Southwest CARE Center

Specialty ServicesBehavioral Health DepartmentProgram Development

Presented by: Jennifer Haley, LMSW

What will be covered in this presentation?

1. Integrated Behavioral Health Project (IBHP)• What?• Evidence?• Why?• Ready?• How?

2. Examine 4 Models for Integrating Behavioral Health in a Primary Care Setting

• Center for Excellence in Integrated Care (CEIC) - Clinical Pathways• SBIRT Colorado and Ryan White A & B, DOH• Community Health Center, Inc. of Connecticut • Buncombe County Health Center of North Carolina• Family Health Centers of San Diego, FQHC and PCMH

3. What do these models have in common, what does the evidence suggest?

4. Proposal for Behavioral Health Integration at the SCC Specialty Clinic

Integrated Behavioral Health ProjectIBHP has created a virtual library as a resource for those contemplating, planning, or operating treatment programs that integrate behavioral and medical services.

IBHP is a team of consultants working for CCI and the California Mental Health Services Authority (CalMHSA) as part of its Statewide Stigma and Discrimination Reduction Initiative. CalMHSA is an organization of county governments working to improve mental health outcomes for individuals, families and communities. CalMHSA administers programs funded by the Mental Health Services Act (Prop. 63) on a statewide, regional and local basis.

What is Integrated Behavioral Healthcare?

Levels of Integrated Care

• Level One: Minimal Collaboration• Level Two: Basic Collaboration At a Distance• Level Three: Basic Collaboration On-Site• Level Four: Close Collaboration In a Partly Integrated System• Level Five: Close Collaboration In a Fully Integrated System

Level Four and FiveClose Collaboration In a Partly Integrated

SystemMental health and other healthcare professionals

share the same sites and have some systems in common, such as scheduling or charting. There are regular face-to-face interactions about patients, mutual consultation, coordinated treatment plans for difficult cases, and a basic understanding and appreciation for each other's roles and cultures. There is a shared allegiance to a biopsychosocial/systems paradigm. However, the pragmatics are still sometimes difficult, team-building meetings are held only occasionally, and there may be operational discrepancies such as co-pays for mental health but not for medical services. There are likely to be unresolved but manageable tensions over medical physicians' greater power and influence on the collaborative team.

Close Collaboration In a Fully Integrated System

Mental health and other healthcare professionals share the same sites, the same vision, and the same systems in a seamless web of biopsychosocial services. Both the providers and the patients have the same expectation of a team offering prevention and treatment. All professionals are committed to a biopsychosocial/systems paradigm and have developed an in-depth understanding of each other's roles and cultures. Regular collaborative team meetings are held to discuss both patient issues and team collaboration issues. There are conscious efforts to balance power and influence among the professionals according to their roles and areas of expertise.

Level Four and Five ContinuedClose Collaboration In a Partly Integrated

System

Where practiced: Some HMOs, rehabilitation centers, and hospice centers that have worked systematically at team building. Also some family practice training programs.

Handles adequately: Cases with significant biopsychosocial interplay and management complications.

Handles inadequately: Complex cases with multiple providers and multiple larger systems involvement, especially when there is the potential for tension and conflicting agendas among providers or triangling on the part of the patient or family.

Close Collaboration In a Fully Integrated System

Where practiced: Some hospice centers and other special training and clinical settings.

Handles adequately: The most difficult and complex biopsychosocial cases with challenging management problems.

Handles inadequately: Cases where the resources of the health care team are insufficient or where breakdowns occur in the collaboration with larger service systems.

Why Behavioral Health Integration?Prevalence of Mental Health

conditions in Primary Care and in the General Public

"The current prevalence estimate is that about 20% of the U.S. population is affected by mental disorders during a given year. In general, 19% adults have a mental disorder alone in one year; 3% have both mental and addictive disorders; and 6% have addictive disorders alone. A subpopulation of 5.4% of adults is considered to have a serious "mental illness."

