The Culture of Integrated Services

1. The Culture of Integrated Services Thomas E. Freese, PhD Sherry Larkins, PhD UCLA Integrated Substance Abuse Programs Pacific Southwest Addiction Technology Transfer Center

2. LA County DMH Innovations Projects The County of Los Angeles Department of Mental Health has collaborated with the Department of Health Services (DHS) to implement the following programs in an effort toward integration: • The LACDMH/DHS Collaboration Program • Healthy Way L.A. Community Partners • Project 50 • MHSA Innovation Programs • Center for Community Health of Downtown Los Angeles • LACDMH & HealthCare Partners Collaborative Care Program

3. The County of Los Angeles Department of Mental Health has collaborated with the Department of Health Services (DHS) to implement the following programs in an effort toward integration: • The LACDMH/DHS Collaboration ProgramDMH has co-located small teams comprised of social workers, marriage and family counselors, and medical case workers, in DHS Comprehensive Health Centers (CHC) and Multiservice Ambulatory Care Clinics (MACC) on a full-time basis. The DMH teams deliver short-term, early intervention, evidenced-based, specialty mental health services using the Mental Health Integration Program (MHIP) model to treat persons with mild to moderate mental health symptoms. MHIP is a stepped collaborative care model shown effective in treating persons with depression and anxiety seen in primary care settings. Clinical consultation with a psychiatrist is available to both the treatment teams and to the primary care providers.

4. The County of Los Angeles Department of Mental Health has collaborated with the Department of Health Services (DHS) to implement the following programs in an effort toward integration: • Healthy Way L.A. Community PartnersDMH has partnered with numerous health care agencies under contract with the DHS, known as Community Partners (CP), to provide short-term, early intervention, evidence-based, specialty mental health services on-site at the CP agencies. CPs, many of which are also Federally Qualified Health Centers (FQHC), are providing services using the MHIP model. DMH has and continues to provide training on the MHIP model to clinical staff employed by the CPs who are providing services to individuals with mild to moderate mental health symptoms. Furthermore, partnerships have been established between the CPs and existing DMH directly-operated and contracted specialty mental health clinics to provide a well-coordinated referral process between health and mental health when a consumer requires a level of care beyond a short-term early intervention.

5. The County of Los Angeles Department of Mental Health has collaborated with the Department of Health Services (DHS) to implement the following programs in an effort toward integration: • Project 50Project 50 is a demonstration program to identify, engage, house and provide integrated supportive services to the 50 most vulnerable, long-term chronically homeless adults living on the streets of Skid Row. The Los Angeles County Board of Supervisors passed the motion to implement Project 50 in November 2007. Project 50 involves three phases: • Registry Creation • Outreach Team • Integrated Supportive Services Team. Currently, Project 50 is operating in the third phase. Four Project 50 Replication sites have been developed in Santa Monica, Van Nuys, Venice and Hollywood. They are at various stages of implementation.

6. The County of Los Angeles Department of Mental Health has collaborated with the Department of Health Services (DHS) to implement the following programs in an effort toward integration: • MHSA Innovation ProgramsDMH community stakeholders have identified four (4) models of care that integrate mental health, physical health and substance abuse services. MHSA Innovation (INN) model programs seek to learn which practices increase quality of services, improve consumer outcomes, promote community collaboration and the most cost effective in order to meet the spectrum of needs of individuals who are uninsured/ economically disadvantaged, homeless and members of underrepresented ethnic populations. By implementation and evaluation of new and innovative approaches, the time-limited MHSA INN model programs will contribute to learning and inform future practice. The four Innovation Models include: • Integrated Clinic Model (ICM) • Integrated Mobile Health Team Model (IMHT) • Community-Designed Integrated Service Management Model (ISM) • Integrated Peer Run Models-Peer Run Integrated Service Management (PRISM) & Peer Run Respite Care Homes (PRRCH)

7. The County of Los Angeles Department of Mental Health has collaborated with the Department of Health Services (DHS) to implement the following programs in an effort toward integration: • Center for Community Health of Downtown Los AngelesLed by the Los Angeles County Chief Executive Office (CEO), the Center for Community Health of Downtown Los Angeles (CCHDLA) is a private/public partnership that employs a one-stop shop of resources approach for homeless and low-income people in the Skid Row area of downtown Los Angeles. Opened in 2009, it has increased access to all health-related services, including primary health care, specialty care, mental health, substance abuse, optometry, dentistry, medication, x-rays, HIV education and prevention, and STD and TB clinics. Known as an “Integrated Care for the Homeless Model,” CCHDLA employs an Integrated Services Team approach in which all partner agencies involved in the consumer’s care confer and develop a comprehensive, integrated treatment plan and service delivery.

