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What is it?
How does it work?
Who does it serve?
INTEGRATED CARE
RURAL INTEGRATED WELLNESS PROGRAM
SARA RICHARDSON RNLISA NEEMAN LCSW
COPE Cent
er
Community Behavioral Health CenterPsychotherapy ServicesEvidence-Based PracticeCoping Skills DevelopmentCase ManagementMedication ManagementPsychosocial RehabResidential Services Respite ServicesEmergency Triage ServicesNo CSU
COPE CENTERCHAUTAUQUA OFFICE OF PSYCHOTHERAPY AND
EVALUATION, INC.
My name is Sara RichardsonRegistered Nurse since 2005Labor & Delivery Nurse 2005-2014BS Degree Human Services May ‘14
RN Care Coordinator July ‘14Developed & Implemented RIWP MSN Nurse Educator May ‘17
A LITTLE ABOUT MYSELF
What is i t?
How does i t work?
Who does it serve?
INTEGRATED CARE
What is it?Integrated Care defined
How does it work?Integrated Care models discussed
Who does it serve?Population served
INTEGRATED CARE
Learn how the Integrated Care Model works.
Learn the benefits of Integrated Care
Learn who benefits most from Integrated Care
GOALS FOR TODAY
What
Is
It?
INTEGRATED CARE
INTEGRATED CARE
“Integrating care is vital to addressing all the healthcare needs of individuals with mental health and substance use problems—regardless of whether primary care services are integrated into behavioral health systems, or vice versa. Many integrated care models illustrate the successful integration of primary care into behavioral healthcare, and can guide behavioral healthcare organizations in integrating primary care into their own service system.” SAMHSA
Systematic CoordinationSimultaneous consideration of all health conditions
Health professionals working togetherCoordinated diagnoses and treatment that compliment each other
Tailored to the individualUnderstanding the whole person
INTEGRATED CARE - WHAT IS IT?
Integrated Care is also known as……Case ManagementAdvanced Care ManagementTargeted Case ManagementHigh-Risk Case ManagementCare CoordinationDisease ManagementCollaborative Care
INTEGRATED CARE - WHAT IS IT?
•Integrates•Who a person is •With how they feel•With what they believe•With what they need
INTEGRATED CARE – WHAT IS IT?
How
Does
It
Work?
INTEGRATED CARE
Doherty, McDaniel, Baird, and Reynolds Levels of Integration
Four Quadrant ModelThe IMPACT ModelThe Chronic Care Model
INTEGRATED CARE TOOLS/MODELS
Evolving Models of Behavioral Health Integration in Primary Care
Integration of Mental Health/Substance Abuse and Primary Care
The Integrated Behavioral Health Project’s Partners in Health: Primary Care/County Mental Health Collaboration Toolkit
Depression and Primary Care
INTEGRATED CARE RESOURCES
Levels of Integration ModelDoherty, McDaniel, and Baird (1995, 1996)
Describes degree of involvement and sophistication in collaborative healthcare
The Four Quadrant ModelWidely used by The National CouncilPopulation-based planning frameworkPerson-centered Healthcare Home
TODAY WE WILL DISCUSS…
Proposed use of the levels would:Evaluate Establish goals Assist in research Compare models with varying populations
LEVELS OF INTEGRATION MODEL
Leveling SystemLevel 1 Minimal CollaborationLevel 2 Basic Collaboration at a Distance
Level 3 Basic Collaboration OnsiteLevel 4 Close Collaboration In a Partially Integrated System
Level 5 Close Collaboration In a Fully Integrated System
LEVELS OF INTEGRATION MODEL
Level 1 - Minimal Collaboration Separate systemsSeparate facilitiesCommunication is rareLittle appreciation of each other’s role
FIVE LEVELS OF COLLABORATION
Level 2 Basic Collaboration from a DistanceSeparate systemsSeparate facilitiesPeriodic focused communication, mostly written
View each other as outside resourcesLittle understanding of each other’s role
FIVE LEVELS OF COLLABORATION
Level 3 Basic Collaboration OnsiteSeparate systemsSame facilitiesRegular communication, occasionally face-to-face
Some appreciation of each other’s role and general sense of larger picture
FIVE LEVELS OF COLLABORATION
Level 4 Close Collaboration – Partially IntegratedSome shared systemsSame facilitiesFace-to-Face consultation; coordinated treatment plans
Basic appreciation of each other’s role
FIVE LEVELS OF COLLABORATION
Level 5 Close Collaboration – Fully IntegratedShared systems and facilities in seamless bio-psychosocial web
Consumers and providers have some expectations of the shared system
In-depth appreciation of each other’s roleCollaborative routines are regular and smoothConscious, influential sharing based on situation and expertise
“Together, we teach others how to be a team in caring for consumers and in how to design a care system”
FIVE LEVELS OF COLLABORATION
Populations to be served
Conceptual Framework
Collaborative Planning Tool
Developing an Integrated Care System
Environmental Factors
HOW DOES IT WORK?
