Building the Integrated Primary Care Medical Home Neil Korsen, MD, MSc Mary Jean Mork, LCSW C-IBHA, New Orleans April 16, 2009

Overview Background Description of our integration program Our approach to implementation Measuring success Financial sustainability

Objectives Describe one approach to implementing integrated care Understand the use of process redesign and measurement as part of an improvement program Describe financial challenges and one possible solution to financial sustainability of integrated care.

Mental Health Integration in Maine

MaineHealth An integrated delivery system in 11 counties in Maine Includes –Acute care hospitals –A psychiatric hospital –Physician practices –Home health agencies –Long term care facilities –Other health care organizations

Why Mental Health Integration? Depression in Primary Care program since 2001 –MacArthur Foundation RESPECT trial –Robert Wood Johnson Foundation Depression in Primary Care demonstration program Achieved system level changes in adult depression care

Shortcomings of Depression Program Did not: Address needs of those caring for children and adolescents Address common mental health co-morbidities of depression Do enough to build working relationships between primary care and mental health clinicians and organizations

Integration as a Solution Primary care clinicians provide more than half of all mental health care and some primary care patients won’t go to specialty mental health. Pilot integration programs had developed around the state. MaineHealth Strategic Plan included piloting mental health integration (MHI). Received a grant from the Maine Health Access Foundation (MeHAF) that helped fund the MHI pilot.

Integration Model Adapted from Intermountain Healthcare (IH), who demonstrated: Improved ability of Primary Care Physician to diagnose and treat common mental health conditions Increased satisfaction of patients and primary care staff No increase in overall healthcare costs

The Program 18-month Collaborative-style Learning Community: –Learn the MHI model and implement key components –Gather for periodic learning sessions –Collect and report data about processes and outcomes –Participate in site visits, conference calls, listserve 12 Primary Care Sites (6-8 more joining spring 2009): –Rural Health Clinics (RHC) –Federally Qualified Health Centers (FQHC) –Private and hospital owned practices 8 Mental Health Partners (3 additional agencies spring 2009): –Specialty Mental Health agencies –Community Mental Health Centers –Hospital-owned behavioral health organizations

Principles of our Integration Program Relationships: Mental Health and Primary Care Standardized mental health screening and assessment tools Stratification to guide level of intervention Team approach to care Periodic reassessment of patient Links to external resources –Mental health providers –Community resources

Role of Mental Health Specialist: Integrated Behavioral Health Work side-by-side with primary care staff Brief, flexible problem-focused approach to treatment Assist with diagnosis and management of people with common mental health problems Assist in the care of people with psychosocial problems related to medical diagnoses

Access Standardized Assessment & Risk Stratification Care Management Support for Behavioral Change Mental Health Treatment & Consultation Specialty Mental Health Primary Care Medical Home Community Resources e.g., NAMI

Rate yourself on Behavioral Health Integration Spend 5 minutes talking to your neighbor about a couple of these questions from the Behavioral Health Integration Survey: –#1 - The Behavioral Health Consultant (BHC) is located in the exam room area of the clinic and provides services there. –#12 - All members of the primary care team understand the role of the BHC and how to utilize him/her –#15 - PCPs routinely discuss patient care issues with the BHC prior to and after same-day handoffs or prior to a scheduled initial visit. –#16 - The BHC provides periodic training and education for medical staff on behavioral health topics (e.g., at a provider meeting, through a monthly newsletter or a lunch time training on a topic of interest to PCPs).

Levels of Integration ModelLevel of Integration Attributes Separate Space & Mission --Traditional Behavioral Health Specialty Model One-on-one Referral Relationship +Preferred Provider. Some information exchange Co-location++On-site Behavioral Health Unit/Separate Team Collaborative Care +++On site. Shared cases with Behavioral Health specialist Integrated Care+++++Primary Care Team member Doherty, McDaniel and Baird, 1996

An Example of Integrated Practice: the Video Level Five Mental Health Clinician working side-by-side with primary care staff Brief, flexible problem-focused approach to treatment Warm hand-offs Curbside consults

A Framework for Building the Integrated Medical Home

What is the Aim? To serve patients better through integrated, effective, efficient, financially sustainable mental health care in primary care

Form the Right Team Involve representatives of all groups that will be affected by the change Leave titles at the door – everyone can contribute to making this work Team should meet regularly to review data and plan tests of change.

Patient and Family Self report/MHI Packet Mental Health Specialist Diagnose, Treat MHI Packet Care Manager Follow up, Family Adherence Patient Education MHI Packet NAMI Community Resources Family Support Psychiatrist Or APRN Consult, Train MHI Packet Mental Health Integration: Team Roles Mental Health Specialist Diagnose, Treat Primary Care Provider Support Staff Screen, Diagnose, Treat Care Manager Follow up, Family Adherence Patient Education Psychiatrist Or APRN Consult, Train NAMI Community Resources Family Support Patient and Family

Identify Your Population

Integrated Care is for: People with symptoms or problems that warrant a mental health assessment People being treated for mental health conditions who are not improving People who need help with behavioral, emotional or psychosocial aspects of medical problems

High risk populations People with chronic illnesses or chronic pain People with a disability People with substance abuse problems Kids with school, sleep or behavior problems People with persistent somatic complaints and negative workup

Develop Efficient and Effective Processes

Tools You Can Use Patient walk through – To understand the process through the eyes of your patients Process Flow Charting – To display the process to help you think about how to introduce changes

Pt calls or presents with possible MH concerns MH screening material to patient Patient completes screening Screening reviewed and scored Patient and team develop care plan Follow up visit and reassess Ongoing monitoring and treatment prn

PDSA Cycle Plan Identify: -the problem -the most likely causes -potential solutions Do Implement solutions and collect data Study Analyze data and develop conclusions Act Recommend action/ further study

Why Test Changes? Increases belief that the change will result in improvements in your setting Learn how to adapt the change to conditions in your setting Evaluate the costs and “side-effects” of changes Minimize resistance when spreading the change throughout the organization

Process and Outcome Measures

Pt calls or presents with possible MH concerns MH screening material to patient Patient completes screening Screening reviewed and scored Patient and team develop care plan Follow up visit and reassess Ongoing monitoring and treatment prn

Pt calls or presents with possible MH concerns MH screening material to patient Patient completes screening Screening reviewed and scored Patient and team develop care plan Follow up visit and reassess Ongoing monitoring and treatment prn # Screening completed/ %Returned Care Mgmt. Specialty MH OUTCOMES: Clinical Functional Satisfaction Financial

Process Measures Mental Health Screening Forms –Distributed –Completed Utilization of Specialty Mental Health Care –Care manager –Internal mental health provider –External mental health provider

Outcome Measures Clinical –PHQ-9 score tracking Functional –Functional assessment Satisfaction –Patient –Provider –Staff Financial –Revenues generated from integrated services

Finances of Integrated Care

The Problems with Integrated Care No one seems to know how to get paid Mental Health regulations and licensing expectations don’t fit the primary care setting Confidentiality vs. “shared records” Lack of clarity and understanding about present practices Complicated licensing and reimbursement rules without accessible experts

How will we achieve financial sustainability? Understand the current rules Identify opportunities and barriers that affect sustainability Use understanding of current rules to: –Recommend most effective way to organize services –Maximize reimbursement for integrated care Target barriers with highest priority and/or are most likely to be able to change

Remember… Involve the right people Start small and build gradually Share selflessly and steal shamelessly Think about sustainability –Clinical sustainability – discover the processes that work in your setting and spread them –Financial sustainability – understand the rules and use them to your advantage

Start where you are Use what you've got Do what you can Arthur Ashe