Integrating Behavioral Health and Physical Health:

1
Integrating Behavioral Health and
Physical Health

• The Time is Now

2
Introductions

• Noreen Fredrick
• Executive Director
• Mon Yough Community Services
• McKeesport, PA
• Stephen Christian-Michaels
• COO
• Family Services of Western Pa
• New Kensington, PA

3
Overview

• Health Status of People with SPMI
• Fractured System
• Models of Integration
• Chronic Care Model
• Impact Model
• Person Centered Healthcare Home
• Cherokee Model CMHC/FQHC
• Research Based Best Practice Components
• Types of Integration Initiatives
• Family Services of W. Pa Experience
• Mon Yough Experience

4
Health Status of People with Serious Mental
Health Diagnoses

• High prevalence of modifiable risk factors
• Obesity tobacco use and alcohol use
• Group homes -- exposure to infectious diseases
• -- peers negatively
  influencing unhealthy risk factors
• 60 of premature deaths in individuals with
  schizophrenia due to
• cardiovascular disease
  pulmonary infectious diseases
• Higher rates of COPD and Diabetes than in the
  general population
• Premature death - 25 years younger than the
  general population.
• Medication side effects often exacerbates health
  status

5
Health Status of People with Serious Mental
Health Diagnoses

• Hispanics, African Americans or Asian and Pacific
• Islanders have varying disparities in death
  rates
• The widest gap is seen in black males with a life
• expectancy of 69.5 years in 2004, 8.3 years
  shorter
• than the national average.
• None have a life expectancy that is equivalent to
  those with serious mental illness. 25 years..
• This disparity is alarming

6
Health Status of People with Serious Mental
Health Diagnoses

• Adults in Health Choices
• Annual increases 24 - 28 (new consumers)
• Have not previously used services
• In addition to already burgeoning caseloads
• Main Diagnoses
• 27 major depression
• 23 schizophrenia
• 15 bipolar disorder
• 15 other depressive disorders
• About 40 co-occurring
• 51 MH only
• 6 substance abuse/dependence only

7
Health System is a Fractured System

• People not identified w/depression early enough
• Post Partum Depression often not diagnosed
• 75 Anti-Depressant meds prescribed by PCPs
• PCPs often discontinue anti-depressant before
  full effect is realized

8
Community Mental Health/Primary Care Split

• Consumers not engaged with PCP
• .use Emergency
  Departments for routine care
• PCPs often feel unprepared to deal with
  behavioral health disorders
• PCPs frustrated when they refer into CMHCs
• long waiting lists, drop outs before first
  appointment/soon after
• CMHCs feel unprepared to deal with even routine
  health issues
• CMHCs busy, refer people back to PCPs for
  depression, ADD, etc
• No infrastructure readily available to enhance
  communication
• Difficult for real communication given busy
  schedules

9
What contributes to the Fractured Health System

• Billing systems are different
• Evolving EHR are usually separate w/no interfaces
• BH is carved out of managed care plans
• Referrals from PCPs tend to be to MDs they know
• Psychiatry is the lowest paid specialty of
  physicians
• Psychiatry/Therapy split off from medicine

10
Integrated Care To Be Or NOT

• Models of integration
• Separate Locations Coordinated cross referral
• Co-Location BH on site, parallel practice
• Integrated/Joint Care separate but combined
• Integrated Centers - Fiscally and Structurally
• Integrated Health Systems Kaiser HMO
• 5 Years from now in a reformed healthcare system
• there may not be a role for CMHCs that are
  not
• involved in Integrated Care

11
Characteristics of Current System

• Current care is crisis driven
• Provider centric not patient/consumer centric
• Care is episodic and reactive
• There is not a life time view of disorders
• Care tends to be more modality driven, not
• population driven

12
Chronic Care A Model to Assist in Integration

• Developed by Edward H. Wagner, MD, MPH
• MacColl Institute for Healthcare Innovation
• Organized, planned productive interactions
  improve outcomes
• More fully engage individual is in self care
  activities and
• Leads to better health outcomes.
• People w/SMI share same characteristics as
  chronic physical
• conditions
• dealing with symptoms disability
• emotional impact family issues
• complex medication regimens difficult lifestyle
  adjustments
• difficult to obtain helpful care

13
Used with permission. Wagner, E., Chronic Disease
Management What Will it Take to Improve Chronic
Care for Chronic Illnesses? Effective Clinical
Practice , Aug/Sept 1988 Vol 1
14
Essential Element of Good Chronic Illness Care
Prepared Practice Team
Informed, Activated Patient
Productive Interactions
Used with permission. Wagner, E., Chronic Disease
Management What Will it Take to Improve Chronic
Care for Chronic Illnesses? Effective Clinical
Practice , Aug/Sept 1988 Vol 1
15
What characterizes an
informed, activated patient?
They have the motivation, information, skills,
and confidence necessary to effectively make
decisions about their health and manage it.
Used with permission. Wagner, E., Chronic Disease
Management What Will it Take to Improve Chronic
Care for Chronic Illnesses? Effective Clinical
Practice , Aug/Sept 1988 Vol 1
16
What characterizes a
prepared practice team?
Prepared Practice Team
At the time of the interaction they have the
patient information, decision support, and
resources necessary to deliver high-quality
care.
Used with permission. Wagner, E., Chronic Disease
Management What Will it Take to Improve Chronic
Care for Chronic Illnesses? Effective Clinical
Practice , Aug/Sept 1988 Vol 1
17
Six Components of Chronic Care Model

