Understanding Primary and Behavioral Healthcare Integration

Understanding Primary and Behavioral Healthcare Integration

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Description: Understanding primary and behavioral health care integration, Audience Poll, Bidirectional Integrated Care 101, Integrated health care, Bidirectional integration, Seeking BH care in primary care, Why seek MH care in PC, Medical issues in BH settings, Integrating BH into PC, Strongest evidence base, Integrating PC into BH, The Medical Home.

Author: Laurie Alexander PhD, Karl Wilson PhD (Fellow) | Visits: 1769 | Page Views: 1799
Domain:  Medicine Category: Therapy Subcategory: Behavioral Medicine 
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Laurie Alexander, PhD Alexander BH l d Consulting

Karl Wilson, PhD Crider Health Center

Audience Poll:
How do you self-identify?
Consumer Family member Mental health or substance use provider Primary care provider Ad t Advocate Policymaker Funder

Laurie Alexander Ph D Alexander, Ph.D. Alexander Behavioral Healthcare Consulting laurie.alexander09@gmail.com laurie alexander09@gmail com

For today � The basics

Definition of bidirectional integrated care Rationale for integrated care Approaches to integrated care pp g State & national activities How you can get involved & learn more


Bidirectional I Bidi i l Integrated C d Care 101

What is bidirectional integrated care?

Integrated health care

"...in essence integrated health care is the ...in systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health p ob e s often occur the same time. problems o te occu at t e sa e t e Integrating services to treat both will yield e best esu s and e os the bes results a d be the most acceptable and effective approach for g gg those being served." Hogg Foundation for Mental Health,,
Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S., www.hogg.utexas.edu

Bidirectional integration

Integrating PC services into MH/SU settings AND Integrating MH/SU services into PC settings
**In both cases, the services are not just provided, but coordinated with other care delivered in that setting
*PC = primary care; *MH = mental health; *SU = substance use

A word of clarification

Focus is on the integration of services This may or may not involve the integration, or merging, of organizations (often not)

Will not cover organizational / structural integration or payment / financing today but useful today, information on those topics in resource list later in presentation


Bidirectional I Bidi i l Integrated C d Care 101

Why integrate p y y g physical and behavioral health care?

Seeking BH care in primary care

Most people seek help for BH problems in PC settings ~1/2 of all care for common psychiatric g disorders happens in PC settings Populations of color are even more likely to t seek or receive care in PC th i k i i than in specialty BH settings
*PC = primary care *BH = behavioral health (i.e., MH + SU)


Why seek MH care in PC settings?

Uninsured or underinsured Limited access to public MH services Cultural beliefs and attitudes Availability of MH services, especially in y , p y rural areas
*PC = primary care *MH = mental health

BH problems in primary care p p y

Mild to moderate BH issues are common in PC settings
Anxiety, depression, substance use in adults y, p , Anxiety, ADHD, behavioral problems in children Prevention and early intervention opportunity

People with common medical disorders have high rates of BH issues

E.g., Diabetes, heart disease, & asthma + depression Worse outcomes & higher costs if both problems aren't addressed

Usual care in PC settings g

MH problems often go undetected and untreated i PC d in When PCPs do detect MH problems, they tend to undertreat them Populations of color, children and color adolescents, older adults, uninsured, and low-income patients more often receive p inadequate care for MH problems SU care involves same issues if not worse issues,
*PCP = primary care provider; *SU = substance use; *MH = mental health

Medical issues in BH settings g

People with serious mental illness ( p (SMI) are ) dying 25 years earlier than the general population. 2/3 of premature deaths are due to preventable/treatable medical conditions such as cardiovascular, pulmonary, and infectious diseases. 44% of all cigarettes consumed nationally are smoked by people with SMI SMI.

See www.nasmhpd.org for Morbidity And Mortality In People With Serious Mental Illness report (2006)

Medical issues in BH settings g

Oregon state study found that those with coco occurring MH/SU disorders had worst early mortality gap

age of death for those with co-occurring MH/SU = 45 years (vs. 53 for those with SMI)

B. Mauer & C. Weisner (2010) California Institute for Mental Health webinar The Case for Integrated Care: www.cimh.org/LinkClick.aspx?fileticket=AK6sNXKyXo%3d&tabid=804

Usual care in PC settings g

BH consumers in PC settings:

less likely to receive effective medical care, including preventive services difficulties establishing relationships with PCPs


limitations and stigma

Usual care in MH settings g

2007 survey of National Council members (CMHCs) revealed limited capacity to screen and provide medical care:
2/3 1/2

can screen for common medical problems.

can provide treatment or referral for those conditions. can provide some medical services on-site.
* CMHCs = Community mental health centers Druss, et al (2008). Psychiatric Services, 59:917-920.


