1

Presented by:Diana Knaebe, Heritage Behavioral Health Center

Macon County Initiative Integrating Behavioral Health and

Primary Care

2

Integration Partnership Background

1. Description/History of Partnerships

2. Rationale for involvement

3. Evolution of Partnerships and programs – services offered

4. Next Steps

3

Heritage Behavioral Health Center

Community Health Improvement Center

4

Integration Partnership Background

Description/History of PartnershipCommunity Health Improvement Center and

Heritage

Have had working relationship for the past fifteen years; initially, there were cooperative efforts with mutual referrals to assure that clients received needed primary care/mental health services.

Early on the entities worked cooperatively with a local pharmacy, and developed a system utilizing bubble cards containing daily prescribed dosages of medications for medical and psychiatric problems which could be taken by the client on a daily basis.

5

Integration Partnership Background

• In July 2006, the United Way funding allowed Heritage to provide an adult psychiatrist on-site at CHIC. This psychiatrist provided psychiatric care, support, and follow up to patients, and consultation to medical physicians 9 hours per month. The CHIC physicians were so pleased with the immediate psychiatric consultation available that the pediatric providers requested on-site psychiatric availability.

• Consequently, in April 2007, a child and adolescent psychiatrist was added. He provides mental health services to the primary heath center 4 hours per month, direct care to patients, and consultation and education to the medical physicians.

6

Integration Partnership Background

• United Way funding allowed CHIC to provide a APN as well as a liaison on-site at a Homeless Day Center operated by Heritage. This allowed access to health care by individuals many of whom had not received health care in years.

• Both organizations have attended the National Council’s Integrated Care Sessions for past 5 years.

Participated in National Council’s Integrated Collaborative Care Project in 2007

Participated in MHCA Integrated Healthcare Learning Community August 2009-November 2010

7

Rethinking the Format of Visions

M E D I C A L H O M E Primary Care Mental Health Clinic Center

U N I F I E D F U N D I N G

CORE COMPETENCIES

CORE PROGRAMS

INTERVENTIONS

8

Reasons/Rationale for Partnerships

Ultimately to Implement a patient centered medical home – true integration of care

Better Overall health outcomes.Improved access and retention of clients

Joint referral process and records access Clinical processes defined for collaboration and joint education for staff Nurse practitioners and/or Physician Assistants at both CHIC and

Heritage Clients only seen at one site for all needs – as much as possible unless

need specialty care Maximizing revenue (current and new services) Efficient/effective/efficacious care Non-duplication of care and services Education sharing component for staff and clients

9

Cultural Issues/differences

Term-language Differences How patients/clients are seen – length of time

for visit and follow upFunding Streams and Mechanisms often very

differentDetermination of “hand-offs” and/or referrals

Releases – Medical Records

10

The Four Quadrant Clinical Integration Model For the Adult Population/ Heritage & CHIC Adaptation

Quadrant IIHigh Behavioral Health (BH)Low Physical Health (PH)Heritage is medical home. Care to be provided by or arranged by Heritage BH Counselor Criteria for placement in this quadrantMay have accessed services at CHIC or HBHEligible for 132 Services•Has low physical health risk/ complexityNeeds psychotropic medication provided by psychiatrist at HBHPhysical health care by PCP located at HBHMay have stigma issue about going to HeritageNeeds case management, housing, assistance with finances & or Heritage Payee servicesDual problems of S/A & MH (requires treatment for both)Inpatient Hospitalization in past or required now.Needs daily living skills trainingNeeds outreach services provided by HeritageActions to Be Taken :Clinician arranges case management services for housing and other community supportsArranges for S/A treatmentArranges for access to primary health care if enters @ HBH, and assures communication with Primary Care Physician (PCP)BH Clinician provides assessment, Psychiatrist provides and monitors needed medication

Quadrant IVHigh Behavioral Health (BH)High Physical Health (PH)Heritage is medical home with counseling and case management services provided at HeritageCriteria for placement in this quadrantAccesses services at Heritage in most casesPhysical health care by PCP located at HeritageEligible for 132 Services•Has complex and high risk physical problems, and requires regular physician visits, and or specialty physician care•Needs a BH case manager at HBH who provides assistance with housing, financial assistance•May have Dual problems of S/A and MH (requires treatment for both)•Needs inpatient hospitalization for either physical or mental health issuesActions to Be Taken:Primary Dr provides primary care and assures specialty physical health care when neededHeritage BH counselor assures collaboration between BH & PH BH clinician arranges for case management and other needed support servicesPsychiatrist provides and monitors needed medicationIf no Primary care physician at HBH, will receive primary care at CHIC

