Development of Integrated Care: Collaboration of Healthcare, FBOs and CBOs

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Development of Integrated CareCollaboration of
Healthcare, FBOs and CBOs

• Rick McNeese, Ph.D.First Step Recovery and
  Wellness Center

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Issues Covered

• Focus on collaboration in health care
• Terminology Same but different!
• First Steps integrated care model
• Working with various professional cultures
• The business side
• Barriers to integration

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Acknowledgments

• Denny Berens, Coordinator, DHSS Office of Rural
  Health
• Nebraska Medical Association
• Nebraska Psychological Association
• First Step Staff
• First Step Integrated Care Work Group

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Background

• NWU, B.S. in Biopsychology, 1971
• TCU, M.S. and Ph.D. in Psychology, 1975 and 1976
• SHSU Psychology Faculty, Assistant and Associate
  Professor, 1976 -1985
• LMEF Family Practice Program, 1985-1998
• First Step 1998-Present

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Professional themes

• Multidisciplinary studies
• Researching collaboration and integration models
• Making psychology useful

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Key professional experiences

• Lincoln Medical Education Foundations (LMEF)
  Family Practice Program
• Integration of Mental Health and Family Practice
  training and treatment
• Exposure to the culture of Family Practice
• Relationships with 100 M.D.s across Nebraska

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Case 1

• 22 y/o male from small town
• Depressed with recent breakup
• Also recent of deaths of his only two siblings
• Drinking beyond moderation
• What would MH or SA or Pastor or M.D. do?

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First Step Recovery and Wellness Center

• Multidisciplinary Treatment Center
• Mental Health
• Substance Abuse
• Compulsive Gambling
• Biofeedback and Neurofeedback
• Eating Disorders

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Case 2

• Lay leader of congregation
• Providing support for a 47 y/o male
• Alcohol dependent
• Depressed
• What do you do?

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Comments about collaboration

• This is difficult work and not for the weak of
  heart
• Be ready to Grope, Growl, Grasp and Grow
• Also very gratifying because integrated care
  works
• Different way to work, not just more people
  working together

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Case 3

• Mental health counselor
• 35 y/o male
• Diagnosed Bipolar Disorder
• What do you do?

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Why Collaborate or Integrate? The Simple Truth.

• Studies show that
• If PCP adds BHP to treatment of depression,
  success doubles from 45 to 90
• If BHP adds PCP to treatment of alcoholism,
  abstinence triples at 12 month follow up
• First Step Integrated Care Screen data

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However, there is an important barrier to
integration

• We operate on a Guild Model
• We work in our silos created by licensing laws

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Guild model

• Works on principle of exclusion
• Whereas integration is a complex social cause
  requiring many participants
• And guilds are how professionals protect their
  license and make a living!!
• This will be a very real barrier to change

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Case 4

• Family Physician
• 45 y/o male
• 75 overweight
• Sleep apnea
• Depressed
• Heavy smoker 1.5 2 ppd
• Stroke in 1996 resulting in full disability

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Lesson of the Tower of Babel

• When language fails, human communication and
  cooperation are impossible.
• We speak the world into being.
• Our language creates our reality.
• This workshop is about learning the language of
  collaboration and integration

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And in rural state like Nebraska,

• We can lead the nation with integration
• We are large enough to have the problems
• Yet small enough to have the relationships that
  will make this work
• Nebraska can become the nations laboratory

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Terms

• Mental Health
• Alcohol and Drug Abuse or Dependence
• Behavioral Health
• Behavioral Health Providers (BHPs)
• MH SA Counselors
• Primary Care Providers (PCPs)
• F.P.s, Peds, OB/Gyn, Internists
• P.A.s, N.P.s, etc

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George Carlin would love it!

• Integration doesnt mean Integration
• You can Collaborate and not Integrate
• Treating the Family doesnt mean Treating the
  Family
• Evidence based is not collecting evidence

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Workshop Objectives Why, What, How and Now

• Why?
• Federal support of Integrated Care
• Carve outs to Carve ins
• What?
• Collaborative and Integrated Care
• Essential features
• Screening data and treatment implications
• How?

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Why?

