Presentation on theme: "Macon County Initiative Integrating Behavioral Health and Primary Care"— Presentation transcript:
1 Macon County Initiative Integrating Behavioral Health and Primary Care Presented by:Diana Knaebe, Heritage Behavioral Health Center
2 Integration Partnership Background Description/History of PartnershipsRationale for involvementEvolution of Partnerships and programs – services offeredNext Steps
3 Heritage and CHIC Integrated Care Project Heritage BehavioralHealth CenterCommunity Health Improvement Center
4 Integration Partnership Background Description/History of PartnershipCommunity Health Improvement Center and HeritageHave had working relationship for the past fifteen years; initially, there were cooperative efforts with mutual referrals to assure that clients received needed primary care/mental health services.Early on the entities worked cooperatively with a local pharmacy, and developed a system utilizing bubble cards containing daily prescribed dosages of medications for medical and psychiatric problems which could be taken by the client on a daily basis.
5 Integration Partnership Background In July 2006, the United Way funding allowed Heritage to provide an adult psychiatrist on-site at CHIC. This psychiatrist provided psychiatric care, support, and follow up to patients, and consultation to medical physicians 9 hours per month. The CHIC physicians were so pleased with the immediate psychiatric consultation available that the pediatric providers requested on-site psychiatric availability.Consequently, in April 2007, a child and adolescent psychiatrist was added. He provides mental health services to the primary heath center 4 hours per month, direct care to patients, and consultation and education to the medical physicians.
6 Integration Partnership Background United Way funding allowed CHIC to provide a APN as well as a liaison on-site at a Homeless Day Center operated by Heritage. This allowed access to health care by individuals many of whom had not received health care in years.Both organizations have attended the National Council’s Integrated Care Sessions for past 5 years.Participated in National Council’s Integrated Collaborative Care Project in 2007Participated in MHCA Integrated Healthcare Learning Community August 2009-November 2010
8 Reasons/Rationale for Partnerships Ultimately to Implement a patient centered medical home – true integration of careBetter Overall health outcomes.Improved access and retention of clientsJoint referral process and records accessClinical processes defined for collaboration and joint education for staffNurse practitioners and/or Physician Assistants at both CHIC and HeritageClients only seen at one site for all needs – as much as possible unless need specialty careMaximizing revenue (current and new services)Efficient/effective/efficacious careNon-duplication of care and servicesEducation sharing component for staff and clients
9 Cultural Issues/differences Term-language DifferencesHow patients/clients are seen – length of time for visit and follow upFunding Streams and Mechanisms often very differentDetermination of “hand-offs” and/or referralsReleases – Medical Records
10 The Four Quadrant Clinical Integration Model For the Adult Population/ Heritage & CHIC Adaptation Quadrant IIHigh Behavioral Health (BH)Low Physical Health (PH)Heritage is medical home. Care to be provided by or arranged by Heritage BH CounselorCriteria for placement in this quadrantMay have accessed services at CHIC or HBHEligible for 132 ServicesHas low physical health risk/ complexityNeeds psychotropic medication provided by psychiatrist at HBHPhysical health care by PCP located at HBHMay have stigma issue about going to HeritageNeeds case management, housing, assistance with finances & or Heritage Payee servicesDual problems of S/A & MH (requires treatment for both)Inpatient Hospitalization in past or required now.Needs daily living skills trainingNeeds outreach services provided by HeritageActions to Be Taken :Clinician arranges case management services for housing and other community supportsArranges for S/A treatmentArranges for access to primary health care if HBH, and assures communication with Primary Care Physician (PCP)BH Clinician provides assessment,Psychiatrist provides and monitors needed medicationQuadrant IVHigh Physical Health (PH)Heritage is medical home with counseling and case management services provided at HeritageAccesses services at Heritage in most casesPhysical health care by PCP located at HeritageHas complex and high risk physical problems, and requires regular physician visits, and or specialty physician careNeeds a BH case manager at HBH who provides assistance with housing, financial assistanceMay have Dual problems of S/A and MH (requires treatment for both)Needs inpatient hospitalization for either physical or mental health issuesActions to Be Taken:Primary Dr provides primary care and assures specialty physical health care when neededHeritage BH counselor assures collaboration