Integrated Care Challenges in a Public Health Setting

1
Integrated Care Challenges in a Public Health
Setting

• Collaborative Family Healthcare Association
• 10th Annual Conference
• Denver, CO Nov.
  7, 2008
• Ashley Lester, LCSW Stephen Snow, PhD, LPC
• Integrated Care Clinicians
• Buncombe County Health Center
• RHA Health Services, Inc.
• Asheville, N.C. 28801

2
Introductions

• Ashley
• LCSW, University of Denver, 1996
• Integrated Care, RHA/BCHC Primary Care Clinic
• Bilingual (Spanish/English) Therapist
• Certified Yoga Teacher
• Steve
• PhD, Counseling, UNC Charlotte, 2005
• Private practice (family violence/complex trauma)
• Integrated Care, RHA/BCHC Primary Care Clinic
• Executive Director, CFHA
• Previous careers journalism, telecommunications

3
Overview

• Introduction
• Overview of BCHCs population
• Integrated care interventions
• Challenges and creative responses
• Case examples
• Final comments and questions
• Resources

4
Buncombe County Health Center

• 36,000-40,000 patient visits annually
• 12 medical clinicians
• 3 integrated care clinicians
• Safety net for indigent care in Buncombe County,
  (150,000 people)
• 1 of 2 primary care clinics out of 100 Health
  Departments in NC (county funded)
• 4 clinics APC, CPC, FP, PNC

5
Our Beginnings

• Duke Depression Grant
• 5 full time integrated care clinicians
• Budget cuts, county contracted out positions

6
RHA Health Services, Inc.

• RHA Behavioral health established in 1995
  not-for-profit company serving people with mental
  illness, substance abuse, and developmental
  disabilities.
• RHA Health Services and RHA Howells provide
  residential, vocational, and educational programs
  for more than 1500 infants, children,
  adolescents, and adults in North Carolina and
  Tennessee
• More than 700 employees deliver a wide variety of
  care, from community support to intensive in-home
  and crisis management.
• 200 million in revenue 23 million in free
  services

7
Clinic Population

• 13 latino (adult) 54 latino (child)
• Latino population has increased 210 in past 10
  years
• .01 Ukrainian/Russian speaking
• .002 Other languages
• 11 African American
• 76.9 Caucasian

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Public Health Population

• Largely indigent, some homeless, little money,
  little education, disorganized, chaotic lives
• 53 Uninsured
• 38 Medicaid
• 5 Medicare
• 4 Private insurance

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Low-Income Patients

• Living in poverty is a health risk. The stresses
  of the lives of people in poverty take a greater
  toll on their bodies than is true for people with
  adequate financial resources.
• Low-income and underserved populations are less
  likely than the general public to accept a mental
  health definition of their problem. If they do
  accept a referral for mental health services,
  they have much greater difficulty with travel and
  scheduling.

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Low-Income Patients

• Garrison, et. al., (1992), in a study in
  Springfield, MA, found that while low income
  patients have higher levels of psychosocial
  needs, medical providers are less likely to
  address psychosocial needs in this population
  than in more affluent populations.
• Lower institutional trust, clinicians lack of
  assertive treatment.
• Physicians were more likely to try to deal with
  parents concerns if the payment type was
  anything except Medicaid and more likely to try
  to refer Medicaid patients to specialty mental
  health services.
• Garrison, W., Bailey, E., Garb, J. Ecker, B.
  (1992). Interactions between parents and
  pediatric primary care physicians about
  children's mental health.  Hospital Community
  Psychiatry 43 489-493.

