Jill Rinehart, MD Breena Holmes, MD

 Describe the growing need for co-located support in primary care practices  Outline several Vermont models of behavioral health support in primary care  Describe one practices’ innovation, including use of Blueprint and care coordination Vermont Department of Health

 20-24% of all children will be treated for behavioral health symptoms by the time they reach age 18.  Up to 70% of primary care medical appointments are for issues related to psychosocial concerns Vermont Department of Health

 For those under 18 years of age, the five medical conditions that ranked highest in terms of the number of individuals with expenses for care in 2008 included acute bronchitis, asthma, trauma-related disorders, otitis media, and mental disorders. Vermont Department of Health

 Family Integrated Health Care Model ◦ VCHIP, VDH, DMH ◦ Co-located mental health workers in primary care ◦ Child Psychiatry consultation for child health providers through and phone consultation  Vermont Family Wellness Model ◦ 3 tiers  Blueprint for Health ◦ Community Health Teams (centralized) ◦ Community Health Teams (co-located) Vermont Department of Health

 Every medical home that serves children has a care coordinator  Care coordinator can connect families to needed resources in a timely manner  CSHN can reach each practice via Care Coordinator  Network of care coordination that supports behavioral health needs of families—from parenting support, to coordinated behavioral assessment and psychiatric treatment Vermont Department of Health

The Concept The Person 1. Needs assessment for care coordination and continuing care coordination engagement 2. Care planning and communication 3. Facilitating care transitions 4. Connecting with community resources and schools 5. Transitioning to adult care Antonelli et al (2009); Rinehart (2014)

 1.Reduce fragmentation of care for an identified population  2.Guide a family-centered, multi-disciplinary team process in the joint development and use of a plan of care  3.Enable the child/family and their “care neighborhood” to communicate, collaborate, and operate from the “same page”  4.Deliver oversight/accountability ◦ Jeanne McAllister, et. al, supported by Lucille Packard Foundation for Children with Special Health Care Needs  Vermont Department of Health

Care Study 1: Matt 13 year old boy with autism, non-verbal, self injury, polydipsia Parents struggling with bolting, overall safety Middle school unable to educate or keep safe Medical issues of skin infections, enuresis, sleep dysfunction Family has gone above and beyond capacity of most families to deal with this at home

Care Planning 1: Patient/Family/Team GoalsCICP Negotiated ActionsProcess and Outcome Measures Less Self InjuryPsychiatry Assessment, co- management from psychiatry, medical home and subspecialists In-home behaviorists Keeping family together Less need for police, mental health crisis support Improve school attendance Improve education supports Same behavior plan across settings Explore alternative school placement Clear communication between home/school/providers Alternative program found Repetitive behaviorsImproved psych pharm Improved wrap around services Improved behavior plans Innovation: across silos of mental health, developmental disabilities, children with special health care needs, and school

Care Study 2: Mary 4 year old with tuberous sclerosis  self-injurious behaviors  Tantrums  sleep dysfunction  heading toward inpatient psychiatry hospitalization Despite having a VT developmental services waiver, respite care and a team of multidisciplinary medical experts at Massachusetts General Hospital

Care Study 2: Mary (Cont) Intractable seizures seemed the least of her concerns in comparison to behaviors Strengths:  Strong parent involvement and expertise  Loving respite family  Mary engaging  Verbal with cognitive strength (can anticipate seizures)

Care Planning 2: Patient/Family/Team GoalsCICP Negotiated ActionsProcess and Outcome Measures Less need for “crisis” intervention Co-management from psychiatry, medical home and subspecialists In-home behaviorists Less need for police, mental health crisis support Improve SleepSame behavior plan across settings Less communication errors about medications Improved work attendance Increase Home Safety-of Mary and family Improved psych pharm CSHN SW: Waiver allowed for enhanced access to in-home behaviorists Innovation: region contracted with vendor outside of network Less Crisis Need Mary to attend school Improve social relationships Communication opened between school, behavioral plans, family, medical home Making academic gains Attendance improved Cannot pick her out from peers

Pediatric Collaborations Chittenden County (Rinehart, 2014)

Vermont Department of Health 1 HRC Pediatricians 2 University Pediatrics 3 Green Mountain Pediatrics (Bennington) 4 Rutland (RRMC) 5 St. Johnsbury 6 Mount Ascutney /Ottaqueechee (Windsor/Woodstock) 7 Rainbow Pediatrics(Middlebury) 8 MPAM(Middlebury/Porter) 9 South Royalton 10 Barre- Associates in Pediatrics (2) CHC Timberlane Essex Pediatrics Maine

Definition of Integrated Care  Integrated care is the seamless provision of health care services, from the perspective of the patient and family, across the entire care continuum. It results from coordinating the efforts of all providers, irrespective of institutional, departmental, or community-based organizational boundaries.

 Practices with co-located behavioral health services ◦ struggled with integration elements that addressed the use of behavioral health skills by the entire primary care team and the delivery of evidence-based interventions  Co-located practices were the most integrated with clinic-system processes and in elements of relationship and communication  Pediatric and non-co-located practices struggled most with clinic-system processes and community integration

Informal Supports Extended Family Friends Groups Religious Organizations Cultural Supports Clubs Recreation Camps Community and State Services CSCHN Economic Services Developmental Services Mental Health Early Intervention Home Health Services Children’s Palliative Care WIC Child Protection Private Therapists Personal Care School Teachers Case Manager Speech PT/OT Counsellors Other Services Medical Specialists Specialty Providers Clinics Financial Supports Insurance Respite Childcare Subsidy Economic services Social Security Food Subsidy Employment Childcar e Teacher s Genogram of Household Members Parents Siblings Child Extended Family Others

© Cristin Lind

 Behavioral Health encompasses ◦ Mental health ◦ Substance abuse and dependence ◦ Life style choices which promote risk factors  Integration is Essential for Success– evidence base exists  Care Coordination is Necessary but not Sufficient to Achieve Integration  CC is the set of activities which occurs in “the space between” ◦ Visits, Providers, Hospital stays  Only way to succeed is to engage all stakeholders– including patients and families– as participants and partners