Transcript Reverse Co

REVERSE CO-LOCATION:
INTEGRATING PRIMARY CARE
INTO A BEHAVIORAL HEALTH
SETTING
Lawrence A. Real, MD
Medical Director
Horizon House Inc
Philadelphia DBHiDS
June 2013
WHAT IS “REVERSE COLOCATION”?
Primary care located
within a behavioral
health setting
WHY BRING PRIMARY CARE INTO THE
BEHAVIORAL HEALTH SETTING?
Because our
people are dying!
INCREASED MORBIDITY
AND MORTALITY
 People with serious mental illness (SMI) die on
average 25 years earlier than the general
population
 Though suicide and injury account for maybe
1/3 of this, 60% of premature deaths are due to
preventable medical conditions, and most of those
due to cardiovascular disease
 These preventable medical conditions are linked
to high rates of modifiable risk factors
Parks et al, Morbidity and Mortality in People with Serious Mental Illness, National Association of
State Mental Health Program Directors, October 2006
Reversing Early Mortality Due to Obesity and Cardiovascular Risk Factors in Mental Illness: What
Works in Changing Health Behaviors Bartels Feb ‘12
MODIFIABLE RISK FACTORS
 High incidence of smoking
Individuals diagnosed with psychiatric disorders
smoke ~ ½ the cigarettes smoked in U.S.
 Sedentary life style
 High rates of obesity, poor nutrition
Over 42% of people with SMI are obese**
 Co-morbid substance use disorders
 Limited access to quality
healthcare?
*National Epidemiologic Survey on Alcohol & Related Disorders, 2002
**Dartmouth Health Promotion Research Team, 2012
SPECTRUM OF COLLABORATIVE
CARE MODELS
Coordination
Co-location
Integration
“COLLABORATIVE” vs “INTEGRATED”
Collaborative care involves behavioral health
working WITH physical health… [or vice versa]
Integrated care involves behavioral health
working WITHIN, and as a part of, physical
health… [or vice versa]
In collaborative care, patients perceive
behavioral health care as a separate service
received from a specialist…[or vice versa]
In integrated care, patients perceive
behavioral health care as a routine part of
primary care…[and vice versa]
Strosahl, in Integrated Care: the Future of Medical and Mental Health
Collaboration, 1998
Bottom Line on Co-location

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Co-location does not equal integration!
It does, via physical proximity, create an
opportunity for improved collaboration
The devil is very much in the details,
i.e., how well you plan and execute
How are we attempting to integrate
care at Horizon House?
Our Journey to Integrated Care

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
September 7, 2010 –Horizon House
partners with Delaware Valley
Community Health, and the
Fairmount Primary Care Center
at Horizon House opens at our 30th
St location
September 30, 2010 – Horizon
House receives a 4-year Physical
and Behavioral Health Care
Integration grant from SAMHSA
June 2013– Over 600 patients have
received primary care on site
SAMHSA Grant Results in Expanded Staffing
 Full-time certified Physician Assistant
 Supervising physician, 1/2 day/wk
 Team leader/ Medical assistant
 Billing clerk/administrative assistant
 Project Manager (HH)
 Data Coordinator (HH)
 Health Integration Specialist (HH)
 Health Educator (DVCH)
Certified Peer Specialist (2)
} DVCH
Services Offered as of Opening Day
•Insurance
eligibility assistance
•Adult
primary and preventive care
and health education*
•TB
Testing
•Lung
function testing (Spirometry)
•EKGs
Dental, Podiatry and Health
Education Group Services (at DVCH’s
Health Center at 1412 Fairmount
Avenue)
Prescriptions: filled through
patients’ current pharmacy.
•
Psychotropic medications: prescribed
by behavioral health providers.
•
•Immunizations
•Onsite
•OB/GYN
lab services
•Referrals
to specialists/help in
making appointments
•Physician
available by phone
after hours
•Appointment
Reminders
Ophthalmology and/or optometry
services: Referrals to Wills Eye
Hospital.
THREE KEY TASKS
1. Can you increase access to primary care, and
thereby improve the management of chronic
illnesses?
2. Can you improve the early detection and/or
prevention of other disease states?
3. Can you “create health” by engaging people in
wellness activities before, during or after the
emergence of serious medical co-morbidities?
What do you need?
