Mental Health Care is Health Care' The integrative approach to comprehensive medical care

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Mental Health Care is Health Care.The
integrative approach to comprehensive medical care

• Presented by
• Douglas County Hospital
• PrimeWest Health System

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Outline

• General Overview
• Screening and Triage
• Clinic Care Coordination
• Psychological Evaluation
• Psychiatric Evaluation
• Administrative Challenges and Barriers

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General Overview

• Susan Meland, MD
• Douglas County Hospital-MHU
• Psychiatrist for the Integrated Team

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What is Integrated Care?

• It is a system of health delivery that recognizes
  that mental health disorders must be treated with
  the same degree of importance as physical
  disorders.

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Integrated Care is also.

• A system which attempts to bridge the gap that
  currently exists between the delivery of mental
  health care and general medical care.

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And.

• The system that we are developing and hope to
  develop further includes
• Active clinical case coordination
• Placement of mental health providers for both
  adults and children in the general medical
  clinics (we now see patients at both Alexandria
  Clinic and Broadway Medical Center)
• Mental health evaluations and triage by
  psychologists
• Case consultations between primary care providers
  and psychiatrists (both child and adult)
• Direct patient evaluations by psychiatric
  providers
• Educational seminars for primary care providers
• Outcome measurements

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So what are the problems with the traditional
model?
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Problems

• There are barriers to integrated care on multiple
  levels including clinical, financial, policy and
  organizational. These include
• Fragmentation of care physical separation of
  providers
• Separation of medical records. The left hand
  doesnt know what the right hand is doing.
• Limited communication between medical and mental
  health providers
• Primary care is often responding to multiple
  presenting problems creating time management
  issues

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More problems..

• Primary care often have limited training in
  psychiatric disorders and their treatment
• Primary care often have limited access to
  specialty mental health providers
• Shortage of mental health professionals
  especially in rural settings
• Psychiatrists attempt to manage large caseloads
  which limits access to patients who are in
  crisis. In the meantime, patients in crisis are
  being managed by primary care, emergency rooms
  and may ultimately be hospitalized.

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And yet more problems

• Patients variable treatment adherence
• Unnecessary duplicate diagnostics
• Stigmatizing attitudes toward mental illness
• Lack of insurance parity for psychiatric
  disorders
• Financial disincentives for physicians to treat
  psychiatric disorders
• Inability to bill essential activities, such as
  consultation between mental health providers and
  primary care

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Why is Integrated Care Important?

• 20 of adults and children have a mental health
  disorder
• Mental health disorders can be disabling and rank
  second only to cardiovascular conditions as a
  leading cause of worldwide disability
• The majority of people with mental health
  disorders do not receive proper treatment

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Importance (cont)

• Mental health disorders frequently co-occur with
  other mental or physical disorders. Examples
  include
• Depression and cancer
• Depression and diabetes
• Depression and heart disease
• Depression and HIV/AIDS
• Depression and Stroke

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Importance (cont)..

• Estimates state that approximately half of those
  with mental disorders go undiagnosed in primary
  care
• Primary care has the potential for early
  identification of symptoms of mental disorders
  and can provide cost-effective treatment,
  especially for those with less severe mental
  disorders
• People may be more amenable to mental health
  treatment if it is delivered in their medical
  clinic rather than going to a free standing
  mental health unit

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Especially important because

• MENTAL HEALTH IS FUNDMENTAL TO OVERALL HEALTH!
  Mental health and physical health are
  interdependent and therefore should be treated in
  an interdependent health care system

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Outline

• General Overview
• Screening and Triage
• Clinic Care Coordination
• Psychological Evaluation and Management
• Psychiatric Evaluation
• Administrative Challenges and Barriers

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Screening and Triage Process

• Jeanne Barlage, RN
• PrimeWest Health System
• Integrated/Shared Care Manager

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Triage

• What is the acuity?
• How bad is it?
• Symptoms
• Impairment in functioning
• Suffering
• Emergent safety is concern (suicidal)
• Urgent referral needed, child is not
  functioning
• Routine follow up needed
• No referral or follow up
• Read Sulik MD, Centracare Integrated Behavioral
  Health Initiative

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Outline

• General Overview
• Screening and Triage
• Clinic Care Coordination
• Psychological Evaluation
• Psychiatric Evaluation
• Administrative Challenges and Barriers

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Clinic Care Coordination

• Ann Challes, RN
• Clinic Care Coordinator
• PrimeWest Health System

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Clinic Care Coordination

• PrimeWest Health has hired and placed a clinic
  care coordinator in the clinic
• Clinic care coordinator schedules the child or
  adult for a mental health diagnostic assessment
  at the medical clinic
• Clinic care coordinator is present for the MH
  professionals explanation of findings
  appointment

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Coordination (cont)

• Care coordinator follows up with the family on
  the recommendations and provides assistance as
  needed
• Diagnostic assessment is part of the medical
  clinic record within 7 days.

