Transcript Slide 1

Strengthening Relationships
Between Primary Care and
Behavioral Health
Mary Jean Mork, LCSW
Neil Korsen, MD, MSc
April 17, 2009
Outline of Presentation
 Who are we and where do we come
from? – Our model
 The importance of team
 The Culture Clash challenge
 Communication
 Levels of Integration
 How to improve
 Where are you?
Objectives
Attendees will:
1. Be able to identify their level of
integration
2. Describe steps they can take to
increase their level of integration
3. Articulate components of effective
communication for integrated
practice
Mental Health Integration in Maine
MaineHealth Members and
Affiliates
PenBay
MaineGeneral
Stephens Memorial
St. Andrew’s
St. Mary’s
Miles Memorial
Spring Harbor
Maine Medical
Center
Midcoast
SMMC
Primary Care and Mental Health
Primary Care
• Multi-site Practices •
• Hospital-owned
Practices
• Residency Practice •
• Solo Private
Practice
•
• FQHC look-alike
• Rural Health Clinics •
Mental Health
Medical Center
Outpatient
Psychiatry
Hospital-owned
Behavioral Health
Community Mental
Health Centers
Consumer Case
Management Agency
Primary Care Medical Home
Specialty
Mental
Health
Standardized
Assessment &
Risk Stratification
Support for
Behavioral
Change
Mental Health
Treatment &
Consultation
Care Management
Community Resources
e.g., NAMI
Team building
Our integrated faculty team
 Medical Director – Family Physician
 Program Managers
 LCSW
 Educator with health science background
 Psychiatrists
 Child
 Adult
 Administrative Professional
Mental Health Integration:
Team 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
Psychiatrist
Or APRN
Consult, Train
NAMI
Community
Resources
Family
Support
Who needs to build relationships?
 Program staff (with each other)
 Program staff and participating organizations
 Primary care and mental health
administrators
 Primary care team, mental health provider,
care manager
The foundation of teamwork is interpersonal
relationships
Relationship building:
MHI faculty role
 Get people together – learning
sessions, conference calls, site visits,
listserve
 Facilitate the conversation
 Listen
 Provide knowledge and tools
 Be encouraging
 Never give up!
Relationships with Patients:
The Benefit of Integration and
Collaboration?
Patients who:
 Experience their life problems as “medical”
 Have not been socialized to the concept of
“emotional distress” or to the idea of
therapy
 Feel blamed by a referral to Mental Health
 Feel abandoned by a referral to Mental
Health
 Patients dealing with behavioral or
emotional aspects of medical conditions
High risk populations
 People with chronic illnesses or chronic
pain
 People with a disability
 Kids with school, sleep or behavior
problems
 People with persistent somatic complaints
and negative medical work-up
Patients in Integrated Care compared to
Specialty Mental Health
 More likely to be first mental
health contact
 Less psychologically “sick”
 Less likely to define themselves as
impaired
 Require fewer visits
Primary Care and Mental Health:
The Culture Clash Challenge
Mental Health
Specialist in
Primary Care:
How about those
differences?
Mental Health Specialist in Primary Care:
Other Differences
Primary Care
Mental Health
Pace
15 minute appointment
50 minute sessions
Setting
An exam room
A living room
Language
Diagnosis, medical
terminology, complaints
Assessment, mental health
terminology, issues
Hierarchy
Clear – Dr. in charge
Diffuse – Administrator in
charge with med director
Flow
Flexible patient flow
Scheduled client flow
Levels of Integration
Improving Relationships at
Every Level
Levels of Integration
Level of
Integration
Attributes
Minimal
Collaboration
I
Separate site & systems
Minimal communication
Basic
Collaboration
from a distance
II
Active referral linkages
Some regular communication
Basic
Collaboration
on site
III
Shared site; separate systems
Regular communication
Collaborative
Care
partly integrated
IV
Shared site; some shared systems
Coordinated treatment plans
Regular communication
Fully Integrated
System
V
Shared site, vision, systems
Shared treatment plans
Regular team meetings
Modified from Doherty, McDaniel, and Baird - 1996
What is your level of integration?
