Title: Development of Integrated Care: Collaboration of Healthcare, FBOs and CBOs
1Development of Integrated CareCollaboration of
Healthcare, FBOs and CBOs
- Rick McNeese, Ph.D.First Step Recovery and
Wellness Center
2Issues Covered
- Focus on collaboration in health care
- Terminology Same but different!
- First Steps integrated care model
- Working with various professional cultures
- The business side
- Barriers to integration
3Acknowledgments
- Denny Berens, Coordinator, DHSS Office of Rural
Health - Nebraska Medical Association
- Nebraska Psychological Association
- First Step Staff
- First Step Integrated Care Work Group
4Background
- NWU, B.S. in Biopsychology, 1971
- TCU, M.S. and Ph.D. in Psychology, 1975 and 1976
- SHSU Psychology Faculty, Assistant and Associate
Professor, 1976 -1985 - LMEF Family Practice Program, 1985-1998
- First Step 1998-Present
5Professional themes
- Multidisciplinary studies
- Researching collaboration and integration models
- Making psychology useful
6Key professional experiences
- Lincoln Medical Education Foundations (LMEF)
Family Practice Program - Integration of Mental Health and Family Practice
training and treatment - Exposure to the culture of Family Practice
- Relationships with 100 M.D.s across Nebraska
7Case 1
- 22 y/o male from small town
- Depressed with recent breakup
- Also recent of deaths of his only two siblings
- Drinking beyond moderation
- What would MH or SA or Pastor or M.D. do?
8First Step Recovery and Wellness Center
- Multidisciplinary Treatment Center
- Mental Health
- Substance Abuse
- Compulsive Gambling
- Biofeedback and Neurofeedback
- Eating Disorders
9Case 2
- Lay leader of congregation
- Providing support for a 47 y/o male
- Alcohol dependent
- Depressed
- What do you do?
10Comments about collaboration
- This is difficult work and not for the weak of
heart - Be ready to Grope, Growl, Grasp and Grow
- Also very gratifying because integrated care
works - Different way to work, not just more people
working together
11Case 3
- Mental health counselor
- 35 y/o male
- Diagnosed Bipolar Disorder
- What do you do?
12Why Collaborate or Integrate? The Simple Truth.
- Studies show that
- If PCP adds BHP to treatment of depression,
success doubles from 45 to 90 - If BHP adds PCP to treatment of alcoholism,
abstinence triples at 12 month follow up - First Step Integrated Care Screen data
13However, there is an important barrier to
integration
- We operate on a Guild Model
- We work in our silos created by licensing laws
14Guild model
- Works on principle of exclusion
- Whereas integration is a complex social cause
requiring many participants - And guilds are how professionals protect their
license and make a living!! - This will be a very real barrier to change
15Case 4
- Family Physician
- 45 y/o male
- 75 overweight
- Sleep apnea
- Depressed
- Heavy smoker 1.5 2 ppd
- Stroke in 1996 resulting in full disability
16Lesson of the Tower of Babel
- When language fails, human communication and
cooperation are impossible. - We speak the world into being.
- Our language creates our reality.
- This workshop is about learning the language of
collaboration and integration
17And in rural state like Nebraska,
- We can lead the nation with integration
- We are large enough to have the problems
- Yet small enough to have the relationships that
will make this work - Nebraska can become the nations laboratory
18 Terms
- Mental Health
- Alcohol and Drug Abuse or Dependence
- Behavioral Health
-
- Behavioral Health Providers (BHPs)
- MH SA Counselors
- Primary Care Providers (PCPs)
- F.P.s, Peds, OB/Gyn, Internists
- P.A.s, N.P.s, etc
19George Carlin would love it!
- Integration doesnt mean Integration
- You can Collaborate and not Integrate
- Treating the Family doesnt mean Treating the
Family - Evidence based is not collecting evidence
20Workshop Objectives Why, What, How and Now
- Why?
- Federal support of Integrated Care
- Carve outs to Carve ins
- What?
- Collaborative and Integrated Care
- Essential features
- Screening data and treatment implications
- How?
21Why?
- Mural dyslexia
- The inability to see the handwriting on the wall!
