1. Integrating Behavioral Health Care into the Navy Medical Home Port (Patient Centered Medical Home)
Good morning, my name is Lieutenant Rocio Porras and this is Commander Patricia Hasen. We will be presenting the integration of behavioral health care into the Navy Medical Home Port which is the Navy’s name for the Patient Centered Medical Home. We both join you today from the Family Medicine Department at the Naval Hospital Camp Pendleton located in Southern California. If you would like a copy of these slides, please note my address at the end of the presentation and I will gladly you a copy. CDR Hasen’s address is also provided, but she will be PCSing next week. It is a rather large document, so a civilian address may be better than a military address due to the size constraints.
Patricia C. Hasen, CDR, NC, USN
Rocio Porras, LT, NC, USN
Family Medicine Department
Naval Hospital Camp Pendleton
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

2. Disclosure / Disclaimer
LT Rocio Porras and CDR Patricia Hasen have nothing to disclose. The views and opinions expressed during this presentation do not necessarily reflect those of Naval Hospital Camp Pendleton, the Department of the Navy or the Department of Defense.
We have nothing to disclose and the views and opinions expressed during this presentation do not necessarily reflect those of Naval Hospital Camp Pendleton, the Department of the Navy or the Department of Defense.
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

3. Objectives Define Behavioral Health and Health.
Verbalize the rationale for integrating Behavioral Health (BH) in the Patient Centered Medical Home (PCMH)
Discuss how integration of BH is in alignment and consistent with principles of the PCMH, the Quadruple Aim and the MHS.
Discuss the benefits of integrating BH in the PCMH.
Compare and contrast the three models of BH integration in the PCMH Describe how to build BH in your clinic.
Verbalize required elements for successful integration of behavioral health in an outpatient clinic setting.
Verbalize principles for leading and managing change
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

4. Define Behavioral Health and Health
“is integral to overall health as mind and body are inseparable. As a general concept, behavioral health is the reciprocal relationship between human behavior and the well-being of the body, mind, and spirit, whether considered individually or as an integrated whole.” (PC-PCC, 2012)
HEALTH
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”(WHO, 1946)
For the purposes of this presentation, Behavioral Health is defined to include mental health conditions, including substance use and health behaviors. Behavioral health is the larger construct consisting of any and all mental health conditions.
Health is impacted by physio-psycho-social problems and they are so intertwined that it can become difficult to discern what the root problem may be as behavioral health problems masquerade physical complaints.
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

5. ‘Would you tell me, please, which way I ought to go from here?’
“…she was a little startled by seeing the Cheshire Cat sitting on a bough of a tree a few yards off...”
‘Would you tell me, please, which way I ought to go from here?’
‘That depends a good deal on where you want to get to,’ said the Cat.
‘I don’t much care where ­’ said Alice.
‘Then it doesn’t matter which way you go,’ said the Cat.
‘ ­so long as I get somewhere,’ Alice added as an explanation.
‘Oh, you’re sure to do that,’ said the Cat, ’if you only walk long enough.’
(Carroll, 1865)
A quote from Alice in Wonderland.
I want you to think about your practice and your clinic. What is your roadmap? Where are you going? How do you get there? What does the road look like? What does the destination look like? How do you know when you got there? Where are you going with your Patient Centered Medical Home? Integration of specialty care? Integration of Behavioral Health?
Ask your self:
Why are we on this road?
What are the benefits of taking this road?
Where is my road map?
What are my goals? (goals give you direction and measures)
Cheshire Cat pictures (screencaps) from Disney's Alice I
in Wonderland. Image Source Page:
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

6. Strain of Past Decade of War
The strain of the past decade of war places unique stressors on military and family member and the military community and prolonged exposure to stressors (combat-related and otherwise) may take a substantial psychological toll on military and family members (Defense Board, 2011). The symptoms families may experience and their cumulative effects impact family resiliency and may resonate chronically for years. This poses not only a threat to the family unit, but to military readiness and mission accomplishment.
The Institutes of Medicine 2006 report calls for improved coordination of BH problems (IOM, 2006). Seldom occurring in isolation, these problems frequently accompany each other, are intertwined with medical conditions or masquerade as separate somatic problems making accurate diagnosis and appropriate treatment difficult and threatening recovery and overall health. Primary Care (PC) is the largest platform for health care delivery in the US and is the defacto platform for treating BH problems. Therefore, it stands to reason that since health problems are so intertwined, PC and BH are inseperable. This calls for improved coordination and collaboration between medical and behavioral health providers and Medical Home Teams to improve overall health outcomes and military readiness.
[Photo on left: Corpsman Up - Navy Petty Officer 3rd Class Benjamin Knauth (blue), a 29-year-old native of Centennial, Colo., and Petty Officer 2nd Class Dustin Koch, a 26-year-old native of Las Cruces, N.M., corpsmen with 3rd Battalion, 3rd Marine Regiment, place reassuring hands on the shoulder of an Afghan National Policeman while examining his injuries in the battalion aid station here following an attack by a suicide bomber in Helmand province's Garmsir district, April 19, The 3/3 corpsmen treated eight injured Afghan policemen after being faced with a mass casualty situation following the attack on an ANP precinct headquarters in Garmsir's Lakari region. Ten of the 18 total ANP casualties died from wounds sustained in the attack. After initially being stabilized by three 3/3 corpsmen at Combat Outpost Sharp, eight casualties were transported to FOB Delhi and treated by a team of 28 Navy personnel. Medical evacuation helicopters later transported six ANP casualties to Camp Dwyer's Casualty Support Hospital for further treatment, while the remaining two were treated and released. (U.S. Marine Corps photo by Cpl. Reece Lodder)
[Photo on Right: Goodbye, Best Friend. Yeager, an improvised explosive device detection dog, lies in front of a battlefield cross as Staff Sgt. Derick Clark, a kennel supervisor with Headquarters and Service Company, 2nd Battalion, 9th Marine Regiment, and 26-year-old native of Hillsdale, Mich., and Chief Warrant Officer 2 Michael Dale Reeves, a kennel officer in charge with 2nd Bn., 9th Marines and 41-year-old native of Mt. Pleasant, S.C., observe a moment of silence in honor of Lance Cpl. Abraham Tarwoe, a dog handler and mortarman who served with Weapons Company, 2nd Bn., 9th Marines, during a memorial service here, April 22, Tarwoe, who became Yeager's handler in July 2011, was killed in action during a dismounted patrol in support of combat operations in Helmand province's Marjah district, April 12. Tarwoe's fellow Marines remember him for his contagious laughter and smile, and his unfaltering courage on the battlefield. (U.S. Marine Corps photo by Cpl. Alfred V. Lopez)
U.S. Marine Corps photo by Cpl. Reece Lodder. Taken 19 April
U.S. Marine Corps photo by Cpl. Alfred V. Lopez. Taken 22 April
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

