1. Macon County Initiative Integrating Behavioral Health and Primary Care
Presented by:
Diana Knaebe, Heritage Behavioral Health Center

2. Integration Partnership Background
Description/History of Partnerships
Rationale for involvement
Evolution of Partnerships and programs – services offered
Next Steps

3. Heritage and CHIC Integrated Care Project
Heritage Behavioral
Health Center
Community Health Improvement Center

4. Integration Partnership Background
Description/History of Partnership
Community Health Improvement Center and Heritage
Have had working relationship for the past fifteen years; initially, there were cooperative efforts with mutual referrals to assure that clients received needed primary care/mental health services.
Early on the entities worked cooperatively with a local pharmacy, and developed a system utilizing bubble cards containing daily prescribed dosages of medications for medical and psychiatric problems which could be taken by the client on a daily basis.

5. Integration Partnership Background
In July 2006, the United Way funding allowed Heritage to provide an adult psychiatrist on-site at CHIC. This psychiatrist provided psychiatric care, support, and follow up to patients, and consultation to medical physicians 9 hours per month. The CHIC physicians were so pleased with the immediate psychiatric consultation available that the pediatric providers requested on-site psychiatric availability.
Consequently, in April 2007, a child and adolescent psychiatrist was added. He provides mental health services to the primary heath center 4 hours per month, direct care to patients, and consultation and education to the medical physicians.

6. Integration Partnership Background
United Way funding allowed CHIC to provide a APN as well as a liaison on-site at a Homeless Day Center operated by Heritage. This allowed access to health care by individuals many of whom had not received health care in years.
Both organizations have attended the National Council’s Integrated Care Sessions for past 5 years.
Participated in National Council’s Integrated Collaborative Care Project in 2007
Participated in MHCA Integrated Healthcare Learning Community August 2009-November 2010

7. Rethinking the Format of Visions

8. Reasons/Rationale for Partnerships
Ultimately to Implement a patient centered medical home – true integration of care
Better Overall health outcomes.
Improved access and retention of clients
Joint referral process and records access
Clinical processes defined for collaboration and joint education for staff
Nurse practitioners and/or Physician Assistants at both CHIC and Heritage
Clients only seen at one site for all needs – as much as possible unless need specialty care
Maximizing revenue (current and new services)
Efficient/effective/efficacious care
Non-duplication of care and services
Education sharing component for staff and clients

9. Cultural Issues/differences
Term-language Differences
How patients/clients are seen – length of time for visit and follow up
Funding Streams and Mechanisms often very different
Determination of “hand-offs” and/or referrals
Releases – Medical Records

10. The Four Quadrant Clinical Integration Model For the Adult Population/ Heritage & CHIC Adaptation
Quadrant II
High Behavioral Health (BH)
Low Physical Health (PH)
Heritage is medical home. Care to be provided by or arranged by Heritage BH Counselor
Criteria for placement in this quadrant
May have accessed services at CHIC or HBH
Eligible for 132 Services
Has low physical health risk/ complexity
Needs psychotropic medication provided by psychiatrist at HBH
Physical health care by PCP located at HBH
May have stigma issue about going to Heritage
Needs case management, housing, assistance with finances & or Heritage Payee services
Dual problems of S/A & MH (requires treatment for both)
Inpatient Hospitalization in past or required now.
Needs daily living skills training
Needs outreach services provided by Heritage
Actions to Be Taken :
Clinician arranges case management services for housing and other community supports
Arranges for S/A treatment
Arranges for access to primary health care if HBH, and assures communication with Primary Care Physician (PCP)
BH Clinician provides assessment,
Psychiatrist provides and monitors needed medication
Quadrant IV
High Physical Health (PH)
Heritage is medical home with counseling and case management services provided at Heritage
Accesses services at Heritage in most cases
Physical health care by PCP located at Heritage
Has complex and high risk physical problems, and requires regular physician visits, and or specialty physician care
Needs a BH case manager at HBH who provides assistance with housing, financial assistance
May have Dual problems of S/A and MH (requires treatment for both)
Needs inpatient hospitalization for either physical or mental health issues
Actions to Be Taken:
Primary Dr provides primary care and assures specialty physical health care when needed
Heritage BH counselor assures collaboration between BH & PH
BH clinician arranges for case management and other needed support services
If no Primary care physician at HBH, will receive primary care at CHIC
Quadrant I
Low Behavioral Health
Low Physical Health
CHIC is medical home with on site CHIC BH clinician
Criteria For Placement in this quadrant
Low physical health risk/complexity
Slightly elevated health or BH risk
Client may need BH and or S/A triage, assessment, and service planning
Brief BH counseling or treatment or group therapy
May need referral to community and educational resources
May need health risk education
Drs only clients at HBH would be appropriate in this quadrant
PCP provides primary care and uses screening tools and guidelines to serve most individuals in Primary Care
Refers to & collaborates with psychiatrist to assure coordinated care
CHIC BH clinician provides formal and informal consultation to the PCP
CHIC BH clinician provides brief counseling
Psychiatric consultation provided to PCP if needed
Quadrant III
High Physical Health
Low Behavior Health
CHIC is medical home with on site CHIC BH clinician
Criteria for Placement in this quadrant
Has complex and high risk physical health problems, and requires regular physician visits, and or specialty physician care
Low BH needs, but needs screening by PCP using screening tools
May need BH triage or assessment
May need consultation to the PCP
May need referral to community educational resources
Actions To Be Taken:
PCP provides primary care and assures specialty care when needed
PCP utilizes BH screening tools and guidelines to serve most individuals in Primary Care
BH clinician provides triage, assessment, & consultation with PCP

