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Building the Integrated Primary Care Medical Home

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Building the Integrated Primary Care Medical Home Neil Korsen, MD, MSc Mary Jean Mork, LCSW C-IBHA, New Orleans April 16, 2009 Overview Background Description of our ... – PowerPoint PPT presentation

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Title: Building the Integrated Primary Care Medical Home


1
Building the Integrated Primary Care Medical Home
  • Neil Korsen, MD, MSc
  • Mary Jean Mork, LCSW
  • C-IBHA, New Orleans
  • April 16, 2009

2
Overview
  • Background
  • Description of our integration program
  • Our approach to implementation
  • Measuring success
  • Financial sustainability

3
Objectives
  • Describe one approach to implementing integrated
    care
  • Understand the use of process redesign and
    measurement as part of an improvement program
  • Describe financial challenges and one possible
    solution to financial sustainability of
    integrated care.

4
Mental Health Integration in Maine
5
MaineHealth
  • An integrated delivery system in 11 counties in
    Maine
  • Includes
  • Acute care hospitals
  • A psychiatric hospital
  • Physician practices
  • Home health agencies
  • Long term care facilities
  • Other health care organizations

6
(No Transcript)
7
Why Mental Health Integration?
  • Depression in Primary Care program since 2001
  • MacArthur Foundation RESPECT trial
  • Robert Wood Johnson Foundation Depression in
    Primary Care demonstration program
  • Achieved system level changes in adult depression
    care

8
Shortcomings of Depression Program
  • Did not
  • Address needs of those caring for children and
    adolescents
  • Address common mental health co-morbidities of
    depression
  • Do enough to build working relationships between
    primary care and mental health clinicians and
    organizations

9
Integration as a Solution
  • Primary care clinicians provide more than half of
    all mental health care and some primary care
    patients wont go to specialty mental health.
  • Pilot integration programs had developed around
    the state.
  • MaineHealth Strategic Plan included piloting
    mental health integration (MHI).
  • Received a grant from the Maine Health Access
    Foundation (MeHAF) that helped fund the MHI pilot.

10
Integration Model
  • Adapted from Intermountain Healthcare (IH), who
    demonstrated
  • Improved ability of Primary Care Physician to
    diagnose and treat common mental health
    conditions
  • Increased satisfaction of patients and primary
    care staff
  • No increase in overall healthcare costs

11
The Program
  • 18-month Collaborative-style Learning Community
  • Learn the MHI model and implement key components
  • Gather for periodic learning sessions
  • Collect and report data about processes and
    outcomes
  • Participate in site visits, conference calls,
    listserve
  • 12 Primary Care Sites (6-8 more joining spring
    2009)
  • Rural Health Clinics (RHC)
  • Federally Qualified Health Centers (FQHC)
  • Private and hospital owned practices
  • 8 Mental Health Partners (3 additional agencies
    spring 2009)
  • Specialty Mental Health agencies
  • Community Mental Health Centers
  • Hospital-owned behavioral health organizations

12
Principles of our Integration Program
  • Relationships Mental Health and Primary Care
  • Standardized mental health screening and
    assessment tools
  • Stratification to guide level of intervention
  • Team approach to care
  • Periodic reassessment of patient
  • Links to external resources
  • Mental health providers
  • Community resources

13
Role of Mental Health Specialist Integrated
Behavioral Health
  • Work side-by-side with primary care staff
  • Brief, flexible problem-focused approach to
    treatment
  • Assist with diagnosis and management of people
    with common mental health problems
  • Assist in the care of people with psychosocial
    problems related to medical diagnoses

14
Primary Care Medical Home
Access
Community Resources e.g., NAMI
15
Rate yourself on Behavioral Health Integration
  • Spend 5 minutes talking to your neighbor about a
    couple of these questions from the Behavioral
    Health Integration Survey
  • 1 - The Behavioral Health Consultant (BHC) is
    located in the exam room area of the clinic and
    provides services there.
  • 12 - All members of the primary care team
    understand the role of the BHC and how to utilize
    him/her
  • 15 - PCPs routinely discuss patient care issues
    with the BHC prior to and after same-day handoffs
    or prior to a scheduled initial visit.
  • 16 - The BHC provides periodic training and
    education for medical staff on behavioral health
    topics (e.g., at a provider meeting, through a
    monthly newsletter or a lunch time training on a
    topic of interest to PCPs).