-Mental Health Report of the US Surgeon General, 1999.

A national survey found that 32% of undiagnosed, asymptomatic adults would likely turn to their primary care physician to help with mental health issues; only 4% would approach a mental health professional.

-Mental Health Association, America's Mental Health Survey, conducted by Roper Starch Worldwide, 2000.

Co-Occurrence of Mental Health and Physical Conditions

The Benefits of Integrated Care• Primary care community clinics are often the “first line of defense,” providing early intervention.

The presence of mental health professionals leads to increase recognition of behavioral needs and disorders.

• Integrated behavioral care produces significant positive results, including decreases in client depression levels, improvement in quality of life, decreased stress and lower rates of psychiatric hospitalization.

• More people will be reached and more access afforded if behavioral care is based in primary care settings. Studies have shown that initially most people turn to primary care providers, not specialty mental health clinics, with their emotional problems.

• Both medical and behavioral professionals can get the “full picture” about the clients they’re treating.

• Offering behavioral health services in nontraditional settings encourages participation by people wanting to avoid the stigma surrounding mental health treatment. Studies have demonstrated possible effects of perceived stigma by showing that clients are less likely to follow up on referrals made to mental health settings than they are to in-house services.

Evidence that Integrated Care Works1. Clinical Outcomes: Effective Collaborative Chronic Care Models increase physical quality of life,

social functioning, medication adherence and decreased mental health symptoms and substance use.

2. Cost Effectiveness: Decreased medical costs, ED utilization, inpatient services, net cost decreases in the first year averaging $500-$1500 in first year.

3. Client Satisfaction: Preference for on site services, average 75% symptom decrease, 95% satisfied/very

satisfied.

4. Provider Satisfaction: Average 90% of providers prefered a collaborative and integrated approach, 87% saw increase in patient wellness.

5. Follow through with referral and engagement in services: Average specialty mental health services drop 38%. Average 71% engagement with integrated services vs. 49% with outside referrals.

6. Reduce Stigma: “Shame, stigma, and discrimination are major reasons why people with mental health problems avoid seeking treatment, regardless of their race or ethnicity.” -Surgeon General’s Report on Mental Health, 1999.

Patient DirectedIt is important to meet the needs of patientsexperiencing mental health challenges and to buildstrong partnerships with community-based groupsincluding CMHC for specialty services outside ofthe integrated care settings capacity (i.e. inpatient).

At the SCC Specialty Clinic this would involveBuilding capacity for Primary Care Behavioral Health and integrated Brief-Intervention and Treatment services.

Dimensions of Integration• Mission Integration – The extent to which the behavioral and general medical service systems

are pointing toward the same health objectives, goals and strategies. [Rule: The goal is to improve the “health of the entire population, not just to treat the sick.]

• Clinical Service Integration – The degree to which general medical and behavioral providers seamlessly engage in coordinated assessment, intervention, and follow-up activities. [Rule: the more co-management processes, protocols and assessment tools, the better.]

• Physical Integration – The degree to which the general medical and behavioral health providers work in the same space, allowing for instantaneous access to care. [Rule: Co-location is NOT the same as integration.]

• Operations Integration – The degree to which the general medical and behavioral health providers work off the same clinic “platform”. {Rule: The more operations processes are shared (scheduling, reception, QI, support staff), the better.]

• Information Integration – The degree to which the general medical and behavioral health provider can access real time client care information. [Rule: Separate charts and sequestered information hamper collaboration.]

• Financial Integration – The degree to which general medical and behavioral health services are funded as a “basic” form of health care. {Rule: Integrative behavioral care should be financed as a “core primary care service.] -- Kirk Stroshal, Ph.D., 2007 presentation, Collaborative Family Healthcare Association conference

Ready? Provider Organization Readiness Assessment

Primary Care, Mental Health, Substance Use DisorderWhat is Needed to Succeed in the New Healthcare Ecosystem?