7. A Military Readiness Concern
Beneficiaries face barriers to receiving care for their personal and family problems, some self-imposed. Active duty personnel are subject to stigma and fear for their careers, while family members and retirees are affected by the reluctance of mental health providers to accept TRICARE insurance.
Military spouses and military families need easy access to stigma-free behavioral health (BH) care to assist in building resilience and providing long-term support that strengthens military families and better equips them to weather frequent, multiple deployments. Family resilience is a military readiness issue and thus a Force Health Protection concern. Integrating BH resources into existing familiar structures such as the Patient Centered Medical Home (PCMH) to improve early screening, recognition, identification and treatment of stressors that threaten resiliency and the family unit benefits families and the military.
[Left Photo: Daddy Down Under - Lance Cpl. David Allen, rifleman, Fox Company, 2nd Battalion, 3rd Marine Regiment, comforts his wife and baby girl before preparing to leave for his deployment to Darwin, Australia, April 2. The Company will work closely with their Australian allies on world-class ranges to increase their training capabilities.(U.S. Marine Corps photo by Cpl. Vanessa American Horse)
[Right Photo: Fight for First - Capt. Jonathan Disbro and Cpl. Kionte Storey, Wounded Warriors with the West Team, fight for the lead in the 200m race during the 2012 Marine Corps Trials, hosted by the Wounded Warrior Regiment, at Marine Corps Base Camp Pendleton, Calif., Feb. 19, Storey won the 100m, 200m and was a part of the winning 400m relay team. Wounded Warrior Marines, veterans and allies are competing in the second annual trials, which include swimming, wheelchair basketball, sitting volleyball, track and field, archery and shooting. The top 50 performing Marines will earn the opportunity to compete in the Warrior Games in Colorado Springs in May. (U.S. Marine Corps photo by Sgt. Mark Fayloga)
U.S. Marine Corps photo by Cpl. Vanessa American Horse. Taken 2 April
U.S. Marine Corps photo by Sgt. Mark Fayloga. Taken 19 Feb
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

8. Whom We Serve Beneficiaries by Category Active duty: 1.7 million
Over 9.6 Million Beneficiaries
Program Enrollment
Beneficiaries by Category
Active duty: 1.7 million
Active duty family: 2.4 million
Retirees: 1 million
Retiree family: 1.8 million
Medicare-eligible: 2.1 million
5.4 million TRICARE Prime
3.7 mil in direct care system
1.7 mil in contractor networks
2.1 mil TRICARE Standard/Extra
Others use TRICARE Reserve Select, TRICARE For Life
I wanted to put up a snap-shot of who we serve. This is why we are here today. For our patients. Keep in mind the numbers of people we serve and when we say something decreases costs by $100 a patient, look at what that really is – that is a significant savings across the enterprise of the MHS.
I’m hopeful that you will be active participants in the integration of BH into your PCMH and will take away knowledge to better enhance your practice.
We have four goals for you. Namely, you’ll:
State the reasons (and benefits) for integrating
Describe what integration looks like
State what our goals are for integrating BH in the PCMH
Describe what you as an Ambulatory Care Nurse can do to make this journey more comfortable along the way (and hugely successful)!
The role of the nurse is pivotal in the implementation, ongoing maintenance and success of PCMH initiatives that optimize health of our patients. As ambulatory care nurses, we can exert a large amount of influence on the health care that patients receive and can make critical recommendations and improvements that impact health.
Source: TMA, 2011.
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