8. The County of Los Angeles Department of Mental Health has collaborated with the Department of Health Services (DHS) to implement the following programs in an effort toward integration: • LACDMH & HealthCare Partners Collaborative Care ProgramDMH has developed an integrated pilot program with HealthCare Partners (HCP) and LA Care Health Plan to treat chronically and persistently mentally ill (CPMI) patients through collaborative care. Dually-eligible (Medicare/Medi-Cal) individuals who enroll in an LA Care Medicare Advantage program will be primarily treated in HCP's Collaborative Care Centers, though they could also receive their care at home, in long-term care facilities and elsewhere depending on the individual needs of the patient. The patient's treatment plan is co-managed by a medical doctor and a psychiatrist along with a team of nurse practitioners, care managers, social workers, and psychologists. The patient’s medical care is fully integrated with behavioral health interventions that include pharmacologic and behavioral/social skills. It is anticipated that diagnoses included in this treatment model will predominately include: schizophrenia, bi-polar and obsessive-compulsive disorders, severe major depression with and without psychotic features, severe chemical dependency and dementia.

9. LA County DMH Innovations Projects • These projects represent a dramatic shift toward a whole health orientation. This means that we all need to think about the work that we do as part of a wholistic system, rather than a separate entity. • This new orientation leads to the need for mental health staff to fulfill new roles in all DMH settings that ensure that services are provide in an integrated way. This will: • Increase treatment efficacy • Improve client outcomes • Increase staff satisfaction and decrease burnout See Handout for a full description of each project

10. What Will We Cover? • Primary care culture and effective communication • Role definitions for Mental Health staff in primary care settings • Medical issues that commonly co-occur with mental health and substance use • Barriers to service access • A case example.

11. International Comparison of Spending on Health, 1980–2010 Average spending on healthper capita ($US PPP) Total health expenditures aspercent of GDP Notes: PPP = purchasing power parity; GDP = gross domestic product. Source: Commonwealth Fund, based on OECD Health Data 2012.

12. Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 65 Percent of Expenses 1% 5% 22% $90,061 10% 50% $40,682 65% 50% $26,767 97% $7,978 Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009 Annual mean expenditure Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

13. Consequences of MH Disorders • In the USA and Canada, mental health disorders account for 25% of all years of life lost to disability and premature mortality1 • One in four American adults experience a mental health disorder in a given year, and 1 in 17 have a seriously debilitating mental illness2 • Among those who die by suicide, more than 90% • have a diagnosable disorder4. • In 2008, suicide was the tenth leading cause of death in the USA6. World Health Organization. (2004). The world health report 2004: changing history. Annex Table 3. A126-A127. Geneva: WHO. Kessler RC, et al. (2005). Archives of General Psychiatry, 62: 617-627. US Department of Health and Human Services. (1999). Mental health: a report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, 1999. Minino AM, et al. (2011). Final Data for 2008. National Vital Statistics Reports 2011; 59(10): 01-127. Available: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_10.pdf.

14. Shifting to a Whole Health Perspective • Mental health and substance use services are integral to health care services. The goals of DMH initiatives are: • Ensure positive experiences of care • Enhance customer services • Ensure care is effective • Develop bi-directional care/behavioral health homes • Implement data outcomes system to enable monitoring of client progress • Control/reduce costs • Develop strategies to extend care • Develop strategies to reduce readmission and preventable hospitalizations

15. The Medical System Primary Care • The aims of primary care are to provide broad spectrum of care • both preventive and curative; • over a period of time; and • to coordinate all of the care the patient receives. • All family physicians and most pediatricians and internists are in primary care. • www.medicinenet.com