Quadrant II
High Behavioral Health (BH)Low Physical Health (PH) Heritage is medical home. Care to be provided by or arranged by Heritage BH Counselor Criteria for placement in this quadrant May have accessed services at CHIC or HBH Eligible for 132 Services
Has low physical health risk/ complexity Needs psychotropic medication provided by psychiatrist at HBH Physical health care by PCP located at HBH May have stigma issue about going to Heritage Needs case management, housing, assistance with finances & or Heritage
Payee services Dual problems of S/A & MH (requires treatment for both) Inpatient Hospitalization in past or required now. Needs daily living skills training Needs outreach services provided by HeritageActions to Be Taken : Clinician arranges case management services for housing and other
community supports Arranges for S/A treatment Arranges for access to primary health care if enters @ HBH, and assures
communication with Primary Care Physician (PCP) BH Clinician provides assessment, Psychiatrist provides and monitors needed medication
Quadrant IVHigh Behavioral Health (BH)High Physical Health (PH) Heritage is medical home with counseling and case management services provided at Heritage Criteria for placement in this quadrant Accesses services at Heritage in most cases Physical health care by PCP located at Heritage Eligible for 132 Services
Has complex and high risk physical problems, and requires regular physician visits, and or specialty physician care
Needs a BH case manager at HBH who provides assistance with housing, financial assistance
May have Dual problems of S/A and MH (requires treatment for both)Needs inpatient hospitalization for either physical or mental health issues
Actions to Be Taken: Primary Dr provides primary care and assures specialty physical health care
when needed Heritage BH counselor assures collaboration between BH & PH BH clinician arranges for case management and other needed support
services Psychiatrist provides and monitors needed medication If no Primary care physician at HBH, will receive primary care at CHIC
Quadrant ILow Behavioral HealthLow Physical Health CHIC is medical home with on site CHIC BH clinician Criteria For Placement in this quadrant May have accessed services at CHIC or HBH Low physical health risk/complexity Slightly elevated health or BH risk Client may need BH and or S/A triage, assessment, and service planning Brief BH counseling or treatment or group therapy May need referral to community and educational resources May need health risk education Drs only clients at HBH would be appropriate in this quadrantActions to Be Taken: PCP provides primary care and uses screening tools and guidelines to serve
most individuals in Primary Care Refers to & collaborates with psychiatrist to assure coordinated care CHIC BH clinician provides formal and informal consultation to the PCP CHIC BH clinician provides brief counseling Psychiatric consultation provided to PCP if needed
Quadrant III High Physical Health Low Behavior Health CHIC is medical home with on site CHIC BH clinician Criteria for Placement in this quadrant Has complex and high risk physical health problems, and requires regular
physician visits, and or specialty physician care Low BH needs, but needs screening by PCP using screening tools May need BH triage or assessment May need consultation to the PCP May need referral to community educational resourcesActions To Be Taken:
PCP provides primary care and assures specialty care when neededPCP utilizes BH screening tools and guidelines to serve most individuals in
Primary CareBH clinician provides triage, assessment, & consultation with PCP
QUADRANT I
PopulationLow to moderate behavioral health complexity/risk.
