Jill Rinehart, MD Breena Holmes, MD. Describe the growing need for co-located support in primary...
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Transcript of Jill Rinehart, MD Breena Holmes, MD. Describe the growing need for co-located support in primary...
Jill Rinehart, MDBreena Holmes, MD
Describe the growing need for co-located support in primary care practices
Outline several Vermont models of behavioral health support in primary care
Describe one practices’ innovation, including use of Blueprint and care coordination
Vermont Department of Health
20-24% of all children will be treated for behavioral health symptoms by the time they reach age 18.
Up to 70% of primary care medical appointments are for issues related to psychosocial concerns
Vermont Department of Health
For those under 18 years of age, the five medical conditions that ranked highest in terms of the number of individuals with expenses for care in 2008 included acute bronchitis, asthma, trauma-related disorders, otitis media, and mental disorders.
Vermont Department of Health
Family Integrated Health Care Model◦ VCHIP, VDH, DMH◦ Co-located mental health workers in primary care◦ Child Psychiatry consultation for child health providers
through email and phone consultation Vermont Family Wellness Model
◦ 3 tiers
Blueprint for Health◦ Community Health Teams (centralized)◦ Community Health Teams (co-located)
Vermont Department of Health
Every medical home that serves children has a care coordinator
Care coordinator can connect families to needed resources in a timely manner
CSHN can reach each practice via Care Coordinator
Network of care coordination that supports behavioral health needs of families—from parenting support, to coordinated behavioral assessment and psychiatric treatment
Vermont Department of Health
The Concept The Person
1. Needs assessment for care coordination and continuing care coordination engagement
2. Care planning and communication
3. Facilitating care transitions 4. Connecting with community
resources and schools5. Transitioning to adult care
Antonelli et al (2009); Rinehart (2014)
1.Reduce fragmentation of care for an identified population
2.Guide a family-centered, multi-disciplinary team process in the joint development and use of a plan of care
3.Enable the child/family and their “care neighborhood” to communicate, collaborate, and operate from the “same page”
4.Deliver oversight/accountability
◦ Jeanne McAllister, et. al, supported by Lucille Packard Foundation for Children with Special Health Care Needs
Vermont Department of Health
Care Study 1: Matt
13 year old boy with autism, non-verbal, self injury, polydipsiaParents struggling with bolting, overall safetyMiddle school unable to educate or keep safeMedical issues of skin infections, enuresis, sleep dysfunctionFamily has gone above and beyond capacity of most families to deal with this at home
Care Planning 1:
Patient/Family/Team Goals CICP Negotiated Actions Process and Outcome Measures
Less Self Injury Psychiatry Assessment, co-management from psychiatry, medical home and subspecialists
In-home behaviorists
Keeping family together
Less need for police, mental health crisis support
Improve school attendanceImprove education supports
Same behavior plan across settings
Explore alternative school placement
Clear communication between home/school/providers
Alternative program found
Repetitive behaviors Improved psych pharmImproved wrap around servicesImproved behavior plans
Innovation: across silos of mental health, developmental disabilities, children with special health care needs, and school
Care Study 2: Mary4 year old with tuberous sclerosis
self-injurious behaviorsTantrumssleep dysfunction heading toward inpatient psychiatry hospitalization
Despite having a VT developmental services waiver, respite care and a team of multidisciplinary medical experts at Massachusetts General Hospital
Care Study 2: Mary (Cont)
Intractable seizures seemed the least of her concerns in comparison to behaviorsStrengths:
Strong parent involvement and expertiseLoving respite familyMary engagingVerbal with cognitive strength (can anticipate seizures)
Care Planning 2:
Patient/Family/Team Goals CICP Negotiated Actions Process and Outcome Measures
Less need for “crisis” intervention
Co-management from psychiatry, medical home and subspecialists
In-home behaviorists
Less need for police, mental health crisis support
Improve Sleep Same behavior plan across settings
Less communication errors about medications
Improved work attendance
Increase Home Safety-of Mary and family
Improved psych pharmCSHN SW: Waiver allowed for enhanced access to in-home behaviorists
Innovation: region contracted with vendor outside of network
Less Crisis Need
Mary to attend schoolImprove social relationships
Communication opened between school, behavioral plans, family, medical home
Making academic gainsAttendance improvedCannot pick her out from peers
Vermont Department of Health
1 HRC Pediatricians2 University Pediatrics3 Green Mountain Pediatrics (Bennington)4 Rutland (RRMC)5 St. Johnsbury6 Mount Ascutney /Ottaqueechee (Windsor/Woodstock)7 Rainbow Pediatrics(Middlebury)8 MPAM(Middlebury/Porter)9 South Royalton10 Barre- Associates in Pediatrics (2)CHCTimberlaneEssex PediatricsMaine
Integrated care is the seamless provision of health care services, from the perspective of the patient and family, across the entire care continuum. It results from coordinating the efforts of all providers, irrespective of institutional, departmental, or community-based organizational boundaries.
Practices with co-located behavioral health services◦ struggled with integration elements that
addressed the use of behavioral health skills by the entire primary care team and the delivery of evidence-based interventions
Co-located practices were the most integrated with clinic-system processes and in elements of relationship and communication
Pediatric and non-co-located practices struggled most with clinic-system processes and community integration
Informal Supports
Extended FamilyFriendsGroups
Religious Organizations
Cultural SupportsClubs
RecreationCamps
Community and State Services
CSCHNEconomic Services
Developmental Services
Mental Health Early Intervention
Home Health Services
Children’s Palliative Care
WICChild Protection
Private TherapistsPersonal Care
SchoolTeachers
Case ManagerSpeechPT/OT
Counsellors
Other Services
MedicalSpecialists
Specialty Providers
Clinics
Financial SupportsInsuranceRespite
Childcare Subsidy
Economic servicesSocial
SecurityFood Subsidy Employment
Childcare
Teachers
Genogram of Household MembersParentsSiblings
ChildExtended Family
Others
© Cristin Lind
Behavioral Health encompasses◦ Mental health◦ Substance abuse and dependence◦ Life style choices which promote risk factors
Integration is Essential for Success– evidence base exists Care Coordination is Necessary but not Sufficient to
Achieve Integration CC is the set of activities which occurs in “the space
between”◦ Visits, Providers, Hospital stays
Only way to succeed is to engage all stakeholders– including patients and families– as participants and partners