1. Integrating Primary Care and Behavioral Health: Lessons From a Ground View to 1,000 Feet Integrating Behavioral Health Project September 11, 2008 Larry Mauksch, M.Ed Department of Family Medicine University of Washington

2. Principles for success in practice change Build relationships through experiential team training on clinical and operational topics Have regular huddles and meetings Create team ownership of change, challenges, and successes Find out what is important to patients in life, in problem focus, in treatment, and in relationships

3. Principles for success in practice change Figure out what to change first, don’t change everything at once, be patient but persistent Do not let staff turnover cause system decay Track Progress: patient, team, system, cost Create back-up systems to optimize clinical success: –multidisciplinary transdisciplinary

4. Principles for success in practice change Conserve resources and intensify care for patients with greater complexity (stepped care) CELEBRATE SUCCESS!!!

5. DepressionObesity Substance abuseDiabetes Family Person

6. Biopsychosocial patient centered care Primary Care Provider Patient Psychiatric Consult or Tx Self Management Group Care Management Beh Health Consult or Tx

7. Shared Space Hallway Updates and consults 3-way meetings Financial Incentive To Work Together Integrated Information System: Electronic Medical Record Provider communication Patient tracking for f/u Organizational Features Promoting Integration Leadership Shared Mission / Vision Team Training Ongoing Training Primary Care Provider Patient Self Management Group Case Management Psychiatric Consult or Tx Beh Health Consult or Tx

8. Marillac Clinic Background Primary care clinic: –medical, dental, mental health, optical Only serves people: – at or below 200% Fed poverty guidelines –uninsured (no Medicaid or Medicare) Grand Junction, Colorado –2004 population of Mesa Country = 127,000 Private, non profit, not an FQHC In 2004: 9700 visits from 3100 patients

9. Prevalence : Marillac-500 Vs PHQ-3000

13. Collaborative Care: Phases of Integration at Marillac Preliminary work (1994-1996)- Therapist leaves at 6 mo Phase 1 (1997-1998) Building a conceptual and physical commitment in the clinic and community Phase 2 (summer, 1998 - summer, 1999) Intensive training Phase 3 (spring 1999 – spring 2002) Building the Marillac system and design of interagency model Phase 4 (2002-2006) Quality improvement within Marillac and across agencies Phase 5 (2006…) Decay, retraining and transformation towards a medical home

14. Principles of change Lasting collaboration requires an educational and training process that builds relationships between disciplines A new culture Meaningful and sustainable changes in service require change in system design Chronic care model: Information systems, provider training, promotion of self management, expert consultation and decision support, community involvement

15. Essential Ingredient: Organizational / Structural Strong board and executive director support Providers co-located for better communication Combined medical record (paper going to EHR) with full access to MH and PC providers Inter-agency collaboration –Funding –Shared training –Inter-agency communication and referral systems

16. Psychologist Family Therapist & Psychiatrist Addictions Counselor Case Manager Medical Exam Rooms Medical Exam Rooms Medical Provider Stations Medical Exam Rooms Medical Exam Rooms Medical Exam Rooms Medical Assistant Stations Medical Exam Rooms Medical Exam Rooms Medical Exam Rooms ReceptionFront Office Physical Layout Bathroom

17. Essential Ingredients: Clinical Staff and interdisciplinary team training  Clinicians and staff  Clinicians and staff from community agencies Patient tracking and follow-up  Assessment of population needs and quality of care

18. Clinical training Didactic topics (evidenced based) Patient and family centered communication skills Primary care counseling skills Collaborative care communication skills Experiential approaches Shadowing Regular interdisciplinary case conferences

19. Collaborative Tips: Behavioral Health Provider Adherence –Monitor dose –Monitor side effects –Monitor beliefs –Assess symptoms Consult with MD/PA/NP –Medication –Successes –Obstacles Share therapeutic info –Family, cultural issues –Strategies Monitor overall health quality of life –Note physical symptoms –Health maintenance –Chronic illness mgmt –Chronic illness beliefs

