1

Behavioral Health-

Primary Care Integration

to Improve Child

Wellness: A Clinical and

Business Perspective

Children’s Mental Health Research and Policy Conference

March 2-5, 2014

Sherry Shamblin, Ph.D., PCC-S and

Dawn Graham, Ph.D.

Ob

jec

tives

• Participants will compare strengths and

challenges for three integration models:

Facilitated Referral, Co-Location, and

Full Integration.

• Participants will recognize implications

of these three models

• Participants will identify specific action

steps to take in order to begin or

enhance integration efforts in their home

communities.

2

Wh

at is

“inte

gra

ted

ca

re”

Wh

y inte

gra

tion

?

Behavioral health conditions among children and youth

today occur at a disturbing rate, impacting their overall

growth and development and leading to higher mortality

rates as they reach adulthood. In fact, studies have shown

that adults with mental illness who are served in the public

mental health system have a shortened life expectancy of

11 to 25 years on average when compared to the general

population. Key to disrupting this phenomenon is the

development of preventive and early identification

strategies, including integrating care systems for children

with behavioral health conditions that address the primary

care, behavioral health, specialty care, and social support

needs of children and youth with behavioral health issues

in a manner that is continuous and family-centered.

(Integrating Behavioral Health and Primary Care for

Children and Youth: Concepts and Strategies SAMHSA,

2013)

3

Wh

y Inte

gra

tion

?

Epidemiology of Pediatric

Mental Health Conditions

• 9.5-14.2% of children birth to 5 have Social

emotional problems interfering with functioning

• 21% of children and adolescents in the U.S. meet

diagnostic criteria for a mental health disorder with

impaired functioning

• 16% of children and adolescents in the U.S. have

impaired mental health functioning and do not

meet criteria for a disorder

• 13% of school-aged, 10% of preschool children

with normal functioning have parents with

“concerns”

• 50% of adults in U.S. with mental health disorders

had symptoms by the age of 14 years

(Frankowski, Gruttadaro, & Palfrey, 2011)

Wh

y Inte

gra

tion

?

Mental Health Conditions in

Children with Chronic Illness:

Hidden Morbidity

• Children with chronic illness are 2 times more

likely to have psychosocial dysfunction

• Children with mental health problems (and their

parents) are higher users of healthcare services

in general (e.g., emergency room use)

(Frankowski, Gruttadaro, & Palfrey, 2011)

4

Wh

y Inte

gra

tion

?

• “By 2020-2030, it is estimated that up to 40% of patient visits to pediatricians will involve long-term chronic disease management of physical and psychological/behavioral conditions.”

• “In 2020 pediatricians have a wider array of skills including more in-depth knowledge of, and comfort treating, behavioral, developmental, and mental health concerns. Medical education includes mental health interventions, which are now an established aspect of pediatric care.”

-AAP Task Force on the Vision of Pediatrics 2020

Impact on Primary Care

Wo

rkfo

rce

Iss

ue

s?

• Insufficient #s of child mental health specialists, especially, child psychiatrists and providers to young children

• Little support for prevention or services to children with emerging or mild/moderate conditions

• Administrative barriers in insurance plans limit access to providers

• Families commonly seek help for mental health problems in primary care settings

• The Pediatric workforce faces many challenges

5

Inte

gra

tion

Mo

de

ls

A Continuum of Care

•Screening with Facilitated Referrals

•Co-Location of Behavioral Health

and Primary Care

•Full Integration of Behavioral Health

and Primary Care

Fac

ilitate

d R

efe

rrals

Pathways Community HUB Model

http://www.innovations.ahrq.gov/guide/

HUBManual

Screening in primary care settings

with care coordination-referral process

for high-risk screens (i.e. ASQ:SE)

Regularly scheduled meetings with

child serving agencies (i.e. FCFC)

6

Co

-Loc

atio

n

Michigan Washtenaw Community

Health Organization

Armstrong Pediatrics in

Pennsylvania http://www.milbank.org/publications/milbank-reports/32-

reports-evolving-models-of-behavioral-health-integration-

in-primary-care

http://www.mentalhealth.va.gov/coe/cih-

visn2/Documents/Clinical/Operations_Policies_Procedure

s/MH-IPC_CCC_Operations_Manual_Version_2_1.pdf

Full In

teg

ratio

n

Cherokee Health Systems

www.cherokeehealth.com

University of Southern Maine

University of Massachusetts/ Dr. Blount

http://www.umassmed.edu/cipc

7

Mo

tivatio

n fo

r Inte

gra

tion

Southeast Ohio

• Rural

• Appalachian

• High Poverty

• Rates of Mental

Illnesses range from

24%-41%

• All Counties are

MPSA’s

Pa

rtne

ring

for S

olu

tion

s

Integrating Professionals for

Appalachian Children

A Rural Health Network of Community

and Ohio University Partners

8

Vis

ion

of a

Be

tter Fu

ture

Vision: Healthy development for all

children in our area. Mission: By leveraging our expertise

and integrating our resources, IPAC will develop innovative, culturally-sensitive programs that address the critical and complex challenges impacting the health and mental health of our region’s children and families.

