Integrating Mental Health Promotion A New Dimension in Drug & Alcohol Service Delivery.
California Institute of Mental Health, Alcohol and Drug Policy … · 2016-03-30 · A Webinar...
Transcript of California Institute of Mental Health, Alcohol and Drug Policy … · 2016-03-30 · A Webinar...
Primary Care, Mental Health, and Substance Use IntegrationA Webinar Series Sponsored by:
California Institute of Mental Health, Alcohol and Drug Policy Institute and,Integrated Behavioral Health Project
Bridging Differences in the “Cultures of PC/MH/SUJune 10, 2010
Faculty:
Mary Rainwater,LCSW,FacultyMary Rainwater,LCSW, Project Director, Integrated Behavioral Health Project
San Mateo Behavioral Health and Recovery Services PanelCheryl Walker, MFT, Unit Chief, Primary Care Interface TeamLinford Gayle, Director Office of Consumer & Family Affairs
Cynthia Chatterjee, MD, Psychiatrist, Primary Care Interface TeamStephen Kaplan, LCSW, Director of AOD Services
Gale Bataille, MSW, Moderator and Integation Consultant to CiMH______________________________________________________________________________
This free webinar series is supported through MHSA funding under contract withthe CA State Department of Mental Health as well funding from the Alcohol and Drug Policy Institute.
IBHP participation is supported by The California Endowment.
Cultural Challenges to IntegratingCare
National policies, systems-level financialand regulatory barriers have led to “silo’s”of care
Physical and behavioral health clinicians Physical and behavioral health clinicianshave different practice and diagnosticstyles that have led to very different work“cultures”– Different work and productivity patterns.
– Different training, professional orientations,philosophies and perceptions of behavioralhealth conditions.
Primary Care Behavioral Health Comparedto Mental Health/Substance Use Treatment
Primary Care Behavioral Health Mental Health/Substance Use
Population-based; mental healthseen as just one component ofoverall health care
Client-based; specific requirementsfor service acceptance; focus onmental health care or substanceuse treatment
Treatment usually for person with Treatment typically restricted toTreatment usually for person withmild to moderate impairments,those coping with situational stressand stabilized persons with seriousmental illness
Treatment typically restricted topersons experiencing or at risk ofserious mental illness or thoseexperiencing psychiatricemergency or crisis; substance useservices often narrow andrestricted typically due to funding
Treatment usually limited ; one tothree visits; typically shorter induration, 15 to 30 minutes (thoughcould be longer depending on co-morbidity)
Often long-term treatment; numbervariable, related to client condition;visits may be longer in duration;include psycho-social and rehaboptions beyond individual visits
Primary Care Behavioral Health Compared toMental Health or Substance Use Treatment
Primary Care Behavioral Health Mental Health/Substance Use
Informal counseling session,vulnerable to frequent interruption;visits often timed around medicalprovider visits; therapeuticrelationship generally not primaryfocus
More formal session, privateinterchange; mental health orsubstance use is reason for visit;establishment of therapist-clientrelationship important; substanceuse group sessionsfocus use group sessions
Treatment often encompassesbehavioral aspects of healthcare, likepain management, smokingcessation, etc.
Treatment emphasis is on mentalhealth or substance use interventionsor rehabilitation services
Care management is often minimal,due to lack of reimbursement
Care management emphasis is oftenon psychosocial aspects of care
Behavioral counselor part of ahealthcare team; interventionsupports medical provider decisionmaking
Counselor relationship oftennonaligned with a team; interventiongenerally not tied to medicalhealthcare
Primary Care Behavioral HealthCompared to Mental Health or SubstanceUse Treatment
Primary Care Behavioral Health Mental Health or Substance Use
Documentation tends toward brief,immediate, problem focused recordsand often integrated with the medicaltreatment chart
Documentation generally moreextensive in response to publicfunding requirements and greaterrange of services; records stand-treatment chart range of services; records stand-alone; substance use confidentialitystandards
Stigma often minimal due tonormalization of setting
Stigma usually high
Primary care physicians may lackknowledge of behavioral health carewhich may lead to under-diagnosingand/or reluctance to identify andtreat or may be dismissive ofcomplaint due to perceptions aboutmental health or substance use
Specialty providers may over-diagnose; difficult to find mentalhealth professionals “traditionally”trained willing to work in primarycare model
Opportunities to Bridge the Culture Gaps
Integration efforts must occur at multiple systemlevels.
Aligned financial incentives can jump-startactivity and provide needed focus to programpartners.partners.• Rewarding quality care (i.e., pay-for-performance)• Mechanisms for sharing savings from reductions
in avoidable emergency and inpatient utilizationacross delivery systems
Buy in from administration/management –need tounderstand and promote the value of integratedbehavioral health (relatively low cost strategyto improve care quality, productivity, andclient/provider satisfaction)
Opportunities to Bridge the Culture Gap
Provider engagement is critical to achieving
buy-in and sustainability.
