Integrating Behavioral Health and Physical Health:

1. Integrating Behavioral Health and Physical Health: The Time is Now

2. Introductions • Noreen Fredrick • Executive Director • Mon Yough Community Services • McKeesport, PA • Stephen Christian-Michaels • COO • Family Services of Western Pa • New Kensington, PA

3. Overview • Health Status of People with SPMI • Fractured System • Models of Integration • Chronic Care Model • Impact Model • Person Centered Healthcare Home • Cherokee Model – CMHC/FQHC • Research Based Best Practice Components • Types of Integration Initiatives • Family Services of W. Pa Experience • Mon Yough Experience

4. Health Status of People with Serious Mental Health Diagnoses • High prevalence of modifiable risk factors: • Obesity; tobacco use and alcohol use • Group homes -- exposure to infectious diseases -- peers negatively influencing unhealthy risk factors • 60% of premature deaths in individuals with schizophrenia due to: cardiovascular disease pulmonary infectious diseases • Higher rates of COPD and Diabetes than in the general population • Premature death - 25 years younger than the general population. • Medication side effects often exacerbates health status

5. Health Status of People with Serious Mental Health Diagnoses • Hispanics, African Americans or Asian and Pacific Islanders have varying disparities in death rates • The widest gap is seen in black males with a life expectancy of 69.5 years in 2004, 8.3 years shorter than the nationalaverage. • None have a life expectancy that is equivalent to those with serious mental illness. 25 years…….. This disparity is alarming

6. Health Status of People with Serious Mental Health Diagnoses Adults in Health Choices: • Annual increases: 24% - 28% (new consumers) • Have not previously used services • In addition to already burgeoning caseloads • Main Diagnoses • 27% major depression • 23% schizophrenia • 15% bipolar disorder • 15% other depressive disorders • About 40% co-occurring • 51% MH only • 6% substance abuse/dependence only

7. Health System is a Fractured System • People not identified w/depression early enough • Post Partum Depression often not diagnosed • 75% Anti-Depressant meds prescribed by PCP’s • PCP’s often discontinue anti-depressant before full effect is realized

8. Community Mental Health/Primary Care Split • Consumers not engaged with PCP…… • …….use Emergency Departments for routine care • PCP’s often feel unprepared to deal with behavioral health disorders • PCP’s frustrated when they refer into CMHC’s • long waiting lists, drop out’s before first appointment/soon after • CMHC’s feel unprepared to deal with even routine health issues • CMHC’s busy, refer people back to PCP’s for depression, ADD, etc • No infrastructure readily available to enhance communication • Difficult for real communication given busy schedules

9. What contributes to the Fractured Health System • Billing systems are different • Evolving EHR are usually separate w/no interfaces • BH is carved out of managed care plans • Referrals from PCP’s tend to be to MD’s they know • Psychiatry is the lowest paid specialty of physicians • Psychiatry/Therapy split off from medicine

10. Integrated Care: To Be Or NOT • Models of integration • Separate Locations – Coordinated cross referral • Co-Location – BH on site, parallel practice • Integrated/Joint Care – separate but combined • Integrated Centers - Fiscally and Structurally • Integrated Health Systems – Kaiser HMO • 5 Years from now in a reformed healthcare system there may not be a role for CMHC’s that are not involved in Integrated Care

11. Characteristics of Current System • Current care is crisis driven • Provider centric not patient/consumer centric • Care is episodic and reactive • There is not a life time view of disorders • Care tends to be more modality driven, not population driven

12. Chronic Care: A Model to Assist in Integration • Developed by Edward H. Wagner, MD, MPH MacColl Institute for Healthcare Innovation • Organized, planned & productive interactions improve outcomes: • More fully engage individual is in self care activities and • Leads to better health outcomes. • People w/SMI share same characteristics as chronic physical conditions: dealing with symptoms disability emotional impact family issues complex medication regimens difficult lifestyle adjustments difficult to obtain helpful care

13. Used with permission. Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses? Effective Clinical Practice , Aug/Sept 1988 Vol 1

14. Essential Element of Good Chronic Illness Care Prepared Practice Team Informed, Activated Patient Productive Interactions Used with permission. Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses? Effective Clinical Practice , Aug/Sept 1988 Vol 1

