1. Jennifer Langhinrichsen-Rohling, USA Michele Brazeal and Timothy Rehner, USM Glenn Rohrer, UWF Joy and Howard Osofsky, LSUHSC

2. Each FQHC has to go through their own developmental process ‣ Goal of integrated care is to build interdisciplinary teams of caring people  So its not just the MD or RN that feels the burden of making a call about a patient. ‣ Process is compounded by existing silos ‣ Requires a consistent effort to keep all the pieces working together ‣ Needs “Transitional Government”

3.  FQ integration with existing MH Center (2 EHRs shared via the HIE)  Mental Health Center adds Primary Care (Cherokee model)  Mental Health travels to and exists within the FQ at certain times and/or via technology

4. Assessment of existing staff  Compile a spreadsheet of your all behavioral health providers  Licensure  Credentialed  Supervisor  Documenting in EHR  Billing for services

5. Program Assessment  Behavioral Health Funding (different sources)  Overall team concept (existing buy-in)  Standardized Assessment Protocol  Staff training on integrated health ◦ General ◦ Specific  Billing obstacles (if any)  Organizational Structure

6. Behavioral Health Clinical Director Infectious Disease Add. BH providers Substance Abuse Add. BH providers Consult & Outreach Add. BH providers Primary Care Add. BH providers

7. Patients via Universal Screening Patients via Chronic Health Condition Patients via Doctor, Nurse, or Other Staff Referral Patients via Crisis

8.  Who will administer? ◦ Patient completes screening forms in waiting room ◦ MA administers screening during Vital Sign Check ◦ BH provider administers screening while patient is waiting ◦ BH provider goes from room to room with other members of the primary care team

9. Choose Measures Set up in EHR  PHQ 2  PHQ 9  GAD 2  GAD 7  MAST  Stress level  Stressors  Easy scoring  Flags for the BH provider

10. PHQ-2 Administered with vital signs Significant Score Refer to Behavioral Health No action Required Universal Screening Universal Screening Patient

11. PHQ9 Screen Nothing Endorsed No BH PHQ9 < 10 MILD One Session BH with MI PHQ9 > 10 Moderate 1 to 4 session Crisis, HIGH PHQ9 Referral

12.  Staff training  A high volume of patients may be generated by universal screening  Protocol for patients who endorse some suicidal ideation but aren’t hospitalizable

13.  Identify target population ◦ Diabetes ◦ Obesity ◦ Uncontrolled hypertension ◦ Asthma ◦ Chronic Pain  Select measures to assess effectiveness  Establish protocols for BH staff contacts with patients (via chart review?)  Train BH staff on chronic health conditions

14.  Endorsement Memo  Identify open-minded physician to kick-off project  Work with nurse on medical plan for each patient

15. Chronic Care Patient Identified by BH staff Patient accepts service Seek support from Patient Primary Care Provider Enroll in chronic condition support program Patient accepts service Provide Patient w/contact info Chronic Care Patient

16.  Find willing provider (champion)  Place BH provider in same space and EHR  Have a referral procedure ◦ Best case warm-hand off ◦ Next positive endorsement and easy access ◦ Least effective – tell patient to schedule after Medical appointment is finished

17. Physician identifies patient need Behavioral Health Services available Locate BH provider for immediate assessment Referral to MH Services Physician Referral Physician Referral (Warm Hand Off)

18.  Variance in the type of patient referred  Referred patients may require more mental health care than is typically available through a FQ’s BH department  May be in conflict with other long-standing providers in the community; begin to be viewed as a mental health center  BH providers may be under-utilized as they wait for referrals  Growing consequences of long-term caseloads or ancillary duties  Possibility that this model may reduce the likelihood of doing brief evidence-based treatments in the context of an integrated health team

19. Crisis Refer to BH services Behavioral Health Services available Follow Professional Guidelines or Clinic Protocol Patient in Crisis Patients in Crisis May express: - suicidal thoughts - homicidal thoughts Appear: - confused - distraught - agitated

20.  Staff coverage may vary  Require more mental health care than is available through a FQ  Old crisis protocols tend to be abandoned  Interface with hospitals and specialty services are still required

21.  Which model will your FQ tackle first?  Which staff members will be involved in the delivery of the chosen model?  Which staff members will be delivering BH services within the model?  How will you garner staff participation and understanding of the new workflow and new staff roles? ◦ Intake staff ◦ BH staff ◦ Billing staff ◦ Medical staff ◦ Patients

22. GoalAction StepPerson Responsible Date to be Completed Notes Improve BH infrastructure Put PHQ9 into vital sign field in EHR