• Self-Management Support individuals are
  supported in achieving goals and fully engaged in
  care.
• Delivery System Design transform practice form
  reactive to planned and proactive.
• Decision Support - care is based on evidence
  based guidelines and uses systems to inform and
  prompt providers and individuals about care needs.

18
Six Components of Chronic Care Model

• Clinical Information Systems use of registries
  to provide patient specific and population based
  support to teams, reminders, data and provider
  feedback. With the correct tools providers can
  analyze all of their consumer needs, access
  recent lab work, prescriptions filled, and
  visits.
• Community utilize resources in the community.
  This is a
• natural strength for the CMHC with
  integration existing as
• part of the community supports.
• Health System creation of a quality oriented
  system
• through leadership and continuous quality
  improvement.

19
Four Quadrant Integrated Care Model

• The NCCBH proposed model for the clinical
  integration of health and behavioral health
  services starts with a description of the
  populations to be served.
• Quadrant I Low MH - Low PH, served in
  primary care
• 
  BH staff on-site provides services
  
• Quadrant II High MH - Low PH, served in the
  MH system
• 
  PH service provided at CMHC
• Quadrant III Low MH - High PH, served in
  primary care
• 
  BH staff on-site provide services
• 
  PH case mgt provided
• Quadrant IV High MH - High PH, served in MH
  system with
• 
  specialty care case management
• 
  for both PH and BH disorders
• 
  
• National Council for Community Behavioral
  Healthcare

20
The Person-Centered Healthcare Home

• Stepped care clinical approach
• Healthcare implemented bi-directionally
• Identify people in primary care with behavioral
  health conditions ands serve them there unless
  they need stepped specialty behavioral health
  care and
• B Identify and serve people in behavioral health
  care that need routine primary care and step them
  to full-scope health care home for more complex
  care

www.TheNationalCouncil.org/ResourceCenter
21
Impact Model - Depression

• Collaborative care individual PCPs works with
  BH care manager/behavioral health consultant to
  implement a treatment plan with consultation with
  the psychiatrist and pharmacist
• Depression Screen of all Patients in Medical
  Practice
• Motivational Interviewing, Behavioral Activation
  and Problem Solving Therapy
• Goal is to make incremental changes in life style
  practices
• Medication prescribed by PCP
• Health registry used to
• Prompts follow-up sessions, outreach, staged
  interventions
• Collects medical and behavioral health data
• Tracks changes, outcomes

22
Cherokee Model

• Fully integrated structurally and financially
• Combined Services
• Community Mental Health Center
• Federally Qualified Health Center
• National Council for Community Behavioral Health
  Care

23
Federally Qualified Health CentersPossible
Structures

• FQHC and CMHC merged to one organization
• Federally Qualified Health Centers provides its
  own BH services via its own staff integrated
  team
• Funding from one stream, One EHR
• Federally Qualified Health Centers with
  contracted CMHC services integrated
• CMHC co-locates staff at FQHC and provides BH
  services in a parallel practiceone stop shop

24
Research Based Best Practice Components

• Regular screens registry tracking/outcome
  measurement
• Medical nurse practitioners/PCP located in BH
  clinic
• Primary care supervising MD
• Embedded RN care manager
• Evidenced based practices to improve health of
  SMI pop.
• Wellness programs
• National Council of Community Behavioral Health
  Care

25
Integration Initiatives

• Screening of Depression for all PCP patients
  (PHQ-9)
• Screening for Unhealthy Substance Use (SBIRT)
• Screening of Post Partum Depression OB and
• 
  Pediatricians
• Depression Screening, Motivational Interviewing,
  Behavioral Activation, Problem Solving Therapy
  (IMPACT)
• Medical Services provided in MH Centers

26
Challenges

• We need to be part of putting the mind and body
  back together
• Healthcare reform is going to drive more focus on
  integration

27
Family Services Experience

• Co-location
• Integrated Care, BH service at Medical Clinic
• Proposed Medical Services at CMHC

28
Family Services Co-Location

• MD Frustration at long waiting time to see
  Psychiatrist
• MH CRNP at Family Practice office in New
  Kensington
• 
  (UPMC)
• Started at ½ day/week, moved to two half days per
  week
• 50 75 new clients seen per year
• Moderate Depression, often linked to MH Clinic
• Very little collaborative care
• Some phone consultation between MD and
  Psychiatrist

