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PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION.

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Presentation on theme: "PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION."— Presentation transcript:

1 PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION PRACTICAL APPROACHES TO IMPLEMENTATION

2 Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida Anthony R. Bichel, Ph.D. Apalachee Center Inc., Tallahassee, Florida Rick Hankey, Senior V. P. and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida Coastal Behavioral Healthcare

3 LEARNING OBJECTIVES PROVIDE AN OVERVIEW OF INTEGRATED BEHAVIORAL HEALTH AND PRIMARY CARE INCREASE KNOWLEDGE OF THE IMPLEMENTATION PROCESS AND SUSTAINABILITY DESCRIBE LESSONS LEARNED Coastal Behavioral Healthcare

4 OUTLINE History Define The Problem Today What Changed? Why Now? What Is Integrated Care? The Implementation Process Sustainability Lessons Learned Coastal Behavioral Healthcare

5 HOW DID PHYSICAL AND MENTAL HEALTH BECOME SEPARATED? Coastal Behavioral Healthcare

6 HISTORY 1950 – 1960: Most people with mental illness were living in asylums. In the 60s: Due to John F. Kennedy and advances in medical thinking, changed from institutional care to community based system – 1990: Number of people living in tax- funded institutions was reduced by 50%. Today: Approximately one-fifth of the 1950s number reside in institutional care. Coastal Behavioral Healthcare

7 PROMISES MADE AND PROMISES BROKEN Coastal Behavioral Healthcare Money was intended to follow consumers into community programs. This didn’t happen. Employer paid insurance had no reason to pick up the bill. Most didn’t. Operating two systems: state and community. Never had enough money to fund both. Community based mental health system has always been underfunded.

8 TODAY PEOPLE WITH SMI DIE ON AVERAGE 25 YEARS SOONER THAN THE GENERAL POPULATION Coastal Behavioral Healthcare

9 OF THE SIX MAJOR CAUSES OF DEATH IN THE UNITED STATES, THERE IS AN INCREASED RISK OF DEATH AMONG THE SERIOUSLY MENTALLY ILL MAJOR CAUSE OF DEATHINCREASED RISK OF DEATH CARDIOVASCULAR3.4 X LUNG CANCER3 X STROKE 2 X IN THOSE LESS THAN 50 YEARS OF AGE RESPIRATORY5 X DIABETES3.4 X INFECTIOUS DISEASES3.4 X Bob Sharp, Fl Council For Community Mental Health Coastal Behavioral Healthcare

10 FACTORS INCREASING HEALTH RISK Poverty Poor access to Primary Care Disconnectedness of “Physical” & “Mental” health care systems Weight Gain Tobacco and Substance Abuse Medications Less likely to be screened Self-Care Capacity/Resource Cognitive, Affective and Behavioral symptoms System Navigation Barriers Coastal Behavioral Healthcare

11 WHAT'S CHANGED AND WHY CHANGE NOW? 4-Year Grant from The Substance Abuse And Mental Health Services Administration (SAMHSA) – $500,000 Per Year The Purpose Of The Grant Is To Improve The Physical Health Status Of People With Serious Mental Illness The Challenge Is To Establish A System That Bridges The Gap Between Mental Health Care And General Medical Care 4-Year Grant from The Substance Abuse And Mental Health Services Administration (SAMHSA) – $500,000 Per Year The Purpose Of The Grant Is To Improve The Physical Health Status Of People With Serious Mental Illness The Challenge Is To Establish A System That Bridges The Gap Between Mental Health Care And General Medical Care “It’s the right thing to do!” Linda Rosenberg of The National Council Coastal Behavioral Healthcare

12 $28 MILLION DOLLARS GIVEN TO 56 COMMUNITY BEHAVIORAL HEALTH CARE AGENCIES TO INTEGRATE PRIMARY AND BEHAVIORAL HEALTH CARE SERVICES FIVE REGIONS FLORIDA IS IN REGION 3 SAMHSA GRANT PROGRAM

13 West Region (1) 10 Grantees

14 West Region 1 Central Region 2 Southeast Region 3 Midwest Region 4 NE & MidAtlantic Region 5 AK: Wrangell Community Services AZ: CODAC Behavioral Health Services FL: Coastal Behavioral HealthcareIL: Human Service CenterCT: Bridges - A Community Support System CA: Mental Health Systems CO: Mental Health Center of Denver FL: Lifestream Behavioral CenterIL: Trilogy IncCT: Community MH Affiliates CA: Alameda Co Behavioral Health Care Services TX: Austin-Travis CO MH/MR Center FL: Miami Behavioral Health Center IL: Hertiage Behavioral Health Center MA: Community Healthlink Inc CA: Asian Community MH Services TX: Montrose Counseling Center FL: Community Rehabilitation Center IN: Adult & Child Mental Health Center ME: Community Health and Counseling Service CA: Glenn County Health Services Agency OK: North Care CenterFL: Apalachee Center, IncIN: Southlake Community Mental Health Center NH: Community Council of Nashua CA: Tarzana Treatment Centers, Inc. OK: Oklahoma Dept of MH/SA FL: Lakeside Behavioral HealthcareIN: Centerstone of INNJ: Care Plus NJ OR: Native American Rehab Assoc of the NW UT: Weber Human ServicesGA: Cobb/Douglas Community Service Board KY: Pennyroyal Regional MH/MR Board NJ: Catholic Charities, Diocese of Trenton WA: Asian Counseling and Referral Services SC: State Dept of MHMI: Washetenaw Community Health Organization NY: VIP Community Services WA: Downtown Emergency Service Center OH: Center for Families and Children NY: Postgraduate Center for Mental Health OH: Shawnee MH CenterNY: Bronx-Lebanon Hospital Center OH: Southeast Inc.NY: International Center for the Disabled OH: Greater Cincy BH ServicesNY: Fordham Tremont CMHC WV: Prestera Center for MH Services PA: Milestone Centers PA: Horizon House RI: Kent Center for Human/Org Development RI: The Providence Center MD: Family Services, Inc