- Changes in health care are imminent
22Why? Review Federal support of Integrated Care
23Ensuring the Supply of Mental and Behavioral
Health Services and Providers Summit
- Meeting in Des Moines, IA, September, 2000
- Substance Abuse and Mental Health Services
Administration (SAMHSA) - Health Resources and Services Administration
(HRSA) - Bureau of Primary Health Care (BPHC)
- National Health Service Corp (NHSC)
- Group of representatives from Nebraska attended
this Midwestern assembly of states
24U.S. Surgeon Generals Report, 1999
- David Satcher, M.D., Ph.D.
- Goal Interdisciplinary approach to achieve 100
access and eliminate disparities by the year 2010 - Commitment to partnering with communities to
build a comprehensive primary care system that
includes mental health, behavioral health, and
substance abuse services. - First recognition of mental health and substance
abuse as priority health concern
25Nebraskas physicians need
- Quick access to reimbursable, trained BHPs
- Quick access to psychiatrists in ER or hospital
- Simplified access to multidisciplinary services
- Increased care for specific populations and
problems - Improved reimbursement for behavioral health
- Resource directory
- Programs for uninsured patients
26FBOs and CBOs should look at these needs to
develop a niche
- Recruit and retain BHPs
- Telehealth support
- Support multidisciplinary teams
- Help with underserved populations
- Community Resource Directories
- Help with uninsured patients
27Case 5
- Substance abuse counselor
- 34 y/o recently divorced male
- Alcohol dependent
- Insomnia
- Extreme anxiety
- Prevents participation in community support group
28Carve outs to Carve ins Charles Kiesler,
American Psychologist, 2000
- 75 now under MCO but 88 Carved out
- 46 of disabled have three or more coexisting
chronic problems - Treating coexisting problems in segregated
systems is costly - E.g., In case of dual disorders, SA counselor has
little or no access to PCP or Psychiatrist
29Carve outs to Carve ins Charles Kiesler,
American Psychologist, 2000
- Three revolutions in American health care
- Expansion (1940s-60s), Cost containment
(1960s-90s) - Era of assessment and accountability
- Therefore, movement toward evidenced-based
treatments - Who adds value to treatment effectiveness?
- This will influence system design and access
- Reducing inappropriate care is one way to reduce
costs
30Why now? Economic reasons
- Many studies show cost reductions or offsets
between 20-40 - 57 controlled studies show 27 cost savings after
costs of BHP are subtracted - People will drop out of all systems except
medical system as shown by results of closing
CMHCs - Distressed are high utilizers of more expensive
medical care - Untreated depressed patient uses 2-3 times annual
medical services
31However
- MDs cannot refer all patients
- Between 50 and 90 of referrals across town do
not make it to BHP - Patients need to feel that they came to the RIGHT
PLACE
32Economic reasons
- Health care costs cannot be contained in
segregated systems - Eg., consider all the services a dysfunctional
CD or MH family can utilize - Mother sees PCP for headaches
- Adolescent seen by MHP
- Father seen by GI specialist for GI bleeding
- Fathers alcoholism is undetected and untreated
33Economic reasons
- Financial risks now being shifted to consumer and
providers - Distressed people are high utilizers of medical
care - Nebraska law permits insurance companies to deny
charges for self-inflicted injuries. Already
distressed patient just got worse! - 70 of medical visits are driven by psychosocial
factors.Name that Pain Game
34Case 6
- Priest consulted by family
- 23 y/o female
- Bulimia
35Why now? The Evolution of Primary Care Medicine
- Family Physicians have been trained and now
expect it - Family Practice lead the way (1976) in creating
collaboration in training - By the way, there are no longer GPs
- Primary care includes family practice,
pediatrics, internal medicine, and
obstetrics/gynecology - These are the front line medical specialties
(Common things are common)
36PCPs are the defacto mental health providers in
U.S.
