No Wrong Door: Assuring Services and Seamless Care

Transcription

1 No Wrong Door: Assuring Services and Seamless Care Barbara Mauer, MCPP Consulting Commissioner Betts, Tennessee Department of Mental Health & Developmental Disabilities Lougene Marsh, Flint Hills Health Center Lyon County Kansas

2 Agenda Welcome and Introductions Pellavi Sharma, ASTHO National Perspective on Integration of Mental Health, Primary Care and Public Health Tennessee s Perspective on Integration of Mental Health, Primary Care and Public Health Lyon County s Perspective on Integration of Mental Health, Primary Care and Public Health Q & A Barbara Mauer, MSW, CMC, Managing Consultant, MCPP Healthcare Consulting Commissioner Virginia Trotter Betts, Tennessee Department of Mental Health & Developmental Disabilities Lougene Marsh, Director and Health Officer, Flint Hills Community Health Center/Lyon County Health Department, Emporia, Kansas Exit survey open for participants on Web Closing Remarks Julie Nelson Ingoglia, NACCHO

3 Objectives At the conclusion of this Web cast participants will have: Increased their awareness of opportunities at the state and local levels for public health, primary care and mental health entities can to work together to provide seamless care. Increased their knowledge of promising practices of state health agencies and local health departments to integrate public health, mental health and primary care Increased their knowledge of the outcomes of the integration of public health, primary care and mental health services. Increase their knowledge of challenges associated with integration.

4 National Perspective on Integration of Mental Health, Primary Care and Public Health ASTHO-NACCHO No Wrong Door: Assuring Services and Seamless Care September 3, 2008 Barbara J. Mauer, MSW CMC MCPP Healthcare Consulting National Council for Community Behavioral Healthcare Consulting Team MCPP HEALTHCARE CONSULTING

5 Elements of BH/PC Integration Financial or structural integration does not assure clinical integration Clinical integration helps us focus on what people need Public sector efforts focused on financial integration (carve-ins) have had limited success BUT clinical integration requires financial and structural supports in order to be successful Clinical Financial Structural Behavioral Health/Primary Care Integration MCPP HEALTHCARE CONSULTING

6 Collaborative Models Around the Country BH/PC integration started in Kaiser, Group Health, Health Partners, U.S. Army healthcare delivery systems where BH started as and still is also a specialty service Research and national initiatives have focused on depression in primary care MacArthur Initiative on Depression and Primary Care Institute for Healthcare Improvement (IHI) Health Disparities Collaboratives (with HRSA and CHCs) RWJ Project: Depression in Primary Care Linking Clinical and System Strategies Many localized initiatives, with differing approaches the focus of work within the National Council has been on the safety net system MCPP HEALTHCARE CONSULTING

7 National Comorbidity Survey Replication The National Comorbidity Survey Replication (NCS-R) is a household survey taken every 10 years Did not include homeless and institutionalized populations, or clinically complex disorders such as schizophrenia likely that the prevalence rates are underestimates 26% of the general population reported symptoms sufficient for diagnosing a mental disorder in the past 12 months Mental disorders gain the strongest foothold in youth: 50% of all cases start by age 14; 75% by age 24 Disorder severity: 22% of the 12-month cases were classified as serious, 37.3% moderate and 40.4% mild Thanks to Dennis Freeman of Cherokee, who prepared the following NCS graphic presentation slides MCPP HEALTHCARE CONSULTING

8 National Comorbity Survey Replication Provision of Behavioral Health Care: Setting of Service No Treatment 59% Treatment 41% SOURCE: Wang, Philip S., et al, Twelve-Month Use of Mental Health Services in the United States, Arch Gen Psychiatry, 62, June 2005 MCPP HEALTHCARE CONSULTING

9 National Comorbidity Survey Replication Provision of Behavioral Health Care: Setting of Service General Medical 56% No Treatment 59% 41% Receiving Care MH Professional 44% SOURCE: Wang, Philip S., et al, Twelve-Month Use of Mental Health Services in the United States, Arch Gen Psychiatry, 62, June 2005 MCPP HEALTHCARE CONSULTING

