PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION
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PRIMARY AND BEHAVIORALHEALTHCARE INTEGRATION
PRACTICAL APPROACHES TO IMPLEMENTATION
Coastal Behavioral Healthcare
Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida
Anthony R. Bichel, Ph.D.Apalachee Center Inc., Tallahassee, Florida
Rick Hankey, Senior V. P. and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida
PRESENTERS
Coastal Behavioral Healthcare
LEARNING OBJECTIVESPROVIDE
AN OVERVIEW OF INTEGRATED BEHAVIORAL HEALTH AND PRIMARY CARE
INCREASE KNOWLEDGE OF THE IMPLEMENTATION
PROCESS AND SUSTAINABILITY
DESCRIBE LESSONS LEARNED
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OUTLINE• History• Define The Problem Today• What Changed? Why Now?• What Is Integrated Care?• The Implementation Process• Sustainability• Lessons Learned
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HOW DID PHYSICAL AND MENTAL HEALTH BECOME
SEPARATED?
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HISTORY1950 – 1960: Most people with mental illness were living in asylums.
In the 60s: Due to John F. Kennedy and advances in medical thinking, changed from
institutional care to community based system.
1980 – 1990: Number of people living in tax-funded institutions was reduced by 50%.
Today: Approximately one-fifth of the 1950s number reside in institutional care.
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PROMISES MADE AND PROMISES BROKEN
Money was intended to follow consumers into community programs. This didn’t happen.
Employer paid insurance had no reason to pick up the bill. Most didn’t.
Operating two systems: state and community. Never had enough money to fund both.
Community based mental health system has always been underfunded.
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TODAY PEOPLE WITH SMI DIE ON AVERAGE 25 YEARS
SOONER THAN THE GENERAL POPULATION
They are not dying from their mental illness, but from their
chronic and untreated physical illnesses.
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OF THE SIX MAJOR CAUSES OF DEATH IN THE UNITED STATES,
THERE IS AN INCREASED RISK OF DEATH AMONG THE SERIOUSLY MENTALLY ILL MAJOR CAUSE OF DEATH INCREASED RISK OF DEATHCARDIOVASCULAR 3.4 XLUNG CANCER 3 XSTROKE 2 X IN THOSE LESS THAN
50 YEARS OF AGE
RESPIRATORY 5 XDIABETES 3.4 XINFECTIOUS DISEASES 3.4 X
Bob Sharp, Fl Council For Community Mental Health
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FACTORS INCREASING HEALTH RISK
Under Diagnosis &
Under Treatment
Poverty Poor access to Primary Care
Disconnectedness of “Physical” & “Mental” health care systems
Weight Gain
Tobacco and Substance Abuse
Medications
Less likely to be screened
Self-Care Capacity/Resource
Cognitive, Affective and Behavioral symptoms
System Navigation Barriers
WHAT'S CHANGED AND WHY CHANGE NOW?
4-Year Grant from The Substance Abuse And Mental Health Services Administration (SAMHSA) – $500,000 Per Year
The Purpose Of The Grant Is To Improve The Physical Health Status Of People With Serious Mental Illness
The Challenge Is To Establish A System That Bridges The Gap Between Mental Health Care And General Medical Care
“It’s the right thing to do!”Linda Rosenberg of The National Council
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$28 MILLION DOLLARS GIVEN TO 56 COMMUNITY BEHAVIORAL HEALTH CARE AGENCIES TO INTEGRATE PRIMARY AND
BEHAVIORAL HEALTH CARE SERVICES
FIVE REGIONS
FLORIDA IS IN REGION 3
SAMHSA GRANT PROGRAM
UT
AZ NM
WY
MT ND
SD
NE
KS
OK
TX LA
AR
MO
IA
MNWI
MI
IL IN
KYWV
OH
MD
OR
CA
AKHI
NV
ID
WA
CO
NJDE
MA
NH
CT
VT
PA
NY
RI
ME
ALMS
TNSC
NC
VA
FL
GA
DC
Central Region (2)8 Grantees Midwest Region (4)
13 Grantees
Northeast & Mid-Atlantic Region (5)17 Grantees
Southeast Region (3)8 Grantees
West Region (1)10 Grantees
West Region 1
Central Region 2
Southeast Region 3
Midwest Region 4
NE & MidAtlantic
Region 5AK: Wrangell Community Services
AZ: CODAC Behavioral Health Services
FL: Coastal Behavioral Healthcare
IL: Human Service Center
CT: Bridges - A Community Support System
CA: Mental Health Systems
CO: Mental Health Center of Denver
FL: Lifestream Behavioral Center
IL: Trilogy Inc CT: Community MH Affiliates
CA: Alameda Co Behavioral Health Care Services
TX: Austin-Travis CO MH/MR Center
FL: Miami Behavioral Health Center
IL: Hertiage Behavioral Health Center
MA: Community Healthlink Inc
CA: Asian Community MH Services
TX: Montrose Counseling Center
FL: Community Rehabilitation Center
IN: Adult & Child Mental Health Center
ME: Community Health and Counseling Service
CA: Glenn County Health Services Agency
OK: North Care Center FL: Apalachee Center, Inc IN: Southlake Community Mental Health Center
NH: Community Council of Nashua
CA: Tarzana Treatment Centers, Inc.
