behavioral health integration · collaborative care · Integrated Care

Top Ten Useful Measures, Assessments, and Tools for Collaborative Practices

(This blog post is a reprint of a piece in the CFHA Blog from January 15th, 2015. Click here for the original post. Reprinted with permission.)

In primary care, more than half of the office visits are for somatic complaints, which are often associated with depression and anxiety. These conditions often go undetected and can have a significant impact on health outcomes. As providers adopt a collaborative approach to care, many have incorporated the use of assessments for screening and early detection of symptoms of mental health and substance use conditions.

With an abundance of assessments, measures, and tools available for use, many collaborative care practices are challenged with determining which are most effective for use in the limited time available during a routine office visit. Screenings are important for all age groups. Below is a list of the top ten tools for use in practices. These ten were selected based on a number of factors, including reliability, validity, sensitivity, efficiency, and cost. In most cases, the tools are available for use at no cost. Most are also available in multiple languages as well.

  1. PHQ-9: The Patient Health Questionnaire (9) is widely used among primary care providers to identify depression. With only nine questions, this tool is easy to use and has been validated for early detection.
  2. AUDIT: The Alcohol Use Disorders Identification Test is a 10-item questionnaire developed by the World Health Organization and is found to be very effective in primary care settings.
  3. GAD-7: The seven-item General Anxiety Disorder screening identifies whether a more complete assessment is needed.
  4. DAST-10: The Drug Abuse Screen Test is a brief 10-item self-report tool that is effect for screening adults and adolescents for drug abuse.
  5. PC-PTSD: This four-item screen is effective for detecting post-traumatic stress disorder in primary care settings.
  6. Pediatric Symptoms Checklist: The 17-item version is easy to use in family practices for detecting developmental and behavioral problems.
  7. SBQ-R: The Suicide Behaviors Questionnaire is a four-question scale for assessing suicide-related thoughts and behaviors.
  8. Brief Pain Inventory: The tool is widely used in medical settings for assessing pain, and is available in 23 languages.
  9. Insomnia Severity Scale: This seven-question screening assessment is effective in identifying problems with sleeping.
  10. MDQ: The Mood Disorder Questionnaire (MDQ) is a 13-item questionnaire used to screen for bipolar disorder symptoms.

In order to limit the list to ten, there are many excellent tools that did not make this list. For example, some providers prefer the CAGE-AID to the AUDIT-7 for alcohol screening. In addition, many will find it very useful to have additional tools on hang to screen for additional conditions, such as:

  • Geriatric depression
  • Eating disorders
  • Postpartum depression
  • Intimate partner violence
  • ADHD
  • Autism

Integrating these tools into your electronic health record, including them in patient kiosks, and/or instructing support staff to make select tools available for completion while in the reception area are ways in which these cools have been included in practices. With routine use of many of these screening tools, collaborative care practices will efficiently and effectively detect signs and symptoms of behavioral health conditions. This enables earlier intervention, resulting in better health outcomes.

What is on your top ten list?

behavioral health integration · Integrated Care · mental health

John F. Kennedy’s Community Mental Health Act of 1963: 50th Anniversary

Today marks the 50th anniversary of the date that President John F. Kennedy signed the 1963 Community Mental Health Act into law. It was to be the last before his death on 11/22/63. The Act represents a monumental turning point in the treatment of psychiatric disorders. President Kennedy’s call to action in 1963 was based on a belief that all Americans – including those with mental illnesses, intellectual disabilities, and addictions – have a right to lead dignified lives and to share in the benefits of our society. Patrick Kennedy, nephew of President Kennedy and former U.S. Representative of Rhode Island, is steadfast in his efforts to continue this important work via the Kennedy Forum.

Act of October 31, 1963 “Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963”, Public Law 88-164, 77 STAT 282, “to provide assistance in combating mental retardation through grants for construction of research centers and grants for facilities for the mentally retarded and assistance in improving mental health through grants for construction of community mental health centers, and for other purposes.”, 10/31/1963 (Figure 1 below)

History of Psychiatric Treatment

Figure 1: Mental Retardation and Community Mental Health Centers Construction Act of 1963

Early attempts to treat mental illness are thought to date back to 5000 B.C. or earlier, based on the discovery of trephine skulls. A series of barbaric practices followed for millennia. It is suspected that the first asylums were established around the sixteenth century. These early facilities offered no real treatment despite their primitive attempts at cures, consisting of the use of leeches, purges, barbaric contraptions, and the use of chains and other restraints. Conditions gradually began to improve by the mid 1800s thanks to efforts led by humanitarians such as Dorothea Dix. Treatment reform in the asylums offered a more humane approach to the care of people with mental illness.

