How to Crash the Party: Bringing Behavioral Health Specialists to the Care Coordination Team

1. Session B5a October 18, 2014 How to Crash the Party: Bringing Behavioral Health Specialists to the Care Coordination Team Mary Jean Mork, LCSW Director of Integration MaineHealth and Maine Behavioral Helathcare Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • I have not had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Identify barriers and success factors for care coordination. • Identify a “success factor” to immediately address. • Create a plan for addressing this factor upon return to work.

4. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

5. Agenda • Description of Care Coordination (CC) Team • Challenges for Behavioral Health Specialists (BHS) • Role and value of BHS on the team • Success factors and strategies for maximizing team effectiveness • Activity – Developing Action Plans • Question and answer period

7. Patient Centered Medical Home (PCMH) – the Concept (Behavioral Health) From deGruy 10.10

8. Internet Citation: Figure 1. Family tree of terms in use in the field of collaborative care: A National Agenda for Research in Collaborative Care. June 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/collaborativecare/collab3fig1.html

9. Care Coordination • The deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services. • From: Safety Net Medical Home Initiative. Care Coordination: Reducing Care Fragmentation in Primary Care. Implementation Guide. May 2013

10. “If a person doesn’t have a roof over their head, if they don’t have a meal, if they’re a victim of physical or sexual abuse if their household has a lot of stress in it, if their kids’ school is not safe, then that's going to impact their health…..that health is more than just the pill that we’re giving you or the hospital that we put you in. It’s all the other parts of your life and whether they’re working in harmony.”Dr. Jeffrey Brenner in interview “What Primary Care has to Learn from Behavioral Health”. National Council for Behavioral Health.

11. Meet George

12. Barriers to Care Coordination: Roles Rules Arrangements Turf

13. Who is involved? • Care Managers • Case Managers • Behavioral Health Clinicians • Care Coordinators • Transition coaches • Peer navigators • Health coaches • RN’s in the practice • Primary care providers • Primary care staff • Family and community supports • Other?

14. Mental Health Primary Care Preventative and Acute Care Chronic Care High Utilization Chronic Care with MH Dx Substance Abuse High Utilization with MH Dx • Treatment Team • Case Manager • Team Leader – LCSW • Peer/Youth Support • Psychiatry • Medical Director • Care Team • Provider • Nurse • Medical Assistant • Integrated BH Clinician • Nurse Care Manager • Health coach/navigator Continuum of Care

15. “We're all going to have to give up some turf. After all, it's actually the patient's turf.” Robert McArtor, MD, CMO MaineHealth

16. Patient Population Other Complex Patients Crisis and ED High Utilizers Hospital Patients Coordinated Care Team (Potential Team Members) Care Manager Behavioral Health Clinician Care Coordinator Engagement Specialist Health Guide Resource Specialist Transitions Coach Peer Navigator BHHO Case Manager CCT social worker Specialty Medical Care Primary Care Complex Care Mgmt PCP and Clinical Care Team [Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document. Use the Drawing Tools tab to change the formatting of the pull quote text box.] Specialty Mental Health Care Psychiatric Consultation Care Plan Team Care Coordination System Management

17. Care Coordination and Behavioral Health Saturday, September 20, 2014

18. Q1: Describe your involvement on the care coordination team

19. Q2: I If you have tried to have more involvement in care coordination activities, what barriers have you experienced?

20. Q3: If you are presently involved in care coordination activities in your practice, what has been most successful in helping be part of these activities?

21. What else did I hear? • “It was horrifying. We don’t have anything in our practice.” • “We can’t coordinate unless there’s a mistake in scheduling, because she (the care manger) uses the office when I’m not there.” • “Who is my team?” • “I didn’t fill it out because it doesn’t pertain to me.”

22. Complex Care Teams (Social, behavioral and medical complexities) • Providing: • A multidisciplinary approach to complex care coordination; • Team collaboration; • Community resource partnerships, and • Standardized best practice interventions Community Resource Needs Behavioral Health Needs Medication Access Complex Coordination Needs

23. BHS’s value on CC team • Direct service to Patient • Link to specialty MH and SA treatment • Liaison to psychiatric services • “Triage” role with psychiatry referrals. • Consultation to CC team • System perspective • Behavioral lens for medical system • Medical system lens for behavioral health • Expertise with individualized care plans tailored to patient • Patient and family centered focus

24. Common Challenges for BHS • Population health • Using data to inform work • Understanding nuances of different care management roles • Clarifying roles around behavioral change,e.g. with health coaches • Ability to access specialty MH, SA and psych services

25. CC Success Factors • Clarity, connection and non-duplication of: • Roles • Functions • Responsibilities • Clarity about population being coordinated • Timely and accurate data • Tracked and shared outcomes • “Partnership” approach to care • Individualized patient centered planning process for care plans • Shared Care plans and “alerts” throughout system • Standardized coordination of care • “Team” members have assigned tasks based on individual care plan • “Team” lead to manage complex care situations

26. Strategies to Improve CC • Identify who is coordinating care • Identify leaders • Multidisciplinary case presentations • Target specific patients, design services around individual’s goals, coordinate care, track results • Identify impact measures, e.g. ED usage for specific populations • Make connections with community providers and continuum of care

27. Additional considerations for CC • Funding – are there: • New funding streams that support this work? • Cost savings and medical cost offsets? • Honor the patient voice in development of the care plans • Value and nurture the team relationships!

28. Resources Websites • http://integrationacademy.ahrq.gov/ - AHRQ Academy for Integrating Behavioral Health and Primary Care • www.uwaims.org - Advancing Integrated Mental Health Solutions – resources for implementation from University of Washington • www.integratedprimarycare.com – National clearinghouse site for information on integrated care from University of Massachusetts. • www.integration.samhsa.gov - SAMHSA-HRSA Center for Integrated Health Solutions • www.thenationalcouncil.org – the National Council for Community Behavioral Healthcare. Publications • IHI Innovation Series 2011. Craig, et.al. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. • http://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf • Reducing Care Fragmentation: A Toolkit for Coordinating Care

29. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!