10 Access to Behavioral Health Intervention Primary Care Service 47% 80% of those with no mental health treatment had a primary care service Mental Health Treatment 41% No Treatment 12% MCPP HEALTHCARE CONSULTING

11 Where Should Care Be Delivered? The National Council Four Quadrant Integration Model Organize our understanding of the many differing approaches there is no single method of integration Think about the needs of the population and appropriate targeting of services Clarify the respective roles of PCP and BH providers, depending on the needs of the person being served Identify the system tools and clinician skill and knowledge sets needed and how they vary by subpopulation Population based for system planning, services should be person-centered MCPP HEALTHCARE CONSULTING

12 The Four Quadrant Clinical Integration Model Low High Behavioral Health (MH/SA) Risk/Complexity Quadrant II BH PH BH Care Manager w/ responsibility for coordination w/ PCP PCP (with standard screening tools and guidelines) possibly w/outstationed medical nurse practitioner at BH site Specialty BH Residential BH Crisis/ER Behavioral Health IP Other community supports Quadrant I BH PH PCP (with standard screening tools and BH practice guidelines) PCP-based BH Consultant/Care Manager Psychiatric consultation Quadrant IV BH PH PCP (with standard screening tools and guidelines) possibly w/outstationed medical nurse practitioner at BH site BH Care Manager w/ responsibility for coordination w/ PCP and other Care/Disease Managers Specialty medical/surgical Specialty BH Residential BH Crisis/ ED BH and medical/surgical IP Other community supports Persons with SMI could be served in all settings. Plan for and deliver services based upon the needs of the individual, consumer choice and the specifics of the community and collaboration. Quadrant III BH PH PCP (with standard screening tools and BH practice guidelines) Care/Disease Manager Specialty medical/surgical Psychiatric consultation PCP-based BH Consultant/Care Manager (or in specific specialties) ED Medical/surgical IP SNF/home based care Other community supports Physical Health Risk/Complexity Low High MCPP HEALTHCARE CONSULTING

13 A Brief History of Depression in Primary Care 1970s 1980s: screening for depression: screening may be necessary but is not sufficient 1990s: improved referral to mental health care: only 50 % follow-up on referrals and few receive a full course of treatment 1993: AHCPR (now AHRQ) practice guidelines. Provider training based on guidelines: guidelines and provider education may be necessary but are not sufficient Since 1990: over 35 studies in the US and abroad document that systematic collaborative care is more effective than usual primary care for depression (Gilbody et al, Arch Int Med; 2006) Recent research supports cost-effectiveness of this approach and the cost effectiveness of collaborative care for anxiety disorders. MCPP HEALTHCARE CONSULTING

14 Primary Care and Depression Most PCPs do a good job of diagnosing and beginning treatment for depression (studied 1,131 patients in 45 primary care practices across 13 states) PCPs do less well following up with treatment over time Less than half of patients completed a minimal course of medications or psychotherapy Few patients who don t respond to initial treatment get adequate changes in treatment or referrals to specialists Lowest quality of care among those with the most serious symptoms, including those with evidence of suicide or substance use Our finding of low rates of referral to mental health specialists for complex patients is typically addressed in collaborative care interventions through stepped care (e.g., IMPACT) that prioritizes mental health specialist referrals on the basis of need. (Hepner et al, Ann Int Med, 9/07) MCPP HEALTHCARE CONSULTING

15 Few Depressed Adults Get Effective Treatment Only ~ half are treated Older adults, men, African Americans and Latinos have particularly low rates of depression treatment Most prefer treatment by their primary care physician PCPs prescribe majority of antidepressants MCPP HEALTHCARE CONSULTING

16 IMPACT Study 1,801 depressed older adults with comorbid medical disorders in primary care Randomly assigned to IMPACT care or usual care 18 primary care clinics - 8 health care organizations in 5 states - 8 diverse health care systems primary care physicians Funded by -John A. Hartford Foundation, -California HealthCare Foundation, Robert Wood Johnson Foundation, Hogg Foundation MCPP HEALTHCARE CONSULTING

