Healthcare Synchronization:Healthcare Synchronization:a systemic integration a systemic integration

of of Behavioral Health Behavioral Health

across the Continuum of across the Continuum of Medical CareMedical Care

I didn’t pick my illnesses I didn’t pick my illnesses

To my endocrinologist, To my endocrinologist, I’m a diabeticI’m a diabetic

To my PCP, To my PCP, I have Crohn's DiseaseI have Crohn's Disease

To my OB-GYN,To my OB-GYN,It’s a recurring infection It’s a recurring infection

To my Oncologist, To my Oncologist, I have breast CAI have breast CA

To the hospitalist, To the hospitalist, I’m someone to stabilizeI’m someone to stabilize

To the ED doctor, To the ED doctor, I’ve got panic attacksI’ve got panic attacks

What’s the one thing they What’s the one thing they all have to deal with?all have to deal with?

The reason I have to see The reason I have to see them more than I should?them more than I should?

My depression . . .My depression . . .

. . . . my social . . my social stressors . . .stressors . . .

. . . and my addiction. . . and my addiction

Partial solutions . . .Partial solutions . . .

adding much needed services . . .adding much needed services . . .

Behavioral health inOncology

. . . creating medical homes . . . creating medical homes

But it’s a system’s problem . . . But it’s a system’s problem . . .

Behavioral Health Behavioral Health integration, integration,

like healthcare, like healthcare, has been has been

stitched together stitched together into a monsterinto a monster

““An arm here . . .An arm here . . .. . . a leg there . . . . . a leg there . .

..and last – and last – the brain ”the brain ”

Silos of integration Silos of integration • IndependentIndependent• UncoordinatedUncoordinated• UncooperativeUncooperative• DuplicativeDuplicative• ProtectiveProtective• ““My program” mentality My program” mentality

A philosophy of integration . . .A philosophy of integration . . .

• Behavioral Health is inclusive of promoting Behavioral Health is inclusive of promoting well-being, preventing/intervening in well-being, preventing/intervening in harmful behaviors, and the treatment of harmful behaviors, and the treatment of mental health and addiction disordersmental health and addiction disorders

New assumptions:New assumptions:

• Behavioral Health is a primary service first, a Behavioral Health is a primary service first, a specialty service secondspecialty service second

• Behavioral Health engages all behavioral Behavioral Health engages all behavioral health matters regardless of locationhealth matters regardless of location

• Treatment occurs at the site of the Treatment occurs at the site of the patient’s most numerous medical patient’s most numerous medical utilizationutilization

• Behavioral treatment is synchronized across Behavioral treatment is synchronized across the continuum of medical care the continuum of medical care

• The system engages with patients rather than The system engages with patients rather than patients engaging with departmentspatients engaging with departments

New assumptions:New assumptions:

Behavioral Health Integration Behavioral Health Integration is defined on three levels:is defined on three levels:• Substance abuse and mental Substance abuse and mental

health treatmenthealth treatment• Internal integration of core Internal integration of core

traditional servicestraditional services• External integration into the External integration into the

continuum of medicinecontinuum of medicine

Realigning and repurposing existing Realigning and repurposing existing resources to be FTE neutral resources to be FTE neutral

All integration efforts, All integration efforts, both internal and both internal and

external,external, begin with the begin with the

developmentdevelopmentof the Hybrid Clinicianof the Hybrid Clinician

Creating ethos Creating ethos

As every Marine is a As every Marine is a rifleman . . .rifleman . . .

. . . every clinician . . . every clinician is a hybridis a hybrid

Hybrid Clinician profile: Hybrid Clinician profile: • Licensed Masters-level clinician in social Licensed Masters-level clinician in social

work, psychology or marriage/family work, psychology or marriage/family • Licensed or Certified Alcohol/Drug Abuse Licensed or Certified Alcohol/Drug Abuse

CounselorCounselor• Conceptual/systems thinkerConceptual/systems thinker• Flexible team playerFlexible team player• Strong diagnostic skillsStrong diagnostic skills

Hybrid Clinician profile: Hybrid Clinician profile: • Experienced in different Experienced in different

levels of carelevels of care• Entrepreneurial Entrepreneurial • Desire to be more than “just Desire to be more than “just

a therapist”a therapist”

Skillset of a Hybrid Clinician: Skillset of a Hybrid Clinician: • Knows the entire systemKnows the entire system• Functions at any level of careFunctions at any level of care• Crisis AssessmentCrisis Assessment• Interventionist: CBT/SFBT/MIInterventionist: CBT/SFBT/MI• High Risk Care ManagementHigh Risk Care Management• Utilization ManagementUtilization Management• Registrar Registrar

• Versed in Lean PrinciplesVersed in Lean Principles• Certified in Primary Certified in Primary

Behavioral Health CareBehavioral Health Care

Skillset of a Hybrid Clinician: Skillset of a Hybrid Clinician:

