WelcomeThe National Cooperative Agreement on

Clinical Workforce Development

WEBINAR 7: Achieving Full Integration of Behavioral Health and Primary Care

May 19th, 2016

Presented by the the Community Health Center, Inc. & the MacColl Center for Health Care

Innovation

SpeakersFrom MacColl Center for Health Care Innovation, Group Health Research Institute:Ed Wagner, MD, MPH, Director Emeritus Brian Austin, Deputy DirectorKatie Coleman, MSPH, Research Associate

From Leibig-Shepherd, LLC:Carolyn Shepherd, MD

From Old Town Recovery Center:Shanako DeVoll, CSWA, QMHP, CADC III, IHART Program ManagerErika Armsbury, MSW, QMHP, Director of Clinical Services

From Community Health Center, Inc.:Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director Kerry Bamrick, MBA, Senior Program ManagerTim Kearney, PhD, Chief Behavioral Health Officer Veena Channamsetty, MD, Chief Medical Officer

LEARNING COLLABORATIVE APPLICATIONS NOW OPEN!

o Participation in the Learning Collaborative is FREE for health centers.

o 9-month intensive learning collaborative provided by CHCI, it’s Weitzman Institute and partners

o Team Based Care or Post-Graduate Residency Program

How to apply?-Visit www.chc1.com/nca -PDF of the application is available on

our website -Applications due May 31st

Learning Objectives:1. Participants will be able to describe the features that

distinguish effective behavioral health programs.

2. Participants will be able to describe ways that expanded care team members can work with core team members to provide seamless, non-fragmented care to patients.

Get the Most Out of Your Zoom Experience• Send your questions using Q&A function in Zoom• Look for our polling questions• Live tweet us at @CHCworkforceNCA and #primarycareteams and

#HRSAnca • Recording and slides are available after the presentation on our

website within one week• CME approved activity; requires survey completion • Upcoming webinars: Register at www.chc1.com/nca

Integrating Behavioral Health and Primary Care

Learning from Effective Ambulatory Practices

MacColl Center for Health Care InnovationGroup Health Research Institute

May 19th , 2016

Ed Wagner, Director Emeritus Katie Coleman, Research Associate | Brian Austin, Deputy Director

The Key Functions Of Excellent Primary Care

The challenges of caring for the patient with behavioral health problems

Diverse clinical problems and care/staff needs • Acute distress needing assessment and short-term therapy• Established mental health disorder needing chronic therapy and management• Substance abuse

Added care complexity• Psychiatric disorders and substance abuse problems:

• require specialized assessment and treatment competencies• respond slowly to treatment• Interfere with patient empowerment and self-management competence• often involve complicated pharmacologic issues

Why manage in primary care?• The PC team’s relationships with and knowledge of the patients are often key to recovery.• A PCMH is better able to track and follow patients than most mental health providers.• Only 50% of patients who receive a referral for specialty mental health care ever follow

through with the referral. Among those who do, many do not have more than one visit.

Providing effective care for behavioral health problems in primary care requires:

• Full implementation of the patient-centered medical home.

• Integrated behavioral health expertise; co-location alone is not enough.

• Primary care clinicians willing and able to be accountable for BH care.

• Shared or integrated care: sharing (interactive communication*) of care planning and care management between primary and mental health care;

• Clinical care management services integrated with primary care

* Foy et al. Ann Int Med 2010; 152:247-258

The Principles of Integrated BH Care

10

Team care Primary care and behavioral health providers, whether co-located or not, share care.

Population-based The care team shares a defined group of patients tracked in a registry to ensure no one ‘falls through the cracks.’ Practices

track and reach out to patients who are not improving.

Treat-to-Target Each patient’s treatment plan clearly articulates personal goals and clinical outcomes that are

routinely measured. Treatments are modified until the clinical goals are achieved. Evidence-based care Patients are offered treatments for which there is credible

research evidence to support their efficacy in treating the target.

Adapted from: Behavioral Health Implementation Guide: www. aims.uw.edu

Acute distress assessment and short-term therapy

• Behavioral Health Specialist – usually an LCSW or licensed therapists or counselors

• Available for warm hand-offs – 60-70% of day unscheduled

• Provides short-term therapy only • Documents in EHR• Provides or supports care management services for

patients treated for major depression, anxiety, bi-polar, etc.

• May provide SBIRT services

Established mental health disorder needing chronic therapy and management

Collaborative Care• Proven effective in 75+ randomized trials for anxiety,

depression, PTSD• PCP, BHS and patient discuss and select therapy. If drugs,

PCP prescribes. If psychotherapy, sent to BHS for treatment or referral.

• Patients tracked in a registry and followed by care manager (BHS or RN).

• Care manager discusses patients with psych. consultant.• Treatment adjusted if patient is not improving or therapeutic

target is not achieved.