- They treat 50-70 of BH problems
- Prescribe 70-88 of the psychotropic medications
- 10-15 of PCP patients are for behavioral health
37Case 7
- Counselor
- 44 y/o female
- Referred by employer
- Vague history and uncertain reason for referral
38The experts say
- Alexander Blount, Introduction to Integrated
Primary Care - Kirk Strosahl, Integrating Behavioral Health and
Primary Care Services - James Bray, Collaboration with Primary Care
Physicians
39Blount
- Patients come with undifferentiated problems
- 20 of visits have discoverable organic causes
- 10 of visits are clearly psychological
- Therefore 70 or vast majority have both elements
- 10 most common complaints account for 40 of
visits - But after 1 year, only 10-15 of these had
organic basis - Depression is 2nd most disabling condition (COPD
with limited ADLs)
40Better fit gives better outcomes
- 44 of patients prescribed antidepressant stopped
prescription in three months - Integrated treatment - 74 reduction in symptoms
if outside referral - Adding BHP to PCP in treatment of depression
doubles success from 45 to 90 - Adding PCP to CD treatment triples abstinence at
12 months!
41Limits to what physicians can do
- MDs, even if trained, cannot treat all the
problems - Workpace is too fast (Capacity 30-40/day based
on 15 min visit) - No one can be expected to master all the
desirable skills - Treatment by MDs too expensive
- MDs fear opening a can of worms
42Also a limit to what clergy can do
- Parallels between problems of rurally located
medical professionals and clergy.
43What is Collaborative and Integrated Care
44Integrated Care is not a new concept
- Family Practice as specialty of breadth
- Training since 1976 has included behavioral
health - LMEF Model began in 1985
- Approaching 30 years and 20 years, respectively
- Engels biopsychosocial model dates to 1977
- Many others have collaborated in some manner
45LMEF Family Practice Model
- Department of Behavioral Medicine (1985-1999)
- Training program for residents
- Clinical services for clinic patients
- Psychology training program
- APA accredited predoctoral internship
- Many other mental health trainees
- Pediatrics, Geriatrics, Womens Issues,
Multicultural, Behavioral Medicine components - Discontinued in 1999 for lack of funds
46Several ways of approaching integration
47Integrated Care from Low to High (pre HIPAA!)
- Courtesy report of involvement
- Referral call for information exchange
- Development of special referral relationship
- Meeting to discuss cases
- Meeting of providers with patient
- Work together regularly delivering services
48(No Transcript)
49Four levels of service integration
- Direct service Care of patients
- Program Linkages between local
service systems - Policy Linkages between local
and state systems - Organizational Reconfiguring and
consolidating agencies
50Patient Centered Care
- Historical
Patient Centered - Discipline focused Patient
focused - Problem oriented Goal
oriented - Multidisciplinary
Interdisciplinary - Pt is recipient Pt is
participant - Paternalistic
Respectful - Rigid standardization
Individualistic - Tradition based Evidence
based
51Key elements of Collaborative or Integrated Care
Program
- No Wrong Door or One Stop Shopping
- Triage and up-front screening
- Communication between professionals
- Coordinated BHP and PCP care
- Patient experiences one treatment plan
- Documentation of progress
- Track outcomes
- Viable financial program
52Key elements continued
- Minimal reimbursement disconnects
- Working relationships with public funded service
- Strong and lasting leadership
- Access to levels of care
- Training professionals in and out of school
53Integrating Mental Health and Addictions Treatment
- Development of Multidisciplinary treatment group
- Screening data makes strong case for integrated
care
54First Step Integrated Care Screening Tool
Description
- Seven categories of self reported items
- Chronic Medical Problems
- Psychiatric Care
- Psychological (Brief Symptom Inventory vs.
SAS/SDS) - Michigan Alcohol Screening Test (MAST)
- Drug Awareness Screening Test (DAST)
- South Oaks Gambling Screen (SOGS)
- Broad list of items
55 Drugs 55.5
Substance Abuse N110
Compulsive Gambling 16.4
Chronic Medical 20.9
Stress Symptoms 42.7
Substance Abuse 96.4
Psychiatric 23.4
Abuse 32
Suicide risk 26.4
Eating Disorder 15.5
Psycho-logical 14.5
56Mental Health N42
Drugs 11.9
Chronic Medical 38.1
Gambl-ing 9.5
Alcohol 52.4
Mental Health 35.7
Psychiatric 31
Abuse 40.7
Stress Symptoms 81
Suicide risk 54.8
Eating Disorder 28.6
57Compulsive Gambling N45
Substance Abuse 73.3
Drugs 26.7
Chronic Medical 15.6
Stress Symptoms 55.6
Gambling 86.7
Psychiatric 37.8
Suicide risk 44.4
Abuse 29.3
Eating Disorder 20
Psycho-logical 11.1
58Neurofeedback N39
Chronic Medical 48.7
Drugs 15.4
Gambling 12.8
Alcohol 33.3
Neurofeedback 82.1
Psychiatric 33.3
Abuse 34
Suicide risk 41
Eating Disorder 43.5
Psycho-logical 23.3
59How
60Review First Step Model of Care
61Model Build It, Get It, Use It, Share It,
Follow It, Measure It
62Build It Multidisciplinary Team
- Provider mergers to get team
- Difficult to do in rural areas without providers!