between BH & PHBH clinician arranges for case management and other needed support servicesIf no Primary care physician at HBH, will receive primary care at CHICQuadrant ILow Behavioral HealthLow Physical HealthCHIC is medical home with on site CHIC BH clinicianCriteria For Placement in this quadrantLow physical health risk/complexitySlightly elevated health or BH riskClient may need BH and or S/A triage, assessment, and service planningBrief BH counseling or treatment or group therapyMay need referral to community and educational resourcesMay need health risk educationDrs only clients at HBH would be appropriate in this quadrantPCP provides primary care and uses screening tools and guidelines to serve most individuals in Primary CareRefers to & collaborates with psychiatrist to assure coordinated careCHIC BH clinician provides formal and informal consultation to the PCPCHIC BH clinician provides brief counselingPsychiatric consultation provided to PCP if neededQuadrant IIIHigh Physical HealthLow Behavior HealthCHIC is medical home with on site CHIC BH clinicianCriteria for Placement in this quadrantHas complex and high risk physical health problems, and requires regular physician visits, and or specialty physician careLow BH needs, but needs screening by PCP using screening toolsMay need BH triage or assessmentMay need consultation to the PCPMay need referral to community educational resourcesActions To Be Taken:PCP provides primary care and assures specialty care when neededPCP utilizes BH screening tools and guidelines to serve most individuals in Primary CareBH clinician provides triage, assessment, & consultation with PCP
11 Integration Partnership - Expansion The Administrative and Clinical Collaborative Committees continue to meet on the existing collaboration as well as expanding to additional behavioral health services on site at CHIC and with an intention of continuing to work towards the provision of primary health care in a behavioral health care setting. This project is the logical extension of efforts currently underway between Heritage and CHIC. Heritage and CHIC meet regularly to plan, coordinate, and implement our existing collaboration of integrating behavioral and primary health care. This collaboration is progressive and moving forward.The MCMHB joined the Administrative Committee in late 2009 when we began a “pilot project” to add expertise, additional funds with Medicaid billing through them plus the matching local dollars.
12 Integration Partnership Background Integration: Partnering Agencies 2011The Community Health Improvement Center (CHIC), a primary health care center – Federally Qualified Health Center,Heritage Behavioral Health Center (Heritage), a community behavioral health center – Mental Health, Substance Abuse, Homeless and Housing ServicesThe Macon County Mental Health Board (MCMHB), a public taxing body that funds MH/SA/DD servicesThe Macon County Health Department, public health department (MCHD)
13 Integration Partnership – Expansion Two Macon County Health DepartmentMCHD entered into partnership with IDPA ABCD II (Assuring Better Child Health and Development Initiative) project in State level partners included:Illinois Chapter, American Academy of Pediatrics ( ICAAP) and Illinois Academy of Family PhysiciansOunce of Prevention Fund (OPF)Illinois Department of Human Services (IDHS) Office of Family Health (OFH)IDHS Office of Mental Health (OMH)Illinois Department of Children and Family ServicesIllinois Primary Health Care Association (IPHCALocal partners included:AOK NetworkFQHC: CHICWIC/FCM CoordinatorPediatric/Family Practices:Early Intervention/CFC:Heritage BehavioralI
14 Edinburgh Postnatal Depression Scale (EPDS) Possible Depression is indicated at score of 10 or above. Referral provided for all scores of 10 or higherINITIAL NUMBERS INDICATED HIGH RATE OF NEED !Edinburgh’s Completed :May 05 – September 05 = 434Scores of 10 or higher = 100Result=25% rate of at risk women in need of referral !Current screening rates maintain average of 100 screens completed /month with 10-20% rate of need for referral
15 Hopes & Screams from MCHD MCMHB Board Director enlisted local mental health providers to provide counseling services for clients with positive screening scoresReferral rates outnumbered available resourcesMCMHB providers had long waiting times for client entrySome MCMHB providers were charging clients for services against project agreementSome providers requested clients not be referred if in prenatal stateSome OB providers declined to accept screening resultsMCHD staff expressed frustrations and concerns related to referral inconsistencies
16 MCHD Request to MCMHB Fall 2010 Invited MCMHB Director to Maternal Child Health staff meeting to address staff concerns related to the counseling referral systemStaff relayed numbers of underserved clientsGave examples of referral difficulties with MCMHB paid agenciesRequested on site services and to include home visits for clients with barriers such as daycare, transportation, work/school schedulesGoal= to achieve through partnership timely and adequate service delivery and follow up for at risk women and families
