strengthening relationships between primary care and behavioral health mary jean mork, lcsw neil...
TRANSCRIPT
Strengthening Relationships Between Primary Care and
Behavioral Health
Mary Jean Mork, LCSWNeil Korsen, MD, MScApril 17, 2009
Outline of Presentation
Who are we and where do we come from? – Our model
The importance of team The Culture Clash challenge Communication Levels of Integration
How to improve Where are you?
Objectives
Attendees will:1. Be able to identify their level of
integration2. Describe steps they can take to
increase their level of integration3. Articulate components of effective
communication for integrated practice
MaineHealth Members and Affiliates
PenBay
Miles Memorial
Midcoast
MaineGeneral
Stephens Memorial
St. Mary’s
Spring Harbor
Maine Medical Center
SMMC
St. Andrew’s
Primary Care and Mental Health
Primary Care• Multi-site Practices• Hospital-owned
Practices• Residency Practice• Solo Private
Practice• FQHC look-alike• Rural Health Clinics
Mental Health• Medical Center
Outpatient Psychiatry• Hospital-owned
Behavioral Health• Community Mental
Health Centers• Consumer Case
Management Agency
Acces
s
Standardized Assessment &
Risk Stratification
Care Management
Support for
Behavioral Change Mental
Health Treatment & Consultation
Specialty
Mental Health
Primary Care Medical Home
Community Resources e.g., NAMI
Our integrated faculty team
Medical Director – Family Physician Program Managers
LCSW Educator with health science background
Psychiatrists Child Adult
Administrative Professional
Mental Health Integration:
Team Roles Mental HealthSpecialist
Diagnose, Treat
Primary Care Provider Support Staff
Screen, Diagnose, Treat
Care ManagerFollow up,
Family Adherence Patient Education
PsychiatristOr APRN
Consult, Train
NAMICommunity Resources
Family Support
Patient and Family
Who needs to build relationships?
Program staff (with each other) Program staff and participating organizations Primary care and mental health
administrators Primary care team, mental health provider,
care manager
Relationship building: MHI faculty role
Get people together – learning sessions, conference calls, site visits, listserve
Facilitate the conversation Listen Provide knowledge and tools Be encouraging Never give up!
Patients who:
Experience their life problems as “medical”
Have not been socialized to the concept of “emotional distress” or to the idea of therapy
Feel blamed by a referral to Mental Health Feel abandoned by a referral to Mental
Health Patients dealing with behavioral or
emotional aspects of medical conditions
High risk populations
People with chronic illnesses or chronic pain
People with a disability Kids with school, sleep or behavior
problems People with persistent somatic complaints
and negative medical work-up
Patients in Integrated Care compared toSpecialty Mental Health
More likely to be first mental health contact
Less psychologically “sick” Less likely to define themselves as
impaired Require fewer visits
Mental Health Specialist in Primary Care:Other Differences
Primary Care Mental Health
Pace 15 minute appointment 50 minute sessions
Setting An exam room A living room
Language Diagnosis, medical terminology, complaints
Assessment, mental health terminology, issues
Hierarchy Clear – Dr. in charge Diffuse – Administrator in charge with med director
Flow Flexible patient flow Scheduled client flow
Levels of IntegrationLevel of
IntegrationAttributes
Minimal Collaboration
I Separate site & systems Minimal communication
Basic Collaboration
from a distance
II Active referral linkages Some regular communication
Basic Collaboration
on site
III Shared site; separate systems Regular communication
Collaborative Care
partly integrated
IV Shared site; some shared systemsCoordinated treatment plans
Regular communication
Fully Integrated System
V Shared site, vision, systemsShared treatment plansRegular team meetings
Modified from Doherty, McDaniel, and Baird - 1996
What is your level of integration?What is keeping you from getting
to the next level?Is there one thing you could do
soon, that would enable you to get to the next level?
Level One: Starting to Connect
Ask your clients about their primary care/mental health provider and get a release
Identify patients who could use better coordination – contact their providers
Contact key providers in your area Those treating your most complex
clients Those treating a group of your
patients
Level Two: Building on Basic Collaboration
Garner invitation to staff meeting
Identify clear processes and expectations around communication What should they expect
to get from you? What do you need to hear
from them? How can you share
information better?
Level Three: Sharing More than Space
Set up regular times to “meet” Clarify expectations around
communication & treatment coordination
Begin to “share” processes, e.g., scheduling
Work out record-sharing Define team relationships
Level Four: Increase the Integration
Clarify team mission and roles Formalize team expectations –
when to meet, what to share, etc.
Set up streamlined processes for communication and treatment coordination
Develop ways to learn from each other
Celebrate successes
Level Five: Maintaining & Continuously
Improving Set up formal and informal
learning opportunities Maximize use of staff
meetings, case conferences, huddles, and hand-offs
Always work on improving relationships – both within the team and the larger community
Remember that the patient is the focus of the work
At any level Confidentiality fosters splitting Blanket information release with the goal of
enhancing collaborative care In a Co-located – Integrated Practice
“Curbside consultations” Behavioral health rounds Take the clinician conversation into the
exam room Use words that do not require a physical or
psychosocial definition of the problem
Information Exchange between Providers
When might the MHP be useful?
Think SSRI: Situation Skill-setRelationshipIndicators or outcomes
Certificate Program in Primary Care and Behavioral Health. Department of Family Medicine and Community Health, University of Massachusetts Medical School. Alexander Blount, EdD, Director
Example
“I’d like to have my colleague, Ms. Peterson, work with us to help you figure out ways to reduce your stress in the evenings. She has a great deal of experience helping parents come up with bedtime routines. I think that if your kids went to bed better, you would be less stressed, and your headaches might be reduced. What do you think?”
Successful Communication with Primary Care
Note specific information from the patient/client that might effect treatment
Describe the specific indicators and how they have changed
Share what the patient/client reports as meaningful
Discuss how the Physician and Mental Health Clinician can work together on the treatment
Example
“I met with Ms. Brown and she agrees that she gets as “wound up” as her kids at night. We came up with some calming bedtime activities for the whole family and she agreed to try this for two weeks and report back to us on whether her headaches are reduced with her “winding down” routines. She also agreed to take her medication as prescribed during this time.”
Partnership development
Describe your mh/pc partnership when you began mental health integration – how did it feel?
Use 1-2 word descriptions
Partnership development
Describe your mental health/primary care partnership at 3-6 months - how did it feel?
Use 1-2 word descriptions
Middle Stage - quotes
Matching faces to names More comfortable Continuing the work Still learning Frustrated (e.g., over credentialing) Challenged by the details Impressed with the accomplishments
Part II
Partnership development
Describe your mental health/primary care partnership now (12-18 months) – how does it feel?
Use 1-2 word descriptions
Mature Stage - quotes
Comfortable In sync Efficient Work is rewarding Model is sustainable Very excited and
impressed
Mission driven as a team
Not yet done Helpful to people
being served Crucial – can’t live
without it Fragile