- But at same time, is way to extend few resources
we do have - Use cross training of merged group
- Develop creative connections with others in
community
63Get It Identify multiple problems
- Cross training to acquire and use information
- Integrated Care Screen
- Completed on intake, scored, at start-up of
Integrated Care Treatment Plan - Or completed later as accountability check
64Importance of Problem Identification
- Engels Biopsychosocial Model
- Medical, Individual, Marital, Family, Community,
Cultural/Society - Minkoff in Dual Disorders work conceptualizes
- Low vs. High Intensity
- Psych vs Substance Abuse
- Screening can identify Low vs. High on multiple
dimensions
65Use It Be Able to Treat Multiple Problems
- Co-occurring disorders vs. dual disorders
- Cross training necessary
- Making Referrals
- Office literature and vertical integration
programs
66Would you treat these differently
67Biopsychosocial Screening
68Biopsychosocial Screening
69Treatment Complexity
- Medical, Individual, Marital, Family, Community,
Cultural/Society - Type I Single Low Risk
- Type II Single High Risk
- Type III Two High Risks
- Type IV Multiple High Risks
70Tracks of Treatment
- Integrated Care Treatment Team - The Mayo
- Assess and treat complex cases
- Team evaluation and discussion of integrated
treatment - Team meeting with client/family
- Therapeutic goal of selling treatment
conceptualization
71Share It Integrate Treatment of Multiple
Problems
- Work with PCP, get Release of Information signed
- Have client sign in PCP office
- HIPAA requires special release
- Progress Note to Physician
- Respond to physician needs
- Develop common treatment plan
72Follow It Continuity over time
- One primary therapist over time
- Addictions as chronic relapsing disease
- Stress of predictable life cycle events
- Stress of unpredictable crisis
73Measure It Outcome measures
- Increasing need for documented outcomes
- Accountability
- Research
- Funding support
- Measuring Treatment Outcomes, Patricia Owen, Ph.D
- Hazelden Publishing
74Maintain It Leadership, funding and business
structure
- Takes commitment within the practice
- Takes support from outside the practice
- No magic funding resources at this time
- Best business structure is centralized
- Need strong Implementation Group
- Need good communication, both clinical and
operational
75Implementation findings
- Very important to have mutually supportive team
- Different patient populations in SA and MH
- CD clients referred by legal system and resist
- Quick and least expensive treatment is focus
- MH providers have difficulty referring to SA
programs - Similar problem of PCP referring to MH?
76Implementation findings
- Communication to provider and billing
- Universal Intake Form with clinical and business
info - Universal Internal Referral Form
- Where does the chart live?
- How do you best select, train, and supervise
staff? - Difficulty obtaining psychiatric care
- Lifespan continuity requires stable staff
77How?
78Working with Primary Care Physicians
79Types of services
- Direct patient care
- Consultation to MD
- Co-therapy
- Consultation in other settings, e.g.. Schools
- Community liaison, outreach
- Assessment
- Support for clinical and program development
research - Support for education
80What makes a happy client?
- Guess what, it isnt always therapy!