17 IMPACT Team Care Model Effective Collaboration Prepared, Pro-active Practice Team Practice Support Informed, Activated Patient MCPP HEALTHCARE CONSULTING

18 What is IMPACT Integrated Care? Team care based in primary care setting Effective collaboration between health and mental health providers Adds to Patient/Provider Team: + Care Coordinator + Consulting Psychiatrist MCPP HEALTHCARE CONSULTING

19 IMPACT is Stepped Care Why Stepped Care? Only 30 40% of patients will have a complete response to initial treatment (Star*D: 37 % respond with initial Rx) Majority (60 70%) will require several changes in treatment. Systematic outcomes tracking e.g., PHQ-9 for depression, GAD-7 for anxiety Treatment adjustment as needed - based on clinical outcomes - according to evidence-based algorithm - in consultation with team psychiatrist Relapse prevention MCPP HEALTHCARE CONSULTING

20 IMPACT: Doubles the Effectiveness of Usual Care for Depression 50 % or greater improvement in depression at 12 months 70 Usual Care IMPACT % Participating Organizations Unutzer et al., JAMA 2002; Psychiatr Clin N America 2005 MCPP HEALTHCARE CONSULTING

21 IMPACT: Lower Total Health Care Costs $8,800 $ / year $8,400 $8,000 $7,600 $8,588 $7,949 Study Usual Care Study IMPACT $7,200 $7,471 Post $6,800 Grypma, et al; General Hospital Psychiatry, 2006 MCPP HEALTHCARE CONSULTING

22 IMPACT Lessons Co-location is NOT sufficient Initial treatments are rarely sufficient. Several changes in treatment are often necessary (stepped care) To accomplish this, we need Systematic outcomes tracking (e.g., PHQ-9) to know when change in treatment is needed Active care management to facilitate changes in medication, behavioral activation Consultation with mental health specialist if patients not improving as expected MCPP HEALTHCARE CONSULTING

23 The Patient-Centered Medical Home Principles of the Patient-Centered Medical Home Personal physician Physician directed medical practice (team care that collectively takes responsibility for the ongoing care of patients) Whole person orientation Care that is coordinated and/or integrated Quality and safety (including evidence based care, use of information technology and performance measurement/quality improvement) Enhanced access to care Payment structure that reflects these characteristics beyond the current encounter-based reimbursement mechanisms The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association MCPP HEALTHCARE CONSULTING

24 The Person Centered Healthcare Home A number of organizations in the United States and abroad have adapted and implemented the IMPACT program with diverse populations, serving individuals of all ages and expanding the scope of services beyond depression to those suffering from anxiety, PTSD, ADHD and other conditions frequently found in primary care While care management is incorporated into the medical home, there has not been a clear articulation in the medical home model of the findings from these researched approaches to treating BH concerns in primary care Team based care with a significant care management/bhc component would be better described if the patient-centered medical home were renamed as the person-centered healthcare home The national dialogue regarding the patient-centered medical home should be expanded to encompass the broader concept of a person-centered healthcare home, incorporating the lessons of the IMPACT model and explicitly building in collaborative stepped care approaches, particularly for behavioral health MCPP HEALTHCARE CONSULTING

25 Cherokee Health Systems Mission To improve the quality of life for our patients through the integration of primary care, behavioral health and substance abuse treatment and prevention programs. Together Enhancing Life The Behavioral Health Consultant (BHC) in Primary Care: Management of psychosocial aspects of chronic and acute diseases Application of behavioral principles to address lifestyle and health risk issues Emphasis on prevention and self-help approaches, partnering with patients in a treatment approach that builds resiliency and encourages personal responsibility for health Consultation and co-management in the treatment of mental disorders and psychosocial issues Freeman, D. Presented to National Council for Community Behavioral Healthcare conference, May 2008 MCPP HEALTHCARE CONSULTING

