e-Solutions March 2015
eSolutions: March 2015
Feature article: The Behavioral Health Tide in Primary Care
Grantee Feature: Moving Integration from Pilot to Practice: Mercy Care
Quick Tips: How to Get Started with Integration
Featured resource: Quick Start Guide
Based on an interview with Virna Little, Senior Vice President of Psychosocial Services and Community Affairs, Institute for Family Health, a FY 2014-2015 HRSA Behavioral Health Integration Grantee and a SAMHSA Primary and Behavioral Health Care Integration grantee.
Five to 10 years ago, primary and behavioral health care were completely separate systems. Today, things have changed. The behavioral health capacity within health centers has expanded tremendously.
Why? For one, the financial landscape changed. More safety-net primary care providers realize that providing behavioral health services is financially viable. Support from the FY2014-2015 HRSA behavioral health integration grants and other public and private foundation funding has spurred a new “wave” of integration of behavioral health into primary care. Providers certified as patient-centered medical homes (PCMH), are now required to identify mental health and substance use disorder diagnoses and to track these individuals as part of an at-risk population.
Another reason? Need. Many of the highest health care utilizers —and those that incur the highest costs—are people with mental illnesses and addictions. In addition, as safety-net providers, health centers often provide services to people who have concerns about being engaged in mental health treatment services or who do not have access to these services in their area. As more providers are aware of the correlation between serious mental illnesses (such as bipolar disorder and schizophrenia) and chronic health conditions, they recognize the need to learn how to support people in one setting.
The upshot: coordinated care is becoming an expectation. People no longer wonder if their health information will be shared; they expect to give permission to their providers to do so. They expect, and like, when all of their providers coordinate as a team—a team that can include their doctor, dentist, mental health clinician and social worker.
Building Internal Capacity
In our new health care environment, health care providers want to build capacity internally, but what does that involve? It means formalizing integration across the entire organization and developing the team, strengthening infrastructure and enhancing clinical processes.
Team development means teaching providers how to do warm hand-offs, bringing on clinicians who can treat behavioral health conditions onsite, training everyone on how to work collaboratively and carving out time for team huddles. Learning to work and to develop treatment plans in teams —rather than individually with each patient—is critical to developing internal knowledge. Learning to build partnerships in the community for easier referrals when individuals need further supports (e.g., intensive outpatient, respite, psychosocial rehabilitation) is also important to team development.
Over the last few years, the most critical integration has taken place in health centers and other safety-net provider organizations, where behavioral health providers have supported organizations in building infrastructure to run behavioral health programs. This involves developing systems from billing to ensuring the electronic health record has capacity to capture behavioral health information and establishing new human resources policies and procedures.
Clinical processes and practices need to expand to incorporate treatment for a broader array of conditions. Provider organizations must think about what they add to the mix and then how they will develop their practice to meet identified needs. When participating in health home services, depression registries or initiatives like Zero Suicide, providers must create the infrastructure to maximize outcomes. That can involve building registration functionality, learning to treat to target depression, having a system in place to identify individuals at-risk of suicide, or adopting best practices to identify individuals who have experienced trauma.
What’s still needed?
Organizations must determine if integration moves the needle on supporting healthier outcomes for the people they serve. They cannot merely adopt certain practices and take on services, but instead must learn to look at outcomes (e.g., managed diabetes, lower depression scores for a given population), to be able to show that integration actually does improve health outcomes. The FY 2014-2015 HRSA behavioral health integration grants require health centers to screen for depression and document appropriate follow-up taken. That means organizations must make sure the people they treat get better and must be able to look at these outcomes in a systemic way.
While specific programs and studies have shown the benefits of integrated care, in particular collaborative care, providers as a whole must start taking measurement to the next level. That means looking at the broader questions beyond specific health indicators — looking into the cause and effect of integration on whole health. For example, a new initiative studies how training providers on trauma-informed care practices improves the health of people with chronic illnesses.
To really support integration is to truly get to one-stop shopping for the community – moving toward a goal of “no wrong door” for whole health care.
Mercy Care Services, a HRSA safety-net provider serving the greater Atlanta area started on the road to integrated care like many other organizations – through a strategic planning process.
That process began with a needs assessment that included input from staff. The assessment identified a strong need for behavioral health services throughout their 13 primary care clinics and a desire for training and resources on behavioral health among primary care staff. Mercy Care serves as a safety net provider for their community – more than 95 percent of people they serve are uninsured and 83 percent are below the poverty line. Many of their clinics operate within shelters for the homeless.
To test the viability of integrating behavioral health, Mercy began by giving primary care providers the tools they needed to ask basic questions about patients’ mental health. They incorporated the PHQ-9 assessment tool for depression screening and hired an onsite behavioral health specialist to be available to provide additional services and to coordinate treatment plans.
The test proved successful. Today, Mercy provides integrated care services at each of their clinics and their mobile clinic, which visits different locations around the city, has a behavioral health specialist on board each month. Mercy Care was recently recognized as a Patient-Centered Medical Home.