Low to moderate physical health complexity/risk.
ModelBehavioral health capacity in a primary care setting
Primary care is main focusScreening for behavioral concerns
Stepped care – Referred for psychiatric consultation
QUADRANT I
Primary ProviderMD or ARNPAssures the full-scope healthcare home
Provides assessment, diagnosis, and prescribes treatment
Utilizes standard behavioral health screening tools guidelines
Prescribes psychotropic medications
QUADRANT I
Other ProvidersRN or LPN
Supports primary care provider’s roleProvides triage and assessment as well as brief treatment services
Coordinates referrals to community and educational resources
Facilitates stepped care to specialty medical, surgical, and behavioral health services
QUADRANT I
PopulationLow to moderate behavioral health complexity/risk
Moderate to high physical health complexity/risk
QUADRANT III
ModelBehavioral health capacity in a primary care settingPrimary care is main focusMedical/Surgical ServicesCare management Screening for behavioral concernsStepped care – Referred for psychiatric consultation
QUADRANT III
Primary ProviderMD or ARNP
Assures the full-scope healthcare home
Provides assessment, diagnosis, and prescribes treatment
Utilizes standard behavioral health screening tools guidelines
Prescribes psychotropic medicationsCollaborates with specialty medical, surgical, and behavioral health providers
QUADRANT III
Other Providers RN or LPN
Supports primary care provider’s roleProvides triage and assessment as well as brief treatment services
Coordinates referrals to community and educational resources
Provides health education and behavioral supports regarding lifestyle and chronic health conditions
Facilitates stepped care to specialty medical, surgical, and behavioral health services
QUADRANT III
PopulationModerate to high behavioral health complexity/risk
Low to moderate physical health complexity/risk
QUADRANT II
ModelPrimary care capacity in a behavioral health settingBehavioral health care is main focusSpecialty behavioral health servicesRecovery supportWellness programs Health ScreeningsStepped Care – Referred for medical consultation
QUADRANT II
Primary ProviderPsychiatrist or Psychiatric ARNPEvaluates mental health statusPrescribes psychotropic medications
Collaborates with therapistsCollaborates with RN/LPN
QUADRANT II
Other Providers RN or LPN
Provides standard health screenings and preventative services
Provides behavioral health triage and assessment
Coordinates behavioral health servicesEnsures coordinated service planningConducts Wellness ProgramsProvides care coordinationFacilitates stepped care for medical consultation
QUADRANT II
The PopulationModerate to high behavioral health complexity/risk
Moderate to high physical health complexity/risk
QUADRANT IV
ModelPrimary care capacity in a behavioral health settingBehavioral health care is main focusSpecialty behavioral health servicesRecovery supportWellness programs Health ScreeningsStepped Care – Referred for complex medical consultation
QUADRANT IV
Primary ProviderPsychiatrist or Psychiatric ARNP
Evaluates mental health statusPrescribes psychotropic medicationsCollaborates with therapistsCollaborates with RN/LPN
QUADRANT IV
Primary ProviderMD or ARNP
Assures the full-scope healthcare home
Provides assessment, diagnosis, and prescribes treatment
Utilizes standard health screenings and preventative services
Collaborates with specialty medical and surgical care providers
QUADRANT IV
Other Providers RN or LPN
Provides standard health screenings and preventative services
Provides behavioral health triage and assessment
Coordinates behavioral health servicesEnsures coordinated service planningConducts Wellness ProgramsFacilitates stepped care to specialty medical and surgical care providers
QUADRANT IV
Other Providers – ContinuedNurse Case Manager
Coordinates care between the client, Primary Care Team, Behavioral Health Team, and Specialty Care Services
Collaborates with the behavioral health clinicians, internal case managers and external care managers to support the needs of the client
Links clients to needed services, community resources, and other supportive services to ensure continuity of care
QUADRANT IV
Who
Does
It
Serve?
INTEGRATED CARE
WHO DOES IT SERVE?
EVERYBODY
WHO DOES IT SERVE?
