The Role of the Medical Neighborhood in Behavioral Health-Primary Care Integration

1. The Role of the Medical Neighborhood in Behavioral Health-Primary Care Integration R. Scott Hammond, MD, FAAFP Medical Director, Westminster Medical Clinic Clinical Professor, University of Colorado, School of Medicine Daniel Fishbein, PhD Vice President for Corporate Business Development Jefferson Center for Mental Health

2. Integration: An Evolving Relationship Source: http://uwaims.org

3. Two Cultures, One Patient

4. Steps to Creating a MN • Clear vision • Belief • Purpose • Choose partner wisely who shares your vision • Acceptance • Perseverance • Develop a Shared Culture • Trust • Common ground • Build medical team first • Team identity • Role clarification

8. Building a Neighborhood Phase 1: Planning Phase 2: Implementation Phase 3: Evaluation Phase 4: Sustainability and Continuous Improvement

9. Phases and The 5 A’s Phase 1: WMC established a structure • Adopt Collaborative Guidelines (aka BH Compact) • Care coordination protocol, relation to BH • Develop a Timeline for your office Phase 2: Implementation with BH Neighbors ASK - Develop a list of possible BH Neighbors - Invite them to form a BHNeighborhood ADVISE - Introduce Medical Neighborhood concept - Discuss care delivery philosophies, agree on common values

10. Phases and The 5 A’s Phase 3: Evaluation ASSESS - Fill out Collaborative Guidelines (aka Compact) - Discussion, what is possible/not possible - Once initially implemented, review what is working/not working based on Compact ASSIST - PCP MN Toolkit - BHP MN Toolkit – in development specific to BH; not completed/available to date - A few elements of the Toolkits • 6 Steps to Becoming a Patient-Centered Medical Home Neighbor • “Types” of Care Transition case histories and checklist • PCP-BHP Compact Phase 4: Sustainability ARRANGE - Continuous improvement support, maintenance, and sustainability - Utilize resources • ACT, SIM - Regular communication and feedback

11. Lessons Learned • Cost and Feasibility • Culture and Leadership • Infrastructure and Workflow • Sustaining Adaptive Change

12. Cost and Feasibility Westminster Jefferson Create a base of reliable revenue Determine ROI and risk of facility benchmarks Allow for program flexibility Watch for hidden costs and requirements • First fail and persevere • Find the right partner for sustainability • Other • direct primary care • shared integration • telepsychiatry 14

13. Culture & Leadership Westminster Jefferson Focus on needs and objectives of practice Guided Autonomy – empower on-site BHP to innovate Raise the bar – bidirectional accountability Evolve – continuous program expansion and improvement • Inventory your beliefs and create a vision • Set your goals (REACH) • Build a collaborative team • Create trust and engage individual purpose of staff members • Merge cultures • Understand resistance 16

14. Infrastructure & Workflow Westminster Jefferson Expand ahead of the curve Contingency planning if hit the wall Monitor unexpected outcomes of structural and process changes Keep patient focused • Define visit types and hand-offs • Negotiate workflow expectations, MH model • Create a flexible schedule • Enhance communication • Common language with the “Compact” • Bi-directional information • Shared care plan • Constructive feedback • Address patient expectations 19

15. Sustaining Adaptive Change Westminster Jefferson Welcome and engage BHP into the practice Insist that core standards be met Avoid burnout Assess/ratify value and delight regularly • Autonomy, Mastery, Purpose • Energy Management • Change/sustain fatigue • Decision fatigue • Data fatigue • Work-around fatigue • Frustration entropy • Minimize bureaucracy 21

16. BHC-PCP Integration

17. Extra slides

18. Health Care Delivery in the USA IOM CQC summary Underlying Characteristics Acute Care Model Staccato care Physician Centered Staff supports physician “my practice” mindset Siloes of Care Cut off Focus on success of the silo not the system • Highly Specialized • Compartmentalized • Disorganized • Fragmented • Falls short on measures of clinical quality • M. Carol Greenlee, MD FACP

19. Cardiology Allergy/ Immunology PCP It’s not reimbursed It’s not my responsibility.

20. Collaborative CareReason One: Prevalence Behavioral Health and Primary Care Are Inseparable • 84% of the time, the 14 most common physical complaints have no identifiable organic etiology1 • 80% with a behavioral health disorder will visit primary care at least 1 time in a calendar year2 • 50% of all behavioral health disorders are treated in primary care3 • 48% of the appointments for all psychotropic agents are with a non-psychiatric primary care provider4 1. Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266. 2. Narrow et al., Arch Gen Psychiatry. 1993;50:5-107. 3. Kessler et al., NEJM. 2006;353:2515-23. 4. Pincus et al., JAMA. 1998;279:526-531. 20 20

21. Collaborative CareReason Two: Unmet Behavioral Health Needs • 67% with a behavioral health disorder do not get behavioral health treatment1 • 30-50% of referrals from primary care to an outpatient behavioral health clinic don’t make first appt2,3 • Two-thirds of primary care physicians (N=6,660) reported not being able to access outpatient behavioral health for their patients. Shortages of mental healthcare providers, health plan barriers, and lack of coverage orinadequate coverage were all cited by PCPs as important barriersto mental health care access4 • Kessler et al., NEJM. 2005;352:515-23. • 2. Fisher & Ransom, Arch Intern Med. 1997;6:324-333. • 3. Hoge et al., JAMA. 2006;95:1023-1032. • 4. Cunningham, Health Affairs. 2009; 3:w490-w501. 21

28. Lessons Learned from BH Integration