Transcript Integrating Behavioral Health and Physical Health:

Integrating
Behavioral Health and
Physical Health:
The Time is Now
Introductions
 Noreen Fredrick
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Executive Director
Mon Yough Community Services
McKeesport, PA
 Stephen Christian-Michaels
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COO
Family Services of Western Pa
New Kensington, PA
Overview
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Health Status of People with SPMI
Fractured System
Models of Integration
Chronic Care Model
Impact Model
Person Centered Healthcare Home
Cherokee Model – CMHC/FQHC
Research Based Best Practice Components
Types of Integration Initiatives
Family Services of W. Pa Experience
Mon Yough Experience
Health Status of People with Serious
Mental Health Diagnoses
 High prevalence of modifiable risk factors:
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Obesity; tobacco use and alcohol use
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Group homes -- exposure to infectious diseases
-- peers negatively influencing unhealthy risk factors
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60% of premature deaths in individuals with schizophrenia due to:
cardiovascular disease
pulmonary
infectious diseases
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Higher rates of COPD and Diabetes than in the general population
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Premature death - 25 years younger than the general population.
 Medication side effects often exacerbates health status
Health Status of People with Serious
Mental Health Diagnoses
 Hispanics, African Americans or Asian and Pacific
Islanders have varying disparities in death rates
 The widest gap is seen in black males with a life
expectancy of 69.5 years in 2004, 8.3 years shorter
than the national average.
 None have a life expectancy that is equivalent to
those with serious mental illness. 25 years……..
This disparity is alarming
Health Status of People with Serious
Mental Health Diagnoses
Adults in Health Choices:
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Annual increases: 24% - 28% (new consumers)
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Main Diagnoses
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Have not previously used services
In addition to already burgeoning caseloads
27% major depression
23% schizophrenia
15% bipolar disorder
15% other depressive disorders
About 40% co-occurring
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51% MH only
6% substance abuse/dependence only
Health System is a Fractured System
 People not identified w/depression early enough
 Post Partum Depression often not diagnosed
 75% Anti-Depressant meds prescribed by PCP’s
 PCP’s often discontinue anti-depressant before
full effect is realized
Community Mental Health/Primary
Care Split
•Consumers not engaged with PCP……
…….use Emergency Departments for routine care
•PCP’s often feel unprepared to deal with behavioral health disorders
•PCP’s frustrated when they refer into CMHC’s
long waiting lists, drop out’s before first appointment/soon after
•CMHC’s feel unprepared to deal with even routine health issues
•CMHC’s busy, refer people back to PCP’s for depression, ADD, etc
•No infrastructure readily available to enhance communication
•Difficult for real communication given busy schedules
What contributes to the Fractured
Health System
 Billing systems are different
 Evolving EHR are usually separate w/no interfaces
 BH is carved out of managed care plans
 Referrals from PCP’s tend to be to MD’s they know
 Psychiatry is the lowest paid specialty of physicians
 Psychiatry/Therapy split off from medicine
Integrated Care: To Be Or NOT
 Models of integration
 Separate Locations – Coordinated cross referral
 Co-Location – BH on site, parallel practice
 Integrated/Joint Care – separate but combined
 Integrated Centers - Fiscally and Structurally
 Integrated Health Systems – Kaiser HMO
 5 Years from now in a reformed healthcare system
there may not be a role for CMHC’s that are not
involved in Integrated Care
Characteristics of Current System
 Current care is crisis driven
 Provider centric not patient/consumer centric
 Care is episodic and reactive
 There is not a life time view of disorders
 Care tends to be more modality driven, not
population driven
Chronic Care:
A Model to Assist in Integration
 Developed by Edward H. Wagner, MD, MPH
MacColl Institute for Healthcare Innovation
 Organized, planned & productive interactions improve outcomes:
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More fully engage individual is in self care activities and
Leads to better health outcomes.
 People w/SMI share same characteristics as chronic physical
conditions:
dealing with symptoms
emotional impact
complex medication regimens
difficult to obtain helpful care
disability
family issues
difficult lifestyle adjustments
Used with permission.
Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses?
Effective Clinical Practice , Aug/Sept 1988 Vol 1
Essential Element of Good Chronic Illness Care
Informed,
Activated
Patient
Productive
Interactions
Used with permission.
Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses?
Effective Clinical Practice , Aug/Sept 1988 Vol 1
Prepared
Practice
Team
What characterizes an
“informed, activated patient”?
Informed,
Activated
Patient
They have the motivation, information, skills,
and confidence necessary to
effectively make decisions about
their health and manage it.
Used with permission.
Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses?