• Mural dyslexia
• The inability to see the handwriting on the wall!
• Changes in health care are imminent

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Why? Review Federal support of Integrated Care
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Ensuring the Supply of Mental and Behavioral
Health Services and Providers Summit

• Meeting in Des Moines, IA, September, 2000
• Substance Abuse and Mental Health Services
  Administration (SAMHSA)
• Health Resources and Services Administration
  (HRSA)
• Bureau of Primary Health Care (BPHC)
• National Health Service Corp (NHSC)
• Group of representatives from Nebraska attended
  this Midwestern assembly of states

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U.S. Surgeon Generals Report, 1999

• David Satcher, M.D., Ph.D.
• Goal Interdisciplinary approach to achieve 100
  access and eliminate disparities by the year 2010
• Commitment to partnering with communities to
  build a comprehensive primary care system that
  includes mental health, behavioral health, and
  substance abuse services.
• First recognition of mental health and substance
  abuse as priority health concern

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Nebraskas physicians need

• Quick access to reimbursable, trained BHPs
• Quick access to psychiatrists in ER or hospital
• Simplified access to multidisciplinary services
• Increased care for specific populations and
  problems
• Improved reimbursement for behavioral health
• Resource directory
• Programs for uninsured patients

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FBOs and CBOs should look at these needs to
develop a niche

• Recruit and retain BHPs
• Telehealth support
• Support multidisciplinary teams
• Help with underserved populations
• Community Resource Directories
• Help with uninsured patients

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Case 5

• Substance abuse counselor
• 34 y/o recently divorced male
• Alcohol dependent
• Insomnia
• Extreme anxiety
• Prevents participation in community support group

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Carve outs to Carve ins Charles Kiesler,
American Psychologist, 2000

• 75 now under MCO but 88 Carved out
• 46 of disabled have three or more coexisting
  chronic problems
• Treating coexisting problems in segregated
  systems is costly
• E.g., In case of dual disorders, SA counselor has
  little or no access to PCP or Psychiatrist

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Carve outs to Carve ins Charles Kiesler,
American Psychologist, 2000

• Three revolutions in American health care
• Expansion (1940s-60s), Cost containment
  (1960s-90s)
• Era of assessment and accountability
• Therefore, movement toward evidenced-based
  treatments
• Who adds value to treatment effectiveness?
• This will influence system design and access
• Reducing inappropriate care is one way to reduce
  costs

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Why now? Economic reasons

• Many studies show cost reductions or offsets
  between 20-40
• 57 controlled studies show 27 cost savings after
  costs of BHP are subtracted
• People will drop out of all systems except
  medical system as shown by results of closing
  CMHCs
• Distressed are high utilizers of more expensive
  medical care
• Untreated depressed patient uses 2-3 times annual
  medical services

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However

• MDs cannot refer all patients
• Between 50 and 90 of referrals across town do
  not make it to BHP
• Patients need to feel that they came to the RIGHT
  PLACE

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Economic reasons

• Health care costs cannot be contained in
  segregated systems
• Eg., consider all the services a dysfunctional
  CD or MH family can utilize
• Mother sees PCP for headaches
• Adolescent seen by MHP
• Father seen by GI specialist for GI bleeding
• Fathers alcoholism is undetected and untreated

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Economic reasons

• Financial risks now being shifted to consumer and
  providers
• Distressed people are high utilizers of medical
  care
• Nebraska law permits insurance companies to deny
  charges for self-inflicted injuries. Already
  distressed patient just got worse!
• 70 of medical visits are driven by psychosocial
  factors.Name that Pain Game

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Case 6

• Priest consulted by family
• 23 y/o female
• Bulimia

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Why now? The Evolution of Primary Care Medicine

• Family Physicians have been trained and now
  expect it
• Family Practice lead the way (1976) in creating
  collaboration in training
• By the way, there are no longer GPs
• Primary care includes family practice,
  pediatrics, internal medicine, and
  obstetrics/gynecology
• These are the front line medical specialties
  (Common things are common)

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PCPs are the defacto mental health providers in
U.S.

• They treat 50-70 of BH problems
• Prescribe 70-88 of the psychotropic medications
• 10-15 of PCP patients are for behavioral health

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Case 7

• Counselor
• 44 y/o female
• Referred by employer
• Vague history and uncertain reason for referral

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The experts say

• Alexander Blount, Introduction to Integrated
  Primary Care
• Kirk Strosahl, Integrating Behavioral Health and
  Primary Care Services
• James Bray, Collaboration with Primary Care
  Physicians

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Blount

• Patients come with undifferentiated problems
• 20 of visits have discoverable organic causes
• 10 of visits are clearly psychological
• Therefore 70 or vast majority have both elements
• 10 most common complaints account for 40 of
  visits
• But after 1 year, only 10-15 of these had
  organic basis
• Depression is 2nd most disabling condition (COPD
  with limited ADLs)

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Better fit gives better outcomes

• 44 of patients prescribed antidepressant stopped
  prescription in three months
• Integrated treatment - 74 reduction in symptoms
  if outside referral
• Adding BHP to PCP in treatment of depression
  doubles success from 45 to 90
• Adding PCP to CD treatment triples abstinence at
  12 months!

