Models of Medical Care in the Psychiatric Setting

1. Models of Medical Care in the Psychiatric Setting Jason Cheng, MD Jeanie Tse, MD Institute for Community Living, Inc. Wellness, Resilience, and Recovery for All Philadelphians: Integrated Care in Philadelphia June 25, 2013

2. Objectives At the conclusion of this presentation, participants will be able to: Describe two models of integrating medical care into psychiatric settings Strategize how to modify electronic health record systems at their home institutions to support integration

3. Institute for Community Living • NYC not-for-profit • >100 programs, 10,000 consumers: housing, case management, ACT, PROS (NY only), clinics, shelters & health home • Founded Health Care Choices FQHC • In housing and case management: • >70% schizophrenia / schizoaffective • Primarily paraprofessional workforce

4. Person-centered care • “The patient is the source of control” (IOM) • Goals and values determine how care is provided • Self-management Patient

5. Self-Mgmt Workbooks Co-Loc/ Care Mgmt Pthwys/ MedRisk Mgmt Integrated Electronic Tx Plan

6. PCP Psychiatrist FAMILY / FRIENDS Nurse Care Manager Person Specialists Care manager/ counselor Entitlements Peer health coach

7. Care management Bureau of Primary Health Care Health Disparities Collaborative Develop and maintain rapport with patient and provider Educate the patient and family Monitor symptoms and communicate findings to provider Develop and maintain a self-care action plan Maximize adherence to the treatment plan through negotiation of solutions to treatment-emergent problems

8. Nursing-supported care management • Medical risk screening at intake • Risk stratification and treatment planning in collaboration with nurse • Acute risks • Adherence issues • Need for higher level of care • Monthly multidisciplinary review • Nursing-supported training of behavioral health workers

9. Billing Codes for physical exam, health monitoring and complex care management Physical exam billing if external PCP? Health monitoring rate (billed by MD/PA/NP/RN) is half that of psychotherapy rate (billed by SW) Peer health coaching not reimbursable

10. Electronic Tools Single EHR Health Risk Screening Healthy Living Questionnaire Physical Health Goal Planner Healthy Living Workbook Healthy Living Clinical Pathway

11. Primary care vs. behavioral health culture • Medical vs. psychosocial models • Top-down vs. consensus decision-making • Physician vs. social service leadership • What’s the bridge? • Self-management • Nurse care management

12. Summary • Nursing-supported care management can bridge a number of gaps between primary care and behavioral health • Electronic tools can help support decision making and provision of care within integrated settings • Reimbursement of integrated care still needs to be addressed

13. Drew LaStella, PhD Eduard Levy, MD Jimmy Lindsey, CSCS Rosemarie Sultana-Cordero, MA Marcia Titus-Prescott, RN Jeanie Tse, MD Matt Wofsy, LCSW-R and numerous program staff ICL’s Integrated Health Team: Sonia Barolette, RN Shivonne Blake, CDM Jason Cheng, MD Ruth Chiles, RD Judy Chong, CASAC Elisa Chow, PhD Elizabeth Cleek, PsyD Cindy Freidmutter, JD Please feel free to contact me at JCheng@ICLinc.net Thank you!

14. Bibliography Druss BG, Rohrbaugh RM, Levinson CM, et al: Integrated medical care for patients with serious psychiatric illness: a randomized trial. Archives of General Psychiatry 58:861–868, 2001 Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Affairs, 25 (3): 659-669, 2006 Kilbourne AM, Pirraglia PA, Lai Z, et al. Quality of General Medical Care Among Patients With Serious Mental Illness: does co-location of services matter? Psychiatric Services 62:922–928, 2011. Mauer, B. (2006). Behavioral health/primary care integration: The Four Quadrant Model and evidence based practices . Rockville, MD: National Council for Community Behavioral Healthcare., 2006. (http://www.thenationalcouncil.org/galleries/businesspractice% 20 fi les/4%20Quadrant.pdf/ ) McGuire J, Gelberg L, Blue-Howells J, et al: Access to primary care for homeless veterans with serious mental illness or substance abuse: a follow-up evaluation of colocated primary care and homeless social services. Administration and Policy in Mental Health 36:255–264, 2009 Pollack DA, Raney L, Vanderlip ER. Integrated Care and Psychiatrists. Handbook of Community Psychiatry (McQuistion HL, Sowers WE, Ranz J, Feldman JM, Eds.). Springer, New York, NY 2012