Transcript Integration of Primary Care and Behavioral Health

Integration of Primary Care
and Behavioral Health
Nancy V. Wallace, MSN, FNP
Daily Planet Healthcare for the Homeless
VACPN Conference
October 14, 2011
Learning Objectives
Define integrated care
Explain the need for integrated care
Describe various models of integrated
care
Identify benefits to integration of care
Identify challenges to overcome in the
effort to deliver integrated care
Primary care
Behavioral health
Collaborative care
Integrated care
DEFINE INTEGRATION
Primary Care
The medical setting where patients
receive most of their medical care and
is therefore the first source for
treatment
Family medicine
General medicine
Pediatrics
OB-GYN (sometimes)
Behavioral Health
Includes both mental health and
substance abuse services
In the US, is most often delivered in
separate specialty clinics
Often, substance abuse treatment and
mental health treatment are delivered in
separate facilities
Collaboration vs. Integration
Collaboration
Involves BH working
with primary care
Clients perceive that
they are getting care
from a specialist who
collaborates closely
with their PCP
Integration
Involves BH working
within primary care
Clients perceive BH
services as a routine
part of their health
care
Biopsychosocial model
Biological, psychological, and social
factors all play a significant role in
human functioning in the context of
disease
Often endorsed, seldom practiced
The burden of mental illness is high
You can’t separate the mind and body
Healthy behaviors decrease when mental health is poor
There are medical benefits to good mental health
THE NEED TO INTEGRATE
CARE
The Burden of Mental Illness
In 2008, NIMH estimated that 1 in 4
adults suffer from a diagnosable
mental disorder
Mental illness begins early in life (1/2
by age 14 and ¾ by age 24)
Mental illness is a chronic disease of
the young
You can’t separate the mind
and body
Physical health problems and mental
health problems are correlated
Those with serious medical problems
often have co-morbid mental health
problems
As many as 70% of primary care
visits stem from psychosocial issues
Healthy behaviors decrease
when mental health is poor
Tobacco use among those diagnosed
with mental illness is TWICE that of
the general population
Injury rates (intentional and
unintentional injuries) are 26 times
higher in those with mental illnesses
than the general population
Medical Benefits of Good
Mental Health
Decreased risk for disease, illness,
and injury
Better immune functioning
Improved coping and quicker
recovery
Increased longevity
Lower cardiovascular risk
Common concepts
Coordinated, Co-located, Integrated
Specific examples
MODELS OF INTEGRATED
CARE
Concepts common to all
integrated care models
The medical home
The healthcare team
Stepped care
Four-quadrant clinical integration
The medical home
NCQA’s inclusion criteria:
Patient tracking and registry functions
Use of non-physician staff for case
management
The adoption of evidence-based
guidelines
Patient self-management support and
tests(screenings)
Referral tracking
The healthcare team
The doctor-patient relationship is
replaced with a team-patient
relationship
Members of the team share
responsibility for care. The patient
perceives that the team is responsible
Visits are choreographed with various
team members (nurse, doctor, CM,
pharmacist, etc.)
Stepped care
Causes the least disruption to the person’s
life
Is the least extensive needed for positive
results
Is the least intensive needed for positive
results
Is the least expensive needed for positive
results
Is the least expensive in terms of staff
training required to provide effective
service
Stepped care (BH example)
1. Provide basic education and refer to
self help groups
2. Involve clinicians who provide
psycho-educational interventions
and make follow up phone calls
3. Involve highly trained BH
professionals who use specific
practice algorithms
4. Refer to specialty MH system
Four-Quadrant Clinical
Integration
II.
High BH
needs/Low
PH needs
IV.
High BH
needs/High
PH needs
I.
Low BH
needs/Low
PH needs
III.
Low BH
needs/High
PH needs
Four-Quadrant Clinical
Integration Service Delivery
II.
Served in
primary care
and specialty
MH settings
IV.
Served in
primary care
and specialty
MH settings
I.
Served in
primary care
setting
III.
Served in
primary care
setting
Four-Quadrant Clinical
Integration Examples
II.
Patient with
bipolar disorder
and chronic
pain
IV.
Patient with
schizophrenia
and metabolic
syndrome or
hepatitis C
I.
Patient with
moderate
ETOH abuse
and
fibromyalgia
III.