9. Rationale for Integrating
Population Health
30.5% US adult population meets criteria for one or more mental health problems (estimated for a 1-year period) and only 32% of these receive treatment (Kessler, et. al., 2005).
12-27% of US pediatric population meet behavioral health problem criteria (Simonian, 2006; Sakolsky & Birmaher, 2008)
11-17% of OEF/OIF combat veterans met BH screening criteria (Hoge, et. al., 2004)
80% of BH problems in US youths are not identified or treated (Teen Screen, 2011)
MH problems are 2-3 times more common in patients with chronic health problems (Katon, 2007; Dowrick, et al., 2005)
Half of all life-time BH disorders start by age 14 (TeenScreen, 2011)
National studies estimate that, during a 1-year period, up to 30 percent of the U.S. adult population (18 to 54 years of age) meets criteria for one or more mental health problems. 10.8% are mild, 13.5% are moderate and 6.3% are severe. The most prevalent disorders were Substance Abuse Disorders (e.g., alcohol and drug abuse and 25%, Mood Disorders (e.g., major depression, dysthymia, and bipolar 19% and Anxiety Disorders (e.g., panic disorder, generalized anxiety disorder, phobias, and post-traumatic stress 11% (Kessler et al., 2005).
For US adults and children, the prevalence of BH conditions is approximately 25-30%.
Mental health problems are 2 to 3 times more common in patients with chronic medical illnesses such as diabetes, arthritis, chronic pain, headache, back and neck problems, and heart disease (Katon, 2003; Katon, Lin, and Kroenke, 2007; Scott et al., 2007). Left untreated, mental health problems are associated with considerable functional impairment, poor adherence to treatment, adverse health behaviors that complicate physical health problems, and excess health care costs (Almeida and Pfaff, 2005; Anda et al., 1990; Cronin-Stubbs et al., 2000; DiMatteo, Lepper, and Croghan, 2000; Kessler et al., 2005; Kinnunen et al., 2006; Martini, Wagner, and Anthony, 2002; Merikangas et al., 2007; Scott et al., 2009).
Military members do not seek out care – partly due to stigma
BH problems are intertwined so well with physical complaints that for the 14 most common physical complaints, 84% of the time there is no identifiable organic etiology.
The fact that 80% of people with BH D/O visit a PC at least annually demonstrates missed opportunities to intervene and potentially prevent or mitigate sequelae.
And research tells us that the preponderance of BH tx occurs in PC. However, when providers are polled- they often times feel like they have inadequate skills to recognize, identify, treat, monitor and follow BH problems.
And PC accounts for almost half of ALL psychotropic drug prescribing visits (renewals, new Rx, modification, etc).
The take home message is that BH problems are common and most of the care occurs in the PC sector and we have prime opportunities to address BH issues.
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

10. Rationale for Integrating
Readiness
52% of all BH treatment occurs in Primary Care (Kessler, et al., 2005)
48% of all psychotropic drug visits occur in PC (Pincus, et al., 1998)
80% with BH disorder visit Primary Care at least once a year (Narrow, et al., 1993)
11-17% of OIF/OEF combat veterans met BH screening criteria; only 38-45% indicated an interest in receiving help; only 23-40% reported received professional help in the past (Hoge, et al., 2004)
32% (average) of Military Health System beneficiaries report difficulties accessing BH care (HCSDB, 2008; TMA, 2009)
64% (average) of MHS beneficiaries report difficulties accessing urgent BH care (HCSDB, 2008; TMA, 2009)
Unmet needs of BH care in PC hinders health and resiliency
10% of screens are PTSD positive (Hoge et al, JAMA, 2006;295: )
22% of those who are PTSD screen positive received referrals to a specialist (GAO, 2006)
48-56% of those referred for positive screens were seen by specialist (Hoge et al JAMA 2006;295: )
Hoge 2004: The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a
mental disorder were twice as likely as those whose responses were negative to report
concern about possible stigmatization and other barriers to seeking mental health care:
“I would be seen as weak” 65%
“My unit leadership might treat me differently” 63%
“Members of my unit might have less confidence in me” 59%
“There would be difficulty getting time off work for treatment.” 55%
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

11. Rationale for Integrating
Per Capita Costs
Mental health conditions 3rd costliest medical condition (AHRQ, 2009)
33.2% of adults being treated for BH concerns receive minimally adqequate care (Wang, et al., 2005)
30-50% of referrals from PC to outpatient BH clinic don’t make 1st appt (Fisher & Ransom, 1997; Hoge, et al., 2006)
84% of the time, the 14 most common physical complaints have no identifiable organic etiology (Kroenke & Mangelsdorf, 1989)
40% of premature deaths in the US are from behavioral factors (Kindig & McGinnis, 2007)
Lower costs – medical use decreased 15.7% for those receiving BH treatment and increased 12.3% for controls who did not receive BH treatment (Chiles, Lambert & Hatch, 1999)
BH disorders account for half as many disability days as “all” physical conditions
Annual medical expenses--chronic medical & behavioral health conditions combined cost 46% more than those with only a chronic medical condition
40% of premature deaths can be attributed to preventable behavioral factors, and therefore, the single greatest opportunity to improve health and reduce premature deaths lies in personal behavior (Schroeder, 2007).
Lower costs when BH needs are treated
Medical use decreased 15.7% for those receiving behavioral health treatment, while medical health use increased 12.3% for controls who did not get behavioral health 1.
Depression treatment in primary care for those with diabetes had $896 lower total healthcare cost over 24 months 2.
Depression treatment in primary care had $3,300 lower total healthcare cost over 48 months 3
1. Chiles et al., Clinical Psychology. 1999;6:204–220.
2. Katon et al., Diabetes Care. 2006;29:
3. Unützer et al., American Journal of Managed Care 2008;14:95-100
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