11. Integration Partnership - Expansion
The Administrative and Clinical Collaborative Committees continue to meet on the existing collaboration as well as expanding to additional behavioral health services on site at CHIC and with an intention of continuing to work towards the provision of primary health care in a behavioral health care setting. This project is the logical extension of efforts currently underway between Heritage and CHIC. Heritage and CHIC meet regularly to plan, coordinate, and implement our existing collaboration of integrating behavioral and primary health care. This collaboration is progressive and moving forward.
The MCMHB joined the Administrative Committee in late 2009 when we began a “pilot project” to add expertise, additional funds with Medicaid billing through them plus the matching local dollars.

12. Integration Partnership Background
Integration: Partnering Agencies 2011
The Community Health Improvement Center (CHIC), a primary health care center – Federally Qualified Health Center,
Heritage Behavioral Health Center (Heritage), a community behavioral health center – Mental Health, Substance Abuse, Homeless and Housing Services
The Macon County Mental Health Board (MCMHB), a public taxing body that funds MH/SA/DD services
The Macon County Health Department, public health department (MCHD)

13. Integration Partnership – Expansion Two
Macon County Health Department
MCHD entered into partnership with IDPA ABCD II (Assuring Better Child Health and Development Initiative) project in State level partners included:
Illinois Chapter, American Academy of Pediatrics ( ICAAP) and Illinois Academy of Family Physicians
Ounce of Prevention Fund (OPF)
Illinois Department of Human Services (IDHS) Office of Family Health (OFH)
IDHS Office of Mental Health (OMH)
Illinois Department of Children and Family Services
Illinois Primary Health Care Association (IPHCA
Local partners included:
AOK Network
FQHC: CHIC
WIC/FCM Coordinator
Pediatric/Family Practices:
Early Intervention/CFC:
Heritage Behavioral I

14. Edinburgh Postnatal Depression Scale (EPDS)
Possible Depression is indicated at score of 10 or above. Referral provided for all scores of 10 or higher
INITIAL NUMBERS INDICATED HIGH RATE OF NEED !
Edinburgh’s Completed :
May 05 – September 05 = 434
Scores of 10 or higher = 100
Result=25% rate of at risk women in need of referral !
Current screening rates maintain average of 100 screens completed /month with 10-20% rate of need for referral

15. Hopes & Screams from MCHD
MCMHB Board Director enlisted local mental health providers to provide counseling services for clients with positive screening scores
Referral rates outnumbered available resources
MCMHB providers had long waiting times for client entry
Some MCMHB providers were charging clients for services against project agreement
Some providers requested clients not be referred if in prenatal state
Some OB providers declined to accept screening results
MCHD staff expressed frustrations and concerns related to referral inconsistencies

16. MCHD Request to MCMHB Fall 2010
Invited MCMHB Director to Maternal Child Health staff meeting to address staff concerns related to the counseling referral system
Staff relayed numbers of underserved clients
Gave examples of referral difficulties with MCMHB paid agencies
Requested on site services and to include home visits for clients with barriers such as daycare, transportation, work/school schedules
Goal= to achieve through partnership timely and adequate service delivery and follow up for at risk women and families