26 Cherokee Health Systems Cherokee Health Systems Clinical Model Behaviorist on the Primary Team The BHC is an embedded, full-time member of the primary care team The BHC is a licensed Health Service Provider in Psychology A Psychiatrist is available, generally by telephone, for medication consults Service Description The BHC provides brief, targeted, real-time interventions to address the psychosocial aspects of primary care Typical Service Scenario The Primary Care Provider (PCP) determines that psychosocial factors underlie the patient s presenting complaints or are adversely impacting the response to treatment During the visit the PCP hands off the patient to the BHC for assessment or intervention MCPP HEALTHCARE CONSULTING

27 Cherokee Health Systems Impact of BHC on Subsequent CHS Service Utilization 28% decrease in medical utilization for Medicaid patients 20% decrease in medical utilization for commercially-insured patients 27% decrease in psychiatry visits 34% decrease in psychotherapy sessions 48% decrease in crisis visits MCPP HEALTHCARE CONSULTING

28 National Council Collaborative MCPP HEALTHCARE CONSULTING Care Project Intended as a systems improvement activity that will be ongoing after the project is completed--piloting the use of the collaborative learning model pioneered by IHI and HRSA Started with 4 sites (1/07) each site is a partnership between a CMHC and CHC expanded additional 8 sites (9/07) and 4 sites (8/08) Massachusetts Iowa Montana Washington Florida Indiana Illinois Texas South Dakota Colorado (2) Washington Maryland Indiana Colorado Florida

29 Addressing Substance Use in Primary Care Center for Substance Abuse Treatment has sponsored Screening and Brief Intervention (SBI) programs in 17 states Based on more than 30 controlled clinical trials that demonstrated the clinical efficacy and effectiveness of SBI Screening and brief interventions for more than 424,000 people across inpatient, emergency department, primary and specialty care settings, including CHCs MCPP HEALTHCARE CONSULTING

30 BH Staff Skills Needed in Q I and Q III Primary Care Placing a BH clinician in a primary care setting without a clear clinical model of care that is distinct from specialty BH practice has been identified in many sites as ineffective and inefficient, seen as a failure Establishing a clear clinical model and hiring a BH clinician with the right skills is critical for success Finding BH clinicians with the right skills is an increasing dilemma, almost at the level of the financing dilemma Within the overall BH workforce crisis, this is a specific issue, with only one multidisciplinary post graduate program in the country offering structured training (UMass) MCPP HEALTHCARE CONSULTING

31 Behavioral Health Referrals Primary Care Collaborative Health Services Behavioral Health MCPP HEALTHCARE CONSULTING Physical Health Status

32 Addressing Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying 25 years earlier than the general population (NASMHPD) While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases MCPP HEALTHCARE CONSULTING

33 Maine Study: Comparison of Health Disorders Between SMI & Non-SMI Groups Percent Members SMI (N=9224) Non-SMI (N=7352) Liver Disease Pneumonia/Influenza Heart Disease Cancer Diabetes Dental Disorders Hypertension Infectious Disease COPD Obesity/Dyslipid Gastro-Intestinal Skeletal- Connective MCPP HEALTHCARE CONSULTING

34 Mental Disorders and Smoking 44% of all cigarettes consumed nationally by people with SMI Higher prevalence (56-88% for patients with schizophrenia) of cigarette smoking (overall U.S. prevalence 25%) More toxic exposure for patients who smoke (more cigarettes, larger portion consumed) Smoking is associated with increased insulin resistance Similar prevalence in bipolar disorder George TP et al. Nicotine and tobacco use in schizophrenia. In: Meyer JM, Nasrallah HA, eds. Medical Illness and Schizophrenia. American Psychiatric Publishing, Inc. 2003; Ziedonis D, Williams JM, Smelson D. Am J Med Sci. 2003(Oct);326(4): MCPP HEALTHCARE CONSULTING