• Space for primary care
• Someone to provide PC
• Organizational
commitment
• A way to
• MONEY!!$!!
coordinate/integrate PH/BH
care
• to start it
• Engagement (and re-engagement) of consumers
• to build it
• to sustain it
• Licenses/ approvals
Who Will Provide Primary Care?
1. Facilitated referral (coordination)
 BH organization coordinates referrals and shares
information with PCPs offsite
2.Partnership-based models (reverse co-location)
 Primary care embedded in community-based BH
organization
3. Fully integrated models
 Staff from a single organization provide primary care
and behavioral health care—i.e., do it yourself!
---adapted from Druss, 2011
Lessons Learned: Partnering
You have to either find a partner,
or hire your own primary care
staff—each comes with its own
unique challenges
FINDING A PARTNER:
Compatibility
Characteristics of the “right” partner
 Experience with /commitment to serving
‘safety net’ populations
 Belief in holistic, client-centered services
 Willing to give up preconceived notions
 Creative, flexible--willing to try new things
 Team players, develop concept jointly
 Able to quickly establish services
Lessons Learned: Business
You need a business plan that,
before too long, projects the
primary care operation to at
least break even—while
maintaining quality of care
FINDING A PARTNER:
Feasibility
 Is there sufficient traffic at the site
 Payor mix of potential participants
 Willingness of participants to change
primary care provider
 Can you get Board approvals?
 Can you get HRSA, other approvals for
change of scope [for FQHC]?
“Show Me the Money!”
 Need to take the ‘long view’, see initial
commitment as consistent with your
agency’s service mission
 Creative and assertive in pursuing grants,
‘freebies’, collaborations
 Sustainability still will likely require
parallel changes in service reimbursement
How Will You Engage
Consumers?
 Presumption: utilize their engagement with and
trust in behavioral health team (‘warm handoffs’)
 Make co-located service a preferred choice for
primary care (via screenings, wellness activities,
incentives, good customer service)
 Certified Peer Specialists key members of the team
trying to integrate care
 Motivational interviewing
Who Will Coordinate Care?
 Traditional “case managers”—add this task to
services already being provided
 Create/ hire/ train specialists in healthcare
integration
 Combination of existing personnel (with
additional training) and integration specialists
Assumes coordination of primary/ medical specialty
care via PCP
Lessons Learned: Blending
Cultures
You need to work with your
primary care providers to merge
and adapt the different cultures
that define each of you
Two different worlds?
Behavioral Health World
Physical Health World
We have people in recovery
They have patients
We emphasize engagement first
They have tests to get done
We focus on personal goals and
strengths
They focus on symptoms and
pathology
We’re looking for ways to spend
more time with those we serve
They’re looking to be more efficient
We’re into collaborative approaches, They’re into hierarchical
and shared decision making
relationships, and instructing
patients what to do
FINDING A PARTNER
Challenge of Information Sharing
29
Two different and independent charting systems
More stringent state regulations re sharing of BH info
Participant concerns about sharing BH information
with primary care providers (and vice versa)
Lessons Learned:
Transforming Yourself
You need to persistently work on
changing the culture of your
organization so that it sees itself
as one that provides integrated
health care, not just behavioral
health care
Lessons Learned: Choices
You need to consciously balance
your desire that all your
participants choose primary care
on site with with your desire to
insure they can freely choose
where to receive primary care
Fairmount Primary Care Center at
Horizon House: Accessing Care
 Fairmount PCC available to ALL
HH staff and program participants
 Fairmount PCC must be selected as
primary care provider
 Consistent with FQHC rules,
Fairmount PCC will see people
without health insurance
Lessons Learned: Systems
You need to create and monitor
systems that support the
collaborative care you intend to
provide, especially if you have
gone the ‘partner’ route
Lessons Learned:
“Show Me the Data!”
You need to create a ‘clinical
registry’ that enables you to
track both individual and
population health outcomes
Lessons Learned:
Ownership of One’s Health
Your processes need to allow for
participants to progress to
assuming charge of their own
disease management and
wellness activities
Lessons Learned:
Consumer Involvement
Consumers and their supports need
to actively involved in design and
execution of your plan:
 Peer specialists on the team
 Peer advisory council
 Consumer feedback via surveys
and focus groups
Lessons Learned:
Wellness Matters
A substantial amount of your
effort needs to be devoted to
wellness programming, aimed
both at the management of
chronic illness and at some
combination of illness
prevention and health promotion
Samples of Wellness Activities
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Meditation group
Walking group
Smoking Cessation
Wake and Move
FIT Club (Finding Inspiration Together)
Yoga
Whole Health, Wellness, & Resiliency
Taking Charge of Our Health
Community Inclusion-YMCA and
Farmer’s Markets
Volume 2 Issue 11
June 2013
Monthly Health Watch
Celebrate Men’s Health Awareness month in
June by scheduling and
having a physical examination.