16. The Medical System Primary Care • Practitioner must possess a wide breadth of knowledge in many areas. • Patients consult the same primary care doctor for routine check-ups, and initial consultation about a new complaint. • Common chronic illnesses, often treated in primary care, include: • Hypertension -- Diabetes • Asthma and COPD -- Depression and anxiety • Arthritis and other pain

17. Service Definitions • The person receiving services is called… • The building(s)/place(s) where the person receives services is called… • The room where the person receives services is called… • The person who has the ultimate responsibility for the care of the person is called… • The person who is responsible for care coordination is called…

18. Strategies for successful communication

19. Strategies for successful communication • It is important to understand the system with which you are working

20. Strategies for successful communication • It is important to understand the system with which you are working • Learn about the medical conditions that bring people to primary care

21. Strategies for successful communication • It is important to understand the system with which you are working • Learn about the medical conditions that bring people to primary care • Expand your vocabulary to facilitate communication

22. Strategies for successful communication • It is important to understand the system with which you are working • Learn about the medical conditions that bring people to primary care • Expand your vocabulary to facilitate communication • Stay within your scope of practice in your interactions zzzz

23. Strategies for successful communication • It is important to understand the system with which you are working • Learn about the medical conditions that bring people to primary care • Expand your vocabulary to facilitate communication • Stay within your scope of practice in your interactions • Make yourself visible and useful

24. Strategies for successful communication • It is important to understand the system with which you are working • Learn about the medical conditions that bring people to primary care • Expand your vocabulary to facilitate communication • Stay within your scope of practice in your interactions • Make yourself visible and useful • Be accessible and available

25. Role Delineation Who does what in an integrated care system?

26. Discussion—Roles In an integrated care system, what is the best role of each of the following disciplines. What should they take lead on? How should they be involved in collaboration? • Medical Provider • Mental Health Provider • Substance Use Disorder Provider • Behavioral Health Specialist • Peer Specialist • Family

27. Provider/practice barriers • Differing practice styles • Differing practice cultures and language • Difficulty in matching provider skills with patient needs • Heavy reliance on physician services • Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services 27

28. Provider/practice barriers • Lack of recognition of provider limitations • Lack of MH knowledge in PC providers and lack of health knowledge in BH providers • Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context • Differing confidentiality and information sharing procedures • Differing coding and billing systems • Provider resistance

29. Mountain Park Health CenterIntegrated Behavioral Health From Co-Location to Fully Integrated Care Bill Rosenfeld

30. Primary Care BH Phase 1 Goal: Established a Horizontal Platform • Behavioral Health Consultant (BHC) placed in medical clinic • Considered a member of the primary care team • Provides consultation (not therapy) • Goal of immediate access, minimal barriers • Emphasizes psychoeducation, population mgmt • Focus on improving QOL, quality of health care

31. Pitfalls to Avoid • Part-time IBH coverage • Allowing the BHC “Office Hermit” to go on too long • Clinician’s housed outside of medical providers service delivery area. • Approaching commercial insurance for reimbursement…boomerang effect • Implementing a co-location model

32. BEHAVIORAL HEALTH UTILIZATION Medical Diagnosis Behavioral Health Intervention

33. Improved Health Outcomes • Better blood sugar control • Diminished Missed School Days • Diminished rate of patients asked to leave practice • Patient confidence in self-care enhanced • Ratio of SM goals set and education attended enhanced These goals are important to the patient event if they do not have a primary care provider

34. Impact of Program on Providers • All PCPs reported: • Satisfaction with the BHC service • Access to BHC as “immediate” and “very helpful” • Better able to address behavioral problems • Recommend the service for other medical providers • A majority (> 80%) said because of BHC: • Have greater confidence in how BH issues are treated within the collaborative framework • Able to see more patients in 20 minutes • Better recognize patient behavioral issues

35. Patient Satisfaction • 90% said visit length “Very Good”, or “Excellent” • 88% rated quality of BHC care as “Very Good” or “Excellent” • 94% would recommend BHC to family or friends • 89% said it was helpful to meet w/ BHC • 82% felt BHC involvement resulted in improved health status

