partnerships in behavioral health-models for addressing mental …€¦ · • this integrated...

PartnershipsinBehavioralHealth-ModelsforAddressingMentalHealthinPrimaryCareBenjaminMiller,PsyD(Moderator),DepartmentofFamilyMedicine-CUSchoolofMedicineMarkBorer,MD,AACAPPatrickGordon,MPA,RockyMountainHealthPlansGregReicks,DO,ForesightFamilyMedicine

SusanH.McDaniel,PhD,APA-URMC

Theroleofbehavioralhealthincomprehensiveprimarycare

BenjaminF.Miller(@miller7),SusanMcDaniel(@susanhmcdaniel),PatrickGordon(@RMHP),GregReicks(@GregR02),MarkBorer

#teamrenegade

Thetakeaway• Todaywecanmakesignificantchangestotakecareofpeoplebygivingthemseamlessaccesstobehavioralhealthinprimarycare

• Thisintegratedapproachcanimproveoutcomes• Thisintegratedapproachcansavemoney• Thisintegratedapproachrequirespaymentreformandaninvestmentinprimarycare

Peek,C.J.,NationalIntegrationAcademyCouncil.(2013).LexiconforBehavioralHealthandPrimaryCareIntegration:ConceptsandDefinitionsDevelopedbyExpertConsensus.InAgencyforHealthcareResearchandQuality(Ed.),AHRQPublicationNo.13-IP001-EF.www.coloradosim.org

http://www.coloradosim.org/

DefinitionThecarethatresultsfromapracticeteamofprimarycareandbehavioralhealthclinicians,workingtogetherwithpatientsandfamilies,usingasystematicandcost-effectiveapproachtoprovidepatient-centeredcareforadefinedpopulation.Thiscaremayaddressmentalhealth,substanceabuseconditions,healthbehaviors(includingtheircontributiontochronicmedicalillnesses),lifestressorsandcrises,stress-relatedphysicalsymptoms,ineffectivepatternsofhealthcareutilization.

ValueofIntegration:Physical/BehavioralIntegrationisgoodhealthpolicyandgood forhealth.

Peek,C.J.,NationalIntegrationAcademyCouncil.(2013).LexiconforBehavioralHealthandPrimaryCareIntegration:ConceptsandDefinitionsDevelopedbyExpertConsensus.InAgencyforHealthcareResearchandQuality(Ed.),AHRQPublicationNo.13-IP001-EF.

Resources

• Onestop:http://integrationacademy.ahrq.gov/• Implementationguide:http://www.safetynetmedicalhome.org/change-concepts/organized-evidence-based-care/behavioral-health

• Policy:http://farleyhealthpolicycenter.org• Casestudy:http://www.advancingcaretogether.org/• Webinars:http://www.youtube.com/CUDFMPolicyChannel• Stateexample:http://coloradosim.org/• Nationalorganization:http://www.cfha.net/• More:http://www.pcpcc.org/behavioral-health• Email:[email protected]

http://integrationacademy.ahrq.gov/



http://www.safetynetmedicalhome.org/change-concepts/organized-evidence-based-care/behavioral-health

http://www.safetynetmedicalhome.org/change-concepts/organized-evidence-based-care/behavioral-health

http://farleyhealthpolicycenter.org/

http://farleyhealthpolicycenter.org/

http://www.advancingcaretogether.org/

http://www.advancingcaretogether.org/

http://www.youtube.com/CUDFMPolicyChannel

http://www.youtube.com/CUDFMPolicyChannel

http://coloradosim.org/

http://coloradosim.org/

http://www.cfha.net/

http://www.cfha.net/

http://www.pcpcc.org/behavioral-health

http://www.pcpcc.org/behavioral-health

mailto:[email protected]

RoleofaPsychiatristonthePCMHteam→D

Nuancedleadership:Thepsychiatristisalwaysaleaderonateaminwhichheorsheparticipates,evenwhenheorsheisnottheleaderoftheteam.

Thisincludessharedleadershiproleswithintheintegratedteam,theACO,thepayer-programlinkage,andthecommunitysystemsofcare.

Collaborateswiththefullrangeofmentalhealthprofessionals—

--creatingaccesstoafullrangeofcoordinatedmentalhealthspecialistsontheteam—psychiatrist,psychologist,psychiatricAPRN,socialworker,counselor,behavioralhealthmanager/coordinator.

