ibhc powerpoint

Integrated Behavioral Integrated Behavioral Healthcare:Healthcare:

Effectiveness and FeasibilityEffectiveness and Feasibility

Technical Assistance Center for Technical Assistance Center for Children’s Services (UTACCS)Children’s Services (UTACCS)

Allison Blaine and Kelly C. Feller

September 24, 2008

OutlineOutline

• What is Integrated Behavioral Healthcare What is Integrated Behavioral Healthcare (IBHC)?(IBHC)?

• Strengths of IBHCStrengths of IBHC• Weaknesses of IBHCWeaknesses of IBHC• Models of IBHCModels of IBHC• Limitations of ResearchLimitations of Research• ImplicationsImplications• Suggestions for further researchSuggestions for further research

What is Integrated Behavioral What is Integrated Behavioral Healthcare?Healthcare?

• Collaboration and/or co-location of medical and Collaboration and/or co-location of medical and behavioral health services in effort to more fully behavioral health services in effort to more fully address the needs of an individual client. address the needs of an individual client.

• Services usually include evaluation and treatment of Services usually include evaluation and treatment of both scheduled and walk-in clients.both scheduled and walk-in clients.

• Has been used in rural hospitals, health departments, Has been used in rural hospitals, health departments, rural HMOs, rural physician practices, and pre-natal rural HMOs, rural physician practices, and pre-natal health clinics. health clinics.

• Umbrella term that encompasses numerous modelsUmbrella term that encompasses numerous models

StrengthsStrengths

• AccessAccess• OutcomesOutcomes• Provider ExperienceProvider Experience

StrengthsStrengths

• AccessAccess– ““One-Stop Shopping.”One-Stop Shopping.”– Discrete and appropriate referral to necessary care.Discrete and appropriate referral to necessary care.– Increased access to youth clients through well-Increased access to youth clients through well-

child care and sick visits.child care and sick visits.– Social safety, less stigma.Social safety, less stigma.– Pediatricians are vital gatekeepers to specialized Pediatricians are vital gatekeepers to specialized

care such as behavioral health services care such as behavioral health services

StrengthsStrengths

• OutcomesOutcomes– A wide body of evidence indicates IBHC is A wide body of evidence indicates IBHC is

associated with positive outcomes, especially in associated with positive outcomes, especially in populations with limited access to care. populations with limited access to care.

– Sutliffe (2008) found participants in IBHC scored Sutliffe (2008) found participants in IBHC scored higher on measures of functioning at discharge higher on measures of functioning at discharge than individuals in non-IBH systems. than individuals in non-IBH systems.

StrengthsStrengths

• OutcomesOutcomes– What exactly is responsible for positive outcomes What exactly is responsible for positive outcomes

in IBHC? in IBHC? • Increased access to care = earlier intervention.Increased access to care = earlier intervention.• Varied providers bring diverse knowledge to the Varied providers bring diverse knowledge to the

“table,” able to apply wider array of interventions.“table,” able to apply wider array of interventions.• Clients more likely to access non-medical health care Clients more likely to access non-medical health care

when behavioral health clinicians are involved in when behavioral health clinicians are involved in primary care.primary care.

• Shifts focus of care towards longitudinal rather than Shifts focus of care towards longitudinal rather than acuteacute

StrengthsStrengths

• Provider ExperienceProvider Experience– Even when there is no difference in convenience Even when there is no difference in convenience

for clients, providers still prefer to have behavioral for clients, providers still prefer to have behavioral health integrated into the primary healthcare health integrated into the primary healthcare settingsetting..

WeaknessesWeaknesses

• Disconnection between medical and behavioral Disconnection between medical and behavioral systems of care.systems of care.

• Lack of funding, existing separate facilities, and lack Lack of funding, existing separate facilities, and lack of space are barriers to co-located services. of space are barriers to co-located services.

WeaknessesWeaknesses

• Billing, insurance, and funding issues are especially Billing, insurance, and funding issues are especially necessary and complicatednecessary and complicated

• Often, caseload must be decreased to allow Often, caseload must be decreased to allow professionals ample consultation & training time.professionals ample consultation & training time.

Models of IBHCModels of IBHC

• Two Categories of IBHC ModelsTwo Categories of IBHC Models– TargetedTargeted– Non-TargetedNon-Targeted

Targeted ModelsTargeted Models

• Provide services to clients experiencing Provide services to clients experiencing specific concerns, such as pregnant women specific concerns, such as pregnant women diagnosed with substance abuse.diagnosed with substance abuse.

• Qualifying individuals referred to a medical Qualifying individuals referred to a medical treatment team with specialized knowledge in treatment team with specialized knowledge in that particular area.that particular area.

• Medical treatment team is often trained by Medical treatment team is often trained by outside mental health professionals who outside mental health professionals who regularly visit the medical office. regularly visit the medical office.