From Reception to Referral – Mercy’s Integrated Services Model
Here’s how they moved forward. Every clinic has a central lobby where people check in for appointments, no matter what type of services they are receiving that day. At intake, individuals are asked about their whole health through integrated screening forms. This approach helps to emphasize that mental health and substance use services are a part of whole health, and reduces the unease some people feel about having to go to a “specialized” environment for behavioral health services.
Ongoing training and education is essential to supporting Mercy’s care team in offering continued quality integrated care. A staff psychiatrist leads classes for primary care providers interested in learning more about specific mental health disorders and provides consultation as needed. Mercy uses the IMPACT model as a framework to support provider development.
Mercy also serves as a primary care partner for Cobb and Douglas County Community Services Board, a SAMHSA Primary and Behavioral Health Care Integration (PBHCI) funded community mental health center. This relationship creates more opportunities for access to specialty mental health and substance use services, as the partnership allows Mercy to offer co-located services and facilitates referrals for more intensive behavioral health services.
By incorporating the integrated care team throughout the planning process, Mercy’s primary care and behavioral health providers can tap into the knowledge they have at each clinic – who they serve and the flow of services provided.
Fostering Change that Lasts
One of Mercy’s clinics, a women’s shelter, has a wellness room and provides health education classes. The Satcher Health Leadership Institute conducted a study of the clinic to measure the impact of these initiatives and found that these practice changes, including relaxation techniques and education on hypertension, improved health outcomes, enhanced capacity building and improved collaboration with other providers.
Through careful planning and thoughtful implementation, Mercy has developed an integrated care program that can continue to support the health of many people in the greater Atlanta area well into the future.
How do you support the whole health of your community? Tell us your story at Integration@theNationalCouncil.org.
Integration of behavioral health and primary care affects many areas of an organization. CIHS’ new Quick Start Guide to Behavioral Health Integration (pdf) walks through these areas via an easy to use decision tree. Here are some key questions to consider when getting started with integration.
- Is integration right for your organization? Integration cannot happen without buy-in from across the organization – not just providers, but also organizational leadership and administration. The mission and culture of your organization needs to support and reflect an integrated care approach – including a work plan and business plan that address these services.
- What model is right for you? The standard framework outlines six levels of integrated care and different models for offering care along these levels. Assessment tools help you to determine your organizational readiness.
- What capabilities does your team need to develop? Workforce changes can include bringing on new staff, broadening the knowledge base of existing providers, building partnerships for referral and teaching all staff to adjust to working as an integrated team.
- Do your clinical practices incorporate behavioral health alongside primary care? Start with universal screening and making sure your clinical pathways for chronic illness management include behavioral health. Your electronic medical records should be the centerpiece for communicating findings and treatment recommendations.
- How will you measure integrated care outcomes? Have a plan for assessing your integrated care efforts from a population-based approach. Define some key health indicators to mark success and track your outcomes through continuous quality improvement measures.
Have other questions about implementing integrated care? Peruse the Quick Start Guide and visit CIHS’ website for hundreds of resources on integrated care across a variety of implementation areas.
Chances are, if you’re integrating behavioral health (or considering getting started), then you have some questions about the process. That’s why CIHS developed the Quick Start Guide to Behavioral Health Integration (pdf), an interactive flowchart to walk you through some of the questions to consider when integrating behavioral health care and, most importantly, point you toward helpful resources that can answer those questions.
The ATTC Network released the first in a series of white papers, Integrating Substance Use Disorder and Health Care Services in an Era of Health Care Reform, which describes effective models, interventions and implementation strategies for treating substance use disorders in health care settings.
CDC released the updated Community Health Status Indicators online tool that produces profiles of key indicators of health outcomes, like health care access and quality, health behaviors, social factors and the physical environment for all 3,143 counties in the United States. Organizations can use this data to assess communities, identify health disparities and form partnerships to improve population health.
SAMHSA is now accepting applications for the 2015 “Now is the Time” Project AWARE-Community grants to support the training of teachers, parents, law enforcement, faith-based leaders and others that interact with youth in Mental Health First Aid. Applications are due May 1, 2015.
SAMHSA’s new app Suicide Safe is now available to download. This free suicide prevention and mobile-learning tool helps providers integrate suicide prevention strategies into their practice and reduce suicide risk among those they serve.
DiversityRx supports providers to improve the accessibility and quality of health care for minority, immigrant and indigenous communities through delivery of services that are responsive to cultural and linguistic differences presented by diverse populations. Get resources and view training opportunities on organizational cultural competence, culturally competent care and language access.
In observance of Children’s Mental Health Awareness Day, SAMHSA and HRSA present Consultation for Kids: Models of Psychiatric Consultation in Pediatric Primary Care. Join this webinar on May 4 at 2pm Eastern to learn about the pediatric psychiatric consultation model, hear from a safety-net pediatrician on how a busy clinician can effectively tap into psychiatric consultation to provide high quality mental health care, and learn which components of psychiatric consultation models can be implemented or better utilized in your region, state or community. Register Here.
Have a topic you’d like CIHS to explore on a future webinar? Let us know, email Integration@TheNationalCouncil.org.