Integrated Care Models, Simultaneous, Single-Site ImplementationTeam Roles

First Contact Week 3 Week 5 Week 6 Week 8 Week 10 Week 12 Week

1414 Week Stats

By Team Member Role

• Positive PHQ 2 & 9 • Positive AUDIT • Negative DAST • Diabetic • Chronic Pain

• Repeat PHQ 9 •Diabetes management •Chronic pain management

• Repeat PHQ 9 • Diabetes f/u • Depression medication check

PCP:• 3 Office Visits with PT • 4 Curbside Consults w/ BHC • 1 consulting psychiatrist curbside consult

• Sees PT on warm handoff and addresses: • Motivational Interviewing for problem drinking • Discovers underlying grief issues and provides one coping skill • Recommends SSRI to PCP • Introduces care team model including IMPACT

• Reviews medication adherence and toleration • Reviews ETOH use goals • F/U on homework/ goals including brief processing of grief coping • Informs PCP verbally and/or via EHR note

• Sees PT on warm handoff and addresses: • Chronic pain coping skills; supports PCP decision not to prescribe opiates • SSRI review and medication adherence • Curbside consultation with PCP to discuss ways to encourage PT engagement vs. avoidance of pain

• F/U BHC Only Visit •Repeat PHQ 9 • Check-in on ETOH use, chronic pain management skills • Reassess response to grief reaction

BHC: •4 Office Visits with PT (2 independent, 2 warm-handoff) • 3 SBIRT influenced contacts

• Depression registry inclusion is automatic based on PHQ score

Phone Consult:• Check-in on medication adherence & goals; visit reminder.

Phone Consult:• Repeat PHQ 9• Check-in on SSRI adherence• PCP curbside due to new side effect• Adds patient to consulting psychiatrist care review list due to new side effect

Phone Consult:• Check-in on medication adherence, functioning• Review ETOH use goals including motivational interviewing for relapse prevention

BHC as Care Manager: •3 Phone contacts with PT • 1 Consulting psychiatry contact

• Consulting psychiatrist performs chart review, discusses with BHC and writes note in chart and/or verbally gives recommendations to PCP• PT called by nurse or BHC with instructions

Consulting Psychiatrist:• 1 contact each with BHC, PCP • 1 chart review, note

Why?Combining the models provides the best of all worlds with improved continuity of care (CC), flexibility of intervention (PCBH) and focus on

substance abuse (SBIRT) simultaneously.

BHC Role The BHC could serve the care manager role as well but likely only in a medium to large clinic (6+ PCPs) with multiple BHCs providing coverage. The care manager

duties can also offset the rigor of the BHC clinical role and vice versa.

VariationsCould care proceed differently than the above with different emphases/ roles

of the models and personnel? Absolutely. Care should be responsive to patient needs, tolerance and choice.

Start All At Once?

Our recommendation is not to attempt initial implementation of all pieces simultaneously although aspects of the models, such as the screening

components, can be implemented side-by-side.

Considerations Staffing Arrangements*

Small Clinic M/L Clinic

1-5 PCPs at once 6+ PCPs at once

.5 -1.0 FTE BHC 2.0 FTE BHC

.5-1.0 FTE CM (BHCs also serve as CM)

.05-.10 FTE CP .10-.25 FTE CP* Exemplar only. Other considerations such as patient volume are important to consider. CM = Care Manager; CP = Consulting Psychiatrist; BHC = Behavioral Health Consultant

Sample BHC Work Schedules, Single M/L Clinic*

Mo Tu We Th Fr

BHC 1 AM Clinic Clinic Clinic CM Admin

PM CM Clinic Clinic Clinic Clinic

BHC 2 AM Clinic CM Clinic Clinic Clinic

PM Clinic Admin CM Clinic CM* CM = protected time for care manager duties; Clinic = Operating in clinic as BHC; Admin = Protected time for administrative duties or program development

PCP

BHC

BHC as Care Manager1

Consulting Psychiatrist

Models Color Code: PCBH SBIRT Collaborative Care (Bold)

Mickey, 45, Patient Exemplar

Mickey is a 45-year-old African-American male who presents at his doctor’s office for troubling symptoms including excessive thirst and chronic pain. He also has poorly managed diabetes. The following is how care proceeds over 14 weeks at his doctor’s office where a care team that runs the PCBH, SBIRT & Collaborative Care models is ready to help his presenting and underlying concerns.

1Although in this exemplar the BHC team also performs the care manager role per the schedule on the bottom right, many implementation instances may require a distinct role for a care manager based on available talent, scheduling considerations, clinic size, population needs and other considerations. The skill sets of BHCs are by definition broader than a care manager, therefore in general a BHC can perform a care manager role but a care manager cannot fulfill a BHC role.

© 2016, All Rights Reserved. Center of Excellence for Integrated Care, A Program of the Foundation for Health Leadership & Innovation

MeHAFScore

1Usual Care 2 3 4 5 6 7 8 9

10Full

Integration

Program or Model

Typology- Program SBIRT Model/ Collaborative

Care Model PCBH Model

Six Levels Crosswalk

1Minimal

Collaboration2

Basic Collaboration at a Distance

3Basic

Collaboration Onsite

4Close Collaboration Onsite/

Some System Integration5-6

Full Collaboration/ Transformed practice

Population Penetration

(Four Quadrants)

VariableI

Low BH/ Low PH

I & IIILow BH/ Low PH and/or

Low BH/ High PH I-IV

All Quadrants

Center of Excellence for Integrated CareWhat Is Integrated Care? Definitions and Terms.

Key & Definitions: MeHAF Level: refers to the degree of integration of physical and mental/behavioral health at a particular site compared to usual care as defined by the domains of the MeHAF tool (http://www.mehaf.org/content/uploaded/images/tools-materials/ssa%20surveyjanuary2015.pdf). Program: refers to a site- specific effort to increase the level of integration (that is not defined by a model) compared to usual care. This effort is not generalizable to other sites and is not evidence-based. Model: refers to a discrete, well defined, empirically validated, replicable set of characteristics and pathways which systematically apply studied strategies using a defined workforce to achieve integrated care. Population Penetration: refers to the extent to which a model reaches the population of a site and is represented by the Four Quadrant metric (http://www.integration.samhsa.gov/resource/four-quadrant-model).Six Levels: refers to another commonly used framework of levels of integration (http://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf)

Integrated care is defined by the effort to treat the physical health of patients alongside the mental health of patients. How integrated care is delivered varies by setting and by providers, however, well defined Models of integrated care have emerged in the last decade for integrating behavioral health

services into primary care clinics. Some clinics choose to create their own ways of integrating services outside of these models, and these are then called Programs. Programs are specific to clinics and do not generalize to other situations. More recently programs have emerged to integrate primary medical care into behavioral health settings. These are still emerging and being studied. Both programs and models can also be described as having a certain reach or Population Penetration into the population. Some models, such as the PCBH model have broad penetration in that almost any

patient of a clinic can be impacted by the model whereas the other models by their focus only impact a subset of the clinic population.

PCBHA Behavioral Health Consultant works

alongside a primary care provider providing real-time support to patients and the medical team to any patients

with need in the clinic that day.

SBIRTA bachelor’s or master’s level worker screens patients for substance abuse

conditions and provides brief intervention to those patients who

screen positive.

Collabor-ative Care

A consulting psychiatrist and care manager provides support for

prescribing practices of primary care providers for the care of

depression.

The Models

© 2015, All Rights Reserved. Center of Excellence for Integrated Care, A Program of the Foundation for Health Leadership & Innovation