1. Session # F7
Creating a Culture of Whole Health: Recommendations for Integrating Behavioral Health and Primary Care
Kaile M. Ross, MA, Doctoral Candidate, Graduate Research Assistant
Emma C. Gilchrist, MPH, Deputy Director
Benjamin F. Miller, Psy.D., Director
Eugene S. Farley, Jr. Health Policy Center
University of Colorado School of Medicine
Please insert the assigned session number (track letter, period number), i.e., A2a
Please insert the TITLE of your presentation.
List EACH PRESENTER who will ATTEND the CFHA Conference to make this presentation.
You may acknowledge other authors who are not attending the Conference in subsequent slides.
CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Collaborative Family Healthcare Association 12th Annual Conference

2. Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships during the past 12 months.
You must include ONE of the statements above for this session.
CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message.
The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community.
Collaborative Family Healthcare Association 12th Annual Conference

3. Learning Objectives At the conclusion of this session, the participant will be able to:
List challenges to care delivery in the integrated care setting
Identify potential micro and macro approaches to addressing these challenges
Discuss next steps for implementing recommendations from the “Creating a Culture of Whole Health” report
Include the behavioral learning objectives you identified for this session
Collaborative Family Healthcare Association 12th Annual Conference

4. Bibliography / Reference
Miller, B. F., Gilchrist, E. C., Ross, K. M., Wong, S. L., Green, L.A. (2016, February). Creating a Culture of Whole Health: Recommendations for Integrating Behavioral Health and Primary Care. Available at
Miller, B. F., Gilchrist, E. C., Ross, K. M., Wong, S. L., Blount, A., Peek, C.J. (2016, February). Core Competencies for Behavioral Health Providers Working in Primary Care. Prepared from the Colorado Consensus Conference. Available at
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.
McDaniel, S. H., Hargrove, D. S., Belar, C. D., Schroeder, C., Lerman Freeman, E. (2002). Recommendations for education and training in primary care psychology.
American Academy of Family Physicians, American Board of Family Medicine, Society of Teachers of Family Medicine. (2014). Joint principles: integrating behavioral health care into the patient-centered home. Annals of Family Medicine,
Continuing education approval now requires that each presentation include five references within the last 5 years.
Please list at least FIVE (5) references for this presentation that are no older than 5 years.
Without these references, your session may NOT be approved for CE credit.
Collaborative Family Healthcare Association 12th Annual Conference

5. Learning Assessment A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation.
This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.
Collaborative Family Healthcare Association 12th Annual Conference

8. Methods Who? Participants: 77 interviews & 2 focus groups
Collaborated with partners (RWJF, AHRQ, NIAC) to identify the first wave of key informants
Snowball sampling technique
What?
Semi-structured interview
How?
Inductive thematic content approach

9. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
5 domains of barrier/challenges to care delivery in integrated care:
Culture
Logistics
Workforce
Measurement
Standard of Care & Evidence
Logistics
Measurement

10. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Cultural challenges
“The barrier is that I have to tolerate that I’m not the primary actor sometimes as the physician. It is pretty humbling.”
“The patients come in and say “fix me.” Changing that dynamic so that patients see themselves as part of the solution is important.”
“Sometimes what you’ll hear is I’m glad this person is here. It was great when they first got here and now there are so busy I can’t talk to them and I can’t get to them.”
Logistics
Measurement

11. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Culture Recommendations
Education: “Provide people with enough information so they feel included without overwhelming.”
Leadership: “When [the doctors] aren’t helpful and they seem dismissive in some practices, it is often because leadership didn’t make it clear that this was part of the Mission.”
Commitment: “But we are committing to practicing as a team. So once you say that out loud, a lot of those facets begin to become sort of rules of engagement that people can learn.”
Patient empowerment: “We have already given patients some responsibility over their own care now … provide them with better tools on how to manage their care and still have some sort of medical guidance.”
Public education: addressing mental health stigma
Scheduling: “need to be scheduled so that they do short visits and they have a lot of unscheduled time and spend that time where the family docs are.”
Logistics
Measurement

12. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Logistical Challenges
“The most difficult thing has been logistics. Primary space. And getting the electronic health record to work in an integrated manner.”
“HIPAA and even 42 CFR doesn’t have to be that big a problem. But most mental health people don’t know that and are resistant or are essentially defaulting to non-communication rather than defaulting to communication. So patient’s get put at risk particularly with information about medication, when that isn’t shared and coordinated.”
Logistics
Measurement

13. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Logistical Recommendations
Finance: “Ideally what you would like to see is maybe some better integrated care codes that are developed and paid for by public payers. When you start setting concrete incentives for providers to walk down that path, they will.”
Integrated problem solving: “We have a team of people who have been together since [the beginning] - the physician, one of the nurses, the care coordinator, and myself. So we can really start to think through things regarding workflow.”
Technical assistance: “Unless you have some kind of resource that is available to people that amounts to a Practice Coach. There are some things that you need to know in order to make this a success.”
Logistics
Measurement

14. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Workforce Challenges
“The mental health people don’t know what to do in a medical setting. They have to be trained. They have to learn to be part of a team and how to participate in primary care. Medical people don’t know how behavioral health could be part of their work, or how to involve them. The mental health person ends up saying, “they don’t use me.””
“New doctors always come in and many of the new doctors have no idea about any kind of integrated care.”
“We have very few training programs, whether its psychiatry, psychology, or social work, that educates people about their possible roles in delivering collaborative care.”
Logistics
Measurement

15. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Workforce Recommendations
Readiness: “The readiness work and team building for integration. Because that is where it either fails or succeeds. If you get it right going in [..] you can let it go and it can bloom.”
Behavioral health team expansion: peer advocates, community health workers, self-led support groups
Education and continuing education: inclusion of integrated care training in graduate programs, financial support for educating staff and providers
Logistics
Measurement

16. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Standard of Care & Evidence Challenges –
“Another barrier is lack of standard of care in diagnosis and treatment. On the physical side, we have worked very hard to say, if you come in with these symptoms of congestive heart failure, this is how you should be treated. Those get updated by the medical specialty organization periodically. On the mental health side, if someone presents with psychotic behavior, it really varies from provider to provide, how people are going to be treated.”
“We don’t have a clearing house of this is what works.”
“But what we don’t know is how much integration is necessary to provide a quality outcome. We need to understand how much of a dose”
Logistics
Measurement

17. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Standard of Care & Evidence Recommendations
Consensus: “We have to pull together the multitude of national organizations – whether it is social workers or MFTs or psychologists to come together and set standards of care and agree on what they are going to measure for outcomes.”
Grants: “fund evaluations for these different programs and innovations, around integration”
Program evaluation & measurement: “Learn from experience. Figuring out what thermometers to stick in this and what are the process measures as well as the outcome measures of success is going to be very important.
Leveraging Data: Utilizing available data to answer questions about integrated care delivery
Logistics
Measurement

18. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Measurement Challenges-
“There is still a thinking that somehow patients’ self-reported measures are not valid.”
“And the problem is, [the PHQ-9] is a good screening tool, but we are using it as if it were the equivalent to the an A1c to see if a patient is getting better. After repeatedly filling out that form, no one actually knows the impact or the value or repeatedly saying it is up or down.”
“There is a tendency for practitioners, whether it is on the medical side or behavioral health side, to not be thinking about outcome change. But it is really very important for both the medical and behavioral health professionals that are working with patients to be moving towards outcome change and measuring outcome change.”
Logistics
Measurement

19. Standard of Care & Evidence
Results
Culture
Standard of Care & Evidence
Workforce
Measurement Recommendations-
Streamlining: Automating the measurement process as much as possible; Administering measures online prior to visits
Culture of growth: “…creating an environment where there is more measurement involved that can allow for integration to be less static and more of a learning community where these demonstration projects are tried out and there is rapid learning from those. And that those things that work get scaled up and then also reporting the things that don’t work.”
Patient-centered approach: “So my attitude is that you would identify and measure outcomes for individuals, rather than trying to do population based, unless you are working with everybody that is depressed or everybody has diabetes. But then you lose everybody who’s not.”
Logistics
Measurement

20. Care Delivery - Conclusions
Consistency in challenges & recommendations
Establish & share best available evidence for integrated care
Better measures for patient outcomes and process evaluation
Access to technical assistance and collective wisdom
Education of the up & coming workforce, the existing workforce, the patient, and the community
Relationship building & integrated problem solving

21. Session Evaluation
Please complete and return the evaluation form before leaving this session. Thank you!
This should be the last slide of your presentation
Collaborative Family Healthcare Association 12th Annual Conference