Tag: primary care

behavioral health primary care integration

The Behavioral Health and Primary Care Marriage

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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”
  • 1999 Surgeon General’s Report on Mental Health
    ◊ First major emphasis on integrated care
    ◊ Dr. David Satcher declared:
       “There is no Health without Mental Health”
  • 2006 NASMHPD Report, Morbidity and Mortality in People with Serious Mental Illness:
    ◊ People with serious mental illness are dying 25 years earlier than the general population
    ◊ 60% of premature deaths are due to modifiable and preventable medical conditions

The Primary and Behavioral Healthcare Partnership

  • 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.

  1. VISION
    > DATING: Partner Selection
        • Mutual attraction
        • Determining potential
        • Wooing and courting
        • Proposal

    > The WEDDING: Formalizing the Partnership
    • Merging of goals
    • Co-location
    • Finances

  2. COMMUNICATION
    > Early Phase: The HONEYMOON
    • Identify a common language
        • Sharing decision-making
        • Synergy
    > Problems within the Partnership (AKA The HONEYMOON is OVER!)
        • Addressing internal conflicts
        • The use of candor
        • Temper expectations
  3. COMPROMISE: Making it Work
    >MARITAL COUNSELING
       • Developing shared solutions
       • Delegate trust
       • Create empowerment
       • Determine expectations
  4. OUTCOMES
    >The MATURE PARTNERSHIP: Growing Old Together
       • Enhanced outcomes through blending of resources
       • The whole is greater than the sum of its parts
       • Accountability

In the next post we will explore the early phase in the relationship, the  first key component, Vision.

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Behavioral Health – Primary Care Integration: Choosing a Model

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Which Models Work Best?

There are several model programs for behavioral health and primary care integration in the United States that are currently demonstrating outstanding results, such as Cherokee Health Systems, Intermountain Healthcare, and Washtenaw Community Health Organization. However, to quote Dale Jarvis, of Dale Jarvis and Associates, a national consultant specializing in payment and reimbursement system redesign, financial modeling, and business systems design for healthcare purchasers and providers: “All healthcare is local.”  Behavioral health – primary care partnerships can learn much from the model programs but will need modification to meet the unique needs of their communities. A model that is successful in a rural community may not be effective in an urban setting. State regulations greatly impact the success of various models as well, especially if the model relies heavily on funding sources that may have significant differences from state to state.

The promotion of  behavioral health and primary care integration has been identified nationally as holding promise for improved health outcomes and increased efficiency in the use of healthcare dollars. The United States Department of Health and Human Services, (HHS)  is funding 56 Primary and Behavioral Healthcare Integration (PBHCI) projects in an attempt to identify effective means of integrating healthcare. HHS, in collaboration with the Office of the Assistant Secretary for Planning and Evaluation (ASPE), seeks to answer three questions about the integration of primary and behavioral healthcare, as noted in this excerpt from the 10/21/10 SAMHSA webinar, Primary and Behavioral Healthcare Integration by Trina Dutta:

  1. Outcome Evaluation: Does the integration of primary and behavioral health care lead to improvements in the behavioral and physical health of the population with serious mental illness (SMI) and/or substance use disorders served by the grantees’ integration models?
  2. Process Evaluation: Is it possible to integrate the services provided by primary care providers and community-based behavioral health agencies (i.e., what are the different structural and clinical approaches to integration being implemented)?
  3. Model Evaluation: Which models and/or respective model features of integrated primary and behavioral health care lead to better mental and physical health outcomes?

(Contractor: RAND Corporation)

In a collaborative effort between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) a training and technical assistance center, the Center for Integrated Health Solutions, is available for PBHCI grantees and other organizations that are integrating behavioral health and primary care services. The Center for Integrated Health Solutions is a division of the National Council for Community Behavioral Healthcare.

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Outcome Measures in the Behavioral Health – Primary Care Integration Partnership

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It is all well and good to say that the integration of behavioral health and primary care is beneficial, even vital, to the improvement of health outcomes for people who have a serious mental illness.  However, unless we are able to provide evidence of such, it remains merely speculation. But how can we provide evidence?

Measuring Outcomes

Tracking outcomes allows for determining whether the healthcare interventions are effective. It is particularly important to screen for the following and routinely track as indicated:

  1. Body-mass index (BMI)
  2. Blood pressure
  3. Hemoglobin A1c
  4. Hyperglycemia
  5. Hyperlipidemia
  6. Family history of diabetes, hypertension, and cardiovascular disease
  7. Tobacco use history
  8. Depression
  9. Substance use
  10. Other areas as indicated

There are many screening tools and diagnostic labs that allow for screening many of the above. Ideally, these will be conducted on the initial visit to provide a baseline. Subsequent visits can focus on the areas that were identified a need and allows for tracking effectiveness of treatments.

These measurements provide an objective method of tracking response to treatment. This information is invaluable not only for treatment planning for the individual patient, but also provides data to demonstrate the effectiveness of the healthcare providers.

Demonstrating Treatment Efficacy

Electronic Health Records allow for the efficient gathering and reporting of outcomes. This data may be used as evidence of treatment efficacy, which is necessary for securing and maintaining funding (which is, of course, necessary for staying in business).  This example is from a report from a behavioral health and primary care integration team that highlights the six month outcomes from 295 people served (click here for details):  Behavioral Health – Primary Care Integration Outcomes.

In a similar collaborative effort between a community behavioral health organization and a private disease management initiative, the outcomes indicate a positive correlation between integrated efforts and follow up with health screenings (click here for details): Community Behavioral Health – Private Disease Management Collaboration Outcomes.

These two examples provide evidence of the effectiveness of behavioral health and primary care integration efforts to impact the health outcomes of people with serious behavioral health disorders.

Routine collection and reporting of data provides ongoing feedback to the team. The data allows for:

  1. Reassurance of effectiveness of methods for team members
  2. Evidence of efficacy for regulatory and funding organizations
  3. Timely identification of areas requiring calibration for increased effectiveness
  4. Potential and current patients/clients can make an informed decisions in choosing healthcare providers
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Behavioral Health – Primary Care Integration Partnerships: Measure Outcomes

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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 integration

Behavioral Health – Primary Care Integration Partnerships: Create Empowerment

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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.

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Behavioral Health – Primary Care Integration Partnerships: Delegate Trust

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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
 
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Behavioral Health – Primary Care Integration Partnerships: Determining Expectations

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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.

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

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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.

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

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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.

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

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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.