Practical Considerations for the Implementation of Integration Benjamin Miller Shandra Brown Levey University of Colorado Department of Family Medicine.

Practical Considerations for the Implementation of Integration

Benjamin MillerShandra Brown Levey

University of ColoradoDepartment of Family Medicine

Our questions for the audience• Who works in

• community mental health?• primary care? • substance abuse treatment?• other organizations?

• Who works in with medical providers?• Who has experience with primary care and behavioral health

integration?• How do you interface with medical providers?• What works well when you work medical providers?• What is difficult about working with medical providers?

How do you know that what you’re doing is working?

Desire lines – user created paths related to the wisdom of crowds

Desire Lines• Most PC medical appointments stem from

psychosocial concerns. • Primary care is the de facto MH system, as it is the

setting where most patients with behavioral health conditions seek care.

Desire Lines

• PCPs lack time and training to address the large volume of patients who seek help from psychiatric conditions, psychosocial problems, unhealthy lifestyles, and difficulties making needed changes to cope with chronic illness.

Desire Lines

• MH specialty resources are scarce and patients have difficulty accessing them.

• PCPs often respond by offering prescriptions, which may seem like adequate treatment, but are often not and may lead to new problems.

Desire Lines

• To address these problems, models have been developed for integrating behavioral health and primary care.

The Range: Dispelling the myth of the one trick pony and retraining (Miller, Brown Levey, Kwan, Payne Murphy, in press)

The Behavioral Health Community Challenge• We all pay the price for insufficient care for behavioral

problems.• Break down the barriers to mental health care and

reduce strain on PCPs.• Link physical and mental health in a tangible way by

providing care in the same location - this reduces stigma.• Work towards a true biopsychosocial approach to care

with an integrated health care team.

Operationalizing Your Vision• Approaches to integration vary widely• Co-location – BH placed in PC – Be careful not to

become the “house shrink”• Bidirectional Co-location – PC placed in BH• Collaboration – quality of the relationship between

providers • frequency of sharing info, joint treatment planning,

true biopsychosocial approach• Integration – BH is a regular part of the care team

and no special paperwork or processes are needed to see BH

Operationalizing Your Vision

• Visits• Consider the length of visits (50 mins, 30 mins, 15 mins, 5

mins)• The number of follow up sessions• Are visits 1:1 or with the PCP as a health team• The amount of BH flexible time - for warm hand offs and

co-consults

Operationalizing Your Vision

• Maintain easy access to behavioral health care with population health focus

• Generalist approach - Be ready for…• depression, anxiety, obesity, pain, diabetes,

headaches, hypertension, grief, sleep, stress, adjustment to illness …

Operationalizing Your Vision• Brief, problem focused work• Focus on functional assessment and restoration

• Life context• Description of target behavior• Triggers• What lessens behavior• What happens before/after behavior• What have you tried?

Implementation…Are you ready?• It depends…• Design the model to meet the needs of your population• Buy-in from organizational leadership• Behavioral Health Skills for working with Primary Care• Staff preferences• Logistical considerations (office space)• Look at the Lexicon

What Do We Mean by “Behavioral Health integrated with Primary Care?”

• Shared language• Functional definition• Metrics for

evaluating integration

• Unite the field and move it forward

To create a patient-centered care experience and achieve a broad range of outcomes -clinical, functional, quality of life, and financial – for each patient that no one provider and patient are likely to achieve on their own.

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Goal of Integration

Structure of the Lexicon

The SupportsFunctions and corresponding parameters necessary for “the

how” to become sustainable on a meaningful scale

The HowFunctions necessary to

accomplish “The What”

The ParametersAcceptable differences

between practices

Teams

Systems to Support

IntegrationShared

Patients and Mission

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Defining Functions of Integration

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Enabling Functions That Support Integration

Reliable operations and processes

Alignment of purpose and leadership

Continuous quality improvement and

outcomes monitoring

Sustainable business model

Community Expectation

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Parameters (examples)1. Range of team function available

Foundational:(9 functions)

Foundational plus others for the target

population

Extended functions

6B. Degree that care plans implemented and followed

Less than 40%(not acceptable)

More than 50% Nearly 100%

5A. Shared workflows & protocols in place?

