PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION

1. PRIMARY AND BEHAVIORALHEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION

2. PRESENTERS Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida Anthony R. Bichel, Ph.D. Apalachee Center Inc., Tallahassee, Florida Rick Hankey, Senior V. P. and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida Coastal Behavioral Healthcare

3. LEARNING OBJECTIVES PROVIDE AN OVERVIEW OF INTEGRATED BEHAVIORAL HEALTH AND PRIMARY CARE INCREASE KNOWLEDGE OF THE IMPLEMENTATION PROCESS AND SUSTAINABILITY DESCRIBE LESSONS LEARNED Coastal Behavioral Healthcare

4. OUTLINE • History • Define The Problem Today • What Changed? Why Now? • What Is Integrated Care? • The Implementation Process • Sustainability • Lessons Learned Coastal Behavioral Healthcare

5. HOW DID PHYSICAL AND MENTAL HEALTH BECOME SEPARATED? Coastal Behavioral Healthcare

6. HISTORY Coastal Behavioral Healthcare

7. PROMISES MADE AND PROMISES BROKEN • Money was intended to follow consumers into community programs. This didn’t happen. • Employer paid insurance had no reason to pick up • the bill. Most didn’t. • Operating two systems: state and community. Never had enough money to fund both. • Community based mental health system has always been underfunded. Coastal Behavioral Healthcare

8. TODAY PEOPLE WITH SMI DIE ON AVERAGE 25 YEARS SOONER THAN THE GENERAL POPULATION They are not dying from their mental illness, but from their chronic and untreated physical illnesses. Coastal Behavioral Healthcare

9. OF THE SIX MAJOR CAUSES OF DEATH IN THE UNITED STATES, THERE IS AN INCREASED RISK OF DEATH AMONG THE SERIOUSLY MENTALLY ILL Bob Sharp, Fl Council For Community Mental Health Coastal Behavioral Healthcare

10. FACTORS INCREASING HEALTH RISK Poverty • Poor access to Primary Care • Less likely to be screened Self-Care Capacity/Resource • Disconnectedness • of “Physical” & • “Mental” health • care systems Under Diagnosis & Under Treatment • Cognitive, Affective • and Behavioral • symptoms • Weight Gain System Navigation Barriers Tobacco and Substance Abuse Medications Coastal Behavioral Healthcare

11. 4-Year Grant from The Substance Abuse And Mental Health Services Administration (SAMHSA) – $500,000 Per Year The Purpose Of The Grant Is To Improve The Physical Health Status Of People With Serious Mental Illness The Challenge Is To Establish A System That Bridges The Gap Between Mental Health Care And General Medical Care What's CHANGED AND Why change now? “It’s the right thing to do!” Linda Rosenberg of The National Council Coastal Behavioral Healthcare

12. $28 MILLION DOLLARS GIVEN TO 56 COMMUNITY BEHAVIORAL HEALTH CARE AGENCIES TO INTEGRATE PRIMARY AND BEHAVIORAL HEALTH CARE SERVICESFIVE REGIONSFLORIDA IS IN REGION 3 SAMHSA GRANT PROGRAM

13. Northeast & Mid-Atlantic Region (5) 17 Grantees Central Region (2) 8 Grantees Midwest Region (4) 13 Grantees West Region (1) 10 Grantees WA VT ME MT ND MN OR NH ID WI NY SD MA MI WY RI CT PA IA CA NE NV NJ OH IN DE IL UT WV DC CO MO VA KY KS MD NC TN OK AZ NM AR SC AL MS GA AK Southeast Region (3) 8 Grantees TX LA HI FL

14. LIST OF SAMSHA REGIONS

15. WHAT IS INTEGRATED HEALTHCARE? Coastal Behavioral Healthcare

16. It is a team-based model with medical and mental health providers partnering to facilitate the detection, treatment, and follow-up of both medical and psychiatric disorders in a combined setting. Coastal Behavioral Healthcare

17. SAMSHA GOALS Coastal Behavioral Healthcare

18. ACHIEVING THE GOALS Coastal Behavioral Healthcare

19. IMPLEMENTATION

20. STEP 1 SUCCESS THROUGH PARTNERSHIPS Primary Care Grant Evaluator Laboratory Vendor Medical Supply Company Health Educators Community Stakeholders Business Alliances Coastal Behavioral Healthcare

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22. Understanding The Differences Step 2 They’re different! Acknowledge & Embrace it! Coastal Behavioral Healthcare

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24. Integration Models Step 3 Coastal Behavioral Healthcare

25. Step 4 CRITICAL STEPS

26. Before admitting the first patient, consider: Coastal Behavioral Healthcare

27. SCREENING FORMS FOR PHYSICAL HEALTH DISORDERS Including Obesity, Diabetes, Dyslipidemia, Hypertension, Cardiovascular Disease Coastal Behavioral Healthcare

28. WELLNESS OFFERINGS NUTRITIONAL EDUCATION FOOD TOURS HEALTHY COOKING DIABETES EDUCATION PHYSICAL ACTIVITY ED SMOKING CESSATION ILLNESS SELF-MANAGEMENT STRESS MANAGEMENT PEER SUPPORT RECOVERY ACTIVITIES EXERCISE INSTRUCTION MEDICATION MANAGEMENT Coastal Behavioral Healthcare

