1. Integrated Primary &
Behavioral Healthcare
What is it and how will I know when I
get there?
Deb Hrouda
Center for Evidence Based Practices
Case Western Reserve University, Cleveland, Ohio
www.centerforepb.case.edu

2. www.centerforepb.case.edu

3. www.centerforebp.case.edu
www.centerforepb.case.edu

4. Goals for today
• Discuss why integrated care is so important
• Review models of integration and
implementation
• Convey importance of measuring
implementation outcomes
• Review Integrated Treatment Tool developed
by CEBP
• Meet your needs / answer your questions
www.centerforepb.case.edu

5. Recent data from several states have found that
people with severe and persistent mental illness
(SMI) die, on average,
25 years earlier
than the general population
www.centerforepb.case.edu
5

6. Reasons for Morbidity and Mortality
• Genetic link between BH and other d/os
• Inadequate/non-existent health care (access?)
– Fewer routine preventive services (Druss 2002)
– Worse diabetes care (Desai 2002, Frayne 2006)
– Lower rates of cardiovascular procedures (Druss 2000)
• Side effects of medications
• Smoking
• Poor nutrition
• Inadequate/non-existent physical activity
www.centerforepb.case.edu
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7. Morbidity and Mortality
is largely due to
• Preventable medical conditions
– Cardiovascular disease, diabetes, metabolic syndrome
• High prevalence of modifiable risk factors
– Smoking, obesity, diet, exercise, substance use, infectious
diseases, delayed/no well-care, medication and symptom
management/monitoring
• For people with SPMI, there is an epidemic within a
National epidemic
www.centerforepb.case.edu

8. SPMI alone may be a health risk factor
• Patient factors, e.g.: amotivation, fearfulness,
homelessness, victimization/trauma, resources,
advocacy, unemployment, incarceration, social
instability, and IV drug use
• Provider factors: Comfort level and attitude of
healthcare providers, coordination between mental
health and general health care, stigma
• System factors: Funding, fragmentation
www.centerforepb.case.edu

9. Integrated Primary and
Behavioral Health Care
What does this mean?

10. Integrating Care

11. Levels of “Integrated” Care
• Nothing
• Parallel care
___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___ . ___
• “Facilitated” screening and referral
• Co-location of care/Partnerships
• In-house / Single Provider / Integrated care
– Genuinely Integrated Care
Need: Coordination, Collaboration, & Communication
(Co-habitation ≠ Collaboration)

12. Integrated Primary and
Behavioral Health Care
How will we know
when we get there?

13. Implementation Approach
(the CEBP Way)
• Assess readiness
– Identify Organization’s Stage of Change
• Baseline status (fidelity where applicable)
• Action plan
• Consultation and training
• Ongoing outcomes monitoring
– Implementation/Process – program-level
– Intervention – participant-level
www.centerforepb.case.edu

14. Steps to Creating an Implementation Measure
• See if a model exists (or can be adapted)
• Literature review
• Feedback from the field
• Identify model principles/components
• Define components and incremental steps
• Expert consensus
• Field testing
• Refinement based on feedback
www.centerforepb.case.edu

15. Existing models of
integrating PC/BH
• Few with direct focus on SMI
• Direction is BH into PC
• BH is seen as “specialty care”
• PC physician “directs” care
• Psychiatry is typically “consult” (sometimes
without seeing the patient)
www.centerforepb.case.edu

16. Integrated Treatment Tool
“ITT”
A Tool to Evaluate the Integration of
Primary and Behavioral Health Care
CENTER FOR EVIDENCE
BASED PRACTICES AT

17. Integrated Treatment Tool
“ITT”
• 30 Items
• Each item:
–Definition
–Gradations toward theoretical
ideal (rating 1 – 5)
www.centerforepb.case.edu

18. Integrated Treatment Tool
“ITT”
• Organizational
• Treatment
• Care Coordination/Management
www.centerforepb.case.edu

19. Organizational Characteristics
O1. Org. Philosophy O8. Org.-Wide Training
O2. Org. Policies and O9. Clinical Supervision,
Procedures Guidance & Monitoring
O3. Integrated HIT O10. CQI
O11. Pt-Centered Approach
O4. Multi-Disciplinary
O12. Pt Access & Scheduling
Health Care Approach
O13. Executive Leadership
O5. Interdisciplinary Team Involvement
Communication O14. Integrated Approach
O6. Care Manager
O7. Peer Supports
www.centerforepb.case.edu

20. Treatment Characteristics
T1. Comprehensive Identification
T2. Holistic Integrated Care Plan
T3. Integrated Stage-Appropriate Treatment
T4. Outreach
T5. Stepped Care
T6. Use of Motivational Interventions
T7. Self-Management Skill Development
T8. Pharmacological Approaches
T9. Involvement of Social Support Network
www.centerforepb.case.edu

21. Care Coordination/Management
Characteristics
C1. Activities, Elements, and Domains
C2. Laboratory and Test Tracking
C3. Referral Facilitation and Tracking
C4. Medication Reconciliation
C5. Reminders
C6. Transitions between settings/levels of care
C7. Assessing effectiveness/quality of care rcvd
www.centerforepb.case.edu

22. Questions…?

23. Deb Hrouda, MSSA, LISW-S
Director of Quality Improvement
Center for Evidence-Based Practices (CEBP)
Case Western Reserve University
10900 Euclid Avenue
Cleveland, Ohio 44106-7169
debra.hrouda@case.edu
www.centerforepb.case.edu