16
Levels of Integration
Model Level of Integration Attributes
Separate Space Mission -- Traditional Behavioral Health Specialty Model
One-on-one Referral Relationship Preferred Provider. Some information exchange
Co-location On-site Behavioral Health Unit/Separate Team
Collaborative Care On site. Shared cases with Behavioral Health specialist
Integrated Care Primary Care Team member
Doherty, McDaniel and Baird, 1996
17
An Example of Integrated Practice the Video
  • Level Five
  • Mental Health Clinician working side-by-side with
    primary care staff
  • Brief, flexible problem-focused approach to
    treatment
  • Warm hand-offs
  • Curbside consults

18
  • A Framework for Building the Integrated Medical
    Home

19
What is the Aim?
  • To serve patients better through integrated,
    effective, efficient, financially sustainable
    mental health care in primary care

20
Form the Right Team
  • Involve representatives of all groups that will
    be affected by the change
  • Leave titles at the door everyone can
    contribute to making this work
  • Team should meet regularly to review data and
    plan tests of change.

21
Mental Health IntegrationTeam Roles
Mental Health Specialist Diagnose, Treat
Primary Care Provider Support Staff Screen,
Diagnose, Treat
Care Manager Follow up, Family Adherence
Patient Education
Patient and Family
NAMI Community Resources Family Support
Psychiatrist Or APRN Consult, Train
22
Identify Your Population
23
Integrated Care is for
  • People with symptoms or problems that warrant a
    mental health assessment
  • People being treated for mental health conditions
    who are not improving
  • People who need help with behavioral, emotional
    or psychosocial aspects of medical problems

24
High risk populations
  • People with chronic illnesses or chronic pain
  • People with a disability
  • People with substance abuse problems
  • Kids with school, sleep or behavior problems
  • People with persistent somatic complaints and
    negative workup

25
Develop Efficient and Effective Processes
26
Tools You Can Use
  • Patient walk through
  • To understand the process through the eyes of
    your patients
  • Process Flow Charting
  • To display the process to help you think about
    how to introduce changes

27
Pt calls or presents with possible MH concerns
MH screening material to patient
Patient completes screening
Screening reviewed and scored
Patient and team develop care plan
Follow up visit and reassess
Ongoing monitoring and treatment prn
28
PDSA Cycle
Act Recommend action/ further study
Plan Identify -the problem -the most
likely causes -potential solutions
Do Implement solutions and collect data
Study Analyze data and develop conclusions
29
Why Test Changes?
  • Increases belief that the change will result in
    improvements in your setting
  • Learn how to adapt the change to conditions in
    your setting
  • Evaluate the costs and side-effects of changes
  • Minimize resistance when spreading the change
    throughout the organization

30
  • Process and Outcome Measures

31
Pt calls or presents with possible MH concerns
MH screening material to patient
Patient completes screening
Screening reviewed and scored
Patient and team develop care plan
Follow up visit and reassess
Ongoing monitoring and treatment prn
32
Pt calls or presents with possible MH concerns
MH screening material to patient
Patient completes screening
Screening completed/ Returned
Screening reviewed and scored
Patient and team develop care plan
Follow up visit and reassess
Care Mgmt.
Specialty MH
OUTCOMES Clinical Functional
Satisfaction Financial
Ongoing monitoring and treatment prn
33
Process Measures
  • Mental Health Screening Forms
  • Distributed
  • Completed
  • Utilization of Specialty Mental Health Care
  • Care manager
  • Internal mental health provider
  • External mental health provider

34
Outcome Measures
  • Clinical
  • PHQ-9 score tracking
  • Functional
  • Functional assessment
  • Satisfaction
  • Patient
  • Provider
  • Staff
  • Financial
  • Revenues generated from integrated services

35
Finances of Integrated Care
36
The Problems with Integrated Care
  • No one seems to know how to get paid
  • Mental Health regulations and licensing
    expectations dont fit the primary care setting
  • Confidentiality vs. shared records
  • Lack of clarity and understanding about present
    practices
  • Complicated licensing and reimbursement rules
    without accessible experts

37
How will we achieve financial sustainability?
  • Understand the current rules
  • Identify opportunities and barriers that affect
    sustainability
  • Use understanding of current rules to
  • Recommend most effective way to organize services
  • Maximize reimbursement for integrated care
  • Target barriers with highest priority and/or are
    most likely to be able to change

38
Remember
  • Involve the right people
  • Start small and build gradually
  • Share selflessly and steal shamelessly
  • Think about sustainability
  • Clinical sustainability discover the processes
    that work in your setting and spread them
  • Financial sustainability understand the rules
    and use them to your advantage

39
  • Start where you are
  • Use what you've got
  • Do what you can
  • Arthur Ashe
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