Promoting Improved Integration

Editor's Notes

• #8: Traditional collaborative/integration models: really focused on just the main providers, may not really incorporate the pt needs, but at least is a good starting to point to think of where to place those who deliver the services
• #9: COORDINATED • Routine screening for behavioral health problems conducted in primary care setting• Referral relationship between primary care and behavioral health settings • Routine exchange of information between both treatment settings to bridge cultural differences • Primary care provider to deliver behavioral health interventions using brief algorithms• Connections made between the patient and resources in the community
• #10: CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatmentShared care:1) Washtenaw Community Health Organization (Michigan): The Washtenaw Community Health Organization is a partnership between the county public mental health system and the University of Michigan Health System. The partnership allows for pooling of funds across systems and shared risk. Mental health clinicians from the community mental health center are out-stationed to primary care practices to provide direct treatment. A psychiatrist provides consultation to local public health clinics. The project has added a reverse co-location initiative (see discussion of Practice Model 5) by having a nurse practitioner visit community mental health clinics to provide primary care as well as to coordinate with the patient’s physician if there is one.2) VHA: One model uses a nurse care manager to provide telephone monitoring to individuals with depression and referral to specialty care when needed. The other model uses a software-based assessment to determine three interventions: watchful waiting, treatment by the primary physician, and referral to specialty care.
• #11: CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatmentShared care in reverse:1)Health and Education Services (HES) (Massachussets): a nonprofit, fullservice mental health organization in the North Shorearea. HES is focused on improving the physical health care of its Latino population. A Spanish-speaking nurse practitioner, who has expertise in both primary care and psychiatry, regularly visits three clinics. The nurse is available on a walkin basis to see patients with a range of medical issues.2) Horizon Health Services (NY): Horizon Health Services is a provider of comprehensive substance dependence and mental health services in Buffalo. Three of Horizon’s sites have medical units, where patients are offered an appointment if they do not have a primary care physician. The medical staff includes a family physician, registered nurse, nurse practitioner, LPNs, and HIV counselors.
• #12: INTEGRATED• Medical services and behavioral health services located either in the same facility or in separate locations• One treatment plan with behavioral and medical elements• Typically, a team working together to deliver care, using a prearranged protocol• Teams composed of a physician and one or more of the following:physician’s assistant, nurse practitioner, nurse, case manager, family advocate, behavioral health therapist • Use of a database to track the care of patients who are screened into behavioral health servicesPrimary care psychiatrist:1) MIPS clinic (NY): Clinic located at Strong Ties in Rochester for those with SPMITypically not much focus on primary care psychiatrist – few providers, and still have multiple difficulties, including boundaries (“we don’t hug in psych”)
• #15: Those with low to moderate severity of mental health disorders but a higher level of medical co-morbidity would be best benefit from an integrated approach where mental health is incorporated into a primary care clinic
• #17: Personal physician- Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care Physician directed medical practice- The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Whole person orientationThe personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Includes care for all stages of life; acute care; chronic care; preventive services; and end of life careCare is coordinated and/or integratedAcross all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services) Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner Enhanced access- Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staffQuality and safety Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family Evidence-based medicine and clinical decision-support tools guide decision making Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model Patients and families participate in quality improvement activities at the practice levelPayment: recognizes the added value provided to patients who have a PC-MH and based on the following framework Reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources Support adoption and use of health information technology for quality improvement Support provision of enhanced communication access such as secure e-mail and telephone consultation Recognize the value of physician work associated with remote monitoring of clinical data using technology Allow for separate fee-for-service payments for face-to-face visits. Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits Recognize case mix differences in the patient population being treated within the practice Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting Allow for additional payments for achieving measurable and continuous quality improvements **Medicaid: those with this insurance typically have more instability, more likely to utilize ED services; majority of those on this have multiple chronic conditions with wide psychosocial needs **Funding for IT will help push PCMH
• #33: CO- LOCATED• Medical services and behavioral health services located in the same facility • Referral process for medical cases to be seen by behavioral specialists• Enhanced informal communication between the primary care provider and the behavioral health provider due to proximity• Consultation between the behavioral health and medical providers to increase the skills of both groups• Increase in the level and quality of behavioral health services offered• Significant reduction of “no-shows” for behavioral health treatment
• #34: High BH-low physical health complexity/risk, served in a specialty BH system that coordinates with the PCP.