– Shared philosophy of care forpatient/collaborative team approach and beliefpatient/collaborative team approach and beliefin the model
– How to adapt to PC setting; flexibility indealing with the physical acuity of thepopulation, as well as the environment whereinterruptions are the norm
– Offering practitioner toolkits and learningcollaboratives to customize and implementbest practices for their delivery point andpopulation, reinforcing a spectrum of tailored
Opportunities to Bridge the Culture Gap
Consumer engagement is key and efforts shouldleverage peer support specialists for outreach,enrollment and obtaining consent.• Selling point preventing adverse drug interactions.• Shared development of care plans, maintaining• Shared development of care plans, maintaining
provider relationships and engagement of programdesign
Team-based approach allows access tonecessary range of clinical skills, expertise andmay be most resource efficient.• Clear designation of physical and behavioral
health home• Care coordination support for beneficiaries and
providers (care homes)• Access to psychiatric consultation for PCP
medical provider
Opportunities to Bridge the Culture Gap
Information exchange need not be high-tech, but must be actionable andshared, high priority.• Importance of routine communication,
consultation and coordination• Importance of routine communication,
consultation and coordination• Structures to support information sharing
through medical records• Sharing of educational materials and
strategies and ongoing trainings (beyondthe person providing therapy or behavioralintervention)
• IT infrastructure that tracks behavioralhealth data and clinical outcomes/use ofregistries
Opportunities to Bridge the Culture Gap
Increasing recognition of mental illness andsubstance dependence/addiction as chronicconditions has the potential to further “de-conditions has the potential to further “de-stigmatize”, provide new sharedmethodologies for integrating care andstandardizing treatment approaches.
– Adaptation of the chronic care model
– Movement towards “person centered” treatment
– Integrated person-centered model shares many ofthe underlying principles of a “recovery” model
Bridging Cultures at IntegrationBridging Cultures at IntegrationPointsPoints
County of San Mateo Behavioral Healthand Recovery Services
Moderator/Introducing San Mateo PanelBridging Cultures: A Consumer Perspective
San Mateo will provide a brief overview of their approach tointegrated services and then share their perspectives as serviceproviders at different points of integration, but first…
Linford Gayle, as a consumer with both medical and mental healthissues, what has your experience been like navigating primaryissues, what has your experience been like navigating primarycare and having to deal with the different cultures between PC, MHand SU services?
As a consumer leader in CA, you speak from your own directexperience but are also aware of the perspectives of many others.What has helped or hindered people with mental health andsubstance use problems in getting access to care and treatmentin primary care settings?
Why it is important to “bridge” cultural differences as we work to
integrate care?
Consumer PerspectiveConsumer PerspectiveLinford GayleLinford Gayle--Director of Consumer and Family AffairsDirector of Consumer and Family Affairs
As a consumer I have lived withmental illness, a chronic medicalillness and a history of substanceuseuse
I received treatment for theseconditions in mental health andprimary care settings
Consumer PerspectiveConsumer PerspectiveLinford GayleLinford Gayle--Director of Consumer and Family AffairsDirector of Consumer and Family Affairs
Primary care at times has looked at consumerswith mental illness as not really experiencing themedical illness that they have come to the clinicfor, making the consumer feel that they think thatfor, making the consumer feel that they think thatthey are delusional.
AOD clients, if they are experiencing pain have attimes been made to feel that they are medicationseeking and not really feeling pain.
Consumer PerspectiveConsumer Perspective----Why is Integration SoWhy is Integration SoImportant?Important?Linford GayleLinford Gayle--Director of Consumer and Family AffairsDirector of Consumer and Family Affairs
Many consumers (particularly of color) attributetheir MH symptoms to physical illness & go toHealth Clinic or Emergency Room
– May be referred to MH from PC, but many never go to– May be referred to MH from PC, but many never go toMH Services due to stigma
Stigma reduction through integrated care
PC has historically been more open to input fromconsumers, family and other caring individuals
Linkage/coordination of care is critical whendealing with chronic illness(s)
Consumer PerspectiveConsumer Perspective----PerspectivePerspective----Why isWhy isIntegration with PC Important?Integration with PC Important?
Linford GayleLinford Gayle--Director of Consumer and Family AffairsDirector of Consumer and Family Affairs
PC is less restrictive for people trying to accesstreatment/services;
PC allows more flexibility--you may have greater PC allows more flexibility--you may have greatersay in who you select for your primary andspecialty provider
As a hindrance, in my personal experience therewas not an African American therapist available inmy insurance network
San Mateo has over 12 years experience inproviding integrated PC/MH/SU services facingchallenges & opportunities including:
• Reaching a shared philosophy/shared integration goals
• How to adapt MH/SU to PC environment (including pace)
Moderator/Question?