Quadrant ILow Behavioral HealthLow Physical HealthCHIC is medical home with on site CHIC BH clinicianCriteria For Placement in this quadrantMay have accessed services at CHIC or HBHLow physical health risk/complexitySlightly elevated health or BH riskClient may need BH and or S/A triage, assessment, and service planningBrief BH counseling or treatment or group therapyMay need referral to community and educational resourcesMay need health risk educationDrs only clients at HBH would be appropriate in this quadrantActions to Be Taken:PCP provides primary care and uses screening tools and guidelines to serve most individuals in Primary CareRefers to & collaborates with psychiatrist to assure coordinated careCHIC BH clinician provides formal and informal consultation to the PCPCHIC BH clinician provides brief counselingPsychiatric consultation provided to PCP if needed

Quadrant III High Physical Health Low Behavior HealthCHIC is medical home with on site CHIC BH clinician Criteria for Placement in this quadrantHas complex and high risk physical health problems, and requires regular physician visits, and or specialty physician careLow BH needs, but needs screening by PCP using screening tools May need BH triage or assessmentMay need consultation to the PCPMay need referral to community educational resourcesActions To Be Taken:•PCP provides primary care and assures specialty care when needed•PCP utilizes BH screening tools and guidelines to serve most individuals in Primary Care•BH clinician provides triage, assessment, & consultation with PCP

11

Integration Partnership - Expansion

The Administrative and Clinical Collaborative Committees continue to meet on the existing collaboration as well as expanding to additional behavioral health services on site at CHIC and with an intention of continuing to work towards the provision of primary health care in a behavioral health care setting. This project is the logical extension of efforts currently underway between Heritage and CHIC. Heritage and CHIC meet regularly to plan, coordinate, and implement our existing collaboration of integrating behavioral and primary health care. This collaboration is progressive and moving forward.

The MCMHB joined the Administrative Committee in late 2009 when we began a “pilot project” to add expertise, additional funds with Medicaid billing through them plus the matching local dollars.

12

Integration Partnership Background

Integration: Partnering Agencies 2011

The Community Health Improvement Center (CHIC), a primary health care center – Federally Qualified Health Center,

Heritage Behavioral Health Center (Heritage), a community behavioral health center – Mental Health, Substance Abuse, Homeless and Housing Services

The Macon County Mental Health Board (MCMHB), a public taxing body that funds MH/SA/DD services

The Macon County Health Department, public health department (MCHD)

13

Integration Partnership – Expansion TwoMacon County Health DepartmentMCHD entered into partnership with IDPA ABCD II

(Assuring Better Child Health and Development Initiative) project in 2005. State level partners included:

Illinois Chapter, American Academy of Pediatrics ( ICAAP) and Illinois Academy of Family Physicians

Ounce of Prevention Fund (OPF) Illinois Department of Human Services (IDHS) Office of Family Health (OFH) IDHS Office of Mental Health (OMH) Illinois Department of Children and Family Services Illinois Primary Health Care Association (IPHCA Local partners included: AOK Network FQHC: CHIC WIC/FCM Coordinator Pediatric/Family Practices: Early Intervention/CFC: Heritage Behavioral

I

14

Edinburgh Postnatal Depression Scale (EPDS)

Possible Depression is indicated at score of 10 or above. Referral provided for all scores of 10 or higher

INITIAL NUMBERS INDICATED HIGH RATE OF NEED !

Edinburgh’s Completed :

May 05 – September 05 = 434

Scores of 10 or higher = 100 Result=25% rate of at risk women in need of referral ! Current screening rates maintain average of 100 screens completed /month with 10-20%

rate of need for referral

15

Hopes & Screams from MCHDMCMHB Board Director enlisted local mental health providers to

provide counseling services for clients with positive screening scores

Referral rates outnumbered available resourcesMCMHB providers had long waiting times for client entrySome MCMHB providers were charging clients for services

against project agreement Some providers requested clients not be referred if in prenatal

stateSome OB providers declined to accept screening resultsMCHD staff expressed frustrations and concerns related to

referral inconsistencies

16

MCHD Request to MCMHB Fall 2010Invited MCMHB Director to Maternal Child Health staff meeting

to address staff concerns related to the counseling referral system

Staff relayed numbers of underserved clients

Gave examples of referral difficulties with MCMHB paid agencies

Requested on site services and to include home visits for clients with barriers such as daycare, transportation, work/school schedules

Goal= to achieve through partnership timely and adequate service delivery and follow up for at risk women and families

17

MCMHB Reasons for Involvement

New Medicaid by billing through the MCMHB – directly to DHFSLocal Funds Initiative - matching Medicaid with County dollars

means more money for the communityQuicker access to behavioral health servicesCaptive Audience at CHIC – linkage & need from MCHDEligibility – changes in eligibility over the years in mostly only target

population defined by DHS-OMH – this allows an Expansion of eligibility wider range of individuals than current and potentialStill meeting medically necessity

More holistic care - hopefully better clinical outcomes/people improving/getting better

18

Integration Partnership – Expansion Two Continued

Administrative Team established and meeting to work through challenges, barriers, referral processes, medical record – computer

Members from MCHD, MCMHB, Heritage

Clinical Teams also providing feedback through their supervisors – funnels up to Administrative Team and back to clinical teams/supervisors to smooth the processes

19

MCHD, “Happy Days Are Here!”

January 2011-Part time MCMHB funded Heritage Counselor begins accepting onsite referrals at MCHD and completing home visits.

40 referrals received in the first month! Whew!Initially ,frustration expressed regarding delayed contact

time vs referral numbers …However …Counselor provides assistance with multiple scenariosClients and staff express 100% satisfaction with follow up

services

20

Next Steps MCHD Expansion into Seniors

Plan to use Geriatric Depression Screen

One full-time mental health staff beginning July 2011 might expand to another part-time assigned to the MCHD clients/patients

21

Specific Changes Implemented in the Last Year

Lost the psychiatrist that worked so well for both organizations as a result have added Psychiatric Nurse Practitioner to FQHC

Added Mental Health Therapist to the FQHC site with MCMHC Board Funding

Screening to determine who can be better served at the FQHC as primary – Medical Home

Have received SAMHSA Integrated Primary Care Grant which will allow us to emphasize wellness with SPMI population added Physical PA on site at the Mental Health Center.

MCHD has become 2nd site funded by MCMHB for therapists to see identified by MCHD staff in need of services – primarily an outreach, in-home model though which is different than that at CHIC

22

Lessons Learned – things to Consider when establishing Collaborations for Integration of Care

Can take much more time to work through because our systems are often actually complicated

Are the right people at the table for discussions?Licensure of Sites – Scope of Practice ChangesWritten Agreements

Joint Contracts for purchasing of staff or servicesWho is billing for what?

23

SAMHSA Program Goals

Heritage Behavioral Health Center received a SAMHSA Grant in

September 2010 for its Primary and Behavioral Health Care

Integration (PBHCI) program. Our project focuses on:

individuals with Serious Mental Illness who are on antipsychotic medications and….

have co-occurring metabolic syndrome or a chronic medical condition

Establishment of a primary care clinic at Heritage Behavioral Health Center

Provision of wellness activities/programs Working with 500 SMI adults by the end of the 4th year

24

SAMHSA Program Goals

Health and Illness Background Information Used both as a screening and as a means of documenting

diagnoses (PH and BH) as well as important medical/health history variables SF-36 (short form)

Person Centered Healthcare Home Fidelity Scales and Protocols Developed by our evaluator, TriWest

Based on the conceptual work of Barbara Mauer and collaborators 2-day collaborative assessment process

25

Accomplishments

In 5 months, established a Health & Wellness Suite, including a Primary Care Office at Heritage

Contracted with CHIC Primary Care Clinic to place a Primary Care Physician/Assistant on site

Developed a Clinical Registry

Admitted 57 clients to Health and Wellness Program since Mid March 2011

26

Accomplishments

Received 87 referrals to the program since program began in February 2011

Success Stories: In one month, one client lost 20#, another lost 11#, a third

lost 14#. No one enrolled in the program has gained weight.

Two partially immobile clients are now mobile and

continuing to improve

27

Health and Wellness Activities

Food Pyramid Education weeklyHealthy Cooking Classes weeklyChair Zumba twice per weekModified Yoga weeklyDaily Walking ActivityHealthy Food Shopping As Needed1:1 Food Counseling and Review of Food Tracker as

neededWeekly Off Site Exercise

28

Plans for The Future

Expand hours and responsibilities of P/A to provide all primary care for individuals in the program

Provide fully certified smoking cessation classes to clients

Staff will become certified in smoking cessation, diabetes education, yoga, and zumba

Provide physical illness management education to case managers

Add Peer Support/Mentors to programWellness Model throughout organization

29

Key Contact Person(s) and Contact Information:

Julie Aubert, MCHD, jaubert@maconcountyhealth.org 217-423-6988 ext 1105

Barbara Dunn, CHIC, bdunn@chealthctr.org 217-877-6111

Dennis Crowley, MCMHB, dcrowley@mcmhb.com 423-6199 X 108

Diana Knaebe, Heritage, dknaebe@heritagenet.org

217-420-4702

Karen Shiflett, MCHD, wic@maconcountyhealth.org 217-423-6988 ext 1343