Key opportunity y pp y

Integrating care offers an important opportunity to reduce disparities:
Eliminate Reach

the early mortality gap

people who cannot or will not access specialty BH care early before issues develop or worsen



Bidirectional I Bidi i l Integrated C d Care 101

What is effective integrated g care?

Integrating BH into PC g g

Helpful, Helpful but not sufficient
Physician Screening Referrals Co-location


of services

*PC = primary care *BH = behavioral health (i.e., MH + SU)

Strongest evidence base g

Collaborative care

years of research >38 randomized controlled trials including trials, IMPACT

Adaptation of Wagner's chronic care model
www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Mod el&s=2

IMPACT Study: J Unutzer, JAMA. 2002;288:2836-2845; and AIMS Center http://impact-uw org/

Collaborative care's key ingredients

Care management � Patient education &
empowerment, ongoing monitoring, care/provider coordination

Evidence-based treatments � Effective medication
management, psychotherapy

Expert consultation for patients who are not improving Systematic diagnosis and outcome tracking y g g Stepped care Technology support � registries

J. Unutzer, 2010, www.cimh.org/LinkClick.aspx?fileticket=84F6JQndwg8%3d&tabid=804


Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Identification of behavioral problems (alcohol, other drug, tobacco, depression, anxiety) & level of risk Low risk: Raise awareness and motivate client to change Moderate risk: Provide brief treatment (cognitive behavioral, medications) with clients who acknowledge ) g risks and are seeking help High risk: Refer those with more serious or complicated g p MH/SU conditions to specialty care
Used in primary care centers, hospital ERs, trauma ce e s, a d p a y ca e ce e s, osp a s, au a centers, and other community settings
See http://sbirt.samhsa.gov/ for more information


Integrating PC into BH settings

Same principles appear to apply p p pp pp y Beginning steps

and tracking of basic health indicators for everyone on psychotropic meds
Glucose Glucose,

lipid levels blood pressure weight BMI etc levels, pressure, weight, BMI,


of & coordination with the PCP

Wellness programs, including peer-led Collaborative C ll b ti care
*PCP = primary care provider


Bidirectional I Bidi i l Integrated C d Care 101

Where does the Medical Home fit in?

The Medical Home

Patient-Centered Medical Home (PCMH)
Ongoing relationship with a PCP Team with collective responsibility for ongoing care "Whole person" orientation Whole person


need MH and SU capacity � i.e., MH and SU services need to be integrated into the medical home
home may be a PC or BH setting depending on a person's preference person s

Person-Centered H l h P C d Healthcare H Home

See www.thenationalcouncil.org for more info on the person-centered healthcare home and the role of MH/SU in medical homes. See www.pcpcc.net site for more about medical homes.


Bidirectional I Bidi i l Integrated C d Care

How do people receiving g integrated services feel about their care?


Consumers' take on integration

People receiving integrated services report higher quality of life and greater satisfaction with:
Access Attention Courtesy Coordination Overall

to their treatment preferences & continuity of care
Druss et al, Arch Gen Psychiatry. 2001; 58(9): 861-8. 861 8 Unutzer et al, JAMA. 2002; 288(22): 2836-2845. Ell et al, Diabetes Care. 2010; 33(4): 706-713.



Consumers' take on integration
"It is great having my two providers in the same building because they talk with each other at the time of the problem rather than me having to wait until I see my provider for psych meds and/or my therapist." � Jackie,
Pathways Community Behavioral Healthcare, Clinton, MO


Consumers' take on integration
"Around the time that my bipolar condition was identified, I was diagnosed with kidney disease. Between the two disorders, it was a pretty upsetting time in my life... My doctors, dialysis clinic staff, and mental health case manager are well connected. Th take a team approach, and ll t d They t k t h d they each check on the status of my health... Today I have control over my health; it doesn t doesn't have control of me. The coordinated care allows me to feel like I can go out and be a part of the community." � Cassandra McCallister, Board Member,
Washtenaw Community Health Organization, Ypsilanti, MI


Consumers' take on integration
...I'm not saying everything is p y g y g perfect because it isn't. I'm still working hard with the CBT to change my negative way of thinking. Living with my blindness isn't easy. As Rachel (care manager) says, "It's not for sissies." But I can't imagine where I'd be now if it weren't for the great team that pulled together to make sure I didn't fall through the cracks. th h th k
� Joann Gilbert, Project Vida Health Center, El Paso, TX P
Videotaped at Hogg Foundation's 2008 conference Integrated Health: C ti B d & Mi d R b t L S th l d S i XV Vid


Bidirectional I Bidi i l Integrated C d Care

What is going on around the nation?

