AtlantiCare Health Services Mission Health Care Region II Conference Integration of Behavioral Health in Primary Care June 2, 2010 Region II Conference Integration of Behavioral Health in Primary Care June 2, 2010

What is Primary Health Care? “Essential health care” Universally accessible to individuals and families In a community Provided as close as possible to where people live and work Care based on the needs of the population “Essential health care” Universally accessible to individuals and families In a community Provided as close as possible to where people live and work Care based on the needs of the population

Providing behavioral health in primary care involves Diagnosing and treating people with mental disorders Putting in place strategies to prevent mental disorders Ensuring that primary health care workers are able to apply key psychosocial and behavioral science skills Diagnosing and treating people with mental disorders Putting in place strategies to prevent mental disorders Ensuring that primary health care workers are able to apply key psychosocial and behavioral science skills

For example: Interviewing Counseling Interpersonal skills In their day to day work in order to improve overall health outcomes in primary care (WHO, 1990) Interviewing Counseling Interpersonal skills In their day to day work in order to improve overall health outcomes in primary care (WHO, 1990)

Integration of Behavioral Health in Primary Care Integrating specialized health services – such as mental health services – into PHC is one of WHO’s most fundamental health care recommendations (WHO, 2001)

Rationale for Integrating Behavioral Health Services into PHC Reduced Stigma -  Patients are more comfortable in discussing mental health issues with PC provider  Because primary health care services are not associated with any specific health conditions, stigma is reduced  In general they have an established relationship with primary care provider because they are more inclined to follow up on medical care  “ I am not crazy “  less stigma walking into a PHC setting than a behavioral health setting Improved Access to Care Patients are more likely to keep appointments where multiple issues are being addressed Better coordination of care Treatment of co-morbid physical conditions Reduced Stigma -  Patients are more comfortable in discussing mental health issues with PC provider  Because primary health care services are not associated with any specific health conditions, stigma is reduced  In general they have an established relationship with primary care provider because they are more inclined to follow up on medical care  “ I am not crazy “  less stigma walking into a PHC setting than a behavioral health setting Improved Access to Care Patients are more likely to keep appointments where multiple issues are being addressed Better coordination of care Treatment of co-morbid physical conditions

Co Morbidity Behavioral health is often co-morbid with many physical health problems such as: Heart Disease HIV/AIDS Diabetes Tuberculosis Chronic Pain Behavioral health is often co-morbid with many physical health problems such as: Heart Disease HIV/AIDS Diabetes Tuberculosis Chronic Pain

Co Morbidity When primary health care workers have received some behavioral health care training they can attend to the physical needs of people with behavioral health disorders as well as the behavioral health needs of those suffering from infectious and chronic diseases. This will lead to BETTER health outcomes

Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying 25 years earlier than the general population While suicide and injury account for about % of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006) Persons with serious mental illness (SMI) are dying 25 years earlier than the general population While suicide and injury account for about % of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006)

Improved Prevention and Detection of Behavioral Disorders Primary health care workers are frontline formal health professionals First level of contact of individuals, the family and the community Equipping these workers with behavioral health skills promotes a more holistic approach to patient care and ensures both improved detection and prevention of behavioral disorders Primary health care workers are frontline formal health professionals First level of contact of individuals, the family and the community Equipping these workers with behavioral health skills promotes a more holistic approach to patient care and ensures both improved detection and prevention of behavioral disorders

Treatment and Follow –up of Behavioral Health People who are diagnosed with a behavioral health disorder are often unable to access any treatment for their mental health problems Providing behavioral health services in a PHC, more people will be able to receive the services and care they need because: People who are diagnosed with a behavioral health disorder are often unable to access any treatment for their mental health problems Providing behavioral health services in a PHC, more people will be able to receive the services and care they need because:

Treatment and Follow –up of Behavioral Health Better physical accessibility Primary health care is the first level of contact, usually the closest and the easiest to access for individuals, the family and the community Better financial accessibility 340b program Better acceptability Linked to reduced stigma and easier communication with health care providers Better physical accessibility Primary health care is the first level of contact, usually the closest and the easiest to access for individuals, the family and the community Better financial accessibility 340b program Better acceptability Linked to reduced stigma and easier communication with health care providers

Integrated Care Most effective approach to treat mental health in PC settings Comprehensive Multidisciplinary approach Fully integrated with information available to all practioners Cost-effective Most effective approach to treat mental health in PC settings Comprehensive Multidisciplinary approach Fully integrated with information available to all practioners Cost-effective

Challenges to Overcome for Successful Integration Integration of mental health services requires a lot of careful planning and there are likely to be several issues and challenges that will need to be addressed.

