Strategies to Build Strong Integrated Care Teams

Gail Armstrong, PhD, DNP, RN, ACNS-BC, CNEKathy Reims, MD

Sarah Stalder, PMHNP, RNLexi Barrere, PNP, RN

SIM Learning Collaborative March 7, 2019Broomfield, CO

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Session Objectives

1. Explore communication strategies traditionally used by primary care teams.2. Compare communication priorities and approaches used on behavioral health teams.3. Apply recent teamwork concepts and strategies to develop high functioning, collaborative teams in primary care.

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The Problem….

• Current evidence suggests that BH outcomes are improved through integrated primary care teams

• There is no literature about effective communication strategies.

• “Patients liked having behavioral and medical care under 1 roof; they appreciated that different members of their care team worked together, they reported feeling the positive effects of integration after only a few visits, and their outcomes improved.”

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Generalizations about Teams in PC

• Core team: • Physician • Physician assistant and or nurse practitioner • MAs• Shared nurse care manager• Sometimes social worker, pharmacist, billing specialist and others• Behavioral Health Professional?

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Evolution of PC Communication with PCMH

Autonomous Model• Staff meet needs of patients

with clinician direction• Orders• Transactional interactions to

solve problems or meet service needs

• Meet needs during patient visits

Care Team Model• Staff empowered to meet

patient needs• Standing orders, delegated tasks• Huddles, “teamlet” preparation• Population management,

managing risk

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Those with Mental Health Needs Often Present to Primary Care• Of those individuals with mental health disorders who had received

treatment in the last 12 months:

56% PC setting

44% MH setting

Less than 13% received minimally adequate treatment as measured 2005. 2016 “unsure if care is improved”

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Behavioral Health vs. Medical CultureBehavioral Health Medical

Work alone in quiet office Work closely with others in noisy, faced pacedenvironment

Office has a couch, pillows, soothing colors, dimmed lighting and carpet

Office is often white, sterile with functional furniture

50 min visits that may stretch over many weeks to resolve an issue

15-20 min visit to resolve an issue with a possible follow/up appointment

Services work towards quality of life and goals Services work towards illness reduction goals

Sessions are NEVER interrupted Visits are often interrupted

Information is NEVER shared without appropriate “client” permission

Information is often shared between relevant parties

Use techniques that promote personal growth and self responsibility

Use techniques that promote illness control and reduction of risk of damage from the illness

Burn out prevention and discussion about the impact of a difficult case are seen as essential to provide quality

care

Burn out prevention and discussion about the impact of a difficult case are rarely discussed or acknowledged.

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Behavioral Health Consultant Skills and Background

• Who typically fills this role• Credentialed BH-LCSW, MFT, LPC, Psych NP, or PhD/PsyD (may vary by state)

• Skills• Broad, generalist BH training (including substance use)• Strong assessment, diagnostic, therapeutic and triage skills• Acceptance of change and open to new ideas• Desire for continuous learning• Flexibility• Comfort in working with brief, solution-focused interventions in a time-limited

setting• Communication and consultant skills• Engaging of families and caregivers

Traditional BH Integrated BH

Patient seen in separate office Patient seen in exam roomSeparate Chart Same Chart

Defined Schedule Open Access50 minute visits 20-30 minute visits

Comprehensive BH Documentation Brief DocumentationFocused on resolution of Mental Health

DisordersFocused on functional outcomes for a wide range of Mental Health, Substance Abuse

and Chronic Health Conditions

Separate treatment plan Shared treatment planWorks independently Part of a interdisciplinary team

Communication through e-mail or set meetings

Communication and feedback are immediate

Adding a BHP to a PC Team is not a Slam Dunk!

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Sheridan Health Services

• FQHC• Nurse Run Clinic • PCMH• Empanelment Model• School Based Health Center

• 90% of patients below poverty level

• 56% Medicaid • 3% Medicare • 7% Private Insurance

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Integrated Care Model • Psychiatric Services incorporated into primary care setting

• Improves access to care• Patient Centered Collaboration • Decreases patients lost to follow-up/no-shows• Improves communication • Demonstrates better outcomes/ symptom improvement, functioning,

QOL, Cost Effective • Targets the Triple Aim approach

• Referral to Psych Services made by primary care • PMHNP consults with primary care • Symptom report and HAM-D/BDRS/Screening guide what level of

care the client is needing11

Moving Towards Collaborative care model

• Tiered Consult Model • Based on Advancing Integrated Mental Health Solutions

(AIMS) Model from the University of Washington • Model based on risk stratification • Effective since correct level of care is utilized given acuity

of psychiatric care• Consultations with PCP are opportunities for teaching • Relapse Prevention Plan

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Risk Stratification Via Tier system

TIER 1

• Patients Managed by PCP

• May need BH/ Warm Transfer

• Do not need Psych Consult or Psych Services

TIER 2

• Patients managed by PCP but need consult with PMHNP

• BH is involved • PCP will write

prescriptions

TIER 3

• PMHNP directly seeing patients

• Higher Acuity patients • Dx• Tx• Medication Class• Goal to get 50%

reduction in symptoms per screens

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Communication Model

• Empanelment • Consult Time: Scheduled Consult Time vs.

