This document provides an overview of integrated health care, including definitions, reasons for its importance, elements of successful models, and challenges. In 3 sentences: Integrated health care combines physical and mental health services to provide coordinated care through programs that address things like chronic conditions, health education, and care for complex multi-morbidities common to those with serious mental illness. Barriers to integration include differing clinical approaches between specialties, lack of provider training, financial and legal issues, and cultural differences between specialties. The benefits of integration include improved detection and treatment of health issues, better outcomes, increased adherence to care, and higher patient and provider satisfaction.

1. Jeff Capobianco June 22, 2009

2. Overview of Presentation How do we define Integrated Health Care? Why now? What does a successful model look like? What are some basic elements of Integrated Health Care?

3. “ Integrated Health Care” One of latest “buzz words” in health care There can be confusion about the concept: How do you define Integrated Health Care? What does a successful model look like? Most agree it’s a desirable goal Many not be sure how to get there

4. Defining Integrated Health Care Integrated Health Care = health care services combining the best of conventional & complementary health care. Mosby's Dictionary of Complementary & Alternative Medicine. (2005) Integrated Health Care = basic model for interdisciplinary health care that includes many health care providers, with the specific professions represented on any team varying according to the needs of patients served. Amer. Psychological Asso's Presidential Task Force on Integrative Health Care for an Aging Population (2008).

5. Defining Integrated Health Care “ An ideal system is integrated; for (people) entering a confusing array of services, there is no wrong door. All entry points lead to coordinated care.” Michigan Mental Health Task Force October, 2004

6. Why now? “ 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”. President's New Freedom Commission on Mental Health (2000)

8. Morbidity and Mortality Rates People with serious mental illness are dying nearly three decades earlier (on average) than general population Suicide and injury account for about 30-40% of excess mortality; 60% of premature deaths in persons with schizophrenia due to “natural causes” High prevalence of obesity, diabetes and cardiovascular disease Newer medications for bipolar disorder and schizophrenia can exacerbate metabolic risks BH Providers less likely to screen and monitor regularly J Parks , D Svendsen, P Singer, ME Foti National Association of State Mental Health www.nasmhpd.org (October 2006)

9. Preventable Causes of Morbidity & Mortality Impact of medications Lack of access to healthcare Higher rates of modifiable risk factors: Smoking Alcohol consumption Poor nutrition / obesity Lack of exercise “ Unsafe” sexual behavior IV drug use Residence in group care facilities and homeless shelters Vulnerability due to higher rates of: Homelessness Victimization / trauma Unemployment Poverty Incarceration Social isolation

10. Why now? Nearly 44 million Americans (26% of the population) experience a mental health problem annually Only 5% of those suffering from a mental health problem receive treatment from a mental health professional American Association of State and Territorial Health Officials (2005)

11. Why now? 70-80% of all psychotropic medications are prescribed within primary care settings About ½ the time, mental health problems go undetected in primary care settings Even when diagnosed, these problems tend to be under-treated MH outcomes in primary care patients only slightly better than spontaneous recovery Mental Health Weekly 1997 and Mountain View Consulting Group, Inc.

12. Summarizing: Why now? People are Untreated/Under-treated Over-utilize medical services: Visit physician twice as often as those receiving appropriate care Seek treatment in emergency rooms when in crisis People with persistent depression have annual adjusted medical costs 70% higher than those without depression

13. Summarizing: Why now? Reduces the stigma of mental health by normalizing treatment to a primary care setting For those individuals who do not meet SPMI criteria, primary care can competently provide mental health care coordination/care Integration of the care provides improved access to mental health and primary health with a single door entry Provides the public mental health system a relationship with the community of primary health and allows for sound “exit strategies” Potential for improved health care options by bringing together a fragmented system of care

14. What does IH Care it look like? “ Reunification in practice of mind and body” Health care model in which physical health and mental health clinicians partner to manage the treatment of mental health disorders in the person’s medical home/primary center of care. Includes a single treatment plan focused on what the person needs Moves away from a disease-focused system to a person-centered system Care Integra Behavioral Healthcare Solutions

