Transcript Integrating Primary and Behavioral Health in a CMHC

Macon County Initiative
Integrating Behavioral Health and
Primary Care
Presented by:
Diana Knaebe, Heritage Behavioral Health Center
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Integration Partnership Background
1. Description/History of Partnerships
2. Rationale for involvement
3. Evolution of Partnerships and programs –
services offered
4. Next Steps
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Heritage
Behavioral
Health Center
Community Health Improvement Center
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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.
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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.
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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
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Rethinking the Format of Visions
MEDICAL HOME
Primary Care
Clinic
Mental Health
Center
CORE COMPETENCIES
CORE PROGRAMS
INTERVENTIONS
U N I F I E D
F U N D I N G
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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
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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
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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 enters @ HBH, and assures communication with
Primary Care Physician (PCP)
BH Clinician provides assessment,
Psychiatrist provides and monitors needed medication
Quadrant IV
High Behavioral Health (BH)
High Physical Health (PH)
Heritage is medical home with counseling and case management
services provided at Heritage
Criteria for placement in this quadrant
Accesses services at Heritage in most cases
Physical health care by PCP located at Heritage
Eligible for 132 Services
•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
Psychiatrist provides and monitors needed medication
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
May have accessed services at CHIC or HBH
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
Actions to Be Taken:
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
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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.
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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)
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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 2005. State level partners included:
 Illinois Chapter, American Academy of Pediatrics ( ICAAP) and Illinois Academy of Family
Physicians
 Ounce of Prevention Fund (OPF)
 Illinois Department Iof 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
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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
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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
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Health and Wellness Activities


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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
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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
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Key Contact Person(s) and Contact
Information:
 Julie Aubert, MCHD, [email protected]
 217-423-6988 ext 1105
 Barbara Dunn, CHIC, [email protected]
 217-877-6111
 Dennis Crowley, MCMHB, [email protected]
 423-6199 X 108
 Diana Knaebe, Heritage, [email protected]
 217-420-4702
 Karen Shiflett, MCHD, [email protected]
 217-423-6988 ext 1343
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