Transcript Integrating Behavioral Health and Primary Health Care

AtlantiCare Health Services
Mission Health Care
Region II Conference
Integration of Behavioral Health in
Primary Care
June 2, 2010
What is Primary Health Care?
• “Essential health care”
• Universally accessible to individuals and
families
• In a community
• Provided as close as possible to where
people live and work
• Care based on the needs of the population
Providing behavioral health in
primary care involves
• Diagnosing and treating people with
mental disorders
• Putting in place strategies to prevent
mental disorders
• Ensuring that primary health care workers
are able to apply key psychosocial and
behavioral science skills
For example:
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Interviewing
Counseling
Interpersonal skills
In their day to day work in order to
improve overall health outcomes in
primary care (WHO, 1990)
Integration of Behavioral Health
in Primary Care
• Integrating specialized health services –
such as mental health services – into PHC
is one of WHO’s most fundamental health
care recommendations (WHO, 2001)
Rationale for Integrating Behavioral
Health Services into PHC
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Reduced Stigma  Patients are more comfortable in discussing mental health issues with PC
provider
 Because primary health care services are not associated with any specific health
conditions, stigma is reduced
 In general they have an established relationship with primary care provider
because they are more inclined to follow up on medical care
 “ I am not crazy “
 less stigma walking into a PHC setting than a behavioral health setting
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Improved Access to Care
Patients are more likely to keep appointments where multiple issues are being
addressed
Better coordination of care
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Treatment of co-morbid physical conditions
Co Morbidity
• Behavioral health is often co-morbid with
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many physical health problems such as:
Heart Disease
HIV/AIDS
Diabetes
Tuberculosis
Chronic Pain
Co Morbidity
• When primary health care workers have
received some behavioral health care
training they can attend to the physical
needs of people with behavioral health
disorders as well as the behavioral health
needs of those suffering from infectious
and chronic diseases. This will lead to
BETTER health outcomes
Morbidity and Mortality in People
with Serious Mental Illness
• Persons with serious mental illness (SMI) are
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dying 25 years earlier than the general
population
While suicide and injury account for about 3040% of excess mortality, 60% of premature
deaths in persons with schizophrenia are due
to medical conditions such as cardiovascular,
pulmonary and infectious diseases
(NASMHPD, 2006)
Improved Prevention and Detection
of Behavioral Disorders
• Primary health care workers are frontline formal
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health professionals
First level of contact of individuals, the family
and the community
Equipping these workers with behavioral health
skills promotes a more holistic approach to
patient care and ensures both improved
detection and prevention of behavioral disorders
Treatment and Follow –up of
Behavioral Health
• People who are diagnosed with a
behavioral health disorder are often
unable to access any treatment for their
mental health problems
• Providing behavioral health services in a
PHC, more people will be able to receive
the services and care they need because:
Treatment and Follow –up of
Behavioral Health
• Better physical accessibility
Primary health care is the first level of contact, usually
the closest and the easiest to access for individuals, the
family and the community
• Better financial accessibility
340b program
• Better acceptability
Linked to reduced stigma and easier communication
with health care providers
Integrated Care
• Most effective approach to treat mental
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health in PC settings
Comprehensive
Multidisciplinary approach
Fully integrated with information available
to all practioners
Cost-effective
Challenges to Overcome for
Successful Integration
• Integration of mental health services
requires a lot of careful planning and there
are likely to be several issues and
challenges that will need to be addressed.
