Primary and Behavioral Care Integration West Texas Centers April 16, 2014

1. Primary and Behavioral Care Integration West Texas Centers April 16, 2014

2. “Integration” is Today’s Hot Topic Integrating Mental Health Treatment into the Patient Centered Medical Home AHRQ, June 2010. Evolving Models of Behavioral Health Integration in Primary Care Millibank Memorial Fund, 2010 Report. A Tale of Two Systems: A Look at State Efforts to Integrate Primary Care and Behavioral Health in Safety Net Settings National Academy for State Health Policy, May 2010. Integrated Care Update CareIntegra, February 2007. Integrating Behavioral and Primary Care Community Health Forum, Oct. 2005. How Healthcare Reform Can End The Step-Child Status of Primary Care and Behavioral Health Behavioral Health Central, Jan. 2010. Can Primary Care Docs and Behavioral Specialists Work Together? Behavioral Healthcare Tomorrow, April 2004. Blending Behavioral Health Into Primary Care at Cherokee Health Systems National Register of Health Service Providers In Psychology, Fall 2007.

3. The Integration Stampede

4. When it comes to the health and well-being, it is Important to understand that mental health is part of overall health. NAMI

5. INTEGRATED CARE: WHAT IS IT? “Integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served.”

6. INTEGRATED CARE: WHAT IS IT? “Integration is in response to the fragmentation of health care. As individuals we are not fragmented, we are whole people. The current health care system does not recognize this. Integration is trying to fix a big problem, which is that we have two separate systems that take care of our health. Integration is a game changer for health care.” – Benjamin Miller, Psy.D., assistant professor, Department of Family Medicine, University of Colorado School of Medicine

7. History In the early 1960s, Kaiser Permanente, an early Health Maintenance Organization (HMO), uncovered that 60% of physician visits were either individuals who were somatizing stress or whose physical condition was exacerbated by emotional factors. These findings prompted Kaiser to explore various strategies to better manage psychosocial complaints, with ultimate goal of cost reduction. Psychotherapy, which was offered as a prepaid benefit, was studied as a method to reduce primary care visits while also more properly (and less expensively) addressing the problem at hand. Studies revealed that by participating in brief psychotherapy, medical utilization reduced by 65%. Maine Rural Health Research Center

8. Awakening interest in collaboration • Preferential referral relationship • Formalized screening procedures • Specialty consultation • Disease management • Circuit riding • Contracted providers or services • Co-location of services The First Generation of “Integration”

9. Why seek behavioral health services in the primary care setting? Easier access to care because of a critical shortage of mental health providers, especially in rural communities. Care provided in a primary care setting may be covered by insurance policies that do not include mental health care coverage. Individuals may feel more comfortable in a primary care setting because of stigma associated with seeking care in a mental health care setting. NAMI

10. Reported Integrated Care Benefits Decreased use of unneeded medical and emergency services. Increased attention to the treatment preferences of the individual. Improved adherence to treatment. Greater convenience and satisfaction for patients. Decreased wait times between mental health referrals and initial appointments. Increased likelihood that patients follow through with referral for mental health services and supports. NAMI

11. Persons with Serious Mental Illness Connections to Morbidity and Mortality People with mental health conditions are at risk for physical health problems that deteriorate their quality of life and lead to premature death. The risk is especially high for people with serious mental illness (SMI) such as schizophrenia, bipolar disorder, and major depression. National Association of State Mental Health Program Directors

12. Persons with Serious Mental Illness Connections to Morbidity and Mortality • Medical conditions such as cardiovascular, pulmonary, and infectious diseases account for 60% of premature deaths among people with schizophrenia. • People with SMI have higher rates of risk factors that put them at increased risk of illness and death, including smoking, alcohol consumption, poor nutrition, and unsafe sexual behavior. For example, 75% of individuals with addictions or mental illness smoke cigarettes compared with 23% of the general population. National Association of State Mental Health Program Directors

13. Persons with Serious Mental Illness Connections to Morbidity and Mortality • Second-generation antipsychotic drugs are associated with weight gain, diabetes, high cholesterol, insulin resistance, and metabolic syndrome. • People with SMI undergo fewer routine preventive services, have lower rates of cardiovascular procedures, and have inadequate diabetes care.

