The Integrated Primary Care Behavioral Health Model...Coordinated Care: Primary care and behavioral...

HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County

The Integrated Primary Care Behavioral Health Model

Brian C. Reed MDDirector, Disease Control and Clinical Prevention

Harris County Public HealthJuly 13, 2018


Overview: The Integrated Primary Care Behavioral Health Model

• Institute for Healthcare Improvement Triple Aim• Definition of Integrated Care• The Case for Integrated Primary Care Behavioral

Health Model• Levels of Integration• Integration within Harris Health System• Four Quadrant Model

HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County 3

• Improving the Patient Experience of Care

• Improving the Health of Populations

• Reducing the Per Capita Cost of Healthcare

Institute for Healthcare Improvement : Triple Aim


Defining Population HealthPopulation health is defined as the health outcomes of a group of individuals, including the distribution of outcomes within the group.

•These groups are often geographic population such as nations or communities

•However, the groups may be employees, ethnic groups, disabled persons, prisoners or any defined group

•The health outcomes of such groups are of relevance to policy makers in both the public and private sectors.

•Note that population health is not just the overall health of a population but it also includes the distribution of health.

Dr. David A. Kindig, MD, PhD Emeritus Professor of Population Health Sciences and Emeritus Vice Chancellor for Health Sciences at the University of Wisconsin-Madison School of Medicine

http://www.youtube.com/watch?v=FYTqg3Jk9U4



Definition Population Health:Population Health Outcomes

• Most health improvement models seek to:• Increase overall population health• Eliminate disparities within the population

•In this model overall population health is evaluated by two measures:

•Mortality – length of life•Health related quality of life

•Since another goal is to reduce disparities in these health outcomes among different subgroups in the population, this figure seeks to capture disparities based upon

•Race/Ethnicity•Socioeconomic Status•Geography•Gender




Definition Population Health:Health Care Determinants

• Health care determinants include:•Access•Cost•Quantity and Quality of health care services

•Individual behavior determinants include:•Lifestyle habits•Diet & Exercise•Smoking

•Social environment determinants include•Education•Income•Occupation

•Physical environment determinants•Water quantity•Lead exposure

•Genetic determinants include genetic composition of individuals or populations




Defining Population Health:Impact of Policies and Programs

• Policies and programs produce changes in health determinants or factors.•These health determinants produce health outcomes.•Examples of policy changes that impact health are the following:

•Smoking bans•Excise taxes on cigarettes•Excise taxes on alcohol•Seat belt laws•Water fluoridation•Restaurant menu labeling.

•The inherent value of a population health perspective is that it facilitates integration of knowledge across the many factors that influence health and health outcomes.




Definition of Integrated Care


The Case for Integrated Primary Care Behavioral Health Model People with mental illness are dying on average 10 years earlier

than the general population. The average life expectancy of an individual with a severe mental illness is

approximately 49-60 yrs. compared to 78.6 years. Greater likelihood of death from heart disease, pneumonia, influenza and

other respiratory ailments. 7 of the 10 leading causes of have a psychological and/or behavioral

component. This includes heart disease, cancer, strokes, diabetes, chronic lower

respiratory disease, accidents and suicide Health care visits often have psychosocial drivers. Integrated Primary Care Behavioral Health can produce cost savings Fewer hospitalizations Fewer emergency room visit


Three Main Categories of Care Coordinated Care:

Primary care and behavioral health providers communicate about shared patients

Maintenance of separate facilities and systems

Co-Located Care: Behavioral health and primary care have a co-located practice at the same

facility. There is closer collaboration with some systems integration

Integrated Care: There is a systematic clinical approach to identify patients who are in need of

behavioral health services Providers jointly plan and execute goals Co-manage patients and maintain shared schedules Develop integrated care plans


Three Main Categories of CareCoordinated Care: Level 1: Minimal Collaboration Behavioral health and primary care providers work in separate facilities and

have separate systems. Providers rarely communicate about cases.