Impromptu Consults• Communication:

• Standard SBAR Format• Consults are mostly verbal • Referrals are written

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Roles and Communication

• ACE TEAM (Assess, Care Coordination and Evidence Base Practice to Enhance Integration of Behavioral Health in Primary Care)

• AM Huddles: Patient needs (Meds, PDMP, follow-up), Tier Assignment, SBHC huddles with PCP

• Primary Care Huddles: Currently staffing related will transistion

• RN Role: • Liaison between primary care needs and Psych Services • Role will transition to more assessment, patient follow-up in new tiered

model

• Case Management• Addresses Social Determinates of Health

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Primary Care and mental Health • PCPs have limited scheduled time with patients • BH warm transfer enables additional assessment• Lower acuity patients: PCP can see/ assess, monitor

medication management • Consults with PMHNP • PMHNP transfers patients back to PCP after cx is in

remission/ stable/ scores indicate a 50% reduction or HAM-D is 7 or less.

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Collaborative Care

• Monthly Integrated Care Meetings • Lead by BH Provider• All team members present

• Tracking Outcome Measures• HAM-D, BDRS tracked by PMHNP, PHQ-9, GAD-7….

Tracked in primary care• Challenges: Moving to tiered system, Lack of full

access to documentation. Ex. BH Notes 17

Tactics to “Integrate Culture”

• Space:• Share work space

• Structure: • Share reporting structure• Include medical team in BH hiring decisions; “fit”• Define clear scope of work for BH staff based on clinic

need• Prepare staff with clear expectations of how to use BH • Introduce BH staff as part of the clinical team• Build workflows that fit into existing processes• Include BH staff in staff meetings and clinic

responsibilities• Communication

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Clustering Recommendations into Specific Strategies

1. One structure for whole team: Rounding, Huddles, Debriefs 2. Medical Team/BH team on same page with language, communication:

SBAR, Read Backs & Closing the Loop of Communication3. Clear range of work = clear roles with everyone working at the top of

their scope4. Make BH concerns a routine component of primary care = Structured

Care Rounds

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1.Briefing Checklist (Sometimes Called Rounds)

TOPIC

Who is on your team today?

All members understandand agree upon goals?

Roles and responsibilitiesunderstood?

Staff availability?

Workload?

Available resources?

Review of the day’s patients?

Use briefing checklist to plan and manage your briefs

Include the following:

Clarify who will lead the team

Open lines of communication among team members

Set the tone for the upcoming slate of patients

Establish the protocols, responsibilities, and expected behaviors

Prepare the team for the flow of the day

Specify expectations

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1. AHRQ Suggested Daily Briefing Checklist

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1. Huddles

Held for problem-solving purposes

Quick, reactive, touch-base meetings to regain situation awareness

Allows team members to:

Discuss critical issues and emerging events

Anticipate outcomes and likely contingencies

Assign resources

Express concerns

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1. Use a Huddle To Change the Plan

• Huddles provide an opportunity to informally monitor situations

• With a huddle, the leader changes the plan and shares information with the team

• It is an important tool for monitoring and updating the team

• What are some examples of when a huddle would be appropriate in your practice?

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1. Debrief• Short, informal information exchange used as a

process improvement tool• Occurs after an event or shift

• Designed to improve teamwork skills• Actions and outcomes are discussed• Can include:

• An accurate reconstruction of key events• Analysis of what worked or did not work

and why• What should be done differently next time • Recognition of good team contributions

or catches

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1. Debrief ChecklistTOPIC

Communication clear?

Situation awarenessmaintained?

Workload distribution?

Did we ask for or offerassistance?Were errors made or avoided?What went well, what should change, what can improve?

Debrief checklist helps ensure that all information is discussed

Assess each of the following:

Team membership

Situation awareness

Mutual support

Communication

“What are our takeaways or lessons learned from this experience?”

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®

1. Handoffs

The transfer of information (along with authority and responsibility) during transitions in patient care

It includes an opportunity to ask questions, clarify, and confirm

Both authority and responsibility are transferred

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1. Handoffs

A proper handoff includes the following components:

Responsibility: Person is aware of assuming responsibility

Accountability: You are accountable until both parties are aware of the transfer

Uncertainty: Clear up all ambiguity before the transfer is complete

Communicate verbally

Acknowledged: Ensure that the handoff is understood and accepted

Opportunity: Evaluate the situation for both safety and quality

1. Handoff Exercise

Develop a handoff checklist based upon needs of your particular office:

How is your team unique?

