Reverse Co-Location: Integrating Primary care into a Behavioral Health Setting

1. Lawrence A. Real, MD Medical Director Horizon House Inc Reverse Co-Location: Integrating Primary care into a Behavioral Health Setting Philadelphia DBHiDS June 2013

3. WHAT IS “REVERSE CO-LOCATION”? Primary care located within a behavioral health setting

4. WHY BRING PRIMARY CARE INTO THE BEHAVIORAL HEALTH SETTING? Because our people are dying!

5. INCREASED MORBIDITY AND MORTALITY • People with serious mental illness (SMI) die on average 25 years earlier than the general population • Though suicide and injury account for maybe 1/3 of this, 60% of premature deaths are due to preventable medical conditions, and most of those due to cardiovascular disease • These preventable medical conditions are linked to high rates of modifiable risk factors Parks et al, Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors, October 2006

6. Reversing Early Mortality Due to Obesity and Cardiovascular Risk Factors in Mental Illness: What Works in Changing Health Behaviors Bartels Feb ‘12

7. MODIFIABLE RISK FACTORS • High incidence of smoking • Individuals diagnosed with psychiatric disorders smoke ~ ½ the cigarettes smoked in U.S. • Sedentary life style • High rates of obesity, poor nutrition • Over 42% of people with SMI are obese** • Co-morbid substance use disorders • Limited access to quality healthcare? • *National Epidemiologic Survey on Alcohol & Related Disorders, 2002 • **Dartmouth Health Promotion Research Team, 2012

10. SPECTRUM OF COLLABORATIVE CARE MODELS

11. “COLLABORATIVE” vs “INTEGRATED” Collaborative care involves behavioral health working WITH physical health… [or vice versa] Integrated care involves behavioral health working WITHIN, and as a part of, physical health… [or vice versa] In collaborative care, patients perceive behavioral health care as a separate service received from a specialist…[or vice versa] In integrated care, patients perceive behavioral health care as a routine part of primary care…[and vice versa] Strosahl, in Integrated Care: the Future of Medical and Mental Health Collaboration, 1998

12. Bottom Line on Co-location • Co-location does not equal integration! • It does, via physical proximity, create an opportunity for improved collaboration • The devil is very much in the details, i.e., how well you plan and execute

13. How are we attempting to integrate care at Horizon House?

14. Our Journey to Integrated Care • September 7, 2010 –Horizon House partners with Delaware Valley Community Health, and the Fairmount Primary Care Center at Horizon House opens at our30th St location • September 30, 2010 –Horizon House receives a 4-year Physical and Behavioral Health Care Integration grant from SAMHSA • June 2013– Over 600 patients have received primary care on site

15. SAMHSA Grant Results in Expanded Staffing • Full-time certified Physician Assistant • Supervising physician, 1/2 day/wk } DVCH • Team leader/ Medical assistant • Billing clerk/administrative assistant • Project Manager (HH) • Data Coordinator (HH) • Health Integration Specialist (HH) • Health Educator (DVCH) • Certified Peer Specialist (2)

16. Services Offered as of Opening Day

17. THREE KEY TASKS Can you increase access to primary care, and thereby improve the management of chronic illnesses? Can you improve the early detection and/or prevention of other disease states? Can you “create health” by engaging people in wellness activities before, during or after the emergence of serious medical co-morbidities?

18. What do you need? • Space for primary care • Someone to provide PC • A way to coordinate/integrate PH/BH care • Engagement (and re-en- gagement) of consumers • Licenses/ approvals • Organizational commitment • MONEY!!$!! • to start it • to build it • to sustain it

19. Who Will Provide Primary Care? • 1. Facilitated referral (coordination) • BH organization coordinates referrals and shares information with PCPs offsite • Partnership-based models (reverse co-location) • Primary care embedded in community-based BH organization • 3. Fully integrated models • Staff from a single organization provide primary care and behavioral health care—i.e., do it yourself! • ---adapted from Druss, 2011

20. Lessons Learned: Partnering You have to either find a partner, or hire your own primary care staff—each comes with its own unique challenges

21. FINDING A PARTNER:Compatibility • Characteristics of the “right” partner • Experience with /commitment to serving ‘safety net’ populations • Belief in holistic, client-centered services • Willing to give up preconceived notions • Creative, flexible--willing to try new things • Team players, develop concept jointly • Able to quickly establish services

22. Lessons Learned: Business You need a business plan that, before too long, projects the primary care operation to at least break even—while maintaining quality of care

23. FINDING A PARTNER:Feasibility • Is there sufficient traffic at the site • Payor mix of potential participants • Willingness of participants to change primary care provider • Can you get Board approvals? • Can you get HRSA, other approvals for change of scope [for FQHC]?

