Beth Phoenix, RN, PhD Aaron Miller, RN, MS, PMHNP Sherri Borden, RN, MS, ANP Matt Tierney, RN, MS, NP UCSF School of Nursing None of the presenters has any conflicts of interest to disclose Beth Phoenix, RN, PhD Clinical Professor Miller, Phoenix, Borden, Tierney 1
HUMAN BEINGS ARE UNITARY BUT OUR HEALTH CARE SYSTEM IS FRAGMENTED Behavioral Health Care People with SMI die 25 yrs. earlier than others Excess morbidity/mortality largely due to treatable medical conditions caused by modifiable risk factors Inadequate access to medical care a significant risk factor (Parks, et al., Morbidity & mortality in people with serious mental illness, 2006) www.integration.samhsa.gov/about us/what is integrated care MH problems are common & disabling 70% of those seeking care for MH conditions tx d in PC Quality of care for MH conditions provided by PCPs not optimal Insufficient training Competing demands Miller, Phoenix, Borden, Tierney 2
CENTER FOR INTEGRATED HEALTH SOLUTIONS Workforce needs Financing Clinical practice Models of integrated care AFFORDABLE CARE ACT Services for MH & addictive disorders must be covered in health plans Providers will need to integrate behavioral health services and primary care Broad based biopsychosocial approach Multilingual/multicultural re: medical & MH care systems Focus on human responses to health problems Pragmatic problem solving approach Miller, Phoenix, Borden, Tierney 3
MODELS OF COLLABORATION Consultation Collaborative Integrated Majority of mental health care provided by PCP PMHNP functions as expert resource Provides Education Evaluation of care Expertise for complex cases PMHNP is provider of MH care Pt. referrals by PCPs May be embedded in PC setting or part of referral network Coordination of care supported by mutual referral & communication Miller, Phoenix, Borden, Tierney 4
Dual education as PCP & PMHNP Provide both PC & MH services May include significant care management Effective for populations with complex medical & psychiatric comorbidity Aaron Miller, RN, MS, PMHNP BC Assistant Clinical Professor www.marinclinics.org Marin Community Clinic: Marin County, CA Federally Qualified Health Center Primary Care Centered Multiple Specialties Miller, Phoenix, Borden, Tierney 5
www.marinclinics.org Constant financial pressures Multiple competing projects/goals Multiple specialties Multiple locations Changing management Mild Silo ization Miller, Phoenix, Borden, Tierney 6
2 part time psychiatrists 1 Full Time/ Part Time PMHNP 2 full time LCSW s and 1 part time LCSW 1 Behavioral Health Director Referral based collaborative role Psychiatric medication mgmt Adults & children Case management Brief supportive, cognitive & PS therapy Monitoring of chronic health conditions Emergent Psychiatric Triage Behavioral Health Primary Care Women s Health Outside Specialist Miller, Phoenix, Borden, Tierney 7
Patient enters care with PCP PHQ 9 of 10+ Rx &/or automatic referral Behavioral Health Evaluation/Treatment Brief PST Medication Mgmt if necessary Patient stabilizes and returns to PCP PCP mgmt of psych meds Referral back to BH if necessary Primary Care Behavioral Health Primary Care 3 month waitlist for new patients Miller, Phoenix, Borden, Tierney 8
Shirley 56 y.o. Caucasian female who recently fired her PCP at another clinic location. H/O of polysubstance abuse On chronic opiates & benzodiazepines Personality Disorder with severe mood dysregulation Memory problems & LOC fluctuations Frequent ED visits Provider splitting behavior Marta 39 y.o. monolingual Salvadorean female Somatization Disorder, PTSD and Major Depression Immigration Issues Uninsured High utilizer of primary care & specialist services Relationship with Primary Care Program and integration planning Regular Care Coordination Relationship with Outside Resources Value of integration must be demonstrated to management Miller, Phoenix, Borden, Tierney 9
http://leadingforachange.wor dpress.com/2010/02/02/whatto do about those damnorganization silos part 1/ Sherri Borden APRN, ANP, PMHNP, CNS Associate Clinical Professor Miller, Phoenix, Borden, Tierney 10
Psychiatric Emergency/ Hospital/Dore Urgent Care Acute Diversion or Residential Care Connect to ongoing services: Public health plan, primary &mental health care Progress Foundation Programs: 3acute care, 3 transitional, &1 long term Providing primary & acute care to mentally ill, homeless & substance users Psychiatric assessment & medication management Connecting with community resources Working with a multidisciplinary staff Miller, Phoenix, Borden, Tierney 11