12. Rationale for Integrating
Nationwide, overall treatment costs for mental disorders rose from $35 billion (in 2006 dollars) to nearly $58 billion, making it the costliest medical condition between 1996 and 2006 (CDC). In 2008, mental health conditions were the third most costly condition (along with cancer), exceeded only by heart conditions and trauma related disorders (CDC).
It stands to reason that several of the family member visits can be recouped into the Direct Care sector, enhancing treatment as well as decreasing costs.
Source: MHS 2012 Stakeholder’s Report
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

13. Determinants of Health
The actual causes of illness and death in the United States often
relate to personal behaviors that the health care system fails to
address. To achieve our transformation from healthcare to health, we
will have to learn better ways to help people adopt a healthier
lifestyle. In the near term, we will focus on ways to reduce obesity
and reduce tobacco use.
Source: MHS 2012 Stakeholder’s Report
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

14. Rationale for Integrating
Experience of Care
Better access to BH services
Stigma-free BH access
Better health outcomes
Improved satisfaction
Ongoing education to Medical Home teams and residents
Better health outcomes
Quantitative & qualitative reviews or RCTs demonstrated better outcomes in depression, panic disorder, tobacco use, alcohol misuse, diabetes, irritable bowel syndrome, primary insomnia, chronic pain and somatic complaints
Improved satisfaction
Quantitative & qualitative reviews1-4
Depression1-4
Panic Disorder1,2
Other Studies5
Tobacco
Alcohol Misuse
Diabetes, IBS, Primary Insomnia
Chronic Pain, Somatic Complaints
1. Butler et al., AHRQ Publication No. 09- E003. Rockville, MD. AHRQ
2. Craven et al., Canadian Journal of Psychiatry. 2006;51:1S-72S.
3. Gilbody et al., British Journal of Psychiatry, 2006;189:
4. Williams et al., General Hospital Psychiatry, 2007; 29:
5. Hunter et al., Integrated Behavioral Health in Primary Care: APA, 2009.
Patient Satisfaction1-5
Provider Satisfaction6,7
1. Chen et al., American Journal of Geriatric Psychiatry. 2006; 14:
2. Unutzer et al., JAMA. 2002; 288:
3. Katon et al., JAMA. 1995; 273:
4. Katon et al., Archives of General Psychiatry. 1999; 56:
5. Katon et al., Archives of General Psychiatry. 1996; 53:
6. Gallo et al., Annals of Family Medicine. 2004; 2:
7. Levine et al., General Hospital Psychiatry. 2005; 27:
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

15. Rationale for Integrating
Current military environment
Stigma
Family Readiness affects Military Readiness
Strain of past decade of war
Lack of BH capacity in MTF for Family members
Lack of community capacity for Family members
Lack of providers who accept TRICARE
Cultural gap between military and civilian providers
The military family is under stress and will remain so for some time. Our focus is shifting from healthcare to health and the family is a major determinant of overall health status. Enhancing resilience and readiness of the family enhances overall military readiness.
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

16. Summary of Rationale for Integrating
BH problems are common
Complex inter-relationship between physical and psycho-social symptoms
PC is largest platform for health care delivery in the US
PC is the defacto BH treatment platform
BH problems often go unrecognized in PC
When recognized, treatment is often suboptimal
BH problems compromise the quality and outcomes of treatment for physical health conditions
The leading preventable cause of premature death is behavior
Appropriate BH treatment can alleviate impediments to well-being
BH treatment can assist in building resiliency and maintaining military readiness
– Reason 1: Prevalence of BH Problems in PC
– Reason 2: Unmet BH Needs in PC
– Reason 3: Cost of Unmet Needs
– Reason 4: Lower Cost When Needs are Met
– Reason 5: Better Health Outcomes
– Reason 6: Improved Satisfaction
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

17. Benefits of Integration
When BH is integrated in the PCMH:
Less stigma - patients prefer to be seen at PCMH rather than specialty clinic
Better coordination - shorter wait times and better communication
Reduce morbidity with early recognition and treatment
Serve all patients - opportunity for prevention
Integration of physical and emotional care
Integrate screening and brief psychosocial update into visit - improved screening, recognition, identification, early intervention, treatment, monitoring
Conduct an assessment alone or collaboratively
Overcome barriers to seeking mental health care
Skills to build resilience, promote healthy lifestyles
Improves Military Readiness
Improve Physical, Emotional and Social Well-Being
Keeping healthy people healthy
Reducing modifiable lifestyle risk factors
Optimizing care and support for those with disease or conditions
Reduce the impact of predictable stressful events (deployments)
Expand the focus from Health Care to Health and Well-being
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18. Illustration in PC Morning Clinic
56 yo diabetic with poor control 19 yo smoker for P.E. 33 yo with multiple somatic complaints 7 yo for earache 67 yo w/insomnia 70 yo w/sinusitis 52 yo hypertensive patient for f/u 45 yo w/tinnitus 38 yo w/acute asthma 29 yo w/chest pain & SOB
an example of a representative morning schedule in primary care.
Source: Blount,
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19. Example with Highlighted Mental Health Needs
56 yo diabetic with poor control
19 yo smoker for P.E.
33 yo w/ multiple somatic complaints
7 yo for earache
67 yo w/insomnia
70 yo w/sinusitis
52 yo hypertensive patient for f/u
45 yo w/tinnitus
38 yo w/acute asthma
29 yo w/chest pain & SOB
Old Dx BPD
Depression
Alcohol abuse
Panic disorder
Now here is the same list with representative mental health
Source: Blount,
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

