Practical Considerations for the Implementation of Integration

1. Practical Considerations for the Implementation of Integration Benjamin Miller Shandra Brown Levey University of Colorado Department of Family Medicine

2. Our questions for the audience • Who works in • community mental health? • primary care? • substance abuse treatment? • other organizations? • Who works in with medical providers? • Who has experience with primary care and behavioral health integration? • How do you interface with medical providers? • What works well when you work medical providers? • What is difficult about working with medical providers?

3. How do you know that what you’re doing is working?

4. Desire lines – user created paths related to the wisdom of crowds

5. Desire Lines • Most PC medical appointments stem from psychosocial concerns. • Primary care is the de facto MH system, as it is the setting where most patients with behavioral health conditions seek care.

6. Desire Lines • PCPs lack time and training to address the large volume of patients who seek help from psychiatric conditions, psychosocial problems, unhealthy lifestyles, and difficulties making needed changes to cope with chronic illness.

7. Desire Lines • MH specialty resources are scarce and patients have difficulty accessing them. • PCPs often respond by offering prescriptions, which may seem like adequate treatment, but are often not and may lead to new problems.

8. Desire Lines • To address these problems, models have been developed for integrating behavioral health and primary care.

9. The Range: Dispelling the myth of the one trick pony and retraining (Miller, Brown Levey, Kwan, Payne Murphy, in press)

10. The Behavioral Health Community Challenge • We all pay the price for insufficient care for behavioral problems. • Break down the barriers to mental health care and reduce strain on PCPs. • Link physical and mental health in a tangible way by providing care in the same location - this reduces stigma. • Work towards a true biopsychosocial approach to carewith an integrated health care team.

11. Operationalizing Your Vision • Approaches to integration vary widely • Co-location – BH placed in PC – Be careful not to become the “house shrink” • Bidirectional Co-location – PC placed in BH • Collaboration – quality of the relationship between providers • frequency of sharing info, joint treatment planning, true biopsychosocial approach • Integration – BH is a regular part of the care team and no special paperwork or processes are needed to see BH

12. Operationalizing Your Vision • Visits • Consider the length of visits (50 mins, 30 mins, 15 mins, 5 mins) • The number of follow up sessions • Are visits 1:1 or with the PCP as a health team • The amount of BH flexible time - for warm hand offs and co-consults

13. Operationalizing Your Vision • Maintain easy access to behavioral health care with population health focus • Generalist approach - Be ready for… • depression, anxiety, obesity, pain, diabetes, headaches, hypertension, grief, sleep, stress, adjustment to illness …

14. Operationalizing Your Vision • Brief, problem focused work • Focus on functional assessment and restoration • Life context • Description of target behavior • Triggers • What lessens behavior • What happens before/after behavior • What have you tried?

15. Implementation…Are you ready? • It depends… • Design the model to meet the needs of your population • Buy-in from organizational leadership • Behavioral Health Skills for working with Primary Care • Staff preferences • Logistical considerations (office space) • Look at the Lexicon

16. What Do We Mean by “Behavioral Health integrated with Primary Care?” • Shared language • Functional definition • Metrics for evaluating integration • Unite the field and move it forward

17. Goal of Integration To create a patient-centered care experience and achieve a broad range of outcomes -clinical, functional, quality of life, and financial – for each patient that no one provider and patient are likely to achieve on their own.