1. Fully Ready2. Substantial3. Progress4. Just Began5. Not Ready

Total 21-126=High127-252=Moderate253-525=Low

Readiness Questions Continued•How will clients be identified?•Who will prescribe antidepressants?•Who will provide counseling/psychotherapy?•Who will provide mental health backup?•Who will track clinical outcomes and how?•How will treatment changes be initiated?•How will team members communicate?•What is the overall implementation strategy?•Who will lead/coordinate the effort?•What kind of provider/staff training is needed?•What structural/program changes are needed?•What are anticipated barriers and challenges?•How will we measure success?•How can the model be sustained?

How?SystemsRoles and ResponsibilitiesProceduresHolistic (the whole person mind and body)

Program Evaluation (process, global, satisfaction)

Evidence-based Clinical Approaches

5 Integrated Behavioral Health Models

1. Center for Excellence in Integrated Care (CEIC) - Clinical Pathways

2. Screening Brief Intervention and Referral to Treatment (SBIRT)

3. Community Health Center, Inc. of Connecticut

4. Buncombe County Health Center of North Carolina

5. Family Health Centers of San Diego

Center for Excellence in Integrated Care

NY State Health Foundation“Clinical Pathways” for integrating behavioral services. Screening, assessment, and treatment planning.

CEIC Clinical PathwaysScreening, Assessment and Treatment Planning are the foundationof effective Service for MH and SU.

Screening• There is “No Wrong Door” for a patient to be referred to a Behavioral Health

Consultant for an Assessment.

• An empathetic referral can come from any provider or direct staff contact (i.e Case Manager, Nurse, Medical Assistant, Research, Pharmacist, etc.).

• A Universal Screen is integrated care best practice. Protocol for defining a positive screen. (i.e. SBIRT)

• The purpose of the universal screen is to identify if further assessment is warranted.

Assessment Best Practices • Is a Behavioral Health condition present?

• Engagement and Connection

• Person-Centered, Culturally Competent, and Trauma Informed.

• Comprehensive BioPsychoSocial, Mental Status Exam, and Functional Assessment.

• Utilizes validated instruments in Diagnostic Formulation.

• On-going assessment as part of treatment and outcome measures.

12 Steps of an Assessment 1. Engagement2. Collateral3. Associated Conditions4. Quadrant and Locus5. LOC6. Diagnosis7. Impairment8. Strengths and Supports9. Cultural and Linguistic10. Problem Domains11. Stage of Change12. Plan Treatment

Integrated Treatment Planning PCP works with CM and BHC to develop a plan together with patient collaboration.

• Evidence- & Consensus-based Practices (ECBPs), client preferences, shared decision making and clinical expertise.

• Integrated SA and MH Treatments.• A focus on dual recovery and self-management of chronic conditions.• Addressing housing, vocational, family, legal, and medical problems.• Approaches that are recovery-oriented, person centered, culturally competent.• Treatment planning should be client centered, addressing client’s goals and using

treatment strategies that are acceptable to them.

There should be equivalent attention to and resources for Screening & Assessment, and for the parallel development of consensus- and evidence-based treatment services.

Evidence-Based Practices for Integrated BH

• Motivational Interviewing (MI)• Cognitive Behavioral Therapy (CBT)• Improving Mood and Promoting Access to Collaborative Treatment (IMPACT)• SBIRT• Chronic Condition Self-Management• Mutual Self Help Groups• Contingency Management• Community Reinforcement Approach (CRA)• Integrated Dual-Diagnosis Treatment (IDDT)• Behavioral Couples and Family Therapy• Relaxation and Stress Reduction• Brief Intervention (BI)• Acceptance and Commitment Therapy (ACT)• Recovery Model• Stepped Care• Trauma-Informed and Trauma-Specific (i.e. Seeking Safety)

SBIRTScreening, Brief Intervention, Referral to Treatment

SBIRT The approach to SAMHSA’s Screening, Brief Intervention, and Referral to Treatment

(SBIRT) Initiative is simple.Screening. With just a few questions on a questionnaire or in an interview,

practitioners can identify patients who have alcohol or substance use or mental health problems and determine how severe those problems already are.