20. Example with Highlighted Psychosocial Distress
56 yo diabetic with poor control
19 yo smoker for P.E.
33 yo with multiple somatic complaints
7 yo for earache
67 yo w/insomnia
70 yo w/sinusitis
52 yo hypertensive patient for f/u
45 yo w/tinnitus
38 yo w/acute asthma
29 yo w/chest pain & SOB
Anxious (Old Dx BPD )
(Depression)
Bedwetting
(Alcohol abuse)
Family violence
Hypochondriasis
(Panic disorder)
Then there are psychosocial problems that people bring that may not meet criteria for a
mental health diagnosis, or may not be identified because there is a physical problem that
takes up the available time and attention.
Source: Blount,
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

21. Example with Highlighted Behavioral Health Needs
56 yo diabetic with poor control
19 yo smoker for P.E.
33 yo with multiple somatic complaints
7 yo for earache
67 yo w/insomnia
70 yo w/sinusitis
52 yo hypertensive patient for f/u
45 yo w/tinnitus
38 yo w/acute asthma
29 yo w/chest pain & SOB
Smoking/weight loss (Anxious; Old Dx BPD )
Smoking cessation
(Depression)
(Bedwetting )
(Alcohol abuse)
(Family violence )
Cardiac risk factors
(Hypochondriasis)
Medication compliance
(Panic disorder)
Finally, there are behavioral health needs, in the form of changes of health behavior that
can be extremely important for the health and happiness of patients.
For every need listed, there is a reasonable behavioral health intervention available. It
would seem that a BH specialist in this PC setting would get a number of referrals out of this morning’s work. However the average number of referrals out of an array like this would be 0 to 1.
Source: Blount,
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

22. Integration is Consistent with Joint Principles of the PCMH
Personal Physician
Physician-directed Medical Practice
Whole Person Orientation
Care is Coordinated and/or Integrated
Quality and Safety
Enhanced Access
Payment Reform
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

23. Integration is Consistent with the Quadruple Aim
Readiness
Pre- and Post-deployment
Family Health
Behavioral Health
Professional Competency/Currency
Delivering the Right Care at the Right Time
Population Health
Healthy service members, families, and retirees
Quality health care outcomes
Prevalence of BH conditions in PC
A Positive Patient & Staff Experience
Patient and Family centered Care, Access, Satisfaction
Cost
Responsibly Managed
Focused on value
Cost of unmet needs; decreased costs when address BH needs
MHS Leadership is committed to delivering value to all we serve.
The Quadruple Aim represents our strategic goals and value proposition:
improved readiness, better care, better health and responsibly
managed costs.
To maintain a fit, healthy and ready force, all aspects of the service member’s situation must be addressed. Thisincludes not only the Service Member’s personal health and readiness, but that of his or her family member’s too.
The Quadruple Aim and the PCMH are enduring constructs of care and provide strategic vision for our future.
This is what will assist us in moving from health care to health (if you saw General Horoho’s MHS presentation)
•Understanding desired end-state Balanced approach to Quadruple Aim
Readiness maximized
Health outcomes and patient experience improved
Sustainable costs
Screening for Family-centered medical readiness is
discussed in the context of family stability issues that
raise the risk of premature redeployment of the Active
Duty Service Member. Family Medical Readiness supports the health and resilient family
Family medical readiness supports readiness, pop health, and experience of care
Strategic Imperatives directly affected by Family Medical Readiness
Individual Medical Readiness (holistic)
Psychological Health
Engaging patients in healthy behaviors
Wounded warrior care
The MHS Quadruple Aim:
Readiness
Ensuring that the total military force is medically ready to deploy and that the medical force is ready
to deliver health care anytime, anywhere in support of the full range of military operations, including
humanitarian missions.
Population Health
Reducing the generators of ill health by encouraging healthy behaviors and decreasing the likelihood
of illness through focused prevention and the development of increased resilience.
Experience of Care
Providing a care experience that is patient and family centered, compassionate, convenient, equitable,
safe and always of the highest quality.
Per Capita Cost
Creating value by focusing on quality, eliminating waste and reducing unwarranted variation;
considering the total cost of care over time, not just the cost of an individual health care activity.
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24. Integration is Consistent with the MHS Mission
Provide optimal health services in support of our nation’s military mission—anytime, anywhere.
DoD Mission To provide the military forces needed to deter war and to protect the security of our country.
All we do and all of our efforts must support our mission.
As part of the MHS 2012 Strategic initiatives, one is to Integrate and optimize psychological health programs to improve outcomes and enhance value
Source: MHS.
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25. 3 Models of Integration Care Management Model
Primary Care Behavioral Health Model
Blended Model
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26. Care Management Model
Population-based model of care typically focused on a discrete clinical problem (e.g., depression).
It incorporates specific pathways to systematically address how BH problems are managed in PC.
PC providers & care managers share information via direct communication, shared medical record, treatment plan, and standard of care.
Typically, there is some form of systematic interface with the outpatient mental health
Briefly discuss what this might look like in R-MIL
Share info--via direct communication, shared medical record, treatment plan, and standard of care
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