- It is having a financially satisfied customer
- Unsatisfied substance abuse client will add to
resentment - Unsatisfied mental health client will get more
depressed, avoidant, or more emotional
81Core areas of knowledge and skills for BHP
provider in PCP
- Biological components of health and illness
- Cognitive components of health and illness
- Behavioral and developmental aspects of health
and illness - Sociocultural components of health and illness
- Health policy and health care systems
- Common primary care problems
82Core areas of knowledge and skills for BHP
provider in PCP
- Clinical assessment of common primary care
conditions - Clinical interventions in primary care
- Interprofessional collaboration in primary care
- Ethical and legal issues in primary care
- Professional issues in primary care
83Core areas of knowledge and skills for BHP
provider in PCP
- Medication knowledge
- Must function as eyes and ears of physician
- Individual, group, and psycho educational skills
- Life Satisfaction Class rather than Depression
Group - Good case managers
- Cognitive/behavioral and brief therapy methods
- Family systems approach
84Working effectively with Primary Care Physicians
- PCPs are gifted individuals with commitment to
families - The most psychologically oriented of all MDs
- Their practice teaches them importance of
psychological care if residency didnt - Continuity of care for total family
- Hierarchical nature of medicine
- Defined boundaries of specialization
- Well defined standards of care in all
specialties
85Working effectively with Primary Care Physicians
- Ultimate responsibility for patient
- Develop trusted referral relationships
- Liability conscious
- Discuss before documenting
- See large volumes of patients
- Care for a population as well as patient
- Some are more procedurally oriented
86Working effectively with Primary Care Physicians
- Some practice independently while others rely
more on consultants - Expect consultants to communicate through phone
and reports - Expect immediate access
- Learn by doing and BHP is expected to teach
- Provide first line of treatment until referral
necessary - PCPs expect to coordinate so exercise care in
your referrals
87Working effectively with Primary Care Physicians
- They respect BHPs who can work with the
complexity of psychosocial issues - Sensitive to patient issues but will avoid
opening a problem if they cannot treat or refer - Expect a diagnosis and treatment plan
- Prefer brief consults over meetings
- Little tolerance for impractical or theoretical
- Tremendous power over community but not their
lives
88Working effectively with Primary Care Physicians
- You must be generalist to work with PCP
- PCP expects you to be expert in broad range of
DSM disorders - Dont wait for patients to come to you
- MDs dont identify them and they wont come to
you - Patients can have serious and terminal illness
- Careful health history
- Do not over focus on psychosocial
- Be prepared to deal with serious and terminal
illnesses
89Working effectively with Primary Care Physicians
- Important to develop relationship with MD, get
their explanation of patient problem, clarify
their needs, and secure their support for
treatment - Have working knowledge of training and approach
to problems - Consider developing a group practice then link
with PCP practice - Broaden role to include prevention, outreach,
community orientation, program development,
research, political advocacy
90Working effectively with Primary Care Physicians
- PCPs referral question
- Communicate back to PCP (usually a paragraph or
two) - Even a report should not exceed a page
- If longer, include a summary paragraph
- Clarify patients understanding of why PCP
referred them - Be aware of patients perception of you
- Give the PCP clear concise facts and specific
treatment recommendations
91Working effectively with Primary Care Physicians
- MDs work quickly and results expected quickly
- MDs refer out and you may need to refer as well
- But MD expects to coordinate or make referral
- MDs expect diagnosis and succinct treatment plan
92Working effectively with Mental Health
Counselors, CPCs
93Working effectively with Drug and Alcohol
Counselors
94Working effectively with Social Workers
95Working effectively with Psychologists
96Review essential business functions
- Committed leadership
- Clear organizational structure
- Strong business management
97Essential business functions
- Good intake process enables clean start
- Getting information from client
- Calling insurance company for benefits
- Asking the right questions
- Getting client to understand benefits
- Getting them to understand their ultimate
responsibility
98Intake process continued
- Must give client a disclaimer, just as insurance
company does - Dilemma - Checking insurance as courtesy to
client is interpreted as agency taking
responsibility for insurance reimbursement
problems - Complication of different coverage for different
providers - Makes referral between programs complicated
- It cannot be SEAMLESS because of insurance
differences
99Review essential business requirements
- Insurance and billing for mental health and
substance abuse - Consolidation of services requires integrated
information systems - Patients provide insurance information once
- Integrated clinical and business information
system - Tracking and Follow-up checks and balances
- Use community board to educate community and
destigmatize
100Office organization