15. Informed, Activated Patient What characterizes an “informed, activated patient”? They have the motivation, information, skills, and confidence necessary to effectively make decisions about their health and manage it. Used with permission. Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses? Effective Clinical Practice , Aug/Sept 1988 Vol 1

16. What characterizes a “prepared” practice team? Prepared Practice Team At the time of the interaction they have the patient information, decision support, and resources necessary to deliver high-quality care. Used with permission. Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses? Effective Clinical Practice , Aug/Sept 1988 Vol 1

17. Six Components of Chronic Care Model • Self-Management Support – individuals are supported in achieving goals and fully engaged in care. • Delivery System Design – transform practice form reactive to planned and proactive. • Decision Support - care is based on evidence based guidelines and uses systems to inform and prompt providers and individuals about care needs.

18. Six Components of Chronic Care Model • Clinical Information Systems – use of registries to provide patient specific and population based support to teams, reminders, data and provider feedback. With the correct tools providers can analyze all of their consumer needs, access recent lab work, prescriptions filled, and visits. • Community – utilize resources in the community. This is a natural strength for the CMHC with integration existing as part of the community supports. • Health System – creation of a quality oriented system through leadership and continuous quality improvement.

19. Four Quadrant Integrated Care Model • The NCCBH proposed model for the clinical integration of health and behavioral health services starts with a description of the populations to be served. • • Quadrant I: Low MH - Low PH, served in primary care BH staff on-site provides services • • Quadrant II: High MH - Low PH, served in the MH system PH service provided at CMHC • • Quadrant III: Low MH - High PH, served in primary care BH staff on-site provide services PH case mgt provided • • Quadrant IV: High MH - High PH, served in MH system with specialty care case management for both PH and BH disorders National Council for Community Behavioral Healthcare

20. The Person-Centered Healthcare Home Stepped care clinical approach Healthcare implemented bi-directionally • Identify people in primary care with behavioral health conditions ands serve them there unless they need stepped specialty behavioral health care; and B Identify and serve people in behavioral health care that need routine primary care and step them to full-scope health care home for more complex care www.TheNationalCouncil.org/ResourceCenter

21. Impact Model - Depression • Collaborative care – individual PCP’s works with BH care manager/behavioral health consultant to implement a treatment plan with consultation with the psychiatrist and pharmacist • Depression Screen of all Patients in Medical Practice • Motivational Interviewing, Behavioral Activation and Problem Solving Therapy • Goal is to make incremental changes in life style practices • Medication prescribed by PCP • Health registry used to • Prompts follow-up sessions, outreach, staged interventions • Collects medical and behavioral health data • Tracks changes, outcomes

22. Cherokee Model • Fully integrated structurally and financially • Combined Services • Community Mental Health Center • Federally Qualified Health Center National Council for Community Behavioral Health Care

23. Federally Qualified Health CentersPossible Structures • FQHC and CMHC merged to one organization • Federally Qualified Health Centers provides its own BH services via its own staff = integrated team Funding from one stream, One EHR • Federally Qualified Health Centers with contracted CMHC services integrated • CMHC co-locates staff at FQHC and provides BH services in a parallel practice…one stop shop

24. Research Based Best Practice Components • Regular screens & registry tracking/outcome measurement • Medical nurse practitioners/PCP located in BH clinic • Primary care supervising MD • Embedded RN care manager • Evidenced based practices to improve health of SMI pop. • Wellness programs National Council of Community Behavioral Health Care

25. Integration Initiatives • Screening of Depression for all PCP patients (PHQ-9) • Screening for Unhealthy Substance Use (SBIRT) • Screening of Post Partum Depression – OB and Pediatricians • Depression Screening, Motivational Interviewing, Behavioral Activation, Problem Solving Therapy (IMPACT) • Medical Services provided in MH Centers

26. Challenges • We need to be part of putting the mind and body back together • Healthcare reform is going to drive more focus on integration

27. Family Services Experience • Co-location • Integrated Care, BH service at Medical Clinic • Proposed Medical Services at CMHC

28. Family Services – Co-Location • MD Frustration at long waiting time to see Psychiatrist • MH CRNP at Family Practice office in New Kensington (UPMC) • Started at ½ day/week, moved to two half days per week • 50 – 75 new clients seen per year • Moderate Depression, often linked to MH Clinic • Very little collaborative care • Some phone consultation between MD and Psychiatrist