Level 2: Basic Collaboration at a Distance Behavioral health and primary care providers work in separate facilities and

have separate systems. Providers view each other as resources and communicate periodically about

shared patients. Behavioral health is still viewed as specialty care.

Key Element is Communication (Note differences between frequency and type of communication)


Three Main Categories of CareCo-located Care: Level 3: Basic Collaboration Onsite Behavioral health and primary care providers are co-located in the same

facility. They may or may not share the same practice space. Providers continue to use separate systems but communicate more often via

telephone, e-mail or in person conversations. There is a shared patients are moved between behavioral health and primary

care via a referral process.

Level 4: Close Collaboration with Some System Integration Behavioral health and primary care providers are co-located in the same

practice space and there is closer collaboration. Behavioral health providers are often embedded within the primary care

practice and have the ability to access and enter notes into a shared medical record.

Key Element is Physical Proximity


Three Main Categories of Care Integrated Care: Level 5: Close collaboration approaching an integrated practice There are high levels of integration and collaboration. Providers communicate frequently and work as a team. Behavioral health and

primary care providers are co-located in the same facility.

Level 6: Full collaboration in a Transformed/Merged Practice This is the highest level of integration. Providers and patients view the clinical operation as a single health system that

has been designed to treat the whole person.

Key Element is Practice Change (There must be blending/blurring of cultures and no discipline predominates)


Integration Vs. Traditional ModelIntegrated Care Traditional Mental health

Population Based Client Based

Informal inflow Formal referral and acceptance process

Open Access (client is usually seen on the same day as referral)

Appointments and usually wait list

Visits typically 15-30 minutes Visits usually 45 minutes – 60 minutes

Treatment is typically limited to 1-3 visits Often long term treatment

Mental health is just one component of overall care Focus upon mental health

More informal counseling ; prone to interruption More formal and private

Frequent consultation with medical provider for clients with co-occurring health and mental health conditions

Little or no interaction with medical provider regarding medical conditions


Primary Care Behavioral Health Integration within Harris Health System Rationale

All psychiatric care provided at one location

6 month waiting period for new appointments

Pilot A psychiatrist was placed one half day

per week in 3 community health centers.

Goal was to increase timely access The psychiatrist was responsible for

evaluation and treatment of scheduled patients.

The psychiatrist also implemented curbside consultations.


Primary Care Behavioral Health Integration within Harris Health System

Bi-Directional Flow of PatientsEducation Funding $54,000 educational grant from

Abbott Laboratories for a formal lecture series $450,000 grant from Hogg

Foundation for July 2005 –June 2006 $700,00 in additional support

from HCHDResults


The Four Quadrant Clinical Integration Model (MH/SU)

Quadrant II

MH/SU PH • Outstationed medical nurse

practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP

• MH/SU clinician/case manager w/ responsibility for coordination w/ PCP

• Specialty outpatient MH/SU treatment including medication-assisted therapy

• Residential MH/SU treatment • Crisis/ED based MH/SU interventions • Detox/sobering • Wellness programming • Other community supports

Quadrant IV



• Nurse care manager at MH/SU site • MH/SU clinician/case manager • External care manager • Specialty medical/surgical • Specialty outpatient MH/SU treatment

including medication-assisted therapy • Residential MH/SU treatment • Crisis/ED based MH/SU interventions • Detox/sobering • Medical/surgical inpatient • Nursing home/home based care • Wellness programming • Other community supports

•

MH/SU

Risk

/Comp

lexity

Quadrant I

MH/SU PH • PCP (with standard screening tools

and MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)

• PCP-based BHC/care manager (competent in MH/SU)

• Specialty prescribing consultation • Wellness programming • Crisis or ED based MH/SU

interventions • Other community supports

Quadrant III

MH/SU PH • PCP (with standard screening tools and

MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)


• Specialty medical/surgical-based BHC/care manager

• Specialty prescribing consultation • Crisis or ED based MH/SU interventions • Medical/surgical inpatient • Nursing home/home based care • Wellness programming • Other community supports

Physical Health Risk/Complexity

Low High

Low

High

Persons with serious MH/SU conditions could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration.


