People Recover

Treatment is effective

Prevention works

Behavorial Health is Essential To Health

Disclaimer

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The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS)."

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Quick Poll

Please write in the answer that is most true to you.

When you think of

“Integrated Care” what other words come to mind?

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Answer Below

Recovery-oriented Practices in Integrated Care Settings:

Lessons, Resources, and Tools

(Part 4 of 4)

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Jerry Koch, CPSLynn Community Health Center

Laura Galbreath, MPPIntegrated Healthcare Consultant

Real People, Real Lives

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Jerry Koch• Peer Specialist• Lynn Community Health Center -

A SAMHSA/HRSA Primary and Behavioral Health Care Integration (PBHCI) Grantee Program

Reaching out to others.

Helping others.

Healing through helping.

Laura and Jerry: Interview

What do integrated services look like for individual receiving services at Lynn Community Health Center?

How did you bridged the connection between your mental health recovery

and physical health and wellness?

As a Peer Specialist, how are you supporting others in making the

same connection between recovery and wellness?

What one step can the attendees do to support the integration of physical

health and wellness as part of a recovery oriented system of care?

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No wrong door to

recovery

No wrong door to health and wellness

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Co-occurrence between complex health conditions

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Legend:

Physical Illness + Mental Illness

= Complex Illness

CHS Integration Infographic retrieved from: https://www.integration.samhsa.gov/about-us/CIHS_Integration_Infographic_11x8.5_printable.pdf

Mental Illness

No Mental Illness

Racial and ethnic minorities and persons with limited English proficiency often seek behavioral health assistance through their primary care providers.

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Primary and Behavioral Health Integration

"The care a individual experiences as a result of a team of primary care and behavioral health clinicians, working together with individuals and families, using a systematic and cost-effective approach to provide person-centered care for a defined population."*

*Lexicon for Behavioral Health and Primary Care Integration, AHRQ

https://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf

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Integration Terms

Research LiteratureCollaborative Care

PolicyHealth Home

Accrediting BodiesPatient-centered Medical

Home

Provider AgenciesPatient-centered Healthcare

Home

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Integrated Care Works!

Improves provider satisfaction Increases adherence to medication Decreases medical utilization among individuals using

high amounts of services Improves individual outcomes Reduces healthcare costs Improves individual's quality of life

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Integrated care aligned with other initiativesExample: Core Elements to Guide Integrated Care for People who are dually eligible

1. Comprehensive assessment to determine needs2. Personalized (person-centered) plan of care3. Multidisciplinary care team4. Family caregiver involvement5. Comprehensive provider network6. Strong home- and community-based options7. Adequate consumer protections8. Robust data-sharing and communications system9. Financial incentives aligned with integrated, quality care

From the Beneficiary Perspective: Core Elements to Guide Integrated Care for Dual Eligibles: http://www.chcs.org/media/TCDE_Core_Elements_122010.pdf14

Value-added service in BH/PC Integration Behavior change experts

Ability to provide home visits

Experience providing community-based case management

Connections to community resources

Ability to implement discharge plans in the home

BH/PC = Behavioral Health and Primary Care15

Enhancing Your Skills

A culture of healthTeam-based careProfessional developmentCommunicating Success

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Through what lens do you view the

world?

Organizational Culture

• The lens through which an organization views their work.• Shared philosophy that drives decision making.• Shared value system, mission, vision, and purpose.

• Common language that facilitates communication.• Policies and procedures that reflect and reinforce a shared vision.• Activities, services, environment align with the vision.• Power, authority, decision making, resources are distributed in a

manner consistent with communicated values.

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Organizational Culture of Wellness

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• Agency wide wellness team• Person centered wellness

programs• System-wide focus of leadership• Integration of health, wellness

with behavioral health• Workforce development

Organizational Culture of Wellness

(cont.)

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• Community Connections• Language and Messaging• Workforce Wellness• Organizational Policies• Performance Evaluation

and Data

Team-based Integrated Care

“The high-performing team is now widely

recognized as an essential tool for constructing a more person-centered,

coordinated, and effective health care delivery

system.” Lathan Medical Group – Times Union Blog

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Essential Elements of an Integrated Team

Leadership and organization commitment to designing and staffing integrated teams.

