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.
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.
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.
GAD-7: The seven-item General Anxiety Disorder screening identifies whether a more complete assessment is needed.
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.
PC-PTSD: This four-item screen is effective for detecting post-traumatic stress disorder in primary care settings.
SBQ-R: The Suicide Behaviors Questionnaire is a four-question scale for assessing suicide-related thoughts and behaviors.
Brief Pain Inventory: The tool is widely used in medical settings for assessing pain, and is available in 23 languages.
Insomnia Severity Scale: This seven-question screening assessment is effective in identifying problems with sleeping.
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:
Intimate partner violence
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.
When Bob Dylan wrote this iconic song, many felt that it captured the spirit of social and political upheaval of the 1960s, much in the same way that we view mental health as “a-changin’.” And these changes require mental/behavioral health providers to change the manner in which they deliver services.
Reports over the past decade have brought attention to the current mental health crisis:
In addition, over the past few years far too many catastrophic events have brought attention to this mental health crisis, resulting in a public outcry, demanding that changes are made to prevent future tragedies.
But change isn’t easy.
The relatively brief history of community mental health services has been a challenging one. Just a few months ago, as we celebrated the 50th anniversary of President John F. Kennedy’s signing the Community Mental Health Bill into law, the conversations quickly progressed to the subject that is on the minds of virtually all behavioral health providers—and an unusually large number of the general public and policy makers, given the historical lackluster interest in the topic—mental health is in dire need of change.
The economic downturn in the US in 2008 resulted in massive budget cuts in all but a few states. The March 2011 NAMI report, State Mental Health Cuts: A National Crisis, demonstrated the cumulative cut to mental health services in the U.S. during that time was nearly $1.6 billion. Community mental health services plummeted from being barely adequate to the critical point in many states. Safety-net providers were forced to close programs due to the slashed budgets. Many of those affected ended up on the streets or in jail.
The recent announcement on the anniversary of the Sandy Hook tragedy, of the planned infusion of dollars into help repair our broken mental health system, is encouraging. However, the entire mental health system is in dire need of an overhaul. One that looks at the broader healthcare picture and strategically plans for mental health and substance use disorder treatment to be included. A person-centered, whole health approach to treatment is necessary for improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care: the Triple Aim.
Dr. Dale Klatzker knows that, although it isn’t easy, change is vital for community behavioral health providers.
It’s exciting to be able to offer a look at integrated care from the perspective of a provider, particularly a provider who has demonstrated leadership excellence in integrating behavioral health and primary care services. Dr. Klatzker currently serves as the Chief Executive Officer of The Providence Center in Providence, Rhode Island. He has been a leader in behavioral healthcare for more than 35 years. Since becoming president/CEO of The Providence Center in 2004, Dr. Klatzker, a visionary, has transformed the system of care, quality of service delivery, and social policy decision making at The Providence Center and the state of Rhode Island. Click here for Dr. Dale Klatzker’s bio.
Dr. Klatzker:Change is a good thing. Most CMHCs haven’t changed a lot. They haven’t prepared themselves to change a lot and have marginalized themselves and the people that they serve by not being more a part of the mainstream. We have sets of skills that are integral to wellness and to health across a wide spectrum. We need to be proud of what we do, but also to expand it and extend it because this is the perfect time for this. We have a lot of things to offer that others are trying to replicate.
Things don’t stay static. You have to look though the windshield but also through the rear-view mirror. You have to know where you are but you also have to know where you’re going.
As executive director/CEO of a behavioral health organization, you have the obligation to push yourself, and that will push your organization, to do what is necessary so that your mission is reinforced but also to serve the needs of the community. It’s hard to do that if you’re doing the same thing you did 20 years ago. We do our consumers a disservice if we do that.
Person-centered approach to care
Dr. Klatzker: What we’ve embraced here – what’s part of the DNA of the organization at The Providence Center – we believe in a person-centered approach to care. No two people are exactly the same. The people that we work for deserve as much access to a wide array of both health and social supports as anyone. That’s how you have to guide yourself. When you’re thinking of those things, primary care integration, working much more toward the mainstream of traditional healthcare is imperative for us.(7:14)
What we’ve found is, if you can build those relationships and find the right connections, then others will embrace you and value you for what you bring to the table. In fact, we bring a lot. Partnership is always the first choice, the default.