For example : Training of Staff Uncomfortable in dealing with mental disorders Overall reluctance of primary health care workers Availability of time Adequate supervision of primary care staff Human resource management issues- competencies Training of Staff Uncomfortable in dealing with mental disorders Overall reluctance of primary health care workers Availability of time Adequate supervision of primary care staff Human resource management issues- competencies

Clinical Barriers to Integrated Care Traditional separation of mental health issues from general medical issues Lack of awareness of mental health screening tools in the primary care setting Physician’s limited training in psychiatric disorders and their treatment Traditional separation of mental health issues from general medical issues Lack of awareness of mental health screening tools in the primary care setting Physician’s limited training in psychiatric disorders and their treatment

Financial Barriers Lack of insurance parity for psychiatric disorders Medicaid’s low reimbursement rates Billing restrictions Lack of insurance parity for psychiatric disorders Medicaid’s low reimbursement rates Billing restrictions

The following challenges are examples that policymakers should consider: 1. Reimbursement for mental health services from Managed Behavioral Health Care Organizations 2. Reimbursement after an initial mental health screening or diagnosis 3. Limitations in reimbursement for non-physician providers, i.e case management 4. Limitations on billing for mental health services and an additional medical visit on same day 5. Coding and provider combinations that generate adequate reimbursements from Medicaid/Medicare 1. Reimbursement for mental health services from Managed Behavioral Health Care Organizations 2. Reimbursement after an initial mental health screening or diagnosis 3. Limitations in reimbursement for non-physician providers, i.e case management 4. Limitations on billing for mental health services and an additional medical visit on same day 5. Coding and provider combinations that generate adequate reimbursements from Medicaid/Medicare

Policy Barriers Health and Mental Health funding streams Difficulty in sharing information due to HIPPA regulations Health and Mental Health funding streams Difficulty in sharing information due to HIPPA regulations

Organizational Barriers Shortage of mental health professionals Limited communication between medical and mental health providers Lack of agreement between medical and mental health provides Shortage of mental health professionals Limited communication between medical and mental health providers Lack of agreement between medical and mental health provides

ApproachDescriptionBenefitsLimitations ConsultationMental health experts are available by telephone or video conferencing to provide consultation on medication management and in some cases direct mental health consultation to individuals and families and referrals to local mental health specialist Increases access to psychiatrists and other mental health specialists, particularly in underserved communities with mental health workforce shortages; improves prescribing practices Does not provide psychotherapy and evidence-based mental health services Co-locationPrimary care and mental health clinicians are physically located in the same treatment setting. Mental health providers may be independent practitioners or co-located in primary care but employed by mental health, or other systems Can reduce the wait for mental health services; may increase the likelihood that individuals and families will follow through with mental health treatment Co-location does not guarantee collaboration or an integrated approach to practice Collaborative and integrated models Primary care practice has mental health clinicians on staffs that assess and treat individuals and families, provide phone consultation to other systems, and facilitate case conferences. Integrated practice recognizes the link between medical and mental health in every primary care encounter and provides integrated care A comprehensive approach that enables primary care to provide the full continuum of services: screening, assessment, and treatment Challenges include financial sustainability of mental health staff; billing complexities

AtlantiCare’s Journey Established 330h center in 2003 Grant requires mental health and substance use services Psychiatric APN through NHSC until May 2009 Introduced PhQ-9 to medical staff Established 330h center in 2003 Grant requires mental health and substance use services Psychiatric APN through NHSC until May 2009 Introduced PhQ-9 to medical staff

Co-location CIP grant dollars – satellite site MHC – AIS program Open July 2009 CIP grant dollars – satellite site MHC – AIS program Open July 2009

Adult Intervention Services AtlantiCare Behavioral Health A unique pilot program developed by Atlanticare Behavioral Health to address the needs of the residents of Atlantic County One of two services of this type in the state. Atlanticare Behavioral Health developed the program at the request of the state. A unique pilot program developed by Atlanticare Behavioral Health to address the needs of the residents of Atlantic County One of two services of this type in the state. Atlanticare Behavioral Health developed the program at the request of the state.