Progress Foundation: Mental Health Program Started in 1969 For clients who burned all of their bridges Programs located in residential neighborhood Started in 1994 as a collaboration with UCSF School of Nursing, Progress Foundation and San Francisco General Hospital to improve discharge time Journey started with 1 program Now 9 programs in San Francisco and 1 in Napa with 6 nurse practitioners Bob is 36 year old male with a history of incarceration x 10 years. He has been homeless for the past 5 years after release and heavily using crack cocaine and methamphetamines. He presents to Dore Urgent Care Clinic (DUCC) in withdrawal from substances, depressed and wanting a new start. CMP: IDDM (unstable), Chronic pain No regular primary care No support systems History of violence Miller, Phoenix, Borden, Tierney 12
Pain management & substance use Multiple comorbid conditions Lack of social support Lack of impulse control Lack of medical & psychiatric services Affect regulation Staff Education Linking to Public Health Plan or Medi cal Brokering patient to new primary care provider Pain Management linkage Teaching skills for how to get needs met Coaching to negotiate the system Building trust & mutual respect: Listening Bob transitioned to a 90 day program Relapse Broke Pain contract with providers Altercation with another resident & discharged Re presented to Dore Urgent Care 6 months later Miller, Phoenix, Borden, Tierney 13
Willingness to work with people repeatedly The need to be heard Patience Your expectations and aspirations may not be the patient s Matt Tierney, PMHNP, ANP, CNS Assistant Clinical Professor Need for opiate replacement OBIC: a place to start and stabilize Refer ongoing treatment to primary care or mental health care Miller, Phoenix, Borden, Tierney 14
Need for greater treatment availability History: only licensed NTPs DATA 2000 expanded treatment options. Buprenorphine FDA approved Treats withdrawal and cravings Stops disease progression 8 Hr training and special license First US clinic dedicated to buprenorphine induction alone MD trainees: if induction and stabilization were done for us Funded by San Francisco Department of Public Health staffed by UCSF Focus on Integration Primary Care Mental Health Care OBIC Psychosocial Services? Specialty Care Any door is the right door Miller, Phoenix, Borden, Tierney 15
NP FUNCTION Direct patient care: Medication initiation & stabilization Counseling & education VALUE Treatment familiar to patients and providers Community providers receptive to integrating care for stabilized patients NP FUNCTION Diagnose opiate dependence and appropriateness for treatment Create a treatment plan VALUE Provide every part of buprenorphine treatment except the prescription Set the stage for collaborative care model NP FUNCTION NPs provide health & mental health assessments & referrals VALUE A point of entry to mental health care & primary care Any door is the right door Miller, Phoenix, Borden, Tierney 16
NP FUNCTION Re stabilization services for patients who relapse or conditions change VALUE Safety net for increased patient care & provider support Meets patients where they are NP FUNCTION Assessments & referrals to other behavioral health VALUE Assist patients to: Psychiatrists & psychotherapy Other substance use counseling, medical detox, residential treatment NP FUNCTION Clinical documentation: Electronic Medical Record VALUE Improved communication between multidisciplinary providers Enhanced continuity of patient centered care Miller, Phoenix, Borden, Tierney 17
NP FUNCTION Training site & consultation service for community mental health & primary care providers VALUE Increased provider skillfulness & confidence providing integrated officebased buprenorphine care New psychiatric stabilization Clinic Initiate & Stabilize treatment Refer ongoing care to mental health or primary care clinics Mental Health need Assess, start treatment, stabilize Refer stable patient to community based care Miller, Phoenix, Borden, Tierney 18
1. C.S. Mott Children s Hospital National Poll on Children s Health. (2008). Ann Arbor, MI: Univ. of MI Division of General Pediatrics. Retrieved from http://mottnpch.org/reports surveys/mental health serviceschildren and adolescents missed opportunities primary care. 2. 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. 3. Parks, J., Svendsen, D., Singer, P. & Foti, M.E. (2006). Morbidity and mortality in people with severe mental illness. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council. 4. SAMHSA HRSA Center for Integrated Health Solutions. www.integration.samhsa.gov/ Miller, Phoenix, Borden, Tierney 19