Primary Care, Mental Health, and Substance Use IntegrationA Webinar Series Sponsored by:

California Institute of Mental Health, Alcohol and Drug Policy Institute and,Integrated Behavioral Health Project

Bridging Differences in the “Cultures of PC/MH/SUJune 10, 2010

Faculty:

Mary Rainwater,LCSW,FacultyMary Rainwater,LCSW, Project Director, Integrated Behavioral Health Project

San Mateo Behavioral Health and Recovery Services PanelCheryl Walker, MFT, Unit Chief, Primary Care Interface TeamLinford Gayle, Director Office of Consumer & Family Affairs

Cynthia Chatterjee, MD, Psychiatrist, Primary Care Interface TeamStephen Kaplan, LCSW, Director of AOD Services

Gale Bataille, MSW, Moderator and Integation Consultant to CiMH______________________________________________________________________________

This free webinar series is supported through MHSA funding under contract withthe CA State Department of Mental Health as well funding from the Alcohol and Drug Policy Institute.

IBHP participation is supported by The California Endowment.

Cultural Challenges to IntegratingCare

National policies, systems-level financialand regulatory barriers have led to “silo’s”of care

Physical and behavioral health clinicians Physical and behavioral health clinicianshave different practice and diagnosticstyles that have led to very different work“cultures”– Different work and productivity patterns.

– Different training, professional orientations,philosophies and perceptions of behavioralhealth conditions.

Primary Care Behavioral Health Comparedto Mental Health/Substance Use Treatment

Primary Care Behavioral Health Mental Health/Substance Use

Population-based; mental healthseen as just one component ofoverall health care

Client-based; specific requirementsfor service acceptance; focus onmental health care or substanceuse treatment

Treatment usually for person with Treatment typically restricted toTreatment usually for person withmild to moderate impairments,those coping with situational stressand stabilized persons with seriousmental illness

Treatment typically restricted topersons experiencing or at risk ofserious mental illness or thoseexperiencing psychiatricemergency or crisis; substance useservices often narrow andrestricted typically due to funding

Treatment usually limited ; one tothree visits; typically shorter induration, 15 to 30 minutes (thoughcould be longer depending on co-morbidity)

Often long-term treatment; numbervariable, related to client condition;visits may be longer in duration;include psycho-social and rehaboptions beyond individual visits

Primary Care Behavioral Health Compared toMental Health or Substance Use Treatment

Primary Care Behavioral Health Mental Health/Substance Use

Informal counseling session,vulnerable to frequent interruption;visits often timed around medicalprovider visits; therapeuticrelationship generally not primaryfocus

More formal session, privateinterchange; mental health orsubstance use is reason for visit;establishment of therapist-clientrelationship important; substanceuse group sessionsfocus use group sessions

Treatment often encompassesbehavioral aspects of healthcare, likepain management, smokingcessation, etc.

Treatment emphasis is on mentalhealth or substance use interventionsor rehabilitation services

Care management is often minimal,due to lack of reimbursement

Care management emphasis is oftenon psychosocial aspects of care

Behavioral counselor part of ahealthcare team; interventionsupports medical provider decisionmaking

Counselor relationship oftennonaligned with a team; interventiongenerally not tied to medicalhealthcare

Primary Care Behavioral HealthCompared to Mental Health or SubstanceUse Treatment

Primary Care Behavioral Health Mental Health or Substance Use

Documentation tends toward brief,immediate, problem focused recordsand often integrated with the medicaltreatment chart

Documentation generally moreextensive in response to publicfunding requirements and greaterrange of services; records stand-treatment chart range of services; records stand-alone; substance use confidentialitystandards

Stigma often minimal due tonormalization of setting

Stigma usually high

Primary care physicians may lackknowledge of behavioral health carewhich may lead to under-diagnosingand/or reluctance to identify andtreat or may be dismissive ofcomplaint due to perceptions aboutmental health or substance use

Specialty providers may over-diagnose; difficult to find mentalhealth professionals “traditionally”trained willing to work in primarycare model

Opportunities to Bridge the Culture Gaps

Integration efforts must occur at multiple systemlevels.

Aligned financial incentives can jump-startactivity and provide needed focus to programpartners.partners.• Rewarding quality care (i.e., pay-for-performance)• Mechanisms for sharing savings from reductions

in avoidable emergency and inpatient utilizationacross delivery systems

Buy in from administration/management –need tounderstand and promote the value of integratedbehavioral health (relatively low cost strategyto improve care quality, productivity, andclient/provider satisfaction)

Opportunities to Bridge the Culture Gap

Provider engagement is critical to achieving

buy-in and sustainability.

