1. Building and Sustaining Relationships between Primary and Behavioral Healthcare Amy M. Kilbourne, PhD, MPH VA Ann Arbor Serious Mental Illness Treatment Research and Evaluation Center Department of Psychiatry, University of Michigan

2. Learning Objectives 1.To understand the multilevel, system-level barriers to implementing the Chronic Care Model for depression management in primary care settings, particularly those focused on practice and provider issues 2. To identify potential barriers to fostering relationships between primary care and mental health providers, and strategies for strengthening collaborations with primary care and mental health providers 3. To understand the concept of Participatory Management and how it could be used to identify and reduce barriers to implementation, notably by making the business cases to providers

3. Barriers to Integrated Behavioral Health-Primary Care: 6-P Framework  Patients/Consumers (e.g., symptoms)  Providers (e.g., time, tools, training, territory)  Practices/Clinical (e.g., lack of systems to coordinate care, cultural differences)  Health Plans/Organizations (e.g., financing)  Purchasers/State (e.g., not on radar screen, lack of info on return-on-investment)  Populations/Policies (e.g., stigma)

4. PCP, MH Provider Barriers  Turnover  Losing interest  Competing demands  Territories

5. PCP, MH Provider Strategies  Turnover  ID 2-3 champions  Losing interest  Periodic CMEs, trainings Regularly report performance Visit practices  Competing demands  Find “win-win” opportunities (e.g., streamline intakes)  Territories  Respect cultural differences (e.g., privacy concerns)

6. Implementing Change: Participatory Management Combines traditional and emerging approaches:  Barrier and solution “analysis”  Obtain buy-in upfront  Adapt new strategies via shared decision making  Shift decision making authority to stakeholders AND “end users” (e.g., front-line staff, consumers)  Recognition of day-to-day barriers, culture of practices  Help senior leaders and front line staff understand what’s in it for them  Customization to specific settings

7. Participatory Management Process 1: ID strategy Process 2: Customize Process 3: Evaluate Process 4: Implement Improved Process, outcomes Provider, Plan, and Consumer Input Adapted Chronic Care Model Provider, consumer feedback Provider, consumer consensus Provider, consumer buy-in

8. Participatory Management PM Process Components Process 1: DesignIdentify model and barriers to implementation, solutions Process 2: Customization Cross-functional team of consumers, providers to refine model based on potential barriers Process 3: Evaluation and Refinement Establish measures Piloting and further customization Process 4: Implementation Full-scale intervention Formative evaluation, ROI

9. Participatory Management: WCHO Integrated Care Program  National learning community to foster integrated care headquartered in southeastern MI  Wide range in size, # providers, years providing integrated care, but some common themes:  45% are rural  38% no joint MH-PC staff meetings  38% do not share common medical record  47% collect symptom data, 41% Rx, Labs

10. WCHO Learning Community Common Barriers  Culture (“finding BH providers who know primary care and vice-versa,” “differences in philosophies”)  Funding (“siloed at state level,” different rules across populations, regions)  Provider lack of time/space to coordinate  Client complexity, privacy concerns  Lack of real-time data on client outcomes  Lack of “clear mission” or “model”

11. Challenges  Resources  Administrative/Operations  Financing  Governance  Clinical

12. Addressing Challenges  Administrative/Operations  Templates for MOUs, agreements, job descriptions, responsibilities  IT barriers (firewalls) and privacy concerns  Common methods for analyzing data and measures  Financing  State variations in funding rules, creative funding sources  Start-up costs  CPT codes and reimbursement  Demonstrate cost efficiency, return-on-investment  Governance  Input on political issues  Liability (professional roles, clinical responsibility)  Clinical  Cultural differences and readiness to change (providers, organizations)  Lack of protocols and clarity in delineation of roles, balancing workflow  Lack of common integrated care model  Involvement of ERs  Sustaining provider use of integrated care strategies

13. Making the Business Case  Clinical (outcomes, processes of care)  Organizational (fidelity)  Economic (costs)  Social (satisfaction, stories)

14. Making the Business Case Momentum and Lessons Learned  RWJF Depression in Primary Care National Demonstration Program  Linking clinical and economic strategies  8 organizations: 4 Medicaid  Washington Circle Indicators  Bringing performance measurement to consumers, purchasers  VA Primary Care-Mental Health Integration Initiative

15. Clinical Performance Measures  No-show rates  % achieving remission (PHQ-9)  % on pharmacotherapy >=6 months  % receiving recommended toxicity monitoring tests for medications  # hospitalizations/ER visits  % receiving follow-up care post-hospitalization

16. Making the Business Case

17. WIIFM? Benefits depend on audiencePracticePlanState Counts towards QI activity√√ Empowers providers√ Reduces costs (inpatient, etc.)√√√ Reduces duplicative care (Rx)√√√ Applicable to other populations√√ Attractive to purchasers√√

18. Summary: 6-P Framework: Strategies to Reduce Barriers Patient/ Consumer Practices/ Clinical Purchasers (State/Private) Education on privacy issues and confidentiality Evaluate preferences, promote self-management Opinion leaders from PC, BH Provide guidelines, communication with care manager Invest in care management (NP, MSW, RN) Improve information systems – establish registry Comprehensive outcomes data (claims, consumer) Develop a business case Return-on-investment (State-level data) Persistence in light of “crisis du jour” Populations and Policies Engage community stakeholders Increase demand for quality care, enhance advocacy Providers Plan/Organization Pincus et al. 2003; Kilbourne et al. 2008