Whole Person Carein a Behavioral Health Setting

Phase 1 Webinar Series

CPAA/AIMS Center Training Program

February 19, 2019

TEAM ROLES AND READINESS FORINTEGRATING CARE

Learning Objectives

By the end of this session, teams will be ableto:• Define team member roles and responsibilities forintegrated care in a behavioral health setting

• Explore opportunities for new roles andresponsibilities in a fully integrated model of care

How Do We Think about What a PC ina BH Program Ends Up Doing?

• Screen• Link• Teach Support

• Coordinate• Treat to Target• Improve Health Numbers

IMPROVE HEALTH

Summary of Project Descriptions

• CORE Health• Consejo Counseling• Cascade Mental Health• Community Youth Services• Willapa Behavioral Health

Client Centered Team:Behavioral Health Home

PCP

Psychiatrist and /or PCP consultantCase Manager Mental Health Center

Primary CarePCP

Medical ConsultantCase Manager

Patient

Behavioral Health Agency

Primary Care

Nurse CareManager /

Registry Function

Care Functions

Screening Functions

Psychiatric Prescriber Functions

Case Management Functions

Registry Functions

Medical Consultant Functions

PCP Functions

Screening Functions

• Some means of gathering data– Vital signs– Lab data– Smoking status

• How can you do this?– Medical assistant or nurse in BHA setting– Data from primary care partner– Clipboards at front desk

Psychiatric Prescriber Functions

• Review physical data• Clarify history• Exam• Synthesize and plan• Communicate with PCP – form letters?• Communicate with care management

Case Management Functions

• Care coordination• Client engagement• Managing transitions of care• Health promotion• Referral to community services

The Case Manager is the “BusinessEnd of the Stick “

• The place in the system where the client and thesystem treating the client are most impacted

• Most of the other functions exist in order to getthe case manager where they need to be, whenthey need to be there

Reflection & Discussion

Does someone at your agency currentlyperform case management functions?

Please describe– Coordination of care– Managing care transitions– Referrals to community services

Reflection & Discussion

Could existing case management functions beused to address physical health?

For example:– Coordination of care– Managing care transitions– Referrals to community services

Client Centered Team:Behavioral Health Home

PCP

Psychiatrist and /or PCP consultantCase Manager Mental Health Center

Primary CarePCP

Medical ConsultantCase Manager

Patient

Behavioral Health Agency

Primary Care

Nurse CareManager /

Registry Function

Registry/Care Management Function

• Uses client data to organize the team’sresponse to physical health needs

• Doesn’t have to be impossibly complicated• Someone has to track the clients, but itdoesn’t have to be a doctor or a nurse

• A function, not a person

Registry Example

Performing Case and Care ManagementFunctionsMultiple staff can perform these functions and havedifferent strengths/weaknesses:

– Behavioral health case managers• Used to coordinating care, interfacing with the outside world• Less medical background

– Nurses• More medical background• [Sometimes] less comfort with SMI population• More expensive!

– Peers• The benefit of lived experience• Less medical background

Medical Consultant Functions

• Collaboration with BH team• Teaching, monitoring of patients• Commonly not located in your organization• Could be a variety of providers

– MD, ARNP, PA– Pharmacist– RN

Reflection & Discussion

Does your agency have someone medical tocall with a question?

Please describe.– Should I worry about this tremor?– Does this medication list make sense?– etc

PCP Functions

• Direct medical services (onsite or offsite)• Coordination with PCP important task of thecare management team

Coordinating Care on a Budget

• Choose a small group to cut your teeth on.• Get data – improvements can be invisible to thenaked eye and staff can become demoralized– But don’t be obsessional about perfect registry product

• Don’t overreach and try to cure the $3Mman• Do things in bulk– if the staff is asking EVERYONEabout smoking, it gets to be automatic sooner.

• Proximity matters – if people rub elbows, not somany meetings need to be scheduled

• Phone calls are quicker than trips

Reflection & Discussion

Have you considered a creative way to meet PCin BH needs?

Please describe– Coordination of care– Managing care transitions– Referrals to community services

More Than One Way to Get Tasks Done

• Changing roles of existing staff– OP nurses expanding into population health– Case managers expanding role definition– Peers

• Primary role in supporting good health behaviors

– Support staff• Clerical support of registry function

Team Building Worksheet

Team Building Worksheet Example Action Items

1. Continue team meetings & site calls with AIMSCenter

2. Complete Team Building Worksheet

3. Email to Juliann (salisj2@uw.edu) by Friday,3/15/19

4. Be prepared to share by Tuesday, 3/19/19

Training Website

https://aims.uw.edu/wastate/content/whole person care training program

• Find webinar recordings, training resources & calendar• Share your best practice documents, workflows, or

presentations!• “None of us is as smart as all of us”

What’s Next• Attend webinar, "Foundational Concepts for Integration in a BehavioralHealth Setting"

• Project Description submitted before next webinar

1. FoundationalConcepts forIntegration

• Attend webinar, "Team Roles and Readiness for Integrating Care" and sharefinal Project Description

• AIMS Team Building Worksheet submitted before next webinar

2. Team Roles andReadiness for

Integrating Care

• Attend webinar, "Develop Your Clinical Workflow for IntegratedCare" and share team roles

• Drafted workflow for screening or treatment of your target populationsubmitted before next webinar

3. Develop YourClinical Workflowfor Integrated Care

• Attend webinar, "Population Management Using a Registry to TrackOutcomes" and share workflow development

• Finalize workflow and registry strategy

4. PopulationManagement

Using a Registry toTrack Outcomes

Reflection & Discussion

• Team Sharing– After today, what questions do you have for us?– What tools or resources would be helpful fromthe AIMS Center?

THANK YOU!