What is keeping you from getting
to the next level?
Is there one thing you could do
soon, that would enable you to get
to the next level?
Level One:
Starting to Connect
 Ask your clients about their
primary care/mental health
provider and get a release
 Identify patients who could use
better coordination – contact
their providers
 Contact key providers in your
area
 Those treating your most complex
clients
 Those treating a group of your
patients
Level Two:
Building on Basic Collaboration
 Garner invitation to staff
meeting
 Identify clear processes
and expectations around
communication
 What should they expect
to get from you?
 What do you need to hear
from them?
 How can you share
information better?
Level Three:
Sharing More than Space
 Set up regular times to “meet”
 Clarify expectations around
communication & treatment
coordination
 Begin to “share” processes, e.g.,
scheduling
 Work out record-sharing
 Define team relationships
Level Four:
Increase the Integration
 Clarify team mission and roles
 Formalize team expectations –
when to meet, what to share,
etc.
 Set up streamlined processes
for communication and
treatment coordination
 Develop ways to learn from
each other
 Celebrate successes
Level Five:
Maintaining & Continuously
Improving
 Set up formal and informal
learning opportunities
 Maximize use of staff
meetings, case conferences,
huddles, and hand-offs
 Always work on improving
relationships – both within
the team and the larger
community
 Remember that the patient is
the focus of the work
Communication between Physician
and MHP
Information Exchange between
Providers
 At any level
 Confidentiality fosters splitting
 Blanket information release with the goal of
enhancing collaborative care
 In a Co-located – Integrated Practice
 “Curbside consultations”
 Behavioral health rounds
 Take the clinician conversation into the
exam room
 Use words that do not require a physical or
psychosocial definition of the problem
When might the MHP be useful?
Think SSRI:
Situation
Skill-set
Relationship
Indicators or outcomes
Certificate Program in Primary Care and Behavioral Health. Department of Family
Medicine and Community Health, University of Massachusetts Medical School. Alexander
Blount, EdD, Director
Example
“I’d like to have my colleague, Ms. Peterson,
work with us to help you figure out ways to
reduce your stress in the evenings. She has a
great deal of experience helping parents come
up with bedtime routines. I think that if your
kids went to bed better, you would be less
stressed, and your headaches might be reduced.
What do you think?”
Successful Communication with
Primary Care
 Note specific information from the
patient/client that might effect
treatment
 Describe the specific indicators and
how they have changed
 Share what the patient/client reports
as meaningful
 Discuss how the Physician and
Mental Health Clinician can work
together on the treatment
Example
“I met with Ms. Brown and she agrees
that she gets as “wound up” as her kids
at night. We came up with some calming
bedtime activities for the whole family
and she agreed to try this for two weeks
and report back to us on whether her
headaches are reduced with her “winding
down” routines. She also agreed to take
her medication as prescribed during this
time.”
Partnership Development
Partnership development
 Describe your mh/pc partnership
when you began mental health
integration – how did it feel?
 Use 1-2 word descriptions
Beginning Stage - quotes
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Part I
Disconnected
Skeptical
Impatient
Optimistic
Hopeful
Eager
Fortunate
Partnership development
 Describe your mental health/primary
care partnership at 3-6 months how did it feel?
 Use 1-2 word descriptions
Middle Stage - quotes
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Matching faces to names
More comfortable
Continuing the work
Still learning
Frustrated (e.g., over credentialing)
Challenged by the details
Impressed with the accomplishments
Part II
Partnership development
 Describe your mental health/primary
care partnership now (12-18
months) – how does it feel?
 Use 1-2 word descriptions
Mature Stage - quotes
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Comfortable
In sync
Efficient
Work is rewarding
Model is sustainable
Very excited and
impressed
 Mission driven as
a team
 Not yet done
 Helpful to people
being served
 Crucial – can’t live
without it
 Fragile
Fred and Eleanor