Integrated Care Challenges in a Public Health Setting

Collaborative Family Healthcare Association10th Annual Conference

Denver, CO Nov. 7, 2008

Ashley Lester, LCSW; Stephen Snow, PhD, LPCIntegrated Care CliniciansBuncombe County Health CenterRHA Health Services, Inc.Asheville, N.C. 28801

Introductions Ashley

LCSW, University of Denver, 1996 Integrated Care, RHA/BCHC Primary Care Clinic Bilingual (Spanish/English) Therapist Certified Yoga Teacher

Steve PhD, Counseling, UNC Charlotte, 2005 Private practice (family violence/complex trauma) Integrated Care, RHA/BCHC Primary Care Clinic Executive Director, CFHA Previous careers: journalism, telecommunications

Overview

Introduction Overview of BCHC’s population Integrated care interventions Challenges and creative responses Case examples Final comments and questions Resources

Buncombe County Health Center

36,000-40,000 patient visits annually 12 medical clinicians 3 integrated care clinicians Safety net for indigent care in

Buncombe County, (150,000 people) 1 of 2 primary care clinics out of 100

Health Departments in NC (county funded)

Our Beginnings

Duke Depression Grant 5 full time integrated care clinicians Budget cuts, county contracted out

positions

RHA Health Services, Inc. RHA Behavioral health established in 1995; not-

for-profit company serving people with mental illness, substance abuse, and developmental disabilities.

RHA Health Services and RHA Howells provide residential, vocational, and educational programs for more than 1500 infants, children, adolescents, and adults in North Carolina and Tennessee

More than 700 employees deliver a wide variety of care, from community support to intensive in-home and crisis management.

$200 million in revenue; $23 million in free services

Clinic Population

13% latino (adult) 54% latino (child) Latino population has increased 210% in

past 10 years .01 % Ukrainian/Russian speaking .002% Other languages 11% African American 76.9% Caucasian

Public Health Population

Largely indigent, some homeless, little money, little education, disorganized, chaotic lives % uninsured % medicaid/medicare % insured - other

Low-Income Patients Living in poverty is a health risk. The

stresses of the lives of people in poverty take a greater toll on their bodies than is true for people with adequate financial resources.

Low-income and underserved populations are less likely than the general public to accept a mental health definition of their problem. If they do accept a referral for mental health services, they have much greater difficulty with travel and scheduling.

Low-Income Patients Garrison, et. al., (1992), in a study in Springfield,

MA, found that while low income patients have higher levels of psychosocial needs, medical providers are less likely to address psychosocial needs in this population than in more affluent populations. Lower institutional trust, clinicians’ lack of

assertive treatment. Physicians were more likely to try to deal with

parents’ concerns if the payment type was anything except Medicaid and more likely to try to refer Medicaid patients to specialty mental health services.

Garrison, W., Bailey, E., Garb, J. & Ecker, B. (1992). Interactions between parents and pediatric primary care physicians about children's mental health.  Hospital & Community Psychiatry 43: 489-493.

Clinic Population Most common issues presented Lethargy, headaches, chest pain, chronic pain, etc. Translates into:

Depression Anxiety/panic PTSD Substance Abuse Complex trauma Unresolved grief Physical / sexual trauma Bipolar disorder Personality disorder Somatized disorders

Integrated Care Interventions

Triage Short-term therapy Telephone counseling Clinical case management Psychiatric consultation Follow up clinic visits Groups

Triage When medical clinician suspects mental health issue,

therapist is paged. Assessment

time – avg. 20 minutes BHQ Differential diagnosis Risk for self-harm or harm to others Motivational interviewing, stages of change, psychoeducation Referral out or follow-up with integrated care clinician

Ruling out resources Eligibility for speciality mental health system

AdvocacyConcrete needs

* Challenge – NC Mental Health Reform

September 2008 Triages

Unduplicated PT Count: 170 Total # of PT Visits: 362 Total # of Triages: 101 Total hours in Svc. Del.: 250.2 (15,025

minutes in direct contact) Average Productivity: 78.3%

2007-2008 Contacts

0

50

100

150

200

250

300

350

400

July Aug Sep Oct Nov Dec Jan Feb M ar Apr M ay Jun Jul 8-Aug Sep-08

Total visits Unduplicated visits Total triages Percentage

Behavioral Health Questionnaire (BHQ) One-page, two-sided brief assessment

questionnaire. Depression questions

Nine weighted questions, including SI/HI CAGE

Four-question Substance Abuse measure Bipolar questions

Mania, irritability, problems because of periods of hyper-alertness

Anxiety questions General & immediate symptoms

Domestic/family violence questions Still to be designed

Options After Triage

Short-term (@ 8 sessions/meetings) therapy

Phone counseling Clinical case management Follow up while in clinic

Examples/Cases L.S.: Bipolar-disordered/dually

diagnosed woman J.H.: Depressed man with chronic

illnesses (depression, COPD, diabetes) S.H.: Woman with trauma, anxiety,

depression and unresolved grief J.S.: Chronic back pain, depression,

Hep C, med-seeking behavior

Institutional Challenges North Carolina mental health reform in chaos Rising numbers of uninsured adds stress to

system Lack of therapy guidelines (evidence-based) Legal barriers to communication among

providers Organizational and professional culture

differences between PC and BH Clinical and fiscal separation of physical and

mental health care

-- adapted from presentation in 2006 by Susan Mims, Buncombe County Medical Director

With Challenges, Creative Responses

Psychiatric consultation Groups – specifically stress reduction Close professional relationships w/

therapists in private practice Connections in community w/ Spanish

speaking providers Education for clinicians Do not bill

Final Comments

This model has some significant benefits, especially creative flexibility.

This model also has some significant limitations, including limited referral options.

All in all, the model is additive and still developing.

A Few Resources Books

Blount, A. (1998). Integrated primary care: The future of medical and mental health collaboration. Norton: New York

Gatchel, R & Oordt, M. (2003). Clinical health psychology and primary care: Practical advice and clinical guidance for successful collaboration American Psychological Association: Washington, D.C.

Web sites http://www.integratedprimarycare.com/ http://www.primarycareshrink.com http://www.mahec.net/ic/ http://www.thenationalcouncil.org/

A Few More Resources www.depression-primarycare.org The MacArther Foundation Institute for Healthcare Improvement (IHI)

www.ihi.org/collaboratives RWJ Project: Depression in Primary Care

www.wpic.pitt.edu/dppc National Council for Community Behavioral Heathcare

www.nccbh.org/html/learn/primary.htm Developmental Behavioral Pediatrics Online www.dbpeds.org

http://cartesiansolutions.com ( Financial information) http://www.cfha.net http://www.parc.net.au http://www.shared-care.ca http://www.behavioral-health-integration.com/news.php http://www.shepscenter.unc.edu/index.html http://www.icarenc.org/

The EndThanks for listening. For a free copy of this

presentation:CFHA Members: http://www.cfha.orgNon-members:http://www.commcure.com/cfha1108.ppt

Please provide credit for any material you use. For more information on this and other trainings, workshops and consultations, please go to www.commcure.com.

Contact us at:Ashley: ashley.lester@buncombecounty.org 828-250-5340Steve: ssnow@rhanet.org 828-250-5254