Lori Raney, MD

1. Primary Care Providers Working in Mental Health Settings:Improving Health Status in Persons with Mental Illness • Lori Raney, MD • With: Katie Friedebach, MD; Todd Wahrenburger, MD; Jeff Levine, MD; and Susan Girois, MD

2. Disclosures • Dr. Raney: Consultant, National Council • Dr. Wahrenberger:Nothing to disclose • Dr. Girois: PBHCI Grantee • Dr. Levine: PBHCI Grantee • Dr. Friedebach: Nothing to disclose

3. Module 2Overview of the Behavioral Health Environment • Learning Objectives: • Appreciate the philosophy, funding and organizational structure of public mental health settings • List the personnel employed in these settings, their job functions and how the teams operate • Describe the integrated care team roles and responsibilities in these settings

4. Pre Test Questions • The Community Mental Health Center Act is approximately how old? • 10 years • 30 years • 40 years • 50 years • Staff found in community mental health center (CMHC) environments can include: • Case managers • Social Workers • Nurses • Peers • All the above • With proper access to care, what percent of people with serious mental illness may experience intermediate to excellent outcomes? • 10% • 20% • 50% • 70%

5. Overview of Module 2 • History of public mental health and CMHCs • Who are the staff? • Lexicon • Services provided by team members • Service planning • Health Insurance Portability and Accountability Act (HIPAA) and 42 Code of Federal Regulations (CFR) • Recovery movement

6. A different world A PCP said to me… “Walking into our CMHC was like walking onto mars”

7. Brief History of Community Mental Health • Move people out of mental institutions and into the community, based on concept of “moral treatment” from Pinel, 1700s “the insane came to be regarded as normal people who had lost their reason as a result of severe psychological stress.” • 1908 - First national mental health advocacy organization (now Mental Health America) was established by Clifford Beers, a formerly hospitalized person with a mental illness. • 1949– Approval of chlorpromazine (Thorazine), and discovery that lithium treats mania • 1963– Community Mental Health Center Act signed by President Kennedy, mostly unfunded • mid 60’s – Medicare/Medicaid offered some funding for care – partial hospitalization

8. Brief History of Community Mental Health cont. • 1980 – National Mental Health Service Systems Act – unfunded, then eliminated in 1981– “transitional institutionalization” to nursing homes, jails or prisons, boarding homes, foster care. LA county jail “largest psychiatric hospital in the country” • 1996 – State hospital populations to 62,000 from 5.5M; managed care • Late 90s to 2000 –symptom control rehab recovery • 2003 – President’s New Freedom Commission on Mental Health • 2008 – Parity Act: equivalent payment for medical and mental health • 2010 – Affordable Care Act – funding for programs such as PBHCI grantees and State Plan Amendments Feldman, 2012, Textbook of Community Psychiatry

9. Case Manager LCSW PCP Psychiatric Providers Psychologist Licensed therapist Admin Nurse Peers Addictions Counselor Housing

10. Who Receives Services? • In certain behavioral health settings, you may find non-medical staff do not use the term “patient” to refer to the people they serve. • Instead, settings may use: • Consumer • Client • Customer • Different settings use different terminology – ask staff and the people you serve their preference.

11. Person-First Language • We are not defined by our problems or diagnoses, or by a single aspect of who we are; we are people first and foremost. • Descriptions of the people you serve should reflect this, such as, “people with mental health or substance use problems or challenges” rather than “mentally ill people” or “addicts.” SAMHSA’s Resource Center to Promote Acceptance, Dignity and Social Inclusion Associated with Mental Health (ADS Center)

12. Army of Providersand Array of Services • Medical – MD, DO, APN, PA • Psychotherapy – many flavors, see slide 17 • Case Management – link to community supports (e.g., housing, education) • Crisis Services – manage emergency situations, arrange hospitalization, emergency commitments if needed • Assertive Community Treatment (ACT) – mobile units that reach more severely ill patients • Peer Services – individuals in recovery from their own mental health conditions helping others • Vocational Support – assistance in preparing for, finding, and being successful in employment • Substance Abuse Treatment – detox, outpatient groups, medication assistance • Psychiatric Rehabilitation – develop skills to function in communities • Clubhouse – self-support services • Wellness Education – helps patients manage their symptoms at home

13. Multidisciplinary Team Approach Example: Adult Team Meeting Psychiatric Providers Case Managers Nurses Therapists Peer Specialist Discuss patients who are struggling Discuss new patient evaluations Debrief traumatic events Discuss physical health issues with in-house PCPs Education – medication side effects, etc. Frequent re-admissions

14. MD, DO, APN, PA • New evaluations and medication follow-ups • Team leaders – Adult, Child, etc. • Inpatient psychiatric services Psychiatric Providers • Nursing homes • Child psychiatric services • Consult liaison to hospitals • Jail services • Screening for side effects of second generation antipsychotics (SGAs) per protocols, ltihium, depakote labs, following BMI, blood pressures • Limit the effects of SGAs, response to the iatrogenic effects of medications

15. Bachelor’s degree usually • Day-to-day support, encouragement • Medication compliance – pill boxes • Food stamps • Housing, heat Case Managers: Crucial Link to Implementing Care Plan • Transportation • Disability applications • Connect to PCPs in the community • Monitor symptoms and report to team • Education, reinforcement, follow-up • ** Education regarding other chronic medical conditions – Case to Care, etc.