New treatment options followed in the early twentieth century, including psychoanalysis, introduced by Austrian neurologist, Sigmund Freud, and electroconvulsive therapy, introduced by Italian neuropsychiatrists, Ugo Cerletti and Lucio Bini. Psychopharmacology followed, arguably providing the single most significant change in treatment to date. A former colleague, psychiatrist, Dr. John Wolaver, remarked that when Thorazine was introduced in the psychiatric hospitals, the facilities were suddenly calm and quiet for the first time. It seemed to be a miracle cure. Psychopharmacology provided the next necessary step that led to deinstitutionalization.

The introduction of the Mental Retardation and Community Mental Health Centers Construction Act of 1963, Public Law 88-164, a bold new effort,  forever changed the face of mental health treatment. Prior to this, it was not uncommon for individuals with behavioral health conditions to be hospitalized for many years; hundreds of thousands lived their lives in institutions and were buried on the grounds. Unfortunately, this deinstitutionalization effort fell short of its goal. The USA Today report, Kennedy’s Vision for Mental Health Never Realized, takes a candid look at this.

Figure 2 below illustrates the decrease in inpatient treatment between 1950 and 1995. As the psychiatric hospitals decreased in size, the homeless population grew. The jails and prisons began to fill with the individuals with behavioral health conditions. According to the 10/24/13 article, Why Are The Three Largest Mental Health Care Providers Jails? published by NewsOne:  The three largest mental health providers in the nation are the following jails: Cook County in Illinois, Los Angeles County and Rikers Island in New York. 

Figure 2: Deinstitutionalization

Integrated Care

Many thought-leaders believe that we have embarked upon another pivotal point in mental health (or more broadly, behavioral health) treatment. Mental Health: A Report of the Surgeon General published in 1999 called for the integration of behavioral health and primary care. And the 2006 NASMHPD report, Morbidity and Mortality in People with Serious Mental Illness has prompted the movement toward a whole health approach to treatment that integrates behavioral health and primary healthcare. This promising trend offers hope for improved access for individuals who live with mental health and/or substance use disorders, improved health outcomes, and controlling healthcare spending.

Let us work together to address health conditions wherever the individual presents for treatment. Healthcare must be redefined to include behavioral health. By removing the healthcare silos, providers will begin to recognize and treat the comorbid conditions in their patients. Mind-body integration improves patient outcomes and reduces costs.

Integrated care is necessary for improving the lives of of those who might have spent his or her life chained in a dungeon centuries ago. It is a key element in our efforts to achieve the Triple Aim.

Affordable Care Act · behavioral health integration · healthcare integration · mental health

The Role of Integrated Care in Mental Health: Mental Health Blog Day 2013

Blog for MH 2013

I’m happy to be participating in blogging for mental health today. I’m joining in on this year’s blog party because mental health awareness is so important. Each mental health blogger has a unique perspective, addressing important topics such as awareness, recovery, wellness, public policy, services, co-occurring mental health and substance use disorders, etc., providing a personal, professional, or business perspective – or any combination of the three. These interesting and informative mental health blogs will provide an abundance of good reading for blog connoisseurs today!

Integrated care, a whole-health approach to healthcare, plays a very important role in mental health. This perspective has been gaining more and more attention over the past decade or so. It is not uncommon for people who receive mental health treatment to have little or no coordination of services with their primary care provider. Conversely, many people seeking primary care services have unmet mental health and/or substance use disorder treatment needs. This lack of coordination frequently results in sub-par outcomes, yet is often much more expensive as a result of duplicate or counter-indicated procedures and treatment. Lack of coordination results in costly emergency department visits, providing episodic treatment rather than a much more effective chronic care regimen and focus on prevention.

In my last post, I suggested that Integrated Care Awareness Day be recognized during Mental Health Month. As we increase awareness of the need to focus on healthcare in a holistic way, we begin to change the perception of mental health, not only for healthcare providers and policy-makers, but also for the public at large. Through improving access to services, controlling healthcare costs, and through tracking and improving health outcomes, we as a society can transition toward a wellness approach in healthcare.

