How to Crash the Party: Bringing Behavioral Health Specialists to the Care Coordination Team Mary Jean Mork, LCSW Director of Integration MaineHealth and Maine Behavioral Helathcare Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session B5a October 18, 2014

Faculty Disclosure  I have not had any relevant financial relationships during the past 12 months.

Learning Objectives At the conclusion of this session, the participant will be able to:  Identify barriers and success factors for care coordination.  Identify a “success factor” to immediately address.  Create a plan for addressing this factor upon return to work.

Learning Assessment  A learning assessment is required for CE credit.  A question and answer period will be conducted at the end of this presentation.

Agenda  Description of Care Coordination (CC) Team  Challenges for Behavioral Health Specialists (BHS)  Role and value of BHS on the team  Success factors and strategies for maximizing team effectiveness  Activity – Developing Action Plans  Question and answer period

Patient Centered Medical Home (PCMH) – the Concept From deGruy (Behavioral Health)

Internet Citation: Figure 1. Family tree of terms in use in the field of collaborative care: A National Agenda for Research in Collaborative Care. June Agency for Healthcare Research and Quality, Rockville, MD.

Care Coordination The deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services. From: Safety Net Medical Home Initiative. Care Coordination: Reducing Care Fragmentation in Primary Care. Implementation Guide. May 2013

“ If a person doesn’t have a roof over their head, if they don’t have a meal, if they’re a victim of physical or sexual abuse if their household has a lot of stress in it, if their kids’ school is not safe, then that's going to impact their health…..that health is more than just the pill that we’re giving you or the hospital that we put you in. It’s all the other parts of your life and whether they’re working in harmony.” Dr. Jeffrey Brenner in interview “What Primary Care has to Learn from Behavioral Health”. National Council for Behavioral Health.

Meet George

Barriers to Care Coordination: Roles Rules Arrangements Turf

Who is involved?  Care Managers  Case Managers  Behavioral Health Clinicians  Care Coordinators  Transition coaches  Peer navigators  Health coaches  RN’s in the practice  Primary care providers  Primary care staff  Family and community supports  Other?

Mental Health Primary Care Treatment Team Case Manager Team Leader – LCSW Peer/Youth Support Psychiatry Medical Director Care Team Provider Nurse Medical Assistant Integrated BH Clinician Nurse Care Manager Health coach/navigator Preventative and Acute Care Chronic Care High Utilization Chronic Care with MH Dx Substance Abuse High Utilization with MH Dx

“We're all going to have to give up some turf. After all, it's actually the patient's turf.” Robert McArtor, MD, CMO MaineHealth

[Type a quote from the document or the summary of an interesting point. You can position the text box anywhere in the document. Use the Drawing Tools tab to change the formatting of the pull quote text box.] Specialty Mental Health Care Coordinated Care Team ( Potential Team Members ) Care Manager Behavioral Health Clinician Care Coordinator Engagement Specialist Health Guide Resource Specialist Transitions Coach Peer Navigator BHHO Case Manager CCT social worker Complex Care Mgmt Primary CareSpecialty Medical Care Hospital Patients Psychiatric Consultation Other Complex Patients Care Plan Team Care Coordination System Management Patient Population Crisis and ED High Utilizers PCP and Clinical Care Team

Powered by Care Coordination and Behavioral Health  Saturday, September 20, 2014

Q1: Describe your involvement on the care coordination team

Q2: I If you have tried to have more involvement in care coordination activities, what barriers have you experienced?

Q3: If you are presently involved in care coordination activities in your practice, what has been most successful in helping be part of these activities?

What else did I hear?  “It was horrifying. We don’t have anything in our practice.”  “We can’t coordinate unless there’s a mistake in scheduling, because she (the care manger) uses the office when I’m not there.”  “Who is my team?”  “I didn’t fill it out because it doesn’t pertain to me.”

Complex Care Teams (Social, behavioral and medical complexities) Behavioral Health Needs Complex Coordination Needs Medication Access Community Resource Needs Providing: A multidisciplinary approach to complex care coordination; Team collaboration; Community resource partnerships, and Standardized best practice interventions

BHS’s value on CC team  Direct service to Patient  Link to specialty MH and SA treatment  Liaison to psychiatric services  “Triage” role with psychiatry referrals.  Consultation to CC team  System perspective  Behavioral lens for medical system  Medical system lens for behavioral health  Expertise with individualized care plans tailored to patient  Patient and family centered focus

Common Challenges for BHS  Population health  Using data to inform work  Understanding nuances of different care management roles  Clarifying roles around behavioral change,e.g. with health coaches  Ability to access specialty MH, SA and psych services

CC Success Factors  Clarity, connection and non-duplication of:  Roles  Functions  Responsibilities  Clarity about population being coordinated  Timely and accurate data  Tracked and shared outcomes  “Partnership” approach to care  Individualized patient centered planning process for care plans  Shared Care plans and “alerts” throughout system  Standardized coordination of care  “Team” members have assigned tasks based on individual care plan  “Team” lead to manage complex care situations

Strategies to Improve CC  Identify who is coordinating care  Identify leaders  Multidisciplinary case presentations  Target specific patients, design services around individual’s goals, coordinate care, track results  Identify impact measures, e.g. ED usage for specific populations  Make connections with community providers and continuum of care

Additional considerations for CC  Funding – are there:  New funding streams that support this work?  Cost savings and medical cost offsets?  Honor the patient voice in development of the care plans  Value and nurture the team relationships!

Resources Websites  - AHRQ Academy for Integrating Behavioral Health and Primary Care  - Advancing Integrated Mental Health Solutions – resources for implementation from University of Washington  – National clearinghouse site for information on integrated care from University of Massachusetts.  - SAMHSA-HRSA Center for Integrated Health Solutions  – the National Council for Community Behavioral Healthcare. Publications  IHI Innovation Series Craig, et.al. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs.   Reducing Care Fragmentation: A Toolkit for Coordinating Care

Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!