the integrated primary care behavioral health model...coordinated care: primary care and behavioral...
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HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
The Integrated Primary Care Behavioral Health Model
Brian C. Reed MDDirector, Disease Control and Clinical Prevention
Harris County Public HealthJuly 13, 2018
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Overview: The Integrated Primary Care Behavioral Health Model
• Institute for Healthcare Improvement Triple Aim• Definition of Integrated Care• The Case for Integrated Primary Care Behavioral
Health Model• Levels of Integration• Integration within Harris Health System• Four Quadrant Model
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County 3
• Improving the Patient Experience of Care
• Improving the Health of Populations
• Reducing the Per Capita Cost of Healthcare
Institute for Healthcare Improvement : Triple Aim
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County 4
Defining Population HealthPopulation health is defined as the health outcomes of a group of individuals, including the distribution of outcomes within the group.
•These groups are often geographic population such as nations or communities
•However, the groups may be employees, ethnic groups, disabled persons, prisoners or any defined group
•The health outcomes of such groups are of relevance to policy makers in both the public and private sectors.
•Note that population health is not just the overall health of a population but it also includes the distribution of health.
Dr. David A. Kindig, MD, PhD Emeritus Professor of Population Health Sciences and Emeritus Vice Chancellor for Health Sciences at the University of Wisconsin-Madison School of Medicine
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County 5
Definition Population Health:Population Health Outcomes
• Most health improvement models seek to:• Increase overall population health• Eliminate disparities within the population
•In this model overall population health is evaluated by two measures:
•Mortality – length of life•Health related quality of life
•Since another goal is to reduce disparities in these health outcomes among different subgroups in the population, this figure seeks to capture disparities based upon
•Race/Ethnicity•Socioeconomic Status•Geography•Gender
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County 6
Definition Population Health:Health Care Determinants
• Health care determinants include:•Access•Cost•Quantity and Quality of health care services
•Individual behavior determinants include:•Lifestyle habits•Diet & Exercise•Smoking
•Social environment determinants include•Education•Income•Occupation
•Physical environment determinants•Water quantity•Lead exposure
•Genetic determinants include genetic composition of individuals or populations
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County 7
Defining Population Health:Impact of Policies and Programs
• Policies and programs produce changes in health determinants or factors.•These health determinants produce health outcomes.•Examples of policy changes that impact health are the following:
•Smoking bans•Excise taxes on cigarettes•Excise taxes on alcohol•Seat belt laws•Water fluoridation•Restaurant menu labeling.
•The inherent value of a population health perspective is that it facilitates integration of knowledge across the many factors that influence health and health outcomes.
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Definition of Integrated Care
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
The Case for Integrated Primary Care Behavioral Health Model People with mental illness are dying on average 10 years earlier
than the general population. The average life expectancy of an individual with a severe mental illness is
approximately 49-60 yrs. compared to 78.6 years. Greater likelihood of death from heart disease, pneumonia, influenza and
other respiratory ailments. 7 of the 10 leading causes of have a psychological and/or behavioral
component. This includes heart disease, cancer, strokes, diabetes, chronic lower
respiratory disease, accidents and suicide Health care visits often have psychosocial drivers. Integrated Primary Care Behavioral Health can produce cost savings Fewer hospitalizations Fewer emergency room visit
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Three Main Categories of Care Coordinated Care:
Primary care and behavioral health providers communicate about shared patients
Maintenance of separate facilities and systems
Co-Located Care: Behavioral health and primary care have a co-located practice at the same
facility. There is closer collaboration with some systems integration
Integrated Care: There is a systematic clinical approach to identify patients who are in need of
behavioral health services Providers jointly plan and execute goals Co-manage patients and maintain shared schedules Develop integrated care plans
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Three Main Categories of CareCoordinated Care: Level 1: Minimal Collaboration Behavioral health and primary care providers work in separate facilities and
have separate systems. Providers rarely communicate about cases.