29. Family Services – Integrated Care at Medical Clinic • Partnership matured • Agreed to seek out funding to move to integrated care • Together support regional Integrated Care Summit mtg • Family Practice-UPMC started screening for Depression • Applied for several grants, not funded • Approached Managed Care Company • Managed Care – Health/BH – funded project/collect data

30. Family Services – Integrated Care at Medical Clinic • Foundation sought out partnership along with 3 other sites • Goals: • Establish communication policies between medical & BH Providers • Increase the appropriate assessment & utilization of BH services • Decrease: • Emergency Department usage • hospital admissions • Re-admissions • Hospital length of stays • Assure that BH provider is a financially viable position

31. Family Services – Integrated Care at Medical Clinic • IMPACT/Depression Screening • SBIRT/Unhealthy Substance Use Screening • Engagement/Behavioral Activation/Problem Solving Treatment • Grant fund position for 18 months • Goal: Demonstrate ability to reduce by 6 inpatient hospital admits • Pgh Regional Healthcare Initiative provides consult/project mgt • University of Washington/IMPACT provides • Training • Consultation • Health Registry

32. Family ServicesMedical Services at CMHC • SAMHSA Proposal • Family Practice staff contracted to provide medical services • MD, Nurse Practitioner and Nurse become part of MH Teams • Build a physical fitness center at CMHC • Peer support used to engage consumers in healthy lifestyles • Build EHR Interfaces to share summary notes • Build Health Registry into BH EHR to implement Chronic Care Model • Change physical layout of office for (4) interdisciplinary teams • Services: Health Screening, Nutrition Counseling, Fitness Groups Health Improvement plans, Consultation, Care Mgt

33. Mon Yough ExperienceSAMHSA Grant: Emerg Dept Diversion • Partners: • UPMC for Life • UPMC McKeesport Hospital • Latterman Family Health clinic • UPMC McKeesport Internal medicine • MYCS • Goal: • Decrease Emergency Department usage • Determined Access as the issue • Increased midlevel practitioner time at Latterman and MYCS as we agreed that we all serve the same group of clients

34. Mon YoughEvolution of the Partnership • Grant led to beginning of “partnership model” between Latterman Family health and MYCS. • CRNP .5 FTE located in Behavioral health clinic • Primary care supervising physician • Imbed Psych Rehab in clinic setting to promote wellness as core goals and work with nursing staff to structure wellness activities • Next Steps: • Create registry tracking • Embed evidenced based practice in daily practice

35. Mon YoughChronic Care Model  CMHC • Development of a “chronic care” team within adult Outpatient clinic • Co-locate treatment; psych rehab, supported employment and service coordinator in one area • PH and BH team live in the same building

36. Mon YoughPerinatal Depression Project • Rand project – targeting perinatal depressed Moms in a variety of settings including OB clinic; pediatricians • MYCS partnered with Magee in Clairton • Behavioral health time provided on site • Lessons learned… • Helped with imbedding of BH case manager in Latterman clinic to assess need /level of support and type of integration • Next Step use existing “SHIP” infrastructure to create collaboration among community using logic model approach

37. Mon YoughTraining the Work Force • Latterman Clinic is a Family Practice education site. • MYCS will serve as the rotation site for dual boarded Family Practice/Psych Fellowship 4 hours a week • Latterman Clinic • Provide physical health care in MYCS clinic • Provide supervision of primary care at MYCS clinic • MYCS will serve as the psych rotation education site for Family Practice Residents

38. Learning Collaborative • Set up learning collaboratives • Use consultants to help cross walk systems • Share information across projects • Examples: • Collaborative learning across BH and PH • Collaborative learning across CMHC’s • List Serves on Integrated Care • Regional Learning Collaboratives

39. Resources • Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses: Effective Clinical Practice, Aug/Sept 1988 Vol. 1 • National Council of Community Behavioral Health Care. Winter 2009. A Two-Way Street Behavioral Health Care and Primary Care Collaboration. • Morbidity and Mortality in People with Serious Mental Illness, National Association of State mental Health program Directors, Medical Directors Council; Editors: parks, Svendson, Singer, Foti, Technical Writer: B Mauer. October 2006; Report available at www.namsmhpd.org • List Serve: http://lists101.his.com/mailman/listinfo/pc-bh-integration

40. Contact Information Noreen Fredrick fredricknm@mycs.org (412) 673-8035 Stephen Christian-Michaels christian-michaelss@fswp.org (412) 820-2050 x438