Building the Integrated Primary Care Medical Home

Neil Korsen, MD, MSc

Mary Jean Mork, LCSW

C-IBHA, New Orleans

April 16, 2009

Overview

• Background

• Description of our integration program

• Our approach to implementation

• Measuring success

• Financial sustainability

Objectives

• Describe one approach to implementing integrated care

• Understand the use of process redesign and measurement as part of an improvement program

• Describe financial challenges and one possible solution to financial sustainability of integrated care.

Mental Health Integration in Maine

MaineHealth

• An integrated delivery system in 11 counties in Maine

• Includes – Acute care hospitals– A psychiatric hospital – Physician practices – Home health agencies– Long term care facilities – Other health care organizations

Why Mental Health Integration?

• Depression in Primary Care program since 2001– MacArthur Foundation RESPECT trial– Robert Wood Johnson Foundation

Depression in Primary Care demonstration program

• Achieved system level changes in adult depression care

Shortcomings of Depression Program

Did not: • Address needs of those caring for children and

adolescents• Address common mental health co-morbidities

of depression• Do enough to build working relationships

between primary care and mental health clinicians and organizations

Integration as a Solution

• Primary care clinicians provide more than half of all mental health care and some primary care patients won’t go to specialty mental health.

• Pilot integration programs had developed around the state.

• MaineHealth Strategic Plan included piloting mental health integration (MHI).

• Received a grant from the Maine Health Access Foundation (MeHAF) that helped fund the MHI pilot.

Integration Model

Adapted from Intermountain Healthcare (IH), who demonstrated:

• Improved ability of Primary Care Physician to diagnose and treat common mental health conditions

• Increased satisfaction of patients and primary care staff• No increase in overall healthcare costs

The Program

18-month Collaborative-style Learning Community:– Learn the MHI model and implement key components

– Gather for periodic learning sessions

– Collect and report data about processes and outcomes

– Participate in site visits, conference calls, listserve

12 Primary Care Sites (6-8 more joining spring 2009): – Rural Health Clinics (RHC)

– Federally Qualified Health Centers (FQHC)

– Private and hospital owned practices

8 Mental Health Partners (3 additional agencies spring 2009):– Specialty Mental Health agencies– Community Mental Health Centers– Hospital-owned behavioral health organizations

Principles of our Integration Program

• Relationships: Mental Health and Primary Care• Standardized mental health screening and

assessment tools• Stratification to guide level of intervention • Team approach to care • Periodic reassessment of patient• Links to external resources

– Mental health providers– Community resources

Role of Mental Health Specialist: Integrated Behavioral Health

• Work side-by-side with primary care staff • Brief, flexible problem-focused approach to

treatment• Assist with diagnosis and management of people

with common mental health problems• Assist in the care of people with psychosocial

problems related to medical diagnoses

Acces

s

Standardized Assessment &

Risk Stratification

Care Management

Support for

Behavioral Change Mental

Health Treatment & Consultation

Specialty

Mental Health

Primary Care Medical Home

Community Resources e.g., NAMI

Rate yourself on Behavioral Health Integration

• Spend 5 minutes talking to your neighbor about a couple of these questions from the Behavioral Health Integration Survey:– #1 - The Behavioral Health Consultant (BHC) is located in the

exam room area of the clinic and provides services there. – #12 - All members of the primary care team understand the role

of the BHC and how to utilize him/her – #15 - PCPs routinely discuss patient care issues with the BHC

prior to and after same-day handoffs or prior to a scheduled initial visit.

– #16 - The BHC provides periodic training and education for medical staff on behavioral health topics (e.g., at a provider meeting, through a monthly newsletter or a lunch time training on a topic of interest to PCPs).

Levels of Integration

Model Level of Integration

Attributes

Separate Space & Mission

-- Traditional Behavioral Health Specialty Model

One-on-one Referral

Relationship

+ Preferred Provider. Some information exchange

Co-location ++ On-site Behavioral Health Unit/Separate Team

Collaborative Care

+++ On site. Shared cases with Behavioral Health specialist

Integrated Care +++++ Primary Care Team member

Doherty, McDaniel and Baird, 1996

An Example of Integrated Practice: the Video

• Level Five

• Mental Health Clinician working side-by-side with primary care staff

• Brief, flexible problem-focused approach to treatment

• Warm hand-offs

• Curbside consults

A Framework for Building the Integrated Medical Home

What is the Aim?