Brief Intervention. If screening results indicate moderate risk, individuals receive brief interventions. The intervention educates them about their substance use, alerts them to possible consequences, and motivates them to change their behavior.

Brief Treatment. If individuals are at moderate to high risk, the next step is brief treatment. Similar to brief intervention, this emphasizes motivations to change and client empowerment.

Referral to Treatment. For those whose screening indicates a severe problem or dependence, the next step is referral to substance abuse treatment.

SBIRT Colorado and Ryan White

With Ryan White Part B funding, the Colorado Department of Public Health And Environment, in collaboration with SBIRT Colorado, continues to expand SBIRT to HIV clinics and AIDS service organizations.

SBIRT will be a requirement, effective 2013, for any agency funded by CDPHE to provide case management and healthcare services for people living with HIV. To improve medication adherence, SBIRT is also part of the AIDS Drug Assistance Program phone-based medication therapy management program. The STI/HIV Prevention Program will include mental health and substance use prescreening as a best practice in all CDPHE-funded HIV prevention interventions.

Community Health Center, Inc.Unified Primary Care and Behavioral Health

Connecticut’s United Behavioral Health and Primary Care Clinical Model

Community Health Center, Inc., is a multi-site FQHC withfour sites providing co-located primary care and behavioralhealth services, which are embedded into the center’soperational framework. The interdisciplinary team shareswork space and meets daily for a “morning huddle” to reviewpatient treatment plans. All patients are screened using thePHQ-9. The “warm handoff,” in which the physician directlyintroduces the patient to the behavioral health clinician inthe exam room, is used to transition patients from primarycare staff to behavioral health clinicians.

Buncombe County Health CenterPrimary Care Behavioral Health Model

Primary Care Behavioral Health

This practice provides 85 percent of the safety-net care for low-income county residents. It is staffed by twelve physicians, physician assistants, and nurse practitioners, with three full-time co-located behavioral health clinicians. Clinicians work side by side with physicians. While a typical physician may see fifteen patients a day, a typical behavioral health clinician will see about ten patients. Behavioral health clinicians work out of medical examination rooms. One “behaviorist” is always on-call and available to immediately triage patients. The physicians and clinicians use the same waiting room and the same medical record. The behavioral health clinician makes specific, evidence-based recommendations to the physician. Prompt feedback is given to the physician either verbally or in a chart note. The behavioral health clinician is a member of the primary care team and is viewed more as a primary care provider than as a specialty mental health therapist.

Family Health Centers of San DiegoFQHC and PCMH

PCMH Connections for Multiply Diagnosed HIV+

Family Health Centers of San Diego (FHCSD) is the second-largest federally qualified health center (FQHC) in the U.S. (measured by unique clients served per year). In 2011, it became the 2nd FQHC in the country to be designated a Primary Care Medical Home (PCMH) by The Joint Commission. As the regional lead agency for HRSA's Health Care for the Homeless Program (HCHP), the clinic has a long history of innovation designed to meet the needs of homeless San Diegans—20% of whom are military veterans (a rate higher than even Los Angeles). Among our past innovations are the use of three Mobile Medical Units (MMUs) to serve homeless clients in places where they congregate—and then connect them with a medical home clinic. Among FHCSD’s Ryan White-supported HIV+ clients who are in HIV care, over 50% meet the definition of homelessness used in this RFP. Last year, FHCSD served 22,421 unduplicated homeless clients through its HCH program.

PCMH Connections for Multiply Diagnosed HIV+ (cont.)

