Transcript Primary and Behavioral HealthCare Integration Project
PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION
Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida Anthony R. Bichel, Ph.D.
Apalachee Center Inc., Tallahassee, Florida Rick Hankey, Senior V. P. and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida
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LEARNING OBJECTIVES PROVIDE
AN OVERVIEW OF INTEGRATED BEHAVIORAL HEALTH AND PRIMARY CARE
INCREASE
KNOWLEDGE OF THE IMPLEMENTATION PROCESS AND SUSTAINABILITY
DESCRIBE
LESSONS LEARNED
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OUTLINE
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History
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Define The Problem Today
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What Changed? Why Now?
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What Is Integrated Care?
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The Implementation Process
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Sustainability
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Lessons Learned
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HOW DID PHYSICAL AND MENTAL HEALTH BECOME SEPARATED?
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HISTORY
1950 – 1960: Most people with mental illness were living in asylums.
In the 60s: Due to John F. Kennedy and advances in medical thinking, changed from institutional care to community based system.
1980 – 1990: Number of people living in tax funded institutions was reduced by 50%.
Today: Approximately one-fifth of the 1950s number reside in institutional care.
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PROMISES MADE AND PROMISES BROKEN
Money was intended to follow consumers into community programs. This didn’t happen.
Employer paid insurance had no reason to pick up the bill. Most didn’t.
Operating two systems: state and community. Never had enough money to fund both.
Community based mental health system has always been underfunded.
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TODAY PEOPLE WITH SMI DIE ON AVERAGE 25 YEARS SOONER THAN THE GENERAL POPULATION
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OF THE SIX MAJOR CAUSES OF DEATH IN THE UNITED STATES, THERE IS AN INCREASED RISK OF DEATH AMONG THE SERIOUSLY MENTALLY ILL
MAJOR CAUSE OF DEATH CARDIOVASCULAR LUNG CANCER STROKE RESPIRATORY DIABETES INFECTIOUS DISEASES INCREASED RISK OF DEATH 3.4 X 3 X 2 X IN THOSE LESS THAN 50 YEARS OF AGE 5 X 3.4 X 3.4 X
Bob Sharp, Fl Council For Community Mental Health Coastal Behavioral Healthcare
FACTORS INCREASING HEALTH RISK
Poverty Less likely to be screened Poor access to Primary Care Self-Care Capacity/Resource Cognitive, Affective and Behavioral symptoms Disconnectedness of “Physical” & “Mental” health care systems Weight Gain System Navigation Barriers Tobacco and Substance Abuse Medications
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WHAT'S CHANGED AND WHY CHANGE NOW?
4-Year Grant from The Substance Abuse And Mental Health Services Administration (SAMHSA) – $500,000 Per Year The Purpose Of The Grant Is To Improve The Physical Health Status Of People With Serious Mental Illness The Challenge Is To Establish A System That Bridges The Gap Between Mental Health Care And General Medical Care
“It’s the right thing to do!”
Linda Rosenberg of The National Council
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SAMHSA GRANT PROGRAM
$28
MILLION DOLLARS GIVEN TO
56
COMMUNITY BEHAVIORAL HEALTH CARE AGENCIES TO INTEGRATE PRIMARY AND BEHAVIORAL HEALTH CARE SERVICES FIVE REGIONS FLORIDA IS IN REGION
3
CA AK West Region (1) 10 Grantees OR WA NV HI ID AZ UT MT WY Central Region (2) 8 Grantees CO NM ND SD NE KS TX OK MN IA MO AR LA Midwest Region (4) 13 Grantees WI IL MI IN OH KY WV Northeast & Mid-Atlantic Region (5) 17 Grantees VT ME NH NY PA CT NJ RI DE DC MD MA VA TN SC NC MS AL GA Southeast Region (3) 8 Grantees FL
West Region 1 Central Region 2 AK: Wrangell Community Services CA: Mental Health Systems CA: Alameda Co Behavioral Health Care Services CA: Asian Community MH Services AZ: CODAC Behavioral Health Services CO: Mental Health Center of Denver TX: Montrose Counseling Center FL: Coastal Behavioral Healthcare FL: Lifestream Behavioral Center TX: Austin-Travis CO MH/MR Center FL: Miami Behavioral Health Center FL: Community Rehabilitation Center CA: Glenn County Health Services Agency CA: Tarzana Treatment Centers, Inc.
OR: Native American Rehab Assoc of the NW WA: Asian Counseling and Referral Services OK: North Care Center OK: Oklahoma Dept of MH/SA UT: Weber Human Services Southeast Region 3 FL: Apalachee Center, Inc GA: Cobb/Douglas Community Service Board SC: State Dept of MH Midwest Region 4 IL: Human Service Center IL: Trilogy Inc NE & MidAtlantic Region 5 CT: Bridges - A Community Support System CT: Community MH Affiliates IL: Hertiage Behavioral Health Center MA: Community Healthlink Inc IN: Adult & Child Mental Health Center ME: Community Health and Counseling Service IN: Southlake Community Mental Health Center FL: Lakeside Behavioral Healthcare IN: Centerstone of IN KY: Pennyroyal Regional MH/MR Board MI: Washetenaw Community Health Organization NH: Community Council of Nashua NJ: Care Plus NJ NJ: Catholic Charities, Diocese of Trenton NY: VIP Community Services WA: Downtown Emergency Service Center OH: Center for Families and Children OH: Shawnee MH Center NY: Postgraduate Center for Mental Health NY: Bronx-Lebanon Hospital Center OH: Southeast Inc.