• #39: This afternoon I will briefly discuss the current problems we face within the field of CAP, some creative solutions, and 2 successful models of integration. I will conclude by discussing some policy changes that have occurred to promote the development of integrative models of care.
• #41: In 2001, Dr. David Satcher declared a state of crisis in the mental health of children and adolescents
• #42: The statistics are alarming. Almost one in five children have a diagnosable mental health disorder at any given time. Up to 1/2 of all lifetime cases of mental illness begins by age 14. And yes, psychosocial and mental health concerns are often mentioned during primary care appointments, but there are still approx 80% of kids with psychopathology who are not identified or treated. The consequences of untreated mental health disorders have a domino effect. It is known that children and adolescents that are untreated have higher school absence rates, lower school performance, impaired relationships, higher rates of STDs, pregnancy, and substance abuse, limited to no employment opportunities, and poverty in adulthood.
• #43: Mental illness, whether untreated or treated, account for considerable costs to multiple systems of care, an estimate of over $200 billion annually.This slide, although rather busy, is another take on the domino effect. Anindividual’s health problems, in turn, may lead to adverse consequences for others. In addition, health problems typically lead to increased costs secondary to reduced productivity and earnings and the increased use of social services such as child welfare and juvenile justice. As cliché as it may sound, the children are our future and they deserve a place that not only identifies and treats pathology, but promotes physical and mental well being.
• #44: Such interventions can be integrated with routine health care and wellness promotion, as well as in schools, within families, and in the community. This would require the collaborative efforts of a multidisciplinary team including pediatricians, psychiatrists, educators and community based agencies to build strong children.
• #45: To meet the needs of the children, there has to be a sufficient number of providers. And we all are aware of the workforce shortage. A study commissioned by the AACAP in 2003 found there was, on average, only one child psychiatrist for every 15,000 youth under 18. The data shows that Pennsylvania is one of the few states with a higher number of CAPs, however the need is still abundant. The U.S. Bureau of Health Professions project that there will be 8,300 CAPs in 2020 but they are also projecting the need of 12,600 CAPs to provide services
• #46: These numbers highlight the need to develop prevention training standards and training programs across disciplines including health, education, and social work. There are available training programs on mental health topics for primary care resident physicians, continuing medical education courses for established primary care providers, and continuous quality improvement (CQI) initiatives for entire health care systems. However, there are some studies that show these education and training approaches have not been shown to have consistent beneficial effects on either provider behaviors or patient-level outcomes, especially long-term.
• #47: With the current NFL lockout , increasing numbers of children and adolescents in need of mental health services and the shortage of providers, there is a need for some creative solutions…. Thank goodness for hockey and basketball!
• #48: The concept of the medical home was first introduced by the American Academy of Pediatrics
• #49: The interpretation of the medical home has transformed over the years and in 2007 the collaborative efforts of the American Academy of Family Physicians, American Academy of Pediatrics,American College of Physicians, and American Osteopathic Association outlined 7 principals of the Patient-Centered Medical Home.
• #50: Personal physician: Each patient is to have an ongoing relationship with a personal physician trained to provide 1st contact, continuous and comprehensive care.Physician directed medical practice:The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients Whole person orientation: The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. Care is coordinated across all elements of the complex health care system and the patient’s community.Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need in a culturally and linguistically appropriate manner Enhanced access: Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff Quality and safety: Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes. Evidence-based medicine and clinical decision-support tools guide decision making. Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication Payment should recognize the added value provided to patients who have a PC-MH and should reflect the value of physician and non-physician staff care management work that falls outside of the face-to-face visit. Payment should also support provision of enhanced communication access such as secure e-mail and telephone consultation and recognize the value of physician work associated with remote monitoring of clinical data using technology.
• #51: The medical home model provides children and families the opportunity to engage in mental health services within a familiar environment anddecreasing the stigma attached to seeking mental health treatment. There are several other benefits of this model, especially improving access to care.
• #52: While the concept of a medical home is not specifically an integrated behavioral health model, it clearly encompasses the philosophy of integration. This model has the potential to shift costs from acute care to prevention, chronic care management and recovery
• #53: Bridging the patient –centered medical home with integrated care is an innovative approach that facilitates partnerships between individuals and their healthcare providers
• #54: Collaborative care and integrated care are the two terms most often used to describe the interface of primary care and behavioral health care. They are often used interchangeably, but the terms are not used consistently in the field. Biopsychosocial model acknowledges that biological, psychological, and social factors all play a significant role in human functioning in the context of disease. This model is endorsed by most medical professionals yet seldom practiced. However, it is the theory at the root of collaborative and integrated care and is universally embraced as a “best practice.”