To serve patients better through integrated, effective, efficient, financially sustainable mental health care in primary care

Form the Right Team

Involve representatives of all groups that will be affected by the change

Leave titles at the door – everyone can contribute to making this work

Team should meet regularly to review data and plan tests of change.

Mental HealthSpecialist

Diagnose, Treat MHI Packet

Care ManagerFollow up, Family Adherence

Patient Education MHI Packet

NAMICommunity Resources Family Support

PsychiatristOr APRN

Consult, TrainMHI Packet

Patient and FamilySelf report/MHI Packet

Mental Health Integration:

Team Roles Mental HealthSpecialist

Diagnose, Treat

Primary Care Provider Support Staff

Screen, Diagnose, Treat

Care ManagerFollow up,

Family Adherence Patient Education

PsychiatristOr APRN

Consult, Train

NAMICommunity Resources

Family Support

Patient and Family

Identify Your Population

Integrated Care is for:

• People with symptoms or problems that warrant a mental health assessment

• People being treated for mental health conditions who are not improving

• People who need help with behavioral, emotional or psychosocial aspects of medical problems

High risk populations

• People with chronic illnesses or chronic pain• People with a disability• People with substance abuse problems• Kids with school, sleep or behavior problems• People with persistent somatic complaints and

negative workup

Develop Efficient and Effective Processes

Tools You Can Use

• Patient walk through – To understand the process through the eyes

of your patients

• Process Flow Charting– To display the process to help you think

about how to introduce changes

Pt calls or presents with possible MH concerns

MH screening material to patient

Patient completes screening

Screening reviewed and scored

Patient and team develop care plan

Follow up visit and reassess

Ongoing monitoring and treatment prn

PDSA Cycle

PlanIdentify: -the problem-the most likely causes-potential solutions

DoImplement solutions

and collect data

StudyAnalyze data

and develop

conclusions

ActRecommend

action/further study

Why Test Changes?

• Increases belief that the change will result in improvements in your setting

• Learn how to adapt the change to conditions in your setting

• Evaluate the costs and “side-effects” of changes• Minimize resistance when spreading the change

throughout the organization

Process and Outcome Measures

Pt calls or presents with possible MH concerns

MH screening material to patient

Patient completes screening

Screening reviewed and scored

Patient and team develop care plan

Follow up visit and reassess

Ongoing monitoring and treatment prn

Pt calls or presents with possible MH concerns

MH screening material to patient

Patient completes screening

Screening reviewed and scored

Patient and team develop care plan

Follow up visit and reassess

Ongoing monitoring and treatment prn

# Screening completed/ %Returned

Care Mgmt.

Specialty MH

OUTCOMES:

Clinical

Functional

Satisfaction

Financial

Process Measures

• Mental Health Screening Forms– Distributed– Completed

• Utilization of Specialty Mental Health Care– Care manager– Internal mental health provider– External mental health provider

Outcome Measures

• Clinical– PHQ-9 score tracking

• Functional– Functional assessment

• Satisfaction– Patient– Provider– Staff

• Financial– Revenues generated from integrated services

Finances of Integrated Care

The Problems with Integrated Care

• No one seems to know how to get paid• Mental Health regulations and licensing expectations

don’t fit the primary care setting• Confidentiality vs. “shared records”• Lack of clarity and understanding about present

practices • Complicated licensing and reimbursement rules without

accessible experts

How will we achieve financial sustainability?

• Understand the current rules • Identify opportunities and barriers that affect

sustainability • Use understanding of current rules to:

– Recommend most effective way to organize services

– Maximize reimbursement for integrated care

• Target barriers with highest priority and/or are most likely to be able to change

Remember…

• Involve the right people• Start small and build gradually • Share selflessly and steal shamelessly• Think about sustainability

– Clinical sustainability – discover the processes that work in your setting and spread them

– Financial sustainability – understand the rules and use them to your advantage

Start where you are

Use what you've got

Do what you can Arthur Ashe