integrated behavioral health in newaygo county – flying the plane as we build it

INTEGRATED BEHAVIORAL HEALTH IN NEWAYGO COUNTY – FLYING THE PLANE AS WE BUILD ITDr. Mark Kuiper, MDSarah Bowman, LMSW

Why integrate care?

70% of all PC visits have psychosocial drivers 50% of patient w/diabetes will suffer from

depression 90% of most common complaints have no organic

basis 67% of all psychoactive agents are prescribed by

PCP 80% of antidepressants are prescribed by PCP

Why integrate care?

Individuals with serious mental illness die more than 25 years earlier than general population

Only 1in 4 patients referred to specialty MH/SA make the first appointment

Seven of the ten leading causes of death (heart disease, cancer, stroke, chronic lower respiratory disease, accidents, diabetes and suicide) have a psychological and/or behavioral component

Picture this…..

The woman with chronic pain starts using a few coping skills and stops abusing her pain meds

The man with diabetes starts checking and recording his blood sugars daily and recognizes the impact his food choices are having on his blood sugar.

The obese child you have been treating looses 8lbs. 70% of the patients you refer to specialty MH/SA

treatment actually follow up and participate in tx. The man with schizophrenia and heart disease starts

walking daily and takes his medication as ordered. He even starts eating a few healthy foods daily.

Prior to IBH in Newaygo County….

Now……

How we got here……

Executive Level Support and Space

Getting to know your co-pilots Meeting of the Minds Identified IBH Champions Joint Interviews Flying without a pilot’s license

What does our plane look like?

School based clinics IBH services provided by NCMH clinician at White

Cloud Family Health Care (WCFHC) Co-located NCMH access at WCFHC NCMH “liaison” role for patients/consumers served

by both NCMH and WCFHC

Our Flight Manual

IBH Clinical Protocol Referral Process Patient flow Quadrant Model Documentation

Quadrant Model

Quadrant I Patients with low behavioral health and low physical health needs Served in primary care setting Example: patients with moderate alcohol abuse and fibromyalgia

Quadrant II Patients with high behavioral health and low physical health needs Served in primary care and specialty mental health settings Example: Patients with bipolar disorder and chronic pain Note: When mental health needs are stable, often mental health care can be transitioned back to primary care.

Quadrant III Patients with low behavioral health and high physical health needs Served in primary care setting Example: patients with moderate depression and uncontrolled diabetes

Quadrant IV Patients with high behavioral health and high physical health needs Served in primary care and specialty mental health setting Example: patients with schizophrenia and metabolic syndrome or hepatitis C

Newaygo County Mental Health Primary Care Provider Consultation NoteName:Insurance:DOB:Date/Time: Presenting Problem:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Diagnosis: Axis I:  ____________________________

____________________________Axis 2:  ____________________________

____________________________

Disposition: Referred  To:  NCMH Vera’s House WISE Arbor Circle/ NMSAS John Bjork ____________Linked with: Food Pantry DHS Tru North _______________________Provided Psychoeducation on: Depression  Positive Parenting Practices Substance Abuse Anxiety Communication Diabetes Anger Relationships Smoking Cessation Health/Nutrition Heart Disease Asthma

Plan: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________Clinician Signature Date_____________________________________ _________________Primary Care Provider Signature Date

Our initial flight data…..

Start date May 18th

136 IBH contacts 19 min is average length of contact 6 NCMH direct referrals 4 referrals to other CMH centers 4 NCMH potential referrals but were not completed

(patient not interested in services, guardian not present to seek services, etc)

Referrals By Quadrant Type

Q1 Low BH Low PH26%

Q2 High BH Low PH42%

Q3 Low BH High PH

14%

Q4 High BH High PH

18%

Presenting Physical Health Issue

Cardiac4% Asthma

3%

Chronic Pain13%

Smoking3%

Liver Disease4%

Injury1%

COPD2%Autism

2%Metabolic

1%Pregnancy5%

Diabetes7%

Arthritis4%

Infant/Child Developent29%

Hypertension5%

Fibromyalgia2%

Weight Issues4%

Cancer1%

Sleep3%

Bronchitis1%

Head Injury1%

Menopause1%

Presenting Physical Health Issue

Presenting Behavioral Health Issue

Substance Abuse8%

Depression35%

Stressors13%

Parenting6%

Anger3%

Anxiety20%

ADHD5%

Developmental Disability2%

Grief/Loss3%

Thought Disorder

1% Personality Disorder1%

Trauma2%

ODD0%

RAD1%

Presenting Behavioral Health Issue

“NCMH liaison” Role

45 contacts in September alone! Two IBH clinicians

Assigned to specific NCMH clinical teams Attend daily or weekly team meetings

Primary gatekeeper between NCMH and WCFHC Records requests Psychiatric consults Advocating for NCMH consumer’s physical health needs Overall care coordination *Success Story!!

A work in progress

“NCMH liaison” Role

Co-located access at WCFHC site Full access screening is completed at WCFHC at

time of appointment with PCP *Success Story!!

When Turbulence Hits….

Technology Difficult to do concurrent documentation

Two Separate Medical Records Medical Provider’s World View

Behavioral Health?......

To Screen or Not To Screen? Two different funding structures

Billing, coding questions – who is the “go to”person?

Next Steps

Record Review/Needs Assessment of mutual consumers/patients

Create collaborative patient/consumer PH and BH goals/outcomes

Identify specific populations and provide evidence based interventions

Securing primary care services for NCMH consumers with no PCP (on site or at FQHC)

Billing, Billing, Billing, Billing, Billing Expand – future sites

Questions?

Sources

Robinson and Reiter 2007 Colton and Manderscheid 2006 Mauer 2006 Kroenke et al 1989 Karen Way 1999 Centers for Disease Control and Prevention 2005 Contact sbowman@nmch.org for full citations