Local / regional activities g

Thousands of BH & PC providers partnering

Mid-State Health Center (NH) Meridian Behavioral Healthcare (FL) Volunteer Behavioral Health Care Services (TN) ( ) Verde Valley Guidance Clinic (AZ) People's Community Clinic (TX) Navos (WA) Sierra Medical Center (CA)

Integrated systems

Crider Health Center (MO) Cherokee Health Systems (TN) Washtenaw Community Health Organization (MI) Intermountain Healthcare (UT & ID)

State-level work

State efforts via Transformation and block grant funds in AL, MI, PR, WV, MO, OK, OH, NM, & WA National C N ti l Council-led statewide l il l d t t id learning i communities in TX, ME, & IL

Funded by Hogg Foundation, Maine Health Access Foundation Foundation, & Community Behavioral Healthcare Association of Illinois

Minnesota DIAMOND California's CalMEND initiative

National / federal efforts

Health reform � PCMH payment reform via Medicaid; PC
in BH demonstration grants

SAMHSA PC BH Integration grants HRSA behavioral health expansion grants Patient-Centered Primary Care Collaborative SAMHSA/HRSA TA Center (upcoming) AHRQ resource center (upcoming)


Bidirectional I Bidi i l Integrated C d Care

How do I get involved? g

Where to start

Learn more

Learning more g

National Council � listserv & website Hogg Foundation for Mental Health � resource guide California Institute for Mental Health � webinars IBHP - CA Endowment/Tides C t � tool kit E d t/Tid Center AIMS Center � University of Washington � training y g g Patient-Centered Primary Care Collaborative Collaborative Family Healthcare Association

Where to start

Start conversations with local providers or your own PCP

awareness Share information

Get involved in advocacy

issues Incorporation of recovery principles Training and other workforce issues

Getting started as a provider g p

Map core functions on to staffing resources

are the basic activities your center needs to accomplish? is doing them currently? If no one, who could t k th ld take them on? ? additional resources are necessary, if any?



AIMS Center planning tools

Laurie Alexander, Ph.D. g Alexander Behavioral Healthcare Consulting laurie.alexander09@gmail.com


Community Mental Health Center since 1979 Community Health Center since 2006
Vi i Vision: Full, productive, h lth li F ll d ti healthy lives f everyone for Mission: To build resilience and promote health through community partnerships Became FQHC in 2007


Service area:

Children and Families

520,000 people Four Missouri counties outside St. Louis

School-based prevention/ mental health promotion and early intervention (53 000 children and (53,000 youth/year) School- and home-based interventions (system of ) care)


Adults with serious mental illness
Community Support Teams Two ICCD certified clubhouses Housing
Supported community living Psychiatric group home HUD apartments
Crisis beds

Transitional and supported employment


General public through three integrated care p g g sites
Primary health care Psychiatry and mental health supports P hi d lh lh Pediatrics One includes dentistry and oral health school outreach One includes Ob/Gyn


Overcoming the Barriers

Financing (capital and operating) Fi i ( it l d ti ) Cultural barriers between primary care/mental health delivery / y systems/practitioners. Lack of practitioner training in the health service area that is not their own area of expertise. Information sharing Space
Issues of confidentiality Electronic Health Record


Partners with physicians to address behavioral health needs identified in the b h i lh lh d id ifi d i h primary care setting. Develops joint plans with medical providers on behavioral health aspects of patient care. Provides crisis intervention, brief assessment and referral, behavioral interventions, and education for primary care patients with mental health substance health, abuse, and issues of medical compliance.


BHS Model vs. Traditional MH Model >population mgmt. >specialty care >15-25 min. visits >45-60 min. visits >1-3 visits >5 or more visits >no l limit on # of f >5-7 patients/day d patients per day


BHS Model vs. >open access >any medical issue >BHS interruptible >Goal: enhance G l h overall health

Traditional MH Model >waiting list >mental health issues >"do not disturb" >Diagnose and d treat DSM disorder


Community Support Workers, Care Coordinators, School Based Mental Health C di S h lB dM lH lh Specialists, Clinical Case Managers and Peer Specialists

Supports clients in meeting their treatment plan goals identified in the primary care, mental health and dental health service settings settings. Interacts with Behavioral Health Specialist, Medical Case Manager, and Nurse Liaison as needed needed. New role: Health Coach � Health Navigator


Moving to a Wellness Model
Nutrition Exercise Healthy Living

Maintaining a Recovery Orientation Enhancing Cultural Competence
Independent Living Work


Contact Information
Laurie Alexander, PhD laurie.alexander09@gmail.com laurie alexander09@gmail com Karl Wilson, PhD KWilson@cridercenter.org