AMHC Integrated Service ApproachFebruary 9, 2010

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AMHC Locations

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AMHC & Integration: 36 Year History Strategic priority for AMHC Vision aligned with Four Quadrant, Strosahl and Care Model Dedicated to improving health and wellness through a biopsychosocial

approach Implementing brief treatment and Stanford chronic disease lifestyle

management model developed by Guided by written, customized integration protocols for defined diseases

and supported by expert training resources Grounded in principles of providing immediate access to most

appropriate, highest quality, affordable service Informed by decades of experience working in Aroostook County, in

Maine, nationally through MHCA, and internationally through IIMHL

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IOM Influence Grounded in the Institute of Medicine’s

(IOM) Crossing the Quality Chasm aims: patient-centered safe timely efficient effective equitable

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Service Models Four Quadrant Clinical Integration Model Chronic Care Model Strosahl Primary Behavioral Health Care

Model

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Four Quadrant Clinical Integration ModelFour Quadrant Clinical Integration ModelPresentation by Service Population and Setting

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Informed,ActivatedPatient

ProductiveProductiveInteractionsInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliveryDeliverySystemSystemDesignDesign

DecisionDecisionSupportSupport

ClinicalClinicalInformationInformation

SystemsSystems

Self-Self-Management Management

SupportSupport

Health SystemHealth System

Resources and PoliciesResources and Policies

CommunityCommunity

Health Care OrganizationHealth Care Organization

/ ICIC

PHQ-9Registry

Self-Mgmt Tools

Care Mgmt Psych consult

Care Model

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Strosahl Primary Behavioral Health Model Goal is to increase effectiveness of primary

care providers in addressing behavioral health needs of patients.

Focus on managing psychosocial aspects of disease by addressing lifestyle and health-risk issues through brief consultative interventions and temporary co-management of behavioral health conditions.

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Self-Care

Medical & drug

interventions

Psychosocial and alternative

therapeutic interventions

Self-Care

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Self-care Objectives Patient at the center and in control of his

health. Uses a broad variety of techniques to attain

and achieve optimal health. This is a fundamental shift in the paradigm of

health services currently focused on treating disease and expects practitioners to work with a patient to inform and support his ability to guide his own self-care.

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Advantages Improve access to behavioral and physical health

services Apply evidence based practices to improve client

outcomes Improve provider communication and coordination

of care Foster a multi-disciplinary team approach to treating

substance abuse with a co-occurring chronic health issues (cancer, cardiovascular, COPD, depression, diabetes)

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Advancing Approach to Practice Embedding primary care family practice physician

into AMHC’s service site to provide outpatient and medication management services

Primary goals: Encourage self-care Improve type and quality of services Meet unmet needs Increase cost efficiency Address workforce issues and offer professional

advancement Improve primary care physician ability to treat patients

with chronic mental illness

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Key Activity Milestones Administrators and clinical staff were oriented to the principles of the Four Quadrant Model

and how it interfaces and complements the Planned (Chronic) Care Model. Written, customized integration protocols for depression, anxiety, substance abuse, sexual

assault, were developed Assessment tools for depression, PQ-9, and substance abuse, the CAGE, were implemented

and are used at the sites. One blended record at the primary care site. Periodic provider team meetings held to address care coordination and collaboration issues Scheduling, staff credentialing and billing issues were improved Successfully secured DHHS

reconsideration and approval for FQHC’s to bill MaineCare and be reimbursed for services provided by LMSW-cc credentialed clinicians.

Clinician assignments to support the integration efforts were maintained, with 90% of initial placements sustained throughout the life of the project.

Six Pines physicians have staffed AMHC’s opioid replacement therapy clinic since July 2006.

AMHC implemented an account management approach to working with the primary care practices to ensure immediate responsiveness to addressing clinical approach, staff availability, credentialing, scheduling, and billing issues.

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Why integrate services? International, national and state level movement to integration of services

Federal Level Public Support HRSA and SAMHSA and their counterparts in other countries through the

International Initiative for Mental Health Leadership (IIMHL) Private National Organizations

Institute of Medicine (IOM) National Council for Community Behavioral Healthcare (NCCBH) Mental Health Corporations of America (MHCA) and its counterpart State Level

Public support Department of Health and Human Services (DHHS)

Private Maine State Organizations Maine Health Access Foundation (MeHAF) Quality Counts (QC) Primary Care Association (MePAC) Association of Mental Health Services (MAMHS) Association of Substance of Abuse Programs (MASAP)

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Potential and Sought After Rewards Improved Health Outcomes

Healthier Patients Increased Patient Satisfaction

MeHAF focus groups found MH & SA patients reported having a higher degree of integrated

care PH patients express a sense of loss when case management services

offered by specialty providers were stopped and they returned to “regular care”

Improved staff satisfaction Working Conditions

Perceived effectiveness in delivering quality services Coordination of services across multi-disciplinary professional

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Potential and Sought After Rewards Improved Organizational Performance

Achieving Service Mission and Business Objectives Service Effectiveness

More comprehensive array of service responses aligned with true service needs

Service Efficiency Increased capacity and productivity achieved through appropriate

utilization of multi-disciplinary staff resources Improved Financial Performance

Reduced cost of providing services when responses are aligned with true service needs

Improved revenues generation resulting from increased productivity across multi-disciplinary staff.

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How integrated are we? 5 Levels of Integration

I. Minimal collaboration II. Basic collaboration from a distance III. Basic on site collaboration IV. Close collaboration that is partly integrated V. Fully integrated System

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Project Mission “To provide comprehensive, patient centered

care that offers concurrent prevention and management of multiple physical and behavioral healthcare service needs of a patient in relationship to his or her family, life events, and environment.”

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Project Activities 1. Confirm:

Medical Director’s commitment to participate in and help guide the process.

Behavioral and Physical Healthcare Provider willingness to Improve integrated services Participate in regularly scheduled multi-disciplinary staff meetings

2. Provide Refresher and Ongoing Education Integration Models and/or Evidence Based Practices Strategies to reduce barriers and advance integrated service practice

3.Commit to Including Patients in the Project to Help: Increase awareness, encourage participation, and reduce stigma.

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Project Activities 4. Improve Delivery of Substance abuse and

Co-occurring Disorder Services 5. Implement Care Coordination and Patient

Self-management Services 6. Identify, Implement and Monitor

Measurable Indicators to Support the Reporting of Achieved Outcomes.

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Integration Barriers in Maine Culture and Practice Patterns

Selecting integration model(s) based on practice context

15 minute visit vs. 50 minute therapy session Education of providers is silo’d and there is no or

limited understanding across disciplines.

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Integration Barriers in Maine Stigma and lack of awareness

Stigma associated with some behavioral and physical health service needs is a barrier to seeking and providing service.

Patient and provider lack awareness about integrated care and the advantages.

Patients generally lack an understanding about how they may be able to self-manage care and advocate for integrated services.

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Integration Barriers in Maine Reimbursement: No reimbursement for

integrative (e.g., collaborative care and team approaches), care coordination, and preventative services.

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Next Steps