FHCSD, People Assisting The Homeless, and the Institute for Public Health (IPH) at San Diego State University are collaborating on a pilot to evaluate a program designed to connect 12 dual-diagnosed HIV + homeless San Diegans per quarter (48 per year) with a PCMH, HIV care, alcohol and other drug (AOD) abuse treatment, psychiatric medication if indicated, behavioral health care, three months of transitional housing at Connections to help stabilize the client—leading to a permanent housing placement with ongoing PCMH and social service supports upon graduation. The project has been designed to cost-effectively leverage the Health Care for the Homeless & Ryan White Care Act infrastructure of San Diego. IPH will conduct a local evaluation and FHCSD will coordinate reporting with the federal ETAC overseeing this demonstration project.

What do these models have in common?Evidence Informed Practice

• Collaborative Care, Team-based, and Care Coordination• Person-Centered Care Home (PCMH or PCMH)- In-house model• Evidence Based-Practices, Brief Evidence-Based Psychotherapy, Classes/Groups• Honor consumer choice• Facilitate receipt of care (i.e. warm hand off, on site services) • Consulting Psychiatrist available 1-2 hours a weeks for PCP consultation• Screen, Assessment, Diagnosis, Treatment/Intervention, and Outcome Measures• Educate Providers and Consumers• Stepped care based on assessed Level of Care and clinical outcomes Chronic

condition self-management (i.e. skills training, groups, coaching, recovery model)• Standardized Behavioral Health delivery, documentation streamlined, and

standardized billing.• Tracking Behavioral Health services and referrals• Collaboration with CMHCs for unstable, crisis, or high acuity when not appropriately

serviced in a Primary Care Setting.

SCC ProposalBringing it all together

Patient Centered Medical Home (PCMH)• Clinical Pathways• SBIRT• Fully Integrated Hybrid Model: Unified

Primary Care/Behavioral Health Model and Primary Care Behavioral Health model

• Community-Based Partnerships/System of Care for wrap-around services (i.e. care coordination, constellation of services for quadrant levels I-IV)

• Outreach

Toward a Fully Integrated Hybrid Model

• Quadrants 1-IV (Low and high behavioral health needs especially high bh and high ph)

• Cross-discipline education and training needs are substantial• Office systems needs are substantial• Coordination of care among providers generally not a funded activity• Same-day billing• Patients have benefit packages for medical and mental health coverage• Lack of parity means that payment can be vastly different• If a new appointment is required, issues with no-show can increase• Sufficient funds to cover cost of employees needed• New codes for tobacco, substance, and behavioral interventions may not

be covered by various players.

Toward a Fully Integrated Hybrid Model (cont.)

Close collaboration in a fully integrated system – the behavioral health provider and primary care provider are on the same team.

• Single treatment plan (i.e. PH and BH)• No Wrong Door• Consulting Psychiatrist• Behavioral Health Clinician (i.e. consulting on the spot, brief intervention, and brief

treatment).• Universal screening and “warm hand offs”• “Behaviorist” available to triage patients (i.e. mini-MDTs)• “Wide-net” - brief focused interventions in lab rooms (15-20 min)• In-house Behavioral Health Services, Brief Treatment (evidence-based practices)• Outreach and home visits to engage patients in PCMH

References1. CalMHSA: IBHP California Mental Health Services Authority, Integrated Mental Health Project,

http://www.ibhp.org/2. New York State Health Foundation: Center for Exellance in Integrated Care,

http://nyshealth-ceic.org/3. SAMSHA and HRSA, Center for Integrated Health Solutions, http://www.integration.samhsa.gov/4. SAMSHA Screening, Brief Intervention, Refer to Treatment,

http://www.samhsa.gov/prevention/sbirt/5. SBIRT Colorado, http://www.improvinghealthcolorado.org/6. Cherokee Health Systems, a Tennessee FQHC and CMHC, http://www.cherokeehealth.com/7. La Clínica de la Raza, a California FQHC, http://www.laclinica.org/