Relationships: The Behavioral Health Consultant, Primary Care Physician, and Psychiatrist i t Healthcare Integration Webinar National Council for Community Behavioral Healthcare February 25, 2010

The Status Quo > Our minds and our bodies are always together in our lives, except when we enter the health care system. There they are often separated, and totally distinct specialties take over. > Cynthia M. Watson, M.D. > thepfizerjournal.com 2

An Alternative: Integrated Care > Reunification in practice of mind and body > Health care model in which h physical health h and mental health clinicians partner to manage health conditions > Shift away from disease-focused system to a person-centered system > Single treatment plan focused on what patients/consumers need

Medical Homes > Medical care and behavioral health care is provided in one location that is welcoming and easy to navigate. > Mental health and primary care clinicians work together as a single team for the benefit of the consumer. > The focus is on collaboration,, wellness and recovery

Medical Home Models > Embed mental health staff in primary care clinics > Import primary care providers into mental health clinics

Prevalence of Psychiatric Disorders in Low-income Primary Care Patients 35% of low-income patients with a psychiatric diagnosis saw their PCP in the past 3 months 90% of patients preferred integrated care Based on findings, authors argue for system change Disorder Low-Income Patients General PC Population* At Least One Psychiatric Dx 51% 28% Mood Disorder 33% 16% Anxiety Disorder 36% 11% Alcohol Abuse 17% 7% Eating Disorder 10% 7% Source: Mauksch LB, et. Al. Mental Illness, Functional Impairment, and Patient Preferences for Collaborative Care in an Uninsured, Primary Care Population. The Journal of Family Practice, 50(1):41-47, 2001.

Why Integrate Care? > Mental health consumers are much less likely to receive care for chronic physical health conditions than the general population > Serious mental illness is associated with increased morbidity and mortality due to general medical conditions

Why Should We Be Concerned About Morbidity and Mortality? > Individuals with serious mental illness served by our public mental health systems die, on average, 25 years earlier than the general population.

The Washtenaw Experience > Core elements of successful integration > Establishing the environment if it doesn t already exist

WCHO Mission Statement > To provide leadership for the development and implementation of unique, effective models of integrated (mental health, substance abuse, physical health) healthcare that create medical homes for Medicaid and indigent consumers.

Four Quadrant Integration Model High Quadrant II BH high, PH low Quadrant IV BH high, PH high Behavioral Health Risk/ Status Low CMH or PCP Medical Home Quadrant I BH low, PH low PCP Medical Home CMH and PCP Comanaged Care Quadrant III BH low, PH high PCP Medical Home Physical Health Risk/ Status High

Core Environmental Factors For Successful Integration > Recognize that the population exists in the practice > Consciously decide how the practice will address behavioral healthcare integration > Establish a learning environment > Have leadership, both administrative and clinical > Understand the capacity of the practice to provide integrated care > Individual characteristics of the primary care providers and mental health professionals > The role of the psychiatrist and behavioral health professional

Recognize That the Population Exists In the Practice > Know, acknowledge and accept that the target population exists in the practice Already committed to your patients > If the perception is that it doesn t exist: Provide evidence that it does Implement simple screening tools to demonstrate presence of bh behavioral lh health needs

Packard Health > A private, non-profit Family Practice > Staff includes 7 PCPs (6 MD, 1 NP), health educator, and administrative and office staff > The population 7,000 patients / 19,000 annual visits Provide care regardless of insurance status 50% uninsured or underinsured; 50% conventionally insured or pay market rates

The Packard Collaboration > The needs at Packard Many patients with significant mental health conditions most not meeting CMH criteria Primary care providers prescribing for complex patients who have no primary mental health provider > Desired outcomes To create access to mental health services To reduce fragmentation of services for vulnerable patients To utilize existing resources more effectively to achieve improvements in health status CSTS graduates

Consciously Decide How the Practice Will Address Healthcare Integration > Refer to outside providers > Provide onsite comprehensive care Continuum of fi integration i

Implications of the Referral Model > PRISM-E Study 11 sites, 50 primary care clinics, referral to MH specialty clinics 24,863 patients, t 65 or older, screened, evaluated and randomized d to integrated care or referral care 20% scored positive for psychological distress, 8% for at risk diki drinking, 5%hd had suicidal iidlth thoughts ht The best referral process ever Engagement rate for depression integrated integrated model 76%, referral model 55% Engagement rate for alcohol integrated model 72%, referral model 29%

The Synergy PACKARD CSTSA > Patients with complex > Establishment of primary needs mental health provider > Trust relationship with > Coordination of treatment primary health provider (i.e. Medications) > More appropriate use of provider time Use of multidisciplinary resources to improve health outcomes Blending organizational resources to improve access