– Shared philosophy of care forpatient/collaborative team approach and beliefpatient/collaborative team approach and beliefin the model

– How to adapt to PC setting; flexibility indealing with the physical acuity of thepopulation, as well as the environment whereinterruptions are the norm

– Offering practitioner toolkits and learningcollaboratives to customize and implementbest practices for their delivery point andpopulation, reinforcing a spectrum of tailored

Opportunities to Bridge the Culture Gap

Consumer engagement is key and efforts shouldleverage peer support specialists for outreach,enrollment and obtaining consent.• Selling point preventing adverse drug interactions.• Shared development of care plans, maintaining• Shared development of care plans, maintaining

provider relationships and engagement of programdesign

Team-based approach allows access tonecessary range of clinical skills, expertise andmay be most resource efficient.• Clear designation of physical and behavioral

health home• Care coordination support for beneficiaries and

providers (care homes)• Access to psychiatric consultation for PCP

medical provider

Opportunities to Bridge the Culture Gap

Information exchange need not be high-tech, but must be actionable andshared, high priority.• Importance of routine communication,

consultation and coordination• Importance of routine communication,

consultation and coordination• Structures to support information sharing

through medical records• Sharing of educational materials and

strategies and ongoing trainings (beyondthe person providing therapy or behavioralintervention)

• IT infrastructure that tracks behavioralhealth data and clinical outcomes/use ofregistries

Opportunities to Bridge the Culture Gap

Increasing recognition of mental illness andsubstance dependence/addiction as chronicconditions has the potential to further “de-conditions has the potential to further “de-stigmatize”, provide new sharedmethodologies for integrating care andstandardizing treatment approaches.

– Adaptation of the chronic care model

– Movement towards “person centered” treatment

– Integrated person-centered model shares many ofthe underlying principles of a “recovery” model

Bridging Cultures at IntegrationBridging Cultures at IntegrationPointsPoints

County of San Mateo Behavioral Healthand Recovery Services

Moderator/Introducing San Mateo PanelBridging Cultures: A Consumer Perspective

San Mateo will provide a brief overview of their approach tointegrated services and then share their perspectives as serviceproviders at different points of integration, but first…

Linford Gayle, as a consumer with both medical and mental healthissues, what has your experience been like navigating primaryissues, what has your experience been like navigating primarycare and having to deal with the different cultures between PC, MHand SU services?

As a consumer leader in CA, you speak from your own directexperience but are also aware of the perspectives of many others.What has helped or hindered people with mental health andsubstance use problems in getting access to care and treatmentin primary care settings?

Why it is important to “bridge” cultural differences as we work to

integrate care?

Consumer PerspectiveConsumer PerspectiveLinford GayleLinford Gayle--Director of Consumer and Family AffairsDirector of Consumer and Family Affairs

As a consumer I have lived withmental illness, a chronic medicalillness and a history of substanceuseuse

I received treatment for theseconditions in mental health andprimary care settings

Consumer PerspectiveConsumer PerspectiveLinford GayleLinford Gayle--Director of Consumer and Family AffairsDirector of Consumer and Family Affairs

Primary care at times has looked at consumerswith mental illness as not really experiencing themedical illness that they have come to the clinicfor, making the consumer feel that they think thatfor, making the consumer feel that they think thatthey are delusional.

AOD clients, if they are experiencing pain have attimes been made to feel that they are medicationseeking and not really feeling pain.

Consumer PerspectiveConsumer Perspective----Why is Integration SoWhy is Integration SoImportant?Important?Linford GayleLinford Gayle--Director of Consumer and Family AffairsDirector of Consumer and Family Affairs

Many consumers (particularly of color) attributetheir MH symptoms to physical illness & go toHealth Clinic or Emergency Room

– May be referred to MH from PC, but many never go to– May be referred to MH from PC, but many never go toMH Services due to stigma

Stigma reduction through integrated care

PC has historically been more open to input fromconsumers, family and other caring individuals

Linkage/coordination of care is critical whendealing with chronic illness(s)

Consumer PerspectiveConsumer Perspective----PerspectivePerspective----Why isWhy isIntegration with PC Important?Integration with PC Important?

Linford GayleLinford Gayle--Director of Consumer and Family AffairsDirector of Consumer and Family Affairs

PC is less restrictive for people trying to accesstreatment/services;

PC allows more flexibility--you may have greater PC allows more flexibility--you may have greatersay in who you select for your primary andspecialty provider

As a hindrance, in my personal experience therewas not an African American therapist available inmy insurance network

San Mateo has over 12 years experience inproviding integrated PC/MH/SU services facingchallenges & opportunities including:

• Reaching a shared philosophy/shared integration goals

• How to adapt MH/SU to PC environment (including pace)

Moderator/Question?

