Tag Archives: Dr. Bob Climko

Behavioral Health – Primary Care Integration Partnerships: Measure Outcomes

MEASURING OUTCOMES

The value of shared outcomes
It should be no surprise to either behavioral health nor primary care partner that measuring outcomes is important. Each organization has a number of metrics that are tracked routinely.  Measuring outcomes of the integrated partnership are just as important. These outcomes should be jointly agreed upon early in the project. Periodic re-evaluation of the outcomes is beneficial to assuring that they remain relevant to each partner. Be prepared to modify as needed.

Identifying outcomes to be measured and faithfully tracking them provides the necessary data for the organizations’ decision makers. The data serves to demonstrate the effectiveness to others as well as for use in securing additional funding in the future.  Outcome measures need not be expensive or overly complicated. The important thing is to be consistent.

Measuring the benefits of the partnership 
The integrated behavioral – health primary care partnership is far greater than the sum of its parts. The synergistic effect of the partnership results in enhancing the lives of the individuals served to a degree that cannot be matched by either organization alone. Treating the hypertension of a person who also suffers from schizophrenia has a far greater impact that in treating either of the comorbid disorders separately. Measuring the outcomes clearly demonstrates the value of the partnership and the significant impact on the life of the individuals served. While most healthcare professionals are driven by the day to day intrinsic value of helping, successes identified in objective reports serve as further motivation to dedicated members of the team.

There is a clear benefit in having fewer services that must be duplicated when the behavioral health and the primary care is provided separately. When exams and diagnostic tests are done by one provider, there is considerable cost savings. Tracking these savings will demonstrate the added value of the partnership.

Quality of life and client satisfaction surveys are effective ways of determining the value that is provided through the collaborative approach to treatment.

It is not enough to feel that you are doing a good job when it comes to demonstrating success. Through measuring the value of services provided in an integrated behavioral health – primary care partnership, the value of the partnership can be indicated in undisputable terms.

This is the last in the series of steps for a successful behavioral health – primary care partnership. These eight steps have been adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June1998. Vol. 18 . No. 3:

  1. Establishing the Mission of the Partnership
  2. Identifying a Common Language
  3. Maintain Pacing, Flexibility, and Capacity
  4. The Value of Shared Solutions
  5. Determining Expectations
  6. Delegate Trust
  7. Create Empowerment
  8. Measure Outcomes

Behavioral Health – Primary Care Integration Partnerships: Create Empowerment

According to BusinessDictionary.com:

Empowerment:
“Management practice of sharing information, rewards, and power with employees so that they can take initiative and make decisions to solve problems and improve service and performance. It is based on the concept of giving employees the skills, resources, authority, opportunity, motivation, as well as holding them responsible and accountable for outcomes of their actions.” 

Some of the most successful companies in the world understand the added-value of empowering their employees (think Starbucks or Ritz-Carlton). After reading the definition from BusinessDictionary.com, it begs the question of why ANY company would not insist on the promotion of employee empowerment.

CREATE EMPOWERMENT 

Champions at all levels promote success
The success of a partnership between a primary care organization and a behavioral health organization for the provision of integrated service delivery is dependent on the involvement of everyone from the onset. This requires empowering champions at all levels to move the mission forward and create accountability.  Not only is it important for the people at the top to believe in the project, it is even more important for the people who will be providing the services, coordinating the flow, scheduling the appointments, etc. to be empowered to do whatever is necessary to make sure that the clients get the service they require and deserve. This empowerment promotes buy-in among staff. The level of commitment that the members of the team have determines whether a project succeeds or not.  

Encourage communication…don’t shoot the messenger
Communicating with everyone and soliciting feedback ensures ongoing focus on the mission. Be sure to create a forum that allows both positive and negative feedback. Many promising endeavors have failed because the front line staff were not encouraged to share observations of trends or occurrences that were early indicators of problems. Frequent communication among everyone on the team is vital. Management, clinicians, and support staff from both organizations should be included in meetings, emails, and conference calls that allow and encourage an exchange of information and ideas among everyone. In addition, frequent treatment team meetings with clinicians from each organization will ensure an integrated approach for the services provided.

Adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June 1998. Vol. 18 . No. 3.

Behavioral Health – Primary Care Integration Partnerships: Delegate Trust

The delicate subject of trust is the focus of this installment in the series devoted to creating a healthy integrated partnership between behavioral health and primary care. This has been adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June 1998. Vol. 18 . No. 3.
 
DELEGATING TRUST
 
Trust is necessary to overcome expected conflict
When team members of the behavioral health and the primary care organizations come together for an integrated partnership, typically everyone is on their best behavior. It is easy to have a harmonious relationship at this stage. However, when conflict first intrudes, particularly regarding shared goals and outcomes, the amount of trust between partners can make or break the partnership. Create the forums at the onset to maintain a system of checks and balances. Face-to-face time creates a forum for maintaining checks and balances to ensure fidelity to the mission. Constantly solicit feedback from partners at all levels. The transparency also breeds trust.
 
Focus on building trust at all levels
It takes a significant amount of trust for a person to commit to any partnership; the behavioral health primary care integrated partnership is no different. Often the partnership is created when two leaders, most likely chief executive officers of the organizations, decide to bring together their collective expertise. The two CEOs build upon their mutual shared experiences of serving on committees, community boards, etc. together. They travel in similar circles and have developed reciprocal trust and respect. Unfortunately, a frequently overlooked aspect of this process is the fact that the managers and frontline staff who must join together to make the collaborative partnership a reality have NOT had the opportunity to develop that same level of trust. The wise leader recognizes the importance of building the trust necessary for a solid foundation between partners. Trust does not automatically filter down. Devoting considerable face time during the planning stage aids in establishing a firm foundation of trust. Dedicated time for regular interaction (weekly/monthly meetings, conference calls, etc.) helps to maintain the connection. Maintaining the flow of communication helps everyone to stay current with expectations and reduces the chance of surprises, which can quickly erode trust. Bringing together staff with their counterparts allows for those relationships to develop separately in addition to the collective partnership/relationship. It also allows issues and solutions to be addressed at the appropriate level. Medical Directors must communicate with Medical Directors; nurses communicate with nurses. When the CEOs communicate with each other in their decision-making process, they will benefit from the solidarity among the matched pairs in gathering input. Making informed decisions prevents leaders from forcing issues and promotes the trust that is so vital to success relationships.
 
“The glue that holds all relationships together – including the relationship between the leader and the led is trust, and trust is based on integrity.” -Brian Tracy
 

Behavioral Health – Primary Care Integration Partnerships: Determining Expectations

The majority of integrated partnership failures occur due to irreconcilable differences.  This step focuses on the sensitive issue of the compromise on expectations.

This fifth installment of vital steps for creating a successful behavioral health – primary care partnership, has been adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June1998. Vol. 18 . No. 3.  

DETERMINE EXPECTATIONS

This step addresses the issue of the expected outcomes for the partnership, building upon the shared mission:

What results do you expect from the partnership?

Do your expectations coalesce with those of your partner?

Compromise is in order at this juncture. Chances are good that each partner will agree on some things, but not on all things. The most successful of partnerships will devote adequate time and energy at this point to identify mutually agreed upon expectations and how results will be measured. The partnership creates enhanced outcome opportunities. Open communication on an ongoing basis helps to keep everyone on track. Internal conflicts are inevitable and should be discussed openly. The partners must address differences of opinions on an ongoing basis to prevent resentments from building.

Partnerships create an opportunity for enhanced outcomes through blending of resources to maximize the capacity of each organization. The result is a synergy far greater than the individual components. The integrated behavioral health – primary care partnership is far more effective and powerful than the single behavioral health or primary care clinic.  Addressing all healthcare needs of the individual yields benefits that far exceed treatment focused only on behavioral health or primary care concerns.