17 MCMHB Reasons for Involvement New Medicaid by billing through the MCMHB – directly to DHFSLocal Funds Initiative - matching Medicaid with County dollars means more money for the communityQuicker access to behavioral health servicesCaptive Audience at CHIC – linkage & need from MCHDEligibility – changes in eligibility over the years in mostly only target population defined by DHS-OMH – this allows an Expansion of eligibility wider range of individuals than current and potentialStill meeting medically necessityMore holistic care - hopefully better clinical outcomes/people improving/getting better
18 Integration Partnership – Expansion Two Continued Administrative Team established and meeting to work through challenges, barriers, referral processes, medical record – computerMembers from MCHD, MCMHB, HeritageClinical Teams also providing feedback through their supervisors – funnels up to Administrative Team and back to clinical teams/supervisors to smooth the processes
19 MCHD, “Happy Days Are Here!” January 2011-Part time MCMHB funded Heritage Counselor begins accepting onsite referrals at MCHD and completing home visits.40 referrals received in the first month! Whew!Initially ,frustration expressed regarding delayed contact time vs referral numbers …However …Counselor provides assistance with multiple scenariosClients and staff express 100% satisfaction with follow up services
20 Next Steps MCHD Expansion into Seniors Plan to use Geriatric Depression ScreenOne full-time mental health staff beginning July 2011 might expand to another part-time assigned to the MCHD clients/patients
21 Specific Changes Implemented in the Last Year Lost the psychiatrist that worked so well for both organizations as a result have added Psychiatric Nurse Practitioner to FQHCAdded Mental Health Therapist to the FQHC site with MCMHC Board FundingScreening to determine who can be better served at the FQHC as primary – Medical HomeHave received SAMHSA Integrated Primary Care Grant which will allow us to emphasize wellness with SPMI population added Physical PA on site at the Mental Health Center.MCHD has become 2nd site funded by MCMHB for therapists to see identified by MCHD staff in need of services – primarily an outreach, in-home model though which is different than that at CHIC
22 Lessons Learned – things to Consider when establishing Collaborations for Integration of Care Can take much more time to work through because our systems are often actually complicatedAre the right people at the table for discussions?Licensure of Sites – Scope of Practice ChangesWritten AgreementsJoint Contracts for purchasing of staff or servicesWho is billing for what?
23 SAMHSA Program GoalsHeritage Behavioral Health Center received a SAMHSA Grant in September 2010 for its Primary and Behavioral Health Care Integration (PBHCI) program.Our project focuses on:individuals with Serious Mental Illness who are on antipsychotic medications and….have co-occurring metabolic syndrome or a chronic medical conditionEstablishment of a primary care clinic at Heritage Behavioral Health CenterProvision of wellness activities/programsWorking with 500 SMI adults by the end of the 4th year
24 SAMHSA Program Goals Health and Illness Background Information Used both as a screening and as a means of documenting diagnoses (PH and BH) as well as important medical/health history variables SF-36 (short form)Person Centered Healthcare Home Fidelity Scales and ProtocolsDeveloped by our evaluator, TriWestBased on the conceptual work of Barbara Mauer and collaborators2-day collaborative assessment process
25 AccomplishmentsIn 5 months, established a Health & Wellness Suite, including a Primary Care Office at HeritageContracted with CHIC Primary Care Clinic to place a Primary Care Physician/Assistant on siteDeveloped a Clinical RegistryAdmitted 57 clients to Health and Wellness Program since Mid March 2011
26 AccomplishmentsReceived 87 referrals to the program since program began in February 2011Success Stories:In one month, one client lost 20#, another lost 11#, a third lost 14#. No one enrolled in the program has gained weight.Two partially immobile clients are now mobile and continuing to improve
27 Health and Wellness Activities Food Pyramid Education weeklyHealthy Cooking Classes weeklyChair Zumba twice per weekModified Yoga weeklyDaily Walking ActivityHealthy Food Shopping As Needed1:1 Food Counseling and Review of Food Tracker as neededWeekly Off Site Exercise
28 Plans for The FutureExpand hours and responsibilities of P/A to provide all primary care for individuals in the programProvide fully certified smoking cessation classes to clientsStaff will become certified in smoking cessation, diabetes education, yoga, and zumbaProvide physical illness management education to case managersAdd Peer Support/Mentors to programWellness Model throughout organization