36. Hidden Benefits • MPHC dismisses 75% fewer patients from our practice since socially embedding a BHC in Internal Medicine • Positive impact on recruitment of medical providers • Broad range of staff training possibilities

37. Thanks for Bill Rosenfeld for providing this information www.mountainparkhealth.org/

38. Medical issues that commonly co-occur with mental health and substance use

39. Diabetes

40. Type 1 and Type 2 Diabetes • Type 1 diabetes is usually diagnosed in children and young adults. The the body does not produce insulin. Only 5% of people with diabetes have this form of the disease. • Type 2 diabetes, the most common form of diabetes, either the body does not produce enough insulin or the cells ignore the insulin. Insulin takes the sugar from the blood into the cells. If insulin is not working, glucose builds up in the blood instead of going into cells, it can lead to diabetes complications. Type 2 diabetes is more common in African Americans, Latinos, Native Americans, Asian Americans, Native Hawaiians and other Pacific Islanders, as well as the aged population.

41. Type 2 Diabetes Overview Basic Overview: • Metabolic disease. • Hyperglycemia (too much sugar) due to insulin resistance and defects in insulin secretion. • Diabetes can lead to: • blindness • heart & blood vessel disease • stroke • kidney failure • amputations • nerve damage. http://safediabetes.blogspot.com/2010/12/how-to-reduce-impact-type-2-diabete.html

42. Sign & Symptoms • Often no symptoms at all. • Most common symptoms include: • Blurred vision • Erectile dysfunction • Fatigue • Frequent or slow-healing infections • Increased appetite • Increased thirst • Increased urination http://www.thetype2diabetesdiet.com/wp-content/uploads/2009/03/symptoms-for-type-2-diabetes.gif

43. Percent of Individuals with Diabetes Gender* Age* Ethnicity** *American Diabetes Association, 2011. **US DHHS Office of Minority Health, 2010

44. Importance of Hemoglobin A1c Test (HbA1c) • The hemoglobin A1c test is used to determine how diabetes is being controlled. • HbA1c provides an average of your blood sugar control over a six to 12 week period. • When blood sugar is too high, sugar builds up in your blood and combines with your hemoglobin, becoming "glycated." • For people without diabetes, the normal range for the HbA1c test is 4% - 6%. The goal for people with diabetes is an hemoglobin A1c less than 7%. • Retest should occur every three months to determine level of control.

45. Why is it important to know the Hemoglobin A1c for: • The Medical Provider • The Substance Use Disorders Provider • The Mental Health Provider • Peers and Family

46. Type 2 Diabetes Relationship with SUD • Heavy alcohol consumption can increase risk factors including: body-mass index, low HDL (“good”) cholesterol and cigarette smoking (Tsumura, 1999). • A history of substance use is associated with earlier age of onset of diabetes (Johnson, 2001). • SUD is associated with increased mortality in diabetics (Jackson, 2007). Significance of Behavioral Health • Diabetes patients also have increased depression. Both diet control and depression respond to behavioral activation strategies • In 2006, it was the seventh leading cause of death, and cost the US $174 billion in medical costs, loss of productivity, disability costs

47. Type 2 Diabetes & Your Clients • Medical services available on-site better link clients in SUD treatment to medical services compared to those with outside referrals (Friedmann, 1999). • Social support for abstinence can increase linkage to medical services. (Saitz, 2004). • Encourage activities that improve diabetes: • Betterdiet. • Reduce simple carbohydrate intake (i.e. potatoes, white bread, corn, soda, candy, sweets). • More exercise. • Maintainregular appointments with doctor overseeing diabetes treatment.

48. Hypertension Common Medical Issues Associated with Mental Health and Substance Use Disorders

49. Percent of Individuals with Hypertension (Age 20+) Gender* Age* Ethnicity* *Centers for Disease Control and Prevention, 2012.

50. Hypertension: Clinical Description • Blood pressure (BP) is the force against the walls of one’s arteries while blood is pumping. • Hypertension is when BP is too high. • Example BP: 120/80 mmHg (“120 over 80”) • Systolic (top number): pressure while heart contracts. • Normal is <120. High is >180. • Diastolic (bottom number) pressure while heart relaxes & enlarges. • Normal is <80. High is >80.