Protocols and workflows not in place

(Not acceptable)

Protocols and workflows in place

5B. Level that protocols are followed

Less than 50%(Not acceptable)

More than 50%, less than 100%

Nearly 100%(standard work)

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“Supported by” Parameters (examples)

12. Scale of practice data collected, used

Minimum(defined)

Partial(defined)

Full / standard work

9. Level of office practice design & reliability

Non-systematic(not acceptable)

non-standard processes vary by individual & day

Partially routinizedsome standards set for

some processes

Standard workWhole system operates

in standard expected way

11. Level of business model support

Integrated BH not fully supported(defined)

Integrated BH fully supported(defined)

8. Level of community expectation for integrated BH / PC

Little or none(defined)

Expected in pockets

(defined)

Widely understood and

expected

Tools• In-service presentations and handouts so that BHPs can influence and support PCPs

Your Behavioral Health Team at A.F. Williams

We would like to take this opportunity to introduce you to the Behavioral Health Team at A.F. Williams. We are a team of licensed psychologists, post-doctoral psychology fellows, and pre-doctoral psychology interns who work with you and your providers at A.F. Williams to provide comprehensive, whole-person care for your mind and body.

Some of the areas that we help with (just to name a few) include:

Pain Management

Improving Sleep

Adjustment to Illness

Management of Hypertension

Management of Diabetes

Weight Management

General Adjustment

Stress

Anxiety

Depression

Smoking Cessation

We work side by side with your AF Williams providers so you may see us in an appointment with your providers, or you may be able to schedule an individual or group appointment with us depending on your needs and preferences. You can speak with your provider for a referral or call (720) 848-9102 to schedule an appointment.

We are here to be a part of your health team and help you

approach your health in a holistic way!

Tools• BH Screen

Tools

• BH handouts for patients with educational and actionable item components to support SMS with goal setting

Action Plans for Depression Management• Action plans can be presented by a BHP or PCP• Action Plans include:

• brief psychoeducation• insight development• coping skills• goal setting for self management support

Action Plan for Depression Treatment - Psychoeducation

• Nearly 17% of adults in the U.S. experience depression at some point in their life. It can affect feelings, thoughts, behaviors, relationships and physical health.

• “Depression symptoms” include a sense of sadness or unhappiness, a lack of interest in things you used to enjoy, changes in appetite, difficulty concentrating, trouble sleeping, loss of energy, feelings of worthlessness, and may include thoughts of suicide.

• Strategies to help reduce depression that you may want to try:

• 1. Take a breath break. When you notice depression symptoms, try a relaxation breath. STOP, breathe and then decide on your next step.

• 2. When feeling blue, get ACTIVE! It is great for your body and mind. When we are active the brain releases feel good chemicals that can help decrease depression. Activities such as walking, swimming, running, gardening, biking, or house cleaning can help you get the just 10 minutes of light physical activity needed each day to help reduce your depression.

• 3. Connect. When feeling depressed, it can be helpful to talk with a friend or family member. Staying connected to people who are positive and supportive is always a good coping strategy.

• 4. Pleasant activities/hobbies. Increasing the number of fun, enjoyable, and meaningful activities or hobbies in your life can also help you feel less depressed.

