Integrating Mental Health into Primary Care: Sustainable Partnerships

1. Jane Hamel-Lambert, MBA, PhD Karen Montgomery-Reagan, DO, FAAP, FACOP Sherry Shamblin, PCC-S Dawn Murray, DO March 20, 2009 Integrating Mental Health into Primary Care: Sustainable Partnerships

2. Overview • IPAC: A Rural Health Network • Integration Efforts • Developmental Screening and Surveillance • Co-Locating Mental Health in Primary Care • Co-Location Interagency Partnerships • University Medical Associates, Inc • Tri-County Mental Health & Counseling Services • Family Healthcare, Inc.

3. Introductions • Jane Hamel-Lambert, MBA, PhD • President, IPAC; Department of Family Medicine, Ohio University’s College of Osteopathic Medicine • Karen Montgomery-Reagan, DO, FAAP, FACOP • Chair, Pediatrics, Ohio University College of Osteopathic Medicine; University Medical Associates, Inc. • Sherry Shamblin, PCC-S • Early Childhood Mental Health Consultant, Clinical Supervisor, Tri-County Mental Health & Counseling Services, Inc. • Dawn Murray, DO • Medical Director, Family Healthcare, Inc.

4. Integrating Professionals for Appalachian Children

5. IPAC: A Rural Health Network • Interdisciplinary collaboration hinges on interagency cooperation • MHPSA. • Retention/recruitment • Thank you to Office of Rural Health Policy (P10 RH06775, D06RH07920)

6. Integration Goals • Adoption of routine developmental surveillance • Improves early identification • Alternative to “wait and see” • Co-location of Mental Health Providers • Improves access • Improves quality through care coordination • Improves patient outcomes • Developing common language

7. AAP guideline • Developmental Surveillance and Screening Algorithm • 9, 18, 30 months give screening tool • If at risk, refer for further evaluation • http://www.medicalhomeinfo.org/Screening/DPIP%20Follow%20Up.html

8. Adoption of the Ages and Stages Questionnaires • ASQ & ASQ:SE • Childcare programs • Primary care settings • Shift away from clinical impressions (watch and listen) to using formal parent-completed, normed screening tool. • Reassurance and Risk

9. SCREENS • ASQ Screens 5 Domains • Communication • Gross Motor • Fine Motor • Problem solving • Personal-social • ASQ:SE • Social-Emotional development

10. Why ASQ Tools? • CHEAP! • ASQ – 3 (May 2009) … $249 and ASQ:SE… $149.00 • Low cost alternative—annual cost of $25-50 for following children • Permission granted to photocopy

11. Quick and Easy Utility Parent satisfaction survey (N=731) (publisher data) • How long did it take to complete the questionnaire? • 70% Less than 10 minutes • 28% 10-20 minutes • 2% More than 20 minutes • It was easy to understand the questions? • 97% Easy • 3% Sometimes • 0% Not easy

12. Accurate: ASQ • Normative sample of over 8000 questionnaires, high reliability (> 90%), internal consistency, sensitivity, and specificity • See www.brookespublishing.com for ASQ User’s Guide Technical Report for complete psychometric data.

13. Parent Report: ASQ Research • As accurate as formal measures for identifying cognitive delay (Glascoe, 1989, 1990; Pulsifer, 1994) • As accurate as formal measures for identifying language delay (Tomblin, 1987) • As accurate as formal measures for identifying symptoms of ADHD and school related problems (Mulhern, 1994) • More accurate than Denver for predicting school-age learning problems (Diamond, 1987)

14. Physicians trust it • Catches kid earlier than she may have • Opens up conversations with parents regarding observations • Monitoring • Billable • Generate Revenue

15. Billing • CPT Code: 96110 (limited evaluation) • E/M Modifier – 25: Significant Separately Identifiable Evaluation and Management Service by the Same Physician or the Same Day of the Procedure or Other Service • Document administration, interpretation (normal, abnormal, parent discussion and referral/action) • Medicaid Relative Value (staff admin) = $13.64 (2005)

16. Generalizability • Depression for adults: PHQ -9 • Patient Health Questionnaires • Improves identification • Tool for communication

17. Co-location of Mental Health Providers in Primary Care

18. UMA is a multispecialty group dedicated to serving southeastern Ohio. Affiliated with Ohio University College of Osteopathic Medicine Karen Montgomery-Reagan, DO, FACOP, FAAP University Medical Associates, Inc

19. Motivation for Co-Location Program • Practice Group has a need for mental health services • Difficulty with referrals; seems like a black hole.. • Making appointment calls • CMHC required in person to schedule appointment • Families need access to service • Waiting for appointments • Communication • Did they go, what was the dx, were they discharged from care? • What was the Primary Doc role?

20. Family Benefits • Clients familiar with surroundings and comfortable with office staff/patients • Ease of scheduling for patient and physicians • Referral sheet to reception • Families provided intake paperwork • Appointment scheduled right then and there • Parents/patients more willing to try mental health services provided at our office

21. Family Quotes • Patient: I’ve tried counseling before • I have individuals that will fit your personality… (choice) • I will speak with the provider individually • If it doesn’t work, I have other avenues • Patient: If you think this person will help, I will give it a try… • Patient: How soon? It always take so long to get it

22. Physician Benefits • Physicians find mental health a benefit for their patients • Physician have direct contact with provider • Curbside consults, guides diagnostics, treatment planning • Communication easy on site, no phone message • Don’t wait until it’s a disaster---crisis • Appointment info is charted • I know if they are going and continuing care • Physicians are able to directly discuss cases with the mental health professional on site

23. Infrastructure • Scheduling • On site facilitates follow through • Sooner access is easier to negotiate • Office Space • Location matters • Shape, size and absence of medical gear • Private practitioner vs CMH clinicians • MH Practitioner Billing • Providers are doing their own billing • Record Keeping • Doc charts have mental health progress note

24. Real Numbers • Three Providers • 2 ½ days of service combined • Numbers of Families • 78 families have been provided service • Numbers of Visits • Over 250 appointments (Jan08/May08) • No Show rates • Medicaid (approx 29%) NS rate > than privately insured NS rate (approx 10 – 12%)

25. TCMH-CS is a licensed Community Mental Health Center serving four counties in southeastern Ohio Tri-County Mental Health and Counseling Services, Inc.