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Clinic Population

• Most common issues presented
• Fatigue, headaches, insomnia, chronic pain, etc.
• Translates into
• Depression
• Anxiety/panic
• PTSD
• Substance Abuse
• Complex trauma
• Unresolved grief
• Physical / sexual trauma
• Bipolar disorder
• Personality disorder
• Somaticized disorders

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Integrated Care Interventions

• Triage
• Short-term therapy
• Telephone counseling
• Clinical case management
• Psychiatric consultation
• Follow up clinic visits
• Groups

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Triage

• When medical clinician suspects mental health
  issue, therapist is paged.
• Assessment
• time avg. 20 minutes
• BHQ
• Differential diagnosis
• Risk for self-harm or harm to others
• Motivational interviewing, stages of change,
  psychoeducation
• Referral out or follow-up with integrated care
  clinician
• Ruling out resources
• Eligibility for specialty mental health system
• Advocacy
• Concrete needs
• Challenge NC Mental Health Reform

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September 2008 Triages

• Unduplicated PT Count 170
• Total of PT Visits 362
• Total of Triages 101
• Total hours in Svc. Del. 250.2 (15,025 minutes
  in direct contact)
• Average Productivity 78.3

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2007-2008 Contacts
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Behavioral Health Questionnaire (BHQ)

• One-page, two-sided brief assessment
  questionnaire.
• PHQ-9
• Nine weighted questions, including SI/HI
• CAGE
• Four-question Substance Abuse measure
• Bipolar questions
• Mania, irritability, problems because of periods
  of hyper-alertness
• Anxiety questions
• General immediate symptoms
• Domestic/family violence questions
• HITS screening

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Options After Triage

• Short-term therapy (_at_ 8 sessions/mtgs.)
• Telephone counseling
• Clinical case management
• Psychiatric consultation
• Follow up clinic visits
• Groups

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Institutional Challenges

• North Carolina mental health reform in chaos
• Rising numbers of uninsured adds stress to system
• Lack of therapy guidelines (evidence-based)
• Legal barriers to communication among providers
• Organizational and professional culture
  differences between PC and BH
• Clinical and fiscal separation of physical and
  mental health care
• -- adapted from presentation in 2006 by Susan
  Mims, Buncombe County Medical Director

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With Challenges, Creative Responses

• Psychiatric consultation
• Groups specifically stress reduction
• Close professional relationships w/ therapists in
  private practice
• Connections in community w/ Spanish speaking
  providers
• Education for clinicians
• Do not bill

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Examples/Cases

• S.T. Chronically depressed woman in acrimonious
  custody battle
• J.H. Depressed man with chronic illnesses
  (depression, COPD, diabetes)
• S.H. Woman with trauma, anxiety, depression and
  unresolved grief
• R.H. Chronic, depression, advanced Hep C

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Final Comments

• This model has some significant benefits,
  especially creative flexibility.
• This model also has some significant limitations,
  including limited referral options.
• All in all, the model is additive and still
  developing.

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A Few Resources

• Books
• Blount, A. (1998). Integrated primary care The
  future of medical and mental health
  collaboration. Norton New York
• Gatchel, R Oordt, M. (2003). Clinical health
  psychology and primary care Practical advice and
  clinical guidance for successful collaboration
  American Psychological Association Washington,
  D.C.
• Web sites
• http//www.cfha.net
• http//www.integratedprimarycare.com/
• http//www.primarycareshrink.com
• http//www.mahec.net/ic/
• http//www.thenationalcouncil.org/

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A Few More Resources

• www.depression-primarycare.org The MacArther
  Foundation
• Institute for Healthcare Improvement (IHI)
  www.ihi.org/collaboratives
• RWJ Project Depression in Primary Care
  www.wpic.pitt.edu/dppc
• National Council for Community Behavioral
  Heathcare www.nccbh.org/html/learn/primary.htm
• Developmental Behavioral Pediatrics Online
  www.dbpeds.org
• http//cartesiansolutions.com ( Financial
  information)
• http//www.parc.net.au
• http//www.shared-care.ca
• http//www.behavioral-health-integration.com/news.
  php
• http//www.shepscenter.unc.edu/index.html
• http//www.icarenc.org/

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The End

• Thanks for listening. For a free copy of this
  presentation
• CFHA Members http//www.cfha.org
• Non-members
• http//www.commcure.com/cfha1108.ppt
• Please provide credit for any material you use.
  For more information on this and other trainings,
  workshops and consultations, please go to
  www.commcure.com.
• Contact us at
• Ashley ashley.lester_at_buncombecounty.org
  828-250-5340
• Steve ssnow_at_rhanet.org 828-250-5254