PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION

PRIMARY AND BEHAVIORALHEALTHCARE INTEGRATION

PRACTICAL APPROACHES TO IMPLEMENTATION

Coastal Behavioral Healthcare

Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida

Anthony R. Bichel, Ph.D.Apalachee Center Inc., Tallahassee, Florida

Rick Hankey, Senior V. P. and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida

PRESENTERS


LEARNING OBJECTIVESPROVIDE

AN OVERVIEW OF INTEGRATED BEHAVIORAL HEALTH AND PRIMARY CARE

INCREASE KNOWLEDGE OF THE IMPLEMENTATION

PROCESS AND SUSTAINABILITY

DESCRIBE LESSONS LEARNED


OUTLINE• History• Define The Problem Today• What Changed? Why Now?• What Is Integrated Care?• The Implementation Process• Sustainability• Lessons Learned


HOW DID PHYSICAL AND MENTAL HEALTH BECOME

SEPARATED?


HISTORY1950 – 1960: Most people with mental illness were living in asylums.

In the 60s: Due to John F. Kennedy and advances in medical thinking, changed from

institutional care to community based system.

1980 – 1990: Number of people living in tax-funded institutions was reduced by 50%.

Today: Approximately one-fifth of the 1950s number reside in institutional care.


PROMISES MADE AND PROMISES BROKEN

Money was intended to follow consumers into community programs. This didn’t happen.

Employer paid insurance had no reason to pick up the bill. Most didn’t.

Operating two systems: state and community. Never had enough money to fund both.

Community based mental health system has always been underfunded.


TODAY PEOPLE WITH SMI DIE ON AVERAGE 25 YEARS

SOONER THAN THE GENERAL POPULATION

They are not dying from their mental illness, but from their

chronic and untreated physical illnesses.


OF THE SIX MAJOR CAUSES OF DEATH IN THE UNITED STATES,

THERE IS AN INCREASED RISK OF DEATH AMONG THE SERIOUSLY MENTALLY ILL MAJOR CAUSE OF DEATH INCREASED RISK OF DEATHCARDIOVASCULAR 3.4 XLUNG CANCER 3 XSTROKE 2 X IN THOSE LESS THAN

50 YEARS OF AGE

RESPIRATORY 5 XDIABETES 3.4 XINFECTIOUS DISEASES 3.4 X

Bob Sharp, Fl Council For Community Mental Health


FACTORS INCREASING HEALTH RISK

Under Diagnosis &

Under Treatment

Poverty Poor access to Primary Care

Disconnectedness of “Physical” & “Mental” health care systems

Weight Gain

Tobacco and Substance Abuse

Medications

Less likely to be screened

Self-Care Capacity/Resource

Cognitive, Affective and Behavioral symptoms

System Navigation Barriers

WHAT'S CHANGED AND WHY CHANGE NOW?

4-Year Grant from The Substance Abuse And Mental Health Services Administration (SAMHSA) – $500,000 Per Year

The Purpose Of The Grant Is To Improve The Physical Health Status Of People With Serious Mental Illness

The Challenge Is To Establish A System That Bridges The Gap Between Mental Health Care And General Medical Care

“It’s the right thing to do!”Linda Rosenberg of The National Council


$28 MILLION DOLLARS GIVEN TO 56 COMMUNITY BEHAVIORAL HEALTH CARE AGENCIES TO INTEGRATE PRIMARY AND

BEHAVIORAL HEALTH CARE SERVICES

FIVE REGIONS

FLORIDA IS IN REGION 3

SAMHSA GRANT PROGRAM

UT

AZ NM

WY

MT ND

SD

NE

KS

OK

TX LA

AR

MO

IA

MNWI

MI

IL IN

KYWV

OH

MD

OR

CA

AKHI

NV

ID

WA

CO

NJDE

MA

NH

CT

VT

PA

NY

RI

ME

ALMS

TNSC

NC

VA

FL

GA

DC

Central Region (2)8 Grantees Midwest Region (4)