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Limits to what physicians can do

• MDs, even if trained, cannot treat all the
  problems
• Workpace is too fast (Capacity 30-40/day based
  on 15 min visit)
• No one can be expected to master all the
  desirable skills
• Treatment by MDs too expensive
• MDs fear opening a can of worms

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Also a limit to what clergy can do

• Parallels between problems of rurally located
  medical professionals and clergy.

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What is Collaborative and Integrated Care
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Integrated Care is not a new concept

• Family Practice as specialty of breadth
• Training since 1976 has included behavioral
  health
• LMEF Model began in 1985
• Approaching 30 years and 20 years, respectively
• Engels biopsychosocial model dates to 1977
• Many others have collaborated in some manner

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LMEF Family Practice Model

• Department of Behavioral Medicine (1985-1999)
• Training program for residents
• Clinical services for clinic patients
• Psychology training program
• APA accredited predoctoral internship
• Many other mental health trainees
• Pediatrics, Geriatrics, Womens Issues,
  Multicultural, Behavioral Medicine components
• Discontinued in 1999 for lack of funds

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Several ways of approaching integration
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Integrated Care from Low to High (pre HIPAA!)

• Courtesy report of involvement
• Referral call for information exchange
• Development of special referral relationship
• Meeting to discuss cases
• Meeting of providers with patient
• Work together regularly delivering services

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Four levels of service integration

• Direct service Care of patients
• Program Linkages between local
  service systems
• Policy Linkages between local
  and state systems
• Organizational Reconfiguring and
  consolidating agencies

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Patient Centered Care

• Historical
  Patient Centered
• Discipline focused Patient
  focused
• Problem oriented Goal
  oriented
• Multidisciplinary
  Interdisciplinary
• Pt is recipient Pt is
  participant
• Paternalistic
  Respectful
• Rigid standardization
  Individualistic
• Tradition based Evidence
  based

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Key elements of Collaborative or Integrated Care
Program

• No Wrong Door or One Stop Shopping
• Triage and up-front screening
• Communication between professionals
• Coordinated BHP and PCP care
• Patient experiences one treatment plan
• Documentation of progress
• Track outcomes
• Viable financial program

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Key elements continued

• Minimal reimbursement disconnects
• Working relationships with public funded service
• Strong and lasting leadership
• Access to levels of care
• Training professionals in and out of school

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Integrating Mental Health and Addictions Treatment

• Development of Multidisciplinary treatment group
• Screening data makes strong case for integrated
  care

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First Step Integrated Care Screening Tool
Description

• Seven categories of self reported items
• Chronic Medical Problems
• Psychiatric Care
• Psychological (Brief Symptom Inventory vs.
  SAS/SDS)
• Michigan Alcohol Screening Test (MAST)
• Drug Awareness Screening Test (DAST)
• South Oaks Gambling Screen (SOGS)
• Broad list of items

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Drugs 55.5
Substance Abuse N110
Compulsive Gambling 16.4
Chronic Medical 20.9
Stress Symptoms 42.7
Substance Abuse 96.4
Psychiatric 23.4
Abuse 32
Suicide risk 26.4
Eating Disorder 15.5
Psycho-logical 14.5
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Mental Health N42
Drugs 11.9
Chronic Medical 38.1
Gambl-ing 9.5
Alcohol 52.4
Mental Health 35.7
Psychiatric 31
Abuse 40.7
Stress Symptoms 81
Suicide risk 54.8
Eating Disorder 28.6
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Compulsive Gambling N45
Substance Abuse 73.3
Drugs 26.7
Chronic Medical 15.6
Stress Symptoms 55.6
Gambling 86.7
Psychiatric 37.8
Suicide risk 44.4
Abuse 29.3
Eating Disorder 20
Psycho-logical 11.1
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Neurofeedback N39
Chronic Medical 48.7
Drugs 15.4
Gambling 12.8
Alcohol 33.3
Neurofeedback 82.1
Psychiatric 33.3
Abuse 34
Suicide risk 41
Eating Disorder 43.5
Psycho-logical 23.3
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How
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Review First Step Model of Care
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Model Build It, Get It, Use It, Share It,
Follow It, Measure It
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Build It Multidisciplinary Team