Keep in mind core components

Share your handoff checklist with the rest of your team

Discuss whether the handoff checklist would improve workflow or care

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2. Standardized Communication Strategies

• SBAR• Situation• Background• Assessment• Recommendation

• Read Backs• Documented RB X 2

• Closing Loop of Communication• “To close the loop of

communication on this question…”

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2. Brown et al 2011• Sources of team conflict:

• Role boundary issues• Lack of understanding of scope of practice• Accountability

• Barriers to Conflict Resolution:• Lack of time/workload issues• People in less powerful positions (hierarchy

issues)• Lack of recognition or motivation to address

conflict• Avoiding confrontation

• Strategies:• Standardized Communication: CUS

• Flattening the hierarchy/psychological safety• Crucial Conversations Training• Work on roles, delegation and scope

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3. Team Based Relationships

How to Clarify Team Roles?• Structure

• Titles• Job Descriptions• Meeting Structures

• Process• Meeting Schedules• Team Evaluation Process• Inclusion of Patient/Family Feedback for Team

• Behaviors• Communication habits (rounding, huddles, debriefs)• Psychological Safety = Speaking Up

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3. Top-of-License Practice

Scope of the C.N.AScope of C. N.A + LPN + RN +

Diagnosis

Management of Plan of Care

Prescribing medications

APRNScope of C.N.A + LPN +

Performing baseline assessments to help determine plan of care

Adjusts plan of care with LIP

Administers IV medications

Implements independent nursing activities within RN scope

RNScope of C.N.A +

Administers medications

Contribute to assessment of health status of patients

Planning care for a patient whose condition is stable or predictable

LPNVital Signs

Assisting with administrative duties

Assisting with ADLs

C.N.A

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APRN

RN

LPN

C.N.A

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3. Why is Top of License Practice Important?

Increased Efficiency

Need for increased

coordination

Older patients

More complex patients

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4. Structured Care Rounds

• 2015 Mixed Methods Study• N=24• Acute Care for the Elderly• Multi-Disciplinary Team• Improved quality & safety• Notable outcome: increased joy

in work

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As we talk about resources….

• Unique Team Development for an Integrated Team

• Essential Elements• Leadership & Organizational

Commitment• Team Processes• Team Outcomes• Challenges & Barriers• Case Studies

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Resources• TeamSTEPPS: https://www.ahrq.gov/teamstepps/index.html• AHRQ – Comprehensive Unit Safety Program for Teams:

https://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.html

• IHI SBAR Technique: http://www.ihi.org/Topics/SBARCommunicationTechnique/Pages/default.aspx

• SAMHSA: Essential Elements of Effective Integrated Primary Care and Behavioral Health Teams: https://www.integration.samhsa.gov/workforce/team-members/Essential_Elements_of_an_Integrated_Team.pdf

• National Academy of Medicine (formerly IOM): Core Principles & Values of Effective Team-Based Health Care: http://nam.edu/wp-content/uploads/2015/06/VSRT-Team-Based-Care-Principles-Values.pdf

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References• Balasubramanian, B.A., Cohen, D.J., Jetelina, K.K., Dickinson, L.M., Davis, M., Gunn, R., et al. (2017).

Outcomes of integrated behavior health with primary care. Journal of the American Board of Family Physicians, 30(2): 130-139.

• Brown, J., Lewis, L., Kellis, K., Stewar, M., & Freeman, T.R. (2011). Conflict on interprofessional primary health care teams – Can it be resolved? Journal of Interprofessional Care, 25(1): 4-10.

• Garrison, G. M., Angstman, K. B., O'connor, S. S., Williams, M. D., & Lineberry, T. W. (2016). Time to remission for depression with collaborative care management (CCM) in primary care. The Journal of the American Board of Family Medicine, 29(1), 10-17.

• Gausvik, C., Lautar, A., Miller, L., Pallera, H., & Schlaudecker, J. (2015). Structured nursing communication on interdisciplinary acute care tams improves perceptions of safety, efficiency, understanding of care plan as well as job satisfaction. Journal of Multidisciplinary Healthcare, 8: 33-37.

• Katon, W., Unützer, J., Wells, K., & Jones, L. (2010). Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. General hospital psychiatry, 32(5), 456-464.

• Manderscheid, R., & Kathol, R. (2014). Fostering sustainable, integrated medical and behavioral health services in medical settings. Annals of Internal Medicine, 160(1), 61-65.

• Sorel, E., & Everett, A. Psychiatry & Primary Care Integration: Challenges & Opportunities APA Policy Brief. 38

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QUESTIONS?