- Use same receptionist and schedule
- The greater the proximity, the more integrated
- 92 of BHP/PCP consults are brief in ideal ICP
model - Regular staffings or meetings to discuss
difficult cases - Special treatment groups (pain, chronic illness,
depression, obesity, ADD)
101Undertaking a New Project
- Dont assume that project can start just because
MDs are in favor - Clinical team and office manager should
strategize how BHP will be useful - Clinical team, office manager, and BHP should
meet regularly to address problems - Office manager will need to orient support staff
- New ways of operating can be stressful so a
learning environment must be created
102Undertaking a New Project
- The more successful, the more the larger
organization may punish the project - Those who are left out are often critical of
what they are out of - If pilot project works and is implemented on
larger scale, others may feel they are being told
what to do - Keep everyone updated on progress
103Undertaking a New Project
- Key staff not involved should still be made to
feel they are on the ground floor - A dissemination group should provide
communication to larger organization - Updates should tell patient stories/successes
- Be candid about blind alleys that have not worked
104Review Case Studies of Integrated Care
- 15 y/o depressed female with MIP
- 43 y/o male truck driver who misses delivery of
his 5th child - 30 y/o recovering depressed female with weight
gain and chronic fatigue - 27 y/o suicidal female caught embezzling funds
from employer - 49 y/o female more depressed but in less pain
with new rx of Vioxx
105Review barriers to Integrated Care
- Different bureaucracies getting CEUs
- NMA quick, NPA two days slower but unnecessary
- But AMA approval via NMA approved by NPA
- LMHP, Social Work, CPC simply must meet criteria
- CADAC requires 45 days and more info than NMA
- Nursing requirements even more
106Barriers to Integrated Care - 2
- Rural populations is actually quite diverse
- Stigma is higher in rural setting, access is
lower - Availability
- Accessibility (Across the street is too far)
- Rural geography and weather
- In low volume rural setting state-funded systems
essential - But difficult to provide specialty care
- And state programs have little integration
training
107Barriers to Integrated Care - 3
- Reimbursement/Affordability
- Different bureaucratic and funding systems, poor
coordination - Poor patient understanding of insurance
- Poor insurance company of explanations of
benefits - If people with heart attacks had to do what
people with life attacks do to get care, wed
have a lot more dead Nebraskans and considerable
reductions in health care costs. Maybe thats
the point!
108Barriers to Integrated Care - 4
- Physicians paid for procedures, MH paid for time
- Thus, MH paid only for therapy and not for
consultation - Carve outs resulting from mind-body dualism and
cost cutting - Different payors have different requirements
- Different professions have different ethical codes
109Barriers to Integrated Care - 5
- Confidentiality
- MDs work in groups so information is shared
among them - Therapists work alone so information is not
shared - Documentation differences
- MDs expect others to read and use their notes
- Therapists do not expect others to use their
notes - Lack of common language
- Similar language with different meanings
- E.g. Treating the family by PCP vs. Family
therapist
110Barriers to Integrated Care - 6
- Less availability of specialty mental health care
- Children
- Women
- Men (not studied as much)
- Geriatric
- Minorities
- Severely and Persistently Mentally Ill
111Barriers to Integrated Care - 7
- Turf issues and guild model (Exclusion) by
professions - Different beliefs about the change process
- Practice styles (pace and time spent)
- Decades of mutual negative stereotyping
- Data gathering is important to justify positions
112Barriers to Integrated Care - 8
- Decreasing sense of community in rural setting
- Out migration of young, educated residents
- Declining economy and quality of rural life
- Rural areas doing more with even less
- Human resource problems of rural agencies
- Change must come from within the community
- Consensus building is essential
113Barriers to Integrated Care - 9
- Who has control and accountability?
- How are dollars divided?
- Professional cultures conflict
- Availability of providers and network adequacy
- Data management and confidentiality
- Guild model works on principle of exclusion
whereas integration is a complex social cause
requiring many participants
114Barriers to Integrated Care - 10
- Asking others to use tools can be seen as
encroachment on autonomy - Collaboration takes time and there is no
reimbursement - Poor funding of public programs
- Poor funding of substance abuse programs
- Stigma
- HIPPA impact uncertainty
115Important Developments Telehealth
- T1 lines available to NE Critical Care Access
Hospitals - Technology may permit off-site clinical access
- Hospitals may be able to get cost-based
reimbursement by Medicare - Possibly enables them to add BHP staff
- But achieving technology buy-in is process in
itself - Medicare HB Codes permit health related service
billing
116Important Developments
- Early collaborative training is important
- Many training programs now talking of integration
- De-institutionalization is unique challenge to
rural areas - What happens if Regional Centers close or change?
- Fewer resources to cope with high needs clients