Integrated Care Raymond Pomm, MD Vice President of Medical Services Heather Clavette, MA CAP Senior...
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Integrated Care Raymond Pomm, MD Vice President of Medical Services Heather Clavette, MA CAP Senior Director of MAT and Outpatient Services Kristin Barrett,
Integrated Care Raymond Pomm, MD Vice President of Medical
Services Heather Clavette, MA CAP Senior Director of MAT and
Outpatient Services Kristin Barrett, BSN RN Director of
Nursing
Slide 2
Integrated Care Models Behavioral Health in Primary Care
Primary Care in Behavioral Health. Behavioral Health is a misnomer
for many agencies since very few agencies offer mental health and
full range substance abuse services. Primary Care in a true
Behavioral Health setting
Slide 3
Behavioral Health in Primary Care Setting: a small primary care
clinic, large clinic, university-based clinic, public health, etc.
Purpose: integrate mental health and substance abuse services
within a primary care setting
Slide 4
Behavioral Health in Primary Care Challenges: appointment times
are typically months or more apart, lack of specialized trained
staff, lack of programmatic structure for mental health and/or
substance abuse needs, funding issues (especially not- for-profit
agencies), persistent and chronically mentally ill are typically
not compliant with primary care and substance abuse appointments
Stigma: people in primary care are in different stages of denial of
their substance use disorder thereby not wanting to be identified
as such in a non-substance abuse setting, those with mild
psychiatric mental health disorders do not want to be identified
with more severe or dually diagnosed clients
Slide 5
Primary Care in Behavioral Health Setting: a behavioral health
organization: a goal or reality? How many agencies really offer
full service mental health and substance abuse services? Purpose:
(1) integrate primary care in a mental health services organization
or (2) integrate primary care in a full service substance abuse
organization
Slide 6
Primary Care in Behavioral Health Challenges: lack of
specialized trained staff, lack of programmatic and facility
structure for primary care and substance abuse needs,
funding/billing issues especially if not-for- profit agencies,
limiting primary care services to already existing clients Stigma:
substance abuse clients may not want to mix with the persistent and
chronically mentally ill and vice versa
Slide 7
Primary Care and Mental Health in Substance Abuse Setting: a
substance abuse treatment facility, detox, residential, outpatient
Purpose: a substance abuse organization integrating primary care
and mental health services
Slide 8
Primary Care and Mental Health in Substance Abuse Challenges:
many substance abuse treatment agencies do not cater to the
treatment of minor or major psychiatric disturbances, the entire
issue of stabilizing both at the same time becomes an
organizational and structural challenge, different treatment
approaches, lack of specialized staff, funding/billing issues,
interventional strategies differ between mental health and
substance abuse, staff time for coordination of referral and
linkage of specialty services Stigma: mental health clients may not
want to mix with the substance abuse clients
Slide 9
Primary Care in a true Behavioral Health setting History:
Pre-1994 we were strictly a substance abuse treatment facility that
offered residential, methadone and outpatient services (not detox)
In 1994 we added: psychiatric evaluations and medication management
and began development of a co-occurring psychosocial rehabilitation
program
Slide 10
Primary Care in a true Behavioral Health setting contd Between
1994-1996 we developed a specialized intern program which continued
until recent Our psychiatric population rapidly grew and is now
400+ During the growth of our psychiatric services we began and
completed a full training program which changed the treatment focus
of our agency: all counselors were trained to be co-occurring
specialized In 2012, with our methadone population now between
600-700, we established a buprenorphine clinic
Slide 11
Primary Care in a true Behavioral Health setting contd Shortly
after the buprenorphine clinic was deemed successful, we developed
an outpatient detox program Once all new programs were stabilized
we added a primary care program for our clients With the basic
medical home model now established, we partnered with a
University-based HIV treatment clinic to satisfy a specialized
grant for homeless, HIV positive individuals that have a mental
health and/or substance abuse diagnosis. We now offer specialized
primary care services for HIV positive individuals through this as
well as a second grant.
Slide 12
Primary Care in a true Behavioral Health setting contd During
this expansion process we began a specialized pregnant/post partum
program called Building Blocks. We are awaiting an assignment of a
midwife to our team through our association with the University of
Florida Department of OBGYN. This will be discussed by Heather
Clavette. In 2013 we rounded out our Medication Assisted Treatment
(MAT) services to include Vivitrol. In 2013 we were awarded another
grant to offer a medical home model for individuals that have the
potential to develop HIV as well as a mental health and/or
substance abuse diagnosis.
Slide 13
Primary Care in a true Behavioral Health setting contd I can
now proudly state that River Region Human Services offers truly
integrated services.