17. MCMHB Reasons for Involvement
New Medicaid by billing through the MCMHB – directly to DHFS
Local Funds Initiative - matching Medicaid with County dollars means more money for the community
Quicker access to behavioral health services
Captive Audience at CHIC – linkage & need from MCHD
Eligibility – changes in eligibility over the years in mostly only target population defined by DHS-OMH – this allows an Expansion of eligibility wider range of individuals than current and potential
Still meeting medically necessity
More holistic care - hopefully better clinical outcomes/people improving/getting better

18. Integration Partnership – Expansion Two Continued
Administrative Team established and meeting to work through challenges, barriers, referral processes, medical record – computer
Members from MCHD, MCMHB, Heritage
Clinical Teams also providing feedback through their supervisors – funnels up to Administrative Team and back to clinical teams/supervisors to smooth the processes

19. MCHD, “Happy Days Are Here!”
January 2011-Part time MCMHB funded Heritage Counselor begins accepting onsite referrals at MCHD and completing home visits.
40 referrals received in the first month! Whew!
Initially ,frustration expressed regarding delayed contact time vs referral numbers …However …
Counselor provides assistance with multiple scenarios
Clients and staff express 100% satisfaction with follow up services

20. Next Steps MCHD Expansion into Seniors
Plan to use Geriatric Depression Screen
One full-time mental health staff beginning July 2011 might expand to another part-time assigned to the MCHD clients/patients

21. Specific Changes Implemented in the Last Year
Lost the psychiatrist that worked so well for both organizations as a result have added Psychiatric Nurse Practitioner to FQHC
Added Mental Health Therapist to the FQHC site with MCMHC Board Funding
Screening to determine who can be better served at the FQHC as primary – Medical Home
Have received SAMHSA Integrated Primary Care Grant which will allow us to emphasize wellness with SPMI population added Physical PA on site at the Mental Health Center.
MCHD has become 2nd site funded by MCMHB for therapists to see identified by MCHD staff in need of services – primarily an outreach, in-home model though which is different than that at CHIC

22. Lessons Learned – things to Consider when establishing Collaborations for Integration of Care
Can take much more time to work through because our systems are often actually complicated
Are the right people at the table for discussions?
Licensure of Sites – Scope of Practice Changes
Written Agreements
Joint Contracts for purchasing of staff or services
Who is billing for what?

23. SAMHSA Program Goals
Heritage Behavioral Health Center received a SAMHSA Grant in September 2010 for its Primary and Behavioral Health Care Integration (PBHCI) program.
Our project focuses on:
individuals with Serious Mental Illness who are on antipsychotic medications and….
have co-occurring metabolic syndrome or a chronic medical condition
Establishment of a primary care clinic at Heritage Behavioral Health Center
Provision of wellness activities/programs
Working with 500 SMI adults by the end of the 4th year

24. SAMHSA Program Goals Health and Illness Background Information
Used both as a screening and as a means of documenting diagnoses (PH and BH) as well as important medical/health history variables SF-36 (short form)
Person Centered Healthcare Home Fidelity Scales and Protocols
Developed by our evaluator, TriWest
Based on the conceptual work of Barbara Mauer and collaborators
2-day collaborative assessment process

25. Accomplishments
In 5 months, established a Health & Wellness Suite, including a Primary Care Office at Heritage
Contracted with CHIC Primary Care Clinic to place a Primary Care Physician/Assistant on site
Developed a Clinical Registry
Admitted 57 clients to Health and Wellness Program since Mid March 2011

26. Accomplishments
Received 87 referrals to the program since program began in February 2011
Success Stories:
In one month, one client lost 20#, another lost 11#, a third lost 14#. No one enrolled in the program has gained weight.
Two partially immobile clients are now mobile and continuing to improve

27. Health and Wellness Activities
Food Pyramid Education weekly
Healthy Cooking Classes weekly
Chair Zumba twice per week
Modified Yoga weekly
Daily Walking Activity
Healthy Food Shopping As Needed
1:1 Food Counseling and Review of Food Tracker as needed
Weekly Off Site Exercise

28. Plans for The Future
Expand hours and responsibilities of P/A to provide all primary care for individuals in the program
Provide fully certified smoking cessation classes to clients
Staff will become certified in smoking cessation, diabetes education, yoga, and zumba
Provide physical illness management education to case managers
Add Peer Support/Mentors to program
Wellness Model throughout organization

29. Key Contact Person(s) and Contact Information:
Julie Aubert, MCHD,
ext 1105
Barbara Dunn, CHIC,
Dennis Crowley, MCMHB,
X 108
Diana Knaebe, Heritage,
Karen Shiflett, MCHD,
ext 1343