20. Collaborative Tips: Medical/Nursing Provider Share concerns about adherence with MHP Share psychosocial information about patient and family Encourage participation in psychotherapy Assess patient beliefs about psychotherapy Ask what psychotherapeutic goals you can support –Communication skills –Cognitive changes –Behavioral changes –Emotional awareness Share concerns about other health care issues

21. Collaborative Tips: Care Manager Monitor the gaps-- “interstitial thinking” Track patients using systems “owned” by the team. Adapt communication to varying styles of behavioral health and primary care providers Track –Side effects –Adherence –Outcomes Facilitate –Referrals –Needed visits –Defining shared goals –Community connections

22. Marillac Outcomes

23. A Proxy for Integration: Hallway consults Averages in 2003 and 2004 1034 consults between primary care providers and case managers or mental health therapists 405 three way meetings between patients, behavioral health providers and primary care providers

24. Quality of Care Improvement Chart review comparison –All charted mental illnesses 500 consecutive patients in 1999 500 consecutive patients in 2004

27. Stepped Care: 1999 vs 2004 Overall MH contacts and PCP contacts

28. Primary Care Provider Contacts Acute phase (1st 120 days) 1999 (149) 2004 (111) Patients with 1 mental health dx3.2(75)2.4(49) Patients with 2 mental health dx3.7(54)3.6(43) Patients with 3 mental health dx3.7(20)4.4(19) Continuation phase ( 9 months post acute phase) Patients in phase at start36%76% Average number of visits3.12.5

29. Stepped Care: 1999 vs 2004 Team member MH contacts

30. 19992004 Patients Treated Mean Visits Patients Treated Mean Visits P-value Acute Care 1493.161114.81.0001 Contin Care 1393.761934.88.01 Number of Mental Health Contacts with Health Professionals in1999 and 2004

31. Essential Ingredients: Financial Commitment of core organizational resources Multi-organizational support Development of new financial resources –Public and private grants –State health programs –New insurance relationships –State policy changes

32. Donated FTE and Funding in Lieu of Decreased Uncompensated Care From Local hospitals Local mental health centers

33. 1,000 Marillac Patient Hospital Admissions

34. Psychiatry Inpatient Days January - April 2003 versus 2004 100% Marillac Medical Patients

35. Psychiatry Charges: January - April 2003 versus 2004 100% Marillac Medical Patients

36. Research Team Larry Mauksch, M.Ed* Stephen Hurd, Ph.D# Randall Reitz, Ph.D# Susie Tucker, Ed.D# Wayne Katon, MD† Joan Russo, Ph.D† * University of Washington Department of Family Medicine # Marillac Clinic, Grand Junction, Colorado † University of Washington Department of Psychiatry and Behavioral Science

37. Marillac Papers Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J., Walker, E., & Spitzer, R. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract 2001, 50(1), 41-47. Cameron, J. and Mauksch, L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health, 2002, 20(4) 343-363. Mauksch, LB. Katon, W., Russo, J., Tucker, S., Walker, E Cameron, J. The content of a low income, uninsured primary care population: Including the patient perspective. Journal of the American Board of Family Practice, 2003, 16,:278-289. Mauksch, L., Reitz, R., Tucker, S., Hurd, S., Russo, J., Katon,W. Improving Quality of Care for Mental Illness in an Uninsured, Low Income Primary Care Population, General Hospital Psychiatry, 2007, 29, 302-309

38. Remember Build relationships through experiential team training on clinical and operational topics Have regular huddles and meetings Create team ownership of change, challenges, and successes Find out what is important to patients in life, in problem focus, in treatment, and in relationships

39. More to Remember Figure out what to change first, don’t change everything at once, be patient but persistent Do not let staff turnover cause system decay Track Progress: patient, team, system, cost Create back-up systems to optimize clinical success: –multidisciplinary transdisciplinary

40. Still more to remember Conserve resources and intensify care for patients with greater complexity (stepped care) CELEBRATE SUCCESS!!!