18. Structure of the Lexicon

19. Defining Functions of Integration

20. Enabling Functions That Support Integration

21. Parameters (examples) 21

22. “Supported by” Parameters (examples) 22

23. Tools • In-service presentations and handouts so that BHPs can influence and support PCPs

24. Tools • BH Screen

25. Tools • BH handouts for patients with educational and actionable item components to support SMS with goal setting

26. Action Plans for Depression Management • Action plans can be presented by a BHP or PCP • Action Plans include: • brief psychoeducation • insight development • coping skills • goal setting for self management support

27. Action Plan for Depression Treatment - Psychoeducation • Nearly 17% of adults in the U.S. experience depression at some point in their life. It can affect feelings, thoughts, behaviors, relationships and physical health. • “Depression symptoms” include a sense of sadness or unhappiness, a lack of interest in things you used to enjoy, changes in appetite, difficulty concentrating, trouble sleeping, loss of energy, feelings of worthlessness, and may include thoughts of suicide. • Strategies to help reduce depression that you may want to try: • 1. Take a breath break. When you notice depression symptoms, try a relaxation breath. STOP, breathe and then decide on your next step. • 2. When feeling blue, get ACTIVE! It is great for your body and mind. When we are active the brain releases feel good chemicals that can help decrease depression. Activities such as walking, swimming, running, gardening, biking, or house cleaning can help you get the just 10 minutes of light physical activity needed each day to help reduce your depression. • 3. Connect. When feeling depressed, it can be helpful to talk with a friend or family member. Staying connected to people who are positive and supportive is always a good coping strategy. • 4. Pleasant activities/hobbies. Increasing the number of fun, enjoyable, and meaningful activities or hobbies in your life can also help you feel less depressed.

28. Action Plan for Depression Treatment – Building Coping Skills and Developing Insight

29. Action Plan for Depression Treatment – Next Steps MY ACTION PLAN Activity Breeds Activity!! During the next seven days, I will: ____________________________________________________________________________________ Frequency: ___________ times a__________________ Importance:_____ Confidence:_____ I will:____________________________________________________________________________________ Frequency: ___________ times a__________________ Importance:_____ Confidence:_____ I will:____________________________________________________________________________________ Frequency: ___________ times a__________________ Importance:_____ Confidence:_____ This is your ACTION PLAN, so set reasonable goals that you feel you can accomplish! How confident are you that you can follow through with your overall ACTION PLAN before your next visit? 1 2 3 4 5 6 7 8 9 10 Not at All Confident Very Confident If you have questions, contact Behavioral Health Consultant: ________________ Phone: _________________ Next appointment:___________________________________

30. Tools • Evaluation – productivity, satisfaction, clinical change (PHQ-9 for depression, Duke Health Profile for global functioning changes), utilization changes (ER visits, in pt stays) • Know how much integration costs

31. Cost and workflow (not just FTE) Where • Where are important events happening? • Examples: clinic, patient’s home, partner site, internet/web What or How • What is being done to help integrate care? • How much time is being spent on this activity? • Examples: ask questions, look at data, talk with someone, provide instructions, make a decision, connect to a resource When • When is the action performed or in what sequence? • Examples: before, during or after a visit, three months from now, once a year. Who • Who is participating, receiving, or doing something? • Examples: PCP, BH provider, staff, collaborator, patient, computer/Electronic Health Records

32. Examples • Depression Workflow • Pain Clinic

33. Resources • Robinson, P.J. & Reiter, J.T. (2007). Behavioral Consultation and Primary Care. Springer Science + Business Media, LLC. New York. • The Academy for Integrating Behavioral Health and Primary Care: http://integrationacademy.ahrq.gov/ • The Patient Centered Primary Care Collaborative www.pcpcc.net • Dickinson WP, Miller BF. Comprehensiveness and continuity of care and the inseparability of mental and behavioral health from the patient-centered medical home. Families, Systems & Health. 2010;28(4):348-355. • Brown-Levey S, Miller BF, deGruy FV. Behavioral health integration: an essential element of population-based healthcare redesign. Translational Behavioral Medicine. 2012:1-8. • The Collaborative Family Health Care Association: http://www.cfha.net/ • Webinars including Dr. ParindaKhatri on Integrating your Practice: Key Building Blocks

34. Thank You • Benjamin.Miller@ucdenver.edu • @miller7 • Shandra.Brownlevey@ucdenver.edu • @sbrownlevey