26. Components of the Community Mental Health System that Impacted Our Co-Location Efforts

27. Recovery Model vs. Medical Model

28. Recovery Model Focuses on resiliency while reducing symptoms All people have strengths to overcome challenges Individuals are the experts in their experiences so have the voice and choice in services Values unconditional acceptance of the individual

29. Implications of Differences in Practice Models Professional Culture Patient/Client Implications for Assessment/ Diagnosis Organizational Structure Physical Office Space Communication

30. Practitioner Work Style • Consultation • Info goes back and forth • Physician manages case • Mental health • Has time efficiencies • Collaboration • Fuse ideas • Jointly develop treatment plan • “our” patient • Time to develop relationship • Build in communication strategies

31. Billing and Paperwork Procedures • Medicaid/Insurance • Medicaid match • Reimbursement by insurer, by who is delivering services • Electing to serve • Modifying structure of intake paperwork and documentation • Difficult to merge systems even when there is duplication because of ODMH requirements

32. Evaluate Your Practice Needs • Age • Family Care versus Pediatric Practice • Payee source • Mental Health Needs

33. Laying a Good Foundation • Choose the right mental health partner for your practice • Build a working relationship • Build time for communication/interaction • Be prepared to develop joint vision and goals for the partnership

34. Behavioral Health Integration …a work in progress Dawn Murray, DO Family Healthcare, Inc

35. MISSION of FHI (Family Healthcare, Inc.) • The Mission of Family Healthcare, Inc. is to provide access to high quality, affordable, healthcare to everyone without discrimination. • All Community Health Centers have a similar mission.

36. Family Healthcare, Inc • FQHC (federally Qualified Health Center) • Six sites in six counties in Southeastern Ohio • Behavioral health considered a core service, provided on site or through referral agreement • Investigated many models of behavioral health/primary care integration. • IPAC (Integrating Professionals for Appalachian Children) involvement was springboard for our current journey.

37. FQHC • Federally Qualified Health Centers AKA Community Health Centers • Receive 330 grant from federal government which provides for uninsured care. (For FHI, this is about 20% of budget) • Sliding fee scale based on income • Accept most insurances including medicaid (and Medicaid HMO’s), medicare. • Enhanced reimbursement through medicaid and medicare. • Considered safety net providers • FTCA malpractice coverage • Different funding stream than Community Mental Health centers

38. Behavioral Health/Primary care Integration models in FQHC’s • Referral Agreements with Private Psychiatrists or Community Mental Health Centers (no integration) • Complete in house Mental Health program with psychologists, social workers, and psychiatrists as FQHC employees. • In house Behavioral Health Program with Clinical psychologists, LISW’s, counselors under supervision of PCP’s • FQHC contracting with Community Mental Health Agency for mental health personnel • All possible combinations of these.

39. IPAC-Colocated Providers • Involvement in IPAC allowed more collaboration between agencies for ideas to develop. • We started with the original plan of a Tri County counselor in one of our sites. • Quickly saw limitations of this arrangement: • Only available for kids. Not as many kids as predicted. Bigger need for adult services. Better if billing is through FQHC due to another funding stream. • Began contract with Tri County, but still kept IPAC involvement

40. Behavioral Health/Primary Care model • LISW can triage for PCP’s which increases everyone’s efficiency • LISW will keep people for counseling at FQHC and work with PCP to address goals to enhance medical outcomes. • If patient is outside of PCP scope for mental health issues, LISW can start intake paper work, make psychiatric referral and expedite patient care. She can continue counseling at FQHC with support from PCP. This is very important given the long wait times we sometimes have for psychiatrists, especially in rural areas. We can keep people from falling through the cracks.

41. Concerns • Competition for patients/clients • Supervision • Reimbursement • Integration

42. Win-Win • At a time when Mental Health funding is being cut, it is good to have other revenue streams. By contracting for services of the LISW, she actually increased her productivity at the Mental Health Center. FHI is breaking even on the deal, and getting excellent services for our patients.

43. Next Steps • We are working on streamlining our communication between the PCP and the LISW. • Developing a protocol and system to triage more urgent psyche referrals into the Mental Health Center. • We are planning to spread to our other sites. • Continuously communicating between Community Mental Health center, and providers to foster trust, and better integrate our cultures for improved access to quality healthcare for all patients.

44. CoLocation toward Integration • Shift referring “my clients” to jointly taking care of families • Co-Learning • Understanding diagnostic paradigms • Understanding professional biases • MH builds medical knowledge; Doc gains mental health knowledge • Communication Goals • Shared language • Participation in routine meetings • Access to medical charts

45. Lessons Learned • Health delivery system dichotomizes MH and Health • Carve out billings • Different govt oversight agencies (ODH, ODMH); Mission and mandates • Diagnostic tools are different • Philosophies of care • Communication nourishes partnerships • Tensions teach • Build the relationships

46. Questions and Answers

47. Contact Information Jane Hamel-Lambert • hamel-lj@ohio.edu Karen Montgomery-Reagan • montgomeryreagan@oucom.ohiou.edu Sherry Shamblin • sshamblin@tcmhcs.org Dawn Murray • murraydoc@yahoo.com