We don’t chase dollars, we don’t create programs because it’s the idea du jour from some funder somewhere, we consciously look on our mission as our touchstone and build upon that to provide as much choice to the people we serve. We can be very person-centered because there aren’t many gaps in what we’re providing. (They provide a wider array of services than the average CMHC) We’ve consciously built out a wide array because we think it’s the right thing to do. Rather than to take a “no,” if we can’t partner, we build.
Example of a successful integrated care partnership
Dr. Klatzker: The Providence Center is closely connected to one the largest federally qualified health center in the state of Rhode Island, the Providence Community Health Center. We have become the largest community mental health center. Neither had a desire to replicate the services that the other provided. Over the years we’ve built this into a “no wrong door” integrated collaborative effort so that in the mental health center, the FQHC runs a full-service practice with 1100-1200 patients. In the FQHC, we are integrated in their physician practices building and we also have a separate section of their building where we provide longer term care and some other types of specialty care. We’ve integrated our records with each other. We meet frequently to process and to try to figure out how to make our care efficient and effective. We are working closely with them now on adopting our health home model to integrate a modified health home into the FQHC.
Yes, the times they are a-changin’. And so are healthcare providers. (At least the forward-thinking providers like The Providence Center.) They are heeding the findings from the numerous expert reports and research. They are thinking outside the box, adopting a person-centered approach that enables better outcomes for the many who place their trust in them—trusting them to take care of their whole-health needs.
How do partnering Community Behavioral Health Centers (CBHC) and Community Health Centers (CHC) determine the ideal model for their foray into integration? There are many factors to consider such as:
What are the needs of the individuals served by the partnering organizations?
What are the needs of the community?
What resources do the organizations bring to the partnership?
Now that the partners have a solid foundation and clear vision for their collaboration, it is time for the careful planning that is necessary to make it a reality. There are effective tools available to assist organizations in working through this very important process. (Please note that these suggestions and resources are not limited to community providers.)
The MH/Primary Care Integration Options scale is available on the SAMHSA-HRSA Center for Integrated Health Solution website. This is very helpful for leading the discussion among the members of the implementation team. The scale assists the partners not only in determining the current reality but also mutually deciding on the desired level of integration: Minimal Collaboration, Basic Collaboration from a Distance, Basic Collaboration On-Site, Close Collaboration/Partly Integrated, and Fully Integrated/Merged in each of these key functional areas:
Access: How do individuals access services?
Services: Are the services separate and distinct or are the primary care and behavioral health services seamless? Or perhaps somewhere in between.
Funding: Do the partners share resources or are they separate?
Governance: Are there separate boards of directors for each organization?
Evidence-based Practices: Do the organizations administer the PHQ-9 or disease registries, for example, and share the results?
Data: Do the partners share information? Do the providers have access to the partner’s EHR?
This assessment process is most effective when stakeholders from each organization are included. Ideally, representatives are included from clinical, management, and administrative departments, as well as a few individuals who use the services. It’s very helpful to have frontline staff and board members to take part as well. Call center and reception staff offer a unique perspective that leadership frequently finds enlightening.
Another tool to consider is the COMPASS-PH/BH created by Zia Partners. This self-assessment tool is used for primary care/behavioral health integration for implementation of a Comprehensive Continuous Integrated System of Care.
Making the Vision into a Reality
Once the ideal model of integration has been determined, the journey begins to make it a reality. Be sure to stop by for the next installment in the series.
What tools or methods have you found to be helpful when selecting a model for your healthcare integration endeavor?
I would love to hear from you! Please email your suggestions to me at firstname.lastname@example.org for inclusion in a future post.
The early days of the integrated healthcare relationship are typically idyllic, filled with smiles and hopes and dreams. Oh, if we could only maintain that blissful state forever…
Unfortunately relationships don’t maintain a static pattern but are interspersed with disruptions on occasion (or frequently). When these disturbances intervene, the blissful state is challenged.
These are the times that try administrators’ souls.
For a partnership to persevere the inevitable challenges, the basic foundation must be solid. Just as skyscrapers are built with deep foundations that are not only solid but allow flexibility to prevent collapse when severe environmental or other hazardous conditions erupt, the integrated partnership requires a carefully developed, yet flexible foundation. With a firm core, the relationship has the elements in place to withstand challenges that are sure to occur. (Click here for more information on building a successful behavioral health – primary care partnership.)