Staffing the Packard Partnership > A full time behavioral health specialist (MSW) on site and a ½ day per week of psychiatrist > Joint supervision & oversight of the program by Packard, CSTS and WCHO

Establishing a Learning Environment > Support innovation and creativity > Support education and team learning and training > Model personal mastery > Talk about vision > Support systems thinking > If it doesn t exist - Identify leadership and begin to create it through an organizational development plan

Strangers in the Night > Most primary care providers receive little behavioral health training > Psychiatrists receive limited training in outpatient management of chronic medical conditions > Primary care providers and psychiatrists generally receive no significant training in collaborative, integrated practice arrangements

The Great Cultural Divide > Primary Care Docs 10-1515 minute blocks Deal directly with other physicians Find it difficult to deal with interdisciplinary team Medical records short, concise summaries of the diagnosis, s, treatment e and outcome Language = patients Psychiatrists 30-60 minute sessions Time with consumers considered sacrosanct Team decision model Behavioral health records are long and complex Contain goals and objectives Variety of provided services; may be re- evaluated over time Contain consumer input Language = clients or consumers

Learning Environment Critical to Overcoming Barriers > Collaboration across two different cultures Inertia, resistance sta > Provider factors Comfort level, mind/body dichotomy, stigma > Space Integrated care not incorporated into facilities planning > Systems issues Funding streams, payment systems, billing Informatics Documentation, integrated medical record

Leadership > Administrative i i Leadership Identify a champion who won t give up Barrier buster activities > Clinical Leadership Identify a provider with the commitment to lead other providers > If it doesn t exist Identify an opinion leader or two within the office and convince them of the viability Get them trained on a model and have them start using it Organizational leadership development program

Capacity of the Practice > Infrastructure t Technology Space or capacity to share Reception staff > Dedication to integrated healthcare > Collegiality > If it doesn t exist Identify barriers and determine how to and when to create breakthroughs Add to organizational development plan

Individual Characteristics of Integrated Care Staff > General Characteristics Collegial l Flexible (comfort zone, roles, space) Autonomous Multitasking ability and tolerance Practicality (Common sense biopsy) Assertive Clear understanding of what CAN be done

Medical Provider Characteristics > Primary Care Providers Differences in training i (Internal Medicine i vs. Family Practice vs. others) > Psychiatrists Community psychiatry focus Generalist

Roles of the Behavioral Heath Specialist > Direct service provider > Consultant to both psychiatrist i and primary care providers > Speak truth th to power Allow and accept recommendations from non-medical professionals > Community liaison

Behavioral Health Specialist Roles > Brief solution focused therapy and case management > Triage officer, crisis management > Curbside consultation > Joint sessions with PCP staff > Bridge care between PCP and CMH > Provide ongoing follow up for psychiatrist as liaison between PCP and psychiatrist > Manage psychiatry time

Role of the Psychiatrist > Clinician, Educator and Liaison Curbsides Consultation Co-management Co-visits Clinical Teaching Case conferences e ces Community bridging

Psychiatric Outreach: Starting Where the Primary Care Provider Is > Bring the door to the PCPs Meet where he/she is, literally and figuratively PCPs in different stages of change at any given time > Service must meet perceived needs PCPs don t care how much you know until they know you will help Offer service, be concrete, actively listen Make yourself available and indispensable > Remember e Maslow Hierarchy of education/ability Motivational interviewing of PCP See one, do one, teach one

PCP Engagement As Empowerment > Have perception of poor access to psychiatry, poor communication from psychiatry > Opportunity to do with > Have appreciation of PCPs strengths > Build trust and relationships > Work from stance of consensus rather than isolation > Cultivate change together > Facilitate recovery from days of split treatment, practice silos and the mind/body dichotomy

In Summary

Packard Partnership Successes > Improved access to behavioral healthcare > Enhanced provider communication and coordination > Education of primary care providers > Evolution of a novel treatment model > High provider and patient satisfaction > Integrated electronic medical record > Recovery oriented CMH graduates

Core Factors For Successful Integration > Recognize that the population exists in the practice Already committed to your patients > Consciously decide how the practice will address behavioral healthcare integration Make a plan > Establish a learning environment Change is a process Develop a process that supports change > Have leadership, both administrative and clinical Transform the culture as well as the process

Core Factors For Successful Integration > Understand the capacity of the practice to provide integrated care Grow, but know your limits > Individual characteristics of the primary care providers and mental health professionals Get the right people on the bus > The role of the psychiatrist and behavioral health specialist Adapt to the patient t and provider needs Make yourself indispensable

Thank you