extreme collaboration total integration of behavioral clinicians into primary care practice
TRANSCRIPT
Extreme Extreme Collaboration
Collaboration
Total Integration of Total Integration of
Behavioral Clinicians Behavioral Clinicians
into Primary Care Practiceinto Primary Care Practice
Current State of our Fragmented Current State of our Fragmented Healthcare SystemHealthcare System
Hello, uh my name is --------, and I’m calling for my son. Hello, uh my name is --------, and I’m calling for my son. Uh, he has bipolar schizo, and uh…uh…he hasn’t had Uh, he has bipolar schizo, and uh…uh…he hasn’t had no medications for a long time because they don’t wanna no medications for a long time because they don’t wanna give him any medications because he doesn’t have uh give him any medications because he doesn’t have uh Medicare. We tried to get Medicare and they didn’t Medicare. We tried to get Medicare and they didn’t wanna give it to him and I’m really really real real worried wanna give it to him and I’m really really real real worried about him. I’m his mother. He has uh really been um about him. I’m his mother. He has uh really been um depressed depressed and I’m really afraid for him. I depressed depressed and I’m really afraid for him. I would really appreciate it if you would give me a call would really appreciate it if you would give me a call because I need to see somebody. The doctor here in the because I need to see somebody. The doctor here in the won’t be back ‘til May but we can’t really wait that long. I won’t be back ‘til May but we can’t really wait that long. I would just appreciate so much if you could give me a would just appreciate so much if you could give me a call. It’s very important. I would appreciate a call. We call. It’s very important. I would appreciate a call. We need to see you as soon as possible. Please help us.need to see you as soon as possible. Please help us. Thank you.Thank you.
L.C., a 36-year-old divorced mother of three and kindergarten teacher was at the end of her rope, financially and emotionally, when she made the wrenching decision to hand over her son. L.C.’s husband left her alone with three children, including an older bipolar daughter and a 12-year-old boy who is doing well. But her 11-year-old son, Skylar, is bipolar, abusive and violent, she said, and after three years of spotty, expensive and ineffective psychiatric care she could see no other way to get him the intensive help he needs. L.C. said that her son had received psychiatric care off and on, with limited coverage by her insurance plan, but that he often refused to take prescribed medications. When he refused to go to school, she could not afford a sitter and did not know where to turn. “Good luck finding a counselor — they’re all filled up,” she said. “You call a psychiatrist and have to wait three months for an appointment.” Once during a snowstorm, she said, after she drove 25 miles to pick up the boys at school, then 45 miles to a psychiatric appointment, she arrived 15 minutes late. “They said we’d have to make a new appointment for six weeks later,” she said.
- NY Times, November 22, 2008
““Every system is perfectly Every system is perfectly designed to get the results designed to get the results
that it gets.”that it gets.”- Dr Paul Batalden, Dartmouth - Dr Paul Batalden, Dartmouth
UniversityUniversity
What is the current system What is the current system designed for?designed for?
Obstacles to careObstacles to care
Health disparitiesHealth disparities
Poor health outcomesPoor health outcomes
FrustrationFrustration
FailureFailure
What do we know?What do we know?
Mental health can’t be separated from Mental health can’t be separated from physical healthphysical health
People get their health care in primary People get their health care in primary care officescare offices
Mental health disorders are under Mental health disorders are under recognizedrecognized
Most people won’t go to a mental health Most people won’t go to a mental health centercenter
What else do we know?What else do we know?