16. Individuals in recovery trained as service providers – many backgrounds, usually certified by a state certification body or mental health authority, may not have degree • Use their experiences to help others with mental illness. Offer social support, shared experiential knowledge, broker the needs of patients Peer Specialists • Improve activation by motivating patients to participate in their care Develop Wellness Recovery Action Plans (WRAP) with patients Dual relationships may exist between peer specialists and other treatment providers (such as therapists, the PCP or psychiatric providers) as well as with the people they serve. Establishing clear boundaries is an important aspect of training peer specialists and other staff. Vecchio, 2012, Handbook of Community Psychiatry

17. Follow patients in registries to assess progress towards goals and prevent “falling through the cracks” Care Managers • Coordinate services with primary care and medical services • Patient education and follow-up • New addition to the team – usually RNs • Regular review with PCP and team members

18. Primary Care Providers • Direct Care • Case-load reviews with team • Population management – identify priorities • Education of non-medical staff

19. Therapists • Many backgrounds and skills in their tool box. • Psychologists (PhD), Social Work (LCSW), Licensed Professional Counselors (LPC), Marriage and Family Therapists (LMFT), Substance Use Counselors (CAC) • Individual therapies, group therapies, evidence based therapies • Child and Adult specialties, Substance Use specialty

20. Additional Clinical Staff • Vocational Counselors – assist patients with preparing for, finding and being successful with employment • Emergency Services staff – cover outpatient emergencies, may work in hospital ERs, jails. Many backgrounds/licensure. Used to triage and quicker pace of care

21. Evidence-Based Practices • Medication Guidelines • Dialectical Behavioral Therapy (DBT) • Cognitive Behavioral Therapy (CBT) • Supported Employment • Assertive Community Treatment (ACT) • Integrated Dual Diagnosis Treatment (IDDT) • Family Psychoeducation • Self Management – Stanford Self-Management, Health and Recovery Peer (HARP), Living Well, Whole Health Action Management (WHAM)* • IMPACT model *evidence-informed, based on HARP model

22. Integrated Service Planning is the Goal(MH, SUD, Physical Health) Goal is Integrated Service Plan!

23. Providing Information Across Silos of Care • HIPAA permits sharing information, including behavioral health • National consent not necessary, stricter local laws may apply • Exceptions: • 42 CFR, Part 2 - Substance abuse treatment • Determined by location in which tx occurred and information is being released • Applies to organizations that “hold themselves out” as providing substance abuse treatment (Betty Ford Clinic, hospital unit that specifically provides substance use treatment, an individual that only does this) – they are bound by 42 CFR • PCPs can release info they have gathered (e.g. patient on methadone) independently in their clinic under HIPAA and do not fall under 42 CFR because not a location that provides substance abuse treatment • Re-release of records from the methadone clinic requires consent. • Exception? A PCP who works in a methadone clinic! • There has never been a 42 CFR suit www.samhsa.gov/healthprivacy

24. Example – Mr. Jones • Mr. Jones is a 42 year old male with schizophrenia you are treating in a PBHCI grantee site (a mental health center ) • He is getting methadone from a clinic that specifically provides methadone treatment (holds itself out to be a substance use treatment provider) • Mr. Jones tells you he is on methadone and you record this in yourchart • You may release the information you have obtained independently and recorded in your chart to his cardiologist under HIPAA and do not need consent under 42 CFR • You request a copy of his record from the methadone clinic. They must follow 42 CFR to release his records to you • You may not re-release his actual record from the methadone clinic to the cardiologist without consent under 42 CFR

25. Recovery • A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. • Four Dimensions: Health, Stable Home, Purpose and Community Supports • Guiding Principles: Recovery emerges from hope, is person-driven, holistic, supported by peers and allies, culturally based, addresses trauma, involves strengths, occurs via many pathways, and is based on respect SAMHSA 2012 For more information visit www.samhsa.gov/recovery/

26. Recovery Rates – Severe Mental Illness • 1/3 Full Recovery • 1/3 Intermediate Outcome • 1/3 Poor Outcome • You are going to see more patients in the Intermediate and Poor range due to location of service Menezes NM, et al: A Systematic Review of longitudinal outcome studies Of first episode psychosis. Psychol Medicine 2006; 36:1349-1362 Harding, C. M., Brooks, G. W., Asolaga, T. S. J. S., and Breier, A. (1987). The Vermont longitudinal study of persons with severe mental illness. American Journal of Psychiatry, 144, 718-726

27. Harness the Power of the Team!

28. Reflections and Discussion • How do you think you will fit into this environment? • Do you see yourself as a ready and willing “team” player? • What excites you about working in this system?

29. Post Test Questions • The Community Mental Health Center Act is approximately how old? • 10 years • 30 years • 40 years • 50 years • Staff found in CMHC environments can include: • Case managers • Social Workers • Nurses • Peers • All the above • With proper access to care, what percent of people with serious mental illness may experience intermediate to excellent outcomes? • 10% • 20% • 50% • 70%

30. Post Test Answers • The Community Mental Health Center Act is approximately how old? • 10 years • 30 years • 40 years • 50 years • Staff found in CMHC environments can include: • Case managers • Social Workers • Nurses • Peers • All the above • With proper access to care, what percent of people with serious mental illness may experience intermediate to excellent outcomes? • 10% • 20% • 50% • 70%

31. References • Feldman, 2012, Textbook of Community Psychiatry • Vecchio, 2012, Handbook of Community Psychiatry • Menezes NM, et al: A Systematic Review of longitudinal outcome studies • Of first episode psychosis. Psychol Medicine 2006; 36:1349-1362 • Harding, C. M., Brooks, G. W., Asolaga, T. S. J. S., and Breier, A. (1987). The Vermont longitudinal study of persons with severe mental illness. American Journal of Psychiatry, 144, 718-726

32. End of Module 2