NY: International Center for the Disabled OH: Greater Cincy BH Services NY: Fordham Tremont CMHC WV: Prestera Center for MH Services PA: Milestone Centers PA: Horizon House RI: Kent Center for Human/Org Development RI: The Providence Center MD: Family Services, Inc
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IT IS A TEAM-BASED MODEL WITH MEDICAL AND MENTAL HEALTH PROVIDERS PARTNERING TO FACILITATE THE DETECTION, TREATMENT, AND FOLLOW-UP OF BOTH MEDICAL AND PSYCHIATRIC DISORDERS IN A COMBINED SETTING.
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SAMSHA GOALS
REDUCE HEALTHCARE DISPARITIES ELIMINATE THE EARLY MORTALITY GAP REACH PEOPLE WHO CANNOT OR WILL NOT ACCESS PRIMARY HEALTHCARE SERVICES EARLY INTERVENTION AND DETECTION BEFORE ISSUES DEVELOP OR WORSEN
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ACHIEVING THE GOALS
IMPROVE HEALTH AND WELLBEING BY
• Regular screenings and registry tracking • On-site integrated primary care
prevention, screening, and treatment services
• Wellness education and support
activities
• Referral and follow-up
INCREASE CONSUMER PARTICIPATION THROUGH
• Peer involvement in the delivery,
planning and evaluation of services
• Advisory Committee involvement and
feedback
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STEP 1 – SUCCESS THROUGH PARTNERSHIPS STEP 2 - UNDERSTANDING DIFFERENCES STEP 3 - INTEGRATION MODELS STEP 4 – CRITICAL STEPS
Primary Care Grant Evaluator Laboratory Vendor Medical Supply Company Health Educators Community Stakeholders Business Alliances
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MANATEE COUNTY RURAL HEALTH SERVICES – Primary Care UNIVERSITY OF SOUTH FLORIDA – Grant evaluators SWEETBAY PHARMACY Healthy Saver Plus Program
• $7 annual enrollment fee for entire family • 450 generics at $4 per 30-day supply
DIABETIC STAFF AND PATIENT EDUCATION
• Dave Joffe, Sweetbay Pharmacist, • and Diabetes- in-Control, Editor in Chief
PHARMACIST INTERNSHIP PROGRAM
• Student Rotation Affiliation with • Lake Erie College Of Medicine
PFIZER MEDED GRANTS
• Application for funding of a Wellness Peer Advocate Coastal Behavioral Healthcare
They’re different! Acknowledge & Embrace it!
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PRIMARY CARE
PACE SETTING 15 minute appointment An exam room LANGUAGE Diagnosis, medical terminology, complaints
MENTAL HEALTH
50 minute session A comfortable office Assessment, mental health terminology, issues HIERARCHY Clear – Doctor in charge FLOW Flexible patient flow Coastal Behavioral Healthcare Diffuse – Administrator in Charge with Medical Director Scheduled client flow
Integration Model
MINIMAL COLLABORATION BASIC COLLABORATION FROM A DISTANCE BASIC COLLABORATION ON SITE COLLABORATIVE CARE PARTLY INTEGRATED FULLY INTEGRATED SYSTEM
Level of Integration
I II III IV V Coastal Behavioral Healthcare
Attributes
SEPARATE SITE & SYSTEMS MINIMAL COMMUNICATION ACTIVE REFERRAL LINKAGES SOME REGULAR COMMUNICATION SHARED SITE; SEPARATE SYSTEMS REGULAR COMMUNICATION SHARED SITE; SOME SHARED SYSTEMS COORDINATED TREATMENT PLANS REGULAR COMMUNICATION SHARED SITE, VISION, SYSTEMS SHARED TREATMENT PLANS REGULAR TEAM MEETINGS
Organizational Buy-in and Plan Establish Contracts Hire Staff Billing – Opportunities for Sustainability Data Tracking and Collection
Before admitting the first patient, consider:
Space Policies & Procedures Documentation Registration and Scheduling Primary Acute Care Services – Offerings and Expense
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Physical History BMI LDL Abdominal Circumference Co-Occurring Personal Risk Factors Blood Pressure and Pulse HDL TSH Risk of Harm Family Risk Factors Fasting Plasma Glucose Height Total Cholesterol Cholesterol / HDL Ratio Medication Review Depression Screening Complete Metabolic Panel Liver Function Studies NOMS Weight Triglycerides A1C CBC with Differential Physical Exam
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NUTRITIONAL EDUCATION FOOD TOURS HEALTHY COOKING DIABETES EDUCATION PHYSICAL ACTIVITY ED SMOKING CESSATION