• How to adapt MH/SU to PC environment (including pace)

• Team based approaches

• Opportunities for consumer engagement

• Information sharing

Cheryl Walker, as Unit Chief for San Mateo’sPrimary Care Interface Team, how has yourorganization worked to integrate care?

Benefits of IntegrationBenefits of IntegrationCheryl Walker, MFT, Unit Chief, Primary Care Interface TeamCheryl Walker, MFT, Unit Chief, Primary Care Interface Team

Integration points strive to provideseamless continuity of care formedical, mental health, substancemedical, mental health, substanceabuse treatment. Integration pointsare where we experience workrelated challenges and haveopportunities to build effectivecollaboration.

Interface Team Integration PointsInterface Team Integration Points

The Interface Team is embedded in seven primarycare clinics. We have five full time bi-lingual bi-cultural Spanish speaking therapists, one bi-lingualChinese therapist, and two part time bi-culturalpsychiatrists-one is Spanish speaking.psychiatrists-one is Spanish speaking.

Two full time bi-cultural therapists-one is AfricanAmerican the other speaks Spanish, are placed in theCounty’s Human Services Agency. They areembedded part time in four work centers.

Additional Behavioral HealthAdditional Behavioral HealthIntegration PointsIntegration Points

Two nurse practitioners are embedded in threespecialty behavioral health clinics and provideprimary care to S.M.I. consumers.

Behavioral Health Resource Team: Providecase management to assist homeless mentally illconsumers obtain housing, primary care andbehavioral health treatment for mental illnessand addiction.

Primary Care Interface Criteria forPrimary Care Interface Criteria forMental Health TreatmentMental Health Treatment

Mental or emotional illnessnegatively impacting medical care

Crisis intervention/5150Crisis intervention/5150

Serious mental illness /linkage to ACCESSteam

Primary Care Interface ServicesPrimary Care Interface Services

Assess, consult, treat, link, collaborate

Brief Solution Focus treatment

Identify SMI and link to the correct BHRSspecialty team.specialty team.

Link consumers to alcohol and drug treatmentand collaborate with those partners.

Facilitate communication between primarycare and mental health

Key Differences: Primary CareKey Differences: Primary CareBehavioral HealthBehavioral Health

Work Culture

– Focus of Treatment

– Volume– Volume

– Pace

Common Ground

Passion for wellness

The desire to help

Bridging Cultures to FacilitateBridging Cultures to FacilitateCollaborationCollaboration

“Culture is the integrated pattern of humanknowledge, belief and behavior”. Webster’s Dictionary

Work culture of an organization is born out of theWork culture of an organization is born out of theorganization's strategic intent and values. BluEnt

It seems reasonable that changing the work pattern ofemployees from referral to specialists, to effectivecollaboration requires a structural change in belief andbehavior.

Bridging Work CultureBridging Work Culture

The first step is recognizing that work cultures existsand resists change that is not meaningful to thecultures.

The next step is to look for naturally occurringintegration points and recognize these can becomepoints of effective collaboration.

The last step is to acknowledge and grow thecollaboration mindfully.

Bridge Building ToolsBridge Building Tools

Collaborative team able to engageand work with other staff

Identify tools common to both workcultures

Low Tech-Mid Tech-High Tech

Moderator Question?

Dr. Cynthia Chatterjee, you are a psychiatristDr. Cynthia Chatterjee, you are a psychiatristwho has worked in both Primary Care andwho has worked in both Primary Care andMental Health clinic settingsMental Health clinic settings..

Please discuss your role as a Primary CareInterface Team psychiatrist working in primarycare clinics ?

Would you share some vignettes of yourwork with clients?

Psychiatrist RolePsychiatrist Role Cynthia Chatterjee M.DCynthia Chatterjee M.D

Assessment– More in depth than time allowed in PC.

– Additional co- morbidity often diagnosed

Consultation/Brief Treatment– One time or brief treatment and return to provider

or transfer to specialty mental health

Training, support and education forprimary care doctors

Referrals from the Interface TeamReferrals from the Interface TeamTo Higher Level of CareTo Higher Level of Care

The Interface Team screens about 1500 referralsannually and treats 1000

Transfers to a higher level of care are less than 5%and are handed off to the appropriate outpatient adultor youth unit chief by the Interface unit chief. Thisprevents transition errors.

OneOne--Time ConsultationTime Consultation Case VignetteCase Vignette

48-yo woman of Mexican origin with a history ofdepressive episodes since her 30's, currently depressedfor 1 1/2 years. PCP referred her to Interface 6 monthsago and therapist began treatment. Patient had nohistory of antidepressant use. Five months agohistory of antidepressant use. Five months agotherapist suggested to PCP that an antidepressantmight be needed, and PCP started Celexa 20 mg. Sheinitially responded, then worsened again. PCP thenincreased Celexa to 30 mg, but she did notrespond. Interface psychiatrist assessed patient andrecommended that Celexa be increased to 60 mg daily,and that if this dose ineffective to then switch to SNRI.