Sustainability plans are often synonymous with financial sustainability but will occasionally focus on health information technology in the planning as well. The partnership itself, however, is often overlooked in the sustainability plan. This is unfortunate because if the partnership fails, the plan is rendered moot. The actual partnership itself is taken for granted after the initial honeymoon phase. This is a grave mistake for true sustainability.
Consider this scenario: Due to internal operational and fiscal needs, the behavioral health partner’s executive team has decided to reassign the integrated BH counselor who has been working in the primary care clinic for two years. The counselor will be replaced with another counselor who is more experienced and is credentialed in both mental health and substance use disorders. Seeing this rearrangement as a win-win, the behavioral health partner is shocked and confused when they hear that the primary care partner, in reaction to this news, is considering hiring their own counselor instead of accepting the replacement counselor. There are even rumors that they might pull out of the partnership.
What went wrong?
The behavioral health partner failed to include the primary care partner in the discussion, thus failing to honor the relationship; the primary care partner felt disrespected.
Rather than express concern to the behavioral health partner, the primary care partner took a reactionary approach instead.
Unaware of behavioral health partner’s internal issues, the primary care partner assumed the worst.
The behavioral health partner failed to understand the value of the individual to the team, not just for the service provided. Counselors are not interchangeable. The counselor was viewed as a valued member of the primary care team.
The executive teams of the partners stopped communicating after the partnership was launched, resulting in a weakening of the committment by each partner.
The list could go on.
This partnership, though financially sound, has neglected to nurture the core relationship. As long as things were going smoothly, the partnership appeared to be successful. Unfortunately, a slight disruption to the routine has threatened the weak core of the partnership. In addition to the obvious lack of effective communication taking place in this dysfunctional relationship, there are other factors also present that are all too common in partnerships:
Lack of commitment
Lack of respect
Commitment and respect underscore the core requirements for longevity.
All partners must be committed to ensuring that integration efforts have the necessary tools for success. This includes the committment of time, not just financial and other resources. When the commitment is present, there is no concern over “fair weather friends” syndrome.
Are you prepared to make sacrifices necessary for success?
When the going gets tough are you still committed?
Basic respect is crucial. Your partner has many challenges and concerns that are unrelated to your partnership. Respecting that these are important to your partner whether or not you can fully recognize the impact goes a long way toward being a good partner. Taking the time to gain a better understanding is even better.
Do you have a thorough understanding of your partner’s business model?
Do you understand the challenges that your partner faces specific to the specialty such as regulatory, operational, clinical, etc.?
Why are these things important?
Understanding and honoring the things that are important to your partner organization strengthens the core of your relationship. Remember, the Golden Rule applies to behavioral health and primary care integration partnerships, too.
The next key component of a successful Behavioral Health – Primary Care Marriage focuses on Communication.
Early Phase: THE HONEYMOON
In the early days of the partnership, the Honeymoon phase, there is a distinct tendency toward assuming that both partners are speaking the same language and are working toward the same goals. The excitement of the new endeavor and the synergy created initially helps to move things along at a rapid pace. When the behavioral health partner talks about workflow and scheduling appointments, there is little thought given to the fact that these two concepts have VERY different meanings for the primary care provider. It is important to have a thorough review of operations from both perspectives and to find a viable middle-ground that both partners find acceptable. Making open, frequent communication a priority from the onset will prevent problems later on. This should include a thorough overview of each organization’s regulatory, financial, and operational processes as well as overall mission. Don’t assume that the two partners really understand how each other’s organization functions.
Problems within the Partnership (AKA THE HONEYMOON IS OVER!)
If the partners neglect to develop an open culture of communication on the front end, it is likely that miscommunication will develop.
The Honeymoon phase is in jeopardy.
The entrepreneurial partner fails to understand the ongoing delays from the partner with the extensive bureaucratic approval process that prevents a quick turnaround of virtually everything. As misunderstandings develop into disappointments and resentments, the previous harmony is disrupted.
The Honeymoon is over.
Internal conflicts must be addressed immediately with candor. This is a good time to have an open conversation about all the aforementioned points and develop a plan for ongoing, frequent communication. Concerns about the great divide over productivity targets, outcome measures, and caseloads must be openly discussed, among other important points of contention.