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ILLNESS SELF-MANAGEMENT STRESS MANAGEMENT PEER SUPPORT RECOVERY ACTIVITIES EXERCISE INSTRUCTION MEDICATION MANAGEMENT
SUSTAINABILITY WHEN THE FUNDING STOPS
COMPLICATED REIMBURSEMENT – CPT AND ICD-9 CODING SAMSHA’S TARGET POPULATION MUST BE EXPANDED IN ORDER TO SUSTAIN INTEGRATION MODEL
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TARGET POPULATION 18 YEARS OR OLDER SMI-12MONTH DURATION GAF BELOW 60 UNINSURED LACK OF SAME DAY SERVICES REIMBURSEMENT UNDER MEDICAID
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SENIOR LEADERSHIP INVOLVEMENT IS CRITICAL SET GOALS … DEVELOP A ROAD MAP
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FORCE INTEGRATION AT EVERY OPPORTUNITY
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BROAD BASE HOLISTIC CARE … NO SILOS
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HIRE AT LEAST ONE EXPERT IN PRIMARY CARE COST OF PROVIDING PRIMARY CARE IS MORE EXPENSIVE THAN THAT OF MENTAL HEALTH CARE
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WORK ON SUSTAINABILITY IMMEDIATELY … YEAR ONE FOSTER PARTNERSHIPS … CAN INCREASE OFFERINGS WITH LITTLE COST EDUCATING AND ASSISTING PATIENTS IN MANAGING THEIR HEALTH CARE IS VITALLY IMPORTANT. PROVIDING THE SAME ASSISTANCE TO THEIR CARE GIVERS IS ESSENTIAL!
ELECTRONIC HEALTH INFORMATION RECORDS ARE GREAT! PAPER CHARTS ARE NOT!
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CASE STUDY
56-YEAR-OLD WHITE FEMALE MAJOR COMPLAINT: Acute leg ulcers MEDICAL HISTORY: Major Depressive Disorder Generalized Anxiety Diabetes Hypertension Asthma Hyperlipidemia MEDICATION REGIMEN: No Change In More Than 1 Year
CASE STUDY
PHYSICAL EXAM: Weight 302: height 5’1” Blood Pressure: 148/90 Pulse 88 bpm; resp. 22 per minute Lungs clear; no wheezing, rales or rhonchi Lower extremities: + 2 pitting edema bilaterally; pulses fair LABS: ABNORMAL OR RELEVANT LABS ONLY Hemoglobin A1C: 9.2 (normal range 5.9-7) Creatinine: 0.7 mg/dl (normal range: 0.7-1.4 mg/dl) Blood Urea Nitrogen: 18mg/dl (normal range: 7-21) Sodium: 140 mEq/l (normal range 135-145mEq/l LIPID PANEL: Total Cholesterol: 211 mg/dl (normal range<200 mg/dl) LDL, Triglycerides: 10% Above normal in all three Liver function panel: within normal limits
ASSESSMENTS
Poorly Controlled, Severe, Persistent Asthma Foot Ulcer On Left Foot Dyslipidemia : Elevated LDL Despite Statin Therapy Persistent Lower-extremity Edema Despite Diuretic Therapy Hypokalemia Hypertension Elevated Coronary Artery Disease Stable Obesity Stable Financial Constraints Affecting Medication Behaviors Insufficient Patient Education Regarding Purpose And Role Of Medications Wellness, Preventive And Routine Monitoring Issues
OUTCOMES
REFERRAL TO ENDOCRINOLOGIST SAME–DAY APPOINTMENT PATIENT REFERRED BACK TO INTEGRATED PROGRAM WITH MEDICATION CHANGES AND MONTHLY FOLLOW-UP APPOINTMENTS WITH ENDOCRINOLOGIST AMPUTATION AVOIDED - ENDOCRINOLOGIST REPORTED THAT LEFT FOOT AMPUTATION WOULD HAVE RESULTED IF NOT FOR IMMEDIATE REFERRAL
RESOURCES
Aetna Depression In Primary Care Cherokee Health Systems – Training Programs Commonwealth Of Pennsylvania Screening, Brief Intervention, Referral And Treatment Hogg Foundation For Mental Health – Resource Guide Integrated Behavioral Health Project (IBHP) – Tool Kit Integrated Primary Care, Inc.
Intermountain Behavioral Health Program John A. Hartford Foundation- Improving Mood: Promoting Access To Collaborative Care National Council For Community Behavioral Health Care Substance Abuse And Mental Health Services Administration SAMHSA University Of Massachusetts Certificate Program In Primary Behavioral Health Care HRSA- Starting A Rural Health Clinic – A How To Manuel Coastal Behavioral Healthcare
Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida [email protected]
941-331-2530 ext. 1110 Anthony R. Bichel, Ph.D.
Apalachee Center Inc., Tallahassee, Florida [email protected]
850-459-7025 Rick Hankey, Senior Vice President and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida [email protected]
352-315-7810
Coastal Behavioral Healthcare