OK: Oklahoma Dept of MH/SA
FL: Lakeside Behavioral Healthcare
IN: Centerstone of IN NJ: Care Plus NJ
OR: Native American Rehab Assoc of the NW
UT: Weber Human Services
GA: Cobb/Douglas Community Service Board
KY: Pennyroyal Regional MH/MR Board
NJ: Catholic Charities, Diocese of Trenton
WA: Asian Counseling and Referral Services
SC: State Dept of MH MI: Washetenaw Community Health Organization
NY: VIP Community Services
WA: Downtown Emergency Service Center
OH: Center for Families and Children
NY: Postgraduate Center for Mental Health
OH: Shawnee MH Center
NY: Bronx-Lebanon Hospital Center
OH: Southeast Inc. NY: International Center for the Disabled
OH: Greater Cincy BH Services
NY: Fordham Tremont CMHC
WV: Prestera Center for MH Services
PA: Milestone Centers
PA: Horizon House RI: Kent Center for
Human/Org Development RI: The Providence Center MD: Family Services, Inc
LIST OF SAMSHA REGIONS
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WHAT IS
INTEGRATED HEALTHCARE
?
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IT IS A TEAM-BASED MODEL WITH MEDICAL AND MENTAL
HEALTH PROVIDERS PARTNERING TO FACILITATE THE DETECTION, TREATMENT, AND
FOLLOW-UP OF BOTH MEDICAL AND PSYCHIATRIC DISORDERS IN
A COMBINED SETTING.
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SAMSHA GOALSREDUCE HEALTHCARE DISPARITIES
ELIMINATE THE EARLY MORTALITY GAP
REACH PEOPLE WHO CANNOT OR WILL NOT ACCESS PRIMARY HEALTHCARE SERVICES
EARLY INTERVENTION AND DETECTION
BEFORE ISSUES DEVELOP OR WORSEN
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• Regular screenings and registry tracking • On-site integrated primary care
prevention, screening, and treatment services
• Wellness education and support activities
• Referral and follow-up
IMPROVE HEALTH AND
WELLBEING BY
• Peer involvement in the delivery, planning and evaluation of services
• Advisory Committee involvement and feedback
INCREASE CONSUMER
PARTICIPATION THROUGH
ACHIEVING THE GOALS
IMPLEMENTATION
STEP 4 – CRITICAL STEPS
STEP 3 - INTEGRATION MODELS
STEP 2 - UNDERSTANDING DIFFERENCES
STEP 1 – SUCCESS THROUGH PARTNERSHIPS
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SUCCESS THROUGH PARTNERSHIPS
Primary CareGrant Evaluator
Laboratory VendorMedical Supply Company
Health EducatorsCommunity Stakeholders
Business Alliances
STEP 1
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MANATEE COUNTY RURAL HEALTH SERVICES – Primary Care
UNIVERSITY OF SOUTH FLORIDA – Grant evaluators
SWEETBAY PHARMACY Healthy Saver Plus Program • $7 annual enrollment fee for entire family
• 450 generics at $4 per 30-day supply
DIABETIC STAFF AND PATIENT EDUCATION• Dave Joffe, Sweetbay Pharmacist,
• and Diabetes- in-Control, Editor in Chief
PHARMACIST INTERNSHIP PROGRAM • Student Rotation Affiliation with • Lake Erie College Of Medicine
PFIZER MEDED GRANTS• Application for funding of a Wellness Peer Advocate
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Understanding The Differences
They’re different! Acknowledge & Embrace it!