IndividualsCommunitiesProvidersHospitalsCrisis Stabilization UnitsInsurance companiesGovernment
Barriers
and
Benefits
INTEGRATED CARE
FinancialPolicy and RegulationWorkforceClinical information sharing
Physical facilitiesResearch
BARRIERS TO INTEGRATED CARE(AGENCY)
Access to care LanguageLack of support systemFinancial TransportationKnowledge DeficitChild CareStigma
BARRIERS TO INTEGRATED CARE(INDIVIDUAL)
Decreases utilization of Emergency Room for minor medical concerns
Decreases utilization of Crisis Stabilization Units for Baker Act Admissions
Ensures appropriate medication management Increases medication complianceEnsures access to care Provides a unique support system for the
individual served alleviating barriers to health care while encouraging a healthy lifestyle
BENEFITS OF INTEGRATED CARE(AGENCY)
Access to careHolistic careConvenienceDelay to care preventedEstablished support system developed
EHR reduces medical errorsDecreased stigma
BENEFITS TO INTEGRATED CARE(INDIVIDUAL)
According to the Detroit Wayne Mental Health Authority: Improves access to careReduces morbidity and mortalityReduces life threatening and chronic conditions
Provides better monitoring of health conditions
All services can be provided in one locationReduces medication complicationsReduces stigma related to behavioral health
BENEFITS OF INTEGRATED CARE (OVERALL)
Who
Does
It
Benefit?
INTEGRATED CARE
WHO DOES IT BENEFIT?
EVERYBODY
WHO DOES IT BENEFIT?
IndividualsCommunitiesProvidersHospitalsCrisis Stabilization UnitsInsurance companiesGovernment
COPE
Center
RIWP
Model
INTEGRATED CARE
DO YOU KNOW THIS CLIENT?
Ms. Z, 48 year old female, comes to the clinic reporting she is depressed and overwhelmed. She is tearful, and states that she has no medications and can’t afford them. Ms. Z describes “numerous stressors” including being unemployed, having no transportation, an alcoholic husband, a son in jail, and several health problems. Ms. Z has diabetes, anxiety, depression, and chronic pain.
The front desk staff call, reporting that Mr. M is at the counter requesting to be seen right away. His chart has been closed because he hadn’t returned to the clinic following his last hospitalization. He has a history of substance abuse, and a pattern of dropping out of treatment then coming to the clinic asking to be seen immediately. Mr. M has hypertension, obesity, bipolar disorder, and is a smoker.
DO YOU KNOW THIS CLIENT?
People who :
Haven’t had a medical check up in years; ORUse the Emergency Department for all healthcare
Have limited knowledge of their healthHave limited resourcesHave multiple psychosocial issuesMental health conditions impacting physical health conditions impacting mental health conditions
AN UNMET NEED
Original projection of service:125 people to be served in FY 2014/2015 at a cost of $800 per person.Compared to the cost to state for psychiatric hospitalization of $112,000 per admission OR
The average LOS in a CSU of three to five days at $885 to $1475 per episode.
Actual Service:412 duplicated clients served over a 12 month period, 148 total served at a cost of $675.67 per person
AN UNMET NEED
Reduce Baker Act admissions by 10%.
75% of the clients will have a primary care physician.
Reduce ER visits by 20%.
PROGRAM GOALS
Reduce Baker Act admissions by 10%.
The outcome: 0.01% of people served were readmitted under a Baker Act while receiving services and for three months post discharge.
PROGRAM GOALS
75% of the clients will have a primary care physician.
The outcome: 87% of people served either obtained or maintained a primary care provider.
PROGRAM GOALS
Reduce ER visits by 20%.
The outcome: 88% of appointments with a primary care provider were kept.
PROGRAM GOALS
Reduce ER visits by 20%.
The outcome: 18 ER visits for the year.