Four Quadrant Model: Quadrant I

Population: Low to moderate behavioral health complexity and low to moderate physical health complexity. The Model: Person Centered Healthcare Home: A primary care

team that includes a behavioral health consultant/care manager, psychiatric consultant, screening for behavioral health concerns and stepped care. The Providers: Primary care provides full scope healthcare home and uses standard

behavioral health screening tools. Psychiatric consultation is structured to support the primary care

provider and behavioral health consultant/care manager with a focus on treatment planning for those individuals who are not improving.


Four Quadrant Model: Quadrant II

Population: Moderate to high behavioral health and low to moderate physical health complexity and low to moderate physical health complexity. The Model: Person Centered Healthcare Home: Primary care

capacity in a behavioral health setting provided via wellness screenings, a medical nurse practitioner or PCP. The Providers: Primary care provides stepped care to full scope healthcare through

practicing onsite or supervision of a nurse practitioner. Standard health screenings and wellness programs are available.


Four Quadrant Model: Quadrant III

Population: Low to moderate behavioral health complexity and moderate to high physical health complexity The Model: This is Quadrant I care plus medical/surgical

specialty collaboration.


Four Quadrant Model: Quadrant IV

Population: Moderate to high behavioral health complexity and moderate to high physical health complexity The Model: This is Quadrant II care plus medical/surgical

specialty collaboration.


The Four Quadrant Clinical Integration Model (MH/SU)

Quadrant II



• MH/SU clinician/case manager w/ responsibility for coordination w/ PCP

• Specialty outpatient MH/SU treatment including medication-assisted therapy

• Residential MH/SU treatment • Crisis/ED based MH/SU interventions • Detox/sobering • Wellness programming • Other community supports

Quadrant IV



• Nurse care manager at MH/SU site • MH/SU clinician/case manager • External care manager • Specialty medical/surgical • Specialty outpatient MH/SU treatment

including medication-assisted therapy • Residential MH/SU treatment • Crisis/ED based MH/SU interventions • Detox/sobering • Medical/surgical inpatient • Nursing home/home based care • Wellness programming • Other community supports

•

MH/SU

Risk

/Comp

lexity

Quadrant I

MH/SU PH • PCP (with standard screening tools

and MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)


• Specialty prescribing consultation • Wellness programming • Crisis or ED based MH/SU

interventions • Other community supports

Quadrant III

MH/SU PH • PCP (with standard screening tools and

MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)


• Specialty medical/surgical-based BHC/care manager

• Specialty prescribing consultation • Crisis or ED based MH/SU interventions • Medical/surgical inpatient • Nursing home/home based care • Wellness programming • Other community supports

Physical Health Risk/Complexity

Low High

Low

High

Persons with serious MH/SU conditions could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration.


References SAMHSA-HRSA Center for Integrated Health Solutions

https://www.integration.samhsa.gov/integrated-care-models

Partners in Health: Mental Health, Primary Care and Substance Use Interagency Collaboration Tool Kit

http://www.ibhpartners.org/wp-content/uploads/2016/04/IBHPIinteragency-Collaboration-Tool-Kit-2013-.pdf

Behavioral Health/ Primary Care Integration and the Person Centered Healthcare Home

https://www.integration.samhsa.gov/BehavioralHealthandPrimaryCareIntegrationandthePCMH-2009.pdf

https://www.integration.samhsa.gov/integrated-care-models

http://www.ibhpartners.org/wp-content/uploads/2016/04/IBHPIinteragency-Collaboration-Tool-Kit-2013-.pdf

https://www.integration.samhsa.gov/BehavioralHealthandPrimaryCareIntegrationandthePCMH-2009.pdf

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