Perspectives from Primary Care and Psychiatry

1. Punch / Counter-Punch:
Biopsy of a Successful
Integrated Care Program
Perspectives from
Primary Care and Psychiatry
Timothy Florence, MD
Ray Rion, MD
April 25, 2012

2. Pre-partnership Era

3. Goals for Today
 Discuss key elements of a successful
integrated care partnership
 Mind the Gap – avoiding potential
pitfalls and overcoming barriers
 Review roles of professional staff

4. What is a partnership?

5. What is a partnership?

6. There are many kinds of
partnerships

7. Partnership
A voluntary collaborative agreement
between two or more parties in which
participants agree to work together to
achieve a common purpose or
undertake a specific task and to share
risks, responsibilities, resources,
competencies and benefits.

8. The Local “Public Option”

9. Guide Posts of Policy and Practice
 Serve persons with serious mental
illness, developmental disabilities
and severe emotional disturbances
 Provide integrated medical and
behavioral healthcare through
health homes
 Michigan Mental Health Code
 Medicaid regulations

10. Difficult Choices
Greatest Good for the
Greatest Number
Vs
Serving the Least Well Off

11. Why Partner
with Primary Care?
 Mental health consumers are less likely
to receive care for chronic physical
health conditions than the general
population
 Serious mental illness is associated with
increased morbidity and mortality
due to general medical conditions

12. Why Partner
with Primary Care?
 Individuals with serious mental illness served
by our public mental health system die 25
years earlier than the general population.
 NASMHPD 2006
 Chronic conditions receive episodic care
 Prevent disease progression
 Enhance self management/patient activation
 Modify modifiable risk factors

13. WCHO Frequency of Multimorbidity
Nearly three out of
every four
consumers has 2 +
concurrent chronic
conditions
Mental Illness, Developmental Disabilities, Substance Use Disorder, Asthma, Emphysema,
Bronchitis, Heart Disease, Diabetes, Hepatitis, Hypertension, Cholesterol, Chronic Pain.

14. WCHO Disease Management Consumers
with Serious Mental Illness
1 in 3 dual- 1 in 4 dual-
eligibles have eligibles have triad
triad of SMI/HTN/ of SMI/HTN/
Dyslipedemia Diabetes

15. WCHO Disease Management Consumers
with Developmental Disabilities
Nearly 1 in 2
1 in 3 dual-
dual-eligibles
eligibles have
have triad of DD/
triad of DD/HTN/
HTN/
Diabetes
Dyslipidemia

16. Packard Health

17. Packard Health
 A private, tax exempt Family Practice
 Eight PCPs (5 MD, 3 NP), health educator,
and administrative and office staff
 The population
 8000 patients / 19,000 annual visits
 Provide care regardless of insurance
status/sliding fee
 65% uninsured/capitated county plan
(WHP)/Medicaid/Medicare
 35% conventionally insured or pay market rates

18. Packard Health 2012:
A Community Partnership for Care
 Combines primary care, mental
health care, health promotion, and
disease management programs in
one comprehensive family practice
setting.
 Establish ongoing relationships with
our patients to help each individual
achieve his/her fullest health
potential.

19. Prevalence of Psychiatric Disorders in
Primary Care Patients
Mauksch et al, JFP 2001

21. Impact of
Cumulative Social Disadvantage
 Mortality is increased by:
 Lack of adequate housing
 Lower income
 Poor social cohesion
 Limited education
 Multi-morbidity
 Housing, income, and social
relatedness are treatments

22. Why Integrate Care?
The medical model is
necessary but not sufficient
to bend the curve

23. Integrated Health Care
 “Reunification in practice of mind and body”
 Health care model in which “physical health”
and “mental health” clinicians partner to
manage health conditions
 Shift away from disease-focused system to a
person-centered system
 Single treatment plan focused on what
patients/consumers need

24. Core Environmental Factors
For Successful Integration
 Recognize that the population exists in the
practice
 Consciously decide how the practice will address
behavioral healthcare integration
 Establish a learning environment
 Leadership, both administrative and clinical
 Understand the capacity of the practice to
provide integrated care
 Individual characteristics and roles of the
primary care providers and mental health
professionals

25. Recognize That the Population
Exists In the Practice
 Know, acknowledge and accept that the
target population exists in the practice
 Already committed to your patients
 If the perception is that it doesn’t exist:
 Provide evidence that it does
 Implement simple screening tools to
demonstrate presence of behavioral health
conditions and/or needs

26. Packard Health
Collaborative Care
 The Reality  The Plan
 Many patients with  To create access to
significant mental mental health services
health conditions –  To reduce
most not meeting fragmentation of
CMH criteria services for vulnerable
 Primary care patients
providers  To utilize existing
prescribing for resources more
complex patients effectively to achieve
who have no improvements in
primary mental health status
health provider  CSTS “graduates”

27. Consciously Decide How the Practice
Will Address Healthcare Integration
 Refer to outside providers
 Provide onsite comprehensive care
 Continuum of integration

28. The Synergy
PACKARD CSTS
 Patients with  Establishment of
complex needs primary mental health
 Trust relationship provider
with primary  Coordination of
health provider treatment and services
 More appropriate
use of provider
time
•Use of multidisciplinary team to improve health outcomes
•Blending organizational resources to improve access to care

