Checking your vision For your PTO For your practices Using - - PowerPoint PPT Presentation

• Checking your vision

– For your PTO – For your practices

• Using strategies for improving integration at any stage

– Coordination – Co-location – Integration

• Sharing resources and deciding next steps

– For your PTO – For your practices

• What do you want your practice to look like:

– 1 year from now? – 3 years from now? – 5 years from now?

• What gaps exist between where you want to be and

where you are?

• What factors in your patients’ lives seem to most affect

their physical health?

• What as a practice do you currently do to address

those factors?

• How will this bring you joy and fulfillment as a provider
• r care team member?

• Improved continuity of care
• More time for work-life balance and to address other

medical concerns

• Decreased cost
• Increased physical health follow-up
• Increased physician knowledge about BH concerns
• Decreased stigma about BH

(Chomienne et al., 2011; Hine et al., 2017)

• Availability of other mental health practitioners

– Community mental health center – Private practice therapist – Nonprofit therapy agencies

• Forms of insurance and payment accepted by other

mental health practitioners in the area

– Medicaid – Medicare – Commercial insurance

• Relationships you have with mental health

practitioners in the area

– Current communication – bidirectional or unidirectional? – Targeted or general referrals to mental health specialists?

• Level of complexity of

patients’ needs

– Level of medical risk and connections to health behaviors to prevent, manage, and treat problems

• Patients’ receptiveness

to discussion about behavioral health matters

– With you – With someone else

• Providers’ and staff members’ previous training in

addressing behavioral health issues

– Motivational interviewing – Solution-focused therapy – Cognitive behavioral therapy – Screening, brief intervention, and referral to treatment (SBIRT) for substance use disorders

• Providers’ and staff interest in training to enhance

their skills for brief interventions for behavioral health issues

• Space you have in your office that could be utilized

– Full-time vs. part-time – Joint appointments vs. separately scheduled

Coordinated Co-Located Integrated

• Pros

– Reduces financial burden for practice – Reduces administrative burden of hiring and training a new staff member

• Cons

– Contributes to siloed systems for physical and mental health and wellness (perpetuates stigma) – Decreases frequency and depth of communication between medical and behavioral health providers for shared patients – Adds in extra steps of securing signed releases of information to coordinate care for patient

Practice 1 Provider intuition, previous diagnosis, or specific mention from patient  inquiry about BH needs “Black hole” of referrals to community MH providers Provider and staff discomfort with addressing emotional and BH problems of patients Problem-driven processes to respond to patients’ immediate needs

Practice 1 Practice 2 Provider intuition, previous diagnosis, or specific mention from patient  inquiry about BH needs Routine screenings determined appropriate for this patient population “Black hole” of referrals to community MH providers Targeted list of referral sources for specialty MH; care compacts; ROI forms available in-office Provider and staff discomfort with addressing emotional and BH problems of patients Trainings in motivational interviewing, solution focused therapy, suicide assessment, etc. Problem-driven processes to respond to patients’ immediate needs Risk stratification process in place; protocols to specify goals and methods for delivering care, especially for crisis

• Pros

– Improves patients’ ease of access in seeing a behavioral health provider (same office space as PCP) – Reduces stigma and demonstrates PCP’s recognition of the importance of behavioral health – Increases anonymity for patients scheduled to see BHP – Reduces administrative burden of hiring a new staff member – Limits financial burden for practice

• Cons

– Double documentation often needed to satisfy two systems’ requirements – Practice usually has less influence on scheduling ratio

• f open availability vs. scheduled appointments for BHP

Practice 1 Only “billable” psychotherapy visits are scheduled Co-located BHP is unavailable to coordinate care with primary care team members Lack of clarity regarding documentation & communication about shared patients Limited training and onboarding

Practice 1 Practice 2 Only “billable” psychotherapy visits are scheduled Flexibility in schedule to allow for

• ccasional warm hand-offs & co-

visits Co-located BHP is unavailable to coordinate care with primary care team members BHP helps practice coordinate referrals to CMHC or counseling agency when needed; space allows for face-to-face communication Lack of clarity regarding documentation & communication about shared patients Clear contractual agreements between employing entity of BHP and practice site Limited training and onboarding Clear policies and protocols in place; create workflows for screening & intervention

• Pros

– Improves patients’ ease of access in seeing a behavioral health provider (same office space as PCP) – Reduces stigma and demonstrates PCP’s recognition of the importance of behavioral health – Increases anonymity for patients scheduled to see BHP – Practice determines scheduling ratio of open availability vs. scheduled appointments for BHP

• Cons

– Consideration needed for ensuring compliance with regulations for billing, documentation, informed consent, etc. – Increases administrative and financial burden for hiring and training new staff member

• Provider or staff introduces role of

BHP to patient

– Member of team (“therapist”) – Expert in…. – Reasoning/goals

• Followed by brief intervention and

plan for follow-up

– Communicate back to referring provider

• Joint visit for patient to receive

care from medical provider and behavioral health provider in the same appointment

• Usually previously scheduled

• How We Work Together:

– Medical Home Model – Communication

• IBH
• CI

– Quarterly Visits

• Practice example:

– Background:

• Rural Practice
• X Providers, .5 FTE LPC, 1 Care Manager,
• Participated in CPC Classic, currently in CPC+

– Vision: Managing patients with Chronic Pain

• How to get there?
• Where is “there”?

• Practice example:

– First PIP goal: Start with developing consistent process for BH referrals due to depression and measuring if the referral was made.

• “Redesign referral process to Integrated Behavioral

Health team for depression so that it’s timely, consistent, and fits the natural practice flow. The team will know they have achieved this goal by October 15th through: – A written workflow – Increased referrals to IBH for positive PHQ screenings. – This Goal Helps Our Practice Achieve Which SIM Milestone Activity: Milestone 6 – Population management”

• Practice example:

– Next Step: Use the depression process to implement BH referrals for Chronic Pain.

• “In order to provide support and strategies for non-

pharmaceutical pain management, improve percentage of patients with a pain contract that are referred to BHP on the day the contract signed. – Will know they have achieved the goal on 5/15/17 through a report showing improved numbers from a baseline of 0%. – This goal helps the practice achieve which SIM Milestone Activity: Milestone 10 A 2”

• Practice example:

– Now: Population Management. How to manage this population and determine what an improvement is.

• “Behavioral Health Goal: Continue to develop Chronic Pain

Population Management Program. Now that a consistent process for signing chronic pain agreements and BH referrals are in place, standardize workflow for patients that do not meet terms of agreement and evaluate population to understand needs and next

• steps. The team will know they have met this goal by 2/1/18

through: – A written Chronic Pain Agreement Process that addresses patients who do not meet the terms of the signed agreement. – Identification of population demographics, needs, and gaps. – Development of program goals for the Chronic Pain Population (i.e., lower MMEs, reduce number of patients on opioids, patient pain levels, quality of life, etc.)”

– Care Manager, Education, Practice Goals

• Add to your knowledge base by consulting with integrated

BHPs in your area

– Part-time IBH advisor added to your PTO team? – Access to an IBH advisor through participation in healthcare system? – Designate PF as BH champion on your team?

• Facilitate regional networking groups for BHPs working in

primary care

• Connect with other organizations who offer BH integration

support (e.g. CCHAP)

• Partner with organizations with similar missions

– Example: RMHP + St. Mary’s FM residency  CO-EARTH

• Collaborative Family Healthcare Association (CFHA)

– Annual conference (2017 – Houston) – http://www.cfha.net/general/custom.asp?page=ConsultantBureau

• Denver Health Integrated Behavioral Health Academy

– Trainings & technical assistance – http://www.denverhealth.org/for-professionals/clinical- specialties/mental-health/integrated-behavioral-health-academy

• AHRQ’s Academy for Integrating Behavioral Health and

Primary Care

– Integration Playbook – https://integrationacademy.ahrq.gov/playbook/about-playbook

• SAMHSA-HRSA Center for Integrated Health Solutions

– Resources & technical assistance – integration@thenationalcouncil.org

• Collaborative Family Healthcare Association (CFHA)

– Annual conference & speaker/consultant bureau – http://www.cfha.net/general/custom.asp?page=ConsultantBureau

• AHRQ’s Academy for Integrating Behavioral Health and

Primary Care

– Integration Playbook – https://integrationacademy.ahrq.gov/playbook/about-playbook

• Denver Health Integrated Behavioral Health Academy

– Trainings & technical assistance – http://www.denverhealth.org/for-professionals/clinical- specialties/mental-health/integrated-behavioral-health-academy

• UMass Medical School Center for Integrated Primary Care

– Primary Care Behavioral Health (PCBH) Certificate – PCBH short courses – http://www.umassmed.edu/cipc/pcbh/pcbh-certificate-course/

• University of Michigan School of Social Work

– Certificate in Integrated Behavioral Health and Primary Care (IBHPC)

• Pediatric track, adult track, pediatric/adult track

– https://ssw.umich.edu/offices/continuing-education/certificate- courses/integrated-behavioral-health-and-primary-care

• Chomienne, M. H., Grenier, J., Gaboury, I., Hogg, W., Ritchie, P., &

Farmanova-Haynes, E. (2011). Family doctors and psychologists working together: Doctors’ and patients’ perspectives. Journal of Evaluation and Clinical Practice, 17, 282-287.

• Hine, J. F., Grennan, A. Q., Menousek, K. M., Robertson, G., Valleley, R. J.,

& Evans, J. H. (2017). Physician satisfaction with integrated behavioral health in pediatric primary care: Consistency across rural and urban

• settings. Journal of Primary Care and Community Health, 8(2), 89-93.