Step 2
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PRIMARY CARE MENTAL HEALTH
PACE 15 minute appointment 50 minute session
SETTING An exam room A comfortable office
LANGUAGE Diagnosis, medical terminology, complaints
Assessment, mental health terminology, issues
HIERARCHY Clear – Doctor in charge Diffuse – Administrator in Charge with Medical Director
FLOW Flexible patient flow Scheduled client flow
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Step 3 Integration ModelsIntegration Model Level of
Integration Attributes
MINIMAL COLLABORATION I SEPARATE SITE & SYSTEMSMINIMAL COMMUNICATION
BASIC COLLABORATION FROM A DISTANCE II ACTIVE REFERRAL LINKAGES
SOME REGULAR COMMUNICATION
BASIC COLLABORATION ON SITE III SHARED SITE; SEPARATE SYSTEMS
REGULAR COMMUNICATION
COLLABORATIVE CARE PARTLY INTEGRATED IV
SHARED SITE; SOME SHARED SYSTEMSCOORDINATED TREATMENT PLANSREGULAR COMMUNICATION
FULLY INTEGRATED SYSTEM VSHARED SITE, VISION, SYSTEMSSHARED TREATMENT PLANSREGULAR TEAM MEETINGS
CRITICAL STEPSOrganizational Buy-in and Plan
Establish Contracts
Hire Staff
Billing – Opportunities for Sustainability
Data Tracking and Collection
Step 4
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Space
Policies & Procedures
Documentation
Registration and Scheduling
Primary Acute Care Services – Offerings and Expense
Before admitting the first patient, consider:
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Physical History
Personal Risk Factors
Family Risk Factors Height Weight
BMIBlood
Pressure and Pulse
Fasting Plasma Glucose
Total Cholesterol Triglycerides
LDL HDL Cholesterol / HDL Ratio
Complete Metabolic
PanelA1C
Abdominal Circumference TSH Medication
ReviewLiver Function
StudiesCBC with
Differential
Co-Occurring Risk of Harm Depression Screening NOMS Physical Exam
SCREENING FORMS FOR PHYSICAL HEALTH
DISORDERS Including Obesity, Diabetes, Dyslipidemia,
Hypertension, Cardiovascular Disease
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WELLNESS OFFERINGS
NUTRITIONAL EDUCATION
FOOD TOURS
HEALTHY COOKING
DIABETES EDUCATION
PHYSICAL ACTIVITY ED
SMOKING CESSATION
ILLNESS SELF-MANAGEMENT
STRESS MANAGEMENT
PEER SUPPORT
RECOVERY ACTIVITIES
EXERCISE INSTRUCTION
MEDICATION MANAGEMENT
SUSTAINABILITY
COMPLICATED REIMBURSEMENT –
CPT AND ICD-9 CODING
SAMSHA’S TARGET POPULATION MUST BE
EXPANDED IN ORDER TO SUSTAIN INTEGRATION
MODEL
LACK OF SAME DAY SERVICES
REIMBURSEMENT UNDER MEDICAID
WHEN THE FUNDING STOPS
TARGET POPULATION• 18 YEARS OR OLDER• SMI-12MONTH
DURATION• GAF BELOW 60• UNINSURED
HOW WILL WE KNOW PROGRAM GOALS HAVE
BEEN ACHIEVED?