Once the data elements are identified, collect a baseline before starting. The project should first be piloted to allow for evaluation and for adjusting expectations to further clarify the outcomes to be measured. Re-evaluate and respond. Time devoted to this process at the beginning will save considerable time, energy, and frustration further along in the project. With a solid framework of data elements, baseline, and data collection processes in place, outcome measurement will be easy to accomplish. Outcomes that are meaningful to the mission of the partnership will provide the guidance necessary for ongoing success.

 

Behavioral Health – Primary Care Integration Partnerships: The Value of Shared Solutions

The next step in the process of developing a successful behavioral health – primary care integrated partnership, is developing  shared solutions for the partnership. This is adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June 1998. Vol. 18 . No. 3.

 DEVELOPING SHARED SOLUTIONS

When behavioral health and primary care organizations collaborate to provide integrated services, it is very important to develop shared solutions for success in the endeavor. For a partnership to meet the needs of all partners, the decision-making must be shared. The decision makers must be open to new ideas and problem solving. 

One of the most difficult tasks in a partnership is bringing two disparate organizations together, asking them to compromise for the good of the relationship.  All stakeholders traditionally are in favor of creating a shared solution…..as long as they aren’t the ones who are asked to make the change. This step requires taking the time to explore the areas in which the partners can make adjustments versus the areas that require strict adherence to the regulations of the organization.

This step in the partnership requires time to come to an agreement. Negotiations may take some time, but are worth the investment.  Everyone must have skin in the game. During the process of negotiating, the ideal end result will develop from compromise among all partners. Patience and understanding are vital at this point and will ultimately result in a shared solution if the partnership is viable. Shared solutions maximize organizational efficiency and capacity. It helps to avoid the “blame game”.

Healthy partnerships result from both give and take on the part of all partners. Compromise is important for the success of the partnership.  Partners have much more invested in the successful outcome when there is agreement on the ultimate mission.

Behavioral Health – Primary Care Integration Partnerships: Maintain Pacing, Flexibility, and Capacity

This is the third in a series addressing key points in building a successful behavioral health - primary care partnership, adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June 1998. Vol. 18 . No. 3, in this and future posts.

Maintain Pacing, Flexibility, and Capacity

As with most exciting initiatives, there is considerable energy and excitement at the onset of a partnership between behavioral health and primary care organizations for integrated services. Unfortunately, the momentum can drop when the initial excitement succumbs to challenges and roadblocks that delay the results we anticipate. Therefore, this important step should be considered early on. There WILL be challenges to deal with: it’s inevitable. Preparing for this on the frontend will help to prevent disillusionment later on. Remember that the flywheel requires SIGNIFICANT front-loaded energy. So be sure to temper expectations. Early successes are important upon which to build. It helps to make it through the slow periods. Be sure to celebrate ALL successes to fuel enthusiasm and perseverance.

Ongoing communication focused on progress (or lack thereof) toward goals will help to keep everyone on track. Setting aside time to discuss successes and disappointments on a regular basis keeps the team focused. It can be so discouraging when things don’t work out as we had hoped. Taking time to process a disappointment provides the opportunity for several important things to happen: strengthening bonds through shared experiences, recalibrating the project, and finding the gold nuggets of success buried within the disappointment. 

It’s important to ensure that the team is clear on what the goals are. All parties should have an active role in establishing the goals. It’s not uncommon for behavioral health staff and primary care staff to have different objectives leading to the goals. Taking the time to clarify objectives promotes mutual respect and strengthens the relationship further.

As the natural differences between the cultures of the partners emerge, a balance must be achieved between pushing and pulling. Too much coaxing creates resentment, as does the feeling of always having to compromise on expectations. While no one wins all the time, each partner should feel that a few wins have been negotiated. Taking the time to reach a compromise that respects each partner will strengthen the relationship.

While following established timelines and schedules are important, excessive rigidity creates a chasm between partners. Flexibility and sensitivity to capacity issues are critical to the success of the partnership. Don’t forget that reality happens!

