Wendy Bradley, LPC

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Nuka Model of Care
BHC Integration

• Wendy Bradley, LPC

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Objectives

• To understand how we integrated Behavioral Health
  Consultants into our Primary Care system at SCF
• To understand the challenges we faced with BHC
  integration into Primary Care
• To understand how this model might be applied to
  other organizations

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Mission and Vision

• Mission
• Working together with the Native Community to
  achieve wellness through health and related
  services.
• Vision
• A Native Community that enjoys physical, mental,
  emotional and spiritual wellness.

Katherine Gottlieb, MBAPresident and CEO
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Key Points
Shared Responsibility We value working together
with the individual, the family, and the
community. We strive to honor the dignity of
every individual. We see the journey to wellness
being traveled in shared responsibility and
partnership with those for whom we provide
services.
Commitment to Quality We strive to provide the
best services for the Native community. We employ
fully qualified staff in all positions and we
commit ourselves to recruiting and training
Native staff to meet this need. We structure our
organization to optimize the skills and
contributions of our staff.
Family Wellness We value the family as the heart
of the Native community. We work to promote
wellness that goes beyond absence of illness and
prevention of disease. We encourage physical,
mental, social, spiritual, and economic wellness
in the individual, the family, the community, and
the world in which we live.
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Operational Principles

• R E L A T I O N S H I P S

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Why We Integrated Behavioral Health in FMC and
Peds

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

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Background

• Our first attempt at integration failed
• One integrated behaviorist in Pediatrics only
• We were co-located, not integrated
• We needed to identify the best fit for staffing
  the BHC position
• Benchmarking best practices
• Cherokee Health System, Knoxville TN
• SCF Leadership, Providers, BH staff visited

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Background

• Treated the BHC integration as an improvement
  project
• Annual plan with measurement and due dates
• Multi-disciplinary team
• Worked with a consultant from Cherokee Health
  System

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Challenges

• Acceptance and understanding within the
  Behavioral Health Community
• Acceptance by Primary Care Providers
• Space
• Recruiting
• Funding
• Data

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Models of Integration

• Diversification BHC is a active member of the
  Integrated Care Team
• Co-location Behavioral Health Professional
  located on site providing traditional behavioral
  health services
• Referral Behavioral health services provided by
  contracted agency
• Enhancement train primary care providers to
  provide behavioral health services

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A Framework to Integrated Care

• Behavioral Health is ROUTINE component of medical
  care (charts are integrated)
• Shifting Boundaries of Care
• Location
• Staffing
• Scope of Integration
• Horizontal
• Vertical

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Clinician Skills

• Knowledge of Integrated Care Model
• Strong diagnostic and therapeutic skills
• Prevention and Patient Ed
• Brief Solution-Focused Treatment

• Motivational Interviewing
• Communication consultant skills
• Team player, visible, flexible, available
• Masters Level, ANP, or Ph.D/Psy.D
• Primary Care Mental Health

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Recruiting BHCs

• Fit is everything
• Not every Behavioral Health professional is cut
  out to be a BHC
• Characteristics of successful BHCs

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Training Medical Staff

• Screeners
• Introductions
• General Behavioral Health Info
• Use in prevention

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Behavioral Health Staff

• Population based vs. individual
• Generalist vs. Specialty
• Therapy vs. Therapeutic
• Primary customer is primary care team

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Key PointsTraditional vs. Integrated Model

• Traditional
• Separate offices
• Separate notes
• Comprehensive BH documentation
• Emphasis on history
• 50 minute therapy session
• Referral to specialty care for BH issues

• Integrated
• Co-located in offices
• Seen in exam room
• Same chart
• Brief documentation
• Focus on presenting problem
• 20-30 minute interaction
• Consultation and co-management

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Funding

• Flat Rate with medical providers
• Grants (SBIRT)
• Costs savings
• Working with State for follow ups and stand alone
  visits

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What We Do

• Consultation and education to providers and case
  managers on behavioral health issues
• Provide psycho-educational materials and
  workbooks to aid in treatment and understanding
• Acute Care for psychological issues
• Screening, assessment, brief intervention,
  education and follow-up/monitoring for patients
  experiencing mental/medical health issues and
  life stresses
• Joint visits and care conferences with provider
  teams for complex cases
• Consultation with specialists, referral for
  longer term therapeutic interventions

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What We Do

• Assess depression using the Prime MD
• Assess substance abuse using the AUDIT
• Assess cognitive function using the Cognistat
• Assess child development using the ASQ and M/CHAT
• Assess behavioral functioning for chronic pain

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Benefits

• Redirects mental health related office visits and
  provides access to appropriate services
• Frees providers time and resources to allow for
  more efficient use of limited appointment time
• Provides customers with a more comprehensive
  evaluation of symptoms and issues
• Offers providers an in-clinic specialty resource
  for challenging cases
• Customers have immediate access to BHC and follow
  up same day access
• Team approach to care

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Success Data

• customers with gt 6 Visit utilization in 6
  months has decreased since BHC Integration
• -ER 4600 to 3900, UC 5600 to 4600
• -FMC 37,200 to 33,500, Peds 10,100 to 6,200
• 77 Primary Care Clinic staff reported increased
  efficiency
• 88 Primary Care Clinic staff are more satisfied
  with their job since BHC Integration
• 91 increase in access to Behavioral Health
  Service
• 3221 visits in first quarter of 2009

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Next Steps

• Develop BHC track/internship in local university
• Working with state on Medicaid billing
• Increasing local programs for developmental
  delays
• Chronic Pain initiative
• Preconception to age 5

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Getting Started Exercise

• Work with your table to complete the work sheet
  on BHC integration

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Questions?
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Quyana (Central
Yup'ik) Maasee' (Tanana Athabaskan)
Ana-ba-see (Koyukon Athabaskan) Quyanaq
(Inupiaq) Gunalche'esh
(Tlingit) Ha'w'aa
(Haida)Qagaasakung
(Aleut) Thank You!