1. Integrating Primary and Behavioral Care: A Basic Primer Rick Hankey LifeStream Behavioral Center Leesburg, Florida

2. Objectives Provide a basic overview of integrated primary and behavioral care Describe efforts at the national level of health care integration Demonstrate an example of integrated care

3. Why Integration?  People with serious mental illness (SMI) are dying 25 years earlier than the general population. Average age of death for those with co-occurring MH/SU = 45 years (vs. 53 for those with SMI) Two-thirds of premature deaths are due to preventable/treatable medical conditions such as cardiovascular, pulmonary, and infectious diseases. 44% of all cigarettes consumed nationally are smoked by people with SMI. (Morbidity And Mortality In People With Serious Mental Illness Report (2006))

4. SMI Health Risks OF THE SIX MAJOR CAUSES OF DEATH IN THE UNITED STATES, THERE IS AN INCREASED RISK OF DEATH AMONG THE SERIOUSLY MENTALLY ILL MAJOR CAUSE OF DEATH INCREASED RISK OF DEATH (Times) CARDIOVASCULAR 3.4 LUNG CANCER3 STROKE2 RESPIRATORY 5 DIABETES3.4 INFECTIOUS DISEASES3.4 (Florida Council for Mental Health)

5. Factors Increasing Health Risks Poverty Poor access to Primary Care Disconnectedness of “Physical” & “Mental” health care systems Weight Gain Tobacco and Substance Abuse Medication Usage Less likely to be screened Self-Care Capacity/Resource Cognitive, Affective and Behavioral symptoms System Navigation Barriers

6. Patient Centered Medical Home Frequently recommended in healthcare reform, the Patient-Centered Medical Home is a team-based clinical approach that includes the consumer, his or her providers, and family members, when appropriate. This approach centralizes care management and supports individuals as they work toward self-management goals. Care management is central to the Medical Home’s recent shift away from focus on episodic acute care to focus on health management of defined populations, especially those living with chronic health conditions. Many now propose renaming this clinical approach “Person-Centered Healthcare Home,” recognizing the importance of caring for the whole person. Such a shift would necessitate integrating primary and behavioral healthcare explicitly building care manager/behavioral health consultant and consulting psychiatrist functions into the Medical Home model. (SAMHSA/HRSA Center for Integrated Health Solutions)

7. Integrated Health Care “…in essence integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served.” (Hogg Foundation for Mental Health, Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S., www.hogg.utexas.edu)

8. What is Meant by Integration? Bi-directional Integration Integrating Primary Care services into Mental Health/Substance Use settings AND Integrating Mental Health/Substance Use services into Primary Care settings Services are not just provided, but coordinated with other care delivered in that setting Focus is on the integration of services. This may or may not involve the integration, or merging, of the organization

9. Integration ModelLevel of IntegrationAttributes MINIMAL COLLABORATIONI SEPARATE SITE & SYSTEMS MINIMAL COMMUNICATION BASIC COLLABORATION FROM A DISTANCE II ACTIVE REFERRAL LINKAGES SOME REGULAR COMMUNICATION BASIC COLLABORATION ON SITEIII SHARED SITE; SEPARATE SYSTEMS REGULAR COMMUNICATION COLLABORATIVE CARE PARTLY INTEGRATED IV SHARED SITE; SOME SHARED SYSTEMS COORDINATED TREATMENT PLANS REGULAR COMMUNICATION FULLY INTEGRATED SYSTEMV SHARED SITE, VISION, SYSTEMS SHARED TREATMENT PLANS REGULAR TEAM MEETINGS

10. National Effort to Integrate With the goal of improving the physical health status of people with mental illnesses and addictions, the Substance Abuse and Mental Health Services Administration developed the Primary and Behavioral Health Care Integration (PBHCI) Program. Through this program, SAMHSA provides support to communities to coordinate and integrate primary care services into publicly funded, community-based behavioral health settings, resulting in: Improved access to primary care services; Improved prevention, early identification, and intervention to reduce the incidence of serious physical illnesses, including chronic disease; Increased availability of integrated, holistic care for physical and behavioral disorders; and Better overall health status of clients. SAMHSA awarded 64 community behavioral health organizations more than $26.2 million collectively in Primary and Behavioral Health Care Integration.

11. National Integration of Services

12. The W.I.N. Clinic-An Example of Integration

14. The W.I.N. Clinic Exam Room

15. CARE MANAGEMENT SPECIALTY SERVICEPRIMARY CARE SUBSTANCE ABUSE TREATMENT CONTINIOUS CARE WELLNESS ACTIVITIES PREVENTIVE CARE MENTAL HEALTH TREATMENT CONSUMER CENTERED APPROACH HEALTH HOME

16. The W.I.N. Clinic Model Components Integrated Services Screen/registry tracking and outcomes Primary Care staff located in behavioral health setting Embedded Nurse Care Managers Wellness/Prevention programming Evidence Based Models SBIRT IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) Model Motivational Enhancement Techniques (MET) Eli Lilly Wellness Program

17. LPN Care Managers Jack of all trades Case Management Home Visits Consumer Education, Care Coordinator Wellness Activities Glue that holds the treatment team together

18. Health and Wellness Activities  Offer stress management programs to include yoga, acupuncture, breathing exercises, physical exercises, relaxation/meditation.  Nutrition counseling, weight management, and healthy eating seminars. Cooking demonstrations to include organized grocery store shopping trips.  Time Management workshops.  Organized peer support groups.  Smoking cessation.  Wellness testing (fitness and medical tests), health risk appraisals, hypertension screening & education.  Disease management seminars.  In home education sessions by LPN Care Managers.

19. Questions??? Thank you for your attention. Contact Information: Rick Hankey rhankey@lsbc.net