Strengthening Integrated Health

Jennifer Langhinrichsen-Rohling, USAMichele Brazeal and Timothy Rehner,

USMGlenn Rohrer, UWF

Joy and Howard Osofsky, LSUHSC

Each FQHC has to go through their own developmental process

‣Goal of integrated care is to build interdisciplinary teams of caring people So its not just the MD or RN that feels the burden of

making a call about a patient.

‣Process is compounded by existing silos

‣Requires a consistent effort to keep all the pieces working together

‣Needs “Transitional Government”

No one size fits all

FQ integration with existing MH Center (2 EHRs shared via the HIE)

Mental Health Center adds Primary Care (Cherokee model)

Mental Health travels to and exists within the FQ at certain times and/or via technology

Examples of External Models of Integrated Health Care

Assessment of existing staff Compile a spreadsheet of your all

behavioral health providers Licensure Credentialed Supervisor Documenting in EHR Billing for services

Utilizing Current MBH Staff Effectively: Internal BH Staff Integration Assessment

Program Assessment

Behavioral Health Funding (different sources)

Overall team concept (existing buy-in) Standardized Assessment Protocol Staff training on integrated health

◦General◦Specific

Billing obstacles (if any) Organizational Structure

Internal BH Integration Continued…

Behavioral Health Clinical Director

Infectious Disease

Add. BH providers

Substance Abuse

Add. BH providers

Consult & Outreach

Add. BH providers

Primary Care

Add. BH providers

Possible Organizational Charts: What would work at your FQ?

Patients via Universal Screening

Patients via Chronic Health Condition

Patients via Doctor, Nurse, or Other Staff Referral

Patients via Crisis

Multiple Workflow Modelsfor BH providers integrated into Primary Care

sites

Who will administer?

◦ Patient completes screening forms in waiting room

◦ MA administers screening during Vital Sign Check

◦ BH provider administers screening while patient is waiting

◦ BH provider goes from room to room with other members of the primary care team

Patients via Universal Screening

Elements of the Universal Screen

Choose Measures Set up in EHR

PHQ 2 PHQ 9 GAD 2 GAD 7 MAST Stress level Stressors

Easy scoring Flags for the BH

provider

PHQ-2Administered

with vital signs

SignificantScore

YESYES

NO

NO

Refer to Behavioral

Health

No actionRequired

Universal Screening

Universal Screening Patient

PHQ9 Screen

Nothing Endorsed

No BH

PHQ9 < 10MILD

One Session BH

with MI

PHQ9 > 10Moderate

1 to 4 session

Crisis, HIGH PHQ9

Referral

SBIRT An important component of the Universal Screening Model

Staff training

A high volume of patients may be generated by universal screening

Protocol for patients who endorse some suicidal ideation but aren’t hospitalizable

Potential Issues

Identify target population◦ Diabetes◦ Obesity◦ Uncontrolled hypertension◦ Asthma◦ Chronic Pain

Select measures to assess effectiveness

Establish protocols for BH staff contacts with patients (via chart review?)

Train BH staff on chronic health conditions

Initial steps: Chronic Care Patients

Endorsement Memo

Identify open-minded physician to kick-off project

Work with nurse on medical plan for each patient

Initial steps: Chronic Care Patients

Chronic Care

Patient Identified by BH staff

Patient accepts service

Seek support from Patient Primary Care

Provider

YESYES

Enroll in chronic condition support program

YES

YES

Patient accepts service

Provide Patient

w/contact info

Chronic Care Patient

NO

NO

NO

NO

Find willing provider (champion) Place BH provider in same space and EHR Have a referral procedure

◦ Best case warm-hand off◦ Next positive endorsement and easy access◦ Least effective – tell patient to schedule after

Medical appointment is finished

Initial steps: Physician Referral

Physician identifies

patient need

Behavioral Health Services

available

YESYES

NO

NO

Locate BH provider for immediateassessment

Referral to MH Services

Physician Referral

Physician Referral

(Warm Hand Off)

Variance in the type of patient referred

Referred patients may require more mental health care than is typically available through a FQ’s BH department

May be in conflict with other long-standing providers in the community; begin to be viewed as a mental health center

BH providers may be under-utilized as they wait for referrals

Growing consequences of long-term caseloads or ancillary duties

Possibility that this model may reduce the likelihood of doing brief evidence-based treatments in the context of an integrated health team

Concerns about Primary Care Staff Referral System

Crisis

Refer to BH services

Behavioral Health

Servicesavailable

Follow Professional Guidelines

or Clinic Protocol

YES

NO

YES

NO

Patient in Crisis

Patients in CrisisMay express:- suicidal thoughts- homicidal thoughtsAppear:- confused- distraught- agitated

Staff coverage may vary

Require more mental health care than is available through a FQ

Old crisis protocols tend to be abandoned

Interface with hospitals and specialty services are still required

Concerns about MH Crisis services

Which model will your FQ tackle first? Which staff members will be involved in the delivery

of the chosen model? Which staff members will be delivering BH services

within the model? How will you garner staff participation and

understanding of the new workflow and new staff roles?◦ Intake staff◦ BH staff◦ Billing staff◦ Medical staff◦ Patients

Integrated Health Care Goals

Goal Action Step

Person Responsible

Date to be Completed

Notes

Improve BH infrastructure

Put PHQ9 into vital sign field in EHR

Making a Plan