Effective Clinical Practice , Aug/Sept 1988 Vol 1
What characterizes a
“prepared” practice team?
Prepared
Practice
Team
At the time of the interaction they have
the patient information, decision support, and
resources necessary to deliver
high-quality care.
Used with permission.
Wagner, E., Chronic Disease Management: What Will it Take to Improve Chronic Care for Chronic Illnesses?
Effective Clinical Practice , Aug/Sept 1988 Vol 1
Six Components of Chronic Care Model
 Self-Management Support – individuals are supported in
achieving goals and fully engaged in care.
 Delivery System Design – transform practice form
reactive to planned and proactive.
 Decision Support - care is based on evidence based
guidelines and uses systems to inform and prompt
providers and individuals about care needs.
Six Components of Chronic Care Model
 Clinical Information Systems – use of registries to provide
patient specific and population based support to teams,
reminders, data and provider feedback. With the correct tools
providers can analyze all of their consumer needs, access
recent lab work, prescriptions filled, and visits.
 Community – utilize resources in the community. This is a
natural strength for the CMHC with integration existing as
part of the community supports.
 Health System – creation of a quality oriented system
through leadership and continuous quality improvement.
Four Quadrant Integrated Care Model
 The NCCBH proposed model for the clinical integration of health and
behavioral health services starts with a description of the populations
to be served.
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• Quadrant I:
Low MH - Low PH, served in primary care
BH staff on-site provides services
 • Quadrant II: High MH - Low PH, served in the MH system
PH service provided at CMHC
 • Quadrant III: Low MH - High PH, served in primary care
BH staff on-site provide services
PH case mgt provided
 • Quadrant IV: High MH - High PH, served in MH system with
specialty care case management
for both PH and BH disorders
National Council for Community Behavioral Healthcare
The Person-Centered Healthcare Home
Stepped care clinical approach
Healthcare implemented bi-directionally
A. Identify people in primary care with behavioral health
conditions ands serve them there unless they need stepped
specialty behavioral health care; and
B Identify and serve people in behavioral health care that
need routine primary care and step them to full-scope
health care home for more complex care
www.TheNationalCouncil.org/ResourceCenter
Impact Model - Depression
 Collaborative care – individual PCP’s works with BH care
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manager/behavioral health consultant to implement a
treatment plan with consultation with the psychiatrist and
pharmacist
Depression Screen of all Patients in Medical Practice
Motivational Interviewing, Behavioral Activation and
Problem Solving Therapy
Goal is to make incremental changes in life style practices
Medication prescribed by PCP
Health registry used to
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Prompts follow-up sessions, outreach, staged interventions
Collects medical and behavioral health data
Tracks changes, outcomes
Cherokee Model
 Fully integrated structurally and financially
 Combined Services
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Community Mental Health Center
Federally Qualified Health Center
National Council for Community Behavioral Health Care
Federally Qualified Health Centers
Possible Structures
 FQHC and CMHC merged to one organization
 Federally Qualified Health Centers provides its own
BH services via its own staff = integrated team
Funding from one stream, One EHR
 Federally Qualified Health Centers with contracted
CMHC services integrated
 CMHC co-locates staff at FQHC and provides BH
services in a parallel practice…one stop shop
Research Based
Best Practice Components
 Regular screens & registry tracking/outcome measurement
 Medical nurse practitioners/PCP located in BH clinic
 Primary care supervising MD
 Embedded RN care manager
 Evidenced based practices to improve health of SMI pop.
