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

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Overview

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

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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.

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Mental Health Integration in Maine
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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

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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

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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

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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.

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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

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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

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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

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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

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Primary Care Medical Home
Access
Community Resources e.g., NAMI
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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).

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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
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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

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• A Framework for Building the Integrated Medical
  Home

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What is the Aim?

• To serve patients better through integrated,
  effective, efficient, financially sustainable
  mental health care in primary care

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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.

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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
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Identify Your Population
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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

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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

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Develop Efficient and Effective Processes
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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

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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
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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
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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

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• Process and Outcome Measures

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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
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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
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Process Measures

• Mental Health Screening Forms
• Distributed
• Completed
• Utilization of Specialty Mental Health Care
• Care manager
• Internal mental health provider
• External mental health provider

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Outcome Measures

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

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Finances of Integrated Care
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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

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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

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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

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