15 Coastal Behavioral Healthcare

16 IT IS A TEAM-BASED MODEL WITH MEDICAL AND MENTAL HEALTH PROVIDERS PARTNERING TO FACILITATE THE DETECTION, TREATMENT, AND FOLLOW-UP OF BOTH MEDICAL AND PSYCHIATRIC DISORDERS IN A COMBINED SETTING. Coastal Behavioral Healthcare

17 SAMSHA GOALS REDUCE HEALTHCARE DISPARITIES ELIMINATE THE EARLY MORTALITY GAP REACH PEOPLE WHO CANNOT OR WILL NOT ACCESS PRIMARY HEALTHCARE SERVICES EARLY INTERVENTION AND DETECTIONBEFORE ISSUES DEVELOP OR WORSEN Coastal Behavioral Healthcare

18 Regular screenings and registry tracking On-site integrated primary care prevention, screening, and treatment services Wellness education and support activities Referral and follow-up IMPROVE HEALTH AND WELLBEING BY Peer involvement in the delivery, planning and evaluation of services Advisory Committee involvement and feedback INCREASE CONSUMER PARTICIPATION THROUGH Coastal Behavioral Healthcare ACHIEVING THE GOALS

19 STEP 4 – CRITICAL STEPS STEP 3 - INTEGRATION MODELS STEP 2 - UNDERSTANDING DIFFERENCES STEP 1 – SUCCESS THROUGH PARTNERSHIPS

20 Primary Care Grant Evaluator Laboratory Vendor Medical Supply Company Health Educators Community Stakeholders Business Alliances Coastal Behavioral Healthcare

21 MANATEE COUNTY RURAL HEALTH SERVICES – Primary CareUNIVERSITY OF SOUTH FLORIDA – Grant evaluatorsSWEETBAY PHARMACY Healthy Saver Plus Program $7 annual enrollment fee for entire family 450 generics at $4 per 30-day supply DIABETIC STAFF AND PATIENT EDUCATION Dave Joffe, Sweetbay Pharmacist, and Diabetes- in-Control, Editor in Chief PHARMACIST INTERNSHIP PROGRAM Student Rotation Affiliation with Lake Erie College Of Medicine PFIZER MEDED GRANTS Application for funding of a Wellness Peer Advocate Coastal Behavioral Healthcare

22 They’re different! Acknowledge & Embrace it! Coastal Behavioral Healthcare

23 PRIMARY CAREMENTAL HEALTH PACE 15 minute appointment50 minute session SETTING An exam roomA comfortable office LANGUAGE Diagnosis, medical terminology, complaints Assessment, mental health terminology, issues HIERARCHY Clear – Doctor in charge Diffuse – Administrator in Charge with Medical Director FLOW Flexible patient flowScheduled client flow Coastal Behavioral Healthcare

24 Integration Model Level of Integration Attributes MINIMAL COLLABORATIONI 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 SYSTEMS COORDINATED TREATMENT PLANS REGULAR COMMUNICATION FULLY INTEGRATED SYSTEMV SHARED SITE, VISION, SYSTEMS SHARED TREATMENT PLANS REGULAR TEAM MEETINGS Coastal Behavioral Healthcare

25 Organizational Buy-in and Plan Establish Contracts Hire Staff Billing – Opportunities for Sustainability Data Tracking and Collection

26 SpacePolicies & ProceduresDocumentationRegistration and Scheduling Primary Acute Care Services – Offerings and Expense Coastal Behavioral Healthcare Before admitting the first patient, consider:

27 Physical History Personal Risk Factors Family Risk Factors HeightWeight BMI Blood Pressure and Pulse Fasting Plasma Glucose Total Cholesterol Triglycerides LDLHDL Cholesterol / HDL Ratio Complete Metabolic Panel A1C Abdominal Circumference TSH Medication Review Liver Function Studies CBC with Differential Co-OccurringRisk of Harm Depression Screening NOMSPhysical Exam Coastal Behavioral Healthcare

28 NUTRITIONAL EDUCATION FOOD TOURS HEALTHY COOKING DIABETES EDUCATION PHYSICAL ACTIVITY ED SMOKING CESSATION ILLNESS SELF-MANAGEMENT STRESS MANAGEMENT PEER SUPPORT RECOVERY ACTIVITIES EXERCISE INSTRUCTION MEDICATION MANAGEMENT Coastal Behavioral Healthcare