35 CATIE Study Comparison of Metabolic Syndrome and Individual Criterion Prevalence in Fasting SMI Subjects and Matched General Population Subjects Metabolic Syndrome Prevalence SMI Males Gen.Pop. N=509 N=509 SMI Females Gen.Pop. N=180 N= % 19.7% 51.6% 25.1% Waist Circumference Criterion 35.5% 24.8% 76.3% 57.0% Triglyceride Criterion 50.7% 32.1% 42.3% 19.6% HDL Criterion 48.9% 31.9% 63.3% 36.3% BP Criterion 47.2% 31.1% 46.9% 26.8% Glucose Criterion 14.1% 14.2% 21.7% 11.2% CATIE source for SMI data NHANESIII source for general population data Meyer et al., Presented at APA annual meeting, May 21-26, McEvoy JP et al. Schizophr Res. 2005;(August 29). MCPP HEALTHCARE CONSULTING

36 CATIE Study At baseline: 88% of subjects who had dyslipidemia 62.4% of subjects who had hypertension 30.2% of subjects who had diabetes WERE NOT RECEIVING TREATMENT FOR THESE CONDITIONS MCPP HEALTHCARE CONSULTING

37 Prevalence of Diagnosed Diabetes in General Population Versus Schizophrenic Population Diagnosed Diabetes, General Population Diagnosed Diabetes, Schizophrenic Patients Percent of population Schizophrenic: General: y y Harris et al. Diabetes Care. 1998; 21:518. Mukherjee et al. Compr Psychiatry. 1996; 37(1): y y y 75+ y MCPP HEALTHCARE CONSULTING

38 ADA/APA Consensus Conference on Antipsychotic Drugs and Obesity and Diabetes: Baseline Screening Personal / family history of obesity, diabetes, dyslipidemia, hypertension, or cardiovascular disease Weight and height, to calculate BMI Waist circumference at umbilicus Blood pressure Fasting plasma glucose Fasting lipid profile Diabetes Care. 2004;27: MCPP HEALTHCARE CONSULTING

39 Uptake on ADA/APA Screening Recommendations Claims data from the FY CA Medi-Cal system 6,500 individuals with a newly prescribed second generation antipsychotic medication Only 28% had glucose testing and 43% had lipid testing in the six months following the start of the antipsychotic medications. Contrast to the ADA/APA 2004 guidelines, which recommend glucose testing at baseline, at 12 weeks, and then annually and lipid testing at baseline, 12 weeks, and then every 5 years if normal Seattle WA, 2007 screen Medicaid persons with schizophrenia on atypical antipsychotics for metabolic syndrome Able to screen only half of the eligible people Number one barrier access to blood testing MCPP HEALTHCARE CONSULTING

40 The Person-Centered Healthcare Home for People with SMI Note the proposed renaming of the concept, for all populations For BH providers envisioning a future role as person-centered healthcare homes, there are two pathways to follow Providers who want to become full scope person-centered healthcare homes for people with SMI should look to the Cherokee model and seek to become full scope providers of primary care services, for a broad community population as well as for those receiving BH services Providers who want to partner with full scope primary care organizations to create person-centered healthcare homes for individuals with SMI should organize a parallel to the IMPACT primary care model, with collaborative care, care management, a designated PCP consultant, outcome measurement, and stepped care for primary care needs in BH settings MCPP HEALTHCARE CONSULTING

41 The Person-Centered Healthcare Home for People with SMI: Partnership Assure regular screening and registry tracking/outcome measurement at the time of psychiatric visits for all BH consumers receiving psychotropic medications Locate medical nurse practitioners/pcps in BH clinics provide routine primary care services in the BH setting via staff out-stationed under the auspices of a full scope person-centered healthcare home BH organization hiring a nurse practitioner directly, without the backup of a skilled PCP and a full scope healthcare home cannot be described as providing a healthcare home, and is not a recommended pathway Identify a primary care supervising physician within the full scope healthcare home to provide consultation on complex health issues Use evidence based practices developed to improve the health status of all individuals with chronic health conditions, adapting these practices for use in the BH system. Assign nurse care managers to support individuals with elevated levels of glucose, lipids, blood pressure, and/or weight/bmi Create wellness programs MCPP HEALTHCARE CONSULTING

42 Public Health Opportunities The population with SMI is a health disparities population, but has not yet been formally identified as such or made the focus of population based initiatives Include this population in smoking, diabetes, obesity and other chronic disease initiatives Develop surveillance initiatives for both morbidity and mortality in this population MCPP HEALTHCARE CONSULTING

