# Presentation: 383715

## Integrating Behavioral Health and Primary CareIndian Health SystemReadiness Curriculum

- Ann M. Lewis, CEO
- CareSouth Carolina
- Ann.lewis@caresouth-carolina.com

## Objectives

- To describe current perspectives on “Why Integrate”
- To present an array of considerations for those centers interested in integration.
- To present a review of the various models for behavioral health and primary care integration, discussing strengths and weaknesses.
- To describe the core clinical functions of integration
- To share experiences of CareSouth Carolina and other team examples with integration – within the framework of the Care Model

## Why Integrate Behavioral Health and Primary Care?

- Surgeon General’s Report on Mental Health in 1999 – acknowledged the crucial role of primary care in provision of mental health care
- The President’s New Freedom Commission on Mental Health (2003) promoted integration
- Secretary’s National Advisory Committee on Rural Health and Human Services (2004) and Institute of Medicine (2005) call for integration

## Benefits of Integrated Care

- Seamless for the Patient – improves patient satisfaction
- Immediate Access (no referral out)
- Reduces Stigma
- Improves Access for MH expertise
- Immediate “Curbside Consultation”
- Extends Behavioral Change Expertise into the Primary Care Center for improved management of chronic conditions (DM,CVD...)
- Improves medical productivity, access and flow
- Contributes to the improvement of  medical clinical outcomes and functional outcomes
- Depending on state reimbursement structures, behavioral health services can have a positive fiscal impact on the center.

## Common Barriers and Myths (to get over....quickly)

- Our patients do not want to address depression or mental health.
- It is “understandable” that our patients are depressed or mentally unhealthy.
- We do not have the right staff or support, if we ask, we open “Pandora’s Box”
- It will cost too much.
- Our patients need help with social and economic issues, not mental health or depression.

## Considerations:  If you’re thinking about integration...

- How clinical, administrative, and operational functions will be integrated
- How community and market factors affect integration
- What mental health conditions are likely to be seen in the center’s patient population and in the community?
- Will services be provided only to center patients or open to new patients from the community?

## Considerations....

- What types of behavioral health conditions and levels of acuity will be treated within the service?
- What referral sources are available for patients with needs beyond the capacity of the center’s services?
- What level (model) of integration is desired?
- What is the comfort level of the existing PCPs?

## Considerations....

- What administrative, information, and support systems are needed?  Billing, registry, appointment.
- What are the resources and constraints within the community and state.
- What are the state licensing requirements for mental health staff?
- Consider MH clinician’s abilities to engage patients and work well with PCPs.  It is different from private practice and CMHC models.
- What are the state reimbursement structures?  For Medicaid, for managed care, for private insurance?
- What is the pharmaceutical availability for the center? For indigent and uninsured patients?

## Models of Integration

- Diversification – provided on-site directly with Center’s own mental health staff
- Linkage / Co-location – provided on-site by non-Center staff health worker
- Referral – provided off site by non-Center staff under formal arrangement
- Enhancement – train primary care practitioners to provide mental health services on site.

## Diversification Model

- Gives the center control over how behavioral health services are provided
- Ability to provide services to indigent and uninsured
- Reduction of stigma
- Improved patient satisfaction
- Improve likelihood of continuing treatment
- Reducing time demands on PC staff – improving PC productivity
- Integrated medical record with BH tab facilitates patient care planning
- Allows for PC team collaboration in “real time”

## Wind River Behavioral Health Department

- 4  Psychologists (one unfilled)
- 1  Counselor
- 2  Social Workers
- 1  Consulting Psychiatrist

## 2007: Top BH Patient Concerns

- Alcohol Related 25%

- Depression  22%

- Other Emotional Reactions   13%

- Social Services  31%

- Post-Traumatic Stress   9%

**Notes:**
Summary of previous slide collapsing categories

## 2007 Most Frequent Behavioral Health Primary Diagnoses

- 								       # Visits
- Depressive disorder						236
- Family Circumstances					201
- Adjustment disorder (mixed emotions and conduct)		176
- Bereavement						155
- Post-traumatic stress disorder				145
- Adjustment disorder with anxiety/depression			141
- Alcohol dependence (in remission)				122