PROGRAM GOALS
• Population•Adults age 18 years and older•Residents of Walton County • Indigent/Uninsured•Severe/Persistent Mental Health Diagnosis•At least one chronic physical health diagnosis
COPE CENTER RIWP
Model (Similar to Quadrant IV)Person Centered Healthcare Home
Primary care capacity in a behavioral health setting
Utilizing a Nurse Care ManagerAccess to specialty behavioral health services Screening/TrackingWellness programmingHealth education and promotion Care coordination/Case managementStepped Care – Referred to primary care services
COPE CENTER RIWP
ProvidersNurse Care ManagerPsychiatrist and/or Psychiatric ARNP
LPNOutpatient Therapist
COPE CENTER RIWP
Coordination of medical and mental health care services
Health promotion and educationMedication assistance and educationTransportation assistanceAssistance paying for health related
services (copays, labs, diagnostics, etc.)
Assistance completing paperwork related to health services, SSI/SSD, Food Stamps, and Medicaid
PROGRAM SERVICES INCLUDE
Referral receivedMainly internal referrals
Initial Interview Screen completed for eligibility
Integrated Health Assessment completedAssess & identify needs
Individualized Treatment Plan developed Collaboration with client and therapist/LPN
Care Coordination Linkage to primary care services
HOW DOES IT WORK?
Case management including: Health education and promotionMedication assistance and education Transportation assistanceAssistance in paying for office visit copays, labs, diagnostics, etc.
Assistance in completing paperwork Discharge planning as appropriateCrisis Stabilization/Emergency Services
HOW DOES IT WORK?
Community OutreachCase Management StaffingsGeneral/Clinical Staff MeetingsVisiting provider officesHealth fairsWCHIP – Walton County Health Initiative Plan
Conferences
HOW DOES IT WORK?
Lessons Learne
dINTEGRATED CARE
Just because we wanted to have integrated health care doesn’t mean everyone else did
Obvious shortage of providersNo shortage of clients Lack of available resourcesYou can’t serve everyoneHIPAA and coordination of careChallenges related to startupFunding limitations inhibited sustainability
LESSONS LEARNED
Sara Richardson
RN Care Coordinator
COPE Center
THANK YOU
FOR
PARTICIPATING
Click icon to add picture
(n.d.). Retrieved June 9, 2015, from SAMHSA-HRSA Center for Integrated Health Solutions: http://www.integration.samhsa.gov/about-us/what-is-integrated-care
(n.d.). Retrieved June 9, 2015, from SAMHSA-HRSA Center for Integrated Health Solutions: http://www.integration.samhsa.gov/integrated-care-models/list
(n.d.). Retrieved June 9, 2015, from SAMHSA: http://www.integration.samhsa.gov/integrated-care-models/2012-07-23UnderstandingHealthReform.pdf
(n.d.). Retrieved June 9, 2015, from SAMHSA-HRSA Center for Integrated Health Care: http://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf
REFERENCES
(n.d.). Retrieved June 9, 2015, from Alliance for Health Reform: http://www.allhealth.org/briefi ngmaterials/BehavioralHealthandPrimaryCareIntegrationandthePerson-CenteredHealthcareHome-1547.pdf
(n.d.). Retrieved June 9, 2015, from SAMHSA-HRSA: http://www.integration.samhsa.gov/Reimbursement_of_Mental_Health_Services_in_Primary_Care_Settings.pdf
(n.d.). Retrieved June 9, 2015, from State of Il l inois Department of Human Services: https://www.dhs.state.il.us/OneNetLibrary/27897/documents/Mental%20Health/Pelletier/dknabe/HBHoCHICoFouroQuadrantoTemplate2010anddefi nitions.doc
(n.d.). Retrieved June 9, 2015, from Detroit Wayne Mental Health Authority: http://www.dwmha.com/AuthorityDepts/IntegratedHealthcare/About.aspx
REFERENCES
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730893/
J Med. Author manuscript; available in PMC 2009 Nov 1.
Published in final edited form as:Am J Med. 2008 Nov; 121(11 Suppl 2): S1–S7. doi: 10.1016/j.amjmed.2008.09.007PMCID: PMC2730893NIHMSID: NIHMS127093Introduction: Chronic Medical Conditions and
Depression: the View from Primary CareRichard L. Kravitz, MD, MSPH1 and Daniel Ford, MD2
REFERENCES
QUESTIONS