Non-Targeted ModelsNon-Targeted Models

• Provide both physical and behavioral Provide both physical and behavioral health services to all clientshealth services to all clients

• Use of a case management approach that Use of a case management approach that identifies specific client needs, and identifies specific client needs, and specific provider(s) to address those specific provider(s) to address those needs.needs.

Non-Targeted ModelsNon-Targeted Models

• Physicians oversee physical well being, Physicians oversee physical well being, behavioral health professionals oversee mental behavioral health professionals oversee mental well being. well being.

• Clients have access to services within the Clients have access to services within the IBHC, such as time-limited therapy and IBHC, such as time-limited therapy and medication management, and when necessary medication management, and when necessary are referred to outside community supports for are referred to outside community supports for services not available through the IBHC services not available through the IBHC system.system.

Targeted Model IBHC ProgramsTargeted Model IBHC Programs

• Primary Mental Healthcare (PMH) Primary Mental Healthcare (PMH) ModelModel– Developed by Stroshaul in 1998Developed by Stroshaul in 1998

– Clients are primary seen by primary care Clients are primary seen by primary care physician who calls on behavioral health physician who calls on behavioral health professionals to support interventions of the professionals to support interventions of the primary care physician.primary care physician.


• Primary Mental Healthcare (PMH) ModelPrimary Mental Healthcare (PMH) Model– Level of behavioral health professional’s Level of behavioral health professional’s

involvement depends on needs of primary care involvement depends on needs of primary care physicianphysician

– Sessions involving both kinds of professionals are Sessions involving both kinds of professionals are regarded as temporary co-management of the regarded as temporary co-management of the client.client.

– Often primary care physicians will develop a Often primary care physicians will develop a treatment plan that integrates the recommendations treatment plan that integrates the recommendations of a behavioral health professional. of a behavioral health professional.


• Preemptive training to primary care physiciansPreemptive training to primary care physicians .. – Enable physicians to treat specific behavioral health Enable physicians to treat specific behavioral health

concerns without further consultation with behavioral health concerns without further consultation with behavioral health clinicians.clinicians.

– Different than PMH model (last slide) because training is Different than PMH model (last slide) because training is provided provided beforebefore the physician screens a client for behavioral the physician screens a client for behavioral health issues.health issues.

– In a cluster-randomized study of 58 providers, preemptive In a cluster-randomized study of 58 providers, preemptive primary care physician training facilitated physician ability primary care physician training facilitated physician ability to reduce impairment of both child and caregiver (Wissow et to reduce impairment of both child and caregiver (Wissow et al., 2008)al., 2008)

Non-Targeted Model IBHC ProgramsNon-Targeted Model IBHC Programs

• The Four Quadrant Clinical Integration The Four Quadrant Clinical Integration Model (FQCIM)Model (FQCIM)– Developed by the National Council for Developed by the National Council for

Community Behavioral HealthcareCommunity Behavioral Healthcare– On intake, clients are assessed for physical and On intake, clients are assessed for physical and

behavioral health risk then grouped into one of behavioral health risk then grouped into one of four quadrants four quadrants

• Quadrant I: Low B and P health risksQuadrant I: Low B and P health risks• Quadrant II: High BH risk, low PH riskQuadrant II: High BH risk, low PH risk• Quadrant III: Low BH risk, high PH risksQuadrant III: Low BH risk, high PH risks• Quadrant IV: High BP risk, high PH risksQuadrant IV: High BP risk, high PH risks


• The Four Quadrant Clinical Integration Model The Four Quadrant Clinical Integration Model (FQCIM)(FQCIM)– Client receives services from providers specifically geared Client receives services from providers specifically geared

to the individual’s level of physical and behavioral health to the individual’s level of physical and behavioral health risk. risk.

– Clients with mild-moderate behavioral health risks are seen Clients with mild-moderate behavioral health risks are seen in the primary care setting. Clients with more severe in the primary care setting. Clients with more severe impairments are referred to off-site specialty care services. impairments are referred to off-site specialty care services.

– In a community health organization, the FQDIM yielded “a In a community health organization, the FQDIM yielded “a number of positive and enduring outcomes” (Reynolds, number of positive and enduring outcomes” (Reynolds, Chesney, and Capobianco, 2006).Chesney, and Capobianco, 2006).


• The Primary Mental Healthcare Clinic The Primary Mental Healthcare Clinic model (PMHC)model (PMHC)– Uses clinic as a central hub to link clients Uses clinic as a central hub to link clients

with various specialized providers in one with various specialized providers in one locationlocation

– Clients screened for mental and physical Clients screened for mental and physical illness in all visits to primary care provider.illness in all visits to primary care provider.

– If screening indicates behavioral health risk, If screening indicates behavioral health risk, clients are referred to co-located mental clients are referred to co-located mental health services.health services.


