October 24, 2012 Lessons from Project Care, Kern County

Lily Alvarez (Kern County Mental Health) Chris Reilly (Clinica Sierra Vista) Robyn Field, PhD (Sagebrush) Mona Dawar, PhD (National Health Services, Inc.)

 MHSA and Project Care ◦ Includes 8 FQHCs and 1 county hospital outpatient clinic ◦ Expanded workforce includes MFTs and certified SA counselors ◦ Psychiatric consultation ◦ Two services in the same day ◦ Requires physician-led team case review

 What is the model? ◦ Universal screening ◦ Brief consultation in the exam room ◦ Brief interventions ◦ Referrals to specialty care when appropriate ◦ Integrated case conferencing ◦ Using data to monitor progress

 What are the methods? ◦ Universal screening for MH and SUD  PHQ9 (depression)  GAD7 (anxiety)  Audit-C+ (drugs and alcohol) ◦ Brief interventions delivered onsite over 6-10 visits  SUD assessment/BI – ASSIST Model and Motivational Interviewing (MI)  MH treatment (Solution-focused model and MI) ◦ Mandatory case conferencing between physician, psychiatrist, and BH staff

 Evaluation practices and technical assistance ◦ Measures include:  Organization level measurement of integration (DDCHCS)  Staff level surveys  Patient level charting of services using Patient Registries ◦ Training and TA topics include:  Confidentiality/data sharing, Conducting SBIRT and MI, Managing chronic pain, and Working in the healthcare setting

 Specific implementation challenges  Solutions that worked and didn’t work  Organizational level issues  Patient reactions, good and bad  Key messages to share with those starting to integrate SUD and/or MH into PC settings

 Specific Implementation Challenges: Assimilating the traditional 4 per hour primary care visit schedule, with the traditional 50 minute therapy session. If the BHP was too often not available, the PCP’s soon forgot they were there. What is the standard practice model for 20 minute therapy? How do we squeeze a mental health conversation into a 15 minute exam room visit?  Solutions that worked and didn’t work: Rotating the BHP through multiple clinics on designated days (Mobile Brief Services) created a hit or miss referral system, that left BHP’s with little to do when they were there; and PCP’s with nobody to refer to when they needed them. With Project Care we assumed the premise that the BHP would have to be fulltime in the CHC, and find ways to make themselves useful.

 Organizational level issues: Initially the PCP’s wanted easier access to the mental health system - NOT more behavioral health patients in their own CHC’s. The fear in starting integrated services, was it would change the practice – from the mommies and babies they were accustomed to, to people who scare the mommies and babies away. Second, we couldn’t find enough eligible BHP’s to cover our costs.  Patient reactions: Patient reaction followed the providers reaction. What to call the BHP? What threshold decision trees to use to determine a referral? How to explain to the medical patient, a mental health referral?  Key messages to share with those starting to integrate SUD and/or MH into PC settings: Ironically the same premise we crafted for the patients, worked well for our own providers: Clinica Sierra Vista has added a behavioral health provider to its primary care team in recognition of the relationship between a healthy mind and healthy body.

 Implementation Challenges: ◦ Dedicated space for Project Care staff ◦ Documentation guidelines for EMR ◦ Inconsistent management of screening forms  Not always given to patients to complete  Patient takes the form or does not fill it out  Forms get misplaced  Solutions Needing Modification: ◦ Screening form evolved as new ones were added ◦ Spanish translation was added ◦ Responsibility for scoring of screening tool

 Organizational Level Issues: ◦ Team meeting/case conference attendance ◦ Data management  Outcomes tracking must be done by hand  No disease registry in place yet ◦ Integration of the consulting psychiatrist  Patient Responses: ◦ Overwhelmingly positive. Patients like  One-on-one attention  Concern for all aspects of their care  Immediacy of contact during physician visit  Only one negative response, but it was not due to Project Care process

 Provider Responses: ◦ Resident physicians and P.A.s appreciate Project Care staff ◦ Ultimately saves them time ◦ Benefit is immediate; can do warm hand-off and intervention while patient is still in clinic

 Start-Up Suggestions: ◦ Choose therapists wisely  Flexible, proactive, handle ambiguity, form strong relationships ◦ Be willing to modify initial plan as needed ◦ Obtain buy-in from all levels of clinic staff  Welcome feedback ◦ Communication is key ◦ Continue to educate staff over time

 Specific Implementation Challenges: Availability of staff, Creating relationships with PCP’s and getting them invested in the idea of integration.  Solutions that worked and didn’t: We are not always available “on the fly”, trainees results not yet in but likely to be successful.  Organizational level issues: Takes time away from MA’s to administer and record data, which is why some patients receive screens and some don’t.

 Patient reactions: Patients feel understood and supported with handoffs done in person.  Key Messages to share: The foundation for success = building strong relationships with PCP’s and MA’s. ◦ Gets smoother with practice and time; change is slow. ◦ Important to insure an understanding of the value of treating the whole person and that leads to professional commitment. ◦ PCP’s benefit that patients are not bringing their BH complaints to them anymore and that their overall self care often improves once they begin BH treatment.