Behavioral Integration and the Primary Care TeamScreening for depression Medical assistant or Receptionist

Care management for depression RN, Behavioral Health specialist

Referral for longer-term psychotherapy BH Specialist, Referral Coordinator

Crisis management Behavioral Health specialist

Brief Psychotherapy Behavioral Health specialist

Psychotropic Medication PCP or Psych NP

Psychiatric Consultation Consulting Psychiatrist

SBIRT Trained staff to screen, treat, refer

www.improvingprimarycare.org

Resource Spotlight #1

Resource Spotlight #2

www.improvingprimarycare.org

Carolyn Shepherd, M.D.

Behavioral Health

Integration

Clinica Family Health Services

201547,000 Patients210,000 Ambulatory visits5 sites, 15 clinical teams

• Began in 2002• 15 teams of 3.0 in-clinic provider:1.0 BHP• Assigned a panel of approximately 3600 patients• Licensed Clinical Social Worker, Licensed Marriage and

Family Counselor, PsyD• Sit in a co-located space with the team and see patients in

the same patient care rooms, IMPACT model• Four 20-minute recheck slots a day• Majority of patients seen on any day are patients being

seen by the team for medical complaints

Behavioral Health Integration

• BHPs chart in the same chart as the primary care clinicians and the rest of the team

• We have built BH templates that support SFT and CBT• The concatenated document is in the same e-file as all other

notes so the team can communicate and coordinate care effectively

• BHPs attend the huddles, and strategize which patients they will see that day using EHR huddle reports

• BHPs are introduced to new patients with warm handoffs. Sometimes they see the patients first.

• BHPs run our chronic opioid group visits as well as depression group visits and anxiety group visits

Behavioral Health Integration

1. BHPs need a lot of training in solution focused therapy and cognitive behavioral therapy to feel comfortable in a fast moving primary care team (no "50 min. hours").

2. Streamlining the paperwork burden for BHPs is important, this is done at the leadership and state level.

3. Help the BHPs learn to decrease their charting volume, it is critical if other team members are going to be able to confirm the diagnosis and find important data points quickly. We did extensive "best practice charting" training in our EHR for the BHPs.

4. Not all BHPs are cut out for the primary care team. It is helpful to normalize this at the time of hire, and let people "try on" the model without fear of being terminated. We talk about this at hire, and we let applicants shadow our existing BHPs.

Lessons Learned

5. Sometimes it is best to let the BHP go in and talk to a patient with a long list of somatic complaints before the physical provider sees the patient. Often the visit is much shorter for the PCP, and the patient is happier because they did not feel rushed.

6. Continuity and relationship are just as critical for the patient and the BHP as the physical health provider. Reception, call center, MAs, physical health clinicians all need to drive continuity for BHPs.

7. BHPs can communicate with psychiatrists on patients who are not doing well.

8. BHPs who are comfortable in this environment are a phenomenal addition to the primary care team.

Lessons Learned

Behavioral Health Integration

https://clinica.org/innovations/clinica-videos-our-model-care/

Delivering Planned Integrated Care

May 19, 2015

Veena Channamsetty, MD Chief Medical OfficerTim Kearney, Ph.D. Chief Behavioral Health Officer

Behavioral Health Integration

Behavioral Health from the

Beginning

Separate Buildings, Paper

Charts

Integrating Facilities

Integrated Care Record

Innovate Practices:

Changing the Way We Operate

Next Steps

Collaboration Continuum

CHC’s Journey

The Components of Integration

Evaluation

Training

Workflow/Processes

Facilities/Systems

Leadership Structure

Facilities and Physical Model

• Interdisciplinary Pods that Promote Team-Based Care• Open office structure• Collaboration throughout the workday

• Exam rooms and therapy rooms

• Reducing stigma of seeing behavioral health provider – no longer sent “over there”

• Seamless transition between medical and behavioral health

Facilities: One Corridor Care

Systems and TechnologyIntegrated EHR

• Up-to-date patient medical and behavioral health information available.

• Pain scores and access to other data – bi-directional information sharing

• Shared Care Plans• Electronic referral and recall process• Collaborative Care Dashboard

Planned Care Dashboard

PHQ > 15 8/24/15

Systems and Technology and ProcessCollaborative Care Dashboard

Planned Care in Behavioral Health Delivery of Integrated Services

Rethinking the warm hand-off process: Proactive vs Reactive

Processes

• Medical initiated warm hand-off and behavioral health initiated warm hand-off

• Staggered vs. consecutive visits – make our presence known

• Criteria:• No BH services and PHQ above 15• No BH services and BH Diagnosis• No BH services and chronic pain

patient

• Seamless Scheduling

Processes

• Instant access to behavioral health services via messaging service while with patients facilitating:

• Immediate and seamless warm-hand offs to BH

• Transition to nursing for controlled substances

• Transition to dental hygienist for dental treatment

• Behavioral health crisis calls handled by large regional groups of providers

Systems of Integration: Instant Assistance Technology

• Clinical Metrics• Screening for BH need• UDS measure• Improved BH Outcomes

• Practice Metrics• Patients enrolled in BH• Wait time to see BH• ED utilization• Avoidable Hospitalization

