Transcript Improving Collaboration Between Community

Webinar Agenda
 Welcome & Introductions
Todd Molfenter, Dep. Director, NIATx, University of WI-Madison
 Improving Collaboration Between PC & BH
David Bingaman, Dep. Regional Administrator, HRSA Region V
 Integration Models
Laura Galbreath, Dep. Director, SAMHSA/HRSA Center for
Integrated Health Solutions, National Council for Community
Behavioral Healthcare
 WI Case: Tri-County Partnerships
Kristene Stacker, Exec. Dir., Fox Cities Community Health Center
 Project Invitation – Next Steps
Improving Collaboration between
Primary Care and Behavioral Health
Providers
December 13, 2011
David Bingaman, LCSW
DHHS, HRSA
Office of Regional Operations
Improving Collaboration
• Cartesian Dichotomy
• Separation/Fragmentation
• Growing economic incentives for
a more effective approach
Improving Collaboration
• Primary care foundation
• PCPs deliver half of BH care
• PCPs prescribe 70% of
psychotropic drugs
• PCPs have limited BH training;
widespread under diagnosis
Improving Collaboration
Impact of Mental Illness:
26% suffer from a diagnosable mental
disorder in a given year; half meet
criteria for 2 or more
Half of all cases begin by age 14 and ¾
have begun by age 24
Up to 70% of primary care visits stem
from psychosocial issues
Improving Collaboration
• PCPs have limited time to treat
psychosocial issues
• BH care inaccessible to PCPs
• Many referrals do not result in
visits/services
• Limited capacity of BH system
Improving Collaboration
• MH consumers less likely to
receive primary medical care
• SMI associated with increased
morbidity and mortality
Improving Collaboration
Drivers of Change:
• Berwick’s Triple Aim: Better care,
better health, and reduced cost
through quality improvement
• Patient Centered Medical Home
(2011)
• State and Federal budget cuts
Improving Collaboration
Drivers of Change, continued
Affordable Care Act:
Community Health Centers
Medicaid
Mental Health & Substance
Abuse Services
Accountable Care Organizations
Improving Collaboration
NASMHP Director’s Report: “Good
public policy will work to sustain,
support and require integration of
services between the two “safety
net” systems of CHCs and MH
providers with integration ranging
from coordination of care to full
integration of medical and
behavioral service.”
HRSA’s Resources for B.H.
Integration into Primary Care
http://bphc.hrsa.gov/technicalassist
ance/taresources/index.html
David Bingaman, LCSW
Deputy Regional Administrator
Health Resources & Services Administration
(HRSA)
U. S. Department of Health & Human Services
233 N. Michigan Ave., Suite 200
Chicago, IL 60601
312-353-8121
[email protected]
Models for Primary and Behavioral
Health Integration
Laura M Galbreath, MPP
Deputy Director, CIHS
[email protected]
“…in essence integrated health care is the
systematic coordination of physical and
behavioral health care. The idea is that
physical and behavioral health problems
often occur at the same time. Integrating
services to treat both will yield the best
results and be the most acceptable and
effective approach for those being served.”
Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S.,
Hogg Foundation for Mental Health
Behavioral Health Referrals
Primary Care
Collaborative
Care
Physical Health Status
Behavioral Health
Individuals with Serious Mental Illness The Statistics
Persons with serious mental illness (SMI) are dying at the
average age of 53 (comparable to Sub-Saharan Africa)
While suicide and injury account for about 30-40% 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)
OR state study found that those with co-occurring MH/SU
disorders were at greatest risk (average age of
death=45.1 years)
Top Ten Areas for Consideration in Developing and
Supporting Patient Centered Health Care Homes
•State Level Leadership
•Collaboration
•State Level Management
•Confidentiality
•Models/Strategies
•Finance
•Culture
•Data
•Workforce
•Training
Quadrant II
MH/SU PH 
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Outstationed medical nurse
practitioner/physician at MH/SU site
(with standard screening tools and
guidelines) or community PCP
MH/SU clinician/case manager w/
responsibility for coordination w/ PCP
Specialty outpatient MH/SU treatment
including medication-assisted therapy
Residential MH/SU treatment
Crisis/ED based MH/SU interventions
Detox/sobering
Wellness programming
Other community supports
Quadrant IV
MH/SU PH 

Outstationed medical nurse
practitioner/physician at MH/SU site (with
standard screening tools and guidelines)
or community PCP
Nurse care manager at MH/SU site
MH/SU clinician/case manager
External care manager
Specialty medical/surgical
Specialty outpatient MH/SU treatment
including medication-assisted therapy
Residential MH/SU treatment
Crisis/ED based MH/SU interventions
Detox/sobering
Medical/surgical inpatient
Nursing home/home based care
Wellness programming
Other community supports
High
The Four Quadrant Clinical Integration Model (MH/SU)
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MH/SU Risk/Complexity
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Persons with serious MH/SU conditions could be served
in all settings. Plan for and deliver
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services based upon the needs of the individual, personal choice and the specifics of the
community and collaboration.
Quadrant I
MH/SUPH 
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Low
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PCP (with standard screening tools
and MH/SU practice guidelines for
psychotropic medications and
medication-assisted therapy)
PCP-based BHC/care manager
(competent in MH/SU)
Specialty prescribing consultation
Wellness programming
Crisis or ED based MH/SU
interventions
Other community supports
Quadrant III
MH/SU PH 









PCP (with standard screening tools and
MH/SU practice guidelines for
psychotropic medications and
medication-assisted therapy)
PCP-based BHC/care manager
(competent in MH/SU)
Specialty medical/surgical-based
BHC/care manager
Specialty prescribing consultation
Crisis or ED based MH/SU interventions
Medical/surgical inpatient
Nursing home/home based care
Wellness programming
Other community supports
Physical Health Risk/Complexity
Low
High
Models of Bi-Directional Integration
Behavioral Health –Disease Specific
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IMPACT
RWJ
MacArthur Foundation
Diamond Project
Hogg Foundation for Mental Health
Primary Behavioral Healthcare Integration
Grantees
Behavioral Health - Systemic Approaches
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Cherokee Health System
Washtenaw Community Health Organization
American Association of Pediatrics - Toolkit
Collaborative Health Care Association
Health Navigator Training
Physical Health
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TEAMcare
Diabetes (American Diabetes Assoc)
Heart Disease
Integrated Behavioral Health Project –
California – FQHCs Integration
Maine Health Access Foundation –
FQHC/CMHC Partnerships
Virginia Healthcare Foundation – Pharmacy
Management
PCARE – Care Management
Consumer Involvement
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•
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HARP – Stanford
Health and Wellness Screening – New
Jersey (Peggy Swarbrick)
Peer Support (Larry Fricks)
Primary and Behavioral
Health Integration Works
BH→PC RESPECT – MacArthur Initiative
Cluster randomized controlled trial
60% response to treatment and 37% remission
at 6 months, compared to 47% and 27% in usual
care practices
BH→PC IMPACT Study
Randomized clinical trial of collaborative care
intervention for elderly patients
Showed significant improvements in symptoms
and functionality at 6 months, 12 months, and 2
years
BH→PC DIAMOND Initiative
Adapted IMPACT program for general
population setting and studied outcomes
64% response to treatment and 44% remission
at 6 months; 72% response and 52% remission at
12 months
PC→BH P-CARE - NIMH-funded Trial
Medical case management for individuals
with serious mental illnesses
Fewer medical ER visits, improved cardio risk
factors, and more likely to have a usual source
of PCP care
PC→BH Diabetes Care Coordination AHRQ Health Care Innovation
Nursing and mental health care coordination
to educate and empower clients with SMI to
manage their diabetes
The number of clients with ideal blood sugar
levels increased from 32% to 43%. Mean
health risk status improved significantly from
baseline to program.
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Components of Collaborative Care Model
Primary Care
Provider
Screening/
Monitoring
Patient Registry
Stepped Care
Approach
Consulting
Psychiatrist
Care Manager
Relapse Prevention
Collaborative care’s key ingredients
Care management – Patient education & empowerment,
ongoing monitoring, care/provider coordination
Evidence-based treatments – Effective medication
management, psychotherapy, disease management
Expert consultation for patients who are not improving
Systematic diagnosis and outcome tracking
Stepped care
Technology support – registries
J. Unutzer, 2010, www.cimh.org/LinkClick.aspx?fileticket=84F6JQndwg8%3d&tabid=804
S. Gilbody et al, Arch Intern Med. 2006;166:2314-2321
Lessons from Practice Transformation
to a Patient-Centered Medical Home
Six lessons from 36 family practice settings across the country
that participated in a two-year practice transformation
project
1. “Becoming a patient-centered medical home (PCMH) requires transformation.
2.
3.
4.