• Provider mergers to get team
• Difficult to do in rural areas without providers!
• But at same time, is way to extend few resources
  we do have
• Use cross training of merged group
• Develop creative connections with others in
  community

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Get It Identify multiple problems

• Cross training to acquire and use information
• Integrated Care Screen
• Completed on intake, scored, at start-up of
  Integrated Care Treatment Plan
• Or completed later as accountability check

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Importance of Problem Identification

• Engels Biopsychosocial Model
• Medical, Individual, Marital, Family, Community,
  Cultural/Society
• Minkoff in Dual Disorders work conceptualizes
• Low vs. High Intensity
• Psych vs Substance Abuse
• Screening can identify Low vs. High on multiple
  dimensions

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Use It Be Able to Treat Multiple Problems

• Co-occurring disorders vs. dual disorders
• Cross training necessary
• Making Referrals
• Office literature and vertical integration
  programs

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Would you treat these differently
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Biopsychosocial Screening
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Biopsychosocial Screening
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Treatment Complexity

• Medical, Individual, Marital, Family, Community,
  Cultural/Society
• Type I Single Low Risk
• Type II Single High Risk
• Type III Two High Risks
• Type IV Multiple High Risks

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Tracks of Treatment

• Integrated Care Treatment Team - The Mayo
• Assess and treat complex cases
• Team evaluation and discussion of integrated
  treatment
• Team meeting with client/family
• Therapeutic goal of selling treatment
  conceptualization

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Share It Integrate Treatment of Multiple
Problems

• Work with PCP, get Release of Information signed
• Have client sign in PCP office
• HIPAA requires special release
• Progress Note to Physician
• Respond to physician needs
• Develop common treatment plan

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Follow It Continuity over time

• One primary therapist over time
• Addictions as chronic relapsing disease
• Stress of predictable life cycle events
• Stress of unpredictable crisis

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Measure It Outcome measures

• Increasing need for documented outcomes
• Accountability
• Research
• Funding support
• Measuring Treatment Outcomes, Patricia Owen, Ph.D
• Hazelden Publishing

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Maintain It Leadership, funding and business
structure

• Takes commitment within the practice
• Takes support from outside the practice
• No magic funding resources at this time
• Best business structure is centralized
• Need strong Implementation Group
• Need good communication, both clinical and
  operational

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Implementation findings

• Very important to have mutually supportive team
• Different patient populations in SA and MH
• CD clients referred by legal system and resist
• Quick and least expensive treatment is focus
• MH providers have difficulty referring to SA
  programs
• Similar problem of PCP referring to MH?

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Implementation findings

• Communication to provider and billing
• Universal Intake Form with clinical and business
  info
• Universal Internal Referral Form
• Where does the chart live?
• How do you best select, train, and supervise
  staff?
• Difficulty obtaining psychiatric care
• Lifespan continuity requires stable staff

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How?
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Working with Primary Care Physicians
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Types of services

• Direct patient care
• Consultation to MD
• Co-therapy
• Consultation in other settings, e.g.. Schools
• Community liaison, outreach
• Assessment
• Support for clinical and program development
  research
• Support for education

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What makes a happy client?

• Guess what, it isnt always therapy!
• It is having a financially satisfied customer
• Unsatisfied substance abuse client will add to
  resentment
• Unsatisfied mental health client will get more
  depressed, avoidant, or more emotional

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Core areas of knowledge and skills for BHP
provider in PCP

• Biological components of health and illness
• Cognitive components of health and illness
• Behavioral and developmental aspects of health
  and illness
• Sociocultural components of health and illness
• Health policy and health care systems
• Common primary care problems

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Core areas of knowledge and skills for BHP
provider in PCP

• Clinical assessment of common primary care
  conditions
• Clinical interventions in primary care
• Interprofessional collaboration in primary care
• Ethical and legal issues in primary care
• Professional issues in primary care

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Core areas of knowledge and skills for BHP
provider in PCP