• How to adapt MH/SU to PC environment (including pace)
• Team based approaches
• Opportunities for consumer engagement
• Information sharing
Cheryl Walker, as Unit Chief for San Mateo’sPrimary Care Interface Team, how has yourorganization worked to integrate care?
Benefits of IntegrationBenefits of IntegrationCheryl Walker, MFT, Unit Chief, Primary Care Interface TeamCheryl Walker, MFT, Unit Chief, Primary Care Interface Team
Integration points strive to provideseamless continuity of care formedical, mental health, substancemedical, mental health, substanceabuse treatment. Integration pointsare where we experience workrelated challenges and haveopportunities to build effectivecollaboration.
Interface Team Integration PointsInterface Team Integration Points
The Interface Team is embedded in seven primarycare clinics. We have five full time bi-lingual bi-cultural Spanish speaking therapists, one bi-lingualChinese therapist, and two part time bi-culturalpsychiatrists-one is Spanish speaking.psychiatrists-one is Spanish speaking.
Two full time bi-cultural therapists-one is AfricanAmerican the other speaks Spanish, are placed in theCounty’s Human Services Agency. They areembedded part time in four work centers.
Additional Behavioral HealthAdditional Behavioral HealthIntegration PointsIntegration Points
Two nurse practitioners are embedded in threespecialty behavioral health clinics and provideprimary care to S.M.I. consumers.
Behavioral Health Resource Team: Providecase management to assist homeless mentally illconsumers obtain housing, primary care andbehavioral health treatment for mental illnessand addiction.
Primary Care Interface Criteria forPrimary Care Interface Criteria forMental Health TreatmentMental Health Treatment
Mental or emotional illnessnegatively impacting medical care
Crisis intervention/5150Crisis intervention/5150
Serious mental illness /linkage to ACCESSteam
Primary Care Interface ServicesPrimary Care Interface Services
Assess, consult, treat, link, collaborate
Brief Solution Focus treatment
Identify SMI and link to the correct BHRSspecialty team.specialty team.
Link consumers to alcohol and drug treatmentand collaborate with those partners.
Facilitate communication between primarycare and mental health
Key Differences: Primary CareKey Differences: Primary CareBehavioral HealthBehavioral Health
Work Culture
– Focus of Treatment
– Volume– Volume
– Pace
Common Ground
Passion for wellness
The desire to help
Bridging Cultures to FacilitateBridging Cultures to FacilitateCollaborationCollaboration
“Culture is the integrated pattern of humanknowledge, belief and behavior”. Webster’s Dictionary
Work culture of an organization is born out of theWork culture of an organization is born out of theorganization's strategic intent and values. BluEnt
It seems reasonable that changing the work pattern ofemployees from referral to specialists, to effectivecollaboration requires a structural change in belief andbehavior.
Bridging Work CultureBridging Work Culture
The first step is recognizing that work cultures existsand resists change that is not meaningful to thecultures.
The next step is to look for naturally occurringintegration points and recognize these can becomepoints of effective collaboration.
The last step is to acknowledge and grow thecollaboration mindfully.
Bridge Building ToolsBridge Building Tools
Collaborative team able to engageand work with other staff
Identify tools common to both workcultures
Low Tech-Mid Tech-High Tech
Moderator Question?
Dr. Cynthia Chatterjee, you are a psychiatristDr. Cynthia Chatterjee, you are a psychiatristwho has worked in both Primary Care andwho has worked in both Primary Care andMental Health clinic settingsMental Health clinic settings..
Please discuss your role as a Primary CareInterface Team psychiatrist working in primarycare clinics ?
Would you share some vignettes of yourwork with clients?
Psychiatrist RolePsychiatrist Role Cynthia Chatterjee M.DCynthia Chatterjee M.D
Assessment– More in depth than time allowed in PC.
– Additional co- morbidity often diagnosed
Consultation/Brief Treatment– One time or brief treatment and return to provider
or transfer to specialty mental health
Training, support and education forprimary care doctors
Referrals from the Interface TeamReferrals from the Interface TeamTo Higher Level of CareTo Higher Level of Care
The Interface Team screens about 1500 referralsannually and treats 1000
Transfers to a higher level of care are less than 5%and are handed off to the appropriate outpatient adultor youth unit chief by the Interface unit chief. Thisprevents transition errors.