13 Grantees

Northeast & Mid-Atlantic Region (5)17 Grantees

Southeast Region (3)8 Grantees

West Region (1)10 Grantees

West Region 1

Central Region 2

Southeast Region 3

Midwest Region 4

NE & MidAtlantic

Region 5AK: Wrangell Community Services

AZ: CODAC Behavioral Health Services

FL: Coastal Behavioral Healthcare

IL: Human Service Center

CT: Bridges - A Community Support System

CA: Mental Health Systems

CO: Mental Health Center of Denver

FL: Lifestream Behavioral Center

IL: Trilogy Inc CT: Community MH Affiliates

CA: Alameda Co Behavioral Health Care Services

TX: Austin-Travis CO MH/MR Center

FL: Miami Behavioral Health Center

IL: Hertiage Behavioral Health Center

MA: Community Healthlink Inc

CA: Asian Community MH Services

TX: Montrose Counseling Center

FL: Community Rehabilitation Center

IN: Adult & Child Mental Health Center

ME: Community Health and Counseling Service

CA: Glenn County Health Services Agency

OK: North Care Center FL: Apalachee Center, Inc IN: Southlake Community Mental Health Center

NH: Community Council of Nashua

CA: Tarzana Treatment Centers, Inc.

OK: Oklahoma Dept of MH/SA

FL: Lakeside Behavioral Healthcare

IN: Centerstone of IN NJ: Care Plus NJ

OR: Native American Rehab Assoc of the NW

UT: Weber Human Services

GA: Cobb/Douglas Community Service Board

KY: Pennyroyal Regional MH/MR Board

NJ: Catholic Charities, Diocese of Trenton

WA: Asian Counseling and Referral Services

SC: State Dept of MH MI: Washetenaw Community Health Organization

NY: VIP Community Services

WA: Downtown Emergency Service Center

OH: Center for Families and Children

NY: Postgraduate Center for Mental Health

OH: Shawnee MH Center

NY: Bronx-Lebanon Hospital Center

OH: Southeast Inc. NY: International Center for the Disabled

OH: Greater Cincy BH Services

NY: Fordham Tremont CMHC

WV: Prestera Center for MH Services

PA: Milestone Centers

PA: Horizon House RI: Kent Center for

Human/Org Development RI: The Providence Center MD: Family Services, Inc

LIST OF SAMSHA REGIONS


WHAT IS

INTEGRATED HEALTHCARE

?


IT IS A TEAM-BASED MODEL WITH MEDICAL AND MENTAL

HEALTH PROVIDERS PARTNERING TO FACILITATE THE DETECTION, TREATMENT, AND

FOLLOW-UP OF BOTH MEDICAL AND PSYCHIATRIC DISORDERS IN

A COMBINED SETTING.


SAMSHA GOALSREDUCE HEALTHCARE DISPARITIES

ELIMINATE THE EARLY MORTALITY GAP

REACH PEOPLE WHO CANNOT OR WILL NOT ACCESS PRIMARY HEALTHCARE SERVICES

EARLY INTERVENTION AND DETECTION

BEFORE ISSUES DEVELOP OR WORSEN


• Regular screenings and registry tracking • On-site integrated primary care

prevention, screening, and treatment services

• Wellness education and support activities

• Referral and follow-up

IMPROVE HEALTH AND

WELLBEING BY

• Peer involvement in the delivery, planning and evaluation of services

• Advisory Committee involvement and feedback

INCREASE CONSUMER

PARTICIPATION THROUGH

ACHIEVING THE GOALS

IMPLEMENTATION

STEP 4 – CRITICAL STEPS

STEP 3 - INTEGRATION MODELS

STEP 2 - UNDERSTANDING DIFFERENCES

STEP 1 – SUCCESS THROUGH PARTNERSHIPS


SUCCESS THROUGH PARTNERSHIPS

Primary CareGrant Evaluator

Laboratory VendorMedical Supply Company

Health EducatorsCommunity Stakeholders

Business Alliances

STEP 1


MANATEE COUNTY RURAL HEALTH SERVICES – Primary Care

UNIVERSITY OF SOUTH FLORIDA – Grant evaluators

SWEETBAY PHARMACY Healthy Saver Plus Program • $7 annual enrollment fee for entire family

• 450 generics at $4 per 30-day supply

DIABETIC STAFF AND PATIENT EDUCATION• Dave Joffe, Sweetbay Pharmacist,

• and Diabetes- in-Control, Editor in Chief

PHARMACIST INTERNSHIP PROGRAM • Student Rotation Affiliation with • Lake Erie College Of Medicine

PFIZER MEDED GRANTS• Application for funding of a Wellness Peer Advocate


Understanding The Differences

They’re different! Acknowledge & Embrace it!

