Tag: primary care

behavioral health integration

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

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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.

behavioral health integration

Successful Behavioral Health and Primary Care Partnerships

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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.

behavioral health integration

Reducing Health Disparities Among People with Serious Mental Illness

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“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.

behavioral health integration

Behavioral Health and Primary Care Integration

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Where do people who suffer from behavioral health disorders receive healthcare services? The answer is:  It depends.  It largely depends on the severity of their symptoms, it seems.    

According to Dr. Gary Oftedahl of the Institute for Clinical Systems Improvement in The DIAMOND Initiative: A First Year Report approximately 75 percent of all patients with depression are treated by their primary care providers. The typical patient in this setting likely presents with mild to moderate symptoms and has commercial health insurance. Should the primary care provider suggest a referral to a behavioral health professional, the patient would have a low probability of following through with the referral. The stigma associated with behavioral health care blocks the path to specialty behavioral healthcare. It is more socially acceptable to receive services in a primary care setting. Historically, primary care providers have done a fair job in treating behavioral health disorders.   

There is another group of people to consider. Individuals who suffer from serious mental illness, addictive diseases, co-occurring mental illness and addictive diseases, or severe emotional and behavioral disorders tend to seek treatment with specialty behavioral healthcare providers.   This population is much more likely to follow through with treatement in behavioral healthcare settings than in primary care. The typical patient presents with severe symptoms and is uninsured, under-insured, or has Medicaid or Medicare. Unfortunately, this group is also less likely to follow through with primary care prevention or treatment needs.  A 2009 study published in the Journal of the American Board of Family Medicine (JABFM), Health Care for Patients with Serious Mental Illness: Family Medicine’s Role reports that cardiovascular disease is the leading cause of death among people with serious mental illness; approximately two to three times that of the general population. Causes are attributed to poor access to and use of quality health care.  Negative cardiometabolic effects of some new medications increase rates of obesity, diabetes, and hyperlipidemia. Symptoms often go untreated until emergency services are required. 

The integration of behavioral health and primary care is a viable solution to accessing needed services. However, it is not possible to have one model that works for everyone. Some people are most comfortable (and therefore, much more likely to follow through with treatment) obtaining all healthcare services in a primary care setting. In this medical/healthcare home model, behavioral health services are integrated into primary care settings. A behavioral health professional works closely with primary care staff, often immediately available for a consult. The patient is able to receive both primary care and behavioral health services concurrently.

The integration of primary care into the behavioral health setting is most effective with the second group, individuals who suffer from serious mental illness or other behavioral health disorders. One way of creating this medical/healthcare  home model is for a primary care provider to work collaboratively onsite with the behavioral health provider in the behavioral health setting. This partnership ensures the total healthcare of the patient. An effective model is illustrated in this 2010 abstract published in the American Journal of Psychiatry A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evaluation (PCARE) Study by Dr. Ben Druss, et al. 

The concept of medical/healthcare home offers new and exciting insights into how we approach healthcare needs among individuals with behavioral health needs. Perhaps it is the key to eliminating the health disparities of this vulnerable population.

 

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Behavioral Health Integration: The journey begins…

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As I embark upon this new journey of blogging about behavioral health integration, I admit to having mixed feelings. I am excited to explore and share information on reducing and, hopefully, eventually eliminating the health disparities among people who suffer from behavioral health disorders. However, I also find this undertaking to be somewhat daunting.  But this mission is so much larger than any apprehension I might have over stepping into the blogosphere, so here we go!

The subject of behavioral health integration is gaining momentum in the behavioral health industry.  The findings from the now infamous 2006 study published by the National Association of State Mental Health Program Directors (NASMHPD), Morbidity and Mortality in People with Serious Mental Illness  has changed the way we view healthcare. The study revealed that people suffering from serious mental illnesses die, on average, 25 years earlier than the general population. Obviously there’s something we haven’t been doing right. Thankfully, behavioral healthcare experts in the field are working diligently to correct this.  The Behavioral Health Integration Blog will explore the advances in behavioral healthcare focused on eliminating the health disparities among people with behavioral health disorders.

Like most of you in the behavioral health industry, I was not really surprised to learn that people who suffer from behavioral health disorders typically do not get the health care that they require.  If you work in the field long enough you will experience the loss of one (or most likely many) clients who has died prematurely from an illness that was treatable and preventable, such as stroke or heart attack. We often see this among people suffering from serious mental illnesses. This population frequently does not have primary care providers. For a myriad of reasons most do not follow up with healthcare needs outside of the behavioral health system. Through integrating primary care with behavioral health, providers are able to treat all of an individual’s healthcare needs; in essence, treating the whole person. Future blogs will explore various models that are being successfully used to provide total care.

In the weeks to come, I will provide links to the excellent resources that are available on behavioral health integration. All comments are welcome. Addressing this critical health disparity requires a collaborative effort.