Department of Psychiatry, University of Michigan 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

Barriers to Integrated Behavioral Health-Primary Care: 6-P Framework 4/6/2017 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, carved-out MH, Rx) Purchasers/State (e.g., not on radar screen, lack of info on return-on-investment) Populations/Policies (e.g., stigma) Kilbourne, Amy

PCP, MH Provider Barriers 4/6/2017 PCP, MH Provider Barriers Turnover Losing interest Competing demands Territories Kilbourne, Amy

PCP, MH Provider Strategies 4/6/2017 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) Kilbourne, Amy

Implementing Change: Participatory Management 4/6/2017 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 Kilbourne, Amy

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

Participatory Management PM Process Components Process 1: Design Identify 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

Participatory Management: WCHO Integrated Care Program 4/6/2017 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 Kilbourne, Amy

WCHO Learning Community 4/6/2017 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” Kilbourne, Amy

Challenges Resources Administrative/Operations Financing Governance 4/6/2017 Challenges Resources Administrative/Operations Financing Governance Clinical Kilbourne, Amy

Addressing Challenges 4/6/2017 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 Kilbourne, Amy

Making the Business Case 4/6/2017 Making the Business Case Clinical (outcomes, processes of care) Organizational (fidelity) Economic (costs) Social (satisfaction, stories) Kilbourne, Amy

Making the Business Case Momentum and Lessons Learned 4/6/2017 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 Kilbourne, Amy

Clinical Performance Measures 4/6/2017 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 Kilbourne, Amy

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

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