Financial sustainability Financial sustainability is achieved through existing payment mechanisms is achieved through existing payment mechanisms

and creative partnerships with payers and creative partnerships with payers

Building an organic system:Building an organic system:• Embedding infrastructure Embedding infrastructure

rather than just a servicerather than just a service• Hybrid skillsets, i.e., case Hybrid skillsets, i.e., case finding/screening/assessment etc. become a finding/screening/assessment etc. become a centralized function as opposed to discreet centralized function as opposed to discreet disciplines or locations – “no wrong front door”disciplines or locations – “no wrong front door”

• Behavioral health treatment is Behavioral health treatment is synchronized and flows with the synchronized and flows with the patient through the continuumpatient through the continuum

To engage with a Hybrid To engage with a Hybrid is to is to

have access to the continuumhave access to the continuum

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital SystemSingle Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital SystemSingle Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

SpeciallySpeciallyTrainedTrainedHybrid Hybrid

CliniciansClinicians

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital SystemSingle Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

PreviouslyPreviouslyUnidentifiedUnidentified

Psych DriversPsych Drivers

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital SystemSingle Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

PreviouslyPreviouslyUnidentifiedUnidentified

Psych DriversPsych Drivers

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital SystemSingle Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Integrate Integrate intointo

SystemSystemPCPs & PCPs &

SpecialtiesSpecialties

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital SystemSingle Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Integrate Integrate intointo

SystemSystemPCPs & PCPs &

SpecialtiesSpecialties

• ““You can’t do that”You can’t do that”• ““Our system is too big”Our system is too big”• ““You can’t do this all at once”You can’t do this all at once”• ““HIPAA”HIPAA”• ““We can’t afford additional FTEs”We can’t afford additional FTEs”

Challenges/Hurdles:Challenges/Hurdles:

First Steps: First Steps: • Diagnostic assessment of the existing system Diagnostic assessment of the existing system - infrastructure- infrastructure - culture - culture - continuum connectivity- continuum connectivity - nimbleness- nimbleness - current employees for goodness of fit- current employees for goodness of fit• ““Tell the story” – the gospel of the modelTell the story” – the gospel of the model

First Steps: First Steps: • Identify administrator and physician championsIdentify administrator and physician champions• Identify/train 1Identify/train 1stst generation Hybrids and their generation Hybrids and their

leaderleader• Educate payers regarding the model and have Educate payers regarding the model and have

Hybrids credentialed on all panels Hybrids credentialed on all panels • Engage Finance for all proper supportEngage Finance for all proper support• Engage IT for all proper supportEngage IT for all proper support• Identify PCP/Specialty beta sitesIdentify PCP/Specialty beta sites

First Steps: First Steps: • ““Tell the story”Tell the story”• ““Tell the story”Tell the story”• ““Tell the story” Tell the story” • Hybrids must know the Hybrids must know the

model chapter and versemodel chapter and verse

First Steps are bothFirst Steps are bothsequential and simultaneoussequential and simultaneous

efforts efforts

““Move fast slowly” Move fast slowly”

Playing in old Playing in old Yankee Yankee

Stadium while Stadium while building new building new

Yankee Yankee StadiumStadium

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

The Integrated SystemThe Integrated System

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

The Integrated SystemThe Integrated SystemOne One

DepartmentDepartment

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

The Integrated SystemThe Integrated SystemOne One

DepartmentDepartmentOne IdentityOne Identity

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

The Integrated SystemThe Integrated SystemOne One

DepartmentDepartmentOne IdentityOne IdentityMultifaceteMultifacete

dd

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

The Integrated SystemThe Integrated SystemOne One

DepartmentDepartmentOne IdentityOne IdentityMultifaceteMultifacete

ddRevenue Revenue generatinggenerating

Across Across the the

Continuum of CareContinuum of Care

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

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NoNoWrongWrongDoorDoor

The Integrated SystemThe Integrated SystemOne One

DepartmentDepartmentOne IdentityOne IdentityMultifaceteMultifacete

ddRevenue Revenue generatinggenerating

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

The Integrated SystemThe Integrated SystemSupplemented by Supplemented by

billablebillableWeb-basedWeb-based

CBTCBT

Web-basedCBT

What it is and what it does . . . What it is and what it does . . .

What it is and what it does . . . What it is and what it does . . .

infrastructure, not just a service infrastructure, not just a service

What it is and what it does . . . What it is and what it does . . .

infrastructure, not just a service infrastructure, not just a service coordination of systems rather than coordination of systems rather than

clinicians clinicians

What it is and what it does . . . What it is and what it does . . .

infrastructure, not just a service infrastructure, not just a service coordination of systems rather than coordination of systems rather than

clinicians clinicians delivers treatment where the patients delivers treatment where the patients

are are

What it is and what it does . . . What it is and what it does . . .

infrastructure, not just a service infrastructure, not just a service coordination of systems rather than coordination of systems rather than

clinicians clinicians delivers treatment where the patients delivers treatment where the patients

are are reduces stigma and impacts compliancereduces stigma and impacts compliance

What it is and what it does . . . What it is and what it does . . .

infrastructure, not just a service infrastructure, not just a service coordination of systems rather than coordination of systems rather than

clinicians clinicians delivers treatment where the patients delivers treatment where the patients

are are reduces stigma and impacts compliancereduces stigma and impacts compliance

impacts costimpacts cost