Integrating Behavioral Health into Primary Care December 10, 2009

1. Amy Brom, PsyDClinic Psychologist 530.226.1739amyb@redding-rancheria.com Debbie Lupeika, M.D. Integrating Behavioral Health into Primary Care December 10, 2009

2. Workshop Objectives • Evaluate process of care, outcome and cost factors that support change to an integrated services approach • Understand how we integrated Behavioral Health into our Primary Care system at RRIHC • Explore the challenges we faced with BH integration into Primary Care • Consider possible approaches to integrating PC and BH services • Anticipate ways to apply the primary behavioral health model to your clinic

3. Guiding Values “HESTUM” • Help Others • Empower for solutions • Serve with a smile • Treat with Respect • Understand diversity • Meet customer needs

4. Redding RancheriaGuiding Values for Workplace • Serving Others • Working Together • Doing what’s Right • Embracing Change • Respecting Differences • Balancing Life

5. Principles for Success • Establish buy-in that is systemic. • Build relationships through regular huddles and meetings, and experiential team training on clinical and operational topics • Create team ownership of change, challenges, and successes

6. Why We Integrated Primary Care and Behavioral Health Care • COST & UTILIZATION factors: • Push from Clinic Administration • Better utilization of BH staff time ( No shows) • 50% of high utilizers have MH or CD disorders • 70% of all PCP visits have psycho-social drivers – 92% of all elderly patients receive MH care from PCP Patricia Robinson, PhD Mountainview Consulting Group, Inc.

7. Why We Integrated Primary Care and Behavioral Health Care • HEALTH OUTCOME factors: • Repeat referrals: Only 1 in 4 patients referred to specialty MH or CD make the first appointment • Recognizes Behavioral and Psychosocial factors in etiology and treatment of physical disease • Illustrates Biopsychosocial model • 50-60% non-adherence to psychoactive medications within first 4 weeks • Overuse/abuse of psychoactive meds

8. Why We Integrated Primary Care and Behavioral Health Care PROCESS OF CARE factors: • 50% of all BHC is delivered by PCP’s • Routine waiting period to see BH > 1 month • 67% of psycho-active agents are prescribed by PCP’s • 80% of all anti-depressants are prescribed by PCP’s • Patients seek BHC from PCP’s to avoid the stigma of going to a psychiatrist or therapist’s office Patricia Robinson, PhD Mountainview Consulting Group, Inc.

9. Benefits of Integrating Primary Careand Behavioral Health • Improved process of care • Improved recognition of MH and CD disorders (Katon et. al., 1990) • Improved PCP skills in medication prescription practices (Katon et. al., 1995) • Increased PCP use of behavioral interventions (Mynors-Wallace, et. al. 1998) • Increased PCP confidence in managing behavioral health conditions (Robinson et. al.,2000)

10. Clinical Outcome and ServiceQuality Benefits of Integration • 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)

11. Integrated Behavioral Health:Is It a Rose by Any Other Name? The dilemma: • Integrated care has different meanings for different people. • Different models of integrated care lead to different costs and outcomes. • How do we pick an approach?

12. How We Integrated BH Services • Our first attempts at integration failed • Vertical model addressing health behaviors (Chronic Pain, Weight Management) • Marillac Integrated model with one BH “integrated” clinician each day • Tried to do too much, too soon. • We needed to identify the best fit for Integrating at RRIHC. • Quality improvement approach

13. Vertical Integration Model:Chronic Conditions Management Depressive & Anxiety Symptoms Life stress 35% (8,750 Patients) Panic Disorder Generalized Anxiety Somataform Disorders Major Depression AlcoholAbuse/Dependence 35% (8,750 Patients) Vertical Integration Program No Behavioral Health Need 30% (7,500 Patients) Hypothetical Cohort of 25,000 patients

14. Marillac Model Family Therapists & Psychiatrist Addictions Counselor Case Manager Psychologist Medical Exam Medical Exam Medical Providers Bathroom Medical Exam Medical Exam Medical Assistants Station Medical Exam Medical Exam Reception Front Office

15. Benchmarking best practices • Cherokee Health System, Knoxville TN • Marillac Clinic, Grand Junction, CO • Phoenix Indian Medical Center, Phoenix, AZ • Golden Valley Health Centers, Merced, CA • Nuka Model, Southcentral Foundation, AK • Northern Sierra Rural Health Network, CA • Open Door Community Health Clinics, Arcata, CA • Washington Association of Migrant and Community Health Centers, Olympia, WA

16. Challenges: Good News Bad News Space Cost/Funding Gathering Data Staff Turnover • Acceptance and understanding within the Behavioral Health department • Acceptance by Primary Care Providers • Routine team meetings • Documentation in place • Training on track Key Point: Even when you fail, you’re making progress!