29
Family Services Integrated Care at Medical
Clinic

• Partnership matured
• Agreed to seek out funding to move to integrated
  care
• Together support regional Integrated Care Summit
  mtg
• Family Practice-UPMC started screening for
  Depression
• Applied for several grants, not funded
• Approached Managed Care Company
• Managed Care Health/BH funded project/collect
  data

30
Family Services Integrated Care at Medical
Clinic

• Foundation sought out partnership along with 3
  other sites
• Goals
• Establish communication policies between medical
  BH Providers
• Increase the appropriate assessment utilization
  of BH services
• Decrease
• Emergency Department usage
• hospital admissions
• Re-admissions
• Hospital length of stays
• Assure that BH provider is a financially viable
  position

31
Family Services Integrated Care at Medical
Clinic

• IMPACT/Depression Screening
• SBIRT/Unhealthy Substance Use Screening
• Engagement/Behavioral Activation/Problem Solving
  Treatment
• Grant fund position for 18 months
• Goal Demonstrate ability to reduce by 6
  inpatient hospital admits
• Pgh Regional Healthcare Initiative provides
  consult/project mgt
• University of Washington/IMPACT provides
• Training
• Consultation
• Health Registry

32
Family ServicesMedical Services at CMHC

• SAMHSA Proposal
• Family Practice staff contracted to provide
  medical services
• MD, Nurse Practitioner and Nurse become part of
  MH Teams
• Build a physical fitness center at CMHC
• Peer support used to engage consumers in healthy
  lifestyles
• Build EHR Interfaces to share summary notes
• Build Health Registry into BH EHR to implement
  Chronic
• 
  Care Model
• Change physical layout of office for (4)
  interdisciplinary teams
• Services
• Health Screening, Nutrition Counseling, Fitness
  Groups
• Health Improvement plans,
  Consultation, Care Mgt

33
Mon Yough ExperienceSAMHSA Grant Emerg Dept
Diversion

• Partners
• UPMC for Life
• UPMC McKeesport Hospital
• Latterman Family Health clinic
• UPMC McKeesport Internal medicine
• MYCS
• Goal
• Decrease Emergency Department usage
• Determined Access as the issue
• Increased midlevel practitioner time at Latterman
  and MYCS as we agreed that we all serve the same
  group of clients

34
Mon YoughEvolution of the Partnership

• Grant led to beginning of partnership model
  between Latterman Family health and MYCS.
• CRNP .5 FTE located in Behavioral health clinic
• Primary care supervising physician
• Imbed Psych rehab in clinic setting to promote
  wellness as core goals and work with nursing
  staff to structure wellness activities
• Next Steps
• Create registry tracking
• Embed evidenced based practice in daily practice

35
Mon YoughChronic Care Model ? CMHC

• Development of a chronic care team within adult
  Outpatient clinic
• Co-locate treatment psych rehab, supported
  employment and service coordinator in one area
• PH and BH team live in the same building

36
Mon YoughPerinatal Depression Project

• Rand project targeting perinatal depressed Moms
  in a variety of settings including OB clinic
  pediatricians
• MYCS partnered with Magee in Clairton
• Behavioral health time provided on site
• Lessons learned
• Helped with imbedding of BH case manager in
  Latterman clinic to assess need /level of support
  and type of integration
• Next Step use existing SHIP infrastructure to
  create collaboration among community suing logic
  model approach

37
Mon YoughTraining the Work Force

• Latterman Clinic is a Family Practice education
  site.
• MYCS will serve as the rotation site for dual
  boarded Family Practice/Psych Fellowship 4 hours
  a week
• Latterman Clinic
• Provide physical health care in MYCS clinic
• Provide supervision of primary care at MYCS
  clinic
• MYCS will serve as the psych rotation education
  site for Family Practice Residents

38
Learning Collaborative

• Set up learning collaboratives
• Use consultants to help cross walk systems
• Share information across projects
• Examples
• Collaborative learning across BH and PH
• Collaborative learning across CMHCs
• List Serves on Integrated Care
• Regional Learning Collaboratives

39
Resources

• Wagner, E., Chronic Disease Management What
  Will it Take to Improve Chronic Care for Chronic
  Illnesses Effective Clinical Practice, Aug/Sept
  1988 Vol. 1
• National Council of Community Behavioral Health
  Care. Winter 2009. A Two-Way Street Behavioral
  Health Care and Primary Care Collaboration.
• Morbidity and Mortality in People with Serious
  Mental Illness, National Association of State
  mental Health program Directors, Medical
  Directors Council Editors parks, Svendson,
  Singer, Foti, Technical Writer B Mauer. October
  2006 Report available at www.namsmhpd.org
• List Serve
• http//lists101.his.com/mailman/listinf
  o/pc-bh-integration

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Contact Information

• Noreen Fredrick
• fredricknm_at_mycs.org
• [phone]
• Stephen Christian-Michaels
• christian-michaelss_at_fswp.org
• [phone] x438