Access to Services

Stigma is a huge barrier to receiving mental health services. Integrated care allows people to access services through mental health providers or primary care providers. They have the choice to receive mental health services where they are most comfortable.

Controlling Healthcare Costs

Coordination of care and focus on prevention help to control overall healthcare spending. The Affordable Care Act has provided the opportunity for changing the way that healthcare is delivered. Medicaid Health Homes are an example of this.

Improving Health Outcomes

Making use of health information technology enables providers to track outcomes, develop disease registries, and to share information for enhancing the coordination of care. As a result, people have improved health outcomes. They are healthier.

I hope you will stop by again soon. The next several posts to come will be a Thought Leader Series, a conversation with the visionary leaders who are instrumental in developing integrated care through research, policy, practice, and their steadfast passion for improving the lives of so many.

Happy Mental Health Blog Day 2013!

collaborative care

CFHA Blog: Collaborative Care Is An Evidence Based Treatment Model For Depression And Anxiety

Collaborative Care Is An Evidence Based Treatment Model For Depression And Anxiety

Posted By Pamela Williams in CFHA* Blog

As readers of this blog are well aware, depression and anxiety “are a major cause of disease burden and disability with depression projected to become one of the three leading causes of burden of disease by 2030.” It is estimated that 90% of people who suffer from depression and anxiety are treated solely by their primary care physician, and the majority of these interventions are exclusively pharmacological. Many people also report being unsatisfied with the level of care they receive. While these facts point toward collaborative care being a logical and effective treatment model for depression and anxiety, there was not enough research that provided conclusive evidence to support recommending collaborative care for those with depression and anxiety problems until this year.

Click here to read the complete story on the CFHA Blog

*Collaborative Family Healthcare Association (CFHA) promotes a comprehensive and cost-effective model of healthcare delivery that integrates mind and body, individual and family, patients, providers and communities. CFHA achieves this mission through education, training, partnering, consultation, research and advocacy. 

behavioral health integration · behavioral health primary care integration · collaborative care

Mental Illness Awareness Week: Raising Awareness of the Need for Integrating Behavioral Health and Primary Care Services

Mental Illness Awareness Week, October 7 – 13, 2012

In the US the first week of October has been recognized as Mental Illness Awareness Week since 1990 when it was established by Congress in recognition of the National Alliance for Mental Illness’s efforts to increase public awareness about mental illness. Mental Illness Awareness Week also coincides with similar organizational campaigns:

There is no doubt that this campaign has been a successful one, raising awareness, encouraging people to screen for depression, and chipping away at the negativity surrounding mental illness. This theme is aligned with the philosophy of behavioral health integration. Therefore, perhaps a day can be designated for recognizing the importance of integrating behavioral health and primary care services. When physical health and behavioral health are addressed concurrently, people have better health outcomes and are better satisfied with their healthcare services. Integrated healthcare also offers improved access to services and reduces healthcare costs.

Integration has been referred to as the neck; a means of reconnecting the mind and body. In integrated healthcare, the mind and body are addressed as a whole, rather than compartmentalized. There is a focus on prevention and wellness that promotes improved health outcomes. Across the United States and around the world, behavioral health and primary care providers are transitioning service delivery to a more collaborative approach. The United States Department of Health and Human ServicesSubstance Abuse and Mental Health Services Administration has invested in nearly 100 initiatives in their Primary and Behavioral Healthcare Integration grants. This commitment demonstrates the importance placed on integrated healthcare by the United States.

Perhaps we can designate each Friday of Mental Illness Awareness Week as National Behavioral Health and Primary Care Integration Awareness Day.

What do you think?

behavioral health integration · behavioral health primary care integration · healthcare integration

Integration of Behavioral Health and Primary Care: Preparing for Service Delivery

When your behavioral health and primary care integration partnership has worked through the preliminary groundwork for integrating services (click here for more information on planning), it’s time for preparing for the delivery of the services. The detailed outline created in earlier steps becomes your business plan. The plan serves as a map of the partnership’s goals and provides direction for delivering services.