• The Primary Mental Healthcare Clinic model The Primary Mental Healthcare Clinic model (PMHC)(PMHC)– Behavioral and physical health professionals meet Behavioral and physical health professionals meet

with client to create a collaborative treatment plan with client to create a collaborative treatment plan addressing all health needs.addressing all health needs.

– In a large Vermont Veteran’s Clinic, PMHC model In a large Vermont Veteran’s Clinic, PMHC model was associated with “greater proportion of patient was associated with “greater proportion of patient who had screened positive for depression who had screened positive for depression obtaining some depression treatment” and “an obtaining some depression treatment” and “an increase in guideline-adherent…treatment for increase in guideline-adherent…treatment for depression.” (Watts et al., 2008)depression.” (Watts et al., 2008)


• The Great Start Minnesota ProjectThe Great Start Minnesota Project– A statewide consultation network for pediatric A statewide consultation network for pediatric

mental health care professionals.mental health care professionals.– Physicians, behavioral health providers, and Physicians, behavioral health providers, and

educational professions trained on evidence-based educational professions trained on evidence-based intervention/screening for early childhood intervention/screening for early childhood behavioral health disturbances.behavioral health disturbances.


• The Great Start Minnesota ProjectThe Great Start Minnesota Project– Clinic based behavioral health clinicians provide Clinic based behavioral health clinicians provide

consultation and services in collaboration with the primary consultation and services in collaboration with the primary care physician.care physician.

– The St. Cloud model is an extension of Great Start The St. Cloud model is an extension of Great Start Minnesota ProjectMinnesota Project

• Involves school-based crisis therapists, access to emergency child Involves school-based crisis therapists, access to emergency child psychiatry sessions, and education of school professionals on psychiatry sessions, and education of school professionals on children’s mental healthchildren’s mental health

• Decreased total hospital spending by more than $400,000 between Decreased total hospital spending by more than $400,000 between 2000 and 2004.2000 and 2004.


• Medical Home (MH) modelMedical Home (MH) model– Aims to provide “accessible, family-centered, Aims to provide “accessible, family-centered,

continuous, comprehensive, compassionate, continuous, comprehensive, compassionate, developmentally appropriate, coordinate, culturally developmentally appropriate, coordinate, culturally competent, and accountable” care.competent, and accountable” care.

– Emphasis on preventative care, anticipatory Emphasis on preventative care, anticipatory guidance, early intervention, and appropriate use guidance, early intervention, and appropriate use of specialists in conjunction with community of specialists in conjunction with community based organizations (schools, WIC, Head Start, based organizations (schools, WIC, Head Start, etc…)etc…)


• Medical Home (MH) modelMedical Home (MH) model– Family is unit of careFamily is unit of care– Assumption that if caregiver/child Assumption that if caregiver/child

environment is not optimally environment is not optimally functional, than child is not optimally functional, than child is not optimally functional.functional.

Limitations of ResearchLimitations of Research

1.1. Outcome measuresOutcome measures– Medical health care utilizationMedical health care utilization– Financial cost of providing servicesFinancial cost of providing services

2.2. Sparse information about effectiveness of Sparse information about effectiveness of treatment, symptom reduction, increased treatment, symptom reduction, increased functioning, and other client focused functioning, and other client focused outcome. outcome.

ImplicationsImplications• Co-locate services.Co-locate services.

• Become familiar with providers and services Become familiar with providers and services to which clients are referred. to which clients are referred.

• Establish creative, innovative ,and legitimate Establish creative, innovative ,and legitimate billing practices.billing practices.

• Train incoming providers in existing program Train incoming providers in existing program functioning, history, and protocol.functioning, history, and protocol.

ImplicationsImplications• Implement policies aimed at building and maintaining Implement policies aimed at building and maintaining

positive relationships between behavioral and positive relationships between behavioral and physical health providers. physical health providers. – Refer to all professionals as clinicians whether the Refer to all professionals as clinicians whether the

individual is a physical or behavioral health professional.individual is a physical or behavioral health professional.

– Allow ample time for clinicians to consult with other Allow ample time for clinicians to consult with other providersproviders

– Share medical record systems, encourage “open door/open Share medical record systems, encourage “open door/open phone” policies with colleagues, and allow e-mail access to phone” policies with colleagues, and allow e-mail access to consultation. consultation.

ImplicationsImplications• Address the physical and mental well being of Address the physical and mental well being of

each child’s caregiver.each child’s caregiver.

• Strive for cultural awareness and competency.Strive for cultural awareness and competency.

Questions for Additional ResearchQuestions for Additional Research

1.1. How effective are different models of IBHC? How effective are different models of IBHC?

2.2. How does the interplay between specific How does the interplay between specific providers, delivery systems, and client providers, delivery systems, and client populations effect outcomes of IBHC populations effect outcomes of IBHC services?services?

Thank YouThank You

• www.UTACCS.orgwww.UTACCS.org for more information for more information

ibhc powerpoint

Documents