1. 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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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