24. “Show Me the Money!” • Need to take the ‘long view’, see initial commitment as consistent with your agency’s service mission • Creative and assertive in pursuing grants, ‘freebies’, collaborations • Sustainability still will likely require parallel changes in service reimbursement

25. How Will You Engage Consumers? • Presumption: utilize their engagement with and trust in behavioral health team (‘warm handoffs’) • Make co-located service a preferred choice for primary care (via screenings, wellness activities, incentives, good customer service) • Certified Peer Specialists key members of the team trying to integrate care • Motivational interviewing

26. Who Will Coordinate Care? • Traditional “case managers”—add this task to services already being provided • Create/ hire/ train specialists in healthcare integration • Combination of existing personnel (with additional training) and integration specialists • Assumes coordination of primary/ medical specialty care via PCP

27. Lessons Learned: Blending Cultures You need to work with your primary care providers to merge and adapt the different cultures that define each of you

28. Two different worlds? Behavioral Health World We have people in recovery We emphasize engagement first We focus on personal goals and strengths We’re looking for ways to spend more time with those we serve We’re into collaborative approaches, and shared decision making Physical Health World They have patients They have tests to get done They focus on symptoms and pathology They’re looking to be more efficient They’re into hierarchical relationships, and instructing patients what to do

29. FINDING A PARTNERChallenge of Information Sharing • Two different and independent charting systems • More stringent state regulations re sharing of BH info • Participant concerns about sharing BH information with primary care providers (and vice versa)

30. Lessons Learned: Transforming Yourself You need to persistently work on changing the culture of your organization so that it sees itself as one that provides integrated health care, not just behavioral health care

31. Lessons Learned: Choices You need to consciously balance your desire that all your participants choose primary care on site with with your desire to insure they can freely choose where to receive primary care

32. Fairmount Primary Care Center at Horizon House: Accessing Care • Fairmount PCC available to ALL HH staff and program participants • Fairmount PCC must be selected as primary care provider • Consistent with FQHC rules, Fairmount PCC will see people without health insurance

33. Lessons Learned: Systems You need to create and monitor systems that support the collaborative care you intend to provide, especially if you have gone the ‘partner’ route

34. Lessons Learned: “Show Me the Data!” You need to create a ‘clinical registry’ that enables you to track both individual and population health outcomes

35. Lessons Learned: Ownership of One’s Health Your processes need to allow for participants to progress to assuming charge of their own disease management and wellness activities

36. Lessons Learned: Consumer Involvement Consumers and their supports need to actively involved in design and execution of your plan: • Peer specialists on the team • Peer advisory council • Consumer feedback via surveys and focus groups

37. Lessons Learned: Wellness Matters A substantial amount of your effort needs to be devoted to wellness programming, aimed both at the management of chronic illness and at some combination of illness prevention and health promotion

38. Samples of Wellness Activities • Meditation group • Walking group • Smoking Cessation • Wake and Move • FIT Club (Finding Inspiration Together) • Yoga • Whole Health, Wellness, & Resiliency • Taking Charge of Our Health • Community Inclusion-YMCA and Farmer’s Markets

40. Lessons Learned: We’re all in this together! • Learning communities enable us to learn from each others successes and failures • Each of us can use, modify, and develop new EBP’s • How can we make effective collaboration easier for each other?

41. Lessons Learned:“Ya Gotta Believe” • Major Challenge? • Our own nihilism/pessimism

43. The question remains: Can you really make a difference? Health Promotion Programs for Persons with Serious Mental Illness: What Works? A Systematic Review and Analysis of the Evidence Base in Published Research Literature on Exercise and Nutrition Programs Prepared for SAMHSA-HRSA Center for Integrated Health Solutions by the Dartmouth Health Promotion Research Team, Project Director Stephen Bartels, MD February 2012

44. Health Promotion Programs for SMI: Key Findings • Interventions that last > 3 months are superior; the intensive phase of programs should last at least 6 months • Programs that combine education and activity-based approaches are more sucessful than those that focus on non-specific wellness education • Programs that incorporate nutrition education and exercise are superior in inciting weight loss than those that focus on nutrition alone

45. Reversing Early Mortality Due to Obesity and Cardiovascular Risk Factors in Mental Illness: What Works in Changing Health Behaviors? Bartels Feb ‘12

46. Thank you very much!