29 SUSTAINABILITY COMPLICATED REIMBURSEMENT – CPT AND ICD-9 CODING SAMSHA’S TARGET POPULATION MUST BE EXPANDED IN ORDER TO SUSTAIN INTEGRATION MODEL LACK OF SAME DAY SERVICES REIMBURSEMENT UNDER MEDICAID WHEN THE FUNDING STOPS TARGET POPULATION 18 YEARS OR OLDER SMI-12MONTH DURATION GAF BELOW 60 UNINSURED

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31 Coastal Behavioral Healthcare

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33 SENIOR LEADERSHIP INVOLVEMENT IS CRITICAL SET GOALS … DEVELOP A ROAD MAP FORCE INTEGRATION AT EVERY OPPORTUNITY BROAD BASE HOLISTIC CARE … NO SILOS HIRE AT LEAST ONE EXPERT IN PRIMARY CARE COST OF PROVIDING PRIMARY CARE IS MORE EXPENSIVE THAN THAT OF MENTAL HEALTH CARE Coastal Behavioral Healthcare

34 WORK ON SUSTAINABILITY IMMEDIATELY … YEAR ONE FOSTER PARTNERSHIPS … CAN INCREASE OFFERINGS WITH LITTLE COST EDUCATING AND ASSISTING PATIENTS IN MANAGING THEIR HEALTH CARE IS VITALLY IMPORTANT. PROVIDING THE SAME ASSISTANCE TO THEIR CARE GIVERS IS ESSENTIAL! ELECTRONIC HEALTH INFORMATION RECORDS ARE GREAT! PAPER CHARTS ARE NOT! Coastal Behavioral Healthcare

35 MAJOR COMPLAINT: Acute leg ulcers MEDICAL HISTORY: Major Depressive Disorder Generalized Anxiety Diabetes Hypertension Asthma Hyperlipidemia MEDICATION REGIMEN: No Change In More Than 1 Year CASE STUDY 56-YEAR-OLD WHITE FEMALE

36 PHYSICAL EXAM: Weight 302: height 5’1” Blood Pressure: 148/90 Pulse 88 bpm; resp. 22 per minute Lungs clear; no wheezing, rales or rhonchi Lower extremities: + 2 pitting edema bilaterally; pulses fair LABS: ABNORMAL OR RELEVANT LABS ONLY Hemoglobin A1C: 9.2 (normal range 5.9-7) Creatinine: 0.7 mg/dl (normal range: mg/dl) Blood Urea Nitrogen: 18mg/dl (normal range: 7-21) Sodium: 140 mEq/l (normal range mEq/l LIPID PANEL: Total Cholesterol: 211 mg/dl (normal range<200 mg/dl) LDL, Triglycerides: 10% Above normal in all three Liver function panel: within normal limits CASE STUDY

37 Poorly Controlled, Severe, Persistent Asthma Foot Ulcer On Left Foot Dyslipidemia : Elevated LDL Despite Statin Therapy Persistent Lower-extremity Edema Despite Diuretic Therapy Hypokalemia Hypertension Elevated Coronary Artery Disease Stable Obesity Stable Financial Constraints Affecting Medication Behaviors Insufficient Patient Education Regarding Purpose And Role Of Medications Wellness, Preventive And Routine Monitoring Issues ASSESSMENTS

38 REFERRAL TO ENDOCRINOLOGIST SAME–DAY APPOINTMENT PATIENT REFERRED BACK TO INTEGRATED PROGRAM WITH MEDICATION CHANGES AND MONTHLY FOLLOW-UP APPOINTMENTS WITH ENDOCRINOLOGIST AMPUTATION AVOIDED - ENDOCRINOLOGIST REPORTED THAT LEFT FOOT AMPUTATION WOULD HAVE RESULTED IF NOT FOR IMMEDIATE REFERRAL OUTCOMES

39 RESOURCES Aetna Depression In Primary Care Cherokee Health Systems – Training Programs Commonwealth Of Pennsylvania Screening, Brief Intervention, Referral And Treatment Hogg Foundation For Mental Health – Resource Guide Integrated Behavioral Health Project (IBHP) – Tool Kit Integrated Primary Care, Inc. Intermountain Behavioral Health Program John A. Hartford Foundation- Improving Mood: Promoting Access To Collaborative Care National Council For Community Behavioral Health Care Substance Abuse And Mental Health Services Administration SAMHSA University Of Massachusetts Certificate Program In Primary Behavioral Health Care HRSA- Starting A Rural Health Clinic – A How To Manuel Coastal Behavioral Healthcare

40 Les Stratford, RN, BSN, MA, Program Director Coastal Behavioral Healthcare, Sarasota, Florida ext Anthony R. Bichel, Ph.D. Apalachee Center Inc., Tallahassee, Florida Rick Hankey, Senior Vice President and Hospital Administrator LifeStream Behavioral Center, Leesburg, Florida Coastal Behavioral Healthcare


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