This document outlines a quality improvement project aimed at integrating primary care within a rural community behavioral health clinic, addressing barriers and organizational readiness through the Institute for Healthcare Improvement's behavioral health integration capacity assessment tool. It discusses the project's design phases, identifying challenges such as data sharing and organizational resistance while highlighting the necessity for comprehensive care that can improve outcomes for clients with serious mental illnesses. The document emphasizes the importance of leadership commitment, staff engagement, and collaboration between behavioral health and primary care to achieve successful integration.

2. S
Primary Care Integration for a Rural
Community Behavioral Health Clinic
2015 Washington Behavioral Healthcare Conference:
Fulfilling the Promise of Integrated Care
Vancouver, WA June 19, 2015

3. Who We Are!
S A rural community behavioral health agency
S Serving 1600-1700 clients currently
S Outpatient Day Treatment program serving
approximately 70-100 clients

4. Presenters
S Christine Burnell FNP, DNP (Provider )
S Ru Kirk MA (Clinical Director)
S Sue Ehrlich MD (Medical Director)

7. Learning Objectives
S Introduction of the Institute for Healthcare Improvement (IHI) Behavioral Health
Integration Capacity Assessment (BHICA) Tool
S Review structures that support an integrated model including organizational
structures, interest of stakeholders (there are many)
S Share integrated models for mental health and primary care in greater Puget
Sound area
S Share identified barriers of integrated model including organizational resistance
to change, attitudes and beliefs about integrative care, licensing issues,
physical plant changes, data sharing challenges, billing challenges

8. Reasons for Pursuing this Project
S Passion and Compassion
S FNP strategically placed to be a leader in change
S Rural community offering challenges and
opportunities for integration
S Availability of a psychiatrist, Medical Director
S Clinical commitment to treat most vulnerable

9. Reasons for Pursuing this Project
• Easy access
• Customer service built on a
culture of engagement and
wellness
• Comprehensive care
• Excellent outcomes
• Excellent Value
• National Council’s Behavioral Healthcare Centers of Excellence framework

10. Complex Adaptive Systems
High
Professional
and Social
Agreement
about
Outcomes
Low
Plan &
Control
Chaos
Zone of
Complexity
Certainty
About OutcomesHigh Low
From Crossing the Quality Chasm, A New Health System for the Twenty First Century, Institute of Medicine

11. Problem Statement
Those with Serious Mental Illness:
S Life expectancy – is up to 25 years
less than general population
S Live with physical health
comorbidities
S Experience fragmentation between
primary care and behavioral health
S Quality of life consequences. If left
untreated - experience negative
social determinants of health
S Cost – ER visits and hospitalizations
Purpose: To Develop a draft
Implementation plan for the
provision of primary care at the
collaborative agency to serve
those with serious mental illness.

12. Project Design
This was a quality improvement project to examine feasibility of implementing
primary care in a rural community behavioral health setting.
S Phase 1
Clinic Assessment: The IHI Behavioral Health Integration Capacity
Assessment (BHICA) tool was used to assess organizational readiness
for integration at the collaborative agency.

13. Project Design
S Phase 2
Interviews at
 Partner agency (KMHS) where an exemplar integrated model is
in use currently
 Federally Qualified Health Center (FQHC) Peninsula Community
Health Services
 NAVOS
Focused interview questions were derived from the UW AIMS
Center regarding integration readiness.

14. Project Design
S Phase 3
All data was collated and analyzed to create a draft version of an
implementation plan for integrated care.

16. IHI BHICA Tool
Assesses agency capacity for integration with leaders
of organization utilizing the five steps:
S Understanding the Population (for self-reflection as
agency)
S Assessing Agency Infrastructure
S Identifying the Population and Matching Care
S Assessing Three Approaches to Integration
S Financing Integration

17. IHI BHICA Tool
S https://www.resourcesforintegratedcare.com/tool/bhica

18. IHI BHICA Tool: A Snapshot
Process Reliable Impact Resources Notes
2.1.1 Does your organization
routinely collect individual-level
data? Yes Yes
2.1.2 Does your organization
routinely aggregate individual-
level data? Yes Yes
2.1.3 Do you record the names of
individuals' primary care
providers? Yes Yes
2.1.4 Do you record the date of
individuals’ last primary care visit?
Yes No
2.1.5 Do you record progress
notes/the nature of the last
primary care visit? Yes Yes
2.1.6 Do you record the names of
individuals’ home and community-
based supports? Yes Yes
2.1.7 Do you record the number of
past-year hospitalizations for both
psychiatric and medical reasons? Yes Yes Recorded not necc accessible/in chart
2.1.8 Do you record the number of
individuals' past-year ER visits for
both psychiatric and medical Yes Yes
2.1.9 Does your organization
securely exchange individuals’
information with other practices? Yes Yes
Yes or No Notes
2.1.10 Does your practice use an
electronic health record (EHR)? Yes Yes
2.1.11 Does your EHR meet Stage 1
meaningful use criteria? Yes Yes
2.1.12 Are you able to manage
chronic conditions in the EHR? No Higher Yes
2.1.13 Is your EHR able to interface
with other systems outside of the
organization? No Higher No Only within RSN
Table 1 Self-Assessment: Your Infrastructure
2. Assessing Your Infrastructure
2.1. Capacity to Collect Data, Exchange Information, and Monitor Population Health

20. BHICA Tool: Understanding the Population
S Timeline: 4/1/14-3/31/15
S 1522 clients served
S 22,958 services of which 21,113 face-to-face
S 50-60 miles - average proximity to practice