15. Approaches to Health Integration Place primary care within the public mental health system Place mental health services within the primary care setting Place health promotion and disease management programs within the mental health system Place health promotion and disease management programming in the primary care setting

16. Coordinated Community Care Programs Partnerships between several community partners in a common goal to address wellness Targets prevention, early intervention, and targeted disease intervention Primary mission of host site may not be health care- however wellness focus expands mission

17. Continuum of Integration

20. Basic Elements of Integration

21. Financing Public sector financing is a major barrier to achieving clinical integration in most settings Financial or structural integration does not assure clinical integration Improving the health status of those we serve requires all of us to come to the table and work within existing financing structures to find solutions rather than use financing as a way to delay discussions

22. Financing Three fundamentals to successfully implementing financing strategies are: Think of the healthcare money in a community as a collaborative local resource Generate the will to make it work within existing funding mechanisms Be willing to advocate strongly with your state officials for the implementation of currently approved codes for services provided in integrated settings (National Council Magazine, Winter 2009)

23. Clinical- Training & Trust Most primary care physicians receive little training in psychiatry Most psychiatric specialty training does not provide much training in primary care issues Few have worked in a collaborative, integrated practice arrangement Primary Care and Beh Health Clinicians can teach each other skills and in so doing create a more seamless system of care

24. Clinical-Health Education Activities In a recovery-oriented mental health system, physical health care is as central to an individual's service plan as housing, job training, or education Bazelon Center Report (2004) Implementing strategies and programming in order to address chronic conditions Providing consumers with the resources and tools to better manage, treat or prevent complications with chronic health conditions Programs address healthy lifestyles, healthy eating, physical activity and smoking cessation

25. Clinical Identify Clinical practice guidelines, care protocols, chronic care models & disease management approaches that exist specifically for complex multi-morbidities common among individuals with SMI Remember clinical integration requires financial and structural supports in order to be successful

26. Structural Start by finding partners who share mission of serving safety net needs Get champions, directors & boards speaking Develop a strategic plan based on a “rolling start” Develop contracts or MOU’s Develop shared job descriptions and joint hiring

27. Structural Investigate where health information technology and data exchange capabilities exist between providers Target improving access, continuity, and coordination of medical care by focusing on the creation of a medical home where a complete health care profile is served in a seamless system of care

28. Culture Matters… Primary Care Docs Language = patients 10-15 minute blocks Deal one-on-one w/other physicians Find it difficult to deal with interdisciplinary team Medical records short, concise summaries of the diagnosis, treatment and outcome Psychiatrists Language = clients or consumers 45-60 minute sessions Time with consumers considered sacrosanct Behavioral health records are long and complex Contain goals and objectives Variety of provided services; may be re-evaluated over time Contain consumer input

29. Exciting Things to Expect! Financial Barriers Not reimbursed for collaborative work Revenue silos Billing requirements; record-keeping regulations Firewalls in communication systems Legal landmines Stigma and discrimination associated with mental health problems Lack of resources Human (providers; staff) Funding Time/Space Interest Proper tools Language and Cultural Differences

30. “ Opportunity is missed by most people because it is dressed in overalls and looks like work” - Thomas Edison

31. Benefits of Integration Improved detection of physical and behavioral health disorders Significant increase in patients receiving recommended care and positive clinical outcome Higher levels of patient adherence to treatment Better clinical outcomes than by treatment in either sector alone Improved patient and provider satisfaction

32. Never Underestimate the Power of a Shared Vision

33. Children & Teen Resources Early Detection & Intervention for the Prevention of Psychosis Program: www.Preventmentalillnessmi.org http://changemymind.com/ The Early Psychosis Initiative: Early Psychosis: A Physician’s Guide (2000) www.mheccu.ubc.ca/projects/EPI

34. Thanks for the opportunity to speak with you! Jeff Capobianco [email_address] 734.544.6825