29. WHEN THE FUNDING STOPS SUSTAINABILITY • TARGET POPULATION • 18 YEARS OR OLDER • SMI-12MONTH DURATION • GAF BELOW 60 • UNINSURED

30. HOW WILL WE KNOW PROGRAM GOALS HAVE BEEN ACHIEVED? DATA COLLECTION

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32. Coastal Behavioral Healthcare

33. LESSONS LEARNED • SENIOR LEADERSHIP INVOLVEMENT IS CRITICAL • SET GOALS … DEVELOP A ROAD MAP • FORCE INTEGRATION AT EVERY OPPORTUNITY • BROAD BASE HOLISTIC CARE … NO SILOS • HIRE AT LEAST ONE EXPERT IN PRIMARY CARE • COST OF PROVIDING PRIMARY CARE IS MORE EXPENSIVE THAN THAT OF MENTAL HEALTH CARE Coastal Behavioral Healthcare

34. LESSONS LEARNED • WORK ON SUSTAINABILITY IMMEDIATELY … YEAR ONE • FOSTER PARTNERSHIPS … CAN INCREASE OFFERINGS WITH LITTLE COST • EDUCATING AND ASSISTING PATIENTS IN MANAGING THEIR HEALTH CARE IS VITALLY IMPORTANT. PROVIDING THE SAME ASSISTANCE TO THEIR CARE GIVERS IS ESSENTIAL! • ELECTRONIC HEALTH INFORMATION RECORDS ARE GREAT! PAPER CHARTS ARE NOT! Coastal Behavioral Healthcare

35. 56-YEAR-OLD WHITE FEMALE MAJOR COMPLAINT: Acute leg ulcersMEDICAL HISTORY:Major Depressive DisorderGeneralized AnxietyDiabetesHypertensionAsthmaHyperlipidemiaMEDICATION REGIMEN: No Change In More Than 1 Year CASE STUDY

36. PHYSICAL EXAM: Weight 302: height 5’1” Blood Pressure: 148/90 Pulse 88 bpm; resp. 22 per minute Lungs clear; no wheezing, rales or rhonchi Lower extremities: + 2 pitting edema bilaterally; pulses fairLABS:  ABNORMAL OR RELEVANT LABS ONLY Hemoglobin A1C: 9.2  (normal range 5.9-7) Creatinine: 0.7 mg/dl  (normal range: 0.7-1.4 mg/dl) Blood Urea Nitrogen:  18mg/dl  (normal range: 7-21) Sodium: 140 mEq/l (normal range 135-145mEq/lLIPID PANEL: Total Cholesterol: 211 mg/dl (normal range<200 mg/dl) LDL, Triglycerides: 10% Above normal in all three Liver function panel: within normal limits CASE STUDY

37. Poorly Controlled, Severe, Persistent AsthmaFoot Ulcer On Left FootDyslipidemia : Elevated LDL Despite Statin TherapyPersistent Lower-extremity Edema Despite Diuretic TherapyHypokalemiaHypertension ElevatedCoronary Artery Disease Stable Obesity StableFinancial Constraints Affecting Medication Behaviors Insufficient Patient Education Regarding Purpose And Role Of Medications Wellness, Preventive And Routine Monitoring Issues ASSESSMENTS

38. REFERRAL TO ENDOCRINOLOGISTSAME–DAY APPOINTMENT PATIENT REFERRED BACK TO INTEGRATED PROGRAM WITH MEDICATION CHANGES AND MONTHLY FOLLOW-UP APPOINTMENTS WITH ENDOCRINOLOGISTAMPUTATION AVOIDED - ENDOCRINOLOGIST REPORTED THAT LEFT FOOT AMPUTATION WOULD HAVE RESULTED IF NOT FOR IMMEDIATE REFERRAL OUTCOMES

39. Aetna Depression In Primary Care Cherokee Health Systems – Training Programs Commonwealth Of Pennsylvania Screening, Brief Intervention, Referral And Treatment  Hogg Foundation For Mental Health – Resource Guide  Integrated Behavioral Health Project (IBHP) – Tool Kit  Integrated Primary Care, Inc.  Intermountain Behavioral Health Program John A. Hartford Foundation- Improving Mood: Promoting Access To Collaborative Care  National Council For Community Behavioral Health Care  Substance Abuse And Mental Health Services Administration  SAMHSA  University Of Massachusetts Certificate Program In Primary Behavioral Health Care  HRSA- Starting A Rural Health Clinic – A How To Manuel RESOURCES Coastal Behavioral Healthcare

40. CONTACT INFORMATION Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida lstratford@coastalbh.org 941-331-2530 ext. 1110 Anthony R. Bichel, Ph.D. Apalachee Center Inc., Tallahassee, Florida anthonyb@apalacheecenter.org 850-459-7025 Rick Hankey, Senior Vice President and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida rhankey@LSBC.net352-315-7810 Coastal Behavioral Healthcare