Next we will explore the importance of developing shared solutions for a successful behavioral health - primary care partnership.

Behavioral Health – Primary Care Integration Partnerships: Identifying a Common Language

A successful behavioral health - primary care partnership requires focus on building the relationship from the onset.  We will explore the steps that were adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June 1998. Vol. 18 . No. 3, in this and future posts.

Integration of the partners requires a common language

Behavioral health and primary care professionals speak different languages. When the two organizations sit down to discuss the details of the partnership, everyone has stars in his/her eyes in anticipation of the wonderful things to come (and rightly so). However, many seemingly trivial matters are overlooked in the excitement. Identifying a common language between the partners is one such matter that is frequently overlooked.

Clarity of communication enhances mutual understanding of cultures, roles, and expectations

Mutual understanding of cultures, roles, and expectations sets the tone for a respectful, healthy partnership. Like any important relationship, honoring matters of importance to partners creates an environment of trust.

It is crucial to an integrated behavioral health and primary care partnership to clarify language differences and negotiate an agreement. While there are numerous commonalities among healthcare in general, specialty areas have a unique terminology as well. It is important to agree upon a language that all partners understand and agree upon. For example, there are notable differences between contract deliverables for behavioral health and primary care organizations. Failure to clarify this can potentially result in failure to meet targets.

A few examples of language differences:

  • What will the people who are served be called?  Patients, clients, consumers, members are some possibilities
  • The roles of the professionals vary among organizations and must be decided upon for the partnership
  • Medical records
  • Coding
  • Billing
  • Clinic flow
  • Management structure

Once the language has been identified and defined, patience is necessary as each partner adjusts to a new way of doing business. Patience, understanding, and ongoing compromise are key in the success of an integrated partnership.

Next time we will explore the importance of maintaining pacing, flexibility, and capacity in the behavioral health and primary care integrated partnership.

Behavioral Health – Primary Care Integration: Establishing the Mission of the Partnership

Community behavioral health organizations and Federally Qualified Health Centers (primary care organizations) are very mission driven.  There are numerous similarities between the two.  Each is focused on healthcare, serves as safety net provider, and serves people who are uninsured or underinsured. However there are differences as well, as you might expect.  Behavioral health organizations employ psychiatrists, psychiatric extenders, psychiatric nurses, psychologists, counselors, and social workers, and focus primarily on the recovery model. While primary care organizations employ family practitioners, physician assistants, nurse practitioners, medical assistants, nurses, certified nursing assistants, and focus primarily on the medical model. Very different philosophies and cultures. Therefore, it is vital to pay close attention to the partnership when developing a behavioral health – primary care integration partnership. Too often partnerships between the two stumble or perhaps even fail because of neglecting to address some key differences.  As discussed in the last post, for a successful behavioral health - primary care partnership, it is imperative to focus on building the relationship from the onset.  We will explore the steps that were adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June 1998. Vol. 18 . No. 3, in this and future posts.

ESTABLISH THE MISSION OF THE PARTNERSHIP 

Shared Vision

Each organization comes to the partnership with its own mission. It is a mistake to assume that the two separate missions are adequate to drive the partnership to success. It is vital for both organizations to sit down together and create a shared vision for the partnership. This will likely require a merging of goals into a partnership mission statement, comprised of elements in which each partner finds value. The mission statement serves as an anchor and roadmap for the partnership, ensuring that everyone is on the same page and heading in the same direction. This process should not be rushed, allowing time for the expectations of each partner to be explored so that the mission of the partnership can be negotiated. Best results occur when input is obtained from the various stakeholders at all levels. A statement that is meaningful to everyone is most effective. It should be clear, concise, and easily understood.

