Macon County Initiative Integrating Behavioral Health and Primary Care

1. Presented by: Diana Knaebe, Heritage Behavioral Health Center Macon County Initiative Integrating BehavioralHealth and Primary Care

2. Integration Partnership Background • Description/History of Partnerships • Rationale for involvement • Evolution of Partnerships and programs – services offered • Next Steps

3. Heritage and CHIC Integrated Care Project Heritage Behavioral Health Center Community Health Improvement Center

4. Integration Partnership Background Description/History of Partnership Community Health Improvement Center and Heritage • Have had working relationship for the past fifteen years; initially, there were cooperative efforts with mutual referrals to assure that clients received needed primary care/mental health services. • Early on the entities worked cooperatively with a local pharmacy, and developed a system utilizing bubble cards containing daily prescribed dosages of medications for medical and psychiatric problems which could be taken by the client on a daily basis.

5. Integration Partnership Background • In July 2006, the United Way funding allowed Heritage to provide an adult psychiatrist on-site at CHIC. This psychiatrist provided psychiatric care, support, and follow up to patients, and consultation to medical physicians 9 hours per month. The CHIC physicians were so pleased with the immediate psychiatric consultation available that the pediatric providers requested on-site psychiatric availability. • Consequently, in April 2007, a child and adolescent psychiatrist was added. He provides mental health services to the primary heath center 4 hours per month, direct care to patients, and consultation and education to the medical physicians.

6. Integration Partnership Background • United Way funding allowed CHIC to provide a APN as well as a liaison on-site at a Homeless Day Center operated by Heritage. This allowed access to health care by individuals many of whom had not received health care in years. • Both organizations have attended the National Council’s Integrated Care Sessions for past 5 years. • Participated in National Council’s Integrated Collaborative Care Project in 2007 • Participated in MHCA Integrated Healthcare Learning Community August 2009-November 2010

7. Rethinking the Format of Visions

8. Reasons/Rationale for Partnerships Ultimately to Implement a patient centered medical home – true integration of care • Better Overall health outcomes. • Improved access and retention of clients • Joint referral process and records access • Clinical processes defined for collaboration and joint education for staff • Nurse practitioners and/or Physician Assistants at both CHIC and Heritage • Clients only seen at one site for all needs – as much as possible unless need specialty care • Maximizing revenue (current and new services) • Efficient/effective/efficacious care • Non-duplication of care and services • Education sharing component for staff and clients

9. Cultural Issues/differences Term-language Differences How patients/clients are seen – length of time for visit and follow up Funding Streams and Mechanisms often very different Determination of “hand-offs” and/or referrals Releases – Medical Records

10. The Four Quadrant Clinical Integration Model For the Adult Population/ Heritage & CHIC Adaptation

11. Integration Partnership - Expansion The Administrative and Clinical Collaborative Committees continue to meet on the existing collaboration as well as expanding to additional behavioral health services on site at CHIC and with an intention of continuing to work towards the provision of primary health care in a behavioral health care setting. This project is the logical extension of efforts currently underway between Heritage and CHIC. Heritage and CHIC meet regularly to plan, coordinate, and implement our existing collaboration of integrating behavioral and primary health care. This collaboration is progressive and moving forward. The MCMHB joined the Administrative Committee in late 2009 when we began a “pilot project” to add expertise, additional funds with Medicaid billing through them plus the matching local dollars.

12. Integration Partnership Background • Integration: Partnering Agencies 2011 • The Community Health Improvement Center (CHIC), a primary health care center – Federally Qualified Health Center, • Heritage Behavioral Health Center (Heritage), a community behavioral health center – Mental Health, Substance Abuse, Homeless and Housing Services • The Macon County Mental Health Board (MCMHB), a public taxing body that funds MH/SA/DD services • The Macon County Health Department, public health department (MCHD)

13. Integration Partnership – Expansion Two Macon County Health Department MCHD entered into partnership with IDPA ABCD II (Assuring Better Child Health and Development Initiative) project in 2005. State level partners included: Illinois Chapter, American Academy of Pediatrics ( ICAAP) and Illinois Academy of Family Physicians Ounce of Prevention Fund (OPF) Illinois Department of Human Services (IDHS) Office of Family Health (OFH) IDHS Office of Mental Health (OMH) Illinois Department of Children and Family Services Illinois Primary Health Care Association (IPHCA Local partners included: AOK Network FQHC: CHIC WIC/FCM Coordinator Pediatric/Family Practices: Early Intervention/CFC: Heritage Behavioral I

14. Edinburgh Postnatal Depression Scale (EPDS) • Possible Depression is indicated at score of 10 or above. Referral provided for all scores of 10 or higher INITIAL NUMBERS INDICATED HIGH RATE OF NEED ! • Edinburgh’s Completed : • May 05 – September 05 = 434 • Scores of 10 or higher = 100 • Result=25% rate of at risk women in need of referral ! • Current screening rates maintain average of 100 screens completed /month with 10-20% rate of need for referral

15. Hopes & Screams from MCHD MCMHB Board Director enlisted local mental health providers to provide counseling services for clients with positive screening scores Referral rates outnumbered available resources MCMHB providers had long waiting times for client entry Some MCMHB providers were charging clients for services against project agreement Some providers requested clients not be referred if in prenatal state Some OB providers declined to accept screening results MCHD staff expressed frustrations and concerns related to referral inconsistencies