By devoting the necessary focus on the importance of Communication, the partnership will successfully transition to the third key component for a successful behavioral health – primary care marriage, Compromise. The shared mission to reduce health disparities for the individuals served who suffer from comorbid behavioral health and medical conditions will persevere.
However, failure to make this transition may very well land this promising partnership into divorce court.
Every relationship follows a similar pattern. The early phase begins with the selection of a partner. The same holds true for the integrated behavioral health and primary care partnership. It may begin with running into each other at a meeting. Or perhaps while reading the lastest report on the emerging trend of healthcare integration, Accountable Care Organizations, health homes, etc…
The Vision begins to form
The behavioral health and primary care clinics enter into the dating relationship when the leaders of each, who have mutual admiration for each other, begin to recognize the potential of doing business together. One leader calls the other, suggesting they get together for lunch. It’s only lunch, he rationalizes to himself, it doesn’t mean anything…there’s no harm just in talking….
One thing leads to another during the wooing and courting phase; soon the idea transitions and the outline of a plan begins to emerge. The two leaders have entered the early stages of the partnership. The Vision is being created, becoming a driving force for each.
The two organizations soon find themselves having serious discussions about forming a partnership. How did THIS happen?? The proposal is followed with a flurry of planning. There are so many details! Attorneys are kept busy creating a business plan and reviewing financial and regulatory documents, planning for the wedding of two organizations. Decisions must be made of how the assets are to be shared. Finances are sorted, MOUs are signed, and the partnership is official.
The marriage of behavioral health and primary care creates a unique entity that is far greater together than either had, or could have been, alone.
The early stage of the partnership is filled with excitement as the Vision takes shape and becomes reality. The shared vision is driven by the passion to become what neither can achieve alone. The specialty behavioral health provider and the primary care provider have integrated, raising the bar of healthcare for people with behavioral health disorders.
This marriage of healthcare providers is based on a Vision shared by two of eliminating the health disparities of people who suffer from serious mental illness and substance use disorders.
Next time we will explore the second key component of a successful behavioral health and primary care marriage: Communication.
We have ascertained in previous posts the value of the integrated behavioral health and primary care partnership. With shrinking healthcare funding and the unmet healthcare needs of people who have serious behavioral health disorders, there are numerous benefits of collaborative care. The blending of resources, expertise, and passion combine to create a synergy that is not possible with one organization alone.
Healthcare Integration Timeline
In 430 BC Hippocrates declared: “The Body must be treated as a whole and not just a series of parts”
Literature by Dr. Benjamin Maltzberg dating back more than 75 years on studies at the New York State Hospital in Utica has reported “excess mortality due to medical causes in persons with mental disorders”
Allow for individual choice in determining the healthcare home
Ideal for treatment of the whole person
Address the health disparities of people who live with serious behavioral health conditions
Bi-directional integration allows for individual choice in determining the healthcare home
More efficient and effective use of healthcare dollars
CNN Report: Companies merge for a variety of reasons
◊ Expansion of market share
◊ Acquisition of new lines of distribution or technology
◊ Reduction of operating costs
◊ Corporate mergers fail (up to 80%!) for some of the same reasons that marriages do – A clash of personalities and priorities
Four Key Components of a Successful Behavioral Health and Primary Care Marriage
Like all marriages, the behavioral health and primary care marriage requires nurturing. There are four key components that occur at integral stages within the relationship that must be addressed for successful outcomes, aka living happily ever after.
> DATING: Partner Selection
• Mutual attraction
• Determining potential
• Wooing and courting
> The WEDDING: Formalizing the Partnership
• Merging of goals
> Early Phase: The HONEYMOON
• Identify a common language
• Sharing decision-making
> Problems within the Partnership (AKA The HONEYMOON is OVER!)
• Addressing internal conflicts
• The use of candor
• Temper expectations
COMPROMISE: Making it Work
• Developing shared solutions
• Delegate trust
• Create empowerment
• Determine expectations
>The MATURE PARTNERSHIP: Growing Old Together
• Enhanced outcomes through blending of resources
• The whole is greater than the sum of its parts
In the next post we will explore the early phase in the relationship, the first key component, Vision.