27. Primary Care Behavioral Health Model
Population-based model of focused on all enrolled patients (e.g., depression, anxiety, substance use, stress, obesity, diabetes, insomnia, chronic pain)
BHC is embedded with PC team serving as a team member in the assessment, intervention & health care of the patient
BHCs & PCMs share patient information, medical record & coordinate health care plans
Brings a team-based management approach to care
BHC helps PC team improve BH assessment & intervention
BHC sees patients in minute appointments in PC clinic
Same day as well as scheduled appointment availability
BHC focuses on full range of BH & health behavior change
1. serving as a team member in the assessment, intervention & health care of the patient
2. , medical record & coordinate health care plans
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

28. Blended Model Focused on all enrolled patients
Care Manager and Embedded BHP
Continuity of Care
Stepped Care
Access to all enrollees to BHC in the PCMH
Clinical Feasibility and Efficiency
Implements DoD/VA guidelines
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29. Re-Engineering Healthcare Integration Programs (REHIP)
Stepped care for health
From: REHIP
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30. Blended Model
From: REHIP
AAACN Tri-Service Military Pre-Conference 1 May 2012, Walt Disney World Resort

31. Building BH into Your Clinic
Educate yourself – read your instructions, support documents
Educate your staff
Staffing ratios
Facilities – patients seen in the exam room; common check-in areas; BH providers imbedded into the PCMH; can share office spaces with other providers
Administrative support
Templates, business operations, position descriptions, 4th level MEPRS, coding, POM, documentation
Ancillary support staff support
Handling referrals
Referrals to MH
FY12-17 POM
Services requested funding for 429 BH providers to work exclusively in PCMH
Funding for all PCMH FY12-17 requests being evaluated
TriService Recommendations for BH in PCMH
MHS PCMH Guide
Army PCMH OPORD
Navy BUMED PCMH Instruction
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32. Building BH into Your Clinic
Training primary care providers and staff in prevention, recognition, management, and referral of adult and pediatric patients with social and emotional concerns is essential to fully integrating Behavioral Health into Primary Care
Required skills of the Behavioral Health providers
Training program
Phased training program through BUMED by qualified trainers
Didactic and practicum
Phase I – self guided, didactic
Phase II – Didactic, In Vivo, Feedback (San Antonio, July 2012)
Phase III – (6 mo following Phase II), Sustainment training, site visits
Monthly teleconferences with other BH personnel
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33. Principles for Leading & Managing Change
Leading and managing change
Involve the stakeholders – that is the entire staff – in who, what, where, when of integration, accessing BH, utilizing BH
Communicate, communicate, communicate – early and often
Delineate roles
Set up business plan – templates, coding, referral management, appointing, develop patient registry
Care Coordination
Celebrate victories
Lessons learned
Outcomes/Metrics/Dissemination
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34. 8-Step Process for Leading Change
Create urgency
Form a powerful coalition
Create a vision for change
Communicate the vision
Remove obstacles
Create short-term wins
Build on the change
Anchor the changes in corporate culture
What was true more than two thousand years ago is just as true today. We live in a world where "business as usual" IS change. New initiatives, project-based working, technology improvements, staying ahead of the competition – these things come together to drive ongoing changes to the way we work.
Whether you're considering a small change to one or two processes, or a systemwide change to an organization, it's common to feel uneasy and intimidated by the scale of the challenge.
Step One: Create Urgency
There are many theories about how to "do" change. Many originate with leadership and change management guru, John Kotter. A professor at Harvard Business School and world-renowned change expert, Kotter introduced his eight-step change process in his 1995 book, "Leading Change." We look at his eight steps for leading change below.
You know that the change needs to happen, but you don't really know how to go about doing delivering it. Where do you start? Whom do you involve? How do you see it through to the end?
This isn't simply a matter of showing people poor sales statistics or talking about increased competition. Open an honest and convincing dialogue about what's happening in the marketplace and with your competition. If many people start talking about the change you propose, the urgency can build and feed on itself.
For change to happen, it helps if the whole company really wants it. Develop a sense of urgency around the need for change. This may help you spark the initial motivation to get things moving.
Examine opportunities that should be, or could be, exploited.
Identify potential threats, and develop scenarios showing what could happen in the future.
What you can do:
Kotter suggests that for change to be successful, 75% of a company's management needs to "buy into" the change. In other words, you have to really work hard on Step One, and spend significant time and energy building urgency, before moving onto the next steps. Don't panic and jump in too fast because you don't want to risk further short-term losses – if you act without proper preparation, you could be in for a very bumpy ride.
Request support from customers, outside stakeholders and industry people to strengthen your argument.
Start honest discussions, and give dynamic and convincing reasons to get people talking and thinking.
Convince people that change is necessary. This often takes strong leadership and visible support from key people within your organization. Managing change isn't enough – you have to lead it.
Step Two: Form a Powerful Coalition
