Extreme Integrated Care

1
Extreme Collaboration
Total Integration of Behavioral Clinicians into
Primary Care Practice
2
Current State of our Fragmented Healthcare System

• Hello, uh my name is --------, and Im calling
  for my son. Uh, he has bipolar schizo, and
  uhuhhe hasnt had no medications for a long
  time because they dont wanna give him any
  medications because he doesnt have uh Medicare.
  We tried to get Medicare and they didnt wanna
  give it to him and Im really really real real
  worried about him. Im his mother. He has uh
  really been um depressed depressed and Im
  really afraid for him. I would really appreciate
  it if you would give me a call because I need to
  see somebody. The doctor here in the wont be
  back til May but we cant really wait that long.
  I would just appreciate so much if you could
  give me a call. Its very important. I would
  appreciate a call. We need to see you as soon as
  possible. Please help us. Thank you.

3
L.C., a 36-year-old divorced mother of three
and kindergarten teacher was at the end of her
rope, financially and emotionally, when she made
the wrenching decision to hand over her son.
L.C.s husband left her alone with three
children, including an older bipolar daughter and
a 12-year-old boy who is doing well. But her
11-year-old son, Skylar, is bipolar, abusive and
violent, she said, and after three years of
spotty, expensive and ineffective psychiatric
care she could see no other way to get him the
intensive help he needs. L.C. said that her son
had received psychiatric care off and on, with
limited coverage by her insurance plan, but that
he often refused to take prescribed medications.
When he refused to go to school, she could not
afford a sitter and did not know where to turn.
Good luck finding a counselor theyre all
filled up, she said. You call a psychiatrist
and have to wait three months for an
appointment. Once during a snowstorm, she said,
after she drove 25 miles to pick up the boys at
school, then 45 miles to a psychiatric
appointment, she arrived 15 minutes late. They
said wed have to make a new appointment for six
weeks later, she said. - NY Times, November 22,
2008
4
Every system is perfectly designed to get the
results that it gets.

• - Dr Paul Batalden, Dartmouth University

5
What is the current system designed for?

• Obstacles to care
• Health disparities
• Poor health outcomes
• Frustration
• Failure

6
What do we know?

• Mental health cant be separated from physical
  health
• People get their health care in primary care
  offices
• Mental health disorders are under recognized
• Most people wont go to a mental health center

7
What else do we know?

• Access to mental health professionals is
  difficult at best
• particularly for uninsured and underinsured
  populations
• People complain of symptoms
• But providers are obsessed with diagnoses
• Traditional approaches to mental health have
  failed at the population level

8
The Pyramid of Psychosocial Problems in Primary
Care
9
Level I Acute psychiatric emergencies
10
Level I Acute psychiatric emergencies
Level II Chronic severe psychiatric illness
11
Level I Acute psychiatric emergencies
Level II Chronic severe psychiatric illness
Level III Chronic less severe conditions
12
Level I Acute psychiatric emergencies
Level II Chronic severe psychiatric illness
Level III Chronic less severe conditions
Level IV Temporary psychosocial problem
13
Level I Acute psychiatric emergencies
Level II Chronic severe psychiatric illness
Level III Chronic less severe conditions
Level IV Temporary psychosocial problem
Level V Everybody else
14
Salud Family Health Centers
15
Salud Family Health Centers

• Migrant/community health center
• Full range of primary care services including
  obstetrical care
• Full dental services in all clinics
• Mobile unit
• 70,000 unduplicated patients

16
Salud Integrated Care Model

• BHP office in medical exam room space
• BHP spends 70 of time doing screening, brief
  interventions, f/u phone calls, etc
• 30 of time in more traditional therapy
• Solution focused
• Limited number of visits
• Referral as necessary
• Frequent and ongoing consultations among docs and
  BHPs

17
Salud Integrated Care Model

• Population based
• We want to reach EVERY patient
• Real time interventions
• Most patients can see therapist today
• Emphasis on horizontal integration not vertical
  integration
• Casts a wide net in determining need for
  psychosocial intervention
• Broad evaluative measures

18
Requirements for Total Integration

• Co-location
• Universal screening
• Brief interventions
• Solution focused therapy
• BHPs as primary care providers
• BHP adaptation
• Physician adaptation

19
Co-Location

• Co-location means co-location
• Sharing the same space at the same time
• Integrated care means integrated facilities
• Regardless of problem, all patients go in and out
  the same door

20
Universal Screening

• Most mental health disorders are occult
• Most visits to primary care providers have a
  large psychosocial component
• Primary care docs do a relatively bad job of
  uncovering mental health issues
• Most poor health outcomes are related to behavior
  issues

21
Universal Screening

• Screening is screening
• NOT diagnosis
• Screening forms should be straightforward and
  simple
• Positive screens can be followed up with more
  sophisticated and comprehensive evaluation tools
• I recommend face-to-face screening

22
Brief Interventions

• Psychoeducational triage interventions
• 5-15 minutes max
• In the exam rooms
• Goes hand-in-hand with screening
• Requires BHP to work within the chaos of the
  primary care office

23
BHP Adaptation

• Traditional mental health office
• No interruptions
• All apptmts made in advance
• Quiet controlled environment
• Typical primary care office
• Lots of interruptions
• Many walk-in apptmts
• Controlled (barely) chaos

24
Solution Focused Brief Therapy

• Resource activation, not problem activation
• Has an endpoint
• Allows flow of patients in and out of the BHP
  schedule
• More complex patients may need to be referred out
• PCPs dont provide subspecialty care
• This is a primary care model

25
BHPs are Primary Care Providers

• NOT ancillary staff
• If the patient is seeing the BHP, the patient is
  being seen
• BHP assessment is as important as physician
  assessment
• Patients will often identify the BHP as their PCP

26
Requires Broad Training

• LOTS of different duties
• Psychotherapy
• Social work
• Case management
• Other

27
BHP Adaptation

• Your training model may not apply
• Office environment is different
• How patients gain access is different
• Concept of confidentiality is different
• Process orientation vs goal orientation
• Visits are different

28
How do patients gain access to BHP?

• Screening
• Direct appointment
• Referral from provider
• Patient request at medical visit

29
DocBHP Ratio

• ?

30
Resistance

• From BHPs
• I cant just walk in on a patient
• I like to spend more time with patients
• I like to get deep into my patients psyche
• I dont like all the interruptions
• This isnt the way I was trained

31
Resistance

• From medical providers
• Im the captain of the ship
• I dont like other people seeing my patients
• The BHP slows me down
• Im really good at psych stuff and I dont need
  help
• This isnt the way I was trained

32
What do patients think?

• NO resistance
• Accepted part of total care package at Salud
• Seen as value added service

33
Funding
34
Salud Integrated Care Funding Models

• Mental Health Expansion grant from govt
• Partnership with local health district
• Partnership with local mental health center
• Commitment of general primary care funds
• Patient billing

35
Other Funding Possibilities

• Patient billing
• Not likely to work for brief visits
• Could cover 30 of salary
• Subsidies
• Docs benefit from integrated practice
• Communities benefit from integrated practice
• Managed care contracts
• Patients (and therefore insurance companies?)
  benefit from integrated practice
• Medical home may require it

36
Caveats

• You cant manage everything
• We dont do heart surgery in primary care either
• We know how to make referrals to specialists if
  necessary
• Costs are incurred and savings are accrued in
  different places

37
Next Steps

• Outcomes research
• Medical parameters as evidence of effectiveness
  of mental health interventions
• Fewer ER visits, more clinic capacity, fewer lost
  days of work, etc, etc, etc
• Policy changes

38
?
39
(No Transcript)