Where & How Behavioral Health can be Integrated into the Patient-Centered Medical Home (PCMH) *Originally adapted from PCPCC’s Behavioral Health Task Force Slide Deck. Last updated September 2014.

Purpose of Slide Deck To allow users to adapt these slides for your own presentations. Please see the notes sections for more detailed information. This slide deck is focused on the “where” and “how” behavioral health is being integrated into the patient-centered medical home (PCMH). You may also pull slides from Deck 1 to learn about the “why” behavioral health should be integrated into the PCMH. This slide deck is meant for use by organizations considering transformation into a patient-centered medical home (PCMH), those already practicing patient-centered care now moving on to integration of behavioral health, and those wanting to improve their integration model. Many of the slides include basic instruction to be bypassed by experienced clinics. The presenter should consider presenting the material in three sessions based on the audience. If they are already practicing PCMH and know about integration, but are not convinced, go to section two (“Reasons Why Behavioral Health Should be Part of the PCMH”) from the first slide deck. If the clinic is already convinced to integrate, start with the models (“PCMH Integrated Behavioral Health Models“) from this slide deck.

Slide Deck Outline Where Integrated Behavioral Health Models are Happening Models for Integrating Behavioral Health in the PCMH Coordinated Care Models Co-Located Models Integrated Models Resources & Acknowledgements

Where Integration is Happening This map indicates where Behavioral Health Integration activities are happening all across the country. However, this is a snapshot in time and it is not an exhaustive listing of integrated programs. Access the map, http://integrationacademy.ahrq.gov/ahrq_map, for more up-to-date listings and to learn more about these programs. Source: AHRQ, The Academy Integration Map. Accessed September 2014. http://integrationacademy.ahrq.gov/ahrq_map

Models for Integrating Behavioral Health in the PCMH 5

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

Based on Population Needs & Required Systems PCP-based BH provider might work for the PCP organization, a specialty BH provider, or as an individual practitioner; is competent in both mental health and substance abuse assessment and treatment. Source: Mauer BJ (2004). Behavioral Health / Primary Care Integration: The Four Quadrant Model and Evidence-Based Practices. National Council for Community Behavioral Health. www.mcpphealthcare.com

Collaborative Care Collaborative care optimizes all behavioral health resources Source: http://uwaims.org

Relationship Between Medical & Behavioral Health Services (Collaboration for Same-Day Access) Coordinated (shared costs) = Behavioral services by referral at separate location via synchronous (real-time) or asynchronous (later) information exchange Co-Located (separate funding sources)= By referral processes at primary care location (behavioral health visit in referral office) Integrated (same funding resource) = At primary care location (face to face with behavioral health team or by virtual synchronized telemetry) Source: Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems & Health: 21, 121-134.

Coordinated Care Coordinated care elements: Appointment arrival notification Clinical information exchange protocols Coordinated treatment planning and/or problem solving for complex patients or as needed Expect communication to go both ways. Mental health clinicians are healthcare professionals who should be knowledgeable about the patient’s health issues. Ask about the person’s health behavior goals and consider them in treatment planning.

Coordination Plus – Specialty Mental Health as a Consultant to Primary Care Massachusetts Child Psychiatry Access Program For adults in NC, Medicaid pays for time of primary care physician and psychiatrist as patient visit rates (for consultation about a patient) whether the psychiatrist has met the patient or not. When behavioral health clinicians are working in primary care, referrals to specialty care for patients in need of longer-term work is more likely to be successful. Source: Center for Integrated Primary Care, UMass Medical School

Co-Located Behavioral Health (Helps Reduce Stigma!) Behavioral health in the same space with primary care Involvement by referral Separate behavioral health and medical treatment plans Advantages Challenges Access greatly improved Improved patient & provider satisfaction Cost effective Improved clinical outcomes Referrals don’t show Case-loads fill up Slow primary care physician learning curve Communication still difficult

Integrated Primary Care: Behavioral Health Consultant Management of psychosocial aspects of chronic and acute diseases Application of behavioral principles to address lifestyle and health risk issues Consultation and co-management in the treatment of mental disorders and psychosocial issues Source: Center for Integrated Primary Care, UMass Medical School

Models of Integrated Behavioral Health IMPACT/Diamond (Expanded Care Management): Disease based Research heritage Patient outcome evidence Care manager (SW or Psychologist) Behavioral Health Consultant: Program based Clinical heritage Cost & satisfaction evidence Behavioral health consultant The models are beginning to converge: Care manager does other behavioral health care and chronic illness added. Behavioral health care management and case managers added. Beginning disease programs. Array of services beyond disease programs. Source: Center for Integrated Primary Care, UMass Medical School

Integrated Primary Care: The IMPACT Treatment Model Stepped protocol in primary care using antidepressant medications and/or 6-8 sessions of psychotherapy (PST-PC) Treat to target Collaborative care model includes: Care manager: Depression Clinical Specialist Patient education Symptom and side effect tracking Brief, structured psychotherapy: PST-PC Consultation / weekly supervision meetings with Primary care physician Team psychiatrist Source: Center for Integrated Primary Care, UMass Medical School

Fully Integrated Primary Care The System Example – Cherokee Health Systems Source: Center for Integrated Primary Care, UMass Medical School

Substantial Improvement in Depression (≥50% Drop on SCL-20 Depression Score from Baseline) Source: Center for Integrated Primary Care, UMass Medical School

Resources & Acknowledgements 18

Selected Resources AHRQ Academy for Integrating Behavioral Health and Primary Care: http://integrationacademy.ahrq.gov/ AIMS CENTER: http://aims.uw.edu/ Center for Integrated Primary Care: http://www.umassmed.edu/cipc/ Collaborative Family Healthcare Association: www.cfha.net Evolving Models of Behavioral Health Integration in primary Care. Milbank Memorial Fund 2010. http://www.milbank.org Lexicon for Behavioral Health and Primary Care Integration. AHRQ 2013: http://integrationacademy.ahrq.gov/sites/ default/files/Lexicon.pdf National Alliance on Mental Illness. Integrating Mental Health & Pediatric Primary Care Resource Center: http://www.nami.org SAMHSA/HRSA Center for Integrated Health Solutions: http://www.integration.samhsa.gov 19

Case Studies & Videos Case Study: Colorado’s Advancing Care Together. http://www.advancingcaretogether.org/ Video: AIMS Center. Daniel’s Story: An Introduction to Collaborative Care. http://aims.uw.edu/daniels-story-introduction-collaborative-care Webinars: University of Colorado’s Department of Family Medicine Policy Channel. http://www.youtube.com/CUDFMPolicyChannel PCPCC Online Resource: Successful Examples of Integrated Models. http://www.pcpcc.org/content/successful-examples-integrated-models 20

Acknowledgements Special thanks to: PCPCC’s Behavioral Health Group PCPCC’s Behavioral Health Advisory Team Alexander Blount, EdD, University of Massachusetts Parinda Khatri, PhD, Cherokee Health Systems Benjamin Miller, PsyD, University of Colorado George Patrin, MD, Serendipity Alliance CJ Peek, PhD, University of Minnesota David Pollack, MD, Oregon Health & Science University Erik Vanderlip, MD, University of Oklahoma *Originally adapted from PCPCC’s Behavioral Health Task Force Slide Deck. Last updated September 2014. 21