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AMHC Integrated Service ApproachFebruary 9, 2010
February 9, 2010 2
AMHC Locations
February 9, 2010 3
AMHC & Integration: 36 Year History Strategic priority for AMHC Vision aligned with Four Quadrant, Strosahl and Care Model Dedicated to improving health and wellness through a biopsychosocial
approach Implementing brief treatment and Stanford chronic disease lifestyle
management model developed by Guided by written, customized integration protocols for defined diseases
and supported by expert training resources Grounded in principles of providing immediate access to most
appropriate, highest quality, affordable service Informed by decades of experience working in Aroostook County, in
Maine, nationally through MHCA, and internationally through IIMHL
February 9, 2010 4
IOM Influence Grounded in the Institute of Medicine’s
(IOM) Crossing the Quality Chasm aims: patient-centered safe timely efficient effective equitable
February 9, 2010 5
Service Models Four Quadrant Clinical Integration Model Chronic Care Model Strosahl Primary Behavioral Health Care
Model
February 9, 2010 6
Four Quadrant Clinical Integration ModelFour Quadrant Clinical Integration ModelPresentation by Service Population and Setting
February 9, 2010 7
Informed,ActivatedPatient
ProductiveProductiveInteractionsInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliveryDeliverySystemSystemDesignDesign
DecisionDecisionSupportSupport
ClinicalClinicalInformationInformation
SystemsSystems
Self-Self-Management Management
SupportSupport
Health SystemHealth System
Resources and PoliciesResources and Policies
CommunityCommunity
Health Care OrganizationHealth Care Organization
/ ICIC
PHQ-9Registry
Self-Mgmt Tools
Care Mgmt Psych consult
Care Model
February 9, 2010 8
Strosahl Primary Behavioral Health Model Goal is to increase effectiveness of primary
care providers in addressing behavioral health needs of patients.
Focus on managing psychosocial aspects of disease by addressing lifestyle and health-risk issues through brief consultative interventions and temporary co-management of behavioral health conditions.
February 9, 2010 9
Self-Care
Medical & drug
interventions
Psychosocial and alternative
therapeutic interventions
Self-Care
February 9, 2010 10
Self-care Objectives Patient at the center and in control of his
health. Uses a broad variety of techniques to attain
and achieve optimal health. This is a fundamental shift in the paradigm of
health services currently focused on treating disease and expects practitioners to work with a patient to inform and support his ability to guide his own self-care.
February 9, 2010 11
Advantages Improve access to behavioral and physical health
services Apply evidence based practices to improve client
outcomes Improve provider communication and coordination
of care Foster a multi-disciplinary team approach to treating
substance abuse with a co-occurring chronic health issues (cancer, cardiovascular, COPD, depression, diabetes)
February 9, 2010 12
Advancing Approach to Practice Embedding primary care family practice physician
into AMHC’s service site to provide outpatient and medication management services
Primary goals: Encourage self-care Improve type and quality of services Meet unmet needs Increase cost efficiency Address workforce issues and offer professional
advancement Improve primary care physician ability to treat patients
with chronic mental illness
February 9, 2010 13
Key Activity Milestones Administrators and clinical staff were oriented to the principles of the Four Quadrant Model
and how it interfaces and complements the Planned (Chronic) Care Model. Written, customized integration protocols for depression, anxiety, substance abuse, sexual
assault, were developed Assessment tools for depression, PQ-9, and substance abuse, the CAGE, were implemented
and are used at the sites. One blended record at the primary care site. Periodic provider team meetings held to address care coordination and collaboration issues Scheduling, staff credentialing and billing issues were improved Successfully secured DHHS
reconsideration and approval for FQHC’s to bill MaineCare and be reimbursed for services provided by LMSW-cc credentialed clinicians.
Clinician assignments to support the integration efforts were maintained, with 90% of initial placements sustained throughout the life of the project.
Six Pines physicians have staffed AMHC’s opioid replacement therapy clinic since July 2006.
AMHC implemented an account management approach to working with the primary care practices to ensure immediate responsiveness to addressing clinical approach, staff availability, credentialing, scheduling, and billing issues.
February 9, 2010 14
Why integrate services? International, national and state level movement to integration of services
Federal Level Public Support HRSA and SAMHSA and their counterparts in other countries through the
International Initiative for Mental Health Leadership (IIMHL) Private National Organizations
Institute of Medicine (IOM) National Council for Community Behavioral Healthcare (NCCBH) Mental Health Corporations of America (MHCA) and its counterpart State Level
Public support Department of Health and Human Services (DHHS)
Private Maine State Organizations Maine Health Access Foundation (MeHAF) Quality Counts (QC) Primary Care Association (MePAC) Association of Mental Health Services (MAMHS) Association of Substance of Abuse Programs (MASAP)
February 9, 2010 15
Potential and Sought After Rewards Improved Health Outcomes
Healthier Patients Increased Patient Satisfaction
MeHAF focus groups found MH & SA patients reported having a higher degree of integrated
care PH patients express a sense of loss when case management services
offered by specialty providers were stopped and they returned to “regular care”
Improved staff satisfaction Working Conditions
Perceived effectiveness in delivering quality services Coordination of services across multi-disciplinary professional
February 9, 2010 16
Potential and Sought After Rewards Improved Organizational Performance
Achieving Service Mission and Business Objectives Service Effectiveness
More comprehensive array of service responses aligned with true service needs
Service Efficiency Increased capacity and productivity achieved through appropriate
utilization of multi-disciplinary staff resources Improved Financial Performance
Reduced cost of providing services when responses are aligned with true service needs
Improved revenues generation resulting from increased productivity across multi-disciplinary staff.
February 9, 2010 17
How integrated are we? 5 Levels of Integration
I. Minimal collaboration II. Basic collaboration from a distance III. Basic on site collaboration IV. Close collaboration that is partly integrated V. Fully integrated System
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Project Mission “To provide comprehensive, patient centered
care that offers concurrent prevention and management of multiple physical and behavioral healthcare service needs of a patient in relationship to his or her family, life events, and environment.”
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Project Activities 1. Confirm:
Medical Director’s commitment to participate in and help guide the process.
Behavioral and Physical Healthcare Provider willingness to Improve integrated services Participate in regularly scheduled multi-disciplinary staff meetings
2. Provide Refresher and Ongoing Education Integration Models and/or Evidence Based Practices Strategies to reduce barriers and advance integrated service practice
3.Commit to Including Patients in the Project to Help: Increase awareness, encourage participation, and reduce stigma.
February 9, 2010 20
Project Activities 4. Improve Delivery of Substance abuse and
Co-occurring Disorder Services 5. Implement Care Coordination and Patient
Self-management Services 6. Identify, Implement and Monitor
Measurable Indicators to Support the Reporting of Achieved Outcomes.
February 9, 2010 21
Integration Barriers in Maine Culture and Practice Patterns
Selecting integration model(s) based on practice context
15 minute visit vs. 50 minute therapy session Education of providers is silo’d and there is no or
limited understanding across disciplines.
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Integration Barriers in Maine Stigma and lack of awareness
Stigma associated with some behavioral and physical health service needs is a barrier to seeking and providing service.
Patient and provider lack awareness about integrated care and the advantages.
Patients generally lack an understanding about how they may be able to self-manage care and advocate for integrated services.
February 9, 2010 23
Integration Barriers in Maine Reimbursement: No reimbursement for
integrative (e.g., collaborative care and team approaches), care coordination, and preventative services.
February 9, 2010 24
Next Steps