120 South 30th Street 2nd Floor
Philadelphia, PA. 19104
Summer is here and that means it's
a good time to go outside and enjoy
Project HEALTH
Program
the weather:
The return of warmer temperatures
Prevention is key to
health success!
bring the opportunity for freedom, re-
Healthcare is very important with regards for taking control of your health.
Now it is possible to have your medical
care provided in the same location as
your other health services.
laxation, fun seeking, and being closer to
nature. Whether you're relaxing in the
backyard, working in your garden, going
to the pool, or exploring the great outdoors, here are some ways to help keep
Safely enjoy your summer
you and your family healthy this spring
and summer (www.cdc.com).
Beware of nagging bugs
propriate insect and tick repellent and apply it correctly. Prime mosquito-biting
hours are usually from dusk to dawn, but
Inside this issue:
Warmer temperatures aren't just attrac-
ticks are out at all times. Young ticks are so
tive to people, but to mosquitoes, ticks,
small that they can be difficult to see, but
and fleas also. Mosquitoes can transmit
Summer safety 2013
1
Gardening safety
1
Summer skin protection
2
Risk factors for skin cancer
2
Safe summer grilling
3
Project HEALTH NEWS
3
Fairmount Health Center
4
both young and adult ticks hungrily look to
West Nile virus; ticks can transmit Lyme animals and sometimes people to bite and
disease and other serious infections; and imbed themselves (www.cdc.gov). So watch out
fleas can transmit plague like illnesses.
and be safe!
To prevent these conditions, use an ap-
The question is “where and how can I sign
h up”? T e answer is you need to make your first appointment at Fairmount Primary Care Center and
become a member of the Project HEALTH. We are located on 2nd floor
of 120 S. 30th Street. You will now will have access to healthcare providers, medical team, health integration specialist, peer specialist, program
care manager, and health educator.
Comee and m et the whole team.
h
T is is a fabulous package deal. Don’t miss this great opportunity to take part in integrative care.
Individual counseling and several wellness groups are now being offered.
Gardening is a great outdoor activity for
people of all ages. Stay safe and healthy
as you grab your tools and head outside.
Wear gloves, use safety gear when handling equipment and chemicals, protect
yourself from the sun rays and use insect
repellent. Also watch out for extreme
heat and know your limitations to sun
exposure. You can also review and share with
your love ones some tips for preventing heatrelated illnesses. Drink plenty of water and
head for the shade.
Pollens and air pollutants can be triggers for
allergic reactions and asthma. Therefore plan
ahead before heading to garden for fun in the
For information call 215 222-2466.
Please stop by, we are located on the 2nd floor of 120 South
30th Street 19104.
We are here
to serve !
Lessons Learned:
We’re all in this together!
Learning communities enable us to
learn from each others successes
and failures
 Each of us can use, modify, and
develop new EBP’s
 How can we make effective
collaboration easier for each other?

Lessons Learned:
“Ya Gotta Believe”
Major Challenge?
Our own nihilism/pessimism
The question remains: Can you
really make a difference?
Health Promotion Programs for Persons
with Serious Mental Illness: What Works?
A Systematic Review and Analysis of the Evidence
Base in Published Research Literature on Exercise
and Nutrition Programs
Prepared for SAMHSA-HRSA Center for Integrated
Health Solutions by the Dartmouth Health
Promotion Research Team, Project Director Stephen
Bartels, MD February 2012
Health Promotion Programs for SMI:
Key Findings
 Interventions that last > 3 months are
superior; the intensive phase of programs
should last at least 6 months
 Programs that combine education and
activity-based approaches are more
sucessful than those that focus on nonspecific wellness education
 Programs that incorporate nutrition
education and exercise are superior in
inciting weight loss than those that focus
on nutrition alone
Reversing Early Mortality Due to Obesity and Cardiovascular Risk Factors in Mental Illness: What
Works in Changing Health Behaviors? Bartels Feb ‘12
Thank you very much!