cherokee health systems collaborative and integrated care for women across the life span: models,...

Cherokee Health Systems

Collaborative and Integrated Care for Women Across the Life Span:

Models, Successes and Challenges

Collaborative and Integrated Care for Women Across the Life Span:

Models, Successes and Challenges

Dr. Mary Clare Champion Dr. Helen Coons

Dr. Anne Dobmeyer Dr. Sally Haskell

Dr. Susan McDaniel

Dr. Mary Clare Champion Dr. Helen Coons

Dr. Anne Dobmeyer Dr. Sally Haskell

Dr. Susan McDaniel

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #A1October 28, 201110:30AM-12:00PM


Faculty DisclosureFaculty Disclosure

We have not had any relevant financial relationships

during the past 12 months.

We have not had any relevant financial relationships

during the past 12 months.


Need/Practice Gap & Supporting Resources

Need/Practice Gap & Supporting Resources

Women are not only suffering from rising rates of chronic illnesses, but they are the health care leaders for their families. Improving care for

women, both their own health and in their health-related education, will improve

outcomes for entire families.

Women are not only suffering from rising rates of chronic illnesses, but they are the health care leaders for their families. Improving care for

women, both their own health and in their health-related education, will improve

outcomes for entire families.


ObjectivesObjectives

• Identify how health care has an opportunity to improve the health of women through providing comprehensive collaborative care.

• Describe a collaborative model of care that incorporates behavioral health into primary and prenatal care.

• List particular benefits and challenges in utilizing this model in regards to improving family health.

• Identify how health care has an opportunity to improve the health of women through providing comprehensive collaborative care.

• Describe a collaborative model of care that incorporates behavioral health into primary and prenatal care.

• List particular benefits and challenges in utilizing this model in regards to improving family health.


Expected OutcomeExpected Outcome

• An appreciation for having an integrated focus and how this could impact the health of women.

• Strategizing in how to integrate behavioral services within practices bridging between patients receiving primary and prenatal care.

• Increased consideration of how to implement practices that will allow for early identification and intervention of challenges for women.

• An appreciation for having an integrated focus and how this could impact the health of women.

• Strategizing in how to integrate behavioral services within practices bridging between patients receiving primary and prenatal care.

• Increased consideration of how to implement practices that will allow for early identification and intervention of challenges for women.


Integrated Care Defined

Integrated Care Defined

“Integrated Care is a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve the services in relation to access, quality, user satisfaction and efficiency.”

“Integrated Care is a concept bringing together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve the services in relation to access, quality, user satisfaction and efficiency.”

-WHO European Office for Integrated Health Care Services. Integrated Care. Working Definition. 2001


Integrated Care ModelIntegrated Care Model

• Behavioral Health Consultant (BHC) member of Primary Care team

• PCP and BHC often see patient together• Integrated charts and treatment plan• BHC appointments are conducted in exam

room• Open availability for BHC, 100% of time

devoted to integrated care• Brief, focused, evidence-based behavioral

interventions and follow-up

• Behavioral Health Consultant (BHC) member of Primary Care team

• PCP and BHC often see patient together• Integrated charts and treatment plan• BHC appointments are conducted in exam

room• Open availability for BHC, 100% of time

devoted to integrated care• Brief, focused, evidence-based behavioral

interventions and follow-up


Cherokee’s Primary Care Clinical ModelCherokee’s Primary Care Clinical Model

● Embedded Behavioral Health Consultant on the Primary Care Team

● Real time behavioral and psychiatric consultation available to PCP

● Focused behavioral intervention in primary care● Behavioral medicine scope of practice● Encourage patient responsibility for healthful

living● A behaviorally enhanced Healthcare Home

● Embedded Behavioral Health Consultant on the Primary Care Team

● Real time behavioral and psychiatric consultation available to PCP

● Focused behavioral intervention in primary care● Behavioral medicine scope of practice● Encourage patient responsibility for healthful

living● A behaviorally enhanced Healthcare Home


The BHC in Primary Care

The BHC in Primary Care

• Management of psychosocial aspects of chronic and acute diseases

• Application of behavioral principles to address lifestyle and health risk issues

• Emphasis on prevention and self-help approaches, partnering with patients in a treatment approach that builds resiliency and encourages personal responsibility for health

• Consultation and co-management in the treatment of mental disorders and psychosocial issues

• Management of psychosocial aspects of chronic and acute diseases

• Application of behavioral principles to address lifestyle and health risk issues