Formalizing the partnership

When two organizations are collaborating for providing integrated services, it’s important to understand the legal and regulatory requirements. Working through this process should include consultation with an attorney. The following resources provide additional information for consideration:

Service Delivery

Once the legalities have been addressed, including the signing of a Memorandum of Understanding, Business Associates Agreement, etc., it’s (finally!) time to establish a start date and prepare for the delivery of the much needed services. The preliminary work, though tedious at times, was necessary to ensure the success of service delivery.

Careful planning is the hallmark of successful healthcare integration!

Through the careful planning of the behavioral health and primary care providers, they are ready to offer services in a more holistic manner. With co-morbid behavioral and physical health conditions more often the rule rather than the exception, the newly integrated services enable the team to provide much more comprehensive care coordination in this behavioral health and primary care marriage than either partner could have done independently. The whole is greater than the sum of its parts!

Celebrating Success

Once the equipment and supplies are in place, staff training is completed, and the start date has been announced to internal and external referral sources, it’s time to celebrate!

Celebrating important milestones is very important for ongoing success. It is an opportunity to strengthen relations among the healthcare integration team. Also, celebrating milestones is a valuable opportunity for leaders to re-energize their employees around the partnership’s Strategic Objectives by thanking the people who helped make the achievements happen.

Though things won’t always be harmonious, the partnership can persevere the difficult times through establishing a strong core to build upon. As discussed in The Partnership: Creating a Solid Foundation for Successful Healthcare Integration: “A partnership that has the solid and flexible foundation that is necessary for a lasting partnership” will weather the inevitable storms ahead.

If we are together nothing is impossible. If we are divided all will fail.
–Winston Churchill

healthcare integration

Health Information Technology and Healthcare Integration

Health information technology (HIT) is important to healthcare providers for a variety of reasons, not the least of which is for complying with Medicare and Medicaid Electronic Health Records (EHR) Incentive Program requirements.

HIT is critical to the success of health homes and healthcare integration, allowing behavioral health and primary care providers to share information. This sharing enables healthcare providers to have access to all available healthcare information related to the individual being served. And this, of course, results in improved health outcomes. The SAMHSA-HRSA Center for Integrated Health Solutions has a wide array of HIT resources: click here for more information.

The Past

Not too many years ago, healthcare providers were handwriting or dictating their progress notes. When patients were seen outside the office, or if the notes were not yet filed in the chart, the limited amount of information available created a challenge to providing the best care. A patient who was unable to provide a thorough medical history was being treated blindly in some regards. And health implications aside, numerous medical procedures were repeated due to lack of access to the reports. Duplication of the procedures drove up healthcare costs.

In addition, the sharing of information between providers was the exception rather than the rule. Coordination of care between providers for patients referred to specialty care was not reimbursed and, as a result of limited resources, less than ideal. This brief history lesson on medical records serves to illustrate the value of electronic health records and health information technology.

Fast Forward to the Present

Though far from ideal, the healthcare industry is making great strides in health information technology, including health information exchanges (HIEs) designed to facilitate the sharing of data. Despite the rapid progress, sharing information continues to be a challenge for behavioral health and primary care organizations. These integration efforts create unique challenges, largely due to problems with sharing information between two systems. The electronic health records (EHRs) used by primary care providers are seldom compatible with EHRs used by behavioral health providers. While some partnerships have implemented means of addressing this (work arounds), such as a third system to link the two or “home grown” alternatives, there are currently no ideal options available.

These noble community providers persevere however. They are well accustomed to dealing with challenges in the quest for pursuing their mission. People with serious mental illness are dying prematurely; and has been inadvertently perpetuated by this lack of information sharing. In an attempt to be respectful and responsible with healthcare information, limitations (and misunderstandings) have impeded information sharing. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191 and Title 42: Public Health Part 2—Confidentiality of Alcohol and Drug Abuse Patient Records, also known as 42-CFR Part 2, are the most frequently cited reasons for not sharing information. These federal regulations cite guidelines for confidential health information. Though intended to provide clarity, healthcare organizations have interpreted the regulations very conservatively.

The Future

HIT has changed the face of healthcare and holds great promise for the future of behavioral health and primary care integration. Health information technology is not only providing cost-effective means of providing superior collaborative treatment, it is paving  the way for reducing the health disparities for people with serious mental illness and other behavioral health conditions.