You can find effective change leaders throughout your organization – they don't necessarily follow the traditional company hierarchy. To lead change, you need to bring together a coalition, or team, of influential people whose power comes from a variety of sources, including job title, status, expertise, and political importance.
Once formed, your "change coalition" needs to work as a team, continuing to build urgency and momentum around the need for change.
Ask for an emotional commitment from these key people.
Identify the true leaders in your organization.
Work on team building within your change coalition.
Check your team for weak areas, and ensure that you have a good mix of people from different departments and different levels within your company.
A clear vision can help everyone understand why you're asking them to do something. When people see for themselves what you're trying to achieve, then the directives they're given tend to make more sense.
When you first start thinking about change, there will probably be many great ideas and solutions floating around. Link these concepts to an overall vision that people can grasp easily and remember.
Step Three: Create a Vision for Change
Develop a short summary (one or two sentences) that captures what you "see" as the future of your organization.
Determine the values that are central to the change.
Practice your "vision speech" often.
Ensure that your change coalition can describe the vision in five minutes or less.
Create a strategy to execute that vision.
For more on creating visions, see our Mind Tools article on Mission Statements and Vision Statements.
Don't just call special meetings to communicate your vision. Instead, talk about it every chance you get. Use the vision daily to make decisions and solve problems. When you keep it fresh on everyone's minds, they'll remember it and respond to it.
What you do with your vision after you create it will determine your success. Your message will probably have strong competition from other day-to-day communications within the company, so you need to communicate it frequently and powerfully, and embed it within everything that you do.
Step Four: Communicate the Vision
It's also important to "walk the talk." What you do is far more important – and believable – than what you say. Demonstrate the kind of behavior that you want from others.
Talk often about your change vision.
Lead by example.
Apply your vision to all aspects of operations – from training to performance reviews. Tie everything back to the vision.
Openly and honestly address peoples' concerns and anxieties.
Step Five: Remove Obstacles
Put in place the structure for change, and continually check for barriers to it. Removing obstacles can empower the people you need to execute your vision, and it can help the change move forward.
But is anyone resisting the change? And are there processes or structures that are getting in its way?
If you follow these steps and reach this point in the change process, you've been talking about your vision and building buy-in from all levels of the organization. Hopefully, your staff wants to get busy and achieve the benefits that you've been promoting.
Look at your organizational structure, job descriptions, and performance and compensation systems to ensure they're in line with your vision.
Identify, or hire, change leaders whose main roles are to deliver the change.
Take action to quickly remove barriers (human or otherwise).
Identify people who are resisting the change, and help them see what's needed.
Recognize and reward people for making change happen.
Create short-term targets – not just one long-term goal. You want each smaller target to be achievable, with little room for failure. Your change team may have to work very hard to come up with these targets, but each "win" that you produce can further motivate the entire staff.
Nothing motivates more than success. Give your company a taste of victory early in the change process. Within a short time frame (this could be a month or a year, depending on the type of change), you'll want to have results that your staff can see. Without this, critics and negative thinkers might hurt your progress.
Step Six: Create Short-term Wins
Don't choose early targets that are expensive. You want to be able to justify the investment in each project.
Look for sure-fire projects that you can implement without help from any strong critics of the change.
Thoroughly analyze the potential pros and cons of your targets. If you don't succeed with an early goal, it can hurt your entire change initiative.
Reward the people who help you meet the targets.
Launching one new product using a new system is great. But if you can launch 10 products, that means the new system is working. To reach that 10th success, you need to keep looking for improvements.
Kotter argues that many change projects fail because victory is declared too early. Real change runs deep. Quick wins are only the beginning of what needs to be done to achieve long-term change.
Step Seven: Build on the Change
Each success provides an opportunity to build on what went right and identify what you can improve.
Learn about kaizen, the idea of continuous improvement.
Set goals to continue building on the momentum you've achieved.
After every win, analyze what went right and what needs improving.
Step Eight: Anchor the Changes in Corporate Culture
Keep ideas fresh by bringing in new change agents and leaders for your change coalition.
It's also important that your company's leaders continue to support the change. This includes existing staff and new leaders who are brought in. If you lose the support of these people, you might end up back where you started.
Make continuous efforts to ensure that the change is seen in every aspect of your organization. This will help give that change a solid place in your organization's culture.
Finally, to make any change stick, it should become part of the core of your organization. Your corporate culture often determines what gets done, so the values behind your vision must show in day-to-day work.
Include the change ideals and values when hiring and training new staff.
Talk about progress every chance you get. Tell success stories about the change process, and repeat other stories that you hear.