Communicate

Once the mission of the partnership has been determined, it is important to communicate it widely and often. This helps to clarify the mission and keep everyone on track.  It must be communicated with everyone involved in the partnership. Employees at all levels within the partner organizations are vital for success. This includes respectfully taking the time to listen to suggestions, comments, and complaints from all levels, responding accordingly. Touching base with everyone on a regular basis, trouble-shooting, providing feedback, and reassurance assures open communication and greatly increases buy in.

Frontline Champions

The success of the partnership’s mission will depend on frontline champions. In a behavioral health – primary care partnership, the frontline champion might be a nurse, an office manager, a clerk, etc. They need to be identified and empowered from the onset. Your champions provide the energy to motivate the other team members. Rest assured, your project will not succeed without these vital members of the team, serving as cheerleader and providing the enthusiasm and energy necessary to infiltrate the attitudes of the skeptics. The frontline champions help to give substance to the mission, allowing others to gradually begin to see it as well.

Establishing the mission of the partnership is a fun process that begins with two disparate organizations and along the way, creates another unique entity. This third entity is more than mere subsets of the two organizations joined together. It is a new creation with distinctive elements. It is greater than the sum of its parts: It is an Integrated Partnership.

Next time we will explore the importance of identifying a common language for our newly created integrated partnership.

Successful Behavioral Health and Primary Care Partnerships

I am happy to see that there are numerous initiatives underway to address the primary care needs of people with behavioral health disorders. It is heartwarming to see the silos begin to develop cracks, allowing the primary care folks and the behavioral health folks to engage in conversations about how we can work TOGETHER to serve this vulnerable population.

It isn’t easy for two disparate groups to work together.  It takes considerable planning!  Despite the fact that primary care and behavioral health are both healthcare fields, they have vast differences.  The culture, funding streams, philosophy, and overall approach to treatment vary greatly. Therefore, it is not an easy task for these two groups to establish a collaboration for serving the folks with behavioral health disorders….yet they are doing just that!  The mission is bigger than the differences! It is worthwhile to focus on ways to streamline the integration process.

For a successful behavioral health – primary care partnership, it is imperative to address these eight steps that were adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June1998. Vol. 18  No. 3:

  1. ESTABLISH THE MISSION OF THE PARTNERSHIP
    It is vital for both organizations to sit down together and create a shared vision. This will likely require a merging of goals into a partnership mission statement. This mission statement must be communicated with everyone involved in the partnership. The success of the partnership will depend on frontline champions.  They need to be identified and empowered from the onset. They will provide the energy to motivate other team members.
  2. IDENTIFY A COMMON LANGUAGE
    Primary care and behavioral health speak different languages; therefore, a common language must be identified.  Clarity of communication enhances mutual understanding of cultures, roles, and expectations.  While these differences might not seem important at the onset, it will become increasingly important as the partnership progresses.  Most likely, each partner has a different language for many things. There are notable differences between contract deliverables, medical records,  coding, management structure, procedures, and even the language used in describing the clients/patients/consumers/members served.
  3. MAINTAIN PACING, FLEXIBILITY, AND CAPACITY
    It is very important to temper expectations within the partnership. Establishing regular meetings will help to promote ongoing communication. Mutual goals and disappointments should be continually communicated so that they can be addressed immediately. The partners must remain flexible in order to sustain a healthy partnership.
  4. DEVELOP SHARED SOLUTIONS
    The decision makers must be open to new ideas and problem solving. Developing shared solutions maximizes organizational efficiency and capacity. Everyone must have skin in the game! Compromise is important for success.
  5. DETERMINE EXPECTATIONS
    The project should first be piloted to allow for evaluation and for adjusting expectations to ensure that both partners are on the same page. Internal conflicts are inevitable and should be discussed openly.  The partners must address differences of opinions on an ongoing basis. Partnerships create an opportunity for enhanced outcomes through blending of resources to maximize the capacity of each organization.
  6. DELEGATE TRUST
    Face-to-face meetings are essential to establishing and maintaining trust among partners. Be sure to focus on building trust at all levels.  Face-to-face time creates a forum for maintaining checks and balances to ensure fidelity to the mission. Constantly solicit feedback from partners at all levels.
  7. CREATE EMPOWERMENT
    Success is dependent on the involvement of everyone. This requires empowering champions at all levels to move the mission forward.  This empowerment develops buy-in among staff. Communicating with everyone and soliciting feedback ensures ongoing focus on the mission. Be sure to create a forum that allows both positive and negative feedback.
  8. MEASURE OUTCOMES
    Establish the outcomes to be measured early in the project. Be prepared to modify outcomes as needed. Don’t overlook the benefits of partnership that include more efficient allocation of resources, less duplication of services, increased choice among clients, and the synergistic effect of the partnership resulting in enhancing the lives of those we serve.