17. Training Medical Staff • Type of Patient to Refer • Use of Screenings (SBIRT, Teen Screen, etc.) • Introductions – warm hand-offs • General Behavioral Health Info • Use in prevention • How to access Behavioral Staff • Train, train and then train again

18. Quality Improvement Approach • Attempted to find out what the needs of primary customers were. • Measure of provider satisfaction with BH services. • Discussions with providers re: what had worked/had not worked in previous attempts • Analyed patient data who had been referred for IBH for their needs and responses to BH. • Assessed space and access realities

19. Models of Integration • Diversification – BHC is a active member of the Integrated Care Team • Co-location – Behavioral Health Professional located on site providing traditional behavioral health services • Referral – Behavioral health services provided by contracted agency • Enhancement – train primary care providers to provide behavioral health services

20. Close Collaboration in a Fully integrated system Close Collaboration in a partly integrated system Basic on-site Collaboration Collaboration at a Distance Minimal collaboration McDaniel, Hepworth, and Doherty (1992)

21. RRIHC Integrative BH Schedule 8:00 – 5:00 Sample Shortened “traditional” BH sessions to 45 min. Notified all current BH patients of change/reason Staggered 30 minute Integrative slots, 5-6 per one BH staff/day Using 2.5 FTE, offered immediate access to BH five hrs/day Purchased in-house radios for Medical to have access to BH staff Trained Medical staff for scheduling & radio referral.

22. Integrative Time Available to Medical, Daily

23. What We Do • Consultation and education to providers on behavioral health issues • Acute Care for psychological issues • Screening, assessment, brief intervention, education and follow-up/monitoring for patients experiencing mental/medical health issues and life stresses • Joint visits and care conferences with provider teams for complex cases • Consultation with specialists, referral for longer term therapeutic interventions

24. What We Do • Manage chronic patients with PCP in primary provider role • Simultaneous focus on health and behavioral health issues • Effective triage of patients in need of specialty behavioral health • Make BH services available to large percentage of eligible population

25. What We Do • Act as consultant and member of health care team. • Support PCP decision making. • Build on PCP interventions. • Teach PCP “core” behavioral health skills. • Educate/train patient in self management skills • Monitor, with PCP, “at risk” patients.

26. Clinician Skills • Knowledge of Integrated Care Model • Strong diagnostic and therapeutic skills • Prevention and Patient Ed • Brief Solution-Focused Treatment • Motivational Interviewing • Communication & consultant skills • Team player, visible, flexible, available • MFT, LCSW, or Ph.D/Psy.D • “Primary Care Mental Health”

27. Behavioral Health Staff • Generalist vs. Specialty • Therapy vs.Therapeutic • Multiple “customers” include patient, family and primary care team

28. Integrated BH Referral Structure • Patient referred by PCP only; self-referral rare • May accept “warm handoff” on same day basis • BH provider screens PCP appointment schedule to “leverage” medical visits

29. Integrated BH Session Structure • Limited to 1-3 visits in typical case • 15-30 minute visits • Multi-problem patients seen regularly but infrequently over time

30. Integrated BH Intervention Structure • Informal, revolves around PCP assessment and • goals • Low intensity, between session interval longer • Relationship generally not primary focus • Visits timed around PCP visits • Long term follow up rare; reserved for high risk patients

31. “Traditional” vs. Integrated Model Traditional Integrated Co-located in offices Seen in exam room Same chart Brief documentation Focus on presenting problem 20-30 minute interaction Consultation and co-management • Separate offices • Separate notes • Comprehensive BH documentation • Emphasis on history • 50 minute therapy session • Referral to specialty care for BH issues

32. Funding • Flat Rate with medical providers • Grants (SBIRT) • Costs savings • Working with State for follow ups and stand alone visits

33. Integrated BH Intervention Methods • Limited face to face contact • Uses patient education model • Consultant is a technical resource to patient • Emphasis on home-based practice to promote change • May involve PCP in visits with patient

34. Benefits • Redirects mental health related office visits and provides access to appropriate services • Frees providers time and resources to allow for more efficient use of limited appointment time • Offers providers an in-clinic specialty resource for challenging cases • Customers have immediate access to BHC and follow up same day access • Team approach to care

35. Next Steps • Track and monitor quality outcomes • Integration with psychiatry • Improve referrals through use of screenings, AUDIT, Teen Screen, TABS

36. Getting Started Exercise Work with your table to complete the work sheet on BHC integration