How to Crash the Party: Bringing Behavioral Health Specialists to

the Care Coordination Team

Mary Jean Mork, LCSW

Director of Integration

MaineHealth and Maine Behavioral Helathcare

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session B5aOctober 18, 2014

Faculty Disclosure

I have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to: Identify barriers and success factors for care coordination. Identify a “success factor” to immediately address. Create a plan for addressing this factor upon return to work.

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

Agenda

Description of Care Coordination (CC) Team Challenges for Behavioral Health Specialists (BHS) Role and value of BHS on the team Success factors and strategies for maximizing team

effectiveness Activity – Developing Action Plans Question and answer period

Patient Centered Medical Home (PCMH) – the Concept

From deGruy 10.10

(Behavioral Health)

Internet Citation: Figure 1. Family tree of terms in use in the field of collaborative care: A National Agenda for Research in Collaborative Care. June 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/collaborativecare/collab3fig1.html

Care Coordination

The deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the

appropriate delivery of health care services.

From: Safety Net Medical Home Initiative. Care Coordination: Reducing Care Fragmentation in Primary Care. Implementation Guide. May 2013

“If a person doesn’t have a roof over their head, if they don’t have a meal, if they’re a victim of physical or sexual abuse if

their household has a lot of stress in it, if their kids’ school is not safe, then that's going to impact their health…..that health is

more than just the pill that we’re giving you or the hospital that we put you in. It’s all the other parts of your life and whether

they’re working in harmony.”

Dr. Jeffrey Brenner in interview “What Primary Care has to Learn from Behavioral Health”. National Council for Behavioral Health.

Meet George

Barriers to Care Coordination:

RolesRules

ArrangementsTurf

Who is involved?

Care Managers Case Managers Behavioral Health Clinicians Care Coordinators Transition coaches Peer navigators Health coaches RN’s in the practice Primary care providers Primary care staff Family and community supports Other?

Mental Health Primary Care

Treatment Team•Case Manager

•Team Leader – LCSW•Peer/Youth Support

•Psychiatry•Medical Director

Care Team•Provider

•Nurse•Medical Assistant

•Integrated BH Clinician•Nurse Care Manager

•Health coach/navigator

Preventative and Acute Care

Chronic Care

High Utilization

Chronic Care with MH Dx

Substance Abuse

High Utilization with MH Dx

“We're all going to have to give up some turf. After all, it's actually the

patient's turf.”

Robert McArtor, MD, CMO MaineHealth

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Specialty Mental Health Care

 

Coordinated Care Team (Potential Team Members)

Care ManagerBehavioral Health Clinician

Care CoordinatorEngagement Specialist

Health GuideResource SpecialistTransitions Coach

Peer NavigatorBHHO Case Manager

CCT social worker

Complex Care

Mgmt

Primary CareSpecialty Medical Care

Hospital

Patients

Psychiatric Consultation

Other Complex Patients

Care Plan Team

Care Coordination System Management

Patient PopulationCrisis and ED High Utilizers

PCP and Clinical Care

Team

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Care Coordination and Behavioral Health Saturday, September 20, 2014

Q1: Describe your involvement on the care coordination team

Q2: I If you have tried to have more involvement in care coordination activities, what barriers have you experienced?

Q3: If you are presently involved in care coordination activities in your practice, what has been most successful in helping be part

of these activities?

What else did I hear?

“It was horrifying. We don’t have anything in our practice.”

“We can’t coordinate unless there’s a mistake in scheduling, because she (the care manger) uses the office when I’m not there.”

“Who is my team?” “I didn’t fill it out because it doesn’t pertain to me.”

Complex Care Teams(Social, behavioral and medical complexities)

Behavioral HealthNeeds

Complex

Coordination Needs

Medication Access

Community

Resource

Needs

Providing:

•A multidisciplinary approach to complex

care coordination;

•Team collaboration;

•Community resource partnerships, and

•Standardized best practice interventions

BHS’s value on CC team

Direct service to Patient Link to specialty MH and SA treatment Liaison to psychiatric services “Triage” role with psychiatry referrals. Consultation to CC team System perspective

Behavioral lens for medical system Medical system lens for behavioral health

Expertise with individualized care plans tailored to patient Patient and family centered focus

Common Challenges for BHS

Population health Using data to inform work Understanding nuances of different care

management roles Clarifying roles around behavioral change,e.g.

with health coaches Ability to access specialty MH, SA and psych

services

CC Success Factors

Clarity, connection and non-duplication of: Roles Functions Responsibilities

Clarity about population being coordinated Timely and accurate data Tracked and shared outcomes “Partnership” approach to care Individualized patient centered planning process for care plans Shared Care plans and “alerts” throughout system Standardized coordination of care

“Team” members have assigned tasks based on individual care plan “Team” lead to manage complex care situations

Strategies to Improve CC

Identify who is coordinating care Identify leaders Multidisciplinary case presentations Target specific patients, design services around individual’s

goals, coordinate care, track results Identify impact measures, e.g. ED usage for specific

populations Make connections with community providers and continuum

of care

Additional considerations for CC

Funding – are there: New funding streams that support this work? Cost savings and medical cost offsets?

Honor the patient voice in development of the care plans

Value and nurture the team relationships!

Resources

Websites http://integrationacademy.ahrq.gov/ - AHRQ Academy for Integrating Behavioral Health and

Primary Care www.uwaims.org - Advancing Integrated Mental Health Solutions – resources for implementation

from University of Washington www.integratedprimarycare.com – National clearinghouse site for information on integrated care

from University of Massachusetts. www.integration.samhsa.gov - SAMHSA-HRSA Center for Integrated Health Solutions www.thenationalcouncil.org – the National Council for Community Behavioral Healthcare.

Publications IHI Innovation Series 2011. Craig, et.al. Care Coordination Model: Better Care at Lower Cost

for People with Multiple Health and Social Needs. http://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf Reducing Care Fragmentation: A Toolkit for Coordinating Care

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!