• #55: many integrated programs around the country have combined elements of two or more of the models previously discussed. These blended programs are becoming more common because programs are often designed for a particular set of local or statewide circumstances, such as target population, provider and service capacity, funding issues, and regulatory restrictions. 
• #56: The Child and Family Counseling Center is a program here in Pittsburgh based on the medical home model that was developed to provide an unmet need for behavioral health services within local pediatric offices.
• #57: There was a need to provide evaluation and treatment for common mood, anxiety, and behavioral disorders
• #58: A collaborative partnership was developed using consultative and co-location models of care between three systems, CCP, CHP and WPIC
• #59: CCP is a collective group of over 100 pediatricians and several mid level providers who deliver primary care services out of 28 offices which span 8 counties within the greater Pittsburgh area
• #60: CHP is a large level 1 trauma center serving Western PA. CHP was named one of 8 of America’s Best Children’s Hospitals per US News and World Report.
• #61: And WPIC, is one of the largest psychiatric facilities in Western PA serving 25 thousand patients and families a year. It is the site of two combined residency programs, TB and FP/Psych
• #62: To paraphrase, the initialmission of this collaboration was to provide access to quality, evidenced based behavioral health assessments, interventions and treatments in an integrated model within the pediatric primary care setting. Akey to successful implementation of such care is bidirectional communication between PCP and BH providers
• #63: In 2007 the CFCC pilot project was launched. Using a consultative and co-location model, BH specialists were placed in the primary care office to provide evaluation, assessment and treatment of patients referred by their pediatrician. Referral guidelines and treatment protocols were established and adhered to by all providers. Training sessions were provided and consisted of topics ranging from the general nuts and bolts of the program to management of common parental BH questions via phone triage. The use of EMR helped to streamline registration, authorizations, billing and communication.
• #64: I know this is a busy slide, but I wanted to give you an idea of how the CFCC system works. Who and where the care is provided is determined by the severity of symptoms and degree of impairment. Mild symptoms and impairment of various disorders are managed by the pediatrician \\during routine office visits. Moderate to severe symptoms and impairment warrants a referral to a behavioral health therapist for assessment, diagnosis and appropriate treatment. Behavioral health therapist will then refer to the child psychiatrist if medication management is required. Lastly, the pediatrician will refer pts with immediate safety issues to the psychiatric ED or appropriate community agency.
• #65: The pilot was a success and the Child and Family Counseling Center now has 4 child and adolescent psychiatrist providers, 2 of which are triple board trained. Therapists are located at 14 different CCP locations. The center will also see patients who are referred from non Children’s Community Pediatric offices at the central office location in Wexford
• #66: Since Aug of 2008, over 1500 patients have been seen with an average of approx 600 behavioral health visits/month and only a 10% no show rate. As with the national trends, 80% of the diagnoses seen are anxiety, depression or ADHD. And comorbidity does exist.
• #67: In speaking with the pioneers of the program, the strategies for the programs success included buy in by all parties. Everyone must see the value of integration including providers, staff, and most importantly patients and their families. BH manager attended monthly primary care meetings and CAP facilitate BH training sessions for pediatric providers and staff. There is one expert responsible for completing eligibility requirements and billing for all participating practices. For example, once a patient encounter is closed, charges are dropped into an electronic work queue that is processed by the expert.
• #68: The underlying theme for the success of the program is communication… not included in this slide but important role players are other systems of care such as education, the child welfare system, and juvenile justice to name a few.
• #69: Some of the barriers to developing collaborative models are the same as the barriers to mental health care in general… poor access, shortage of providers, stigma, and cultural differences with the traditional delivery of medicine in separate silos and last but certainly not least, funding.
• #70: The Patient Protection and Affordable Care Act has set aside millions of dollars to assist states in planning and implementing Medicaid medical home projects. The Medicaid accountable care organization pilot program establishes a project that will allow qualified pediatric providers to receive recognition and payments under Medicaid as accountable care organizations. In addition, $50 million in grants will be authorized for coordinated and integrated services through the co-location of primary and specialty care in community-based mental and behavioral health settings. According to the patient centered- primary care collaborative, some 44 states and the District of Columbia have passed more than 330 laws relating to the medical home
• #71: There is a need for continuous advocacy efforts to improve reimbursement rates, and incentives for mental health screenings and prevention during primary care well child checks are paramount.