43 Implementation of Integration OPPORTUNITY The promise of the patientcentered medical home can only be fully realized if it becomes the person-centered healthcare home, with behavioral health capacity fully embedded in primary care teams and primary care capacity embedded in behavioral health teams BARRIERS Financing methods Policy and regulation Workforce Clinical information sharing Physical facilities MCPP HEALTHCARE CONSULTING

44 National Council Collaboration Resources Thanks to researchers and to presenters at the National Council Conferences for their materials, which have been integrated into the preceding discussion Visit Background Paper / EBP Paper Finance, Policy and Integration of Services State Assessment Tool List Serve Learning Community See also for Morbidity And Mortality In People With Serious Mental Illness MCPP HEALTHCARE CONSULTING

45 Contact Information Barbara J. Mauer, MSW CMC Phone MCPP HEALTHCARE CONSULTING

46 Tennessee s Perspective on Integration Virginia Trotter Betts, MSN, JD, RN, FAAN Commissioner/TDMHDD ASTHO No Wrong Door Assuring Services Seamless Care September 3, 2008

47 U.S. Health Delivery System The dominant models of providing health care in the United States separate the mind and body. Separation has a negative impact on health care access, health care costs, and quality of care with a disproportionate share of the burden falling on women, the elderly, racial and ethnic minorities, and rural and immigrant populations (Health Care for the Whole Person Statement of Vision and Principles, American Psychological Association).

48 The purpose of the health care system is to reduce continually the burden of illness, injury, and disability, and to improve the health status and function of the people of the United States. A User s Manual For The IOM s Quality Chasm Report (2002)

49 Why Integrate Treatment? 25% of primary care provider patients have a mental disorder* It is estimated that in 60-70% of medical visits there is no medical or biological diagnosis* While effective treatments exist for most common mental disorders, studies have shown many consumers seen in primary care settings do not receive them** *Bazelon Center for Mental Health Law **President s New Freedom Commission on Mental Health

50 Morbidity and Mortality Recent studies found that people with serious mental illness die, on average, at least 25 years earlier than the general population.

51 Morbidity and Mortality The Bazelon study particularly demonstrates that people with serious mental illnesses have poor physical health, including: High rates of diabetes [prevalence rates of 15% for those with major mood disorders; 16-25% for those with schizophrenia; 25% for bipolar disorder; and 50% for schizoaffective disorder] Significant hypertension [34% among those with serious mental illnesses] Cardiac disease [16%] High rates of obesity Elevated risks of breast cancer [9.5 times higher in women with SMI], HIV infection [eight time U.S. prevalence], and hepatitis B and C [five and eleven times the U.S. prevalence, respectively]

52 Recommendation Better coordination is needed between mental health care and primary health care. President s New Freedom Commission on Mental Health (2003)

53 Stigma Barriers to Integration Multiple delivery system funding streams Delivery system design & licensure barriers Workforce training Capacity and distribution of services

54 Accomplishing Integration Expand screening & implement collaborative care models in primary care settings Reimburse for core collaborative care components by public & private insurers Include care management, disease management, and mental health specialist consultation to primary care Include physical health screenings and assessment in mental health settings with pre-arranged referrals/backup for health services Co-locate in either setting; contracted collaborative care

55 Tennessee Integration TennCare TennCare serves as TN s Medicaid Plan In 1996: TennCare Partners, was created for the delivery of all behavioral health services carved out from the existing TennCare program BHOs would provide MH/SA services to all TennCare enrollees, SPMI adults, and children with SED Carve out to protect behavioral health services and assure services for SPMI/SED Successes: an increase of access to care, enhanced partnerships across agencies, and expanded specialty services

