1. Integrated Care: A practice example from the ground up and lessons learned thus far
Phyllis Platt, PhD, MSW.
CEO, Shawnee Christian Healthcare Center, Inc.
Shelia M. Cundiff, LCSW, LCADC
Director of Behavioral Health , Shawnee Christian Healthcare Center, Inc.
Sherita Vernon, CSW, MSSW
BHC Shawnee Christian Healthcare Center, Inc.
Jessica K. Beal, Psy.D.
Integrated Care Program Manager
Passport Health Plan

2. Objectives
Participants will understand the integrated care continuum, options for implementation of healthcare integration, rationale behind choices made by Shawnee Christian Healthcare and how they utilized Passport Health Plan’s consultative services related to integrated healthcare.
Participants will gain insight into the challenges associated with implementation of integrated care from the real life experience of Shawnee Christian in order to gain an understanding of how practice transformation can be successfully managed in the primary care setting.
Participants will learn some of the long term goals of the integrated program at Shawnee Christian and how they plan to measure success

3. Review of Integrated Primary Care

4. What is “Integrated” Care at the Highest Level?
A biopsychosocial approach to health care
Addresses whole person care; assesses and intervenes across all areas impacting overall health and well-being
Brings behavioral health care directly into the primary care setting (but is not limited to just the integration of behavioral health practitioners)
The behavioral health practitioner is member of the primary care treatment team and provides mental health triage and behavioral health intervention in consultation and collaboration with the rest of the treatment team
The behavioral health practitioner PARTNERS with the rest of the team on treatment planning, etc.
Jes

5. Integrated Care Models: Primary Care and Behavioral Health
Collaborative Care Model (CoCM)
Primary Care Behavioral Health (PCBH)
Hybrid Models
Tools/Methods Associated with Integrated Care
Screening, Brief Intervention and Referral to Treatment (SBIRT)
Trauma Informed Care
Depression Screening (e.g.: PHQ9)
Anxiety Screening
SDoH Screening
Jes

6. AIMS Center Collaborative Care Model (CoCM)
PCP
Patient
BHP/Care Manager
Psychiatric Consultant
Additional Clinic or Outside Resources
Jes
IMPACT: Improving Mood Promoting Access to Collaborative Treatment
Other BH Providers
SUD, School Services, CMHC’s, Health Department, Churches, etc.
Outside Resources

7. Behavioral Health Consultant
PCBH/BHC Model
Patient
PCP
Behavioral Health Consultant
Medical Support
(RN/MA)
Administrative Staff
Jes

8. Integrated Care Continuum
Coordinated Healthcare
Minimal Collaboration
Basic Collaboration at a Distance
Co-Located
Healthcare
Basic On-site Collaboration
Close On-site Collaboration
Integrated
Close collaboration approaching an integrated practice
Full collaboration in a TRANSFORMED/merged integrated practice
Jes
Heath B, Wise Romero P, and Reynolds K. 2013; SAMHSA CIHS

9. Integration Trajectory for Clinicians
Multidisciplinary
draws on knowledge from different disciplines but each provider stays within their boundaries-physician decides who participates
Interdisciplinary
analyzes, synthesizes and harmonizes links between different providers into a coordinated and coherent whole-whole team participates
Transdisciplinary
integrates the natural, social and health sciences in a humanities context, and so that all providers transcend their traditional boundaries through understanding of the roles of the other disciplines as pertains to patient care
Jes
Choi and Park, 2006

10. Shawnee Christian Healthcare Center, Inc. An Integration Journey

11. Why Integrate Behavioral Health Into Primary Care?
Mission fit: “caring for the whole person”
Patient – centered medical home standard
Recognizing that neither behavioral health or primary care conditions happen in isolation
Strengthens the patient care team to more effectively increase patient engagement and impact health outcomes
Limited accessible community resources for behavioral health
Phyllis

12. SCHC’s Current Model Patient
Traditional BH Services co-located
SCHC’s Current Model
Patient
PCP
Behavioral Health Provider
Administrative Staff
Medical Support (RN/MA)
LCSW Primary with students
MD/ARNPs
Co-located same day services; traditional therapy co-located as well
Referral triggered by depression screen and SBIRT
Allows for some warm handoffs
Verbal care coordination
Integrated Billing/Scheduling/EMR; BH notes not accessible by PCP
Shelia & Sherita
CEO is Transformation Champion