For example :
• Training of Staff
• Uncomfortable in dealing with mental disorders
• Overall reluctance of primary health care
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workers
Availability of time
Adequate supervision of primary care staff
Human resource management issuescompetencies
Clinical Barriers to Integrated Care
• Traditional separation of mental health
issues from general medical issues
• Lack of awareness of mental health
screening tools in the primary care setting
• Physician’s limited training in psychiatric
disorders and their treatment
Financial Barriers
• Lack of insurance parity for psychiatric
disorders
• Medicaid’s low reimbursement rates
• Billing restrictions
The following challenges are examples that
policymakers should consider:
1. Reimbursement for mental health services from
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Managed Behavioral Health Care Organizations
Reimbursement after an initial mental health screening
or diagnosis
Limitations in reimbursement for non-physician
providers, i.e case management
Limitations on billing for mental health services and an
additional medical visit on same day
Coding and provider combinations that generate
adequate reimbursements from Medicaid/Medicare
Policy Barriers
• Health and Mental Health funding streams
• Difficulty in sharing information due to
HIPPA regulations
Organizational Barriers
• Shortage of mental health professionals
• Limited communication between medical
and mental health providers
• Lack of agreement between medical and
mental health provides
Approach
Description
Benefits
Limitations
Consultation
Mental health experts are
available by telephone or
video conferencing to provide
consultation on medication
management and in some
cases direct mental health
consultation to individuals
and families and referrals to
local mental health specialist
Increases access to
psychiatrists and other mental
health specialists, particularly
in underserved communities
with mental health workforce
shortages; improves
prescribing practices
Does not provide psychotherapy and
evidence-based mental health
services
Co-location
Primary care and mental
health clinicians are
physically located in the same
treatment setting. Mental
health providers may be
independent practitioners or
co-located in primary care but
employed by mental health, or
other systems
Can reduce the wait for
mental health services; may
increase the likelihood that
individuals and families will
follow through with mental
health treatment
Co-location does not guarantee
collaboration or an integrated
approach to practice
Collaborative and integrated
models
Primary care practice has
mental health clinicians on
staffs that assess and treat
individuals and families,
provide phone consultation to
other systems, and facilitate
case conferences. Integrated
practice recognizes the link
between medical and mental
health in every primary care
encounter and provides
integrated care
A comprehensive approach
that enables primary care to
provide the full continuum of
services: screening,
assessment, and treatment
Challenges include financial
sustainability of mental health staff;
billing complexities
AtlantiCare’s Journey
• Established 330h center in 2003
• Grant requires mental health and
substance use services
• Psychiatric APN through NHSC until May
2009
• Introduced PhQ-9 to medical staff
Co-location
• CIP grant dollars – satellite site
• MHC – AIS program
• Open July 2009
Adult Intervention Services
AtlantiCare Behavioral Health
A unique pilot program
developed by Atlanticare
Behavioral Health to address
the needs of the residents of
Atlantic County
One of two services of this
type in the state. Atlanticare
Behavioral Health developed
the program at the request of
the state.
PURPOSE
• To provide comprehensive short-term
interventions to individuals who are
experiencing significant and distressing
symptoms due to mental illnesses
• To bridge the gap between the onset of
acute symptoms and on-going treatment
• To reduce the number of mental health
clients inappropriately treated in the ER
GOALS FOR EARLY
INTERVENTION AND SUPPORT
SERVICES
• To provide accessible early and urgent
intervention, support services, and ongoing
recovery supports to individuals, families, and
consumers in acute distress
• To maintain or enhance the quality of life of the
consumers and their families
• To provide community based crisis intervention
through the development of a community walk in
center and the provision of early intervention
outreach services
TARGET POPULATION
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Adults – 18 years of age or older
Experiencing acute psychiatric symptoms
Co-Occurring substance use disorders
All of whom are in a community setting
and can be safely stabilized, and
subsequently provided ongoing
individualized supports
MHC-AIS Integrated Services
• Monthly meetings established with
Directors, medical and clinical staff and
case management
• Weekly case management meetings
between AIS-MHC to review progress on
mutual patients and develop action plans
for high risk patients
Case Study-Billy E
61 year old African American male
Medical History
• Diabetes,COPD,Hypertension,GERD,
Glaucoma, Hepatitis C, Obesity,
Osteoarthritis, Asthma, Muscle weakness,
Congestive heart failure
Psychiatric History
• Major Depressive Disorder, Anhedonia,
past hx of alcohol abuse (5 yrs sober)
Case study
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Patient of MHC since 2007
Treated for medical and psychiatric issues
May 2009 , psychiatric APN resigned
APN referred Billy to behavioral health
services
Case study
• Billy does not follow through with behavioral health
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referrals
Non-adherent to psychiatric medications and behavioral
health services
No follow through with appointments and specialty
referrals (pulmonologist, nephrology, ID clinic)
Decline in self esteem, feelings of hopelessness, lacks
ability to function in social settings
Difficulty trusting people
Isolating
Feels he has no one in his corner advocating for him
Case study
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Encourage referral to AIS program
co-located with MHC
Intake and Psych evaluation on 3/10/2010
Chief complaint- “I stopped taking my
meds, ran out of them, I can’t sleep, I
worry a lot, I can’t handle my stress. I feel
depressed”
Case study
• Billy accepted to the AIS program
• Begins medication and treatment on 3/10/2010
• Attends 5 groups per week, 1:1 counseling weekly, case
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management services and medication monitoring
Follows through with 90% of appointments
Adherent to psych medication
Successfully follows through with specialty appointments
Involved in social functions – CODI, fashion show,
support groups, computer class
Increase in confidence and self esteem
Case study
• Remained with AIS for 2 months ,
discharged on 5/6/2010 and referred to
ABH outpatient program
• Highest PhQ-9 score was 18
• Recent score 2
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