Integration of Primary Care and Behavioral Health

1. Integration of Primary Care and Behavioral Health Nancy V. Wallace, MSN, FNP Daily Planet Healthcare for the Homeless VACPN Conference October 14, 2011

2. Learning Objectives • Define integrated care • Explain the need for integrated care • Describe various models of integrated care • Identify benefits to integration of care • Identify challenges to overcome in the effort to deliver integrated care

3. Primary care Behavioral health Collaborative care Integrated care Define integration

4. Primary Care • The medical setting where patients receive most of their medical care and is therefore the first source for treatment • Family medicine • General medicine • Pediatrics • OB-GYN (sometimes)

5. Behavioral Health • Includes both mental health and substance abuse services • In the US, is most often delivered in separate specialty clinics • Often, substance abuse treatment and mental health treatment are delivered in separate facilities

6. Collaboration vs. Integration Collaboration Integration Involves BH working within primary care Clients perceive BH services as a routine part of their health care • Involves BH working with primary care • Clients perceive that they are getting care from a specialist who collaborates closely with their PCP

7. Biopsychosocial model • Biological, psychological, and social factors all play a significant role in human functioning in the context of disease • Often endorsed, seldom practiced

8. The burden of mental illness is high You can’t separate the mind and body Healthy behaviors decrease when mental health is poor There are medical benefits to good mental health The need to integrate care

9. The Burden of Mental Illness • In 2008, NIMH estimated that 1 in 4 adults suffer from a diagnosable mental disorder • Mental illness begins early in life (1/2 by age 14 and ¾ by age 24) • Mental illness is a chronic disease of the young

10. You can’t separate the mind and body • Physical health problems and mental health problems are correlated • Those with serious medical problems often have co-morbid mental health problems • As many as 70% of primary care visits stem from psychosocial issues

11. Healthy behaviors decrease when mental health is poor • Tobacco use among those diagnosed with mental illness is TWICE that of the general population • Injury rates (intentional and unintentional injuries) are 26 times higher in those with mental illnesses than the general population

12. Medical Benefits of Good Mental Health • Decreased risk for disease, illness, and injury • Better immune functioning • Improved coping and quicker recovery • Increased longevity • Lower cardiovascular risk

13. Common concepts Coordinated, Co-located, Integrated Specific examples Models of integrated care

14. Concepts common to all integrated care models • The medical home • The healthcare team • Stepped care • Four-quadrant clinical integration

15. The medical home • NCQA’s inclusion criteria: • Patient tracking and registry functions • Use of non-physician staff for case management • The adoption of evidence-based guidelines • Patient self-management support and tests(screenings) • Referral tracking

16. The healthcare team • The doctor-patient relationship is replaced with a team-patient relationship • Members of the team share responsibility for care. The patient perceives that the team is responsible • Visits are choreographed with various team members (nurse, doctor, CM, pharmacist, etc.)

17. Stepped care • Causes the least disruption to the person’s life • Is the least extensive needed for positive results • Is the least intensive needed for positive results • Is the least expensive needed for positive results • Is the least expensive in terms of staff training required to provide effective service

18. Stepped care (BH example) • Provide basic education and refer to self help groups • Involve clinicians who provide psycho-educational interventions and make follow up phone calls • Involve highly trained BH professionals who use specific practice algorithms • Refer to specialty MH system

19. Four-Quadrant Clinical Integration

20. Four-Quadrant Clinical Integration Service Delivery

21. Four-Quadrant Clinical Integration Examples

22. Wide range of models in practice • Can be thought of as a continuum of • Coordinated Care • Co-located Care • Integrated Care • Most models in practice currently are hybrids of the above models

23. Coordinated care • Routine screening for BH problems conducted in primary care • Referral relationship between PCP and BH settings • Routine exchange of information between both treatment settings • PCP delivers BH interventions using brief algorithms • Connections are made between the patient and community resources

24. Co-located care • Medical and BH services are located in the same facility • Referral process for medical cases to be seen by BH (and vice versa) • Enhances communication between providers because of proximity

25. Co-located care • Consultation between providers to increase the skills of both • Increase in the level and quality of BH services offered • Significant reduction of “no-shows” for BH treatment

26. Integrated care • Medical services and BH services are delivered in the same or separate locations • One treatment plan includes both medical and BH elements • A team working together to deliver care using a prearranged protocol

27. Integrated care • Teams composed of a physician and one or more of the following: NP, PA, nurse, case manager, family advocate, BH therapist, pharmacist • Use of a database to track the care of patients who are screened into behavioral health services (and vice versa)

28. A collaboration continuum

29. Collaboration continuum • Minimal • BH and PCP work in separate facilities, have separate systems, and communicate sporadically • Basic Collaboration at a distance • PCP and BH providers have separate systems at separate sites but now engage in periodic communication about shared patients

30. Collaboration continuum • Basic collaboration on-site • BH and PCP have separate systems but share the same facility. Proximity allows for more communication, but each provider remains in his or her own professional culture

31. Collaboration continuum • Close collaboration in a partially integrated system • BH professionals and PCP share same facility and have some systems in common (i.e. scheduling, medical records). Physical proximity allows for face to face communication between providers. There is a sense of being part of a larger team.

32. Collaboration continuum • Close collaboration in a fully integrated system • The BH and PCP are part of the same team. The patient experiences the BH treatment as part of his or her regular primary care

33. For the patient For the providers Benefits to integrated care

34. Benefits to integrated care Patient Provider Practice as a part of a team who's members support each other’s efforts to help improve the heath of patients Learn from other providers Potential payment incentives • Improved health outcomes • Greater engagement in participating in own care • Decreased risk for adverse events • Increased access to services (less stigma, more convenient)

35. Challenges to overcome to fully integrate care

36. Challenges to overcome • Psychiatric resources are scarce • Telemedicine • Mentoring relationships • Primary care resources are scarce • Utilize non-physician staff (NPs, PAs)

37. Challenges to overcome • Privacy concerns limit access to patient records across disciplines • HIPPA allows for sharing information for the purpose of care coordination without a formal consent. State laws are sometimes more strict • There is discussion regarding federal regulation CFR 42 (which regulates SA services information) to allow sharing of information for the purpose of treatment coordination

38. Challenges to overcome • Payment and parity issues • Medical home models typically receive a “per-member-per-month” fee, perhaps the fee could be enhanced for members in higher value quadrants

39. References • Collins, C. 2010. Evolving Models of Behavioral Health Integration in Primary Care. New York, NY:Milbank Memorial Fund. • Mauer, B. 2009. Behavioral Health/Primary Care Integration and the Person-Centered Healthcare Home. Washington, DC: National Council for Community Behavioral Healthcare. Available at http://www.allhealth.org/BriefingMaterials/BehavioralHealthandPrimaryCareIntegrationandthePer son-CenteredHealthcareHome-1547.pdf. • Centers for Disease Control and Prevention. Public Health Action Plan to Integrate Mental Health Promotion and Mental Illness Prevention with Chronic Disease Prevention, 2011–2015. Atlanta: U.S. Department of Health and Human Services; 2011.

40. Discussion • Do you have any questions about the presentation? • Are there any questions about my practice? • What are you doing in your practices? • What challenges have you faced? • Any good outcomes or client feedback?