reverse co-location: integrating primary care into a behavioral health setting philadelphia dbhids...
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REVERSE CO-LOCATION: INTEGRATING PRIMARY CARE INTO A BEHAVIORAL HEALTH SETTING
Philadelphia DBHiDS June 2013
Lawrence A. Real, MDMedical Director
Horizon House Inc
INCREASED MORBIDITY AND MORTALITY
People with serious mental illness (SMI) die on average 25 years earlier than the general population
Though suicide and injury account for maybe 1/3 of this, 60% of premature deaths are due to preventable medical conditions, and most of those due to cardiovascular disease
These preventable medical conditions are linked to high rates of modifiable risk factors
Parks et al, Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors, October 2006
Reversing Early Mortality Due to Obesity and Cardiovascular Risk Factors in Mental Illness: What Works in Changing Health Behaviors Bartels Feb ‘12
MODIFIABLE RISK FACTORS
High incidence of smoking Individuals diagnosed with psychiatric
disorders smoke ~ ½ the cigarettes smoked in U.S.
Sedentary life style High rates of obesity, poor
nutrition Over 42% of people with SMI are obese**
Co-morbid substance use disorders
Limited access to quality healthcare?
*National Epidemiologic Survey on Alcohol & Related Disorders, 2002
**Dartmouth Health Promotion Research Team, 2012
“COLLABORATIVE” vs “INTEGRATED”
Collaborative care involves behavioral health working WITH physical health… [or vice versa]
Integrated care involves behavioral health working WITHIN, and as a part of, physical health… [or vice versa]
In collaborative care, patients perceive behavioral health care as a separate service received from a specialist…[or vice versa]
In integrated care, patients perceive behavioral health care as a routine part of primary care…[and vice versa]Strosahl, in Integrated Care: the Future of Medical and Mental Health Collaboration, 1998
Bottom Line on Co-location
Co-location does not equal integration!
It does, via physical proximity, create an opportunity for improved collaboration
The devil is very much in the details, i.e., how well you plan and execute
Our Journey to Integrated Care
September 7, 2010 –Horizon House partners with Delaware Valley Community Health, and the Fairmount Primary Care Center at Horizon House opens at our 30th St location
September 30, 2010 – Horizon House receives a 4-year Physical and Behavioral Health Care Integration grant from SAMHSA
June 2013– Over 600 patients have received primary care on site
SAMHSA Grant Results in Expanded Staffing
Full-time certified Physician Assistant
Supervising physician, 1/2 day/wk } DVCH
Team leader/ Medical assistant
Billing clerk/administrative assistant
Project Manager (HH)
Data Coordinator (HH)
Health Integration Specialist (HH)
Health Educator (DVCH)
Certified Peer Specialist (2)
Services Offered as of Opening Day
•Insurance eligibility assistance•Adult primary and preventive care and health education*•TB Testing •Lung function testing (Spirometry)•EKGs•Immunizations•Onsite lab services•Referrals to specialists/help in making appointments •Physician available by phone
after hours•Appointment Reminders
•OB/GYN Dental, Podiatry and Health Education Group Services (at DVCH’s Health Center at 1412 Fairmount Avenue) • Prescriptions: filled through patients’ current pharmacy.• Psychotropic medications: prescribed by behavioral health providers.
Ophthalmology and/or optometry services: Referrals to Wills Eye Hospital.
THREE KEY TASKS
1. Can you increase access to primary care, and thereby improve the management of chronic illnesses?
2. Can you improve the early detection and/or prevention of other disease states?
3. Can you “create health” by engaging people in wellness activities before, during or after the emergence of serious medical co-morbidities?
Who Will Provide Primary Care?
1. Facilitated referral (coordination) BH organization coordinates referrals and shares
information with PCPs offsite
2.Partnership-based models (reverse co-location)
Primary care embedded in community-based BH organization
3. Fully integrated models Staff from a single organization provide primary
care and behavioral health care—i.e., do it yourself!
---adapted from Druss, 2011
Lessons Learned: Partnering
You have to either find a partner, or hire your own primary care staff—each comes with its own unique challenges
FINDING A PARTNER: Compatibility
Characteristics of the “right” partner
Experience with /commitment to serving ‘safety net’ populations
Belief in holistic, client-centered services
Willing to give up preconceived notions
Creative, flexible--willing to try new things
Team players, develop concept jointly
Able to quickly establish services
Lessons Learned: Business
You need a business plan that, before too long, projects the primary care operation to at least break even—while maintaining quality of care
FINDING A PARTNER: Feasibility Is there sufficient traffic at the site
Payor mix of potential participants
Willingness of participants to change primary care provider
Can you get Board approvals?
Can you get HRSA, other approvals for change of scope [for FQHC]?
“Show Me the Money!”
Need to take the ‘long view’, see initial commitment as consistent with your agency’s service mission
Creative and assertive in pursuing grants, ‘freebies’, collaborations
Sustainability still will likely require parallel changes in service reimbursement
How Will You Engage Consumers?
Presumption: utilize their engagement with and trust in behavioral health team (‘warm handoffs’)
Make co-located service a preferred choice for primary care (via screenings, wellness activities, incentives, good customer service)
Certified Peer Specialists key members of the team trying to integrate care
Motivational interviewing
Who Will Coordinate Care?
Traditional “case managers”—add this task to services already being provided
Create/ hire/ train specialists in healthcare integration
Combination of existing personnel (with additional training) and integration specialists
Assumes coordination of primary/ medical specialty care via PCP
Lessons Learned: Blending Cultures
You need to work with your primary care providers to merge and adapt the different cultures that define each of you
FINDING A PARTNERChallenge of Information Sharing
Two different and independent charting systems
More stringent state regulations re sharing of BH info
Participant concerns about sharing BH information with primary care providers (and vice versa)
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Lessons Learned: Transforming Yourself
You need to persistently work on changing the culture of your organization so that it sees itself as one that provides integrated health care, not just behavioral health care
Lessons Learned: Choices
You need to consciously balance your desire that all your participants choose primary care on site with with your desire to insure they can freely choose where to receive primary care
Fairmount Primary Care Center at Horizon House: Accessing Care
Fairmount PCC available to ALL HH staff and program participants
Fairmount PCC must be selected as primary care provider
Consistent with FQHC rules, Fairmount PCC will see people without health insurance
Lessons Learned: Systems
You need to create and monitor systems that support the collaborative care you intend to provide, especially if you have gone the ‘partner’ route
Lessons Learned: “Show Me the Data!”
You need to create a ‘clinical registry’ that enables you to track both individual and population health outcomes
Lessons Learned: Ownership of One’s Health
Your processes need to allow for participants to progress to assuming charge of their own disease management and wellness activities
Lessons Learned: Consumer Involvement
Consumers and their supports need to actively involved in design and execution of your plan: Peer specialists on the team Peer advisory council Consumer feedback via surveys and focus groups
Lessons Learned: Wellness Matters
A substantial amount of your effort needs to be devoted to wellness programming, aimed both at the management of chronic illness and at some combination of illness prevention and health promotion
Samples of Wellness Activities
Meditation group Walking group Smoking Cessation Wake and Move FIT Club (Finding Inspiration Together) Yoga Whole Health, Wellness, & Resiliency Taking Charge of Our Health Community Inclusion-YMCA and
Farmer’s Markets
Lessons Learned: We’re all in this together!
Learning communities enable us to learn from each others successes and failures
Each of us can use, modify, and develop new EBP’s
How can we make effective collaboration easier for each other?
The question remains: Can you really make a difference?
Health Promotion Programs for Persons with Serious Mental Illness: What Works?
A Systematic Review and Analysis of the Evidence Base in Published Research Literature on Exercise and Nutrition Programs
Prepared for SAMHSA-HRSA Center for Integrated Health Solutions by the Dartmouth Health Promotion Research Team, Project Director Stephen Bartels, MD February 2012
Health Promotion Programs for SMI: Key Findings
Interventions that last > 3 months are superior; the intensive phase of programs should last at least 6 months
Programs that combine education and activity-based approaches are more sucessful than those that focus on non-specific wellness education
Programs that incorporate nutrition education and exercise are superior in inciting weight loss than those that focus on nutrition alone
Reversing Early Mortality Due to Obesity and Cardiovascular Risk Factors in Mental Illness: What Works in Changing Health Behaviors? Bartels Feb ‘12