21. IHI BHICA Tool: Top Mental Health Diagnoses
9%
Schizoaffective

22. The BHICA Tool: Understanding the Population

23. The BHICA Tool: Top Physical Health Diagnoses

24. BHICA Tool: Understanding the Population
Key Question Left Unanswered
S Unable to determine percentage of population with
multiple chronic conditions

25. Laying the Groundwork for a Draft
Implementation Plan
• Problem: Inaccurate or insufficient data
• Solution: Educate staff - PDSA Cycles to improve performance
• Problem: Insufficient Reporting Capacity
• Solution: Utilize IT Support to Identify Multiple Chronic Conditions
Identify Specific/Vulnerable Populations
Create and Utilize Registries/Other QI Activities
Identify a Small Population for Focused BH/PH
Understanding the Population

26. Laying the Groundwork for a Draft
Implementation Plan
PDSA Model of Improvement

28. Recommendations:
Draft Implementation Plan
Assessing Your Infrastructure
Capacity to Collect Data, Exchange Information, and Monitor Population Health
• Establish Registries for Shared Populations
• Electronic Health Record Sharing
Progress and Outcome Tracking Capability
• Tracking Measures Related to Medications e.g. EMR and RxNT Prescribing Software Do Not
Interface = Robust Full Use of RxNT / Input All Medications
• Track All Provider Satisfaction Measures
Process for Engaging and Communicating with Individuals and Family Members
• Family Resource Coordinator
• Family as a Client Model Could be Adopted vs Individuals When Requested

29. Recommendations:
Draft Implementation Plan
Assessing Your Infrastructure
Capacity to Provide Clients with Community Wellness Resources
• Wellness Coordinator (Healthy Living Coordinator)
• Utilize Outpatient Space in Afternoons to Offer In-House Wellness Program
• Revitalize and Adapt Healthy Living Program as a Program Improvement
Plan engaging both staff and clients toward healthier lifestyles
• Utilize Untapped Resources: Nursing Students UW, PMHNP Students to
Carry Forward this Capstone, Peninsula & Olympic Colleges
• Strengthen Bi-Directional Community Referral and Tracking Systems

30. Recommendations:
Draft Implementation Plan
Assessing Your Infrastructure
Culture to Support Integration: Leadership Culture
• Strong, active commitment by leadership toward integration -key component
organization’s strategic plan
• Education and Engagement of Staff re Integration and PH Indices at All Levels
Critical
• Empower Staff via Feedback Mechanisms with New Initiatives
• Monthly Newsletters to Staff by Leadership
• Weaken Support for Status Quo / Sensitivity to Historical Organizational Shifts

32. BHICA Tool: Identifying the Population & Matching Care
Recommendations:
• Target population identified as day treatment outpatient program
• Most clients would be amenable to this model over seeing their PCP off-site
• Comprehensive case management in place
• A RN/Team approach to addressing individual’s unmet care needs would be a good pilot
for moving toward integration

34. BHICA: Assessing Optimal Integration
Reverse Co-location
Level of Integration Partly integrated system-BH and PC in same facility
with shared appointment and medical record systems.
Physical proximity allows for regular face-to-face
communication among BH and physical health
providers. Collaboration is key
Populations Best Served Quadrants II and IV (High behavioral health needs)
Applicable to all ages with adaptations
Adapted from Milbank 2010 Table 12

35. BHICA: Assessing Optimal Integration
Implementation Barriers Records may remain separated
Consent and privacy issues/meshing paperwork processes,
differences in culture BH/PH
Same-day billing challenges
When new appointments required, issues with no-shows can
increase
Economic Outcomes Generate savings because of leveraging and cost-effectiveness
May generate cost-offset savings
Health Outcomes Considerable potential to reduce lifestyle risk factors
Studies have shown reduction of ER visits and dramatic increases in
screening of hypertension and diabetes (Boardman 2006)
Why Choose This Model? Through billing or partnership a more integrated model between
primary care and specialty mental health is sustainable
Adapted from Milbank 2010 Table 12

36. Recommendations:
Draft Implementation Plan
Financing Integration
• Optimize Existing Revenue Sources
• Marketing and Development Director to Regularly Monitor Up and
Coming Grants
• Champions to Work with Exemplar Sites (KMHS’s Bi-directional Model)
• Engage in Discussions with Insurance Plans to Incentivize them to Pay
for Cost Savings
• Study Billing Regulations that may Pose Restrictive Practice in
Integration Efforts (same day billing)

37. Exemplar Site Interviews
• KMHS: Donna Poole ARNP Prior Acting
Medical Director
• Elena Argomaniz Project Director CMS
Innovation Grant
• Peninsula Community Health Services (FQHC):
Health Administrator/Medical Director
• NAVOS Burien Site: Paul Tegenfeldt Vice
President of Healthcare Integration

38. THE PATHWAY TO THE SUMMIT
• BHICA – First study
• Exemplar site interviews
• Identify strengths/barriers/lessons learned from
exemplars to collate recommendations
• Hire consultant National Leader
• Concepts of integration
• Staff engagement Key Stakeholder Meeting
• Bi-directional Model of patient centered care a focus

40. Learning Objectives
S Introduction of the Institute for Healthcare Improvement (IHI) Behavioral Health
Integration Capacity Assessment (BHICA) Tool
S Review structures that support an integrated model including organizational
structures, interest of stakeholders (there are many)
S Share integrated models for mental health and primary care in greater Puget
Sound area
S Share identified barriers of integrated model including organizational resistance
to change, attitudes and beliefs about integrative care, licensing issues,
physical plant changes, data sharing challenges, billing challenges

42. “Do The Next Right Thing”
S Do one physical thing
S Make one face to face consultation with a provider
S Participate in all opportunities for collaboration
regardless of format
S Shared risk is an opportunity to drive change

43. Thank You ! Questions?