• Experience/Feedback Metrics• Patient experience• Staff experience

• Real Time Operational Data

Evaluation of the Model

Initiative BH Medical

Nursing

Dental

Integrated Care Meetings

r r r

Recalls r r r rBH Groups r rShared Medical Visits r r rWarm Hand-Offs r r r rPrenatal-Dental Project r r rShared Care Plans r r rComplex Care Management

r r r

Trauma Screening & TFCBT

r r

Standing Orders r r r rFluoride Varnish r r r rSBIRT r r r rBH Dashboard r r r rAppointment Allocation r r r r00/00/00

Interdisciplinary Care Initiatives

IHART Integrated Health and Recovery TreatmentBehavioral Health Home

Shanako DeVoll, CSWA, QMHP, CADC IIIIHART Program Manager

Erika Armsbury, MSW, QMHPDirector of Clinical Services

http://www.centralcityconcern.org/

Central City Concern

• Central City Concern is a nonprofit agency serving single adults and families in the Portland metro area who are impacted by homelessness, poverty and addictions.

• Provides a comprehensive continuum of housing options integrated with direct social services including healthcare, recovery and employment.

• CCC currently has a staff of 700+, an annual operating budget of $47 million and serves more than 13,000 individuals annually.

IHART

• All clients check in with a registered nurse before their psychiatric medical provider (PMP) appointment.

• Behavioral health assistant is a Qualified Mental Health Associate (QMHA) and does both administrative tasks as well as behavioral health related support for the team.

• A 30 minute morning huddle is conducted daily to focus on: coordination of care, crisis intervention, linkage to medical appointments and/or follow up, and an overview of clients needs for the day.

• The care team coordinator and/or the behavioral health assistant remain in the team room at all times to manage day to day and to support the team.

• CCC’s Health Services consists of: Old Town Recovery Center (OTRC), Old Town Clinic (OTC) & Central City Concern Recovery Center (CCCRC) IHART is one of 4 care teams located within the Old Town Recovery Center (OTRC)

• OTRC & Old Town Clinic (OTC) are co-located in the heart of downtown Portland

• OTC & OTRC use a shared Electronic Health Record• IHART structure is modeled after medical homes, but tailored to fit the needs of

behavioral health (BH) clients and BH systems. For example:

Who are IHART clients? • Behavioral Health Home with a focus on integration with primary care. • Capacity to serve 300. • Clients are paneled at the Old Town Clinic (OTC) for primary care. • Our clients have tri-morbidity, including Severe and Persistent Mental Illness,

homelessness, medical issues and addiction. • 30% of all intakes to OTRC are from OTC. The majority of those are referred to

IHART.• Clients can also be enrolled on IHART through intake due to complex medical

needs & no current primary care provider.

Sustaining IHART roles• Development & definition of roles was a crucial part in sustaining

IHART.• Team roles & workflows were defined to support staff in working to the

top of their skill set/license. • 10 staff with different disciplines share a team room with the majority

serving in extender roles to the Mental Health Counselors• Support from a program manager, psychiatric providers, registered

nurses and a pharmacist. • Putting systems in place to track the health of the population• Education & training for behavioral staff on ‘Primary Care 101’• Training & supporting behavioral health staff on integrating medical

coordination into behavioral health appointments

Sustaining IHART roles10 roles in the IHART team room

Care team coordinator, QMHP- Day to day coordination and consultation within the team, supervision of QMHA’s, carries a small caseload of 20 clients, and coordinates daily crisis interventions and follow up. 4 Mental health therapist, QMHP- Carry a caseload of 62 clients and are scheduled for individual therapy 60% of the time, the other 40% is spent doing crisis intervention, clinical coordination/case management, groups and documentation. Substance abuse and mental health counselor, QMHA/QMHP, CADC - Facilitation of dual diagnosis groups, carries a case load of 25 clients and provides alcohol and drug case management for the entire population. Behavioral health assistant, QMHA- Is in the team room at all time, answers phone call, triages crisis situations, all administrative coordination, referrals to respites and outside agencies. Case manager, QMHA- Works with the entire population on case management needs, gets assigned daily tasks from therapist and team, coordination and linkage to outside services, housing support and medical appointment coordination. Peer Wellness Coach, QMHA, PWC- Our peer works with individuals to support them in reaching their treatment goals. Attends medical appointments, support around daily living skills and health coaching strategies. Employment specialist, QMHA- Works with 20 IHART clients around supportive employment.

IHART Projects • Metabolic Monitoring Project (MMP) - Supporting

clients on 2nd generation antipsychotics to get their labs completed every 3-6 months.

• Coordination with OTC care teams - Care team managers from OTC attend our morning huddles weekly to coordinate client needs and to brainstorm strategies to best serve mutual clients.

• Wellness Program - 16 week Road to Wellness course that focuses on making small changes in health practices. Two days per week peer run walking group and a weekly check in with our registered nurses.

• Targeted Primary Care – Small group of individuals whose basic medical needs are being addressed by our team with the supervision of their PCP.

• IHART’s third year will focus on data collection.

Q & A, Discussion

RemindersSign up for our next webinar in this series:

Dissolving the Walls: Clinic Community Connections

Thursday, June 2nd, 3-4 p.m EST

Complete our survey!

Learning Collaborative Applications OPEN until MAY 31st

Sign up at www.chc1.com/NCA