ShortShort--Term Treatment and ReferralTerm Treatment and Referralto Mental Health Clinicto Mental Health Clinic Case VignetteCase Vignette

31 yo AA male college student referred to Interface toassess depression and anxiety. Was treated withLexapro up to 30 mg by PCP but notimproved. Interface psychiatrist assessed pt. Pt hadmixed manic symptoms, paranoia, OCD, and PTSDmixed manic symptoms, paranoia, OCD, and PTSD(lost 5 friends to violence), and cannabis abuse. Labsrevealed hyperthyroidism and pt subsequentlydiagnosed with Graves disease. Psychiatrist stabilizedhim on antipsychotics and Depakote. Therapistsupported with therapy. Endocrinologist treatedthyroid condition. Patient referred for substance abusecounseling. Still unclear how much of patient'ssymptoms due to thyroid disorder and cannabis abuse,but patient will likely be referred to the mental healthclinic for long-term treatment.

ShortShort--Term Treatment and ReturnedTerm Treatment and Returnedto Primary Careto Primary Care Case VignetteCase Vignette

33 yo woman of Philippine background referred fordepression, anxiety, and irritability. She had beenstarted by primary care on Lexapro 10mg. Assessment revealed 17 year history ofmethamphetamine, marijuana, and alcohol. Patientmethamphetamine, marijuana, and alcohol. Patienthad recently entered outpatient substance abuseprogram and was clean and sober only 3 months. Shewas also drinking excessive amounts of coffee and hadpoor sleep hygiene. Patient was started on Campral foralcohol cravings, advised to decrease caffeine, andadvised about sleep hygiene. She responded very welland after 3 months returned to primary care formedication management.

Training, Support, and Education forTraining, Support, and Education forPrimary Care ProvidersPrimary Care Providers

Example:Case presentation of a patient referred toInterface, with discussion of relevant

journal articles to clinic's primary carejournal articles to clinic's primary careproviders

Example:Case conference that included patient,patient's primary care provider, therapist,

substance abuse counselor, andpsychiatrist,

to provide a unified treatment plan

Moderator/QuestionSubstance Use Services in Primary Care-Integration and Cultural Bridging

Stephen Kaplan, as AOD Director forBehavioral Health and Recovery Services,what are some of the challenges/barriers tointegrating substance use screening andintervention into primary care clinics?

What are some approaches that you areusing to break down silos that are barriers tointegration?

Alcohol and Other DrugsAlcohol and Other DrugsStephen KaplanStephen Kaplan--DirectorDirector

PIER – SMC’s version of SBIRT

Key “Cultural” Aspects Key “Cultural” Aspects

Steps Taken

Provider ViewpointProvider Viewpoint

MD

SBIRT

San Mateo: Future StepsSan Mateo: Future Steps

Integrative approach to clients with chronic pain

Medical Home Web PageMedical Home Web Page

Expanding SBIRT to all primary care sites

Embedding AOD Specialist into Interface

System Integration/Preparation for Health CareReform

Q&AQ&A

Contact and Resource Information:

Integrated Behavioral Health Project:

Mary Rainwater, L.C.S.W., Project Director

mary@ibhp.org or 323.436.7478

For further resources visit IBHP website at: www.ibhp.org

San Mateo County Behavioral Health & Recovery Services:

Linford Gayle, Director Office of Consumer & Family Affairs

lgayle@co.sanmateo.ca.us or 650-573-2534

Stephen Kaplan, Director of AOD Services

skaplan@co.sanmateo.ca.us, 650-573-3609Celia Moreno, MD, Medical Director, BHRS

cmoreno@co.sanmateo.ca.us 650) 573-2043Cheryl Walker, MFT, Unit Chief, PC Interface, BHRS

cwalker@co.sanmateo.ca.us 650-573-2630

Primary Care, Mental Health, and Substance UseIntegration Webinar Series

Paying for Integrated Services:Paying for Integrated Services:FQHC, Medi-Cal, and Other Funding Strategies

Dale Jarvis, MCPP Health Care ConsultingJune 24, 2010

Please go to http://www.cimh.org/Learning/Online-Learning/Webcasts.aspxfor more information and to register for future webinars.

This free webinar series is supported through MHSA funding under contract withthe CA State Department of Mental Health as well funding from the Alcohol and Drug Policy Institute.

IBHP participation is supported by The California Endowment.