1. Strengthening Relationships Between Primary Care and Behavioral Health Mary Jean Mork, LCSW Neil Korsen, MD, MSc April 17, 2009

2. Outline of Presentation  Who are we and where do we come from? – Our model  The importance of team  The Culture Clash challenge  Communication  Levels of Integration  How to improve  Where are you?

3. Objectives Attendees will: 1.Be able to identify their level of integration 2.Describe steps they can take to increase their level of integration 3.Articulate components of effective communication for integrated practice

4. Mental Health Integration in Maine

5. MaineHealth Members and Affiliates PenBay Miles Memorial Midcoast MaineGeneral Stephens Memorial St. Mary’s Spring Harbor Maine Medical Center SMMC St. Andrew’s

6. Primary Care and Mental Health Primary Care Multi-site Practices Hospital-owned Practices Residency Practice Solo Private Practice FQHC look-alike Rural Health Clinics Mental Health Medical Center Outpatient Psychiatry Hospital-owned Behavioral Health Community Mental Health Centers Consumer Case Management Agency

7. Access Standardized Assessment & Risk Stratification Care Management Support for Behavioral Change Mental Health Treatment & Consultation Specialty Mental Health Primary Care Medical Home Community Resources e.g., NAMI

8. Team building

9. Our integrated faculty team  Medical Director – Family Physician  Program Managers  LCSW  Educator with health science background  Psychiatrists  Child  Adult  Administrative Professional

10. Mental Health Integration: Team Roles Mental Health Specialist Diagnose, Treat Primary Care Provider Support Staff Screen, Diagnose, Treat Care Manager Follow up, Family Adherence Patient Education Psychiatrist Or APRN Consult, Train NAMI Community Resources Family Support Patient and Family

11. Who needs to build relationships?  Program staff (with each other)  Program staff and participating organizations  Primary care and mental health administrators  Primary care team, mental health provider, care manager

12. The foundation of teamwork is interpersonal relationships

13. Relationship building: MHI faculty role  Get people together – learning sessions, conference calls, site visits, listserve  Facilitate the conversation  Listen  Provide knowledge and tools  Be encouraging  Never give up!

14. Relationships with Patients: The Benefit of Integration and Collaboration?

15. Patients who:  Experience their life problems as “medical”  Have not been socialized to the concept of “emotional distress” or to the idea of therapy  Feel blamed by a referral to Mental Health  Feel abandoned by a referral to Mental Health  Patients dealing with behavioral or emotional aspects of medical conditions

16. High risk populations  People with chronic illnesses or chronic pain  People with a disability  Kids with school, sleep or behavior problems  People with persistent somatic complaints and negative medical work-up

17. Patients in Integrated Care compared to Specialty Mental Health  More likely to be first mental health contact  Less psychologically “sick”  Less likely to define themselves as impaired  Require fewer visits

18. Primary Care and Mental Health: The Culture Clash Challenge

19. Mental Health Specialist in Primary Care: How about those differences?

20. Mental Health Specialist in Primary Care: Other Differences Primary CareMental Health Pace15 minute appointment50 minute sessions SettingAn exam roomA living room LanguageDiagnosis, medical terminology, complaints Assessment, mental health terminology, issues HierarchyClear – Dr. in chargeDiffuse – Administrator in charge with med director FlowFlexible patient flowScheduled client flow

21. Levels of Integration Improving Relationships at Every Level

22. Levels of Integration Level of Integration Attributes Minimal Collaboration ISeparate site & systems Minimal communication Basic Collaboration from a distance IIActive referral linkages Some regular communication Basic Collaboration on site IIIShared site; separate systems Regular communication Collaborative Care partly integrated IVShared site; some shared systems Coordinated treatment plans Regular communication Fully Integrated System VShared site, vision, systems Shared treatment plans Regular team meetings Modified from Doherty, McDaniel, and Baird - 1996

23. What is your level of integration? What is keeping you from getting to the next level? Is there one thing you could do soon, that would enable you to get to the next level?

24. Level One: Starting to Connect  Ask your clients about their primary care/mental health provider and get a release  Identify patients who could use better coordination – contact their providers  Contact key providers in your area  Those treating your most complex clients  Those treating a group of your patients

25. Level Two: Building on Basic Collaboration  Garner invitation to staff meeting  Identify clear processes and expectations around communication  What should they expect to get from you?  What do you need to hear from them?  How can you share information better?

26. Level Three: Sharing More than Space  Set up regular times to “meet”  Clarify expectations around communication & treatment coordination  Begin to “share” processes, e.g., scheduling  Work out record-sharing  Define team relationships

27. Level Four: Increase the Integration  Clarify team mission and roles  Formalize team expectations – when to meet, what to share, etc.  Set up streamlined processes for communication and treatment coordination  Develop ways to learn from each other  Celebrate successes

28. Level Five: Maintaining & Continuously Improving  Set up formal and informal learning opportunities  Maximize use of staff meetings, case conferences, huddles, and hand-offs  Always work on improving relationships – both within the team and the larger community  Remember that the patient is the focus of the work

29. Communication between Physician and MHP

30.  At any level  Confidentiality fosters splitting  Blanket information release with the goal of enhancing collaborative care  In a Co-located – Integrated Practice  “Curbside consultations”  Behavioral health rounds  Take the clinician conversation into the exam room  Use words that do not require a physical or psychosocial definition of the problem Information Exchange between Providers

31. When might the MHP be useful? Think SSRI:  Situation  Skill-set  Relationship  Indicators or outcomes Certificate Program in Primary Care and Behavioral Health. Department of Family Medicine and Community Health, University of Massachusetts Medical School. Alexander Blount, EdD, Director

32. Example “I’d like to have my colleague, Ms. Peterson, work with us to help you figure out ways to reduce your stress in the evenings. She has a great deal of experience helping parents come up with bedtime routines. I think that if your kids went to bed better, you would be less stressed, and your headaches might be reduced. What do you think?”

33. Successful Communication with Primary Care  Note specific information from the patient/client that might effect treatment  Describe the specific indicators and how they have changed  Share what the patient/client reports as meaningful  Discuss how the Physician and Mental Health Clinician can work together on the treatment

34. Example “I met with Ms. Brown and she agrees that she gets as “wound up” as her kids at night. We came up with some calming bedtime activities for the whole family and she agreed to try this for two weeks and report back to us on whether her headaches are reduced with her “winding down” routines. She also agreed to take her medication as prescribed during this time.”

35. Partnership Development

36. Partnership development  Describe your mh/pc partnership when you began mental health integration – how did it feel?  Use 1-2 word descriptions

37. Beginning Stage - quotes  Disconnected  Skeptical  Impatient  Optimistic  Hopeful  Eager  Fortunate Part I

38. Partnership development  Describe your mental health/primary care partnership at 3-6 months - how did it feel?  Use 1-2 word descriptions

39. Middle Stage - quotes  Matching faces to names  More comfortable  Continuing the work  Still learning  Frustrated (e.g., over credentialing)  Challenged by the details  Impressed with the accomplishments Part II

40. Partnership development  Describe your mental health/primary care partnership now (12-18 months) – how does it feel?  Use 1-2 word descriptions

41. Mature Stage - quotes  Comfortable  In sync  Efficient  Work is rewarding  Model is sustainable  Very excited and impressed  Mission driven as a team  Not yet done  Helpful to people being served  Crucial – can’t live without it  Fragile

42. Fred and Eleanor