IPA

C/P

roje

ct LA

UN

CH

• Project L.A.U.N.C.H (Linking Actions for

Unmet Needs in Children’s Health) –

SAMHSA grant (2009-2014)

• Written by Integrating Professionals for

Appalachian Children (IPAC) and The

Ohio Department of Health

• LAUNCH promotion of Integration and

Screening Efforts in Southeastern Ohio

• Lessons learned from clinical, business

and policy perspective

9

IPA

C/P

roje

ct LA

UN

CH

How LAUNCH has helped move

integration efforts forward

• Ability to link behavioral health

practitioners with physicians/NPs

• Ongoing education regarding

interdisciplinary care

• Troubleshooting process/flow

challenges

• Resources for emerging agencies

• Personnel support as agencies assess

and create a process for financial

sustainability

Fac

ilitate

d R

efe

rral

Screening/ Assisted Referral

• School Outreach Worker

• Family Navigator Program

• Pathways Care Providers

• Southeast Ohio Interdisciplinary

Assessment Team

10

Fac

ilitate

d R

efe

rral

Lessons/ Findings

• Return on Investment Study for

Family Navigator $1:$4 estimated

savings on preventative care

• Increase in Parent Satisfaction

• Increase in Teacher Satisfaction

• At-Risk Children are Identified

Earlier prior to entering school

• Increased trust between families

and schools; resulting in better

care coordination for children

Co

-Loc

atio

n

• River Rose (OB-GYN) and

Psychology Doctoral Student

• University Medical Associates and

Independent/Private Practitioners

on site (Ph.D & MSW)

• Stagecoach Family Practice/

Health Recovery Services

11

Co

-Loc

atio

n

Lessons/Findings

• Children can be seen immediately

• Less wait time

• Decreased no-shows

• Increased parent satisfaction

• Increased practitioner satisfaction

• On-site care

• Increase

communication/education between

practitioners

Full In

teg

ratio

n

Creating a community where everyone enjoys a healthy body, mind, and spirit.

12

Ho

pe

we

ll He

alth

Ce

nte

rs

• 16 sites across 8 counties in Southeast Ohio

• All counties are rural, and all are located in

Appalachia

• 140 primary care and behavioral health

providers; 4,000 behavioral health clients; and

25,000 primary care patients.

• CARF accredited community mental health

center and a Joint Commission accredited

federally qualified health center

• Formed through the recent business merger of

Tri-County Mental Health and Counseling

Services, Inc. and Family Healthcare, Inc.

Ho

pe

we

ll He

alth

Ce

nte

rs

Lessons Learned/ Findings

• Essential to success: Finding a partner

that had same mission, vision, values,

client population, payee mix (i.e..

previous integration attempts less

successful).

• Expect Normal Group Processes to be

even more pronounced (Forming,

Storming, Norming…)

• Collaboration Survey Results

13

Ho

pe

we

ll He

alth

Ce

nte

rs

Lessons Learned/ Findings

• Business models evolve based on

clinical models; must integrate business

cultures as well as clinical cultures

• Both business and clinical cultural and

professional differences create many

challenges in communication: 5 month

staff survey identified communication as

the number one challenge for the new

organization

Ho

pe

we

ll He

alth

Ce

nte

rs

Lessons Learned/ Findings

Major Clinical Outcome to Date:

Behavioral Health Consultation

Model is improving patient

attendance and decrease patient

no-show (Hammar, 2013)

14

Ho

pe

we

ll He

alth

Ce

nte

rs

Lessons Learned/ Findings

Major Projected Business Outcome

to Date:

“The net impact of all of the changes is an

increase in patient service revenue for Tri-

County’s services under FHC’s auspice

from $8.75 million to $9.84 million, for a net

increase of $1.09 million.”

(Curt Degenfelder Consulting Inc., 2012)

Futu

re R

es

ea

rch

• “Behavioral Health in Primary

Care: How Rural Practitioners

View Quality of Treatment”

12 Provider interviews in Rural

Health settings (ME, TN, and OH)

• Project LAUNCH: Final

Evaluation Report

• Hopewell Health Centers: Focus

Group with BHC’s; Cost Analysis

of BHC Pilot

15

Ap

plic

atio

n to

Po

licy

Policy Implications

• Philosophical Shift in Care

• Educational

• Informing Policy makers

• Those in the field

• New professionals in training

• Financial

• Reimbursement/Managed Care

• New Models for Outcome-Based

Payment (Patient Centered Medical

Home; Behavioral Health Home, etc.)

Ap

plic

atio

n

Things to consider in your

community

• Assess needs (What developmental

stage is your agency? What does your

community need?)

• Identify partners with common vision,

mission, values (who serves similar

population?

• Start small, build the relationships

• What is your end-goal (facilitated

referral, co-location, full integration)

• Combine voices in advocacy efforts

16

Gro

up

Dis

cu

ss

ion

Discussion

Sherry Shamblin (sshamblin@hopewellhealth.org)

Dawn Graham (grahamd@ohio.edu)

Thank you for your participation!