16. MCHD Request to MCMHB Fall 2010 • Invited MCMHB Director to Maternal Child Health staff meeting to address staff concerns related to the counseling referral system • Staff relayed numbers of underserved clients • Gave examples of referral difficulties with MCMHB paid agencies • Requested on site services and to include home visits for clients with barriers such as daycare, transportation, work/school schedules • Goal= to achieve through partnership timely and adequate service delivery and follow up for at risk women and families

17. MCMHB Reasons for Involvement • New Medicaid by billing through the MCMHB – directly to DHFS • Local Funds Initiative - matching Medicaid with County dollars means more money for the community • Quicker access to behavioral health services • Captive Audience at CHIC – linkage & need from MCHD • Eligibility – changes in eligibility over the years in mostly only target population defined by DHS-OMH – this allows an Expansion of eligibility wider range of individuals than current and potential • Still meeting medically necessity • More holistic care - hopefully better clinical outcomes/people improving/getting better

18. Integration Partnership – Expansion Two Continued Administrative Team established and meeting to work through challenges, barriers, referral processes, medical record – computer Members from MCHD, MCMHB, Heritage Clinical Teams also providing feedback through their supervisors – funnels up to Administrative Team and back to clinical teams/supervisors to smooth the processes

19. MCHD, “Happy Days Are Here!” January 2011-Part time MCMHB funded Heritage Counselor begins accepting onsite referrals at MCHD and completing home visits. 40 referrals received in the first month! Whew! Initially ,frustration expressed regarding delayed contact time vs referral numbers …However … Counselor provides assistance with multiple scenarios Clients and staff express 100% satisfaction with follow up services

20. Next Steps MCHD Expansion into Seniors Plan to use Geriatric Depression Screen One full-time mental health staff beginning July 2011 might expand to another part-time assigned to the MCHD clients/patients

21. Specific Changes Implemented in the Last Year Lost the psychiatrist that worked so well for both organizations as a result have added Psychiatric Nurse Practitioner to FQHC Added Mental Health Therapist to the FQHC site with MCMHC Board Funding Screening to determine who can be better served at the FQHC as primary – Medical Home Have received SAMHSA Integrated Primary Care Grant which will allow us to emphasize wellness with SPMI population added Physical PA on site at the Mental Health Center. MCHD has become 2nd site funded by MCMHB for therapists to see identified by MCHD staff in need of services – primarily an outreach, in-home model though which is different than that at CHIC

22. Lessons Learned – things to Consider when establishing Collaborations for Integration of Care Can take much more time to work through because our systems are often actually complicated Are the right people at the table for discussions? Licensure of Sites – Scope of Practice Changes Written Agreements Joint Contracts for purchasing of staff or services Who is billing for what?

23. SAMHSA Program Goals • Heritage Behavioral Health Center received a SAMHSA Grant in September 2010 for its Primary and Behavioral Health Care Integration (PBHCI) program. • Our project focuses on: • individuals with Serious Mental Illness who are on antipsychotic medications and…. • have co-occurring metabolic syndrome or a chronic medical condition • Establishment of a primary care clinic at Heritage Behavioral Health Center • Provision of wellness activities/programs • Working with 500 SMI adults by the end of the 4th year

24. SAMHSA Program Goals Health and Illness Background Information • Used both as a screening and as a means of documenting diagnoses (PH and BH) as well as important medical/health history variables SF-36 (short form) • Person Centered Healthcare Home Fidelity Scales and Protocols • Developed by our evaluator, TriWest • Based on the conceptual work of Barbara Mauer and collaborators • 2-day collaborative assessment process

25. Accomplishments In 5 months, established a Health & Wellness Suite, including a Primary Care Office at Heritage Contracted with CHIC Primary Care Clinic to place a Primary Care Physician/Assistant on site Developed a Clinical Registry Admitted 57 clients to Health and Wellness Program since Mid March 2011

26. Accomplishments • Received 87 referrals to the program since program began in February 2011 Success Stories: • In one month, one client lost 20#, another lost 11#, a third lost 14#. No one enrolled in the program has gained weight. • Two partially immobile clients are now mobile and continuing to improve

27. Health and Wellness Activities • Food Pyramid Education weekly • Healthy Cooking Classes weekly • Chair Zumba twice per week • Modified Yoga weekly • Daily Walking Activity • Healthy Food Shopping As Needed • 1:1 Food Counseling and Review of Food Tracker as needed • Weekly Off Site Exercise

28. Plans for The Future • Expand hours and responsibilities of P/A to provide all primary care for individuals in the program • Provide fully certified smoking cessation classes to clients • Staff will become certified in smoking cessation, diabetes education, yoga, and zumba • Provide physical illness management education to case managers • Add Peer Support/Mentors to program • Wellness Model throughout organization

29. Key Contact Person(s) and Contact Information: • Julie Aubert, MCHD, jaubert@maconcountyhealth.org • 217-423-6988 ext 1105 • Barbara Dunn, CHIC, bdunn@chealthctr.org • 217-877-6111 • Dennis Crowley, MCMHB, dcrowley@mcmhb.com • 423-6199 X 108 • Diana Knaebe, Heritage, dknaebe@heritagenet.org • 217-420-4702 • Karen Shiflett, MCHD, wic@maconcountyhealth.org • 217-423-6988 ext 1343