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Integrating Mental Health into Primary Care: Sustainable Partnerships


Jane Hamel-Lambert, MBA, PhD Karen Montgomery-Reagan, DO, FAAP, FACOP Sherry Shamblin, PCC-S Dawn Murray, DO March 20, 2009 * 40 + physicians, 4 satellitte clinics ... – PowerPoint PPT presentation

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Title: Integrating Mental Health into Primary Care: Sustainable Partnerships

Integrating Mental Health into Primary Care
Sustainable Partnerships
  • Jane Hamel-Lambert, MBA, PhD
  • Karen Montgomery-Reagan, DO, FAAP, FACOP
  • Sherry Shamblin, PCC-S
  • Dawn Murray, DO
  • March 20, 2009

  • IPAC A Rural Health Network
  • Integration Efforts
  • Developmental Screening and Surveillance
  • Co-Locating Mental Health in Primary Care
  • Co-Location Interagency Partnerships
  • University Medical Associates, Inc
  • Tri-County Mental Health Counseling Services
  • Family Healthcare, Inc.

  • Jane Hamel-Lambert, MBA, PhD
  • President, IPAC Department of Family Medicine,
    Ohio Universitys College of Osteopathic Medicine
  • Karen Montgomery-Reagan, DO, FAAP, FACOP
  • Chair, Pediatrics, Ohio University College of
    Osteopathic Medicine University Medical
    Associates, Inc.
  • Sherry Shamblin, PCC-S
  • Early Childhood Mental Health Consultant,
    Clinical Supervisor, Tri-County Mental Health
    Counseling Services, Inc.
  • Dawn Murray, DO
  • Medical Director, Family Healthcare, Inc.

Integrating Professionals for Appalachian
IPAC A Rural Health Network
  • Interdisciplinary collaboration hinges on
    interagency cooperation
  • MHPSA.
  • Retention/recruitment
  • Thank you to Office of Rural Health Policy (P10
    RH06775, D06RH07920)

Integration Goals
  • Adoption of routine developmental surveillance
  • Improves early identification
  • Alternative to wait and see
  • Co-location of Mental Health Providers
  • Improves access
  • Improves quality through care coordination
  • Improves patient outcomes
  • Developing common language

AAP guideline
  • Developmental Surveillance and Screening
  • 9, 18, 30 months give screening tool
  • If at risk, refer for further evaluation
  • http//

Adoption of the Ages and Stages Questionnaires
  • Childcare programs
  • Primary care settings
  • Shift away from clinical impressions (watch and
    listen) to using formal parent-completed, normed
    screening tool.
  • Reassurance and Risk

  • ASQ Screens 5 Domains
  • Communication
  • Gross Motor
  • Fine Motor
  • Problem solving
  • Personal-social
  • Social-Emotional development

Why ASQ Tools?
  • CHEAP!
  • ASQ 3 (May 2009) 249 and ASQSE 149.00
  • Low cost alternativeannual cost of 25-50 for
    following children
  • Permission granted to photocopy

Quick and Easy
  • Utility Parent satisfaction survey (N731)
    (publisher data)
  • How long did it take to complete the
  • 70 Less than 10 minutes
  • 28 10-20 minutes
  • 2 More than 20 minutes
  • It was easy to understand the questions?
  • 97 Easy
  • 3 Sometimes
  • 0 Not easy

Accurate ASQ
  • Normative sample of over 8000 questionnaires,
    high reliability (gt 90), internal consistency,
    sensitivity, and specificity
  • See for ASQ Users
    Guide Technical Report for complete psychometric

Parent Report ASQ Research
  • As accurate as formal measures for identifying
    cognitive delay (Glascoe, 1989, 1990 Pulsifer,
  • As accurate as formal measures for identifying
    language delay (Tomblin, 1987)
  • As accurate as formal measures for identifying
    symptoms of ADHD and school related problems
    (Mulhern, 1994)
  • More accurate than Denver for predicting
    school-age learning problems (Diamond, 1987)

Physicians trust it
  • Catches kid earlier than she may have
  • Opens up conversations with parents regarding
  • Monitoring
  • Billable
  • Generate Revenue