**Notes:**
Top 10 most frequent reasons to come to BH Dept

## Behavioral Medicine

- Falls under Medical Services, integrated into Primary Care
- I provide immediate *preventive medicine * and/or
*    **risk reduction* interventions to patients (15/30/45)
- If indicated,  BH referrals are made or B.Med patients scheduled
- Motivational interviewing is the primary tool
- Currently only at Fort Washakie, will spread to AHC

## Most Frequent Behavioral Medicine Secondary Diagnoses

*Stress-Related Physiological Response Affecting a Medical Condition (316)*
*Pain Disorder Assoc. w/Psych. Factors & a Medical Condition (307.89)*
*Maladaptive Behaviors Affecting a Med. Condition (316)*
*Hx of Past Non-compliance, Hazard to Health (V15.81)*
*Other Psychological Stress (Difficulty Coping) (V62.89)*

## 2007: Top B. Med. Patient Concerns 

## Linkage / Co-location Model

- Contracts with local mental health centers or private providers
- Issues of changes in local or state funding
- Issues of providing care to indigent and uninsured patients
- Issues of support structures:  appointment scheduling, billing, office space, medical record documentation, interaction with PC team.

## Referral Model 

- More frequently used to supplement the Diversification Model
- Addresses the need for care that is beyond the capacity of center’s mental health staff.
- Center must address tracking and follow-up, expectations of reporting from specialist

## Enhancement Model

- Typically used to supplement the Diversification Model
- Improves the capacity of the PCP to work as part of an integrated team.
- Requires targeted training, usually for medication management
- When used as stand alone model:
- Has significant detrimental impact on provider productivity
- Requires targeted training for assessment and counseling treatment

## Core Clinical Functions of Integration

- Integrative Activities –
- Patient screening / assessment – using standardized, evidence based tool (PHQ9);  may be done by PCP team, BH staff, other
- Initial Engagement – Brief introduction to BH staff for evaluation of immediate needs.  Engaging the patient improves likelihood of further treatment. Responding to questions from patient and staff
- Maintaining “walk in” slots for same day access. Consider 15/45 minute schedule
- Coordination with the PCP team
- Follow up and tracking

## Core Clinical Functions of Integration, continued

- Direct Care Services
- Medication management – by PCP
- Counseling and therapy services, individual, family, group – by mental health staff
-  Begin TX within 2 weeks for non-emergency problems
- Psychiatric consultation / referral- phone, telemedicine, appointments

## Let’s talk about specific team experiences with behavioral health integration specific to the components of the Care Model

- CareSouth Carolina
- South Central Foundation
- Gerald Ignace
- Eastern Aleutian Tribes
- Cherokee
- Any others????? (Wind River)

## Care Model

**Informed,**
**Empowered Patient and Family**

**Productive Interactions ****through effective asset based partnering over time**

**Prepared,**
**Proactive**
**Practice Team**

**Improved achievement of patient and community goals**

**Delivery****System**
**Design**

**Decision**
**Support **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community **

**Health Care Organization**

**Care Model**

**Patient**** ****Driven**** **

**Coordinated**

**Timely and Efficient**

**Evidence-based and Safe**

- Wagner, E. et al

## CSC:  Integrated Behavioral HealthHealthcare Organization

*CSC has been engaged with integrated BH and PC for over 15 years.  *
*Division of Behavioral Health is at the top management level in organizational structure.*
*Behavioral Health services are part of the strategic plan,  healthcare plan, business plan and performance improvement plan.*
*Senior Leadership supports integrated behavioral health with the will, the ideas and the execution necessary to insure integration.*
*Behavioral Health has specific system level performance process and outcome measures.*

## Other Team ExperiencesHealthcare Organization:

- Where is Behavioral Health in the organizational structure?
- Is Behavioral Health addressed in organization strategic plan?
- What are some examples of Senior Leader support for Behavioral Health?
- Does the organization have Behavioral Health performance measures?

