1. The Role of the Medical Neighborhood in Behavioral Health-Primary Care Integration
R. Scott Hammond, MD, FAAFP
Medical Director, Westminster Medical Clinic
Clinical Professor, University of Colorado, School of Medicine
Daniel Fishbein, PhD
Vice President for Corporate Business Development
Jefferson Center for Mental Health

2. Integration: An Evolving Relationship
Consultative Model
Psychiatrists sees patients in consultation in his/her office – away from primary care
Co-located Model
Psychiatrist sees patients in primary care
Collaborative Model
Psychiatrist provides caseload consultation about primary care patients; works closely with primary care providers (PCPs) and other primary care-based behavioral health providers (BHP)
Source:

3. Two Cultures, One Patient

4. Steps to Creating a MN Clear vision
Belief
Purpose
Choose partner wisely who shares your vision
Acceptance
Perseverance
Develop a Shared Culture
Trust
Common ground
Build medical team first
Team identity
Role clarification

8. Building a Neighborhood
Phase 1: Planning
Phase 2: Implementation
Phase 3: Evaluation
Phase 4: Sustainability and Continuous Improvement

9. Phases and The 5 A’s Phase 1: WMC established a structure
Adopt Collaborative Guidelines (aka BH Compact)
Care coordination protocol, relation to BH
Develop a Timeline for your office
Phase 2: Implementation with BH Neighbors
ASK
- Develop a list of possible BH Neighbors
- Invite them to form a BH Neighborhood
ADVISE
- Introduce Medical Neighborhood concept
- Discuss care delivery philosophies, agree on common values
Behavior change same for physicians

10. Phases and The 5 A’s Phase 3: Evaluation Phase 4: Sustainability
ASSESS
- Fill out Collaborative Guidelines (aka Compact)
- Discussion, what is possible/not possible
- Once initially implemented, review what is working/not working based on Compact
ASSIST
- PCP MN Toolkit
- BHP MN Toolkit – in development specific to BH; not completed/available to date
- A few elements of the Toolkits
6 Steps to Becoming a Patient-Centered Medical Home Neighbor
“Types” of Care Transition case histories and checklist
PCP-BHP Compact
Phase 4: Sustainability
ARRANGE
- Continuous improvement support, maintenance, and sustainability
- Utilize resources
ACT, SIM
- Regular communication and feedback

11. Lessons Learned Cost and Feasibility Culture and Leadership
Infrastructure and Workflow
Sustaining Adaptive Change

12. Cost and Feasibility First fail and persevere
Westminster
Jefferson
First fail and persevere
Find the right partner for sustainability
Other
direct primary care
shared integration
telepsychiatry
Create a base of reliable revenue
Determine ROI and risk of facility benchmarks
Allow for program flexibility
Watch for hidden costs and requirements 14

13. Culture & Leadership 16 Westminster Jefferson
Inventory your beliefs and create a vision
Set your goals (REACH)
Build a collaborative team
Create trust and engage individual purpose of staff members
Merge cultures
Understand resistance
Focus on needs and objectives of practice
Guided Autonomy – empower on-site BHP to innovate
Raise the bar – bidirectional accountability
Evolve – continuous program expansion and improvement 16

14. Infrastructure & Workflow
Westminster
Jefferson
Expand ahead of the curve
Contingency planning if hit the wall
Monitor unexpected outcomes of structural and process changes
Keep patient focused
Define visit types and hand-offs
Negotiate workflow expectations, MH model
Create a flexible schedule
Enhance communication
Common language with the “Compact”
Bi-directional information
Shared care plan
Constructive feedback
Address patient expectations 19

15. Sustaining Adaptive Change
Westminster
Jefferson
Autonomy, Mastery, Purpose
Energy Management
Change/sustain fatigue
Decision fatigue
Data fatigue
Work-around fatigue
Frustration entropy
Minimize bureaucracy
Welcome and engage BHP into the practice
Insist that core standards be met
Avoid burnout
Assess/ratify value and delight regularly 21

16. BHC-PCP Integration

17. Extra slides

18. Health Care Delivery in the USA
IOM CQC summary
Underlying Characteristics
Highly Specialized
Compartmentalized
Disorganized
Fragmented
Falls short on measures of clinical quality
Acute Care Model
Staccato care
Physician Centered
Staff supports physician
“my practice” mindset
Siloes of Care
Cut off
Focus on success of the silo not the system
M. Carol Greenlee, MD FACP

19. It’s not my responsibility.
Allergy/
Immunology
Cardiology
PCP
In silos – and the primary care silo is a “time bomb”….
It’s not
reimbursed
It’s not my responsibility.

20. Collaborative Care Reason One: Prevalence
Behavioral Health and Primary Care Are Inseparable
84% of the time, the 14 most common physical complaints have no identifiable organic etiology1
80% with a behavioral health disorder will visit primary care at least 1 time in a calendar year2
50% of all behavioral health disorders are treated in primary care3
48% of the appointments for all psychotropic agents are with a non-psychiatric primary care provider4
Mental illness/behavioral health disorder (also known as mental disorder): is a health condition that is characterized by alterations in thinking, mood, or behavior (or some combination thereof), that is mediated by the brain and associated with distress and/or impaired functioning. Mental disorders cause a host of problems that may include personal distress, impaired functioning and disability, pain, or death.
It is estimated that in any given year, one in five adults (20%), will experience a diagnosable mental illness or substance abuse disorder. Research from epidemiological catchment studies suggest that between 14%-20% of children and adolescents, about one in every five, have a diagnosable emotional or behavioral disorder
Source: NBGH: An Employers’ Guide to Behavioral Health Services
1. Kroenke & Mangelsdorf, Am J Med. 1989;86:
2. Narrow et al., Arch Gen Psychiatry. 1993;50:5-107.
3. Kessler et al., NEJM. 2006;353:
4. Pincus et al., JAMA. 1998;279: 20 20 20 20

21. Collaborative Care Reason Two: Unmet Behavioral Health Needs
67% with a behavioral health disorder do not get behavioral health treatment1
30-50% of referrals from primary care to an outpatient behavioral health clinic don’t make first appt2,3
Two-thirds of primary care physicians (N=6,660) reported not being able to access outpatient behavioral health for their patients. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access4
Kessler et al., NEJM. 2005;352:
2. Fisher & Ransom, Arch Intern Med. 1997;6:
3. Hoge et al., JAMA. 2006;95:
4. Cunningham, Health Affairs. 2009; 3:w490-w501. 21 21 21

28. Lessons Learned from BH Integration
First fail and persevere
Learn lessons, scope of integration, humility
Find the right leaders
Wizards to make the impossible possible
Determine open-ended vision (why) and target population (what)
Read the medical literature, review the statistics
Build infrastructure (how)
Integrated Teams, Standing orders, Standardization
Find the right BHP
Pioneer mentality, previous experience in primary care
Merge cultures
1-2 week immersion, Ongoing
Establish common language, common goals, mutual responsibilities, accountability
Primary Care- BH Compact, Ongoing
Adapt schedule
Establish bidirectional information
Accommodate needs of patients and providers while respecting BHP
Shared care plan
Constructive feedback
Learn together, share leadership