Tip: This is just one of the articles on change management on Mind Tools. See also our articles on Change Management, Lewin's Change Model, using the Change Curve, the Burke-Litwin Change Model and Overcoming Cultural Barriers to Change.
Create plans to replace key leaders of change as they move on. This will help ensure that their legacy is not lost or forgotten.
Publicly recognize key members of your original change coalition, and make sure the rest of the staff – new and old – remembers their contributions.
You have to work hard to change an organization successfully. When you plan carefully and build the proper foundation, implementing change can be much easier, and you'll improve the chances of success. If you're too impatient, and if you expect too many results too soon, your plans for change are more likely to fail.
Key Points
Create a sense of urgency, recruit powerful change leaders, build a vision and effectively communicate it, remove obstacles, create quick wins, and build on your momentum. If you do these things, you can help make the change part of your organizational culture. That's when you can declare a true victory. then sit back and enjoy the change that you envisioned so long ago.
Source: Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press.
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35. References
AHRQ. (2009). Heart Conditions, Cancer, Trauma-related Disorders, Mental disorders, and Asthma Were the Five Most Costly Conditions in 1996 and AHRQ News and Numbers, August 5, 2009.
Blount, A. (unk). What Does a Behavioral Health Clinician Add in a Primary Care Practice?: A Set of Stories. Available at
Carroll, L. (1865) Alice’s Adventures in Wonderland. London: Macmillan and Company. Available at
Chiles, J., Lambert, M., & Hatch, A. (1999). The impact of psychological interventions on medical cost offset: A meta-analytic review. Clinical Psychology: Science and Practice, Vol., 6, pp
Croghan, T. W. and Brown, J. D. (2010) Integrating Mental Health Treatment Into the Patient Centered Medical Home. (Prepared by Mathematica Policy Research under Contract No. HHSA I TO2.) AHRQ Publication No EF. Rockville, MD: Agency for Healthcare Research and Quality. Available at
Dowrick, C., Katona, C., Peveler, R., and Lloyed, H. (2005) Somatic Symptoms and Depression: Diagnostic Confusion and Clinical Neglect. British Journal of General Practice, pp Available at
Fisher, L., & Ransom, D. (1997). Developing a strategy for managing behavioral health care within the context of primary care. Archives of Family Medicine, Vol. 6, Issue 4, pp
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36. References
HCSDB. (2008). MHS Beneficiaries’ Access to Behavioral Health Care Issue Brief, Health Care Survey of DoD Beneficiaries (HCSDB), July Available at Hoge, C., Auchterlonie, J., and Miliken, C. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of American Medical Association, Vol. 295, Issue 9, pp Available at Hoge, C., Castro, C., Messer, S., McGurk, D., Cotting, D. and Koffman, R. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, Vol. 351, pp Available at Katon, W., Lin, E., and Kroenke, K. (2007) The Association of Depression and Anxiety with Medical Symptom Burden in Patients with Chronic Medical Illness. General Hospital Psychiatry Vol 29, Issue 2, pp Kessler, R., Demler, O., Frank, R., Olfson, M., Pincus, H., Walter, E., Wang, P., Wells, K., Zaslavsky, A. (2005) Prevalence and Treatment of Mental Disorders, 1990 to New England Journal of Medicine. Vol 352, No 24, pp Available at Kotter, J. (1996). Leading Change. Boston: Harvard Business School Press. Kroenke, K. & Mangelsdorff, D. (1989). Common symptoms in ambulatory care: Incidence, evaluation, therapy and outcome. American Journal of Medicine. Vol. 86, pp 262–266.
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37. References
Kindig, D. & McGinnis, J. (2007). Determinants of U.S. population health: Translating research into future policies. Altarum Policy Roundtable Report. 28 Nov 2007; Washington, D.C. Available at
Narrow, W. E., Regier, D. A., Rae, D. S., Manderscheid, R. W., Locke, B. Z. (1993) Use of Services by Persons with Mental and Addictive Disorders: Findings from the National Institutes of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry, Vol 50, pp
PC-PCC. (2012) Behavioral Health Defined. Available at
Pincus, H. A., Tanielian, M. A., Marcus, S. C., Olfson, M., Zarin, D. A., Thompson, J., & Zito, J. M. (1998) Prescribing Trends in Psychotropic Medications: Primary Care, Psychiatry, and Other Medical Specialties. The Journal of the American Medical Association, Vol 279, Issue 7, pp Available at
TMA. (2009). Health Care Survey of DoD Beneficiaries 2009 Annual Report. Sept 2009.Available at
TMA. (2011) The Evaluation of the TRICARE Program: Fiscal Year 2011 Report to Congress. Available at
Sarkolsky, D., & Birmaher, B. (2008) Pediatric Anxiety Disorders: Management in Primary Care. Current Opinion In Pediatrics, Vol 20, pp
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38. References
Simonian, S. J. (2006). Screening and Identification in Pediatric Primary Care. Behavior Modification. Vol 30, pp TeenScreen . (2011) TeenScreen Primary Care Fact Sheet: Research Supporting the Integration of Mental Health Checkups Into Adolescent Health Care. National Center for Mental Health Checkups at Columbia University. Available at Wang , P., Berglund, P., Olfson , M., Pincus, H., Wells, K. and Kessler, R. (2005). Failure and Delay in Initial Treatment Contact after First Onset of Mental Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol 62, pp Available at Wang, P., Lane, M., Olfson, M., Pincus, H., Wells, K. and Kessler, R. ( 2005) Twelve-Month Use of Mental Health Services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol 62, pp Available at WHO. (1946) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June, 1946.
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39. CDR Patricia C. Hasen, NC, USN
Questions & Comments
CDR Patricia C. Hasen, NC, USN
LT Rocio Porras, NC, USN
We’d like to thank you very much for attending our presentation. If you desire a copy of our slides or wish to contact us, please write down our contact information.
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