Integrating Behavioral Health and Primary Care: A Clinical Model

1
Integrating Behavioral Health and Primary
Care A Clinical Model

• Parinda Khatri, Ph.D.
• Director of Integrated Care
• Cherokee Health Systems

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Our Mission

• To improve the quality of life
• for our patients through the integration of
• primary care, behavioral health and substance
  abuse treatment and prevention programs.
• TogetherEnhancing Life

3
Cherokee Health SystemsSERVICES

• Behavioral Health
• Adult Outpatient
• Adolescent Family Outpatient
• Child Development
• Alcohol Drug Abuse Outpatient
• Intensive Case Management
• HUD Group Homes
• Forensic Evaluations
• Consultation Education
• School Psychology
• Crisis Intervention
• Early Intervention
• Community Health Outreach
• Dental Services
• Prevention Services
• Extractions
• X-Ray
• Amalgams

Primary Care Pediatric Adult Medical
Services Early Childhood Evaluation, Assessment
Treatment Well Baby Check-ups Family
Planning Gynecological Care Complete Physical
Exams Routine Laboratory Tests X-Ray Preventive
Health Services Behavioral Health
Consultation Corporate Health Strategies Employee
Assistance Programs Health Incentive
Programs Management Team Development
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Integration at Cherokee Health Systems

• Comprehensive health care system with a 25 year
  history of outreach and consultation
• Our mission is integrated health services
  delivery
• 11 sites with integrated primary and behavioral
  services
• Behavioral health consultation into the region's
  primary care safety net providers
• Integrated care across the lifespan

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What is Integrated Care?

• "Integrated Care is a concept bringing together
  inputs, delivery, management and organization of
  services related to diagnosis, treatment, care,
  rehabilitation and health promotion. Integration
  is a means to improve the services in relation to
  access, quality, user satisfaction and
  efficiency." WHO European Office for Integrated
  Health Care Services. Integrated Care. Working
  Definition. 2001

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Why Integrate?

• Behavioral and Psychosocial factors in etiology
  and treatment of physical disease
• Primary Care as the locus of treatment for mental
  health disorders
• Financial Advantages
• Improved quality of care
• Patient satisfaction
• Improved provider satisfaction

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Mental Healthcare in USStrosahl, K. (1996)
Primary Mental Healthcare New model for
integrated services, Behavioral Healthcare
Tomorrow, October, 93-96.
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Integrated Care

• Illustrates Biopsychosocial model
• Meets patients where they are
• Unifies medical and mental health practice

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A Framework to Integrated Care

• Behavioral Health is ROUTINE component of medical
  care
• Shifting Boundaries of Care
• Location
• Staffing
• Skills
• Scope of Integrated Care
• Horizontal Integration
• Vertical Integration

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Co-location and Design

• Offices for behavioral providers in primary care
  area
• Behavioral consultation in the medical exam room
• Shared common areas for patients and providers

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Communication Model

• Co-location and Design
• Paperflow
• Integrated Charts
• Regular, face to face verbal feedback
• Brief consultations
• Formal treatment team/case conference
• Phone/Telemedicine Consultation

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Clinical Protocols

• Screening
• Assessment
• Follow-up and Monitoring
• Evidence-based clinical guidelines
• Provider trainings
• Consultation with Specialists

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Levels of Integrated Care

• Level 1 Consultation, brief targeted
  interventions, and management in primary care
  setting
• Level 2 Time limited focused interventions in
  primary care setting
• Level 3 Referral for longer term therapeutic
  interventions with collaboration with primary
  care

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Clinician Characteristics

• Match primary care pace and style
• Respect cultural differences
• Be FLEXIBLE

• Communication skills
• Consultant skills
• Team Player
• Be visible and available
•  

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Clinician Skills

• Knowledge of Integrated Care Model
• Strong traditional clinical skills
• Bio-psycho-social model of health

• Brief, creative, and effective treatment
• Evidence-based Treatment
• Prevention and Patient Education

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Obstacles

• Lack of acceptance of model
• Paradigm shift for Medical Providers, Mental
  Health Providers, and Patients
• Practical considerations--location, finances
• Lack of training
• Resources

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Meeting Challenges

• Training Sessions for Staff
• Space
• Internal Training Programs
• Targeted Recruitment
• Financing

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Lessons Learned

• Define Mission and Philosophy of Integrated Care
  and Share with Everyone
• Administrative, Clinical, Support Staff Buy-In
• Have Champions at Every Level
• Make Change Systematic and Organized
• Continually Re-Evaluate and Respond
• View Integration as Ongoing Process

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Lessons Learned II

• Work as a Team Communicate and Coordinate
• Select Staff Carefully
• Be Creative and Innovative

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Getting Started I

• Identify Patient, Provider, Clinic Needs
• Assess readiness to change
• Understand the system (clinical, operational,
  financial)

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Getting Started II

• Behavioral provider must be on-site, highly
  visible and accessible in the medicine practice
  area
• Behavioral provider must be able to address full
  range of needs-horizontal and vertical strategies
• Behavioral and Medical providers must be
  committed to the philosophy and principles of
  integrated care

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Getting Started III

• Be realistic about time required
• Clarify details (e.G. Charting, billing,
  referrals)
• Involve ALL staff in process
• Scheduling
• Space the final frontier
• Mimic the pace of primary care

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Future Goals

• Refine and implement integrated care model based
  on clinical needs
• Prevention and Health Promotion
• Integrated care network
• Training
• Expand Telehealth Consultation