• Medication knowledge
• Must function as eyes and ears of physician
• Individual, group, and psycho educational skills
• Life Satisfaction Class rather than Depression
  Group
• Good case managers
• Cognitive/behavioral and brief therapy methods
• Family systems approach

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Working effectively with Primary Care Physicians

• PCPs are gifted individuals with commitment to
  families
• The most psychologically oriented of all MDs
• Their practice teaches them importance of
  psychological care if residency didnt
• Continuity of care for total family
• Hierarchical nature of medicine
• Defined boundaries of specialization
• Well defined standards of care in all
  specialties

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Working effectively with Primary Care Physicians

• Ultimate responsibility for patient
• Develop trusted referral relationships
• Liability conscious
• Discuss before documenting
• See large volumes of patients
• Care for a population as well as patient
• Some are more procedurally oriented

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Working effectively with Primary Care Physicians

• Some practice independently while others rely
  more on consultants
• Expect consultants to communicate through phone
  and reports
• Expect immediate access
• Learn by doing and BHP is expected to teach
• Provide first line of treatment until referral
  necessary
• PCPs expect to coordinate so exercise care in
  your referrals

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Working effectively with Primary Care Physicians

• They respect BHPs who can work with the
  complexity of psychosocial issues
• Sensitive to patient issues but will avoid
  opening a problem if they cannot treat or refer
• Expect a diagnosis and treatment plan
• Prefer brief consults over meetings
• Little tolerance for impractical or theoretical
• Tremendous power over community but not their
  lives

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Working effectively with Primary Care Physicians

• You must be generalist to work with PCP
• PCP expects you to be expert in broad range of
  DSM disorders
• Dont wait for patients to come to you
• MDs dont identify them and they wont come to
  you
• Patients can have serious and terminal illness
• Careful health history
• Do not over focus on psychosocial
• Be prepared to deal with serious and terminal
  illnesses

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Working effectively with Primary Care Physicians

• Important to develop relationship with MD, get
  their explanation of patient problem, clarify
  their needs, and secure their support for
  treatment
• Have working knowledge of training and approach
  to problems
• Consider developing a group practice then link
  with PCP practice
• Broaden role to include prevention, outreach,
  community orientation, program development,
  research, political advocacy

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Working effectively with Primary Care Physicians

• PCPs referral question
• Communicate back to PCP (usually a paragraph or
  two)
• Even a report should not exceed a page
• If longer, include a summary paragraph
• Clarify patients understanding of why PCP
  referred them
• Be aware of patients perception of you
• Give the PCP clear concise facts and specific
  treatment recommendations

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Working effectively with Primary Care Physicians

• MDs work quickly and results expected quickly
• MDs refer out and you may need to refer as well
• But MD expects to coordinate or make referral
• MDs expect diagnosis and succinct treatment plan

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Working effectively with Mental Health
Counselors, CPCs
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Working effectively with Drug and Alcohol
Counselors
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Working effectively with Social Workers
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Working effectively with Psychologists
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Review essential business functions

• Committed leadership
• Clear organizational structure
• Strong business management

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Essential business functions

• Good intake process enables clean start
• Getting information from client
• Calling insurance company for benefits
• Asking the right questions
• Getting client to understand benefits
• Getting them to understand their ultimate
  responsibility

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Intake process continued

• Must give client a disclaimer, just as insurance
  company does
• Dilemma - Checking insurance as courtesy to
  client is interpreted as agency taking
  responsibility for insurance reimbursement
  problems
• Complication of different coverage for different
  providers
• Makes referral between programs complicated
• It cannot be SEAMLESS because of insurance
  differences

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Review essential business requirements

• Insurance and billing for mental health and
  substance abuse
• Consolidation of services requires integrated
  information systems
• Patients provide insurance information once
• Integrated clinical and business information
  system
• Tracking and Follow-up checks and balances
• Use community board to educate community and
  destigmatize

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Office organization

• Use same receptionist and schedule
• The greater the proximity, the more integrated
• 92 of BHP/PCP consults are brief in ideal ICP
  model
• Regular staffings or meetings to discuss
  difficult cases
• Special treatment groups (pain, chronic illness,
  depression, obesity, ADD)

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Undertaking a New Project

• Dont assume that project can start just because
  MDs are in favor
• Clinical team and office manager should
  strategize how BHP will be useful
• Clinical team, office manager, and BHP should
  meet regularly to address problems
• Office manager will need to orient support staff
• New ways of operating can be stressful so a
  learning environment must be created

