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Integrating Behavioral Health Pitfalls and Solutions

Integrating Behavioral Health Pitfalls and Solutions. Nelly Burdette, PsyD Faculty, Warren Alpert School of Medicine at Brown University; Center for Integrated Primary Care at University of Massachusetts Medical School. Objectives.

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Integrating Behavioral Health Pitfalls and Solutions

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  1. Integrating Behavioral Health Pitfalls and Solutions Nelly Burdette, PsyD Faculty, Warren Alpert School of Medicine at Brown University; Center for Integrated Primary Care at University of Massachusetts Medical School

  2. Objectives • Define the major models of behavioral health integration within primary care • Identify the clinical, organizational and logistical challenges of these models • Recognize how to pair solutions to these challenges

  3. Terminology • Integrated Care • Rendered by a practice team of primary care and behavioral health providers, working together with patients and families and using a systematic and cost-effective approach to provide patient centered care (4) • Collaborative care=working with primary care team (3) • Integrated care=working within primary care team (3)

  4. Adapted from Blount 2003

  5. Adapted from Blount 2003

  6. “If you build it they will come” • –Field of Dreams

  7. Collaboration Continuum Minimal Collaboration Basic at a Distance Basic On Site Close Partly-Integrated Close Fully Integrated • Doherty 1995

  8. Collaboration Continuum • Minimal Collaboration Mental health and primary care providers work in separate facilities, have separate systems, and communicate sporadically • Basic at a Distance Mental health and primary care providers have separate systems at separate sites, but engage in periodic communication by telephone or letter. Improved coordination is a step forward compared to completely disconnected systems. • Basic On Site Mental health and primary care providers have separate systems but share same facility. Proximity allows for more communication, but each provider remains in his or her own professional culture. • Doherty 1995

  9. Collaboration Continuum • Close Partly-Integrated Mental health and primary care providers share same facility and have some systems in common, such as scheduling appointments or medical records. Physical proximity allows for regular face-to-face communication. A sense of being part of a larger team, in which each professional appreciates his/her role in working together to treat a shared patient. • Close Fully Integrated Mental health provider and primary care provider are part of the same team. The patient experiences the mental health treatment as part of his or her regular primary care. One treatment plan, no confidentiality issues because it is a shared patient. • Doherty 1995

  10. “If primary care treats the body, and mental health treats the head, integrated care is rediscovering the neck” • –Alexander Blount, Ed.D. • Professor of Clinical Family Medicine, • Director of Behavioral Science, • Department of Family Medicine and Community Health, • University of Massachusetts

  11. Clinical Challenges & Solutions Training integrated care providers to fundamentally change how to view their roles within health care (4,6) • Behavioral Health Shadow in PC, shift towards shorter visits, warm hand-offs • Primary Care Huddles, difficult case team meetings

  12. Clinical Challenges & Solutions Measuring Outcomes (4) • If you don't measure it, it didn't happen • Two EHRs to access data? • Infrastructure to run and review population health queries

  13. Organizational Challenges & Solutions • Cultural barriers (6) Language, dress code and interactional style are entirely different • Privacy laws (6) The more restrictions to access of info, the more difficult integration • Sustainability (6) How will this be funded now? How will this be funded in the future?

  14. Logistical Challenges & Solutions Work Flow, Access, Location (4) • How many behavioral health clinicians per primary care practice? (2) Estimated for 2010 in community health centers, per every 2500 medical patients, 0.9 FTE licensed mental health provider , 0.1 FTE psychiatrist, 0.4 FTE other mental health staff, and 0.3 FTE substance abuse provider • Schedules of behavioral health should mimic pace of primary care • Ideal: Middle of the action, embedded within primary care

  15. Logistical Challenges & Solutions Leadership (4) • Politics of one organization x politics of partnering organization = politics infinitum • Ideal: designated point person with integrated care experience and champions within primary care

  16. Integrated care is growing up • Major tasks of adolescence • Independence from traditional psychotherapy models • Body image as a field, how do I look to myself vs how do I look to others • Peer relationships or who are my friends because they're not the ones I went to school with • Sexuality or starting to look like like an adult before actually becoming one

  17. Resources • FINANCIAL • Rhode Island Billing Worksheet - Updated July 2014 (SAMHSA Center for Integrated Health Care Solutions) http://www.integration.samhsa.gov/financing/Rhode_Island.pdf • TRAINING • Core Competencies for Integrated Behavioral Health and Primary Care http://www.integration.samhsa.gov/workforce/Integration_Competencies_Final.pdf • Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit http://www.integration.samhsa.gov/workforce/team-members/Cambridge_Health_Alliance_Team-Based_Care_Toolkit.pdf

  18. Blount, A. (2003). Integrated Primary Care: Organizing the Evidence. Families, Systems, & Health, 21(2):121–33. Available at http://dx.doi.org/doi:10.1037/1091-7527.21.2.121 Burke, B.T., Miller, B.F., Proser, M., Petterson, S.M., Bazemore, A.W., Goplerud, E. & Phillips, R.L. (2013). A needs-based method for estimating the behavioral health staff needs of community health centers. BMC Health Services Research, 13, 245-257. Available at http://www.biomedcentral.com/content/pdf/1472-6963-13-245.pdf Collins,C., Hewson, D.L., Munger, R. and Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. Milbank Memorial Fund. Available at http://www.milbank.org/uploads/documents/10430EvolvingCare/EvolvingCare.pdf Davis, M., Balasubramanian, B.A., Waller, E., Miller, B.F., Green, L.A., & Cohen, D.J. (2013). Integrating Behavioral and Physical Health Care in the Real World: Early Lessons from Advancing Care Together. Journal of American Board of Family Medicine, 26 (5): 588-602. Available at http://www.jabfm.org/content/26/5/588.full.pdf+html Doherty, W. (1995). The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine, 13(3–4):275–81. Available at http://dx.doi.org/doi:10.1037/h0089174. Kessler, R., Stafford, D. & Messier, R. (2009). The Problem of Integrating Behavioral Health in the Medical Home and the Questions it leads to. Journal of Clinical Psychology in Medical Settings, 16, 4-12. Available at http://download.springer.com/static/pdf/516/art%253A10.1007%252Fs10880-009-9146-y.pdf?auth66=1410466158_abfb07ae1bd9a18eb5dc513cf3cd76a6&ext=.pdf References

  19. Questions? • Nelly Burdette, PsyD • NellyBurdette@gmail.com

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