Extreme Collaboration

1. Extreme Collaboration Total Integration of Behavioral Clinicians into Primary Care Practice

2. Current State of our Fragmented Healthcare System Hello, uh my name is --------, and I’m calling for my son. Uh, he has bipolar schizo, and uh…uh…he hasn’t had no medications for a long time because they don’t wanna give him any medications because he doesn’t have uh Medicare. We tried to get Medicare and they didn’t wanna give it to him and I’m really really real real worried about him. I’m his mother. He has uh really been um depressed depressed and I’m really afraid for him. I would really appreciate it if you would give me a call because I need to see somebody. The doctor here in the won’t be back ‘til May but we can’t really wait that long. I would just appreciate so much if you could give me a call. It’s very important. I would appreciate a call. We need to see you as soon as possible. Please help us.Thank you.

3. L.C., a 36-year-old divorced mother of three and kindergarten teacher was at the end of her rope, financially and emotionally, when she made the wrenching decision to hand over her son. L.C.’s husband left her alone with three children, including an older bipolar daughter and a 12-year-old boy who is doing well. But her 11-year-old son, Skylar, is bipolar, abusive and violent, she said, and after three years of spotty, expensive and ineffective psychiatric care she could see no other way to get him the intensive help he needs. L.C. said that her son had received psychiatric care off and on, with limited coverage by her insurance plan, but that he often refused to take prescribed medications. When he refused to go to school, she could not afford a sitter and did not know where to turn. “Good luck finding a counselor — they’re all filled up,” she said. “You call a psychiatrist and have to wait three months for an appointment.” Once during a snowstorm, she said, after she drove 25 miles to pick up the boys at school, then 45 miles to a psychiatric appointment, she arrived 15 minutes late. “They said we’d have to make a new appointment for six weeks later,” she said. - NY Times, November 22, 2008

4. “Every system is perfectly designed to get the results that it gets.” - Dr Paul Batalden, Dartmouth University

5. What is the current system designed for? Obstacles to care Health disparities Poor health outcomes Frustration Failure

6. What do we know? • Mental health can’t be separated from physical health • People get their health care in primary care offices • Mental health disorders are under recognized • Most people won’t go to a mental health center

7. What else do we know? • Access to mental health professionals is difficult at best • particularly for uninsured and underinsured populations • People complain of symptoms • But providers are obsessed with diagnoses • Traditional approaches to mental health have failed at the population level

8. The Pyramid of Psychosocial Problems in Primary Care

9. Level I : Acute psychiatric emergencies

10. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness

11. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness Level III: Chronic less severe conditions

12. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness Level III: Chronic less severe conditions Level IV: Temporary psychosocial problem

13. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness Level III: Chronic less severe conditions Level IV: Temporary psychosocial problem Level V: Everybody else

14. Salud Family Health Centers

15. Salud Family Health Centers • Migrant/community health center • Full range of primary care services including obstetrical care • Full dental services in all clinics • Mobile unit • 70,000 unduplicated patients

16. Salud Integrated Care Model • BHP office in medical exam room space • BHP spends 70% of time doing screening, brief interventions, f/u phone calls, etc • 30% of time in more traditional therapy • Solution focused • Limited number of visits • Referral as necessary • Frequent and ongoing consultations among docs and BHPs

17. Salud Integrated Care Model • Population based • We want to reach EVERY patient • Real time interventions • Most patients can see therapist today • Emphasis on horizontal integration not vertical integration • Casts a wide net in determining need for psychosocial intervention • Broad evaluative measures

18. Requirements for Total Integration Co-location Universal screening Brief interventions Solution focused therapy BHPs as primary care providers BHP adaptation Physician adaptation

19. Co-Location • Co-location means co-location • Sharing the same space at the same time • Integrated care means integrated facilities • Regardless of problem, all patients go in and out the same door

20. Universal Screening Most mental health disorders are occult Most visits to primary care providers have a large psychosocial component Primary care docs do a relatively bad job of uncovering mental health issues Most poor health outcomes are related to behavior issues

21. Universal Screening • Screening is screening • NOT diagnosis • Screening forms should be straightforward and simple • Positive screens can be followed up with more sophisticated and comprehensive evaluation tools • I recommend face-to-face screening

22. Brief Interventions • ‘Psychoeducational triage’ interventions • 5-15 minutes max • In the exam rooms • Goes hand-in-hand with screening • Requires BHP to work within the chaos of the primary care office

23. BHP Adaptation • Traditional mental health office • No interruptions • All apptmts made in advance • Quiet controlled environment • Typical primary care office • Lots of interruptions • Many walk-in apptmts • Controlled (barely) chaos

24. Solution Focused Brief Therapy • Resource activation, not problem activation • Has an endpoint • Allows flow of patients in and out of the BHP schedule • More complex patients may need to be referred out • PCPs don’t provide subspecialty care • This is a primary care model

25. BHPs are Primary Care Providers NOT ancillary staff If the patient is seeing the BHP, the patient is being seen BHP assessment is as important as physician assessment Patients will often identify the BHP as their PCP

26. Requires Broad Training • LOTS of different duties • Psychotherapy • Social work • Case management • Other

27. BHP Adaptation Your training model may not apply Office environment is different How patients gain access is different Concept of confidentiality is different Process orientation vs goal orientation Visits are different

28. How do patients gain access to BHP? Screening Direct appointment Referral from provider Patient request at medical visit

29. Doc:BHP Ratio ?

30. Resistance • From BHPs • I can’t just walk in on a patient • I like to spend more time with patients • I like to get deep into my patients’ psyche • I don’t like all the interruptions • This isn’t the way I was trained

31. Resistance • From medical providers • I’m the captain of the ship • I don’t like other people seeing my patients • The BHP slows me down • I’m really good at psych stuff and I don’t need help • This isn’t the way I was trained

32. What do patients think? NO resistance Accepted part of total care package at Salud Seen as value added service

33. Funding

34. Salud Integrated Care Funding Models Mental Health Expansion grant from govt Partnership with local health district Partnership with local mental health center Commitment of general primary care funds Patient billing

35. Other Funding Possibilities • Patient billing • Not likely to work for brief visits • Could cover 30% of salary • Subsidies • Docs benefit from integrated practice • Communities benefit from integrated practice • Managed care contracts • Patients (and therefore insurance companies?) benefit from integrated practice • Medical home may require it

36. Caveats • You can’t manage everything • We don’t do heart surgery in primary care either • We know how to make referrals to specialists if necessary • Costs are incurred and savings are accrued in different places

37. Next Steps • Outcomes research • Medical parameters as evidence of effectiveness of mental health interventions • Fewer ER visits, more clinic capacity, fewer lost days of work, etc, etc, etc • Policy changes

38. ?