Access to mental health professionals is Access to mental health professionals is difficult at best difficult at best – particularly for uninsured and underinsured particularly for uninsured and underinsured
populationspopulations
People complain of symptomsPeople complain of symptoms– But providers are obsessed with diagnosesBut providers are obsessed with diagnoses
Traditional approaches to mental health Traditional approaches to mental health have failed at the population levelhave failed at the population level
The Pyramid of The Pyramid of Psychosocial Problems Psychosocial Problems
in Primary Carein Primary Care
Level I : Acute psychiatric emergenciesLevel I : Acute psychiatric emergencies
Level I : Acute psychiatric emergenciesLevel I : Acute psychiatric emergencies
Level II: Chronic severe psychiatric illnessLevel II: Chronic severe psychiatric illness
Level I : Acute psychiatric emergenciesLevel I : Acute psychiatric emergencies
Level II: Chronic severe psychiatric illnessLevel II: Chronic severe psychiatric illness
Level III: Chronic less severe conditionsLevel III: Chronic less severe conditions
Level I : Acute psychiatric emergenciesLevel I : Acute psychiatric emergencies
Level II: Chronic severe psychiatric illnessLevel II: Chronic severe psychiatric illness
Level III: Chronic less severe conditionsLevel III: Chronic less severe conditions
Level IV: Temporary psychosocial problemLevel IV: Temporary psychosocial problem
Level I : Acute psychiatric emergenciesLevel I : Acute psychiatric emergencies
Level II: Chronic severe psychiatric illnessLevel II: Chronic severe psychiatric illness
Level III: Chronic less severe conditionsLevel III: Chronic less severe conditions
Level IV: Temporary psychosocial problemLevel IV: Temporary psychosocial problem
Level V: Everybody elseLevel V: Everybody else
Salud Family Health CentersSalud Family Health Centers
Salud Family Health CentersSalud Family Health Centers
Migrant/community health centerMigrant/community health center
Full range of primary care services Full range of primary care services including obstetrical careincluding obstetrical care
Full dental services in all clinicsFull dental services in all clinics
Mobile unitMobile unit
70,000 unduplicated patients70,000 unduplicated patients
Salud Integrated Care ModelSalud Integrated Care Model
BHP office in medical exam room spaceBHP office in medical exam room space
BHP spends 70% of time doing screening, BHP spends 70% of time doing screening, brief interventions, f/u phone calls, etcbrief interventions, f/u phone calls, etc
30% of time in more traditional therapy30% of time in more traditional therapy– Solution focusedSolution focused– Limited number of visitsLimited number of visits– Referral as necessaryReferral as necessary
Frequent and ongoing consultations among Frequent and ongoing consultations among docs and BHPsdocs and BHPs
Salud Integrated Care ModelSalud Integrated Care Model
Population basedPopulation based– We want to reach EVERY patientWe want to reach EVERY patient
Real time interventionsReal time interventions– Most patients can see therapist todayMost patients can see therapist today
Emphasis on horizontal integration not Emphasis on horizontal integration not vertical integrationvertical integration
Casts a wide net in determining need for Casts a wide net in determining need for psychosocial interventionpsychosocial intervention
Broad evaluative measuresBroad evaluative measures
Requirements for Total Requirements for Total IntegrationIntegration
Co-locationCo-location
Universal screeningUniversal screening
Brief interventionsBrief interventions
Solution focused therapySolution focused therapy
BHPs as primary care providersBHPs as primary care providers
BHP adaptationBHP adaptation
Physician adaptationPhysician adaptation
Co-LocationCo-Location
Co-location means co-locationCo-location means co-location– Sharing the same space at the same timeSharing the same space at the same time
Integrated care means integrated facilitiesIntegrated care means integrated facilities– Regardless of problem, all patients go in and Regardless of problem, all patients go in and
out the same doorout the same door
Universal ScreeningUniversal Screening
Most mental health disorders are occultMost mental health disorders are occult
Most visits to primary care providers have Most visits to primary care providers have a large psychosocial componenta large psychosocial component
Primary care docs do a relatively bad job Primary care docs do a relatively bad job of uncovering mental health issuesof uncovering mental health issues
Most poor health outcomes are related to Most poor health outcomes are related to behavior issuesbehavior issues
Universal ScreeningUniversal Screening
Screening is screeningScreening is screening– NOT diagnosisNOT diagnosis
Screening forms should be straightforward Screening forms should be straightforward and simpleand simple
Positive screens can be followed up with Positive screens can be followed up with more sophisticated and comprehensive more sophisticated and comprehensive evaluation toolsevaluation tools
I recommend face-to-face screeningI recommend face-to-face screening
Brief InterventionsBrief Interventions
‘‘Psychoeducational triage’ interventionsPsychoeducational triage’ interventions– 5-15 minutes max5-15 minutes max– In the exam rooms In the exam rooms – Goes hand-in-hand with screening Goes hand-in-hand with screening
