Strengthening Relationships Between Primary Care and

Behavioral Health

Mary Jean Mork, LCSWNeil Korsen, MD, MScApril 17, 2009

Outline of Presentation

Who are we and where do we come from? – Our model

The importance of team The Culture Clash challenge Communication Levels of Integration

How to improve Where are you?

Objectives

Attendees will:1. Be able to identify their level of

integration2. Describe steps they can take to

increase their level of integration3. Articulate components of effective

communication for integrated practice

Mental Health Integration in Maine

MaineHealth Members and Affiliates

PenBay

Miles Memorial

Midcoast

MaineGeneral

Stephens Memorial

St. Mary’s

Spring Harbor

Maine Medical Center

SMMC

St. Andrew’s

Primary Care and Mental Health

Primary Care• Multi-site Practices• Hospital-owned

Practices• Residency Practice• Solo Private

Practice• FQHC look-alike• Rural Health Clinics

Mental Health• Medical Center

Outpatient Psychiatry• Hospital-owned

Behavioral Health• Community Mental

Health Centers• Consumer Case

Management Agency

Acces

s

Standardized Assessment &

Risk Stratification

Care Management

Support for

Behavioral Change Mental

Health Treatment & Consultation

Specialty

Mental Health

Primary Care Medical Home

Community Resources e.g., NAMI

Team building

Our integrated faculty team

Medical Director – Family Physician Program Managers

LCSW Educator with health science background

Psychiatrists Child Adult

Administrative Professional

Mental Health Integration:

Team Roles Mental HealthSpecialist

Diagnose, Treat

Primary Care Provider Support Staff

Screen, Diagnose, Treat

Care ManagerFollow up,

Family Adherence Patient Education

PsychiatristOr APRN

Consult, Train

NAMICommunity Resources

Family Support

Patient and Family

Who needs to build relationships?

Program staff (with each other) Program staff and participating organizations Primary care and mental health

administrators Primary care team, mental health provider,

care manager

The foundation of teamwork is interpersonal relationships

Relationship building: MHI faculty role

Get people together – learning sessions, conference calls, site visits, listserve

Facilitate the conversation Listen Provide knowledge and tools Be encouraging Never give up!

Relationships with Patients:The Benefit of Integration and

Collaboration?

Patients who:

Experience their life problems as “medical”

Have not been socialized to the concept of “emotional distress” or to the idea of therapy

Feel blamed by a referral to Mental Health Feel abandoned by a referral to Mental

Health Patients dealing with behavioral or

emotional aspects of medical conditions

High risk populations

People with chronic illnesses or chronic pain

People with a disability Kids with school, sleep or behavior

problems People with persistent somatic complaints

and negative medical work-up

Patients in Integrated Care compared toSpecialty Mental Health

More likely to be first mental health contact

Less psychologically “sick” Less likely to define themselves as

impaired Require fewer visits

Primary Care and Mental Health: The Culture Clash Challenge

Mental Health Specialist in

Primary Care: How about those

differences?

Mental Health Specialist in Primary Care:Other Differences

Primary Care Mental Health

Pace 15 minute appointment 50 minute sessions

Setting An exam room A living room

Language Diagnosis, medical terminology, complaints

Assessment, mental health terminology, issues

Hierarchy Clear – Dr. in charge Diffuse – Administrator in charge with med director

Flow Flexible patient flow Scheduled client flow

Levels of Integration

Improving Relationships at Every Level

Levels of IntegrationLevel of

IntegrationAttributes

Minimal Collaboration

I Separate site & systems Minimal communication

Basic Collaboration

from a distance

II Active referral linkages Some regular communication

Basic Collaboration

on site

III Shared site; separate systems Regular communication

Collaborative Care

partly integrated

IV Shared site; some shared systemsCoordinated treatment plans

Regular communication

Fully Integrated System

V Shared site, vision, systemsShared treatment plansRegular team meetings

Modified from Doherty, McDaniel, and Baird - 1996

What is your level of integration?What is keeping you from getting

to the next level?Is there one thing you could do

soon, that would enable you to get to the next level?

Level One: Starting to Connect

Ask your clients about their primary care/mental health provider and get a release

Identify patients who could use better coordination – contact their providers

Contact key providers in your area Those treating your most complex

clients Those treating a group of your

patients

Level Two: Building on Basic Collaboration

Garner invitation to staff meeting

Identify clear processes and expectations around communication What should they expect

to get from you? What do you need to hear

from them? How can you share

information better?

Level Three: Sharing More than Space

Set up regular times to “meet” Clarify expectations around

communication & treatment coordination

Begin to “share” processes, e.g., scheduling

Work out record-sharing Define team relationships

Level Four: Increase the Integration

Clarify team mission and roles Formalize team expectations –

when to meet, what to share, etc.

Set up streamlined processes for communication and treatment coordination

Develop ways to learn from each other

Celebrate successes

Level Five: Maintaining & Continuously

Improving Set up formal and informal

learning opportunities Maximize use of staff

meetings, case conferences, huddles, and hand-offs

Always work on improving relationships – both within the team and the larger community

Remember that the patient is the focus of the work

Communication between Physician and MHP

At any level Confidentiality fosters splitting Blanket information release with the goal of

enhancing collaborative care In a Co-located – Integrated Practice

“Curbside consultations” Behavioral health rounds Take the clinician conversation into the

exam room Use words that do not require a physical or

psychosocial definition of the problem

Information Exchange between Providers

When might the MHP be useful?

Think SSRI: Situation Skill-setRelationshipIndicators or outcomes

Certificate Program in Primary Care and Behavioral Health. Department of Family Medicine and Community Health, University of Massachusetts Medical School. Alexander Blount, EdD, Director

Example

“I’d like to have my colleague, Ms. Peterson, work with us to help you figure out ways to reduce your stress in the evenings. She has a great deal of experience helping parents come up with bedtime routines. I think that if your kids went to bed better, you would be less stressed, and your headaches might be reduced. What do you think?”

Successful Communication with Primary Care

Note specific information from the patient/client that might effect treatment

Describe the specific indicators and how they have changed

Share what the patient/client reports as meaningful

Discuss how the Physician and Mental Health Clinician can work together on the treatment

Example

“I met with Ms. Brown and she agrees that she gets as “wound up” as her kids at night. We came up with some calming bedtime activities for the whole family and she agreed to try this for two weeks and report back to us on whether her headaches are reduced with her “winding down” routines. She also agreed to take her medication as prescribed during this time.”

Partnership Development

Partnership development

Describe your mh/pc partnership when you began mental health integration – how did it feel?

Use 1-2 word descriptions

Beginning Stage - quotes

Disconnected Skeptical Impatient Optimistic Hopeful Eager Fortunate

Part I

Partnership development

Describe your mental health/primary care partnership at 3-6 months - how did it feel?

Use 1-2 word descriptions

Middle Stage - quotes

Matching faces to names More comfortable Continuing the work Still learning Frustrated (e.g., over credentialing) Challenged by the details Impressed with the accomplishments

Part II

Partnership development

Describe your mental health/primary care partnership now (12-18 months) – how does it feel?

Use 1-2 word descriptions

Mature Stage - quotes

Comfortable In sync Efficient Work is rewarding Model is sustainable Very excited and

impressed

Mission driven as a team

Not yet done Helpful to people

being served Crucial – can’t live

without it Fragile

Fred and Eleanor