• Emphasis on prevention and self-help approaches, partnering with patients in a treatment approach that builds resiliency and encourages personal responsibility for health

• Consultation and co-management in the treatment of mental disorders and psychosocial issues


Blending BHC into Primary Care

Blending BHC into Primary Care

• BHC is an embedded, full-time member of the primary care team

• BHC provides brief, targeted, real-time interventions to address the psychosocial aspects of primary care

• Primary Care Provider determines that psychosocial factors underlie the patient’s presenting complaints or are adversely impacting the response to treatment

• BHC is an embedded, full-time member of the primary care team

• BHC provides brief, targeted, real-time interventions to address the psychosocial aspects of primary care

• Primary Care Provider determines that psychosocial factors underlie the patient’s presenting complaints or are adversely impacting the response to treatment


Integration in Context…Integration in Context…Full IntegrationFull Integration

Integration in Context…Integration in Context…Full IntegrationFull Integration

PatientPatient

Behavioral Behavioral Health Health

ClinicianClinicianPhysicianPhysician

• Supports cultural Supports cultural competency among competency among staffstaff

• Shared/coordinated Shared/coordinated responsibility of responsibility of carecare

• To the patient it feels To the patient it feels like primary care.like primary care.

• Charting in one Charting in one chart/one formatchart/one format

• Creates seamless Creates seamless spectrum of carespectrum of care

The Primary Care TeamThe Primary Care TeamThe Primary Care TeamThe Primary Care Team


Why is it important to focus on women in

FQHCs?

Why is it important to focus on women in

FQHCs?• Rise in chronic

health concerns– Diabetes, depression,

obesity

• Uninsured women least likely to have had provider visits in the last year

• Uninsured women less likely to have regular screenings

• Rise in chronic health concerns– Diabetes, depression,

obesity

• Uninsured women least likely to have had provider visits in the last year

• Uninsured women less likely to have regular screenings

• Uninsured women report delaying or going without care

• Women are health care leaders for their families– Coordinate care for

children– Care for sick/elderly

relatives

Women and Health Care: A National Profile; Key Findings from the Kaiser Women’s Health Survey , Kaiser Permanente (2004)

• Uninsured women report delaying or going without care

• Women are health care leaders for their families– Coordinate care for

children– Care for sick/elderly

relatives

Women and Health Care: A National Profile; Key Findings from the Kaiser Women’s Health Survey , Kaiser Permanente (2004)


Special Concerns for Women

Special Concerns for Women

• Chronic Health Concerns– Cardiovascular disease– diabetes

• Relationship Health– Domestic violence awareness

• Reproductive Health– Pregnancy care– Education re: contraceptives– Importance of routine preventative care

• Chronic Health Concerns– Cardiovascular disease– diabetes

• Relationship Health– Domestic violence awareness

• Reproductive Health– Pregnancy care– Education re: contraceptives– Importance of routine preventative care


Postpartum DepressionPostpartum Depression

• Onset usually occurs within first 4 weeks of delivery

• Can appear within the first year after delivery

• Prevalence rates vary from 20% to 5%

• Onset usually occurs within first 4 weeks of delivery

• Can appear within the first year after delivery

• Prevalence rates vary from 20% to 5%


SymptomsSymptoms

Same as Major DepressionSame as Major Depression

– Lack of interest in activities

– Agitation/irritability

– Changes in sleep– Changes in

appetite– Crying spells

– Lack of interest in activities

– Agitation/irritability

– Changes in sleep– Changes in

appetite– Crying spells

– Feeling withdrawn or isolated

– Poor energy– Thoughts of death

or suicide– Feelings of shame

or guilt

– Feeling withdrawn or isolated

– Poor energy– Thoughts of death

or suicide– Feelings of shame

or guilt


“Baby Blues”“Baby Blues”

• Up to 80% of new mothers• Symptoms can be present for a few

hours to a few days• Symptoms are milder than a Major

Depressive Episode• Symptoms go away on their own or

with help from support system• Do not require medical intervention

• Up to 80% of new mothers• Symptoms can be present for a few

hours to a few days• Symptoms are milder than a Major

Depressive Episode• Symptoms go away on their own or

with help from support system• Do not require medical intervention


Postpartum PsychosisPostpartum Psychosis• Much more

severe• Break with

reality/presence of psychotic symptoms

• Immediate treatment is imperative

• Much more severe

• Break with reality/presence of psychotic symptoms

• Immediate treatment is imperative

• Andrea Yates– Houston mother

whose mental health deteriorated after the birth of each of her five children. She drowned all five of them in 2001, responding to delusional material telling her that her children were at risk of being harmed.