Collaborateswiththefullrangeofmedicalprofessionalsontheprimarycareteam—

PCP,physicianassistant,primarycareAPRN,nurse,healthmanager/coordinator.

Collaborateswithavarietyofpayersandpotentialpayers–

--forfundingallaspectsofintegratedcareconsultationandteaming.

Accessesandconsultstothematrixofcarewhichsurroundsandsupportsthepatient:

Bringsexpertisenotonlyinpsychopharmacology,butindevelopment,effectivetherapies,familyengagementandassessment,crisismanagement,andintegrativeapproaches.

AACAPsupportstraininganddevelopmentofcollaborativerolesforthechildandadolescentpsychiatrist:

Topromotementalhealthandtreat

anymentalillnessofthechild—whileenhancingstrengths

inthefamilyandsupportsinthecommunity.

Throughcollaborationwithotherprofessionalorganizations—AAP,AAFP,AMA,AdvancedPracticeNurses,APA—bothofthem!,NAMI,andPCPCC.

UtilizingacontinuallyupdatedRoadmap--amembership-widecollaborativeandstrategicplan.

Whichsupportsourprofessionalgrowthasinnovatorsandcollaborators--supportingourfellowprofessionalsindeliveryofthebestteam-basedservices.

Usingevidence-basedandconsensusmodelsfortraininganduniqueservice--includingopennesstonewtrainingparadigms,jointguidelines,andcontinuedresearch.

CAP’sandtheirprogramsmayparticipateinNNCPAP—TheNationalNetworkofChildPsychiatryAccessPrograms.

Thus,apracticingpsychiatristisbetterprepared—

Notonlyforretainingtraditionalroles--ofpsychiatricassessment,developmentalassessment,psychopharmacology,networkingandlevelsofcare,andindividualandfamilytherapies—butalso…

Tospendsomeportionofourprofessionaltimeininnovativeservices:

--Professionaltoprofessionalconsultation--onbehalfofapatient,family,orpopulation.

--Teachingintegratedteamsaboutmentalhealthassessment,screening,”triage”,andprescribing.Goalistohelptheteammanagenotonlystraightforwardmentalhealthissues,buttocollaborateoncomplex,chronic,andmultipleissues,includingsubstanceusedisorders.

--Providingclinicalinputtointegratedteamcasereviews--lookingwithourcolleaguesatmedical,psychiatric&behavioralhealth,andaddictionissuesforholistictreatment.

--Teachingandconsultation--toschools,non-profits,andotherprogramswithinthenetworkofcare.

--SupportingthelinkagebetweennewlycertifiedPCMH’sincommercialinsurerACO’sandstate-establishednetworksofcare.

--Advocatingwithourprofessionalorganizations--forbetterpublicsafetyonissuesthataffectallourpatients,suchasreducingviolenceandincreasingaccesstocareforall.

--WorkingwithprogramsitesonEHRsystems—consultationtemplates,informationsharinghubs,systemcompatibility,documentation.

--Continuingtolearnfromeachofourpartnersinintegratedcare—ittakesateamtosupportthefamilyandtheneighborhoodofcare.

Bringingitalltogether:RMHP’sStrategy

Payment• Non-encounter,

non-volume,riskandresourceadjusted

• Globalbudgets• Globalpayments• Premiumtargets

Workforce• Behavioral

Health• Pharmacy• Care

management• Community

HealthWorkers• CoachingandIT

supportMeasures• Lessismore–

focusoncompetencybuildingand

DataandTechnology• Multi-payer• Multi-provider• Patientreported• Applications

licensingandnetworking

Behaviorishealth–RMHP’sIntegrationStrategy

• Criticalfacetofcomprehensiveprimarycare—nodifferentthaninvestmentsinpractice-basedcaremanagement,measurementandotherdatausecompetencies,technologyandpracticetransformationsupport.

• Globalpaymentbasedupondefinedpracticebudgetsforpersonnel,interventionsandrelatedinfrastructure–tocreateteam-based,whole-personcare

• RMHPpayermixinpracticeis~+30%

• BHprovidersarenottrappedinaworkflowdesignedtomaximizevolume-basedpayments,orpigeonholedintodistinct“physical”and“mentalhealth”codingcategories.

• Primarycarepractices“own”theirownbehavioralhealthresourcesandarefullyaccountableformeasuredoutcomes.