OneOne--Time ConsultationTime Consultation Case VignetteCase Vignette
48-yo woman of Mexican origin with a history ofdepressive episodes since her 30's, currently depressedfor 1 1/2 years. PCP referred her to Interface 6 monthsago and therapist began treatment. Patient had nohistory of antidepressant use. Five months agohistory of antidepressant use. Five months agotherapist suggested to PCP that an antidepressantmight be needed, and PCP started Celexa 20 mg. Sheinitially responded, then worsened again. PCP thenincreased Celexa to 30 mg, but she did notrespond. Interface psychiatrist assessed patient andrecommended that Celexa be increased to 60 mg daily,and that if this dose ineffective to then switch to SNRI.
ShortShort--Term Treatment and ReferralTerm Treatment and Referralto Mental Health Clinicto Mental Health Clinic Case VignetteCase Vignette
31 yo AA male college student referred to Interface toassess depression and anxiety. Was treated withLexapro up to 30 mg by PCP but notimproved. Interface psychiatrist assessed pt. Pt hadmixed manic symptoms, paranoia, OCD, and PTSDmixed manic symptoms, paranoia, OCD, and PTSD(lost 5 friends to violence), and cannabis abuse. Labsrevealed hyperthyroidism and pt subsequentlydiagnosed with Graves disease. Psychiatrist stabilizedhim on antipsychotics and Depakote. Therapistsupported with therapy. Endocrinologist treatedthyroid condition. Patient referred for substance abusecounseling. Still unclear how much of patient'ssymptoms due to thyroid disorder and cannabis abuse,but patient will likely be referred to the mental healthclinic for long-term treatment.
ShortShort--Term Treatment and ReturnedTerm Treatment and Returnedto Primary Careto Primary Care Case VignetteCase Vignette
33 yo woman of Philippine background referred fordepression, anxiety, and irritability. She had beenstarted by primary care on Lexapro 10mg. Assessment revealed 17 year history ofmethamphetamine, marijuana, and alcohol. Patientmethamphetamine, marijuana, and alcohol. Patienthad recently entered outpatient substance abuseprogram and was clean and sober only 3 months. Shewas also drinking excessive amounts of coffee and hadpoor sleep hygiene. Patient was started on Campral foralcohol cravings, advised to decrease caffeine, andadvised about sleep hygiene. She responded very welland after 3 months returned to primary care formedication management.
Training, Support, and Education forTraining, Support, and Education forPrimary Care ProvidersPrimary Care Providers
Example:Case presentation of a patient referred toInterface, with discussion of relevant
journal articles to clinic's primary carejournal articles to clinic's primary careproviders
Example:Case conference that included patient,patient's primary care provider, therapist,
substance abuse counselor, andpsychiatrist,
to provide a unified treatment plan
Moderator/QuestionSubstance Use Services in Primary Care-Integration and Cultural Bridging
Stephen Kaplan, as AOD Director forBehavioral Health and Recovery Services,what are some of the challenges/barriers tointegrating substance use screening andintervention into primary care clinics?
What are some approaches that you areusing to break down silos that are barriers tointegration?
Alcohol and Other DrugsAlcohol and Other DrugsStephen KaplanStephen Kaplan--DirectorDirector
PIER – SMC’s version of SBIRT
Key “Cultural” Aspects Key “Cultural” Aspects
Steps Taken
Provider ViewpointProvider Viewpoint
MD
SBIRT
San Mateo: Future StepsSan Mateo: Future Steps
Integrative approach to clients with chronic pain
Medical Home Web PageMedical Home Web Page
Expanding SBIRT to all primary care sites
Embedding AOD Specialist into Interface
System Integration/Preparation for Health CareReform
Q&AQ&A
Contact and Resource Information:
Integrated Behavioral Health Project:
Mary Rainwater, L.C.S.W., Project Director
[email protected] or 323.436.7478
For further resources visit IBHP website at: www.ibhp.org
San Mateo County Behavioral Health & Recovery Services:
Linford Gayle, Director Office of Consumer & Family Affairs
[email protected] or 650-573-2534
Stephen Kaplan, Director of AOD Services
[email protected], 650-573-3609Celia Moreno, MD, Medical Director, BHRS
[email protected] 650) 573-2043Cheryl Walker, MFT, Unit Chief, PC Interface, BHRS
[email protected] 650-573-2630
Primary Care, Mental Health, and Substance UseIntegration Webinar Series
Paying for Integrated Services:Paying for Integrated Services:FQHC, Medi-Cal, and Other Funding Strategies
Dale Jarvis, MCPP Health Care ConsultingJune 24, 2010
Please go to http://www.cimh.org/Learning/Online-Learning/Webcasts.aspxfor more information and to register for future webinars.
This free webinar series is supported through MHSA funding under contract withthe CA State Department of Mental Health as well funding from the Alcohol and Drug Policy Institute.
IBHP participation is supported by The California Endowment.