Slide 14
Team Integration
Slide 15
Registration Integration Registration staff were informed of
the changes amongst the medical and clinical teams Registration
staff were trained on the various programs that the clients would
be presenting for Registration staff were provided fee and payment
information for the various programs
Slide 16
Clinical Integration Biopsychosocial Assessment Tool was
modified Staff researched needs of accreditation bodies for
compliance Staff researched assessment tools Integrated MH and SA
tool was identified and modified to fit our needs Staff were
trained on the use of the Integrated Mental Health and Substance
Use Assessment Tool Staff were also introduced to the URICA to
monitor stage of change Staff were also introduced to the WHODAS to
monitor change in mental health needs Treatment Plan was modified
Staff were trained on identification and treatment of co-occuring
needs Staff began to identify all needs on the individualized
treatment plan Treatment Team was modified to include medical,
clinical and psychiatric representation
Slide 17
Clinical Integration All counselors underwent and continue to
undergo training on co-occuring needs to include: Substance Abuse
Diagnostic impressions Signs of impairment Signs of withdrawal
Treatment Mental Health Diagnostic impressions Signs of instability
Signs of progression/regression Treatment Medical Needs
Identification, referral and follow up
Slide 18
Clinical Integration Staff were introduced to Evidence Based
Practices (EBPs) Motivation Interviewing (MI) Motivational
Enhancement Therapy (MET) Cognitive Behavioral Therapy (CBT)
Dialectical Behavioral Therapy (DBT) Living in Balance Life of
Recovery (LOR) 12 Step Facilitation Therapy (TSF) Seeking Safety
Triple P Parenting Solutions to Wellness Behavior Modification
Staff began to utilize EBPs in their group and individual
sessions
Slide 19
Community Integration This began to be achieved through our
Building Blocks Program
Slide 20
What is Building Blocks Specialized program for pregnant and
post- partum women in MAT Utilizing evidenced-based clinical and
educational information Covering conception/pregnancy, delivery and
beyond Safe haven for group/clinical support Community partnership
Resource development
Slide 21
Community Integration Who Collaborated Department of Health
Dieticians & Nutritionist Womans Center of Jacksonville
Domestic Violence DCF Who are we and what can we offer Healthy
Mothers, Healthy Babies Coalition of N. FL La Leche North Florida
Child Safety Wolfson Childrens Hospital Planned Parenthood
Independent Pharmacist RNs and LPNs MAT Counselors CPR Instructor
Adoption Attorney Working on: Pediatrician and Midwife
Slide 22
The Pregnant Post Partum Population We have the specialized
programmatic structure for this population; however, we are missing
one important piece for full integration of services. We already
have a relationship with University of Florida Department of OBGYN
and are in ongoing discussions regarding placing a midwife within
our clinic.
Slide 23
Development and Strategies for the Day-to-Day Operations
Slide 24
Benefits of Primary Care in a Behavioral Health Setting Better
population health outcomes Better quality of care More preventative
care Lower costs More equitable care and mitigation of health
disparities
Slide 25
The Foundational Infrastructure of High-Performing Primary Care
Data-Driven Improvement Empanelment and Panel Size Management
Team-Based Care Population Management Continuity of Care Prompt
Access to Care
Slide 26
Data-Driven Improvement Prioritize data collection Develop
reporting systems Be strategic Validate the data Identify
organizational goals Analyze variation
Slide 27
Empanelment and Panel Size Management Empanel all clients Mange
panel size Manage demand
Slide 28
Team-Based Care Elements that are critical for a well-
functioning team: Shared vision, principles and concrete goals
Defined Workflows Training, skills checks and cross training
Communication Ground rules Standing orders
Slide 29
Team-Based Care Build a stable team Develop principles Define
workflow Facilitate communication Establish clinician-approved
standing orders
Slide 30
Population Management Design roles to meet the needs of the
patients Plan for cost recovery challenges
Slide 31
Continuity of Care Set goals Train staff and ensure full
coverage Actively control panel size
Slide 32
Prompt Access to Care Balance demand and capacity Develop a
scheduling system to accommodate patient access Offer access
through multiple channels
Slide 33
Development of Primary Care Clinic Needs Assessment Physical
Logistics Billing Primary Care Team Members Clinic Flow
Communicating Services
Slide 34
Needs Assessment Do they current have a Primary Care provider?
Would clients utilize the clinic? What hours would they access
care? What funding source do they have?
Slide 35
Physical Logistics Available exam room Waiting area for clients
Determining supplies needed Establishing a relationship with a
medical supplier Integrated charts? Location of primary care
charts
Slide 36
Billing Development of a Master Superbill Ensuring that
appropriate codes were listed for services Determining self-pay
fees Process for collecting payment Process for submitting
superbills to fiscal
Slide 37
Primary Care Team Members Utilization of trained staff in
primary care Training of current staff Balancing the schedule of
staff for primary care Utilization of staff that could drive
billing Development of team expectations Identifying specific job
duties for team members
Slide 38
Clinic Flow Scheduling of appointments Determining road map for
clients to check in, make payment, triage with MA/Nurse and
provider Preparation for appointments (pulling medical records,
retrieving requested health records or documents) Scheduling of
return appointments Processing of provider orders (Rxs, consults,
referrals, nurse education)
Slide 39
Communicating Services In writing Verbally Referrals (team or
client) Within the agency (case managers, residential services,
ALF) Upon intake for new clients As needed when clinicians identify
chronic/acute health conditions during assessment Nursing referrals
when issues are identified
Slide 40
Challenges Lack of transportation for clients Previous client
experiences Funding Unfamiliar with referring clients for further
work- up Obtaining medical records Training of staff Limited space
Licensure by Medicaid to perform services Culture of traditional
services
Slide 41
Accomplishments Community collaboration Prompt specialty
referrals and consults Continuity of care Clients developing
healthy relationships with Primary Care Team Clients seeking
preventive health care Clients managing chronic health
conditions