14. Why Behavioral Health Practice in the Primary Care Context Source: Kathol and Gatteau – Healing Mind and Body, 2007 National Association of State Mental Health Program

15. Improvement in depression remission rates: from 42% to 71% (Katon et. al., 1996) • Improved self management skills for patients with chronic conditions (Kent & Gordon, 1998) • Better clinical outcome than by treatment in either sector alone (McGruder et. al., 1988) • Improved consumer and provider satisfaction (Robinson et. al., 2000) • High level of patient adherence and retention in treatment (Mynors-Wallace et. al., 2000) What Does the Research Show About Integration?

16. Integrated Care Co-Located Mental Health • Embedded member of primary care team • Patient contact via hand off • Verbal communication predominate • Brief, aperiodic interventions • Flexible schedule • Generalist orientation • Behavior medicine scope • Ancillary service provider • Patient contact via referral • Written communication predominate • Regular schedule of sessions • Fixed schedule • Specialty orientation • Psychiatric disorders scope Integration vs. Co-Location

17. Key Operational Differences Between Primary Care and Behavioral Health

18. Language Differences for $200 U.D.S. • What is a Urine Drug Screen? • What is a Uniform Data System? • What is All of the Above? Cultural Differences

19. Cultural Differences Clinical Delivery Space

21. Triage/Liaison • Behavioral Health Consultation • Behavioral Health Follow-Up • Adherence Enhancement • Relapse Prevention • Behavioral Medicine • Consultative Co-Management • Group-based interventions • Conjoint Consultation • On-Demand Medication Consultation • Care Management • Psychiatric Consultation • PCP Consultation • School/Agency Consultation • Prevention • Telephone Consultation Typical Behavioral Health Care Services in Primary Care

22. Values/Mission • Cultures/Purposes • Involvements/affiliations • Transparencies/Boards • Finding champions/understanding the challenges • Learning curve (simplicity to complexity) Serious Considerations for Integrations

23. Administrative Team Meetings Meet Weekly, not Weakly Transparency is Vital Shared Objectives – Work Toward Full Integration Creating a Process, Not a Destination – You’re in it for the Long Haul!

24. What are you good at? • What talents, resources can you bring? • Can we disagree, debate, interact and share – and move forward? Leveraging the Relationship

25. Your relationship frames your agreement, not the other way around. • Champions • Meet, talk, socialize, publicize Supporting the Partnership

26. Peanut Butter & Jelly…the perfect model for integration • On their own, they’re fine, together they’re better • You wouldn’t want to separate them once joined • Just a matter of finding the “bread” to hold it together!

27. Who from the senior executive team is going to champion integrated care? • What resources are we going to need to do integrated care? • How much are those resources going to cost us? Important Questions For Executive Management

28. Challenges to Integration Silos exist in how primary care and mental health care are delivered that impede effective communication and collaboration. Lack of training, education and comfort in addressing mental health issues in primary care and other health issues in mental health care settings. Limited time to effectively address mental health issues in primary care. Limited referral sources for mental health care that impact the willingness of primary care providers to screen and to raise concerns about mental health.

29. Challenges to Integration Concerns with strict confidentiality and privacy lawsand the sharing of mental health information between providers. Reimbursement concerns, especially for primary care providers providing mental health care, and concerns that time spent on care collaboration and consultation is often not reimbursed. Lack of fundingsources to create the infrastructure that is needed for integrated care, including training staff, electronic health record systems, finding the right integrated care model that fits the needs of the community and costs to get the care model up and running.

30. Challenges to Integration • Consultation…Patient Not Present • Hallway conversations between providers • Telephone Consult w/Psychiatrist • Multi-Disciplinary Treatment Team Meetings • Difficult Cases • Case Studies & Training • Real-Time Provider Access • Telepsychiatry • Primary Care ALMOST Billable Services

31. Challenges to Integration Location Overhead • Front Office Staff • Clinical Records • Telephone • Lab work • On-Call Corporate Overhead • Management • Clinical Leadership • Technology Support • Purchasing • Facilities Spreading Costs…

32. Reduced ER Utilization • Reduced Inpatient Admissions • Reduced Specialty Referrals • Increased Patient Satisfaction • Increased Primary Care Utilization • Improved Outcomes Placing a VALUE on Integrated Care Can Be Hard to Do

33. Bottom Line: Managing significant change is a messy business! “I like change, as long as it doesn’t affect me.” Anonymous Physician Change Management

34. Questions ? Landon Sturdivant, MPA, LBSW Chief Operating Officer West Texas Centers 432.264.3247 Landon.Sturdivant@wtcmhmr.org