Jill Rinehart, MDBreena Holmes, MD

Describe the growing need for co-located support in primary care practices

Outline several Vermont models of behavioral health support in primary care

Describe one practices’ innovation, including use of Blueprint and care coordination

Vermont Department of Health

20-24% of all children will be treated for behavioral health symptoms by the time they reach age 18.

Up to 70% of primary care medical appointments are for issues related to psychosocial concerns

Vermont Department of Health

For those under 18 years of age, the five medical conditions that ranked highest in terms of the number of individuals with expenses for care in 2008 included acute bronchitis, asthma, trauma-related disorders, otitis media, and mental disorders.

Vermont Department of Health

Family Integrated Health Care Model◦ VCHIP, VDH, DMH◦ Co-located mental health workers in primary care◦ Child Psychiatry consultation for child health providers

through email and phone consultation Vermont Family Wellness Model

◦ 3 tiers

Blueprint for Health◦ Community Health Teams (centralized)◦ Community Health Teams (co-located)

Vermont Department of Health

Every medical home that serves children has a care coordinator

Care coordinator can connect families to needed resources in a timely manner

CSHN can reach each practice via Care Coordinator

Network of care coordination that supports behavioral health needs of families—from parenting support, to coordinated behavioral assessment and psychiatric treatment

Vermont Department of Health

The Concept The Person

1. Needs assessment for care coordination and continuing care coordination engagement

2. Care planning and communication

3. Facilitating care transitions 4. Connecting with community

resources and schools5. Transitioning to adult care

Antonelli et al (2009); Rinehart (2014)

1.Reduce fragmentation of care for an identified population

2.Guide a family-centered, multi-disciplinary team process in the joint development and use of a plan of care

3.Enable the child/family and their “care neighborhood” to communicate, collaborate, and operate from the “same page”

4.Deliver oversight/accountability

◦ Jeanne McAllister, et. al, supported by Lucille Packard Foundation for Children with Special Health Care Needs

Vermont Department of Health

Care Study 1: Matt

13 year old boy with autism, non-verbal, self injury, polydipsiaParents struggling with bolting, overall safetyMiddle school unable to educate or keep safeMedical issues of skin infections, enuresis, sleep dysfunctionFamily has gone above and beyond capacity of most families to deal with this at home

Care Planning 1:

Patient/Family/Team Goals CICP Negotiated Actions Process and Outcome Measures

Less Self Injury Psychiatry Assessment, co-management from psychiatry, medical home and subspecialists

In-home behaviorists

Keeping family together

Less need for police, mental health crisis support

Improve school attendanceImprove education supports

Same behavior plan across settings

Explore alternative school placement

Clear communication between home/school/providers

Alternative program found

Repetitive behaviors Improved psych pharmImproved wrap around servicesImproved behavior plans

Innovation: across silos of mental health, developmental disabilities, children with special health care needs, and school

Care Study 2: Mary4 year old with tuberous sclerosis

self-injurious behaviorsTantrumssleep dysfunction heading toward inpatient psychiatry hospitalization

Despite having a VT developmental services waiver, respite care and a team of multidisciplinary medical experts at Massachusetts General Hospital

Care Study 2: Mary (Cont)

Intractable seizures seemed the least of her concerns in comparison to behaviorsStrengths:

Strong parent involvement and expertiseLoving respite familyMary engagingVerbal with cognitive strength (can anticipate seizures)

Care Planning 2:

Patient/Family/Team Goals CICP Negotiated Actions Process and Outcome Measures

Less need for “crisis” intervention

Co-management from psychiatry, medical home and subspecialists

In-home behaviorists

Less need for police, mental health crisis support

Improve Sleep Same behavior plan across settings

Less communication errors about medications

Improved work attendance

Increase Home Safety-of Mary and family

Improved psych pharmCSHN SW: Waiver allowed for enhanced access to in-home behaviorists

Innovation: region contracted with vendor outside of network

Less Crisis Need

Mary to attend schoolImprove social relationships

Communication opened between school, behavioral plans, family, medical home

Making academic gainsAttendance improvedCannot pick her out from peers

Vermont Department of Health

1 HRC Pediatricians2 University Pediatrics3 Green Mountain Pediatrics (Bennington)4 Rutland (RRMC)5 St. Johnsbury6 Mount Ascutney /Ottaqueechee (Windsor/Woodstock)7 Rainbow Pediatrics(Middlebury)8 MPAM(Middlebury/Porter)9 South Royalton10 Barre- Associates in Pediatrics (2)CHCTimberlaneEssex PediatricsMaine

Integrated care is the seamless provision of health care services, from the perspective of the patient and family, across the entire care continuum. It results from coordinating the efforts of all providers, irrespective of institutional, departmental, or community-based organizational boundaries.

Practices with co-located behavioral health services◦ struggled with integration elements that

addressed the use of behavioral health skills by the entire primary care team and the delivery of evidence-based interventions

Co-located practices were the most integrated with clinic-system processes and in elements of relationship and communication

Pediatric and non-co-located practices struggled most with clinic-system processes and community integration

Informal Supports

Extended FamilyFriendsGroups

Religious Organizations

Cultural SupportsClubs

RecreationCamps

Community and State Services

CSCHNEconomic Services

Developmental Services

Mental Health Early Intervention

Home Health Services

Children’s Palliative Care

WICChild Protection

Private TherapistsPersonal Care

SchoolTeachers

Case ManagerSpeechPT/OT

Counsellors

Other Services

MedicalSpecialists

Specialty Providers

Clinics

Financial SupportsInsuranceRespite

Childcare Subsidy

Economic servicesSocial

SecurityFood Subsidy Employment

Childcare

Teachers

Genogram of Household MembersParentsSiblings

ChildExtended Family

Others

© Cristin Lind

Behavioral Health encompasses◦ Mental health◦ Substance abuse and dependence◦ Life style choices which promote risk factors

Integration is Essential for Success– evidence base exists Care Coordination is Necessary but not Sufficient to

Achieve Integration CC is the set of activities which occurs in “the space

between”◦ Visits, Providers, Hospital stays

Only way to succeed is to engage all stakeholders– including patients and families– as participants and partners