• Andrea Yates– Houston mother

whose mental health deteriorated after the birth of each of her five children. She drowned all five of them in 2001, responding to delusional material telling her that her children were at risk of being harmed.


Mothers at risk…Mothers at risk…

• Under age 20• Unplanned/unwanted

pregnancies• Behavioral health

history – self or family• Stress during

pregnancy• Presence of previous

postpartum depression

• Under age 20• Unplanned/unwanted

pregnancies• Behavioral health

history – self or family• Stress during

pregnancy• Presence of previous

postpartum depression

• Financial stressors

• Poor support• History of child

abuse/neglect• Substance abuse

history• Relationship

concerns

• Financial stressors

• Poor support• History of child

abuse/neglect• Substance abuse

history• Relationship

concerns


Diagnosis?Diagnosis?

• Edinburgh Postnatal Depression Scale– Available in English and Spanish, easy to

administer– Can be given at mom’s postnatal follow-

up or at infant well-child visits

Also important to screen for other reasons for symptoms (i.e., thyroid, substance abuse)

• Edinburgh Postnatal Depression Scale– Available in English and Spanish, easy to

administer– Can be given at mom’s postnatal follow-

up or at infant well-child visits

Also important to screen for other reasons for symptoms (i.e., thyroid, substance abuse)


Awareness is keyAwareness is key

• Vital to inform expectant mom and her support system

• Many new moms ignore or won’t discuss postpartum symptoms

• Psychoeducation can help reduce stigma, encourage mother to report concerns

• Vital to inform expectant mom and her support system

• Many new moms ignore or won’t discuss postpartum symptoms

• Psychoeducation can help reduce stigma, encourage mother to report concerns


Enter the Behavioral Health

Consultant

Enter the Behavioral Health

Consultant• Behavioral Health Consultant

(BHC) can provide psychoeducation about Postpartum Depression– Part of routine care– No stigma– Possible during normal OB

appointment or during follow-up

• Behavioral Health Consultant (BHC) can provide psychoeducation about Postpartum Depression– Part of routine care– No stigma– Possible during normal OB

appointment or during follow-up


Other careOther care

• Along with BHC, expectant mothers can/are seen by– Dentistry– Nutrition

• Along with BHC, expectant mothers can/are seen by– Dentistry– Nutrition


PreventionPrevention

• Increased awareness – both for expectant mom and for those around her

• Improved self care• Screening during pregnancy• Reduced stigma = earlier report =

reduced incidence of more severe symptoms

• Increased awareness – both for expectant mom and for those around her

• Improved self care• Screening during pregnancy• Reduced stigma = earlier report =

reduced incidence of more severe symptoms


Treatment optionsTreatment options

• Early detection is key so treatment can start as soon as possible– Supportive therapy

• Individual/family/support groups/online support

– Psycho-education– Psychopharmacology

• Early detection is key so treatment can start as soon as possible– Supportive therapy

• Individual/family/support groups/online support

– Psycho-education– Psychopharmacology


What if Mom isn’t my patient?

What if Mom isn’t my patient?

• Still important to screen for postpartum depression

• Can incorporate into pediatric well-child visits– Screen with Edinburgh, provider

interview– Provide psycho-education about

symptoms, prevention– Start treatment if necessary

• Still important to screen for postpartum depression

• Can incorporate into pediatric well-child visits– Screen with Edinburgh, provider

interview– Provide psycho-education about

symptoms, prevention– Start treatment if necessary


Challenges Challenges

• Financial barriers– Uninsured/underinsured– Struggles with co-pays

• Patient resistance– Push back when change is necessary– Lack of family awareness/support

• Access to care– Limited access to specialty referrals

• Financial barriers– Uninsured/underinsured– Struggles with co-pays

• Patient resistance– Push back when change is necessary– Lack of family awareness/support

• Access to care– Limited access to specialty referrals


Learning AssessmentLearning Assessment

A learning assessment is required for CE credit.

Attention Presenters:Please incorporate audience interaction through a

brief Question & Answer period during or at the conclusion of your presentation.

This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to

satisfy accreditation requirements.

A learning assessment is required for CE credit.

Attention Presenters:Please incorporate audience interaction through a

brief Question & Answer period during or at the conclusion of your presentation.

This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to

satisfy accreditation requirements.


Session EvaluationSession Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!

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