Cynthia Cartwright, RN MT MSED Neil Korsen, MD MS Mary Jean Mork, LCSW January 22, 2009

1. Bridging the Gap between Primary Care and Mental Health Cynthia Cartwright, RN MT MSEDNeil Korsen, MD MSMary Jean Mork, LCSWJanuary 22, 2009

2. Workshop Outline • Overview of mental health integration and our program (10 min) • Experiences and lessons learned (15 min) • How to bridge gaps and make improvements at every level (10 min) • Summary, Questions, & Discussion (10 min)

3. Overview of Mental Health Integration in Primary Care

4. Standardized Assessment & Risk Stratification Specialty Mental Health Support for Behavioral Change Mental Health Treatment & Consultation Care Management Primary Care Medical Home Access Community Resources e.g., NAMI

5. Components of Our Model • Relationships: Mental Health & Primary Care • Assessment: Standardized mental health packets (adult, child/adolescent, school) • Stratification: Guides level of intervention • Team approach • Periodic reassessment • Links: External resources • Mental health providers • Community resources

6. Mental Health Integration:Team Roles Mental Health Specialist Diagnose, Treat Primary Care Provider Support Staff Screen,Diagnose, Treat Care Manager Follow up, Family Adherence Patient Education Patient and Family NAMI Community Resources Family Support Psychiatrist Or APRN Consult, Train

7. The Program 18-month Collaborative-style Learning Community: Learn the MHI model and implement key components Gather for periodic learning sessions Collect and report data about processes and outcomes Participate in site visits, conference calls, listserve 20 Primary Care/Mental Health Teams: Private and hospital-owned practices Federally Qualified Health Centers (FQHC) Rural Health Clinics (RHC) Local Mental Health Partners: Specialty Mental Health agencies Hospital-owned Behavioral Health organizations Community Mental Health Centers

8. Change Package • Engage the care team • Find a partner (mental health or primary care) • Define mental health team functions in primary care • Define a target patient population • Develop processes/workflows • Manage assessments: baseline & follow-up • Develop team coordination of treatment plan • Bill for services • Maximize financial sustainability • Create links • Access higher level mental health services as needed • Link to community resources

9. Levels of Integration Modified from Doherty, McDaniel, and Baird - 1996

10. Levels of Systematic Collaboration Doherty, McDaniel and Baird

11. Level One – Minimal Collaboration • Separate systems and facilities • Minimal communication • No coordinated treatment

12. Level Two – Basic Collaboration from a distance • Separate systems and facilities • Periodic communication • No awareness of “cultures” • Some coordination of treatment

13. Level Three – Basic Collaboration on site • Shared facility • Separate systems • Regular communication • Appreciation of different roles

14. Level Four – Close collaboration in a partly Integrated System • Shared site • Some shared systems • Regular communication • Treatment coordination • Some tension over roles

15. Level Five – Fully Integrated System • Shared site and systems • Regular face-to-face communication • Shared treatment plans and model • In-depth understanding of roles and culture • Regular team meetings

16. What is your level of integration? • Who are your mental health partners? • How do you collaborate/communicate? • What are your community resources? • What is working to help your patients access mental health care? • What do you need to bridge the gaps?

17. Bridge the Gap and Create Change: Lessons Learned

18. What we have learned • Many patients can benefit from integrated care • Relationship building is crucial • Primary Care and Mental Health have cultural differences • Efficiency and effectiveness is achieved through ongoing team work

19. Many patients can benefit from integrated care: People with symptoms or problems that warrant a mental health assessment People being treated for mental health conditions who are not improving People who are dealing with the psycho-social aspects of their medical condition People with substance abuse problems

20. High risk populations People with chronic illnesses or chronic pain People with a disability Kids with school, sleep or behavior problems People with persistent somatic complaints and negative workup

21. Relationship Building is Crucial

22. Who needs to build relationships? Primary care and mental health Administrators Care Providers Program staff Primary care team PC Office Staff PC Clinicians Mental Health Clinician Care Manager

23. Mission Goals Roles Processes/Procedures Interpersonal Relationships Beckhard, R. Optimizing Team-Building Efforts. Contemporary Journal of Business, Summer 1972.

24. Form the Right Team • Involve representatives of all groups that will be affected by the change • Leave titles at the door – everyone can contribute to making this work • Start with who you have and begin to build your team

25. Team Members Primary Care Office staff Primary Care Clinician (physician, NP, PA) Care Manager Patients and Family Members Mental/Behavioral Health Professional Psychiatric Consultant Community Resources (e.g., NAMI)

26. Primary Care and Mental Health: A Culture Clash?

27. Role of Mental Health Specialist: How about those differences?

28. Role of Mental Health Specialist:Other Differences

29. Moving Beyond your Level: Building a Better Bridge

30. Level One: Starting to Connect • Identify patients who could use better coordination – contact their providers • Contact key mental health clinicians in your area • Those treating your most complex patients • Those treating a group of your patients.

31. Level Two: Building on Basic Collaboration • Invite key mental health contacts to staff meeting • Set up clear processes and expectations around communication • What do you need to hear from them? • What should they expect to get from you? • How can you share information better?

32. Level Three: Sharing More than Space • Set up regular times to “meet” • Clarify expectations around communication & treatment coordination • Begin to “share” processes, e.g., scheduling • Work out record-sharing • Define team relationships

33. Level Four: Increase the Integration • Clarify team mission and roles • Formalize team expectations – when to meet, what to share, etc. • Set up streamlined processes for communication and treatment coordination • Develop ways to learn from each other • Celebrate successes

34. Level Five: Maintaining & Continuously Improving • Set up formal and informal learning opportunities • Maximize use of staff meetings, case conferences, huddles, and hand-offs • Always work on improving relationships – both within the team and the larger community • Remember that the patient is the focus of the work

35. An Example of Integrated Practice: the Video • Level Five • Mental Health Clinician working side-by-side with primary care staff • Brief, flexible problem-focused approach to treatment • Warm hand-offs • Curbside consults

36. Efficiency and effectiveness is achieved through ongoing team work

37. Team work • Remember that relationships are foundational and crucial to the work • Everyone can (and really must) learn from each other • Listen to the patients and families • Surprising things happen even to the most organized team • When things aren’t working – consider how the “system(s)” can be improved

38. Start where you are Use what you've got Do what you can Arthur Ashe