Requires BHP to work within the chaos of Requires BHP to work within the chaos of the primary care officethe primary care office
BHP AdaptationBHP Adaptation
Traditional mental health office Traditional mental health office – No interruptionsNo interruptions– All apptmts made in advanceAll apptmts made in advance– Quiet controlled environmentQuiet controlled environment
Typical primary care officeTypical primary care office– Lots of interruptionsLots of interruptions– Many walk-in apptmtsMany walk-in apptmts– Controlled (barely) chaosControlled (barely) chaos
Solution Focused Brief TherapySolution Focused Brief Therapy
Resource activation, not problem activationResource activation, not problem activation
Has an endpointHas an endpoint
Allows flow of patients in and out of the BHP Allows flow of patients in and out of the BHP scheduleschedule
More complex patients may need to be More complex patients may need to be referred outreferred out– PCPs don’t provide subspecialty carePCPs don’t provide subspecialty care– This is a primary care modelThis is a primary care model
BHPs are Primary Care BHPs are Primary Care Providers Providers
NOT ancillary staffNOT ancillary staff
If the patient is seeing the BHP, the patient If the patient is seeing the BHP, the patient is being seenis being seen
BHP assessment is as important as BHP assessment is as important as physician assessmentphysician assessment
Patients will often identify the BHP as their Patients will often identify the BHP as their PCPPCP
Requires Broad TrainingRequires Broad Training
LOTS of different dutiesLOTS of different duties– PsychotherapyPsychotherapy– Social workSocial work– Case managementCase management– OtherOther
BHP AdaptationBHP Adaptation
Your training model may not applyYour training model may not apply
Office environment is differentOffice environment is different
How patients gain access is differentHow patients gain access is different
Concept of confidentiality is differentConcept of confidentiality is different
Process orientation vs goal orientationProcess orientation vs goal orientation
Visits are differentVisits are different
How do patients gain access to How do patients gain access to BHP?BHP?
ScreeningScreening
Direct appointmentDirect appointment
Referral from providerReferral from provider
Patient request at medical visitPatient request at medical visit
Doc:BHP RatioDoc:BHP Ratio
??
ResistanceResistance
From BHPsFrom BHPs– I can’t just walk in on a patientI can’t just walk in on a patient– I like to spend more time with patientsI like to spend more time with patients– I like to get deep into my patients’ psycheI like to get deep into my patients’ psyche– I don’t like all the interruptionsI don’t like all the interruptions– This isn’t the way I was trainedThis isn’t the way I was trained
ResistanceResistance
From medical providersFrom medical providers– I’m the captain of the shipI’m the captain of the ship– I don’t like other people seeing my patientsI don’t like other people seeing my patients– The BHP slows me downThe BHP slows me down– I’m really good at psych stuff and I don’t need I’m really good at psych stuff and I don’t need
helphelp– This isn’t the way I was trainedThis isn’t the way I was trained
What do patients think?What do patients think?
NO resistance NO resistance
Accepted part of total care package at Accepted part of total care package at SaludSalud
Seen as value added serviceSeen as value added service
FundingFunding
Salud Integrated Care Funding Salud Integrated Care Funding ModelsModels
Mental Health Expansion grant from govtMental Health Expansion grant from govt
Partnership with local health districtPartnership with local health district
Partnership with local mental health centerPartnership with local mental health center
Commitment of general primary care fundsCommitment of general primary care funds
Patient billingPatient billing
Other Funding PossibilitiesOther Funding Possibilities
Patient billingPatient billing– Not likely to work for brief visitsNot likely to work for brief visits
– Could cover 30% of salaryCould cover 30% of salary
SubsidiesSubsidies– Docs benefit from integrated practiceDocs benefit from integrated practice
– Communities benefit from integrated practiceCommunities benefit from integrated practice
Managed care contractsManaged care contracts– Patients (and therefore insurance companies?) Patients (and therefore insurance companies?)
benefit from integrated practicebenefit from integrated practice
– Medical home may require itMedical home may require it
CaveatsCaveats
You can’t manage everythingYou can’t manage everything– We don’t do heart surgery in primary care We don’t do heart surgery in primary care
eithereither– We know how to make referrals to specialists We know how to make referrals to specialists
if necessaryif necessary
Costs are incurred and savings are Costs are incurred and savings are accrued in different placesaccrued in different places
Next StepsNext Steps
Outcomes researchOutcomes research– Medical parameters as evidence of Medical parameters as evidence of
effectiveness of mental health interventionseffectiveness of mental health interventions– Fewer ER visits, more clinic capacity, fewer Fewer ER visits, more clinic capacity, fewer
lost days of work, etc, etc, etclost days of work, etc, etc, etc
Policy changesPolicy changes
?