Step 2


PRIMARY CARE MENTAL HEALTH

PACE 15 minute appointment 50 minute session

SETTING An exam room A comfortable office

LANGUAGE Diagnosis, medical terminology, complaints

Assessment, mental health terminology, issues

HIERARCHY Clear – Doctor in charge Diffuse – Administrator in Charge with Medical Director

FLOW Flexible patient flow Scheduled client flow


Step 3 Integration ModelsIntegration Model Level of

Integration Attributes

MINIMAL COLLABORATION I SEPARATE SITE & SYSTEMSMINIMAL COMMUNICATION

BASIC COLLABORATION FROM A DISTANCE II ACTIVE REFERRAL LINKAGES

SOME REGULAR COMMUNICATION

BASIC COLLABORATION ON SITE III SHARED SITE; SEPARATE SYSTEMS

REGULAR COMMUNICATION

COLLABORATIVE CARE PARTLY INTEGRATED IV

SHARED SITE; SOME SHARED SYSTEMSCOORDINATED TREATMENT PLANSREGULAR COMMUNICATION

FULLY INTEGRATED SYSTEM VSHARED SITE, VISION, SYSTEMSSHARED TREATMENT PLANSREGULAR TEAM MEETINGS

CRITICAL STEPSOrganizational Buy-in and Plan

Establish Contracts

Hire Staff

Billing – Opportunities for Sustainability

Data Tracking and Collection

Step 4


Space

Policies & Procedures

Documentation

Registration and Scheduling

Primary Acute Care Services – Offerings and Expense

Before admitting the first patient, consider:


Physical History

Personal Risk Factors

Family Risk Factors Height Weight

BMIBlood

Pressure and Pulse

Fasting Plasma Glucose

Total Cholesterol Triglycerides

LDL HDL Cholesterol / HDL Ratio

Complete Metabolic

PanelA1C

Abdominal Circumference TSH Medication

ReviewLiver Function

StudiesCBC with

Differential

Co-Occurring Risk of Harm Depression Screening NOMS Physical Exam

SCREENING FORMS FOR PHYSICAL HEALTH

DISORDERS Including Obesity, Diabetes, Dyslipidemia,

Hypertension, Cardiovascular Disease


WELLNESS OFFERINGS

NUTRITIONAL EDUCATION

FOOD TOURS

HEALTHY COOKING

DIABETES EDUCATION

PHYSICAL ACTIVITY ED

SMOKING CESSATION

ILLNESS SELF-MANAGEMENT

STRESS MANAGEMENT

PEER SUPPORT

RECOVERY ACTIVITIES

EXERCISE INSTRUCTION

MEDICATION MANAGEMENT

SUSTAINABILITY

COMPLICATED REIMBURSEMENT –

CPT AND ICD-9 CODING

SAMSHA’S TARGET POPULATION MUST BE

EXPANDED IN ORDER TO SUSTAIN INTEGRATION

MODEL

LACK OF SAME DAY SERVICES

REIMBURSEMENT UNDER MEDICAID

WHEN THE FUNDING STOPS

TARGET POPULATION• 18 YEARS OR OLDER• SMI-12MONTH

DURATION• GAF BELOW 60• UNINSURED

HOW WILL WE KNOW PROGRAM GOALS HAVE

BEEN ACHIEVED?

