advancing team-based care: achieving full integration of behavioral health and primary care
TRANSCRIPT
WelcomeThe National Cooperative Agreement on
Clinical Workforce Development
WEBINAR 7: Achieving Full Integration of Behavioral Health and Primary Care
May 19th, 2016
Presented by the the Community Health Center, Inc. & the MacColl Center for Health Care
Innovation
SpeakersFrom MacColl Center for Health Care Innovation, Group Health Research Institute:Ed Wagner, MD, MPH, Director Emeritus Brian Austin, Deputy DirectorKatie Coleman, MSPH, Research Associate
From Leibig-Shepherd, LLC:Carolyn Shepherd, MD
From Old Town Recovery Center:Shanako DeVoll, CSWA, QMHP, CADC III, IHART Program ManagerErika Armsbury, MSW, QMHP, Director of Clinical Services
From Community Health Center, Inc.:Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director Kerry Bamrick, MBA, Senior Program ManagerTim Kearney, PhD, Chief Behavioral Health Officer Veena Channamsetty, MD, Chief Medical Officer
LEARNING COLLABORATIVE APPLICATIONS NOW OPEN!
o Participation in the Learning Collaborative is FREE for health centers.
o 9-month intensive learning collaborative provided by CHCI, it’s Weitzman Institute and partners
o Team Based Care or Post-Graduate Residency Program
How to apply?-Visit www.chc1.com/nca -PDF of the application is available on
our website -Applications due May 31st
Learning Objectives:1. Participants will be able to describe the features that
distinguish effective behavioral health programs.
2. Participants will be able to describe ways that expanded care team members can work with core team members to provide seamless, non-fragmented care to patients.
Get the Most Out of Your Zoom Experience• Send your questions using Q&A function in Zoom• Look for our polling questions• Live tweet us at @CHCworkforceNCA and #primarycareteams and
#HRSAnca • Recording and slides are available after the presentation on our
website within one week• CME approved activity; requires survey completion • Upcoming webinars: Register at www.chc1.com/nca
Integrating Behavioral Health and Primary Care
Learning from Effective Ambulatory Practices
MacColl Center for Health Care InnovationGroup Health Research Institute
May 19th , 2016
Ed Wagner, Director Emeritus Katie Coleman, Research Associate | Brian Austin, Deputy Director
The challenges of caring for the patient with behavioral health problems
Diverse clinical problems and care/staff needs • Acute distress needing assessment and short-term therapy• Established mental health disorder needing chronic therapy and management• Substance abuse
Added care complexity• Psychiatric disorders and substance abuse problems:
• require specialized assessment and treatment competencies• respond slowly to treatment• Interfere with patient empowerment and self-management competence• often involve complicated pharmacologic issues
Why manage in primary care?• The PC team’s relationships with and knowledge of the patients are often key to recovery.• A PCMH is better able to track and follow patients than most mental health providers.• Only 50% of patients who receive a referral for specialty mental health care ever follow
through with the referral. Among those who do, many do not have more than one visit.
Providing effective care for behavioral health problems in primary care requires:
• Full implementation of the patient-centered medical home.
• Integrated behavioral health expertise; co-location alone is not enough.
• Primary care clinicians willing and able to be accountable for BH care.
• Shared or integrated care: sharing (interactive communication*) of care planning and care management between primary and mental health care;
• Clinical care management services integrated with primary care
* Foy et al. Ann Int Med 2010; 152:247-258
The Principles of Integrated BH Care
10
Team care Primary care and behavioral health providers, whether co-located or not, share care.
Population-based The care team shares a defined group of patients tracked in a registry to ensure no one ‘falls through the cracks.’ Practices
track and reach out to patients who are not improving.
Treat-to-Target Each patient’s treatment plan clearly articulates personal goals and clinical outcomes that are
routinely measured. Treatments are modified until the clinical goals are achieved. Evidence-based care Patients are offered treatments for which there is credible
research evidence to support their efficacy in treating the target.
Adapted from: Behavioral Health Implementation Guide: www. aims.uw.edu
Acute distress assessment and short-term therapy
• Behavioral Health Specialist – usually an LCSW or licensed therapists or counselors
• Available for warm hand-offs – 60-70% of day unscheduled
• Provides short-term therapy only • Documents in EHR• Provides or supports care management services for
patients treated for major depression, anxiety, bi-polar, etc.
• May provide SBIRT services
Established mental health disorder needing chronic therapy and management
Collaborative Care• Proven effective in 75+ randomized trials for anxiety,
depression, PTSD• PCP, BHS and patient discuss and select therapy. If drugs,
PCP prescribes. If psychotherapy, sent to BHS for treatment or referral.
• Patients tracked in a registry and followed by care manager (BHS or RN).
• Care manager discusses patients with psych. consultant.• Treatment adjusted if patient is not improving or therapeutic
target is not achieved.
Behavioral Integration and the Primary Care TeamScreening for depression Medical assistant or Receptionist
Care management for depression RN, Behavioral Health specialist
Referral for longer-term psychotherapy BH Specialist, Referral Coordinator
Crisis management Behavioral Health specialist
Brief Psychotherapy Behavioral Health specialist
Psychotropic Medication PCP or Psych NP
Psychiatric Consultation Consulting Psychiatrist
SBIRT Trained staff to screen, treat, refer
Clinica Family Health Services
201547,000 Patients210,000 Ambulatory visits5 sites, 15 clinical teams
• Began in 2002• 15 teams of 3.0 in-clinic provider:1.0 BHP• Assigned a panel of approximately 3600 patients• Licensed Clinical Social Worker, Licensed Marriage and
Family Counselor, PsyD• Sit in a co-located space with the team and see patients in
the same patient care rooms, IMPACT model• Four 20-minute recheck slots a day• Majority of patients seen on any day are patients being
seen by the team for medical complaints
Behavioral Health Integration
• BHPs chart in the same chart as the primary care clinicians and the rest of the team
• We have built BH templates that support SFT and CBT• The concatenated document is in the same e-file as all other
notes so the team can communicate and coordinate care effectively
• BHPs attend the huddles, and strategize which patients they will see that day using EHR huddle reports
• BHPs are introduced to new patients with warm handoffs. Sometimes they see the patients first.
• BHPs run our chronic opioid group visits as well as depression group visits and anxiety group visits
Behavioral Health Integration
1. BHPs need a lot of training in solution focused therapy and cognitive behavioral therapy to feel comfortable in a fast moving primary care team (no "50 min. hours").
2. Streamlining the paperwork burden for BHPs is important, this is done at the leadership and state level.
3. Help the BHPs learn to decrease their charting volume, it is critical if other team members are going to be able to confirm the diagnosis and find important data points quickly. We did extensive "best practice charting" training in our EHR for the BHPs.
4. Not all BHPs are cut out for the primary care team. It is helpful to normalize this at the time of hire, and let people "try on" the model without fear of being terminated. We talk about this at hire, and we let applicants shadow our existing BHPs.
Lessons Learned
5. Sometimes it is best to let the BHP go in and talk to a patient with a long list of somatic complaints before the physical provider sees the patient. Often the visit is much shorter for the PCP, and the patient is happier because they did not feel rushed.
6. Continuity and relationship are just as critical for the patient and the BHP as the physical health provider. Reception, call center, MAs, physical health clinicians all need to drive continuity for BHPs.
7. BHPs can communicate with psychiatrists on patients who are not doing well.
8. BHPs who are comfortable in this environment are a phenomenal addition to the primary care team.
Lessons Learned
Delivering Planned Integrated Care
May 19, 2015
Veena Channamsetty, MD Chief Medical OfficerTim Kearney, Ph.D. Chief Behavioral Health Officer
Behavioral Health Integration
Behavioral Health from the
Beginning
Separate Buildings, Paper
Charts
Integrating Facilities
Integrated Care Record
Innovate Practices:
Changing the Way We Operate
Next Steps
Collaboration Continuum
CHC’s Journey
The Components of Integration
Evaluation
Training
Workflow/Processes
Facilities/Systems
Leadership Structure
Facilities and Physical Model
• Interdisciplinary Pods that Promote Team-Based Care• Open office structure• Collaboration throughout the workday
• Exam rooms and therapy rooms
• Reducing stigma of seeing behavioral health provider – no longer sent “over there”
• Seamless transition between medical and behavioral health
Facilities: One Corridor Care
Systems and TechnologyIntegrated EHR
• Up-to-date patient medical and behavioral health information available.
• Pain scores and access to other data – bi-directional information sharing
• Shared Care Plans• Electronic referral and recall process• Collaborative Care Dashboard
Systems and Technology and ProcessCollaborative Care Dashboard
Planned Care in Behavioral Health Delivery of Integrated Services
Rethinking the warm hand-off process: Proactive vs Reactive
Processes
• Medical initiated warm hand-off and behavioral health initiated warm hand-off
• Staggered vs. consecutive visits – make our presence known
• Criteria:• No BH services and PHQ above 15• No BH services and BH Diagnosis• No BH services and chronic pain
patient
• Instant access to behavioral health services via messaging service while with patients facilitating:
• Immediate and seamless warm-hand offs to BH
• Transition to nursing for controlled substances
• Transition to dental hygienist for dental treatment
• Behavioral health crisis calls handled by large regional groups of providers
Systems of Integration: Instant Assistance Technology
• Clinical Metrics• Screening for BH need• UDS measure• Improved BH Outcomes
• Practice Metrics• Patients enrolled in BH• Wait time to see BH• ED utilization• Avoidable Hospitalization
• Experience/Feedback Metrics• Patient experience• Staff experience
• Real Time Operational Data
Evaluation of the Model
Initiative BH Medical
Nursing
Dental
Integrated Care Meetings
r r r
Recalls r r r rBH Groups r rShared Medical Visits r r rWarm Hand-Offs r r r rPrenatal-Dental Project r r rShared Care Plans r r rComplex Care Management
r r r
Trauma Screening & TFCBT
r r
Standing Orders r r r rFluoride Varnish r r r rSBIRT r r r rBH Dashboard r r r rAppointment Allocation r r r r00/00/00
Interdisciplinary Care Initiatives
IHART Integrated Health and Recovery TreatmentBehavioral Health Home
Shanako DeVoll, CSWA, QMHP, CADC IIIIHART Program Manager
Erika Armsbury, MSW, QMHPDirector of Clinical Services
http://www.centralcityconcern.org/
Central City Concern
• Central City Concern is a nonprofit agency serving single adults and families in the Portland metro area who are impacted by homelessness, poverty and addictions.