Action Plan for Depression Treatment – Building Coping Skills and Developing Insight

Depression Thermometer

Color in the thermometer to the number (10=high, 0=none) that best describes how depressed you have been in the past week:

How do you feel in you’re your body, your thoughts and your mood when you’re at a…

0 =______________________ ______________________ 5 = ______________________ ______________________ 10 = _____________________ _____________________

1-2-3

1 = STOP 2 = BREATHE 3 = ACT

Remember relaxation can occur in seconds – telling yourself to “STOP” and “BREATHE” can be a quick and effective way to reduce depression. ______________________________

How to question depressed or unhelpful

thinking 1. When you have a negative thought, try to ask yourself how you might see it another way. 2. Is my negative thought always true? How can I stick to the facts? 3. Are there strengths or positives in the situation that I am ignoring? 4. If my best friend or someone I loved had this thought, what would I tell them? 5. What are more helpful or realistic statements to replace the upsetting ones?

Action Plan for Depression Treatment – Next Steps

MY ACTION PLANActivity Breeds Activity!!

During the next seven days, I will:____________________________________________________________________________________Frequency: ___________ times a__________________Importance:_____ Confidence:_____

I will:____________________________________________________________________________________Frequency: ___________ times a__________________Importance:_____ Confidence:_____ I will:____________________________________________________________________________________Frequency: ___________ times a__________________Importance:_____ Confidence:_____

This is your ACTION PLAN, so set reasonable goals that you feel you can accomplish!

How confident are you that you can follow through with your overall ACTION PLAN before your next visit?

1 2 3 4 5 6 7 8 9 10Not at All Confident Very Confident

 If you have questions, contact Behavioral Health Consultant: ________________

Phone: _________________

Next appointment:___________________________________

Tools• Evaluation – productivity, satisfaction, clinical change (PHQ-9

for depression, Duke Health Profile for global functioning changes), utilization changes (ER visits, in pt stays)

• Know how much integration costs

Cost and workflow (not just FTE)Where• Where are important events happening?• Examples: clinic, patient’s home, partner site, internet/web

What or How• What is being done to help integrate care? • How much time is being spent on this activity?• Examples: ask questions, look at data, talk with someone, provide

instructions, make a decision, connect to a resourceWhen• When is the action performed or in what sequence?• Examples: before, during or after a visit, three months from now, once a

year. Who• Who is participating, receiving, or doing something?• Examples: PCP, BH provider, staff, collaborator, patient, computer/Electronic

Health Records

Examples• Depression Workflow

• Pain Clinic

A.F. Williams – Depression 36 Week Care Plan

No

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isit

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By

We

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ß Acute Phase ← | → Continuation Phase →

- Referral made to BH In basket- Group visit during continuation phase- MA schedules 40 min at the end of each visit, Kristina's back-up- Phone calls: RN, BH, CM- Document on SharePoint- CTA for appointment reminders- Phone script for calls- Visit template- Brochure- Visit: Provider and Co-Consultation

Week 6-8Provider/

Co-consult Visit

Week 32Phone Call

Week 9Phone Call

Week 24 Provider/

Co-consult Visit

Week 10-12Provider/

Co-consult Visit

Week 18Phone Call

Week 5Phone Call

Week 2-4Co-consult

Visit

Week 1Phone Call

Week 0Pt. New

Depression Dx

Week 36Provider/Co-consult Visit

Resources• Robinson, P.J. & Reiter, J.T. (2007). Behavioral Consultation and

Primary Care. Springer Science + Business Media, LLC. New York.

• The Academy for Integrating Behavioral Health and Primary Care: http://integrationacademy.ahrq.gov/

• The Patient Centered Primary Care Collaborative www.pcpcc.net

• Dickinson WP, Miller BF. Comprehensiveness and continuity of care and the inseparability of mental and behavioral health from the patient-centered medical home. Families, Systems & Health. 2010;28(4):348-355.

• Brown-Levey S, Miller BF, deGruy FV. Behavioral health integration: an essential element of population-based healthcare redesign. Translational Behavioral Medicine. 2012:1-8.

• The Collaborative Family Health Care Association: http://www.cfha.net/▫ Webinars including Dr. Parinda Khatri on Integrating your

Practice: Key Building Blocks

Thank You

• [email protected]• @miller7

• [email protected]• @sbrownlevey