5.
6.
Technology needed for the PCMH is not plug-and- play.
Transformation to the PCMH requires personal transformation of physicians.
Change fatigue is a serious concern even within capable and highly motivated
practices.
Transformation to a PCMH is a developmental process.
Transformation is a local process.”
Resonates with the experience in implementing integrated care—this is also a process of transforming
personal and organizational practice in the context of local relationships—ideally, the medical home
and integration changes can be woven together
Services Available from CIHS
• Web-based Resources
(http://www.integration.samhsa.gov)
• eSolutions Newsletter
• National Webinars
• Regional and State Based Learning Communities
• Health Home Consultation to States
Tri-County Partnerships
Calumet, Outagamie and
Winnebago Counties working
together with Fox Cities
Community Health Center.
Who am I?
 Kristene Stacker, R.N. Executive Director
Fox Cities Community Health Ctr. (FCCHC)
Fox Cities Community Health
Center: FCCHC
 Started in 1997 as free community
clinic.
 2005 became a FQHC (Federally
Qualified Community Health Center).
 Board of Directors comprised of 51%
consumer/users of the Health Center.
 2009 served 6,989 individual
consumers with 22,000 encounters.
Service Area
 Outagamie County:
 176,695K; 9.8% growth since 2000.
 11.9% over 65; 24.7% under 18.
 91% white;.1% black; 1.7% American Indian;
3% Asian 3.6% Hispanic.
 8.7% below poverty. (increase from 6.9 in 09)
 Health and Human Services agency.
 Regionalized Family Care County.
 County HHS Budget of 59.3 million.
 Median household income $55,100
Service Area
 Winnebago County:
 166,994 (2010 data)
 12.8% 65 or older; 21.1% under 18
 92.59% white, 1.8 %Black, 3.5% Hispanic, .6%
Native American, 2.3 Asian.
 11.9 % Below Poverty increase from 6.9 in
2009)
 Human Services Agency.
 Regionalized Family Care County.
 58 Million County HS Budget.
 Median Household income $47,486
Service Area
 Calumet County:
 48,971K 20.5% growth since 2000.
 3rd fastest growing county is State. 94.3 %
White, .5 %Black, 3.5% Hispanic,2.1@ Asian,
.4% Native American.
 26.9 under 18; 10.8 over 65.
 5.5 % Below Poverty.
 Median Household income $65,600
 Health and Human Services.
 Regionalized Family Care.
 14.9 million County HS Budget (2011).
Outagamie/FCCHC MH Pilot
 2009 began discussions.
 4 main objectives
 Address increasing length of wait for
outpatient MH services.
 Increase MH services available.
 Increase access for Medical Assistance
patients.
 Begin integration of MH into primary
care.
A Phased Approach to Expansion
 Phase I began 4/09 with FCCHC IM
physician providing care at crisis
diversion facility.
 Phase II increase FCCHC’s MH
counselor to 70% productivity
expectation and add 2 contracted MH
therapists from County to FCCHC.
Phased Approach
 Phase III 8/09 added contract
psychiatrist 6 hours per week.
 Additional 4 hours per month
psychiatric care to Brewster Village
(County Nursing Home).
 Most recently, increased to 14 hours
per week of psychiatry time.
Phased Approach-2011
 Added 2 FTE Licensed Professional
Counselors to clinic employment in
2011.
 Calumet County added LPC for weekly
contract hours for group treatment
related to sex offender grant.
 Added contract BH providers through
county contracts and other
community providers.
Project Outcomes
 FCCHC saw improvement in both
provider productivity and
management of MH program.
 FCCHC had 900 MH visits in first 6
months w/ average no show rate of
15% (reduced from 30-40%).
 Increase in access to MH services
within the region.
 FCCHC access to MH services 5 days/wk.
QUESTIONS/COMMENTS
 Contact
 Kristene Stacker
[email protected]
 920-750-6611
Next Steps
Todd Molfenter, Dep. Director, NIATx, University of WI-Madison
Invitation
 Five-month collaborative (Feb-July 2012), no fee to participate.
 Improve collaboration between FQHCs and behavioral health
agencies offering substance abuse services.
 Application:
http://www.niatx.net/WordDoc/WICollaboration/application_WI.docx
 Application deadline: Friday, January 6, 2012
Project Kickoff
 Workshop: Madison, February 16, 8:30am-3:30pm
Questions?
 Call Carol Sherbeck, (608) 265-5997
or email [email protected]