DATA COLLECTION
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DECREASED TOBACCO USAGE
DECREASED OBESITY
INCREASED SELF-MANAGEMENT OF DIABETES
AND/OR CARDIOVASCULAR DISEASE
INCREASED DIABETES OR CARDIOVASCULAR RELATED PHARMACY USE
KEY INDICATORS OF SUCCESS
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INCREASED REFERRAL TO MEDICAL/SURGICAL SPECIALTY CARE
INCREASED RECEIPT OF CLINICAL PREVENTATIVE SERVICES
ImmunizationsCancer Screening
STD And Communicable Disease ScreeningFamily Planning
Dental Care
KEY INDICATORS OF SUCCESS
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LESSONS LEARNED• SENIOR LEADERSHIP INVOLVEMENT IS CRITICAL• SET GOALS … DEVELOP A ROAD MAP
• FORCE INTEGRATION AT EVERY OPPORTUNITY
• BROAD BASE HOLISTIC CARE … NO SILOS
• HIRE AT LEAST ONE EXPERT IN PRIMARY CARE • COST OF PROVIDING PRIMARY CARE IS MORE
EXPENSIVE THAN THAT OF MENTAL HEALTH CARE
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LESSONS LEARNED• WORK ON SUSTAINABILITY IMMEDIATELY … YEAR ONE• FOSTER PARTNERSHIPS … CAN INCREASE OFFERINGS
WITH LITTLE COST• EDUCATING AND ASSISTING PATIENTS IN MANAGING
THEIR HEALTH CARE IS VITALLY IMPORTANT. PROVIDING THE SAME ASSISTANCE TO THEIR CARE GIVERS IS ESSENTIAL!
• ELECTRONIC HEALTH INFORMATION RECORDS ARE GREAT! PAPER CHARTS ARE NOT!
MAJOR COMPLAINT: Acute leg ulcers
MEDICAL HISTORY:Major Depressive DisorderGeneralized AnxietyDiabetesHypertensionAsthmaHyperlipidemia
MEDICATION REGIMEN: No Change In More Than 1 Year
CASE STUDY56-YEAR-OLD WHITE FEMALE
PHYSICAL EXAM: Weight 302: height 5’1” Blood Pressure: 148/90
Pulse 88 bpm; resp. 22 per minute Lungs clear; no wheezing, rales or rhonchi
Lower extremities: + 2 pitting edema bilaterally; pulses fair
LABS: ABNORMAL OR RELEVANT LABS ONLY Hemoglobin A1C: 9.2 (normal range 5.9-7)
Creatinine: 0.7 mg/dl (normal range: 0.7-1.4 mg/dl) Blood Urea Nitrogen: 18mg/dl (normal range: 7-21)
Sodium: 140 mEq/l (normal range 135-145mEq/l
LIPID PANEL: Total Cholesterol: 211 mg/dl (normal range<200 mg/dl)
LDL, Triglycerides: 10% Above normal in all three Liver function panel: within normal limits
CASE STUDY
Poorly Controlled, Severe, Persistent Asthma
Foot Ulcer On Left Foot
Dyslipidemia : Elevated LDL Despite Statin Therapy
Persistent Lower-extremity Edema Despite Diuretic Therapy
Hypokalemia
Hypertension Elevated
Coronary Artery Disease Stable
Obesity Stable
Financial Constraints Affecting Medication Behaviors
Insufficient Patient Education Regarding Purpose And Role Of Medications
Wellness, Preventive And Routine Monitoring Issues
ASSESSMENTS
REFERRAL TO ENDOCRINOLOGIST
SAME–DAY APPOINTMENT
PATIENT REFERRED BACK TO INTEGRATED PROGRAM WITH MEDICATION CHANGES AND MONTHLY
FOLLOW-UP APPOINTMENTS WITH ENDOCRINOLOGIST
AMPUTATION AVOIDED - ENDOCRINOLOGIST REPORTED THAT LEFT FOOT AMPUTATION WOULD HAVE RESULTED
IF NOT FOR IMMEDIATE REFERRAL
OUTCOMES
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RESOURCESAetna Depression In Primary CareCherokee Health Systems – Training ProgramsCommonwealth Of Pennsylvania Screening, Brief Intervention, Referral And Treatment Hogg Foundation For Mental Health – Resource Guide Integrated Behavioral Health Project (IBHP) – Tool Kit Integrated Primary Care, Inc. Intermountain Behavioral Health Program John A. Hartford Foundation- Improving Mood: Promoting Access To Collaborative Care National Council For Community Behavioral Health Care Substance Abuse And Mental Health Services Administration SAMHSA University Of Massachusetts Certificate Program In Primary Behavioral Health Care HRSA- Starting A Rural Health Clinic – A How To Manuel
Coastal Behavioral Healthcare
Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida
[email protected] 941-331-2530 ext. 1110
Anthony R. Bichel, Ph.D.Apalachee Center Inc., Tallahassee, [email protected] 850-459-7025
Rick Hankey, Senior Vice President and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida
[email protected] 352-315-7810
CONTACT INFORMATION