  • CPT Code 96110 (limited evaluation)
  • E/M Modifier 25 Significant Separately
    Identifiable Evaluation and Management Service by
    the Same Physician or the Same Day of the
    Procedure or Other Service
  • Document administration, interpretation (normal,
    abnormal, parent discussion and referral/action)
  • Medicaid Relative Value (staff admin) 13.64

  • Depression for adults PHQ -9
  • Patient Health Questionnaires
  • Improves identification
  • Tool for communication

  • Co-location of Mental Health Providers in Primary

University Medical Associates, Inc
  • UMA is a multispecialty group dedicated to
    serving southeastern Ohio. Affiliated with Ohio
    University College of Osteopathic Medicine
  • Karen Montgomery-Reagan, DO, FACOP, FAAP

Motivation for Co-Location Program
  • Practice Group has a need for mental health
  • Difficulty with referrals seems like a black
  • Making appointment calls
  • CMHC required in person to schedule appointment
  • Families need access to service
  • Waiting for appointments
  • Communication
  • Did they go, what was the dx, were they
    discharged from care?
  • What was the Primary Doc role?

Family Benefits
  • Clients familiar with surroundings and
    comfortable with office staff/patients
  • Ease of scheduling for patient and physicians
  • Referral sheet to reception
  • Families provided intake paperwork
  • Appointment scheduled right then and there
  • Parents/patients more willing to try mental
    health services provided at our office

Family Quotes
  • Patient Ive tried counseling before
  • I have individuals that will fit your
    personality (choice)
  • I will speak with the provider individually
  • If it doesnt work, I have other avenues
  • Patient If you think this person will help, I
    will give it a try
  • Patient How soon? It always take so long to get

Physician Benefits
  • Physicians find mental health a benefit for their
  • Physician have direct contact with provider
  • Curbside consults, guides diagnostics, treatment
  • Communication easy on site, no phone message
  • Dont wait until its a disaster---crisis
  • Appointment info is charted
  • I know if they are going and continuing care
  • Physicians are able to directly discuss cases
    with the mental health professional on site

  • Scheduling
  • On site facilitates follow through
  • Sooner access is easier to negotiate
  • Office Space
  • Location matters
  • Shape, size and absence of medical gear
  • Private practitioner vs CMH clinicians
  • MH Practitioner Billing
  • Providers are doing their own billing
  • Record Keeping
  • Doc charts have mental health progress note

Real Numbers
  • Three Providers
  • 2 ½ days of service combined
  • Numbers of Families
  • 78 families have been provided service
  • Numbers of Visits
  • Over 250 appointments (Jan08/May08)
  • No Show rates
  • Medicaid (approx 29) NS rate gt than privately
    insured NS rate (approx 10 12)

Tri-County Mental Health and Counseling Services,
  • TCMH-CS is a licensed Community Mental Health
    Center serving four counties in southeastern Ohio

Components of the Community Mental Health System
that Impacted Our Co-Location Efforts
Recovery Model vs. Medical Model
Recovery Model
  • Focuses on resiliency while reducing symptoms
  • All people have strengths to overcome challenges
  • Individuals are the experts in their experiences
    so have the voice and choice in services
  • Values unconditional acceptance of the individual

Implications of Differences in Practice Models
  • Professional Culture
  • Patient/Client
  • Implications for Assessment/ Diagnosis
  • Organizational Structure
  • Physical Office Space
  • Communication

Practitioner Work Style
  • Consultation
  • Info goes back and forth
  • Physician manages case
  • Mental health
  • Has time efficiencies
  • Collaboration
  • Fuse ideas
  • Jointly develop treatment plan
  • our patient
  • Time to develop relationship
  • Build in communication strategies

Billing and Paperwork Procedures
  • Medicaid/Insurance
  • Medicaid match
  • Reimbursement by insurer, by who is delivering
  • Electing to serve
  • Modifying structure of intake paperwork and
  • Difficult to merge systems even when there is
    duplication because of ODMH requirements

Evaluate Your Practice Needs
  • Age
  • Family Care versus Pediatric Practice
  • Payee source
  • Mental Health Needs

Laying a Good Foundation
  • Choose the right mental health partner for your
  • Build a working relationship
  • Build time for communication/interaction
  • Be prepared to develop joint vision and goals for
    the partnership