Following these eight steps helps to bridge the differences between behavioral health and primary care to ensure a successful partnership. Many partnerships have been derailed due to poor communication and lack of planning.  Careful preparation at the onset will ensure a productive partnership that will ensure a focused mission to address the health disparities among people with behavioral health issues.

Reducing Health Disparities Among People with Serious Mental Illness

“Psychiatrists need to pay attention to weight, lipid levels, blood pressure, and exercise in our patients with serious mental illness,” declares psychiatrist Dale Svendsen, M.D., medical director at the Ohio Department of Mental Health and co-author of the NASMHPD report. “The psychiatrist of the future is going to have to be more of a general physician than in the past, and our training programs are going to need to adapt.” In Those With Serious Mental Illness Suffer From Lack of Integrated Care, in Psychiatric News January 5, 2007, Vou. 42, No. 1, Pg. 5 Mark Moran summarizes the National Association of State Mental Health Program Directors (NASMHPD) report “Morbidity and Mortality in People With Serious Mental Illness.” Emphasizing the recommendation that people with serious mental illness “be designated as a distinct health-disparities population under the federal government’s initiative to reduce disparities in health outcomes.”  Perhaps psychiatrists need to pick the stethoscope back up again…. and actually  touch their patients.

Moran goes on to look at compelling data: In a study of people (25 to 44 years old) with serious mental illness in Massachusetts over a six year period, the cardiovascular rate was nearly seven times that of the general population. In another study in Ohio, state psychiatric hospital discharges were tracked over a six year period. People who had been hospitalized there died at three times the expected rate, primarily due to cardiovascular disease. The average loss of life was a startling 32 years. The NASMHPD report drew clear connections between antipsychotic medications in the development of metabolic syndrome in people with serious mental illness, particularly when multiple medications are prescribed. Their recommendations include integration of behavioral health and physical health, promotion of  the recovery model, supporting wellness, and the implementation of care-coordination models.

In the nearly four years since this was published, there has been a marked increased in focus on the serious health disparities of this vulnerable population. The question remains whether there has been an improvement in overall health among this group. While ongoing studies must be conducted to adequately address this question, I am encouraged by the concentration on the issue. The National Council for Community Behavioral Healthcare, the Mental Health Corporation of America, Association of Healthcare Research and Quality, the Carter Center, the Collaborative Family Healthcare Association, National Institute of Mental Health, Substance Abuse and Mental Health Services Admistration, National Association of State Mental Health Program Directors, Institute for Clinical Systems Improvement, Collaborative Care Research Network, Health Resources and Services Administration, and a variety of other national and state associations have initiatives directed toward integration efforts. These efforts include new programs, partnerships, grants, learning collaboratives, and research. APS Healthcare of Georgia’s Disease Management division is working on an initiative with various community behavioral health organizations to create a ‘Virtual’ Medical Home. This novel approach is led by Dr. Bob Climko, Senior Medical Director. Health indicators in people with serious mental illness are monitored through telephonic health coaching and Medicaid claims data made available to providers.

It is hopeful that this increased focus will result in a significant increase in longevity for people with serious mental illness. In the words of UN Secretary General Ban Ki-moon, “Let us recognize that there can be no health without mental health.” It would appear that the reverse is true as well: There can be no mental health without health.