The Role of the Medical Neighborhood in Behavioral Health-Primary Care Integration R. Scott Hammond, MD, FAAFP Medical Director, Westminster Medical Clinic Clinical Professor, University of Colorado, School of Medicine Daniel Fishbein, PhD Vice President for Corporate Business Development Jefferson Center for Mental Health

Integration: An Evolving Relationship Consultative Model Psychiatrists sees patients in consultation in his/her office – away from primary care Co-located Model Psychiatrist sees patients in primary care Collaborative Model Psychiatrist provides caseload consultation about primary care patients; works closely with primary care providers (PCPs) and other primary care-based behavioral health providers (BHP) Source: http://uwaims.org

Two Cultures, One Patient

Steps to Creating a MN Clear vision Belief Purpose Choose partner wisely who shares your vision Acceptance Perseverance Develop a Shared Culture Trust Common ground Build medical team first Team identity Role clarification

Building a Neighborhood Phase 1: Planning Phase 2: Implementation Phase 3: Evaluation Phase 4: Sustainability and Continuous Improvement

Phases and The 5 A’s Phase 1: WMC established a structure Adopt Collaborative Guidelines (aka BH Compact) Care coordination protocol, relation to BH Develop a Timeline for your office Phase 2: Implementation with BH Neighbors ASK - Develop a list of possible BH Neighbors - Invite them to form a BH Neighborhood ADVISE - Introduce Medical Neighborhood concept - Discuss care delivery philosophies, agree on common values Behavior change same for physicians

Phases and The 5 A’s Phase 3: Evaluation Phase 4: Sustainability ASSESS - Fill out Collaborative Guidelines (aka Compact) - Discussion, what is possible/not possible - Once initially implemented, review what is working/not working based on Compact ASSIST - PCP MN Toolkit - BHP MN Toolkit – in development specific to BH; not completed/available to date - A few elements of the Toolkits 6 Steps to Becoming a Patient-Centered Medical Home Neighbor “Types” of Care Transition case histories and checklist PCP-BHP Compact Phase 4: Sustainability ARRANGE - Continuous improvement support, maintenance, and sustainability - Utilize resources ACT, SIM - Regular communication and feedback

Lessons Learned Cost and Feasibility Culture and Leadership Infrastructure and Workflow Sustaining Adaptive Change

Cost and Feasibility First fail and persevere Westminster Jefferson First fail and persevere Find the right partner for sustainability Other direct primary care shared integration telepsychiatry Create a base of reliable revenue Determine ROI and risk of facility benchmarks Allow for program flexibility Watch for hidden costs and requirements 14

Culture & Leadership 16 Westminster Jefferson Inventory your beliefs and create a vision Set your goals (REACH) Build a collaborative team Create trust and engage individual purpose of staff members Merge cultures Understand resistance Focus on needs and objectives of practice Guided Autonomy – empower on-site BHP to innovate Raise the bar – bidirectional accountability Evolve – continuous program expansion and improvement 16

Infrastructure & Workflow Westminster Jefferson Expand ahead of the curve Contingency planning if hit the wall Monitor unexpected outcomes of structural and process changes Keep patient focused Define visit types and hand-offs Negotiate workflow expectations, MH model Create a flexible schedule Enhance communication Common language with the “Compact” Bi-directional information Shared care plan Constructive feedback Address patient expectations 19

Sustaining Adaptive Change Westminster Jefferson Autonomy, Mastery, Purpose Energy Management Change/sustain fatigue Decision fatigue Data fatigue Work-around fatigue Frustration entropy Minimize bureaucracy Welcome and engage BHP into the practice Insist that core standards be met Avoid burnout Assess/ratify value and delight regularly 21

BHC-PCP Integration

Extra slides

Health Care Delivery in the USA IOM CQC summary Underlying Characteristics Highly Specialized Compartmentalized Disorganized Fragmented Falls short on measures of clinical quality Acute Care Model Staccato care Physician Centered Staff supports physician “my practice” mindset Siloes of Care Cut off Focus on success of the silo not the system M. Carol Greenlee, MD FACP

It’s not my responsibility. Allergy/ Immunology Cardiology PCP In silos – and the primary care silo is a “time bomb”…. It’s not reimbursed It’s not my responsibility.

Collaborative Care Reason One: Prevalence Behavioral Health and Primary Care Are Inseparable 84% of the time, the 14 most common physical complaints have no identifiable organic etiology1 80% with a behavioral health disorder will visit primary care at least 1 time in a calendar year2 50% of all behavioral health disorders are treated in primary care3 48% of the appointments for all psychotropic agents are with a non-psychiatric primary care provider4 Mental illness/behavioral health disorder (also known as mental disorder): is a health condition that is characterized by alterations in thinking, mood, or behavior (or some combination thereof), that is mediated by the brain and associated with distress and/or impaired functioning. Mental disorders cause a host of problems that may include personal distress, impaired functioning and disability, pain, or death. It is estimated that in any given year, one in five adults (20%), will experience a diagnosable mental illness or substance abuse disorder. Research from epidemiological catchment studies suggest that between 14%-20% of children and adolescents, about one in every five, have a diagnosable emotional or behavioral disorder Source: NBGH: An Employers’ Guide to Behavioral Health Services 1. Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266. 2. Narrow et al., Arch Gen Psychiatry. 1993;50:5-107. 3. Kessler et al., NEJM. 2006;353:2515-23. 4. Pincus et al., JAMA. 1998;279:526-531. 20 20 20 20

Collaborative Care Reason Two: Unmet Behavioral Health Needs 67% with a behavioral health disorder do not get behavioral health treatment1 30-50% of referrals from primary care to an outpatient behavioral health clinic don’t make first appt2,3 Two-thirds of primary care physicians (N=6,660) reported not being able to access outpatient behavioral health for their patients. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access4 Kessler et al., NEJM. 2005;352:515-23. 2. Fisher & Ransom, Arch Intern Med. 1997;6:324-333. 3. Hoge et al., JAMA. 2006;95:1023-1032. 4. Cunningham, Health Affairs. 2009; 3:w490-w501. 21 21 21

Lessons Learned from BH Integration First fail and persevere Learn lessons, scope of integration, humility Find the right leaders Wizards to make the impossible possible Determine open-ended vision (why) and target population (what) Read the medical literature, review the statistics Build infrastructure (how) Integrated Teams, Standing orders, Standardization Find the right BHP Pioneer mentality, previous experience in primary care Merge cultures 1-2 week immersion, Ongoing Establish common language, common goals, mutual responsibilities, accountability Primary Care- BH Compact, Ongoing Adapt schedule Establish bidirectional information Accommodate needs of patients and providers while respecting BHP Shared care plan Constructive feedback Learn together, share leadership