29. Staffing the Packard Partnership
 A full time behavioral health specialist
(LMSW) on site and a ½ day per week
of psychiatry
 Disease management nurse
 Joint supervision & oversight of the
program by Packard, CSTS and WCHO

30. Establishing a
Learning Environment
 Support innovation and creativity
 Support education and team learning
and training
 Model personal mastery
 Talk about vision
 Support systems thinking
 If it doesn’t exist -
 Identify leadership and create it through
an organizational development plan

31. “Strangers in the Night”
 Most primary care providers receive
little behavioral health training
 Psychiatrists receive limited training in
outpatient management of chronic
medical conditions
 Primary care providers and
psychiatrists generally receive no
significant training in collaborative,
integrated practice arrangements

32. The Great Cultural Divide…
 Primary Care Docs  Psychiatrists
 10-15 minute blocks  30-60 minute sessions
 Deal directly with  Time with consumers
other physicians considered sacrosanct
 Find it difficult to deal  Team decision model
with interdisciplinary  Behavioral health records
team are long and complex
 Medical records  Contain goals and objectives
short, concise  Variety of provided services;
summaries of the may be re-evaluated over
diagnosis, treatment time
and outcome  Contain consumer input
 Language = patients  Language = clients or
consumers

33. Learning Environment Critical
to Overcoming Barriers
 Collaboration across two different cultures
 Inertia, resistance
 Provider factors
 Comfort level, mind/body dichotomy, stigma
 Space
 Not incorporated into facilities planning
 Systems issues
 Funding streams, payment systems, billing
 Informatics
 Documentation, integrated medical record

34. Leadership
 Administrative Leadership
 Identify a champion who won’t give up
 Barrier buster activities
 Clinical Leadership
 Identify a provider with a commitment to the
model
 If it doesn’t exist
 Identify an opinion leader or two and convince
them of the viability
 Get them trained and have them start using it
 Organizational leadership development program

35. Capacity of the Practice
 Infrastructure
 Technology
 Space or capacity to share
 Reception staff
 Dedication to integrated healthcare
 Collegiality
 If it doesn’t exist
 Identify barriers and determine how to and
when to create breakthroughs
 Add to organizational development plan

36. Individual Characteristics of
Integrated Care Staff
 General Characteristics
 Collegial
 Flexible (comfort zone, roles, space)
 Autonomous
 Multitasking ability and tolerance
 Practicality (Common sense biopsy)
 Assertive
 Clear understanding of what CAN be
done

37. Medical Provider Characteristics
 Primary Care Providers
 Differences in training (Internal Medicine
vs. Family Practice vs. others)
 Psychiatrists
 Community psychiatry focus
 The Generalist / Teacher

38. Roles of the
Behavioral Heath Specialist
 Direct service provider
 Consultant to both psychiatrist and
primary care providers
 “Speak truth to power”
 Allow and accept recommendations from
non-medical professionals
 Community liaison

39. Roles of the
Behavioral Health Specialist
 Linchpin / Mortar
 Liaison between PCP and psychiatrist
 Triage officer, crisis manager
 Joint sessions (“co-visits”) with PCP staff
 “Curbside” consultant
 Bridge care between PCP and CMH
 Provide ongoing follow up for psychiatrist
 Manager of psychiatry time
 Brief treatments and case management

40. Role of the Psychiatrist
 Educator, Clinician and Liaison
 Curbsides
 Co-visits
 Consultation
 Co-management
 Clinical Teaching
 Case conferences
 Community bridging

41. Outreach
Success depends upon it
O utreach is a
profound
manifestation of
unconditional positive
regard offered
towards a stranger.

42. Psychiatric Outreach:
Starting Where the PCP Is
 Bring the door to the PCP
 Meet where he/she is, literally and figuratively
 Different PCPs => Different stages of change
 Service must meet perceived needs
 PCPs don’t care how much you know until they
know you will help
 Offer service, be concrete, actively listen
 Be always available and become indispensable
 Remember Maslow
 Motivational enhancement of PCP
 See one, do one, teach one

43. Engagement
Central to all work with primary care providers
E ngagement is a
process of relational
discovery between
two or more people. It
is characterized by
mutual respect,
shared responsibility,
and commitment
towards positive
change.

44. PCP Engagement
As Empowerment
 Have perception of poor access to and
communication from psychiatry
 Opportunity to “do with”
 Have appreciation of PCPs’ strengths
 Building of trust and relationships are key
 Work from stance of consensus rather than
coercion or isolation
 Cultivate change together
 Facilitate recovery from days of split treatment,
practice silos and the mind/body dichotomy

45. In Summary

46. Core Factors For
Successful Integration
 Recognize that the population exists in the
practice
 Already committed to your patients
 Consciously decide how the practice will
address behavioral healthcare integration
 Make a plan
 Establish a learning environment
 Change is a process
 Develop a process that supports change

47. Core Factors
For Successful Integration
 Leadership, both administrative and
clinical
 Transform the culture as well as the process
 Understand the capacity of the practice to
provide integrated care
 Grow, but know your limits
 Individual characteristics of the primary
care providers and mental health
professionals
 Get the right people on the bus

48. Core Factors
For Successful Integration
 The role of the psychiatrist and behavioral
health specialist
 Adapt to the patient and provider needs
 Make yourself indispensable

49. Thank you