Team outcomes guide shared treatment approaches and reduces potential conflicts.

Team processes that facilitate communication (e.g. clinical case review, day-to-day operational communication, and process communication

Team development includes the development of a shared vision, team values, and clear roles and responsibilities.

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Cross-Training is Essential

Population Specific Diagnoses and Characteristics

Screening Tools

Integrated Vitals

Specific Techniques (EBP’s)

Team Process

Community Resources

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Organizational Tools

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Links to Explore

SAMHSA/HRSA’s Center for Integrated Health Solutions Tools for Organizations Integrating Primary Care and Behavioral Health

CIHS’ Essential Elements of Effective Integrated Primary Care and Behavioral Health Teams reviews team development within effective integrated primary and behavioral healthcare teams, identifies four essential elements for effective integrated behavioral health and primary care teams, and provides a roadmap for organizations designing their own teams, using examples from these best practices.

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Improving Team Communication

Help and Healing: Resources for Depression Care and Recovery provides talking points for team care, strategies for patient and family education, and fact sheets on depression.

California’s Integrated Behavioral Health Project created a series of Sample Scripts and Procedures for ensuring successful warm hand-offs between primary and behavioral health care staff.

Behavioral health providers can brush up on how to share relevant individuals information with primary care providers by reviewing the Institute for Healthcare Improvement’s SBAR Technique for Communication tool.

The Primary Behavioral Health Care Practice Services Manual includes a sample introductory script for a Behavioral Health Consultant in a primary care setting (see appendix 2) to explain their role to the individual receiving care.

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Questions DiscussionComments

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SAMHSA’s

10 Principlesand

4 Dimensionsof Recovery in

Behavioral Health

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HomeHealth

CommunityPurpose

Recovery to Practice

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Through education, training, and resources SAMHSA’sRecovery to Practice (RTP) program supports the expansion and integration of recovery-oriented behavioral health care delivered in multiple service settings between multiple disciplines.

Free CMERecovery to Practice offers free on-demand courses approved for continuing medical education (CME) courses.

Courses available now:

• Clinical Decision Support for Prescribers Treating Individuals with Co-occurring Disorders (2 courses; 1.5 CME each)

For more information or to register:

https://www.samhsa.gov/recovery-to-practice/clinical-edu-opportunities-recovery-oriented-practice

https://www.samhsa.gov/recovery-to-practice

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Want to continue your learning?

1 Galbreath, Laura, (2013). Will Integrated Care Provide You with Better Care CareCoordination? http://careforyourmind.org/663/

2 Gerrity, M. (2014). Integrating Primary Care into Behavioral Health Settings: What Works for Individuals with Serious Mental Illness. Milbank Memorial Fund. https://www.milbank.org/publications/integrating-primary-care-into-behavioral-health-settings-what-works-for-individuals-with-serious-mental-illness/

3 Hoge M.A., Morris J.A., Laraia M., Pomerantz A., & Farley, T. (2014). Core Competencies for Integrated Behavioral Health and Primary Care. Washington, DC: SAMHSA - HRSA Center for Integrated Health Solutions.

4National Council for Behavioral Health. A Quick Start Guide to Behavioral Health Integration for Safety-Net Primary Care Providers. [n.d.] Washington, D.C.: SAMHSA-HRSA Center for Integrated Health Solutions and National Council for Behavioral Health. https://www.samhsa.gov/system/files/quick-start-integration.pdf

5Stout, S., Klucznik, C., Chevalier, A., Wheeler, R., Azzara, J., Gray, L., Scannell, D., Sweeney, L., Saginario, M., Lopes, I., Meisinger, K., Littlefield. M., & Jorgensen, A. Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit. https://www.samhsa.gov/sites/default/files/programs_campaigns/samhsa_hrsa/team-based-care-implementation.pdf

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Our Fall Series begins onWednesday, October 4th , 1:00 – 2:00 ET

Homelessness and its impact on Recovery

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RTP Training and Technical Assistance

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