56 Tennessee Integration TennCare Transformation Tennessee is geographically divided into three regions: East, Middle, West April 2007: Managed Care Carve-In begins in Middle Tennessee January 2009: Managed Care Carve-Ins implemented in East and West Tennessee Successes: Increased reimbursable mental health screenings in primary care, behavioral health elements in disease management protocol for Chronic Medical Illnesses Concerns: Impact on persons with SPMIs and SEDs, Viability of public mental health/substance abuse specialty procedures, Use of managed care principles on substance abuse services is of concern to A&D providers Lessons learned from Middle TN Integration: Less integration at the provider/service level than initially anticipated

57 Tennessee Integration - Rural Cherokee Health Systems CMHC FQHC Serving health care needs including medical, dental, and behavioral healthcare since 1960 with 23 sites in 13 Tennessee counties Behavioral health consultants work within a primary care setting and are involved in on site and timely assessment, brief intervention and consultation with patients The Primary Care Provider (PCP) determines that psychosocial factors underlie the patient s presenting complaints or are adversely impacting the response to treatment. During the visit the PCP hands off the patient to the BHC for assessment or intervention Services include education, behavioral management and treatment for mental health disorders The Behavioral Health Consultant (BHC) is an embedded, full-time member of the primary care team. The BHC is a licensed Health Service Provide in Psychology. A Psychiatrist is available, generally by telephone, for medication consults

58 Tennessee Integration - Rural Frontier Health Systems (CMHC) A 12-year collaboration with East Tennessee State University Family Practice Physicians Primary care physicians, psychiatrist, mental health therapists, and medical residents participate in case review process Sharing of behavioral and medical health information Referrals to therapist - Therapist influence increases acceptance/access to Mental Health treatment, continuation in treatment and compliance with medications Physician focuses on more time with patient s medical issues

59 Tennessee Integration Urban Emotional Fitness Centers Partnership with Magellan and TDMHDD A faith-based mental health pilot program addressing utilization disparity and under-utilization of mental health services A model of care that attempts to lessen the stigma often associated with accessing mental health services in minority communities If a physical is desired or needed the client is referred to a Program Nurse Practitioner A Licensed Professional Counselor determines needed services and appropriately makes referral A Peer Advocate Liaison (PAL) will help client navigate the systems of care based on referral by Licensed Professional Counselor Services offered on-site in several local churches, a historically safe and trusted environment for many African Americans

60 Goals of an Effective Public Mental Health System Promotion of Mental Health and a life without addiction Prevention of Mental Illnesses and substance abuse disorders Early, Frequent, & Effective Treatment

61 Mental Health & Primary Care Integration Increases access and improves health outcomes by facilitating a setting/structure of destigmatized interventions.

62 Some Closing Thoughts Primary care provides the best platform to increase access to behavioral health interventions. Integrated care is the best anti-stigma strategy. Integrated care is mental health system transformation. A carve-in at the health plan level doesn t assure integrated care at the clinical level. Co-location is necessary but not sufficient for integrated care. When behavioral health is blended into primary care appropriately, patient outcomes improve, providers are happier, and the payer saves $$.

63 Integrating Behavioral Health Services The Integration Journey Of Flint Hills Community Health Center Lyon County Health Department

64 Flint Hills Community Health Center Lyon County Health Department 420 W. 15 th Avenue Emporia, KS

65 Who We Are Federally- funded Community Health Center (since 1997) and Local Public Health Agency CHC: Not-for-profit Corporation contracting with Lyon County to provide public health services

66 Flint Hills Community Health Center Lyon County Health Department

67 Where We Are Located on I-35 between Kansas City and Wichita, Kansas Population of city: 26,760 Population of Lyon County: 35,560 Also serving Chase, Greenwood and Osage Counties: Total population: 63,267

68 Who We Serve 8,836 patients served in ,829 medical users 1,780 dental users 711 patients with mental health primary diagnosis 580 patients in Depression Collaborative (part of Health Disparities Collaborative)

69 Demographics Female patients 59% Male patients 41% Age categories: 18 and under 41% 19 through 64 56% 65 and over 3%

70 More demographics Ethnicity Caucasian 44% African-American 17% Asian Pacific Islanders 1% Latino 38%

71 And even more demographics Poverty Levels / Insurance Status <100% Federal Poverty Level (FPL): 37% % FPL: 26% Uninsured: 48% Medicaid/SCHIP: 22% Medicare: 3% Private Insurance: 27%