Level 2: Basic Collaboration at a Distance Behavioral health and primary care providers work in separate facilities and
have separate systems. Providers view each other as resources and communicate periodically about
shared patients. Behavioral health is still viewed as specialty care.
Key Element is Communication (Note differences between frequency and type of communication)
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Three Main Categories of CareCo-located Care: Level 3: Basic Collaboration Onsite Behavioral health and primary care providers are co-located in the same
facility. They may or may not share the same practice space. Providers continue to use separate systems but communicate more often via
telephone, e-mail or in person conversations. There is a shared patients are moved between behavioral health and primary
care via a referral process.
Level 4: Close Collaboration with Some System Integration Behavioral health and primary care providers are co-located in the same
practice space and there is closer collaboration. Behavioral health providers are often embedded within the primary care
practice and have the ability to access and enter notes into a shared medical record.
Key Element is Physical Proximity
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Three Main Categories of Care Integrated Care: Level 5: Close collaboration approaching an integrated practice There are high levels of integration and collaboration. Providers communicate frequently and work as a team. Behavioral health and
primary care providers are co-located in the same facility.
Level 6: Full collaboration in a Transformed/Merged Practice This is the highest level of integration. Providers and patients view the clinical operation as a single health system that
has been designed to treat the whole person.
Key Element is Practice Change (There must be blending/blurring of cultures and no discipline predominates)
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Integration Vs. Traditional ModelIntegrated Care Traditional Mental health
Population Based Client Based
Informal inflow Formal referral and acceptance process
Open Access (client is usually seen on the same day as referral)
Appointments and usually wait list
Visits typically 15-30 minutes Visits usually 45 minutes – 60 minutes
Treatment is typically limited to 1-3 visits Often long term treatment
Mental health is just one component of overall care Focus upon mental health
More informal counseling ; prone to interruption More formal and private
Frequent consultation with medical provider for clients with co-occurring health and mental health conditions
Little or no interaction with medical provider regarding medical conditions
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Primary Care Behavioral Health Integration within Harris Health System Rationale
All psychiatric care provided at one location
6 month waiting period for new appointments
Pilot A psychiatrist was placed one half day
per week in 3 community health centers.
Goal was to increase timely access The psychiatrist was responsible for
evaluation and treatment of scheduled patients.
The psychiatrist also implemented curbside consultations.
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Primary Care Behavioral Health Integration within Harris Health System
Bi-Directional Flow of PatientsEducation Funding $54,000 educational grant from
Abbott Laboratories for a formal lecture series $450,000 grant from Hogg
Foundation for July 2005 –June 2006 $700,00 in additional support
from HCHDResults
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
The Four Quadrant Clinical Integration Model (MH/SU)
Quadrant II
MH/SU PH • Outstationed medical nurse
practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP
• MH/SU clinician/case manager w/ responsibility for coordination w/ PCP
• Specialty outpatient MH/SU treatment including medication-assisted therapy
• Residential MH/SU treatment • Crisis/ED based MH/SU interventions • Detox/sobering • Wellness programming • Other community supports
Quadrant IV
MH/SU PH • Outstationed medical nurse
practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP
• Nurse care manager at MH/SU site • MH/SU clinician/case manager • External care manager • Specialty medical/surgical • Specialty outpatient MH/SU treatment
including medication-assisted therapy • Residential MH/SU treatment • Crisis/ED based MH/SU interventions • Detox/sobering • Medical/surgical inpatient • Nursing home/home based care • Wellness programming • Other community supports
•
MH/SU
Risk
/Comp
lexity
Quadrant I
MH/SU PH • PCP (with standard screening tools
and MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)
• PCP-based BHC/care manager (competent in MH/SU)
• Specialty prescribing consultation • Wellness programming • Crisis or ED based MH/SU
interventions • Other community supports
Quadrant III
MH/SU PH • PCP (with standard screening tools and
MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)
• PCP-based BHC/care manager (competent in MH/SU)
• Specialty medical/surgical-based BHC/care manager
• Specialty prescribing consultation • Crisis or ED based MH/SU interventions • Medical/surgical inpatient • Nursing home/home based care • Wellness programming • Other community supports
Physical Health Risk/Complexity
Low High
Low
High
Persons with serious MH/SU conditions could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration.
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Four Quadrant Model: Quadrant I
Population: Low to moderate behavioral health complexity and low to moderate physical health complexity. The Model: Person Centered Healthcare Home: A primary care
team that includes a behavioral health consultant/care manager, psychiatric consultant, screening for behavioral health concerns and stepped care. The Providers: Primary care provides full scope healthcare home and uses standard
behavioral health screening tools. Psychiatric consultation is structured to support the primary care
provider and behavioral health consultant/care manager with a focus on treatment planning for those individuals who are not improving.
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Four Quadrant Model: Quadrant II
Population: Moderate to high behavioral health and low to moderate physical health complexity and low to moderate physical health complexity. The Model: Person Centered Healthcare Home: Primary care
capacity in a behavioral health setting provided via wellness screenings, a medical nurse practitioner or PCP. The Providers: Primary care provides stepped care to full scope healthcare through
practicing onsite or supervision of a nurse practitioner. Standard health screenings and wellness programs are available.
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Four Quadrant Model: Quadrant III
Population: Low to moderate behavioral health complexity and moderate to high physical health complexity The Model: This is Quadrant I care plus medical/surgical
specialty collaboration.
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
Four Quadrant Model: Quadrant IV
Population: Moderate to high behavioral health complexity and moderate to high physical health complexity The Model: This is Quadrant II care plus medical/surgical
specialty collaboration.
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
The Four Quadrant Clinical Integration Model (MH/SU)
Quadrant II
MH/SU PH • Outstationed medical nurse
practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP
• MH/SU clinician/case manager w/ responsibility for coordination w/ PCP
• Specialty outpatient MH/SU treatment including medication-assisted therapy
• Residential MH/SU treatment • Crisis/ED based MH/SU interventions • Detox/sobering • Wellness programming • Other community supports
Quadrant IV
MH/SU PH • Outstationed medical nurse
practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP
• Nurse care manager at MH/SU site • MH/SU clinician/case manager • External care manager • Specialty medical/surgical • Specialty outpatient MH/SU treatment
including medication-assisted therapy • Residential MH/SU treatment • Crisis/ED based MH/SU interventions • Detox/sobering • Medical/surgical inpatient • Nursing home/home based care • Wellness programming • Other community supports
•
MH/SU
Risk
/Comp
lexity
Quadrant I
MH/SU PH • PCP (with standard screening tools
and MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)
• PCP-based BHC/care manager (competent in MH/SU)
• Specialty prescribing consultation • Wellness programming • Crisis or ED based MH/SU
interventions • Other community supports
Quadrant III
MH/SU PH • PCP (with standard screening tools and
MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)
• PCP-based BHC/care manager (competent in MH/SU)
• Specialty medical/surgical-based BHC/care manager
• Specialty prescribing consultation • Crisis or ED based MH/SU interventions • Medical/surgical inpatient • Nursing home/home based care • Wellness programming • Other community supports
Physical Health Risk/Complexity
Low High
Low
High
Persons with serious MH/SU conditions could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration.
HCPH Priority Public Health Issues for 2013-2018Selected for the magnitude of the issue and our ability to make progress in Harris County
References SAMHSA-HRSA Center for Integrated Health Solutions
https://www.integration.samhsa.gov/integrated-care-models
Partners in Health: Mental Health, Primary Care and Substance Use Interagency Collaboration Tool Kit
http://www.ibhpartners.org/wp-content/uploads/2016/04/IBHPIinteragency-Collaboration-Tool-Kit-2013-.pdf
Behavioral Health/ Primary Care Integration and the Person Centered Healthcare Home
https://www.integration.samhsa.gov/BehavioralHealthandPrimaryCareIntegrationandthePCMH-2009.pdf