College of Social Work Strategies for Addressing Workforce Issues through Partnerships and Policy: An FQHC-University Partnership Staci Swenson, MA, MSW, LISW S Integrated Care Manager PrimaryOne Health Columbus, Ohio Staci.Swenson@primaryonehealth.org Tamara S. Davis, Ph.D., MSSW Associate Dean for Academic Affairs Principal Investigator, PCBH Program College of Social Work The Ohio State University Columbus, Ohio davis.2304@osu.edu All Ohio Institute on Community Psychiatry March 24, 2017 Acknowledgements This workforce development initiative is a collaboration among: PrimaryOne Health OSU College of Social Work (and originating partner: Mental Health America of Franklin County) This program is partially funded by the MEDTAPP Healthcare Access (HCA) Initiative and utilizes federal financial participation funds through the Ohio Department of Medicaid. Views stated in this presentation are those of the researchers only and are not attributed to the study sponsors, the Ohio Department of Medicaid or to the Federal Medicaid Program. MEDTAPP HCA Initiative funding supports teaching and training to improve the delivery of Medicaid services and does not support the delivery of Medicaid eligible services. 1
Current Context BH Workforce Shortage Behavioral Health Workforce Development Ohio Medicaid Technical Assistance and Policy Programs (MEDTAPP) Healthcare Access Initiative OSU Center of Excellence for IPEP in Promoting the Health and Wellness of Underserved Populations Inter- Professional Education Social Work Behavioral Health in Primary Care Inter- Professional Practice 2
Approach to Integrated Care INTEGRATED PRIMARY CARE OR PRIMARY CARE BEHAVIORAL HEALTH Combines medical & BH services for problems patients bring to primary care, including stress-linked physical symptoms, health behaviors, MH or SA disorders. For any problem, they have come to the right place no wrong door BH professional used as a consultant to PC colleagues (emphasis added) Peek, C.J. (2013, p. 13). Integrated behavioral health and primary care: A common language. In M.R. Talen and A. Burke Valeras (eds.) Integrated Behavioral Health in Primary Care. New York: Springer. Gold Standard Integrated health care is the new gold standard for individuals with general medical and mental disorders, whether their medical home is a primary care clinic or a community mental health center. Smith, T.E., Erlich, M.D., & Sederer, L.I. (2013). Integrating general medical and behavioral health care: The New York State perspective. Psychiatric Services, 64, 828 831 3
Levels of Integrated Healthcare COORDINATED KEY ELEMENT: COMMUNICATION Minimal Collaboration CO-LOCATED KEY ELEMENT: PHYSICAL PROXIMITY INTEGRATED KEY ELEMENT: PRACTICE CHANGE LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 LEVEL 6 Basic Basic Collaboration Collaboration at a Distance Onsite In separate facilities Close Collaboration Onsite with Some System Integration Close Collaboration Approaching an Integrated Practice Behavioral health, primary care and other healthcare providers work: In separate facilities In same facility not necessarily same offices In same space within the same facility In same space within the same facility (some shared space) Full Collaboration in a Transformed/ Merged Integrated Practice In same space within the same facility, sharing all practice space Table adapted from: Heath B., Wise, Romero P., & Reynolds, K. (2013, March). A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. Integrated & Culturally Relevant Care (ICRC): An Education & Training Model for Social Work Students Documentation Diversity Integrated Care Evidence-based Behavioral Health Interventions Competency Scale Health Care Basics Care Coordination & Intervention Planning Technology Screening, Assessment and Diagnosis Davis, T.S., Guada, J., Reno, R., Peck, A., Evans, S., Moskow Sigal, L., & Swenson, S. (2015 on line). Integrated and culturally relevant care: A model to prepare social workers for primary care behavioral health practice, Social Work in Health Care, 54(10), 909-938. 4
