Medical Health Home – an integrated approach to Physical and Behavioral healthcare

Our communities deserve to be HEALTHY 25% of the adult population have a mental health disorder WHILE 58% have physical conditions AND Of those with a mental health disorder, 68% had co-occurring medical conditions

Who are the 68 %? Its our community! Our Family Our Friends Our Neighbors

Meet LM 36 years old, diagnosed with Diabetes: on dialysis, blind, amputations, chronic pain and heart condition causing palpitations Lives with fiance and daughter, proud of parenting Hospitalized average twice a month, most often due to palpitations or missed dialysis, “treated like a junky there.” Not linked to behavioral health care

What is integrated care? “Primary and behavioral health care integration is the systematic coordination of primary and behavioral health care. Since physical and behavioral health problems often occur at the same time, health care professionals want to consider all health conditions at once.”

Variations in Integrated Care 1. “Nobody knows my name. Who are you?” 2. “I help your consumers.” 3. “I am your consultant.” 4. “We are a team in the care of consumers” 5. “Together, we teach others how to be a team in care of consumers and design a care system.”

Converging The Different Worlds: It’s a delicate balance

Our language differs… Mental Health World “client” “consumer” Physical Health World “patient”

Funding You can bill for that??????

BARRIERS of merging the worlds Can Create Beauty

Where we want to be! “Together, we teach others how to be a team in care of consumers and design a care system.”

How do we get there? Patience Education Relationships

Our work in progress The Integrated Care Program Haven House & Neighborhood Health Center of the Lehigh Valley Allentown, PA

Lehigh Valley Integrated Care PCMH Community Engagement Outreach Screening Team based Care Preventive Care Chronic Dz Management Integration Case Management Warm Hand-off Consulting Psychiatry On-site counseling Joint care plans/visits Peer Support Specialist Care Co-located Outpatient Coordination care plan Structured information sharing Psych rehab

The Great Additions Peers helping Peers Screening “patients” Metabolic syndrome Warm hand off

What defines Success? Outcomes State Initiatives