Extreme Collaboration

1. Extreme Collaboration Total Integration of Behavioral Clinicians into Primary Care Practice

2. Just to stay oriented… Community Family

3. What would full integration look like? • Medical health • Behavioral health • Dental health • Pharmaceutical care • Patient education • Case management and other wrap-around services • Public health • Community health • Data management

4. Current State of our Fragmented Healthcare System

5. “Every system is perfectly designed to get the results that it gets.” - Dr Paul Batalden, Dartmouth University

6. What is the current system designed for? • Obstacles to care • Health disparities • Poor health outcomes • Frustration • Failure

7. “Mental health care cannot be divorced from primary medical care, and all attempts to do so are doomed to failure.” Frank DeGruy, 1996 DeGruy F. Mental health care in the primary care setting. in Primary Care: America’s Health in a New Era, Donaldson, et al editors. National Academy Press, Washington DC, 1996

8. What do we know? • People get their health care in primary care offices • Most people won’t go to a mental health center • Access to mental health professionals is difficult at best • particularly for uninsured and underinsured populations

9. What do we know • Mental health disorders are under recognized • Sub threshold conditions cause lots of distress • Mental health can’t be separated from physical health • Traditional approaches to mental health aren’t sufficient

10. The Pyramid of Psychosocial Problems in Primary Care

11. Level I : Acute psychiatric emergencies

12. Level I : Acute psychiatric emergencies Need referral to psychiatrist today Probably need inpatient care Rarely present to PCP offices For example: suicidal depression, acute schizophrenia, manic crisis

13. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness

14. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness • SPMI • Requires psychiatric follow-up but not immediately • 10-15%? of primary care practice

15. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness Level III: Chronic less severe conditions

16. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness Level III: Chronic less severe conditions • Very common in primary care practice • Often not recognized • Therapy helpful • For example: somatization disorder, anxiety, PTSD, depression, etc.

17. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness Level III: Chronic less severe conditions Level IV: Temporary psychosocial problem

18. Level IV: Temporary problem • Sudden, acute mental health problem • May recover uneventfully, or may progress to more chronic problem • For example: marital difficulties, parenting problems, job problems, grief reaction, etc. • All of us are level four patients at one time or another in our lives

19. Level I : Acute psychiatric emergencies Level II: Chronic severe psychiatric illness Level III: Chronic less severe conditions Level IV: Temporary psychosocial problem Level V: Everybody else

20. Requirements for Extreme Collaboration • Change the structure of the practice • Change the way the BHP practices • Change the way the PCP practices • Change the way the patients perceive the practice • Change the services that are offered

21. Salud Family Health Centers

22. Salud Integrated Care Model • BHP office in medical exam room space • BHP spends 70% of time doing screening, brief interventions, f/u phone calls, etc • 30% of time in more traditional therapy • Solution focused • Limited number of visits • Referral as necessary • Frequent and ongoing consultations among docs and BHPs

23. Salud Integrated Care Model • Population based • We want to reach EVERY patient • Real time interventions • Emphasis on horizontal integration not vertical integration • Casts a wide net in determining need for psychosocial intervention • Broad evaluative measures

24. Requirements for Total Integration • Co-location • Universal screening • Brief interventions • Solution focused therapy • ‘Cross training’ • BHPs as primary care providers

25. Co-Location

26. Co-Location • Co-location means co-location • Sharing the same space at the same time • Integrated care means integrated facilities • Regardless of problem, all patients go in and out the same door

27. Universal Screening

28. Universal Screening • Most mental health disorders are occult • Most visits to primary care providers have a large psychosocial component • Primary care docs do a relatively bad job of uncovering mental health issues • Most poor health outcomes are related to behavior issues

29. Universal Screening • Screening is screening • NOT diagnosis • Screening forms should be straightforward and simple • Positive screens can be followed up with more sophisticated and comprehensive evaluation tools • I recommend face-to-face screening

30. Brief Interventions

31. Brief Interventions • ‘Psychoeducational triage’ interventions • 5-15 minutes max • In the exam rooms • Goes hand-in-hand with screening • Requires BHP to work within the chaos of the primary care office

32. BHP Adaptation • Traditional mental health office • No interruptions • All apptmts made in advance • Quiet controlled environment • Typical primary care office • Lots of interruptions • Many walk-in apptmts • Controlled (barely) chaos

33. BHP Adaptation • Office environment is different • How patients gain access is different • Concept of confidentiality is different • Process orientation vs goal orientation • Visits are different

34. Requires Broad Training • LOTS of different duties • Psychotherapy • Social work • Case management • Other

35. Solution Focused Brief Therapy

36. Solution Focused Brief Therapy • Resource activation, not problem activation • Has an endpoint • Allows flow of patients in and out of the BHP schedule • More complex patients may need to be referred out • PCPs don’t provide subspecialty care • This is a primary care model

37. ‘Cross Training’

38. Cross Training • Medical providers comfortable with psych issues and with prescribing psychotherapeutic medications • BHPs comfortable talking about medical issues

39. BHPs are Primary Care Providers

40. BHPs are Primary Care Providers • NOT ancillary staff • If the patient is seeing the BHP, the patient is being seen • BHP assessment is as important as physician assessment • Patients will often identify the BHP as their PCP

41. Case Example • J.N. - 20 yo woman presented for routine prenatal care with physician • As patient was leaving, MHP called her back in for screening • Screening was positive, further assessment uncovered depression • Family issues (husband in Mexico), ‘wantedness’ of pregnancy issues • Ongoing surveillance and treatment by MHP

42. Case Example • Over course of pregnancy, depression worsened • BHP and MD came up with medication/therapy plan • BHP saw patient at each prenatal visit • Delivery was uneventful

43. Case example, cont. • After delivery, J.N. lost job • No money for food • Therapist arranged for food and baby supplies to be delivered to house • Due to extensive knowledge of immigration ‘system’, therapist was able to help with ‘transport’ of J.N.’s husband from Mexico to U.S.

44. How do patients gain access to BHP? • Screening • Direct appointment • Referral from provider • Patient request at medical visit

45. Last 3024 Encounters • 1580 screens • 40% positive (26-65%) • 568 patients seen at request of physician • 876 traditional therapy visits

46. Salud Integrated Care Model Goals • 80% of patients will be screened by BHP yearly • Improved patient satisfaction • Improved provider satisfaction • Improvement in wide range of health parameters • Overall improvement in patient functioning • Healthier communities

47. Funding

48. Salud Integrated Care Funding Models • Mental Health Expansion grant from govt • Partnership with local health district • Partnership with local mental health center • Commitment of general primary care funds

49. Other Funding Possibilities • Patient billing • Not likely to work for brief visits • Subsidies • Docs benefit from integrated practice • Communities benefit from integrated practice • Managed care contracts • Patients (and therefore insurance companies?) benefit from integrated practice • Grants

50. Doc:BHP Ratio ?