PRIMARY CARE Medical residency Pediatrics Integrated Care Behavioral Health Dietetics Patient Navigation Center Pharmacy MEDTAPP Integrated and Culturally Relevant Care OSU College of Social Work Intensive Training Program Women s Health Integration In Contrast Traditional BH Services Accessed By Referral Integration Within PrimaryOne Health 1) Patient registers 1) Patient registers and receives brief BH screening 2) Provider sees patient for medical appointment; Identifies needs 3) Provider refers patient to Community Mental Health agency (CMH) for assessment of BH needs and treatment 4) Treatment a. 1 to 14 days: CMH calls patient to schedule intake appointment b. 21 to 90 days: Patient attends intake appointment for counseling and begins counseling c. Assessment and Treatment Planning 2) Provider sees patient for medical appointment; Review BH screening and appointment 3) Provider transfers ( warm hand off ) to PrimaryOne Health BH Clinician on site 4) Treatment a. Treatment begins immediately b. Patient seen for medical and BH needs at same location increases patient comfort level (reduces sigma) c. If patient needs medication for BH condition, provider can treat with support by psychiatric consultant 5) 90 to 180 days: If patient needs to see psychiatry specialist (especially for kids) 5) For complex cases, internal referral for psychiatry specialist happens quickly 5
Workforce Development Partnership Challenges Successes In the beginning to Who reviews screen? Separate BH Space? BH in Exam Rooms? 6
BRIEF SCREENINGS Who do we get the diagnostic assessment from? Brief only information needed now Frequently involves risk assessment Focus on patient s needs and preferences 7
Where are patients seen? INTEGRATING STUDENTS Students are in the way When are the students coming back? What thoughts come to mind? Social Worker Counselor 8
This is important and I don t want to rush you. Let me get a coworker of mine someone for you to talk to. Patient Scheduling Students independently scheduling Scheduling through the Health Center s call center Documenting in the Electronic Health Record Scanned PDF Notes Some Documentation in the EHR Separate BH Database Full Integration in the EHR 9
What services are we providing to our patients? Diagnostic, Prenatal, Suicide Risk Assessments Short term counseling and education Referrals for longer term counseling Psychiatric care Referrals to community resources and services What services are we providing to our patients? Help with health behavior change Relaxation skills/managing stress Smoking cessation Weight management Coping with chronic pain Increasing engagement with our providers H medical suggestions for health improvement 10
Ohio Medicaid Payment Rules Community Mental Health System Provides payment for case management/pcsp (unlicensed providers able to staff positions) Various levels of behavioral health providers eligible for billing for diagnostic assessments and counseling services including graduate level students/interns Ohio Governor s Office of Health Transformation increase access for MH services and care coordination for persons with disabling MH conditions. Federally Qualified Health Centers No case management payment (social determinants of care not able to be adequately addressed) Only independently licensed social workers (LISW, LCSW) able to be credentialed and bill for any behavioral health/substance abuse services (have to be able to be credentialed with Medicare) Can bill for SBIRT (Screening, Brief Intervention, and Referral to Treatment) Can bill for brief mental health screenings Challenges IC is a paradigm shift takes time and needs planning Provider willingness and readiness to engage BHC and students Key Responses Approach effort top down and bottom up; provider education and support across all levels Relationship development; BHC and students demonstrate worth; training BH tools and supports Interrupted clinical flow Scheduling for BH services Prioritize resources for BH care; support student training needs Collaboratively determine processes; consider BHC/preceptor time and productivity expectations Collaboratively determine processes; consider BHC/preceptor time and productivity expectations 11
Challenges Key Responses Choosing screening tools/processes Use best practices and adapt to setting Determining space for BH preceptors and students BH workforce unprepared for PC; conventional MH approach not appropriate Diagnosing differences between PCP and BHS (DSM vs. ICD) Billing for BH services (preceptors and students) Provide services in medical exam rooms when possible Careful selection of BH preceptors & students re tool practitioners; prepare future BH workforce Communication! Brief BH assessment & collaborative care; teach students both diagnostic schemes Contract with PrimaryOne Health Workforce Successes 50 students completed program 80% employed in high volume Medicaid sites Developed ICRC education & training model for PCBH Developed, implemented & testing integrated care student competency measure Students gaining clinical skills in working with diverse populations Seasoned supervising clinicians learned & training the model Students & supervisors practice in FQHC while forging team based integrated care 12
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