## CSC:  Integrated Behavioral HealthCommunity

*Collaborate with and support local Community Mental Health Centers devastated by state budget cuts*
*Relationship with DJJ to provide mental health care for DJJ adolescents*
*Parenting classes for DSS/CPS families*
*Mental health care for geriatric patients of long term care facilities*
*Relationship with Pee Dee Coalition for depression treatment for domestic violence patients*
*Depression treatment for HIV/AIDS patients in Ryan White program*
*Relationship with McLeod RMC Inpatient Behavioral Health facility for inpatient referrals. *
*Affiliation with local hospital psychiatric geriatric unit and psychiatrist *

## Other Team Experiences:Community

- What are some examples of community relationships your team has established?
- What are some examples of community issues that impact integration plans?

## CSC:  Integrated Behavioral HealthDelivery System Design

*LMSWs and LBSWs at every site (14), employed by CSC*
*Behavioral Health staff consists of MSW and BSW team, providing **“**stepped**”** clinical counseling integrated into primary care*
*Designed appointment systems to support the needs of our  patients including: follow-up activities and multiple appointments on same day max-packing, 15 / 45 minute rule)*
*Nurses triage all patients for **“**red flag**”** depression statements, and initiate PHQ*
*Telephone **“**visits**”** for follow-up and care management*
*“**Primary care**”** mental health assessment & treatment in addition to specialty mental health care*
*Co-location of clinical counselors and primary care providers in the same building, down the hall*

## Other Team ExperiencesDelivery System Design

- What is your current staffing for behavioral health?
- Where are behavioral health staff physically located?
- What is the scope of behavioral health services provided?

## CSC: Integrated Behavioral HealthDecision Support

*ARHQ Guidelines for Depression Management*
*PHQ 9 Symptom checklist for Depression Assessment*
*Psychopharmacology training for all providers and counselors, nurses and social workers*
*DSM IV training for all Behavioral Health staff*
*Evidence based problem-solving therapy*

## Other Team ExperiencesDecision Support

- What are your guidelines, tools, or other resources for decision support.
- Does your team use a specific model for problem solving?

## CSC:  Integrated Behavioral HealthClinical Information System

*Use a Registry (PECS data management system) to track, report and  trigger follow-up dates for improved depression care*
*Mental Health notes are integrated into primary care medical record (tab separation)*
*Data is reported monthly on a Virtual Office.*
*Data is discussed at site meetings, quarterly staff and provider meetings.*
*All data is unblinded.  *

## Other Team ExperiencesClinical Information System

- How does your team manage both individual and population based information?
- How is behavioral health information documented in the medical record?

## CSC: Integrated Behavioral HealthSelf-Management

*CSC Depression management handbook which includes education and action plan*
*Staff trained on self-management goal setting*
*Individualized  self management goal setting implemented*
*Medication monitoring and measurement *

## Other Team ExperiencesSelf Management

- How does your team accomplish self management support?
- Does your team monitor patient medication and/or treatment?

## CareSouth Carolina Performance Measures

- For Depression Management

## Other Team Experiences and Examples of measurement and outcomes

- What does your team measure?
- What are some examples of your team performance?  Outcomes?

## References

- D. Lambert, J. Gale(2006).  Integrating primary care and mental health:  current practices in rural community health centers.  Kansas city, MO:  National Rural Health Association
- Shekar, S. (2003), March24.  Update from the BPHC:   Remarks to the NACHC.  _[http://ftp.hrsa.gov.newsroom/NACHC2003.pdf](http://ftp.hrsa.gov.newsroom/NACHC2003.pdf)_
- Proser, M and Cox, L (2004).  *Health Centers’ Role in Addressing the Behavioral Health Needs of the Medically Underserved.  *NCAHC.  Special topics Issue Brief #8.  Sept.  Washington, DC