Transcript Extreme Integrated Care

Total Integration of
Behavioral Clinicians
into Primary Care Practice
Current State of our Fragmented
Healthcare System
Hello, uh my name is --------, and I’m calling for my son.
Uh, he has bipolar schizo, and uh…uh…he hasn’t had
no medications for a long time because they don’t wanna
give him any medications because he doesn’t have uh
Medicare. We tried to get Medicare and they didn’t
wanna give it to him and I’m really really real real worried
about him. I’m his mother. He has uh really been um
depressed depressed and I’m really afraid for him. I
would really appreciate it if you would give me a call
because I need to see somebody. The doctor here in the
won’t be back ‘til May but we can’t really wait that long. I
would just appreciate so much if you could give me a
call. It’s very important. I would appreciate a call. We
need to see you as soon as possible. Please help us.
Thank you.
L.C., a 36-year-old divorced mother of three and kindergarten teacher was at the
end of her rope, financially and emotionally, when she made the wrenching decision
to hand over her son. L.C.’s husband left her alone with three children, including an
older bipolar daughter and a 12-year-old boy who is doing well. But her 11-year-old
son, Skylar, is bipolar, abusive and violent, she said, and after three years of spotty,
expensive and ineffective psychiatric care she could see no other way to get him the
intensive help he needs. L.C. said that her son had received psychiatric care off and
on, with limited coverage by her insurance plan, but that he often refused to take
prescribed medications. When he refused to go to school, she could not afford a
sitter and did not know where to turn. “Good luck finding a counselor — they’re all
filled up,” she said. “You call a psychiatrist and have to wait three months for an
appointment.” Once during a snowstorm, she said, after she drove 25 miles to pick
up the boys at school, then 45 miles to a psychiatric appointment, she arrived 15
minutes late. “They said we’d have to make a new appointment for six weeks later,”
she said.
- NY Times, November 22, 2008
“Every system is perfectly
designed to get the results
that it gets.”
- Dr Paul Batalden, Dartmouth
University
What is the current system
designed for?
Obstacles to care
Health disparities
Poor health outcomes
Frustration
Failure
What do we know?
Mental health can’t be separated from
physical health
People get their health care in primary
care offices
Mental health disorders are under
recognized
Most people won’t go to a mental health
center
What else do we know?
Access to mental health professionals is
difficult at best
– particularly for uninsured and underinsured
populations
People complain of symptoms
– But providers are obsessed with diagnoses
Traditional approaches to mental health
have failed at the population level
The Pyramid of
Psychosocial Problems
in Primary Care
Level I : Acute psychiatric emergencies
Level I : Acute psychiatric emergencies
Level II: Chronic severe psychiatric illness
Level I : Acute psychiatric emergencies
Level II: Chronic severe psychiatric illness
Level III: Chronic less severe conditions
Level I : Acute psychiatric emergencies
Level II: Chronic severe psychiatric illness
Level III: Chronic less severe conditions
Level IV: Temporary psychosocial problem
Level I : Acute psychiatric emergencies
Level II: Chronic severe psychiatric illness
Level III: Chronic less severe conditions
Level IV: Temporary psychosocial problem
Level V: Everybody else
Salud Family Health Centers
Salud Family Health Centers
Migrant/community health center
Full range of primary care services
including obstetrical care
Full dental services in all clinics
Mobile unit
70,000 unduplicated patients
Salud Integrated Care Model
BHP office in medical exam room space
BHP spends 70% of time doing screening,
brief interventions, f/u phone calls, etc
30% of time in more traditional therapy
– Solution focused
– Limited number of visits
– Referral as necessary
Frequent and ongoing consultations
among docs and BHPs
Salud Integrated Care Model
Population based
– We want to reach EVERY patient
Real time interventions
– Most patients can see therapist today
Emphasis on horizontal integration not
vertical integration
Casts a wide net in determining need for
psychosocial intervention
Broad evaluative measures
Requirements for Total
Integration
Co-location
Universal screening
Brief interventions
Solution focused therapy
BHPs as primary care providers
BHP adaptation
Physician adaptation
Co-Location
Co-location means co-location
– Sharing the same space at the same time
Integrated care means integrated facilities
– Regardless of problem, all patients go in and
out the same door
Universal Screening
Most mental health disorders are occult
Most visits to primary care providers have
a large psychosocial component
Primary care docs do a relatively bad job
of uncovering mental health issues
Most poor health outcomes are related to
behavior issues
Universal Screening
Screening is screening
– NOT diagnosis
Screening forms should be straightforward
and simple
Positive screens can be followed up with
more sophisticated and comprehensive
evaluation tools
I recommend face-to-face screening
Brief Interventions
‘Psychoeducational triage’ interventions
– 5-15 minutes max
– In the exam rooms
– Goes hand-in-hand with screening
Requires BHP to work within the chaos of
the primary care office
BHP Adaptation
Traditional mental health office
– No interruptions
– All apptmts made in advance
– Quiet controlled environment
Typical primary care office
– Lots of interruptions
– Many walk-in apptmts
– Controlled (barely) chaos
Solution Focused Brief Therapy
Resource activation, not problem
activation
Has an endpoint
Allows flow of patients in and out of the
BHP schedule
More complex patients may need to be
referred out
– PCPs don’t provide subspecialty care
– This is a primary care model
BHPs are Primary Care
Providers
NOT ancillary staff
If the patient is seeing the BHP, the patient
is being seen
BHP assessment is as important as
physician assessment
Patients will often identify the BHP as their
PCP
Requires Broad Training
LOTS of different duties
– Psychotherapy
– Social work
– Case management
– Other
BHP Adaptation
Your training model may not apply
Office environment is different
How patients gain access is different
Concept of confidentiality is different
Process orientation vs goal orientation
Visits are different
How do patients gain access to
BHP?
Screening
Direct appointment
Referral from provider
Patient request at medical visit
Doc:BHP Ratio
?
Resistance
From BHPs
– I can’t just walk in on a patient
– I like to spend more time with patients
– I like to get deep into my patients’ psyche
– I don’t like all the interruptions
– This isn’t the way I was trained
Resistance
From medical providers
– I’m the captain of the ship
– I don’t like other people seeing my patients
– The BHP slows me down
– I’m really good at psych stuff and I don’t need
help
– This isn’t the way I was trained
What do patients think?
NO resistance
Accepted part of total care package at
Salud
Seen as value added service
Funding
Salud Integrated Care Funding
Models
Mental Health Expansion grant from govt
Partnership with local health district
Partnership with local mental health center
Commitment of general primary care funds
Patient billing
Other Funding Possibilities
Patient billing
– Not likely to work for brief visits
– Could cover 30% of salary
Subsidies
– Docs benefit from integrated practice
– Communities benefit from integrated practice
Managed care contracts
– Patients (and therefore insurance
companies?) benefit from integrated practice
– Medical home may require it
Caveats
You can’t manage everything
– We don’t do heart surgery in primary care
either
– We know how to make referrals to specialists
if necessary
Costs are incurred and savings are
accrued in different places
Next Steps
Outcomes research
– Medical parameters as evidence of
effectiveness of mental health interventions
– Fewer ER visits, more clinic capacity, fewer
lost days of work, etc, etc, etc
Policy changes
?