Family Healthcare, Inc
  • Behavioral Health Integration a work in progress
  • Dawn Murray, DO

MISSION of FHI (Family Healthcare, Inc.)
  • The Mission of Family Healthcare, Inc. is to
    provide access to high quality, affordable,
    healthcare to everyone without discrimination.
  • All Community Health Centers have a similar

Family Healthcare, Inc
  • FQHC (federally Qualified Health Center)
  • Six sites in six counties in Southeastern Ohio
  • Behavioral health considered a core service,
    provided on site or through referral agreement
  • Investigated many models of behavioral
    health/primary care integration.
  • IPAC (Integrating Professionals for Appalachian
    Children) involvement was springboard for our
    current journey.

  • Federally Qualified Health Centers AKA Community
    Health Centers
  • Receive 330 grant from federal government which
    provides for uninsured care. (For FHI, this is
    about 20 of budget)
  • Sliding fee scale based on income
  • Accept most insurances including medicaid (and
    Medicaid HMOs), medicare.
  • Enhanced reimbursement through medicaid and
  • Considered safety net providers
  • FTCA malpractice coverage
  • Different funding stream than Community Mental
    Health centers

Behavioral Health/Primary care Integration models
in FQHCs
  • Referral Agreements with Private Psychiatrists or
    Community Mental Health Centers (no integration)
  • Complete in house Mental Health program with
    psychologists, social workers, and psychiatrists
    as FQHC employees.
  • In house Behavioral Health Program with Clinical
    psychologists, LISWs, counselors under
    supervision of PCPs
  • FQHC contracting with Community Mental Health
    Agency for mental health personnel
  • All possible combinations of these.

IPAC-Colocated Providers
  • Involvement in IPAC allowed more collaboration
    between agencies for ideas to develop.
  • We started with the original plan of a Tri County
    counselor in one of our sites.
  • Quickly saw limitations of this arrangement
  • Only available for kids. Not as many kids as
    predicted. Bigger need for adult services. Better
    if billing is through FQHC due to another funding
  • Began contract with Tri County, but still kept
    IPAC involvement

Behavioral Health/Primary Care model
  • LISW can triage for PCPs which increases
    everyones efficiency
  • LISW will keep people for counseling at FQHC and
    work with PCP to address goals to enhance medical
  • If patient is outside of PCP scope for mental
    health issues, LISW can start intake paper work,
    make psychiatric referral and expedite patient
    care. She can continue counseling at FQHC with
    support from PCP. This is very important given
    the long wait times we sometimes have for
    psychiatrists, especially in rural areas. We can
    keep people from falling through the cracks.

  • Competition for patients/clients
  • Supervision
  • Reimbursement
  • Integration

  • At a time when Mental Health funding is being
    cut, it is good to have other revenue streams.
    By contracting for services of the LISW, she
    actually increased her productivity at the Mental
    Health Center. FHI is breaking even on the deal,
    and getting excellent services for our patients.

Next Steps
  • We are working on streamlining our communication
    between the PCP and the LISW.
  • Developing a protocol and system to triage more
    urgent psyche referrals into the Mental Health
  • We are planning to spread to our other sites.
  • Continuously communicating between Community
    Mental Health center, and providers to foster
    trust, and better integrate our cultures for
    improved access to quality healthcare for all

CoLocation toward Integration
  • Shift referring my clients to jointly taking
    care of families
  • Co-Learning
  • Understanding diagnostic paradigms
  • Understanding professional biases
  • MH builds medical knowledge Doc gains mental
    health knowledge
  • Communication Goals
  • Shared language
  • Participation in routine meetings
  • Access to medical charts

Lessons Learned
  • Health delivery system dichotomizes MH and Health
  • Carve out billings
  • Different govt oversight agencies (ODH, ODMH)
    Mission and mandates
  • Diagnostic tools are different
  • Philosophies of care
  • Communication nourishes partnerships
  • Tensions teach
  • Build the relationships

Questions and Answers
Contact Information
  • Jane Hamel-Lambert
  • Karen Montgomery-Reagan
  • Sherry Shamblin
  • Dawn Murray