Integrating Behavioral Health and Physical Health: The Time is Now.

Integrating Behavioral Health and Physical Health:

The Time is Now

Introductions

Noreen Fredrick Executive Director Mon Yough Community Services McKeesport, PA

Stephen Christian-Michaels COO Family Services of Western Pa New Kensington, PA

Overview

Health Status of People with SPMI Fractured System Models of Integration Chronic Care Model Impact Model Person Centered Healthcare Home Cherokee Model – CMHC/FQHC Research Based Best Practice Components Types of Integration Initiatives Family Services of W. Pa Experience Mon Yough Experience

Health Status of People with Serious Mental Health Diagnoses

High prevalence of modifiable risk factors:

Obesity; tobacco use and alcohol use

Group homes -- exposure to infectious diseases

-- peers negatively influencing unhealthy risk factors

60% of premature deaths in individuals with schizophrenia due to:

cardiovascular disease pulmonary infectious diseases

Higher rates of COPD and Diabetes than in the general population

Premature death - 25 years younger than the general population.

Medication side effects often exacerbates health status


Hispanics, African Americans or Asian and Pacific Islanders have varying disparities in death rates

The widest gap is seen in black males with a life expectancy of 69.5 years in 2004, 8.3 years shorter than the national average.

None have a life expectancy that is equivalent to those with serious mental illness. 25 years……..

This disparity is alarming


Adults in Health Choices: Annual increases: 24% - 28% (new consumers)

Have not previously used services In addition to already burgeoning caseloads

Main Diagnoses 27% major depression 23% schizophrenia 15% bipolar disorder 15% other depressive disorders

About 40% co-occurring 51% MH only 6% substance abuse/dependence only

Health System is a Fractured System

People not identified w/depression early enough

Post Partum Depression often not diagnosed

75% Anti-Depressant meds prescribed by PCP’s

PCP’s often discontinue anti-depressant before full effect is realized

Community Mental Health/Primary Care Split

•Consumers not engaged with PCP…… …….use Emergency Departments for routine care

•PCP’s often feel unprepared to deal with behavioral health

disorders

•PCP’s frustrated when they refer into CMHC’s long waiting lists, drop out’s before first appointment/soon after

•CMHC’s feel unprepared to deal with even routine health issues

•CMHC’s busy, refer people back to PCP’s for depression, ADD, etc

•No infrastructure readily available to enhance communication

•Difficult for real communication given busy schedules

What contributes to the Fractured Health System

Billing systems are different

Evolving EHR are usually separate w/no interfaces

BH is carved out of managed care plans

Referrals from PCP’s tend to be to MD’s they know

Psychiatry is the lowest paid specialty of physicians

Psychiatry/Therapy split off from medicine

Integrated Care: To Be Or NOT

Models of integration Separate Locations – Coordinated cross referral Co-Location – BH on site, parallel practice Integrated/Joint Care – separate but combined Integrated Centers - Fiscally and Structurally Integrated Health Systems – Kaiser HMO

5 Years from now in a reformed healthcare system there may not be a role for CMHC’s that are not involved in Integrated Care

Characteristics of Current System

Current care is crisis driven

Provider centric not patient/consumer centric

Care is episodic and reactive

There is not a life time view of disorders

Care tends to be more modality driven, not population driven

Chronic Care: A Model to Assist in Integration

Developed by Edward H. Wagner, MD, MPH MacColl Institute for Healthcare Innovation

Organized, planned & productive interactions improve outcomes: More fully engage individual is in self care activities and Leads to better health outcomes.

People w/SMI share same characteristics as chronic physical conditions:

dealing with symptoms disabilityemotional impact family issuescomplex medication regimens difficult lifestyle adjustments

difficult to obtain helpful care

Used with permission.Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses?Effective Clinical Practice , Aug/Sept 1988 Vol 1

Essential Element of Good Chronic Illness Care

Informed,Activated

Patient

ProductiveInteractions

PreparedPractice

Team


What characterizes an “informed, activated patient”?

Informed,Activated

Patient

They have the motivation, information, skills,They have the motivation, information, skills, and confidence necessary to and confidence necessary to

effectively make decisions abouteffectively make decisions about their health and manage it.their health and manage it.


What characterizes a “prepared” practice team?

PreparedPractice

Team

At the time of the interaction they have At the time of the interaction they have the patient information, decision support, and the patient information, decision support, and

resources necessary to deliver resources necessary to deliver high-quality care. high-quality care.


Six Components of Chronic Care Model

Self-Management Support – individuals are supported in achieving goals and fully engaged in care.

Delivery System Design – transform practice form reactive to planned and proactive.

Decision Support - care is based on evidence based guidelines and uses systems to inform and prompt providers and individuals about care needs.

Six Components of Chronic Care Model

Clinical Information Systems – use of registries to provide patient specific and population based support to teams, reminders, data and provider feedback. With the correct tools providers can analyze all of their consumer needs, access recent lab work, prescriptions filled, and visits.

Community – utilize resources in the community. This is a natural strength for the CMHC with integration existing as part of the community supports.

Health System – creation of a quality oriented system through leadership and continuous quality improvement.

Four Quadrant Integrated Care Model

The NCCBH proposed model for the clinical integration of health and behavioral health services starts with a description of the populations to be served.

• Quadrant I: Low MH - Low PH, served in primary care BH staff on-site provides services

• Quadrant II: High MH - Low PH, served in the MH system PH service provided at CMHC

• Quadrant III: Low MH - High PH, served in primary care BH staff on-site provide services PH case mgt provided

• Quadrant IV: High MH - High PH, served in MH system with specialty care case management for both PH and BH disorders National Council for Community Behavioral Healthcare

The Person-Centered Healthcare Home

Stepped care clinical approach

Healthcare implemented bi-directionally

A. Identify people in primary care with behavioral health conditions ands serve them there unless they need stepped specialty behavioral health care; and

B Identify and serve people in behavioral health care that need routine primary care and step them to full-scope health care home for more complex care

www.TheNationalCouncil.org/ResourceCenter

Impact Model - Depression

Collaborative care – individual PCP’s works with BH care manager/behavioral health consultant to implement a treatment plan with consultation with the psychiatrist and pharmacist

Depression Screen of all Patients in Medical Practice Motivational Interviewing, Behavioral Activation and

Problem Solving Therapy Goal is to make incremental changes in life style practices Medication prescribed by PCP Health registry used to

Prompts follow-up sessions, outreach, staged interventions Collects medical and behavioral health data Tracks changes, outcomes

Cherokee Model

Fully integrated structurally and financially Combined Services

Community Mental Health Center Federally Qualified Health Center

National Council for Community Behavioral Health Care

Federally Qualified Health CentersPossible Structures FQHC and CMHC merged to one organization

Federally Qualified Health Centers provides its own BH services via its own staff = integrated team

Funding from one stream, One EHR

Federally Qualified Health Centers with contracted CMHC services integrated

CMHC co-locates staff at FQHC and provides BH services in a parallel practice…one stop shop

Research Based Best Practice Components

Regular screens & registry tracking/outcome measurement

Medical nurse practitioners/PCP located in BH clinic

Primary care supervising MD

Embedded RN care manager

Evidenced based practices to improve health of SMI pop.

Wellness programs

National Council of Community Behavioral Health Care

Integration Initiatives

Screening of Depression for all PCP patients (PHQ-9)

Screening for Unhealthy Substance Use (SBIRT)

Screening of Post Partum Depression – OB and Pediatricians Depression Screening, Motivational Interviewing,

Behavioral Activation, Problem Solving Therapy (IMPACT)

Medical Services provided in MH Centers

Challenges

We need to be part of putting the mind and body back together

Healthcare reform is going to drive more focus on integration

Family Services Experience

Co-location

Integrated Care, BH service at Medical Clinic

Proposed Medical Services at CMHC

Family Services – Co-Location

MD Frustration at long waiting time to see Psychiatrist

MH CRNP at Family Practice office in New Kensington (UPMC) Started at ½ day/week, moved to two half days per week

50 – 75 new clients seen per year

Moderate Depression, often linked to MH Clinic

Very little collaborative care

Some phone consultation between MD and Psychiatrist

Family Services – Integrated Care at Medical Clinic

Partnership matured Agreed to seek out funding to move to integrated care Together support regional Integrated Care Summit mtg Family Practice-UPMC started screening for Depression Applied for several grants, not funded Approached Managed Care Company Managed Care – Health/BH – funded project/collect data

Family Services – Integrated Care at Medical Clinic

Foundation sought out partnership along with 3 other sites Goals:

Establish communication policies between medical & BH Providers Increase the appropriate assessment & utilization of BH services Decrease:

Emergency Department usage hospital admissions Re-admissions Hospital length of stays

Assure that BH provider is a financially viable position

Family Services – Integrated Care at Medical Clinic IMPACT/Depression Screening SBIRT/Unhealthy Substance Use Screening Engagement/Behavioral Activation/Problem Solving

Treatment Grant fund position for 18 months

Goal: Demonstrate ability to reduce by 6 inpatient hospital admits

Pgh Regional Healthcare Initiative provides consult/project mgt

University of Washington/IMPACT provides Training Consultation Health Registry

Family ServicesMedical Services at CMHC SAMHSA Proposal Family Practice staff contracted to provide medical services MD, Nurse Practitioner and Nurse become part of MH Teams Build a physical fitness center at CMHC Peer support used to engage consumers in healthy lifestyles Build EHR Interfaces to share summary notes Build Health Registry into BH EHR to implement Chronic Care Model Change physical layout of office for (4) interdisciplinary teams Services:

Health Screening, Nutrition Counseling, Fitness Groups Health Improvement plans, Consultation, Care Mgt

Mon Yough ExperienceSAMHSA Grant: Emerg Dept Diversion Partners:

UPMC for Life UPMC McKeesport Hospital Latterman Family Health clinic UPMC McKeesport Internal medicine MYCS

Goal: Decrease Emergency Department usage Determined Access as the issue Increased midlevel practitioner time at Latterman and

MYCS as we agreed that we all serve the same group of clients

Mon YoughEvolution of the Partnership Grant led to beginning of “partnership model” between

Latterman Family health and MYCS. CRNP .5 FTE located in Behavioral health clinic Primary care supervising physician Imbed Psych Rehab in clinic setting to promote wellness as

core goals and work with nursing staff to structure wellness activities

Next Steps: Create registry tracking Embed evidenced based practice in daily practice

Mon YoughChronic Care Model CMHC Development of a “chronic care” team

within adult Outpatient clinic

Co-locate treatment; psych rehab,

supported employment and service

coordinator in one area

PH and BH team live in the same building

Mon YoughPerinatal Depression Project

Rand project – targeting perinatal depressed Moms in a variety of settings including OB clinic; pediatricians

MYCS partnered with Magee in Clairton Behavioral health time provided on site Lessons learned… Helped with imbedding of BH case manager in Latterman

clinic to assess need /level of support and type of integration Next Step use existing “SHIP” infrastructure to create

collaboration among community using logic model approach

Mon YoughTraining the Work Force

Latterman Clinic is a Family Practice education site. MYCS will serve as the rotation site for dual boarded

Family Practice/Psych Fellowship 4 hours a week Latterman Clinic

Provide physical health care in MYCS clinic Provide supervision of primary care at MYCS clinic

MYCS will serve as the psych rotation education site for Family Practice Residents

Learning Collaborative

Set up learning collaboratives Use consultants to help cross walk systems Share information across projects Examples:

Collaborative learning across BH and PH Collaborative learning across CMHC’s List Serves on Integrated Care Regional Learning Collaboratives

Resources

Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses: Effective Clinical Practice, Aug/Sept 1988 Vol. 1

National Council of Community Behavioral Health Care. Winter 2009. A Two-Way Street Behavioral Health Care and Primary Care Collaboration.

Morbidity and Mortality in People with Serious Mental Illness, National Association of State mental Health program Directors, Medical Directors Council; Editors: parks, Svendson, Singer, Foti, Technical Writer: B Mauer. October 2006; Report available at www.namsmhpd.org

List Serve: http://lists101.his.com/mailman/listinfo/pc-bh-integration

Contact Information

Noreen Fredrick

[email protected]

(412) 673-8035

Stephen Christian-Michaels

[email protected]

(412) 820-2050 x438

Integrating Behavioral Health and Physical Health: The Time is Now.

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