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Coordinator (cont)

• Designated liaison between patients, mental
  health providers, primary care physicians,
  community providers, and health plan
• Follow-up with the patients on recommendations
  made by the mental health provider in their
  assessment
• Provide communication avenue with the parents and
  providers
• Support role for the patients and family

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Outline

• General Overview
• Screening and Triage
• Clinic Care Coordination
• Psychological Evaluation
• Psychiatric Evaluation
• Administrative Challenges and Barriers

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Child and Adolescent Psychological Evaluations

• Nancy Kiger, PhD, LP
• Douglas County Hospital-MHU
• Psychologist for the Shared Care Team

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Referral to Integrated Care by Physician

• Diagnostic Assessment 90801
• 1st meeting with parent/caregiver
• Meet with child/adolescent (use screening tools)
• Explanation of Findings
• Report Completed (7 days)

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Levels of Care

• No further referral needed
• Referral to return to primary care physician
• Shared care referral (triage)
• Psychiatric referral
• Hospitalization

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Community Coordination

• Early Childhood
• Family School
• Therapy
• Public Health
• Case Management
• Comprehensive Evaluation

• In-home Family Therapy
• Anger Management Group
• Mentor Program
• School Social Worker
• Educational Resources

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Outline

• General Overview
• Screening and Triage
• Clinic Care Coordination
• Psychological Evaluation
• Psychiatric Evaluation
• Administrative Challenges and Barriers

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Adult Psychological Evaluations

• Ryan Voigt, PsyD, LP
• Douglas County Hospital-MHU
• Psychologist for the Integrated Team

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Psychological Evaluation

• Presenting Problem and Life Situation
• Childhood and Family History
• Review of Current Psychiatric Symptoms
• Functional Impairments
• Past Mental Health History
• Substance Use History
• Legal History

• Social and Relationship History
• Education and Employment History
• Psychological Assessment
• Medical History
• Mental Status
• Impression
• Diagnosis
• Recommendations

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Synthesis and Plan of Action

• Basic Needs
• Social Support
• Friends
• Family
• Therapy
• Self help groups
• CSP

• Medication
• Past Trials
• Current Trials
• Complexity of Issues
• Physical Issues
• Vocational/Educational

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Outline

• General Overview
• Screening and Triage
• Clinic Care Coordination
• Psychological Evaluation
• Psychiatric Evaluation
• Administrative Challenges and Barriers

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Psychiatry Evaluation

• Susan Meland, MD
• Douglas County Hospital-MHU
• Psychiatrist with the Integrated Team-Adults

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Psychiatry Role

• One hour initial evaluation at the medical clinic
• Assess many of the same areas as the
  psychologists with special attention to those
  symptoms which may be benefited by the use of
  psychiatric medications
• Gather a thorough medical history (from patient
  and medical record)
• Diagnosis and treatment plan
• Follow-up appointments with plan to eventually
  return management of psychiatric medications to
  the primary care provider

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Additional Psychiatric Roles

• Provide direct consultation to primary care
  providers (physicians and advanced practice
  nurses)
• Educational seminars for primary care (future
  plan)

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Outline

• General Overview
• Screening and Triage
• Clinic Care Coordination
• Psychological Evaluation
• Psychiatric Evaluation
• Administrative Challenges and Barriers

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Administrative Challenges and
Barriers

• Catie Lee, MBA
• Douglas County Hospital-MHU
• Business Manager

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Barriers Challenges

• Inclination to move too quickly towards
  implementation without adequate planning of the
  details while balanced with moving forward and
  not stagnating by over planning the what ifs.
• Ability to adequately educate and engage all of
  the clinic staff that would need to be involved
  in the process
• Inconsistent referrals for designated time
• Willingness of organizations to commit coverage
  for an unguaranteed return on investment
• Administration and Physicians need to buy into
  the integrated care model not only cognitively,
  but financially

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The Learning Process Never Stops

• What we had initially thought to be barriers and
  hurdles did not always play out that way in
  implementation
• Most of the hurdles and barriers we experienced
  were not even mentioned in the process of
  planning
• Lesson Spending too much time on the what
  ifs needs to be monitored and managed
• Buy in of all major parties is essential to
  success
• Measure effort and effect. We have set up
  processes for measuring the effect of these
  processes
• All partners do not speak the same language
• We learned that we are still learning
• Doctors love the process, not so much the
  documentationwe are working on that
• Other partners are knocking at the door

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IT IS IMPORTANT TO RECOGNIZE THAT THE COLLECTIVE
VISION OF WHERE YOU THINK YOU NEED TO GO MAY
CHANGE.