13. Patient Clinic Care Visits
Scheduled Provider
Additional Scheduled Team Member(s)
PRN Consulting Team Member(s)
Allows the patient to schedule a single appointment and know that all their clinical and clinical support needs will be met same day
Allows for overlapping consultation with team members
Patient (& Caregiver)
Shelia and Sherita

14. SCHC’s Steps to Integration
Started with a volunteer LPCC one day/week providing counseling and referral to community linkage agreement partners.
Added MFT student interns in conjunction with a local university.
Hired Director of Behavioral Health Services.
Integrated Behavioral Health module into EHR
Added Behavioral Health Consultant with HRSA Supplemental Funding
Next Step: January add Health Psychology doctoral practicum student and Masters level Social Work interns as part of workforce development grant project with Spalding University.
Phyllis

15. SCHC’s Next Step Patient Co-located
Traditional BH Services co-located
SCHC’s Next Step
Patient
PCP
Behavioral Health Consultant
Administrative Staff
Medical Support (RN/MA)
LCSW Primary with students
MD/ARNPs
Co-located
Referral triggered by behavioral health screens and BHC suggestion
Warm handoffs with BHC available for immediate triage
Care coordination/ daily huddles
Integrated Billing/Scheduling/EMR
Shelia & Sherita

16. SCHC’s Integration Goal
To improve patient health outcomes by delivering whole person care through the full integration of primary care, behavioral health, oral health and other preventive services.
To move from co-located model of integrated care focused on providing traditional behavioral health care to a fully integrated, PCBH model with psychiatry consult support by January 1, 2019.
Phyllis

17. SCHC’s Long Term Vision for Integration
Warm Handoffs to BHC; BHC for triage, brief interventions, chronic care coaching/health behavioral change
Co-located for SUD with space for 30 min BH follow-up sessions; specialty MH co-located
CoCM for psychiatry; tele-psychiatry
All health staff daily huddles
Team based care/Joint decision making
Shared problem lists and treatment plans
Shared EMR, etc. with PCP access to BHC note
Psychiatry
Consult/
Tele-psychiatry
Patient
Medical Provider
BHC
Care Manager
Ancillary Medical Staff
SUD Provider
Phyllis
Traditional BH Services co-located
Other Providers
Community Resources
SDoH.

18. SCHC - Passport Relationship
Passport and Shawnee have a shared vision for service delivery that addresses whole patient care and improves the overall health of the community they serve.
SCHC tapped into resources at Passport to provide initial consultation around integrated care
Passport continues to provide consultation as SCHC rolls out their model and moves the practice towards model fidelity
Passport is very pleased to have a partner like SCHC working towards a high fidelity model of hybrid integrated care and will be reviewing data pre/post implementation for improved health outcomes over time.
Phyllis

19. Challenges/Barriers to Date
Early on it was difficult to meet patient need with limited staff (volunteer provider and student interns)
No real structure to the program in terms of referral and tracking.
Co-location still creates a level of “separateness” between services and providers
Finding the right person to lead the program was challenging and took more time than expected (but worth the wait to get the right person!)
Phyllis

20. Lessons Learned
A champion at all levels is key: Board, Administration, Primary Care, Behavioral Health, Patient Engagement, Front Office
Education across the organization is important for understanding and buy-in.
Having the right Director is most critical to success.
Flexibility is key to manage performance improvement in a quick and timely manner to be most effective.
Linkage agreements are still essential, recognizing that BH staff can’t and shouldn’t handle all conditions.
Shared communication in the EHR important for care coordination and promotes medical provider buy-in and confidence in BH.
Phyllis

21. Q&A
All

22. Contact Information
Phyllis Platt, PhD, MSW.
CEO, Shawnee Christian Healthcare Center, Inc.
Shelia M. Cundiff, LCSW, LCADC
Director of Behavioral Health, Shawnee Christian Healthcare Center, Inc.
Sherita Vernon, CSW, MSSW
BHC Shawnee Christian Healthcare Center, Inc.
Jessica K. Beal, Psy.D.
Integrated Care Program Manager, Passport Health Plan
Cell: