Transitioning from Co-Located to Integrated Care:

Transitioning from Co-Located to Integrated Care: The role of the Behavioral Health Consultant (BHC)in designing and developing behavioral healthcarein the Medical HomeCollaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.Session #D2aOctober 5, 2012

Dennis C. Russo, Ph.D., ABPP Head, Behavioral Medicine Program; Clinical Professor Departments of Family Medicine and Psychology, Brody School of Medicine, East Carolina University

Kari B. Kirian, Ph.D.Clinical Instructor,Behavioral Medicine Program, Dept. of Family Medicine, Brody School of Medicine, East Carolina University

Laura M. Daniels, M.A.Doctoral Student in Clinical Health PsychologyDepartment of PsychologyEast Carolina University

Jennifer L. Hodgson, Ph.D.ProfessorDepartments of Child Development & Family Relations and Family MedicineEast Carolina UniversityCollaborative Family Healthcare Association 12th Annual ConferenceFaculty DisclosureWe have not had any relevant financial relationships during the past 12 months.

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Collaborative Family Healthcare Association 12th Annual ConferenceObjectivesIdentify procedures which provide necessary mission, institutional, and patient centered support to assist training programs in their initial transition from Co-Location to Integrated Care

Evaluate methods for identifying how best to serve the needs of patients within the Integrated Care Setting

Describe the development of a collaborating group of professionals with reference to the makeup of the Behavioral Science Team

Evaluate components essential for ensuring the sustainability of programs educational and clinical services

Include the behavioral learning objectives for this sessionCollaborative Family Healthcare Association 12th Annual ConferenceLearning AssessmentGuided discussion will address audience implementation of a Transition Plan during a problem solving and question/answer session at end of presentation.Collaborative Family Healthcare Association 12th Annual ConferenceTransitioning from Co-Located to Integrated Care:The role of the Behavioral Health Consultant (BHC) in designing and developing behavioral healthcare in the Medical Home

Timeline

Phase 2:Formal Program Development2010-2011

Phase 5: Operating a Sustainable Integrated Primary Care ProgramPhase 1:Prepare forIntegration2008-2010Phase 3:Building Center for Integrated Care2011-2012Phase 4:Beginning Integrated Care2012-2013Transitioning from Co-Located to Integrated Care:Phase I: Building the Basis for an Enduring Program

Re-establishing the behavioral medicine service and curriculum for the Family Medicine Center and Residency Program.

Phase 1: Reintegration(January 2008-January 2010)PrioritiesBuild a team of cliniciansHire a full time director of behavioral medicinePilot an integrated care modelWrite grants to help offset start-up costs

Strategies for successBuild relationships; respect the culture and system as it is and not seeing it as broken but something that can be enhancedBuild a team of BM providers and strengthen the connection to psychiatry Attend as many meetings as possible, BM needs to stay visibleWalk around and spend time in precepting rooms doing video reviews and just waiting for opportunities to educate and integrateReach out to colleagues for ideas

Outcome #1: Grant SupportReceived an Access East grant for $25,000 to fund a part of my position until May 31, 2009.Received an SBIRT grant for $280,000 which resulted in 3 years of funding for program implementation in the Family Medicine Center.

Who accessed our services?58% Physician Extenders 26% Residents16% Faculty

* 1st 9 months of implementing the new service

When were we brought into the Integrated Care process?

50 x Therapist BEFORE PCP130 x Therapist WITH/DURING PCP135 x Therapist AFTER PCP25 x Traditional Session (45 min - 1 hour)

Constellation of Encounters

160 Individual Encounters15 Couple Encounters35 Family Encounters130 Larger System (with provider) Encounters

Length of Encounters17% @ 15 minutes32% @ 30 minutes19% @ 45 minutes23% @ 1 hour9% @ > 1 hour

Services Provided245 x Joining or Assessing95 x Psychoeducation78 x Brief Therapy107 x Lengthy Therapy 66 x Assist with Treatment Plan32 x Lifestyle Change Consultation32 x Psychological or Relational Diagnosis

Most Common Diagnoses/Symptoms Addressed(neither exhaustive nor in a particular order)End of LifePersonality DisordersNew DiagnosisFertility/InfertilityBereavementStress ReductionLifestyle ChangeChallenges and Issues of AdherenceDoctor/Pt relational issues

Depression/Mood DisordersSuicidal/Homicidal IdeationsAnxiety/PhobiasRelational IssuesOverweightDiabetesPTSDADHDChronic Pain/IllnessSubstance Abuse AssessmentDomestic Violence

Lessons learned in this phaseLearned that we need models for helping behavioral health professionals to integrate as well. Taking steps back to help others catch up is hard but importantModel must be fluid, flexible, and yet have a good infrastructure for fidelity and training purposesSustainability is important but complex in academic settings where students cannot be billed for their services.

Next Steps.Decrease the threshold for Behavioral Medicine involvementIncrease screening for psychosocial problemsIncrease numbers of concurrent visits to facilitate cross discipline learning and extend more comprehensive careBilling and Reimbursement

Transitioning from Co-Located to Integrated Care:Phase II: Formal Program Development

Designing a fully Functioning ProgramUnderstand Institutional Mission and PrioritiesWhats our Job? Developing Clinical ServicesIncrease Visibility of ProgramEnsure Sufficient Manpower to get the Job DoneBuild Professional VisibilityDevelop New Funding Resources

Its Health..Not Just Mental Health,Stupid.*

* My apologies to Bill ClintonOur MissionThe presence of an Integrated Behavioral Health Service greatly enhances our ability to care for our patientsClinical ServicesBeing ThereEverywhere..Right Away!

Integrated Care

The Beeper

Brief Traditional Care

Education and Teaching Events

Ensuring Sufficient ManpowerBuilding AlliancesCreate and Enhance Institutional RelationshipsMedical Family Therapy Program, Department of Child Development and Family RelationsDoctoral Program in Clinical Health Psychology, Department of Psychology (APA Accredited)School of Social Work

Dont stop there!Develop relationships with other training sites and academic departments at other institutions

Focusing the Attention of the Department on Integrated CareGrowth of Patient Care

Addressing Sustainability and Funding IssuesFocus on Integrated Care Team EducationVideo PreceptingThe Behavioral Science Base of Integrated CareLearners teaching LearnersIdentify Service Units NecessaryFacultyStudentsThe Billing, Scheduling, and Coding TeamDo it at home. Develop it nationally.System Level Healthcare ChangeIntegrated Care Stakeholders GroupGet more Grant Funding

Center for Integrated Care DeliveryFunded by a grant from Health Resources and Services Administration to The Department of Family Medicine, Brody School of Medicine, East Carolina UniversityTo establish a Center focusing on training strategies for integrated care management of behavioral issues in chronic disease

To build, test, and evaluate new curricula for medical students and residents on integrated care for concurrent depression/behavioral problems and chronic disease in primary care settings

To evaluate and improve care outcomes in underserved populations with chronic diseases and behavioral problems by establishing an integrated care management training program

Health Resources and Services AdministrationTransitioning from Co-Located to Integrated Care:Phase III: Piloting Integrated Care

Now I will be discussing with you the time in our clinic that was very dynamic in more ways than one. During this phase which encompasses about one year of operation, everyone in the clinic was adjusting to many environmental, operational, and clinical changes. Amidst this excitement we began piloting different approaches for integrating and collaborating medical care with behavioral/mental health care.30Phase III: Piloting Integrated CareEnvironmental considerationsTraining BHC LearnersKick-off ConferenceIntegrated Care PilotOutcome Evaluation

So the primary objective of this phase was to eventually pilot integrate care approaches. Naturally, there was a lot of prep and planning that needed occur before the initial transformation from co-located to integrated care.

Therefore the areas I will cover are the environmental considerations, training, our kick-off conf, and the actual pilot project, and my personal reflections and evaluation of the process.31

Environmental considerationsStructural barriersBigger is not always betterMaintaining relationshipsCreativity and openness to various forms of communicationTechnical difficultiesAvailability and flexibility

Understanding the Limitations/Strengths of Environment

Like I said when I started my rotation at FMC, it was an active time for everyone even beyond the receiving the new grant. We adjusting to the new facility. The old facility was small and cramped and the clinics patient load was growing. While this can be uncomfortable at times, the closeness served to facilitate many opportunities for collaboration, spontaneous consultation, and many teachable moments. So when we moved, departments, offices, and individuals were split up and spread out throughout the fantastically spacious facility. This lead to some unanticipated setbacks in our collaborative efforts.

It was apparent that the relationships were strong and friendly however the building structure made it difficult to maintain an open and integrative approach to care. So what we have learned from this move is that how your clinic is set up can essentially dictate how you maintain relationships. For example, BM was on the second floor while the clinics were on the first floor. Also SW was situated on the 1st floor but separate from the clinic.

Therefore, in order to maintain these relationships it was necessary for everyone to remain flexible, open and creative with communication. When the structural environment prevents you from consistently participating in many hallway consults then that can NOT be the go-to method. Alternate methods may include using flags/msgs regularly in the EMR to update providers, paging providers regularly. Another barrier to collaboration may be if offices are not situated conveniently near one another. So taking regular strolls through the clinics and other office areas provide more opportunities for F2F collaboration.

Lastly, technical difficulties can always cause issues with collaboration. Moving to new facility or even switching EMR interfaces can lead to a number of problems like setting up the precepting system and facilities, EMR scheduling slipups, etc. If these probs are not handled then there will be a loss of continuity of care and training opportunites. It is also necessary to be flexible if an error occurs. Again, in order to maintain rel-ships and prevent anyone from slipping through the cracks BHCs need to be available for questions regarding scheduling and need to take time to roam the landscape, respond quickly to pages, take advantage of the EMR system to communicate pt progress and concerns to providers and residents.

32Training BHC LearnersAdvanced students Adjusting from the 50min to 15min sessionsOn-call to the clinicsSkill building at medical settingIncreasing face-time and comfort with medical teamSupervisionAdvanced students from Clinical Health Psych, MFT, and SW, most who have worked previously in medical and MH settingsAdjusting from the 50min to 15min sessionsOn-call to the clinics managing MH crisis, challenging patients, provide consultation, direct referralsSkill building for integrating into a medical team and working in an outpatient medical settingAttending/Presenting Grand Rounds increasing face-time with medical teamSupervision was real-time and individual weekly meetings.

BM student interns were advanced level students trained in counseling and providing therapy from a biopsychosocial perspective using EBPs. The knowledge and skill set the advanced students entered the rotation allowed them to dedicate the bulk of their learning and training in the practice to learning how to interacted with medical teams (e.g. using concise pt encounter summaries) and engage in brief psychotherapy and develop integrative and collaborative treatment plans. Challenges for the students included adjusting from the 50 min hour, real time case conceptualizations, managing patient-therapist confidentiality, and learning that your role is not only to be a support for the patient but also for the medical team who are often frustrated by the patients adherence or psychosocial factors that interfere with clinical care.

33Kick-off conferenceBringing in expertsIncreasing clinic-wide awareness of integrationEstablishing a supportive team atmosphere and patient-centerednessGoal: Educate on benefits of integrated care and skill-training

Integrated Care conference served as a kick-off to a new clinical approach to medical care

Experts from the medical and behavioral health fields: Drs. Frank Degruy (degree) and Susan McDaniel. It was important get expert consultation on the administrative or financial/billing, clinical, and operational aspects of implementing and sustaining an integrated care approach. Also, by bringing in expert consultants there was increased visibility of our clinical service and purpose at the institutional and stakeholder levels.

Goal: Educate on benefits of integrated care and skill-trainingEstablishing a supportive team atmosphere and patient-centeredness

Also, the BHCs role was being redefined as more active member of the team during clinical activities. The conference provided the learners with expert-lead didactic training on the evidence for establishing integrated care teams and exposure to what integrated care looks like when it is done right.

34Kick-off conference: BHC evolving roleBHC is a team leader with the PCPDecreasing time and frequency in the therapy roomIncreasing time in clinic Engaging in brief consultations and interventionsKnowing team strengthsIntegrated Care conferenceFocus on BMs evolving roleTeam leader with the PCPBHC enhancedDecreasing time and frequency in the therapy roomIncreasing time in the clinic doing brief consultations and therapy

35Integrated Care PilotInterdisciplinary inputHuddle PilotScreening PilotScreening at-risk Diabetes Patients PilotBM fully integrated for 2-4 shifts over 2 wk period

Following the conference, leadership met and engaged in brainstorming and planning for piloting different approaches to integrated care. Dpt Chair Dr. Steinweg was very motivated to obtain input at all levels as to how to best implement integrated care (staff, admin, nurses, extenders, etc). Therefore we took the best approaches out there and discussed the feasibility of implementing each as well as identify types of tailoring that would need to occur with-in our unique clinic culture. From this input and feedback we piloted three projects: Huddle, Screening, and one specifically for Diabetic patients.

The Huddle pilot approach required the medical team to huddle with the BM folks at the beginning of the day and identify which patients may require a more collaborative approach (i.e. new patients, at-risk patients previous MH history or difficulty with adherence or multiple psychosocial issues). During the huddle if the PCP did not identify a patient that the BHC had, then this patient was briefly discussed. This required some assertiveness and flexibility on the BHCs part and openmindedness and flexibility on the PCPs part, and trust from everyone.

For Screening Pilot approach the BM team developed an evidence-based biopsychosocial brief patient health screen. All patients presenting that day filled out the screen in the exam room. BM team reviewed each screen and if there was endorsement the PCP and BHC consulted and made the decision to meet separately or together with the patient.

The Diabetes Pilot targeted patients with diabetes and were non-adherent. In ENC diabetes is the single most prevelant chronic health condition. So the question here was is it better to screen a target population who we know struggles with disease self-management or screen the entire clinic population.

These three pilots were implemented for 2-3 weeks, a couple clinic shifts per week. The goal was to identify the most efficient and effective method to bringing BM into real-time clinic and attend holistically to the needs of the patients. 36Personal ReflectionsFacilitating FactorsReviewing clinic scheduleTalking with providers prior to start of clinicFlexible operations Real-time supervisionPCP follow-upBarriers & Opportunities for growthResistance to changeCommunication lapsesClosed-door operationsScheduling with specialties

Rolling with the resistanceFlexibility identifying idiosyncracies, looking for problems and gaps in care Supporting patients and team with changes, acknowledging challenges, emotional and practical supportOpenness to integration: Understanding each health professionals role on the team and getting to know each others personal work style.Failing to close the loop (emr, page, hallway consult)

37What will the future bring?

Transitioning from Co-Located to Integrated Care:Phase IV: Defining, Detailing, Implementing

DefiningBehavioral medicine teamMeet as a teamSolidify our ideas for IPCOperationally define How we want behavioral health to be utilized on the modulesWhat is feasible Who, when, where, what, how?

Operationalizing = defining a fuzzy concept. Had to pull our various disciplines together (MFT, SW, Hlth Psych) to define and solidify our own conceptions of the look of behavioral medicine presence on the modules prior to dissemination to the other parties involved. =-40Detailing Meeting with key groups to educate, elicit concerns, and request inputBehavioral medicine learnersNursing and CMAsResidentsPreceptors Manifest purpose vs. latent purposeImpart information and answer questionsdecrease anticipatory anxietyExtending olive branch- their meeting, their turfIncrease ownership Rapport, communication, and relationships

Implementing: the Grant has Prompted IC delivery in clinicsResidency curriculum changesEvaluation of impact IC DeliveryPager serviceDietician/NutritionPharmacotherapyBehavioral healthPhysical presence of BHC on the resident modules 1-2 days/month every dayOngoing therapy clinic4-6 sessions

Balance: being accepted and being utilizedResidency curriculum changesBH presence and involvement during academic opportunities Direct ObservationInterdisciplinary (MD + BH faculty), video preceptingExpanded teaching strategiesMedium: vignettes, case examples, role play, small group, discussion, etc. Content: IC, evidence-based interventions, interpersonal communication

Evaluation of ImpactDirect observation evaluations Utilization data for IC visitsDiabetes InterviewsPHQ 9, DDS, DES-SF, HRQOL Biologic and psychologic outcomesPatient and provider knowledge and satisfactionInitial OutcomesUtilization DataMean = 46When BHC Met with PatientTime Spent with PatientWho Initiated the Consult?

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