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Undertaking a New Project

• The more successful, the more the larger
  organization may punish the project
• Those who are left out are often critical of
  what they are out of
• If pilot project works and is implemented on
  larger scale, others may feel they are being told
  what to do
• Keep everyone updated on progress

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Undertaking a New Project

• Key staff not involved should still be made to
  feel they are on the ground floor
• A dissemination group should provide
  communication to larger organization
• Updates should tell patient stories/successes
• Be candid about blind alleys that have not worked

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Review Case Studies of Integrated Care

• 15 y/o depressed female with MIP
• 43 y/o male truck driver who misses delivery of
  his 5th child
• 30 y/o recovering depressed female with weight
  gain and chronic fatigue
• 27 y/o suicidal female caught embezzling funds
  from employer
• 49 y/o female more depressed but in less pain
  with new rx of Vioxx

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Review barriers to Integrated Care

• Different bureaucracies getting CEUs
• NMA quick, NPA two days slower but unnecessary
• But AMA approval via NMA approved by NPA
• LMHP, Social Work, CPC simply must meet criteria
• CADAC requires 45 days and more info than NMA
• Nursing requirements even more

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Barriers to Integrated Care - 2

• Rural populations is actually quite diverse
• Stigma is higher in rural setting, access is
  lower
• Availability
• Accessibility (Across the street is too far)
• Rural geography and weather
• In low volume rural setting state-funded systems
  essential
• But difficult to provide specialty care
• And state programs have little integration
  training

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Barriers to Integrated Care - 3

• Reimbursement/Affordability
• Different bureaucratic and funding systems, poor
  coordination
• Poor patient understanding of insurance
• Poor insurance company of explanations of
  benefits
• If people with heart attacks had to do what
  people with life attacks do to get care, wed
  have a lot more dead Nebraskans and considerable
  reductions in health care costs. Maybe thats
  the point!

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Barriers to Integrated Care - 4

• Physicians paid for procedures, MH paid for time
• Thus, MH paid only for therapy and not for
  consultation
• Carve outs resulting from mind-body dualism and
  cost cutting
• Different payors have different requirements
• Different professions have different ethical codes

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Barriers to Integrated Care - 5

• Confidentiality
• MDs work in groups so information is shared
  among them
• Therapists work alone so information is not
  shared
• Documentation differences
• MDs expect others to read and use their notes
• Therapists do not expect others to use their
  notes
• Lack of common language
• Similar language with different meanings
• E.g. Treating the family by PCP vs. Family
  therapist

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Barriers to Integrated Care - 6

• Less availability of specialty mental health care
• Children
• Women
• Men (not studied as much)
• Geriatric
• Minorities
• Severely and Persistently Mentally Ill

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Barriers to Integrated Care - 7

• Turf issues and guild model (Exclusion) by
  professions
• Different beliefs about the change process
• Practice styles (pace and time spent)
• Decades of mutual negative stereotyping
• Data gathering is important to justify positions

112
Barriers to Integrated Care - 8

• Decreasing sense of community in rural setting
• Out migration of young, educated residents
• Declining economy and quality of rural life
• Rural areas doing more with even less
• Human resource problems of rural agencies
• Change must come from within the community
• Consensus building is essential

113
Barriers to Integrated Care - 9

• Who has control and accountability?
• How are dollars divided?
• Professional cultures conflict
• Availability of providers and network adequacy
• Data management and confidentiality
• Guild model works on principle of exclusion
  whereas integration is a complex social cause
  requiring many participants

114
Barriers to Integrated Care - 10

• Asking others to use tools can be seen as
  encroachment on autonomy
• Collaboration takes time and there is no
  reimbursement
• Poor funding of public programs
• Poor funding of substance abuse programs
• Stigma
• HIPPA impact uncertainty

115
Important Developments Telehealth

• T1 lines available to NE Critical Care Access
  Hospitals
• Technology may permit off-site clinical access
• Hospitals may be able to get cost-based
  reimbursement by Medicare
• Possibly enables them to add BHP staff
• But achieving technology buy-in is process in
  itself
• Medicare HB Codes permit health related service
  billing

116
Important Developments

• Early collaborative training is important
• Many training programs now talking of integration
• De-institutionalization is unique challenge to
  rural areas
• What happens if Regional Centers close or change?
• Fewer resources to cope with high needs clients