Costoutcomes

• Substantial,independentlyevaluatedTCOCdifferentials• Normalizedfordifferencesindemographicsandrisk_____________________________________________________• Medicaid -5.5%• Medicare -3.0%• Medicare-MedicaidBeneficiaries -5.4%• Commercial-Pending_____________________________________________________• Combined -4.8%

Comprehensive Primary Care Initiative

Medicaid PRIME

What does a PCMH with Integrated Behavioral Health look like?

95%

5%

Fee For Service

Commercial Plan PFP Incentives

Foresight Revenue 2012

Foresight Revenue 2015

3%5%

68%

4%

8%

1%5%

6%

Fee For Service

Commercial PFP Incentives

Medicaid Capitation

Medicare Incentives

Global IBH PaymentsCPC PMPM

Medicaid Shared Savings

Shared Saving CPC

TypicalmorningofIBHForesight• F/U56yomale,chronicpain,opiates,obesity,depression,HTN,prediabetes–reviewgoalsofhealthiereating,exercise-15min

• WHO62yofemale,HTN,chronicdepression,PHQ14,obesity,DM–discusssleep,exercise,stressmanagement–10min

• F/U27yofemalehighACE,PTSD,migraines,chronicpelvicpain,recurrentdepressionF/Ustressmanagement,counseling,medcompliance,healthybehaviors–10min

• TC34yomalecheckingonreferraltoCMCforBipolar,ADD,medcompliance–5min

• TC15yofemalemigraines,PTSD,F/Ure:ADHDsymptomsmanagement,healthyeating,wtloss–5min

• WHO75yomaleearlydementia,DM,HTN,BKA–coordinatesupportwhenwifehasmajorsurgery–15min

• WHOwithCHWF/UhighERutilizer,PTSD,substanceabuse–reviewcareplan–10min

• TCF/U60femalemajordepression,migraines,PTSD,chronicpaind/ttrauma,socialisolation,PAM3–discussmeds,smallgoals,healthydiet–10min

• WHO40yofemalemultipleunexplainedsymptoms,generalizedpain,highACE,PAM2–relaxation,meditation,spousalsupport–15min

• TCF/U18yomajordepressionsuicidality,referredforcounseling,medicationtolerance–10min

• WHO70yomalealcoholism,majordepressionrecentincarceration,socialisolation-identified,referredlocalresourcesforsocialengagement–15min

• WHO22yofemalemorbidobesity,recurrentdepression,PHQ12–goalsforexerciseandnutrition,mindfulness–15min

• WHO83yofemaleafib,chronicanxiety,frailty,recentdeathofspouse,grievingandworryaboutherhealth–relaxation,refertogriefsupport,counseling–15min

• Identifypts.ComingintomorrowneedingPAM,repeatPHQ,GAD,AuditScreens–30min

PATIENT-CENTERED PRIMARY CARE COLLABORATIVE MEETING, WASHINGTON DC 11/12/2015

MODELS FOR ADDRESSING MENTAL HEALTH IN PRIMARY

CARE EDUCATION & TRAINING

PSYCHOLOGY& INTEGRATED PRIMARY CARESusan H McDaniel PhD ABPP

Dr Laurie Sands Distinguished Professor of Families & Health Director, Institute for the Family, Department of Psychiatry

Associate Chair, Department of Family Medicine University of Rochester Medical Center

Rochester NY

MARRIAGE & FAMILY THERAPY

STUDENTS

FAMILY MEDICINE

RESIDENTS

PSYCHOLOGICAL POSTDOCTORAL FELLOWS

UNIVERSITY OF ROCHESTER FAMILY MEDICINE


15 HRS/WK over

30 MOS

PRIMARY CARE

5 MONTHS PSYCHOSOCIAL MEDICINE

2 YEARS PRIMARY CARE

35 YEARS INTEGRATED PRIMARY CARE SERVICE, EDUCATION & TRAINING

UNIVERSITY OF ROCHESTER MEDICAL CENTER


A “COLLABORATIVE

HABIT”

SHARED MENTAL MODELS ACROSS

DISCIPLINES

INTERPROFESSIONAL TEAM TRAINING

STRONG DISCIPLINARY

IDENTITIES AND SKILL SETS

4 elements OF PRIMARY CARE EDUCATION & TRAINING

(commitment and pride, not tribalism)

(a biopsychosocial approach)

(increased self-awareness, move from “me” to “us,” appreciate colleagues’ contributions, surface and manage conflict, exposure to team science, mindfulness training)

(huddles & debriefing sessions, warm hand-offs, collaborative treatment planning, case-based seminars),

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