Transcript Title of Presentation - Collaborative Family Healthcare Association

Session #H1a
Friday, October 11, 2013 or Saturday, October 12, 2013
Disrupting the Status Quo:
Dismantling Silos in Integrated Training
Colleen Clemency Cordes, Ph.D.
Assistant Director, Nicholas A Cummings Doctor of Behavioral Health Program
Wendy Danto Ellis DHEd, MC, LPC
DIRECTOR – Behavioral health, SCOTTSDALE HEALTHCARE FAMILY PRACTICE RESIDENCY
Collaborative Family Healthcare Association 15th Annual Conference
October 10-12, 2013
Broomfield, Colorado U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Objectives
1) Describe how current educational systems continue to
promote the silos of medical and behavioral healthcare
2) Identify three strategies for transforming our healthcare
programs
3) Describe a unique collaborative partnership between a
behavioral health and medical residency training program and
how this has led to increased provision of collaborative
primary care and enhanced provider satisfaction
Learning Assessment
Audience Question & Answer
“Including IPE enables the professions
to learn with, from, and about each
other. Then, and only then, may they
develop critical appreciation of what
each other contribute to
collaborative practice in response to
[the] increasingly compound and
complex needs presented by
individuals, families, and
communities”
(Barr, 2012, p. 2)
Evolution of Medical Paradigms
WHOLE PERSON/
INTEGRATED
BIOMEDICAL
BIOPSYCHOSOCIAL
Blending Cultures
CULTURE OF MEDICINE
• Pathology based
• Values certainty; dislikes
ambiguity or change
• Expert/ knowing stance
• Goal is for doctor to diagnose
and “fix” the problem
• Functions with a system of
assess, diagnose and treat
• Evidence based
• Outcome oriented
• Training models are rooted in
tradition and power differentials
CULTURE OF
COUNSELING/BEHVIOR
CHANGE
• Resource, resiliency and strength
based
• Values change, differences and
possibilities
• Embraces “not knowing’ stance
• Goal is to connect with the “patient”
and collaboratively define
outcomes/objectives
• Functions within a paradigm of
conversation and collaboration
• Values evidence based in addition to
personal experiences
• Multiple outcomes are
acceptable/valued
• Training models cross over disciplines
and are evolving
EVEN THE IOM AGREES:
Institute of Medicine’s Ten Rules
to Redesign and Improve Care
1. Care based on healing relationships
2. Customization based on patient’s needs and values
3. The patient as the source of control
4. Shared knowledge and the free flow of information
5. Evidence-based decision making
6. Safety as a system property
7. The need for transparency
8. Anticipation of needs
9. Continuous decrease in waster
10.Cooperation among clinicians
TRANSFORMING OUR HEALTHCARE TRAINING
AND EDUCATION PROGRAMS
PUTTING IT INTO PRACTICE
HOW?
We need to break down the silos at multiple levels
• Educational institutions
– Undergraduate, graduate and post-graduate levels
(e.g. medical school, residency programs,
psychology and counselor training etc)
• Vocational training programs
– Medical assistant or dental assistant training
programs
• Governmental and regulatory level
– Licensing boards, reimbursement policies etc.
Interprofessional Education (IPE)
• Any type of educational, training, teaching, or
learning session in which two or more health
and social care professions are learning
interactively
– Family medicine + psychology most common
iteration in U.S.
• But psychologists are only a small percentage of the
BHC workforce
FQHCs Serving as Training Sites for Specialty Behavioral
Health Staff, by Provider Type
* From: Nachc 2010 assessment of behavioral health
services in federally qualified health centers
IPE Outcomes
• IPE has led to positive outcomes in:
–
–
–
–
–
–
Collaborative interactions
Working culture in emergency departments
Patient satisfaction
Decreases in medical errors
Management of care for IPV survivors
Knowledge and skills of professional providers
• Most IPE occurs after licensure, but increasingly
looking at benefits pre-licensure (Barr, 2012)
Implications for Training & Education
I.
FOR PHYSICANS and DENTISTS
II.
FOR MID-LEVEL PROVIDERS (PAs, NPs,PTs, OTs, RNs, etc.)
III. FOR MENTAL HEALTH AND BEHAVIORAL HEALTH
CLINICIANS
IV. FOR SUPPORT STAFF (MAs, Billing, Referral, front office
support)
Goals for Workforce Development
•
Expand the role of consumers and their families to participate in, direct, or accept
responsibility for their own care (provide tools for doing so)
•
Expand the role and capacity of communities to identify local needs and promote health
and wellness (to meet local needs)
•
Implement systematic federal, state, and local recruitment and retention strategies
•
Increase the relevance, effectiveness, and accessibility of (Inter-professional) training and
education
•
Actively foster leadership development among all segments of the workforce
•
Enhance available infrastructure to support and coordinate workforce development effort
•
Implement a national research and evaluation agenda on workforce development
Multiple layers…Our Partnership
DBH INTERN
Practical issues to address…
•
•
•
•
•
•
•
•
•
•
•
Process for referring BH patients from provider
Scheduling of BH patients; follow-up
Fees for BH services; billing
Record keeping; shared EHR or not
Psych medications outside the practice scope of providers
Referrals to ancillary services; community resources (process & follow-up)
BHC communication with other center staff (front office, billing, nursing, providers,
care managers etc)
BHCs at different sites are isolated from each other; how to maintain esprit du
corps
Coverage for vacations/training/etc.
Language/translation services
Each site has its own “cast of characters”; different personalities, different team
members (e.g. dental)
Accreditation Challenges
ACGME vs. FQHC
• Program and Institutional Guideline for Using a Community Health Center
as outpatient clinic site include:
• Behavioral science education must be integrated into the residents’
experiences in the CHC
• The appointment & assignment of faculty preceptors in the CHC must be
under the control of the program director and in the presence of a
qualified faculty …
• The program director must have authority and responsibility for the
educational program of the residents.
• *Example of conflicting regulations, cultures and barriers to integration.
ASU’s Doctor of Behavioral Health Program
Interdisciplinary Training in Action
• Evidence-based interventions for mental health and
chronic illness
• Medical literacy for enhanced collaboration
• Systems awareness and redesign
• Entrepreneurship
• Health behavior change
• Mental health assessment & treatment
• Group medical visits & psycho educational programs
• Program evaluation
• Physician consultation
• And much more!!
DBH in action: Partnership with SHC
• Heuser NOAH – Non-medical pain intervention project – An
excellent example of a successful integration and overcoming
barriers of two cultures.
• Barriers overcome: different definitions of desired outcomes,
VERY different attitudes toward chronic pain patients & change;
office work flow challenges; provider awareness of and
utilization of BHC
• Gains received: Increased patient satisfaction, increased
provider satisfaction; still pending – lower PCP utilization for
non-medical issues; education of providers, resident physicians
and staff on non-medical interventions for chronic pain; revision
of pain policy and pain contract; less need for patient referral to
pain specialists = enhanced patient centered care within PCMH
Best Advice for Successful
Implemtnation: KISS
• “DON’T ASK…DO TELL” (Scripted statements for doctors e.g.
DIABETES – NEWLY DIAGNOSED OR POORLY CONTROLLED DIABETICS
“I’m going to invite in another member of the NOAH health care team who has
special skills in helping people to adjust to the new diagnosis of________.” )
• ONE EASY TO USE STEP…
ALL BH REFERRALS MUST GO THROUGH BEHAVIORAL HEALTH
DIRECTOR OR BEHAVIORAL HEALTH CONSUSLTANT (includes group
visits, psych NP)
ONE STOP SHOPPING…
WE DO ALL THE REST AND REPORT BACK TO YOU
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!