Integrated Care Models, Simultaneous, Single-Site Implementation Team Roles First Contact Week 3 Week 5 Week 6 Week 8 Week 10 Week 12 Week 14 14 Week Stats By Team Member Role • Positive PHQ 2 & 9 • Positive AUDIT • Negative DAST • Diabetic • Chronic Pain • Repeat PHQ 9 •Diabetes management •Chronic pain management • Repeat PHQ 9 • Diabetes f/u • Depression medication check PCP: • 3 Office Visits with PT • 4 Curbside Consults w/ BHC • 1 consulting psychiatrist curbside consult • Sees PT on warm handoff and addresses: • Motivational Interviewing for problem drinking • Discovers underlying grief issues and provides one coping skill • Recommends SSRI to PCP • Introduces care team model including IMPACT • Reviews medication adherence and toleration • Reviews ETOH use goals • F/U on homework/ goals including brief processing of grief coping • Informs PCP verbally and/or via EHR note • Sees PT on warm handoff and addresses: • Chronic pain coping skills; supports PCP decision not to prescribe opiates • SSRI review and medication adherence • Curbside consultation with PCP to discuss ways to encourage PT engagement vs. avoidance of pain • F/U BHC Only Visit •Repeat PHQ 9 • Check-in on ETOH use, chronic pain management skills • Reassess response to grief reaction BHC: •4 Office Visits with PT (2 independent, 2 warm-handoff) • 3 SBIRT influenced contacts • Depression registry inclusion is automatic based on PHQ score Phone Consult: • Check-in on medication adherence & goals; visit reminder. Phone Consult: • Repeat PHQ 9 • Check-in on SSRI adherence • PCP curbside due to new side effect • Adds patient to consulting psychiatrist care review list due to new side effect Phone Consult: • Check-in on medication adherence, functioning • Review ETOH use goals including motivational interviewing for relapse prevention BHC as Care Manager: •3 Phone contacts with PT • 1 Consulting psychiatry contact • Consulting psychiatrist performs chart review, discusses with BHC and writes note in chart and/or verbally gives recommendations to PCP • PT called by nurse or BHC with instructions Consulting Psychiatrist: • 1 contact each with BHC, PCP • 1 chart review, note Why? Combining the models provides the best of all worlds with improved continuity of care (CC), flexibility of intervention (PCBH) and focus on substance abuse (SBIRT) simultaneously. BHC Role The BHC could serve the care manager role as well but likely only in a medium to large clinic (6+ PCPs) with multiple BHCs providing coverage. The care manager duties can also offset the rigor of the BHC clinical role and vice versa. Variations Could care proceed differently than the above with different emphases/ roles of the models and personnel? Absolutely. Care should be responsive to patient needs, tolerance and choice. Start All At Once? Our recommendation is not to attempt initial implementation of all pieces simultaneously although aspects of the models, such as the screening components, can be implemented side-by-side. Considerations Staffing Arrangements* Small Clinic M/L Clinic 1-5 PCPs at once 6+ PCPs at once .5 -1.0 FTE BHC 2.0 FTE BHC .5-1.0 FTE CM (BHCs also serve as CM) .05-.10 FTE CP .10-.25 FTE CP * Exemplar only. Other considerations such as patient volume are important to consider. CM = Care Manager; CP = Consulting Psychiatrist; BHC = Behavioral Health Consultant Sample BHC Work Schedules, Single M/L Clinic* Mo Tu We Th Fr BHC 1 AM Clinic Clinic Clinic CM Admin PM CM Clinic Clinic Clinic Clinic BHC 2 AM Clinic CM Clinic Clinic Clinic PM Clinic Admin CM Clinic CM * CM = protected time for care manager duties; Clinic = Operating in clinic as BHC; Admin = Protected time for administrative duties or program development PCP BHC BHC as Care Manager 1 Consulting Psychiatrist Models Color Code: PCBH SBIRT Collaborative Care (Bold) Mickey, 45, Patient Exemplar Mickey is a 45-year-old African-American male who presents at his doctor’s office for troubling symptoms including excessive thirst and chronic pain. He also has poorly managed diabetes. The following is how care proceeds over 14 weeks at his doctor’s office where a care team that runs the PCBH, SBIRT & Collaborative Care models is ready to help his presenting and underlying concerns. 1 Although in this exemplar the BHC team also performs the care manager role per the schedule on the bottom right, many implementation instances may require a distinct role for a care manager based on available talent, scheduling considerations, clinic size, population needs and other considerations. The skill sets of BHCs are by definition broader than a care manager, therefore in general a BHC can perform a care manager role but a care manager cannot fulfill a BHC role. © 2016, All Rights Reserved. Center of Excellence for Integrated Care, A Program of the Foundation for Health Leadership & Innovation