this case and explaining a bit about what we are doing gives you a glimpse into how this integration can enhance access to treatment, improve the patient experience and lead to more positive patient outcomes from a holistic BPSC perspective that otherwise would not be realized.