72 How We Started In 2000, joined Depression Collaborative, part of what is currently known as Health Disparities Collaborative through Bureau of Primary Health Care (BPHC). Participated in Rand Study. Early 2001 application filed with BPHC for service expansion grant for mental health services Application strengthened because of work with Depression Collaborative Notice of Grant Award received

73 Integrated Service Delivery an evolving model Initial plans to provide specialty mental health services housed in same facility with contracted staff First permutation: mental health professional as an employee of FHCHC. Still viewing as specialty mental health Reasons to change the model: Federal Tort Claims Act protection and ability to bill for services with Medicaid/Medicare

74 The Integrated Service Epiphany Attended Behavioral Health Summit in November, 2001 and introduced to a true integrated model Developed understanding of the strength of integrated behavioral health in primary care; on-site referrals from primary care providers; coaching and mentoring of primary care providers in identifying psychosocial and mental health issues

75 Getting Started Developed Behavioral Health Consultant job description Developed contract for clinical consultation with local community mental health center Hired Licensed Specialist Clinical Social Worker (Medicare/Medicaid requirement for LSCSW or PhD psychologist for billing purposes due to Federally Qualified Health Center status)

76 Still more to do Requested Technical Assistance through Bureau of Primary Health Care Developed Behavioral Health Services manual Trained primary care staff and clinical consultant on the model Developed referral protocol and procedures

77 Our Integrated Service Model All patients receiving behavioral health services must be primary care patients All patients are initially seen by primary care provider All new patients are screened for depression using a standardized screening tool, Patient Health Questionnaire (PHQ) Patients scoring >10 on the PHQ are referred to Behavioral Health Consultant

78 Our Integrated Service Model All patients with diagnosis of depression are entered in the HDC registry and tracked on core measures 1. CSD patients with 50% reduction in PH-Q 2. Patients with dx of depression and documented PH-Q in last 6 months 3. Self-management goal set in last 12 mos. 4. CSD patients with documented PH-Q reassessment between 4-8 wks of last New PH-Q 5. CSD patients who, 4 mos. or longer after New PH-Q have 50% reduction in PMD score.

79 Our Integrated Service Model Behavioral Health Consultation services provide brief solution-focused therapy, assess behavioral health risk management and treatment; develop specific behavioral plans of care and self-management goals that are patient directed Patients requiring long-term psychotherapy, patients with severe and persistent mental illness, and patients requiring psychotropic medications, are referred to specialty mental health services

80 Our Integrated Service Model Behavioral Health Consultant continues to see patient in conjunction with primary care visits involving medication follow-up or other reasons Behavioral Health Consultant occasionally but not routinely has independent visits with patient Goal is to provide all services on the same day. Billing issue with Medicaid/Medicare.

81 Additional Services Chronic Care Case Management services provided as needed Prescription Medication needs are met to extent possible through Pharmaceutical Manufacturers programs 340B contract pharmacy arrangement implemented August, 2005, further increasing availability of required medications and assisting with compliance issues

82 Lessons Learned Patient receptivity to behavioral health services increased because: 1. Behavioral/mental health issues addressed day of PCC visit 2. Clear coordination between primary care provider and behavioral health consultant 3. Decreased stigmatization often associated with receiving services at mental health center

83 Lessons Learned Primary Care providers appreciate the immediate availability of Behavioral Health Consultant for crisis intervention, psycho-social issues, community resources Development and reinforcement of selfmanagement goals through this model strengthens patient outcomes/adherence Primary Care providers do gain confidence in dealing with the psycho-social issues of patients Decreased medical utilization due to frequent utilization; cost savings

84 Challenges Consistent use of screening tools some patient resistance Language barriers Billing and reimbursement Back-up for Behavioral Health Consultant

85 Contact Information Lougene Marsh, MPA Executive Director , x261 Lanis Dieker, LSCSW Behavioral Health Consultant , x 293 ldieker@flinthillshealth.org