 Wellness programs
National Council of Community Behavioral Health Care
Integration Initiatives
 Screening of Depression for all PCP patients (PHQ-9)
 Screening for Unhealthy Substance Use (SBIRT)
 Screening of Post Partum Depression – OB and
Pediatricians
 Depression Screening, Motivational Interviewing,
Behavioral Activation, Problem Solving Therapy
(IMPACT)
 Medical Services provided in MH Centers
Challenges
 We need to be part of putting the mind and body
back together
 Healthcare reform is going to drive more focus on
integration
Family Services Experience
 Co-location
 Integrated Care, BH service at Medical Clinic
 Proposed Medical Services at CMHC
Family Services – Co-Location
 MD Frustration at long waiting time to see Psychiatrist
 MH CRNP at Family Practice office in New Kensington
(UPMC)
 Started at ½ day/week, moved to two half days per week
 50 – 75 new clients seen per year
 Moderate Depression, often linked to MH Clinic
 Very little collaborative care
 Some phone consultation between MD and Psychiatrist
Family Services –
Integrated Care at Medical Clinic
 Partnership matured
 Agreed to seek out funding to move to integrated care
 Together support regional Integrated Care Summit mtg
 Family Practice-UPMC started screening for Depression
 Applied for several grants, not funded
 Approached Managed Care Company
 Managed Care – Health/BH – funded project/collect data
Family Services –
Integrated Care at Medical Clinic
 Foundation sought out partnership along with 3 other sites
 Goals:
 Establish communication policies between medical & BH Providers
 Increase the appropriate assessment & utilization of BH services
 Decrease:
 Emergency Department usage
 hospital admissions
 Re-admissions
 Hospital length of stays
 Assure that BH provider is a financially viable position
Family Services –
Integrated Care at Medical Clinic
 IMPACT/Depression Screening
 SBIRT/Unhealthy Substance Use Screening
 Engagement/Behavioral Activation/Problem Solving
Treatment
 Grant fund position for 18 months
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Goal: Demonstrate ability to reduce by 6 inpatient hospital
admits
Pgh Regional Healthcare Initiative provides consult/project
mgt
 University of Washington/IMPACT provides
 Training
 Consultation
 Health Registry
Family Services
Medical Services at CMHC
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SAMHSA Proposal
Family Practice staff contracted to provide medical services
MD, Nurse Practitioner and Nurse become part of MH Teams
Build a physical fitness center at CMHC
Peer support used to engage consumers in healthy lifestyles
Build EHR Interfaces to share summary notes
Build Health Registry into BH EHR to implement Chronic
Care Model
 Change physical layout of office for (4) interdisciplinary teams
 Services:
Health Screening, Nutrition Counseling, Fitness Groups
Health Improvement plans, Consultation, Care Mgt
Mon Yough Experience
SAMHSA Grant: Emerg Dept Diversion
 Partners:
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UPMC for Life
UPMC McKeesport Hospital
Latterman Family Health clinic
UPMC McKeesport Internal medicine
MYCS
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Decrease Emergency Department usage
Determined Access as the issue
Increased midlevel practitioner time at Latterman and
MYCS as we agreed that we all serve the same group of
clients
Mon Yough
Evolution of the Partnership
 Grant led to beginning of “partnership model” between
Latterman Family health and MYCS.
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CRNP .5 FTE located in Behavioral health clinic
Primary care supervising physician
Imbed Psych Rehab in clinic setting to promote wellness as
core goals and work with nursing staff to structure wellness
activities
 Next Steps:
 Create registry tracking
 Embed evidenced based practice in daily practice
Mon Yough
Chronic Care Model  CMHC
 Development of a “chronic care” team
within adult Outpatient clinic
 Co-locate
treatment; psych rehab,
supported employment and service
coordinator in one area
 PH
and BH team live in the same
building
Mon Yough
Perinatal Depression Project
 Rand project – targeting perinatal depressed Moms in a
variety of settings including OB clinic; pediatricians
 MYCS partnered with Magee in Clairton
 Behavioral health time provided on site
 Lessons learned…
 Helped with imbedding of BH case manager in Latterman
clinic to assess need /level of support and type of integration
 Next Step use existing “SHIP” infrastructure to create
collaboration among community using logic model approach
Mon Yough
Training the Work Force
 Latterman Clinic is a Family Practice education site.
 MYCS will serve as the rotation site for dual boarded
Family Practice/Psych Fellowship 4 hours a week
 Latterman Clinic
 Provide physical health care in MYCS clinic
 Provide supervision of primary care at MYCS clinic
 MYCS will serve as the psych rotation education site
for Family Practice Residents
Learning Collaborative
 Set up learning collaboratives
 Use consultants to help cross walk systems
 Share information across projects
 Examples:
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Collaborative learning across BH and PH
Collaborative learning across CMHC’s
List Serves on Integrated Care
Regional Learning Collaboratives
Resources
 Wagner, E., Chronic Disease Management: What Will it
Take to Improve Chronic Care for Chronic Illnesses:
Effective Clinical Practice, Aug/Sept 1988 Vol. 1
 National Council of Community Behavioral Health Care.
Winter 2009. A Two-Way Street Behavioral Health Care and
Primary Care Collaboration.
 Morbidity and Mortality in People with Serious Mental Illness,
National Association of State mental Health program Directors,
Medical Directors Council; Editors: parks, Svendson, Singer,
Foti, Technical Writer: B Mauer. October 2006; Report
available at www.namsmhpd.org
 List Serve:
http://lists101.his.com/mailman/listinfo/pc-bh-integration
Contact Information
Noreen Fredrick
[email protected]
(412) 673-8035
Stephen Christian-Michaels
[email protected]
(412) 820-2050 x438