PURPOSE PURPOSE To provide comprehensive short-term interventions to individuals who are experiencing significant and distressing symptoms due to mental illnesses To bridge the gap between the onset of acute symptoms and on-going treatment To reduce the number of mental health clients inappropriately treated in the ER To provide comprehensive short-term interventions to individuals who are experiencing significant and distressing symptoms due to mental illnesses To bridge the gap between the onset of acute symptoms and on-going treatment To reduce the number of mental health clients inappropriately treated in the ER

GOALS FOR EARLY INTERVENTION AND SUPPORT SERVICES To provide accessible early and urgent intervention, support services, and ongoing recovery supports to individuals, families, and consumers in acute distress To maintain or enhance the quality of life of the consumers and their families To provide community based crisis intervention through the development of a community walk in center and the provision of early intervention outreach services To provide accessible early and urgent intervention, support services, and ongoing recovery supports to individuals, families, and consumers in acute distress To maintain or enhance the quality of life of the consumers and their families To provide community based crisis intervention through the development of a community walk in center and the provision of early intervention outreach services

TARGET POPULATION Adults – 18 years of age or older Experiencing acute psychiatric symptoms Co-Occurring substance use disorders All of whom are in a community setting and can be safely stabilized, and subsequently provided ongoing individualized supports Adults – 18 years of age or older Experiencing acute psychiatric symptoms Co-Occurring substance use disorders All of whom are in a community setting and can be safely stabilized, and subsequently provided ongoing individualized supports

MHC-AIS Integrated Services Monthly meetings established with Directors, medical and clinical staff and case management Weekly case management meetings between AIS-MHC to review progress on mutual patients and develop action plans for high risk patients Monthly meetings established with Directors, medical and clinical staff and case management Weekly case management meetings between AIS-MHC to review progress on mutual patients and develop action plans for high risk patients

Case Study-Billy E 61 year old African American male Medical History Diabetes,COPD,Hypertension,GERD, Glaucoma, Hepatitis C, Obesity, Osteoarthritis, Asthma, Muscle weakness, Congestive heart failure Psychiatric History Major Depressive Disorder, Anhedonia, past hx of alcohol abuse (5 yrs sober) Medical History Diabetes,COPD,Hypertension,GERD, Glaucoma, Hepatitis C, Obesity, Osteoarthritis, Asthma, Muscle weakness, Congestive heart failure Psychiatric History Major Depressive Disorder, Anhedonia, past hx of alcohol abuse (5 yrs sober)

Case study Patient of MHC since 2007 Treated for medical and psychiatric issues May 2009, psychiatric APN resigned APN referred Billy to behavioral health services Patient of MHC since 2007 Treated for medical and psychiatric issues May 2009, psychiatric APN resigned APN referred Billy to behavioral health services

Case study Billy does not follow through with behavioral health referrals Non-adherent to psychiatric medications and behavioral health services No follow through with appointments and specialty referrals (pulmonologist, nephrology, ID clinic) Decline in self esteem, feelings of hopelessness, lacks ability to function in social settings Difficulty trusting people Isolating Feels he has no one in his corner advocating for him Billy does not follow through with behavioral health referrals Non-adherent to psychiatric medications and behavioral health services No follow through with appointments and specialty referrals (pulmonologist, nephrology, ID clinic) Decline in self esteem, feelings of hopelessness, lacks ability to function in social settings Difficulty trusting people Isolating Feels he has no one in his corner advocating for him

Case study Encourage referral to AIS program co-located with MHC Intake and Psych evaluation on 3/10/2010 Chief complaint- “I stopped taking my meds, ran out of them, I can’t sleep, I worry a lot, I can’t handle my stress. I feel depressed” Encourage referral to AIS program co-located with MHC Intake and Psych evaluation on 3/10/2010 Chief complaint- “I stopped taking my meds, ran out of them, I can’t sleep, I worry a lot, I can’t handle my stress. I feel depressed”

Case study Billy accepted to the AIS program Begins medication and treatment on 3/10/2010 Attends 5 groups per week, 1:1 counseling weekly, case management services and medication monitoring Follows through with 90% of appointments Adherent to psych medication Successfully follows through with specialty appointments Involved in social functions – CODI, fashion show, support groups, computer class Increase in confidence and self esteem Billy accepted to the AIS program Begins medication and treatment on 3/10/2010 Attends 5 groups per week, 1:1 counseling weekly, case management services and medication monitoring Follows through with 90% of appointments Adherent to psych medication Successfully follows through with specialty appointments Involved in social functions – CODI, fashion show, support groups, computer class Increase in confidence and self esteem

Case study Remained with AIS for 2 months, discharged on 5/6/2010 and referred to ABH outpatient program Highest PhQ-9 score was 18 Recent score 2 Remained with AIS for 2 months, discharged on 5/6/2010 and referred to ABH outpatient program Highest PhQ-9 score was 18 Recent score 2

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