Transcript Document

Building and Sustaining
Relationships between
Primary and Behavioral Healthcare
Amy M. Kilbourne, PhD, MPH
VA Ann Arbor Serious Mental Illness Treatment
Research and Evaluation Center
Department of Psychiatry, University of Michigan
Learning Objectives
1. To understand the multilevel, system-level barriers to
implementing the Chronic Care Model for
depression management in primary care settings,
particularly those focused on practice and provider
issues
2. To identify potential barriers to fostering relationships
between primary care and mental health providers,
and strategies for strengthening collaborations with
primary care and mental health providers
3. To understand the concept of Participatory
Management and how it could be used to identify
and reduce barriers to implementation, notably by
making the business cases to providers
Barriers to Integrated Behavioral
Health-Primary Care:
6-P Framework
 Patients/Consumers (e.g., symptoms)
 Providers (e.g., time, tools, training, territory)
 Practices/Clinical (e.g., lack of systems to
coordinate care, cultural differences)
 Health Plans/Organizations (e.g., financing)
 Purchasers/State (e.g., not on radar screen, lack
of info on return-on-investment)
 Populations/Policies (e.g., stigma)
PCP, MH Provider Barriers
 Turnover
 Losing interest
 Competing demands
 Territories
PCP, MH Provider Strategies
 Turnover
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ID 2-3 champions
 Losing interest

Periodic CMEs, trainings
Regularly report performance
Visit practices
 Competing demands

Find “win-win”
opportunities
(e.g., streamline intakes)
 Territories

Respect cultural differences
(e.g., privacy concerns)
Implementing Change:
Participatory Management
Combines traditional and emerging approaches:
 Barrier and solution “analysis”
 Obtain buy-in upfront
 Adapt new strategies via shared decision making
 Shift decision making authority to stakeholders AND
“end users” (e.g., front-line staff, consumers)
 Recognition of day-to-day barriers, culture of practices
 Help senior leaders and front line staff understand
what’s in it for them
 Customization to specific settings
Participatory Management
Provider,
Plan, and
Consumer
Input
Adapted
Chronic
Care
Model
Process 1:
ID
strategy
Provider,
consumer
feedback
Process 2:
Customize
Process 3:
Evaluate
Provider,
consumer
consensus
Process 4:
Implement
Provider,
consumer
buy-in
Improved
Process,
outcomes
Participatory Management
PM Process
Process 1: Design
Process 2:
Customization
Process 3: Evaluation
and Refinement
Process 4:
Implementation
Components
Identify model and barriers to
implementation, solutions
Cross-functional team of
consumers, providers to refine
model based on potential barriers
Establish measures
Piloting and further customization
Full-scale intervention
Formative evaluation, ROI
Participatory Management:
WCHO Integrated Care Program
National learning community to foster integrated
care headquartered in southeastern MI
Wide range in size, # providers, years providing
integrated care, but some common themes:
45% are rural
38% no joint MH-PC staff meetings
38% do not share common medical record
47% collect symptom data, 41% Rx, Labs
WCHO Learning Community
Common Barriers
Culture (“finding BH providers who know
primary care and vice-versa,” “differences in
philosophies”)
Funding (“siloed at state level,” different rules
across populations, regions)
Provider lack of time/space to coordinate
Client complexity, privacy concerns
Lack of real-time data on client outcomes
Lack of “clear mission” or “model”
Challenges
 Resources
 Administrative/Operations
 Financing
 Governance
 Clinical
Addressing Challenges
 Administrative/Operations
 Templates for MOUs, agreements, job descriptions, responsibilities
 IT barriers (firewalls) and privacy concerns
 Common methods for analyzing data and measures
 Financing
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State variations in funding rules, creative funding sources
Start-up costs
CPT codes and reimbursement
Demonstrate cost efficiency, return-on-investment
 Governance
 Input on political issues
 Liability (professional roles, clinical responsibility)
 Clinical
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Cultural differences and readiness to change (providers, organizations)
Lack of protocols and clarity in delineation of roles, balancing workflow
Lack of common integrated care model
Involvement of ERs
Sustaining provider use of integrated care strategies
Making the Business Case
 Clinical (outcomes, processes of care)
 Organizational (fidelity)
 Economic (costs)
 Social (satisfaction, stories)
Making the Business Case
Momentum and Lessons Learned
 RWJF Depression in Primary Care
National Demonstration Program
 Linking clinical and economic strategies
 8 organizations: 4 Medicaid
 Washington Circle Indicators
 Bringing performance measurement to
consumers, purchasers
 VA Primary Care-Mental Health
Integration Initiative
Clinical Performance Measures

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No-show rates
% achieving remission (PHQ-9)
% on pharmacotherapy >=6 months
% receiving recommended toxicity monitoring
tests for medications
 # hospitalizations/ER visits
 % receiving follow-up care post-hospitalization
Making the Business Case
WIIFM?
Benefits depend on audience
Practice
Plan
State
Counts towards QI activity
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Empowers providers
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Reduces costs (inpatient, etc.)
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Reduces duplicative care (Rx)
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Applicable to other populations
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Attractive to purchasers
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Summary: 6-P Framework:
Strategies to Reduce Barriers
Patient/
Consumer
Providers
• Education on privacy issues and confidentiality
• Evaluate preferences, promote self-management
• Opinion leaders from PC, BH
• Provide guidelines, communication with care manager
Practices/
Clinical
• Invest in care management (NP, MSW, RN)
• Improve information systems – establish registry
Plan/Organization
• Comprehensive outcomes data (claims, consumer)
• Develop a business case
Purchasers
(State/Private)
• Return-on-investment (State-level data)
• Persistence in light of “crisis du jour”
Populations
and Policies
• Engage community stakeholders
• Increase demand for quality care, enhance advocacy
Pincus et al. 2003; Kilbourne et al. 2008