Transcript Care Coordination and Behavioral Health

Session B5a
October 18, 2014
How to Crash the Party:
Bringing Behavioral Health Specialists to
the Care Coordination Team
Mary Jean Mork, LCSW
Director of Integration
MaineHealth and Maine Behavioral Helathcare
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
 I have not had any relevant financial relationships
during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
 Identify barriers and success factors for care coordination.
 Identify a “success factor” to immediately address.
 Create a plan for addressing this factor upon return to work.
Learning Assessment
 A learning assessment is required for CE credit.
 A question and answer period will be conducted at the end of
this presentation.
Agenda
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Description of Care Coordination (CC) Team
Challenges for Behavioral Health Specialists (BHS)
Role and value of BHS on the team
Success factors and strategies for maximizing team
effectiveness
 Activity – Developing Action Plans
 Question and answer period
Patient Centered Medical Home (PCMH)
– the Concept
(Behavioral Health)
From deGruy 10.10
Internet Citation: Figure 1. Family tree of terms in use in the field of collaborative care: A National Agenda for Research in Collaborative Care. June 2011.
Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/collaborativecare/collab3fig1.html
Care Coordination
The deliberate organization of patient care
activities between two or more participants
involved in a patient’s care to facilitate the
appropriate delivery of health care services.
From: Safety Net Medical Home Initiative. Care Coordination: Reducing Care
Fragmentation in Primary Care. Implementation Guide. May 2013
“If a person doesn’t have a roof over their head, if they don’t
have a meal, if they’re a victim of physical or sexual abuse if
their household has a lot of stress in it, if their kids’ school is not
safe, then that's going to impact their health…..that health is
more than just the pill that we’re giving you or the hospital that
we put you in. It’s all the other parts of your life and whether
they’re working in harmony.”
Dr. Jeffrey Brenner in interview “What Primary Care has to Learn from Behavioral Health”.
National Council for Behavioral Health.
Meet George
Barriers to Care Coordination:
Roles
Rules
Arrangements
Turf
Who is involved?
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Care Managers
Case Managers
Behavioral Health Clinicians
Care Coordinators
Transition coaches
Peer navigators
Health coaches
RN’s in the practice
Primary care providers
Primary care staff
Family and community supports
Other?
Primary Care
Mental Health
Preventative and
Acute Care
Chronic Care
High Utilization
Chronic Care with MH
Dx
Substance Abuse
High Utilization with
MH Dx
Treatment Team
• Case Manager
• Team Leader – LCSW
• Peer/Youth Support
• Psychiatry
• Medical Director
Care Team
• Provider
• Nurse
• Medical Assistant
• Integrated BH Clinician
• Nurse Care Manager
• Health coach/navigator
“We're all going to have to give up
some turf. After all, it's actually the
patient's turf.”
Robert McArtor, MD, CMO MaineHealth
Patient Population
Hospital
Patients
Specialty Medical
Care
Other
Complex
Patients
Primary Care
Coordinated Care Team
(Potential Team Members)
Care Manager
PCP and
Behavioral Health Clinician
Care Coordinator
Clinical Care
[Type a quote
from the document or the
Engagement Specialist
summary
of an interesting point. You can Team
Health Guide
Complex
position the text box anywhere in the
Resource Specialist
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document.
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change the formatting
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Peer Navigator
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Manager
CCT social worker
Specialty Mental Health
Care
Psychiatric Consultation
Care Plan Team
Care Coordination System Management
Care Coordination and
Behavioral Health
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Saturday, September 20, 2014
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Q1: Describe your involvement on the care coordination team
Q2: I If you have tried to have more involvement in care
coordination activities, what barriers have you experienced?
Q3: If you are presently involved in care coordination activities in
your practice, what has been most successful in helping be part
of these activities?
What else did I hear?
 “It was horrifying. We don’t have anything in our
practice.”
 “We can’t coordinate unless there’s a mistake in
scheduling, because she (the care manger) uses the
office when I’m not there.”
 “Who is my team?”
 “I didn’t fill it out because it doesn’t pertain to me.”
Complex Care Teams
(Social, behavioral and medical complexities)
Providing:
Behavioral
Health
Needs
Medication
Access
Community
Resource
Needs
Complex
Coordination
Needs
• A multidisciplinary
approach to complex
care coordination;
• Team collaboration;
• Community resource
partnerships, and
• Standardized best
practice interventions
BHS’s value on CC team
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Direct service to Patient
Link to specialty MH and SA treatment
Liaison to psychiatric services
“Triage” role with psychiatry referrals.
Consultation to CC team
System perspective
 Behavioral lens for medical system
 Medical system lens for behavioral health
 Expertise with individualized care plans tailored to patient
 Patient and family centered focus
Common Challenges for BHS
 Population health
 Using data to inform work
 Understanding nuances of different care
management roles
 Clarifying roles around behavioral change,e.g.
with health coaches
 Ability to access specialty MH, SA and psych
services
CC Success Factors
 Clarity, connection and non-duplication of:
 Roles
 Functions
 Responsibilities
 Clarity about population being coordinated
 Timely and accurate data
 Tracked and shared outcomes
 “Partnership” approach to care
 Individualized patient centered planning process for care plans
 Shared Care plans and “alerts” throughout system
 Standardized coordination of care
 “Team” members have assigned tasks based on individual care plan
 “Team” lead to manage complex care situations
Strategies to Improve CC
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Identify who is coordinating care
Identify leaders
Multidisciplinary case presentations
Target specific patients, design services around individual’s
goals, coordinate care, track results
 Identify impact measures, e.g. ED usage for specific
populations
 Make connections with community providers and continuum
of care
Additional considerations for CC
 Funding – are there:
 New funding streams that support this work?
 Cost savings and medical cost offsets?
 Honor the patient voice in development of the
care plans
 Value and nurture the team relationships!
Resources
Websites
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http://integrationacademy.ahrq.gov/ - AHRQ Academy for Integrating Behavioral Health and
Primary Care
www.uwaims.org - Advancing Integrated Mental Health Solutions – resources for implementation
from University of Washington
www.integratedprimarycare.com – National clearinghouse site for information on integrated care
from University of Massachusetts.
www.integration.samhsa.gov - SAMHSA-HRSA Center for Integrated Health Solutions
www.thenationalcouncil.org – the National Council for Community Behavioral Healthcare.
Publications
 IHI Innovation Series 2011. Craig, et.al. Care Coordination Model: Better Care at Lower Cost
for People with Multiple Health and Social Needs.
 http://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf
 Reducing Care Fragmentation: A Toolkit for Coordinating Care
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!