Patient with
moderate
depression and
uncontrolled
DM
Wide range of models in
practice
Can be thought of as a continuum of
Coordinated Care
Co-located Care
Integrated Care
Most models in practice currently are
hybrids of the above models
Coordinated care
Routine screening for BH problems
conducted in primary care
Referral relationship between PCP
and BH settings
Routine exchange of information
between both treatment settings
PCP delivers BH interventions using
brief algorithms
Connections are made between the
patient and community resources
Co-located care
Medical and BH services are located
in the same facility
Referral process for medical cases to
be seen by BH (and vice versa)
Enhances communication between
providers because of proximity
Co-located care
Consultation between providers to
increase the skills of both
Increase in the level and quality of BH
services offered
Significant reduction of “no-shows” for
BH treatment
Integrated care
Medical services and BH services are
delivered in the same or separate
locations
One treatment plan includes both
medical and BH elements
A team working together to deliver
care using a prearranged protocol
Integrated care
Teams composed of a physician and
one or more of the following: NP, PA,
nurse, case manager, family
advocate, BH therapist, pharmacist
Use of a database to track the care of
patients who are screened into
behavioral health services (and vice
versa)
A collaboration continuum
MINIMAL
BASIC
At a
distance
BASIC
On-site
CLOSE
Partially
Integrated
CLOSE
Fully
Integrated
Collaboration continuum
Minimal
BH and PCP work in separate facilities,
have separate systems, and
communicate sporadically
Basic Collaboration at a distance
PCP and BH providers have separate
systems at separate sites but now
engage in periodic communication about
shared patients
Collaboration continuum
Basic collaboration on-site
BH and PCP have separate systems but
share the same facility. Proximity allows
for more communication, but each
provider remains in his or her own
professional culture
Collaboration continuum
Close collaboration in a partially
integrated system
BH professionals and PCP share same
facility and have some systems in
common (i.e. scheduling, medical
records). Physical proximity allows for
face to face communication between
providers. There is a sense of being
part of a larger team.
Collaboration continuum
Close collaboration in a fully
integrated system
The BH and PCP are part of the same
team. The patient experiences the BH
treatment as part of his or her regular
primary care
For the patient
For the providers
BENEFITS TO INTEGRATED
CARE
Benefits to integrated care
Patient
Improved health
outcomes
Greater engagement
in participating in own
care
Decreased risk for
adverse events
Increased access to
services (less stigma,
more convenient)
Provider
Practice as a part of a
team who's members
support each other’s
efforts to help improve
the heath of patients
Learn from other
providers
Potential payment
incentives
CHALLENGES TO OVERCOME
TO FULLY INTEGRATE CARE
Challenges to overcome
Psychiatric resources are scarce
Telemedicine
Mentoring relationships
Primary care resources are scarce
Utilize non-physician staff (NPs, PAs)
Challenges to overcome
Privacy concerns limit access to
patient records across disciplines
HIPPA allows for sharing information for
the purpose of care coordination without
a formal consent. State laws are
sometimes more strict
There is discussion regarding federal
regulation CFR 42 (which regulates SA
services information) to allow sharing of
information for the purpose of treatment
coordination
Challenges to overcome
Payment and parity issues
Medical home models typically receive a
“per-member-per-month” fee, perhaps
the fee could be enhanced for members
in higher value quadrants
References
Collins, C. 2010. Evolving Models of Behavioral Health
Integration in Primary Care. New York, NY:Milbank Memorial
Fund.
Mauer, B. 2009. Behavioral Health/Primary Care Integration
and the Person-Centered Healthcare Home. Washington,
DC: National Council for Community Behavioral Healthcare.
Available at
http://www.allhealth.org/BriefingMaterials/BehavioralHealtha
ndPrimaryCareIntegrationandthePer sonCenteredHealthcareHome-1547.pdf.
Centers for Disease Control and Prevention. Public Health
Action Plan to Integrate Mental Health Promotion and Mental
Illness Prevention with Chronic Disease Prevention, 2011–
2015. Atlanta: U.S. Department of Health and Human
Services; 2011.
Discussion
Do you have any questions about the
presentation?
Are there any questions about my
practice?
What are you doing in your practices?
What challenges have you faced?
Any good outcomes or client
feedback?