• Provides a comprehensive continuum of housing options integrated with direct social services including healthcare, recovery and employment.
• CCC currently has a staff of 700+, an annual operating budget of $47 million and serves more than 13,000 individuals annually.
IHART
• All clients check in with a registered nurse before their psychiatric medical provider (PMP) appointment.
• Behavioral health assistant is a Qualified Mental Health Associate (QMHA) and does both administrative tasks as well as behavioral health related support for the team.
• A 30 minute morning huddle is conducted daily to focus on: coordination of care, crisis intervention, linkage to medical appointments and/or follow up, and an overview of clients needs for the day.
• The care team coordinator and/or the behavioral health assistant remain in the team room at all times to manage day to day and to support the team.
• CCC’s Health Services consists of: Old Town Recovery Center (OTRC), Old Town Clinic (OTC) & Central City Concern Recovery Center (CCCRC) IHART is one of 4 care teams located within the Old Town Recovery Center (OTRC)
• OTRC & Old Town Clinic (OTC) are co-located in the heart of downtown Portland
• OTC & OTRC use a shared Electronic Health Record• IHART structure is modeled after medical homes, but tailored to fit the needs of
behavioral health (BH) clients and BH systems. For example:
Who are IHART clients? • Behavioral Health Home with a focus on integration with primary care. • Capacity to serve 300. • Clients are paneled at the Old Town Clinic (OTC) for primary care. • Our clients have tri-morbidity, including Severe and Persistent Mental Illness,
homelessness, medical issues and addiction. • 30% of all intakes to OTRC are from OTC. The majority of those are referred to
IHART.• Clients can also be enrolled on IHART through intake due to complex medical
needs & no current primary care provider.
Sustaining IHART roles• Development & definition of roles was a crucial part in sustaining
IHART.• Team roles & workflows were defined to support staff in working to the
top of their skill set/license. • 10 staff with different disciplines share a team room with the majority
serving in extender roles to the Mental Health Counselors• Support from a program manager, psychiatric providers, registered
nurses and a pharmacist. • Putting systems in place to track the health of the population• Education & training for behavioral staff on ‘Primary Care 101’• Training & supporting behavioral health staff on integrating medical
coordination into behavioral health appointments
Sustaining IHART roles10 roles in the IHART team room
Care team coordinator, QMHP- Day to day coordination and consultation within the team, supervision of QMHA’s, carries a small caseload of 20 clients, and coordinates daily crisis interventions and follow up. 4 Mental health therapist, QMHP- Carry a caseload of 62 clients and are scheduled for individual therapy 60% of the time, the other 40% is spent doing crisis intervention, clinical coordination/case management, groups and documentation. Substance abuse and mental health counselor, QMHA/QMHP, CADC - Facilitation of dual diagnosis groups, carries a case load of 25 clients and provides alcohol and drug case management for the entire population. Behavioral health assistant, QMHA- Is in the team room at all time, answers phone call, triages crisis situations, all administrative coordination, referrals to respites and outside agencies. Case manager, QMHA- Works with the entire population on case management needs, gets assigned daily tasks from therapist and team, coordination and linkage to outside services, housing support and medical appointment coordination. Peer Wellness Coach, QMHA, PWC- Our peer works with individuals to support them in reaching their treatment goals. Attends medical appointments, support around daily living skills and health coaching strategies. Employment specialist, QMHA- Works with 20 IHART clients around supportive employment.
IHART Projects • Metabolic Monitoring Project (MMP) - Supporting
clients on 2nd generation antipsychotics to get their labs completed every 3-6 months.
• Coordination with OTC care teams - Care team managers from OTC attend our morning huddles weekly to coordinate client needs and to brainstorm strategies to best serve mutual clients.
• Wellness Program - 16 week Road to Wellness course that focuses on making small changes in health practices. Two days per week peer run walking group and a weekly check in with our registered nurses.
• Targeted Primary Care – Small group of individuals whose basic medical needs are being addressed by our team with the supervision of their PCP.
• IHART’s third year will focus on data collection.