DATA COLLECTION


DECREASED TOBACCO USAGE

DECREASED OBESITY

INCREASED SELF-MANAGEMENT OF DIABETES

AND/OR CARDIOVASCULAR DISEASE

INCREASED DIABETES OR CARDIOVASCULAR RELATED PHARMACY USE

KEY INDICATORS OF SUCCESS


INCREASED REFERRAL TO MEDICAL/SURGICAL SPECIALTY CARE

INCREASED RECEIPT OF CLINICAL PREVENTATIVE SERVICES

ImmunizationsCancer Screening

STD And Communicable Disease ScreeningFamily Planning

Dental Care

KEY INDICATORS OF SUCCESS


LESSONS LEARNED• SENIOR LEADERSHIP INVOLVEMENT IS CRITICAL• SET GOALS … DEVELOP A ROAD MAP

• FORCE INTEGRATION AT EVERY OPPORTUNITY

• BROAD BASE HOLISTIC CARE … NO SILOS

• HIRE AT LEAST ONE EXPERT IN PRIMARY CARE • COST OF PROVIDING PRIMARY CARE IS MORE

EXPENSIVE THAN THAT OF MENTAL HEALTH CARE


LESSONS LEARNED• WORK ON SUSTAINABILITY IMMEDIATELY … YEAR ONE• FOSTER PARTNERSHIPS … CAN INCREASE OFFERINGS

WITH LITTLE COST• EDUCATING AND ASSISTING PATIENTS IN MANAGING

THEIR HEALTH CARE IS VITALLY IMPORTANT. PROVIDING THE SAME ASSISTANCE TO THEIR CARE GIVERS IS ESSENTIAL!

• ELECTRONIC HEALTH INFORMATION RECORDS ARE GREAT! PAPER CHARTS ARE NOT!

MAJOR COMPLAINT: Acute leg ulcers

MEDICAL HISTORY:Major Depressive DisorderGeneralized AnxietyDiabetesHypertensionAsthmaHyperlipidemia

MEDICATION REGIMEN: No Change In More Than 1 Year

CASE STUDY56-YEAR-OLD WHITE FEMALE

PHYSICAL EXAM: Weight 302: height 5’1” Blood Pressure: 148/90

Pulse 88 bpm; resp. 22 per minute Lungs clear; no wheezing, rales or rhonchi

Lower extremities: + 2 pitting edema bilaterally; pulses fair

LABS: ABNORMAL OR RELEVANT LABS ONLY Hemoglobin A1C: 9.2 (normal range 5.9-7)

Creatinine: 0.7 mg/dl (normal range: 0.7-1.4 mg/dl) Blood Urea Nitrogen: 18mg/dl (normal range: 7-21)

Sodium: 140 mEq/l (normal range 135-145mEq/l

LIPID PANEL: Total Cholesterol: 211 mg/dl (normal range<200 mg/dl)

LDL, Triglycerides: 10% Above normal in all three Liver function panel: within normal limits

CASE STUDY

Poorly Controlled, Severe, Persistent Asthma

Foot Ulcer On Left Foot

Dyslipidemia : Elevated LDL Despite Statin Therapy

Persistent Lower-extremity Edema Despite Diuretic Therapy

Hypokalemia

Hypertension Elevated

Coronary Artery Disease Stable

Obesity Stable

Financial Constraints Affecting Medication Behaviors

Insufficient Patient Education Regarding Purpose And Role Of Medications

Wellness, Preventive And Routine Monitoring Issues

ASSESSMENTS

REFERRAL TO ENDOCRINOLOGIST

SAME–DAY APPOINTMENT

PATIENT REFERRED BACK TO INTEGRATED PROGRAM WITH MEDICATION CHANGES AND MONTHLY

FOLLOW-UP APPOINTMENTS WITH ENDOCRINOLOGIST

AMPUTATION AVOIDED - ENDOCRINOLOGIST REPORTED THAT LEFT FOOT AMPUTATION WOULD HAVE RESULTED

IF NOT FOR IMMEDIATE REFERRAL

OUTCOMES


RESOURCESAetna Depression In Primary CareCherokee Health Systems – Training ProgramsCommonwealth Of Pennsylvania Screening, Brief Intervention, Referral And Treatment Hogg Foundation For Mental Health – Resource Guide Integrated Behavioral Health Project (IBHP) – Tool Kit Integrated Primary Care, Inc. Intermountain Behavioral Health Program John A. Hartford Foundation- Improving Mood: Promoting Access To Collaborative Care National Council For Community Behavioral Health Care Substance Abuse And Mental Health Services Administration SAMHSA University Of Massachusetts Certificate Program In Primary Behavioral Health Care HRSA- Starting A Rural Health Clinic – A How To Manuel


Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida

[email protected] 941-331-2530 ext. 1110

Anthony R. Bichel, Ph.D.Apalachee Center Inc., Tallahassee, [email protected] 850-459-7025

Rick Hankey, Senior Vice President and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida

[email protected] 352-315-7810

CONTACT INFORMATION

mailto:[email protected]



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PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION