Post on 01-Jan-2016
description
Building and Sustaining Relationships between
Primary and Behavioral Healthcare
Amy M. Kilbourne, PhD, MPHVA Ann Arbor Serious Mental Illness Treatment
Research and Evaluation Center
Department of Psychiatry, University of Michigan
Learning Objectives1. To understand the multilevel, system-level barriers
to implementing the Chronic Care Model for depression management in primary care settings, particularly those focused on practice and provider issues
2. To identify potential barriers to fostering relationships between primary care and mental health providers, and strategies for strengthening collaborations with primary care and mental health providers
3. To understand the concept of Participatory Management and how it could be used to identify and reduce barriers to implementation, notably by making the business cases to providers
Barriers to Integrated Behavioral Health-Primary Care:
6-P Framework Patients/Consumers (e.g., symptoms) Providers (e.g., time, tools, training, territory) Practices/Clinical (e.g., lack of systems to
coordinate care, cultural differences) Health Plans/Organizations (e.g., financing) Purchasers/State (e.g., not on radar screen, lack
of info on return-on-investment) Populations/Policies (e.g., stigma)
PCP, MH Provider Barriers
Turnover Losing interest Competing demands Territories
PCP, MH Provider Strategies
Turnover ID 2-3 champions
Losing interest Periodic CMEs, trainingsRegularly report performanceVisit practices
Competing demands Find “win-win”opportunities(e.g., streamline intakes)
Territories Respect cultural differences(e.g., privacy concerns)
Implementing Change: Participatory Management
Combines traditional and emerging approaches: Barrier and solution “analysis” Obtain buy-in upfront
Adapt new strategies via shared decision making Shift decision making authority to stakeholders AND
“end users” (e.g., front-line staff, consumers) Recognition of day-to-day barriers, culture of practices Help senior leaders and front line staff understand
what’s in it for them
Customization to specific settings
Participatory Management
Process 1:ID
strategy
Process 2:Customize
Process 3:Evaluate
Process 4:Implement
ImprovedProcess, outcomes
Provider, Plan, and Consumer
Input
Adapted Chronic
Care Model
Provider, consumer feedback
Provider, consumer consensus
Provider, consumer
buy-in
Participatory Management PM Process Components
Process 1: Design Identify model and barriers to implementation, solutions
Process 2: Customization
Cross-functional team of consumers, providers to refine model based on potential barriers
Process 3: Evaluation and Refinement
Establish measures
Piloting and further customization
Process 4: Implementation
Full-scale intervention
Formative evaluation, ROI
Participatory Management:WCHO Integrated Care Program
National learning community to foster integrated care headquartered in southeastern MI
Wide range in size, # providers, years providing integrated care, but some common themes:45% are rural38% no joint MH-PC staff meetings38% do not share common medical record47% collect symptom data, 41% Rx, Labs
WCHO Learning Community Common Barriers
Culture (“finding BH providers who know primary care and vice-versa,” “differences in philosophies”)
Funding (“siloed at state level,” different rules across populations, regions)
Provider lack of time/space to coordinateClient complexity, privacy concernsLack of real-time data on client outcomesLack of “clear mission” or “model”
Challenges
Resources Administrative/Operations Financing Governance Clinical
Addressing Challenges Administrative/Operations
Templates for MOUs, agreements, job descriptions, responsibilities IT barriers (firewalls) and privacy concerns Common methods for analyzing data and measures
Financing State variations in funding rules, creative funding sources Start-up costs CPT codes and reimbursement Demonstrate cost efficiency, return-on-investment
Governance Input on political issues Liability (professional roles, clinical responsibility)
Clinical Cultural differences and readiness to change (providers, organizations) Lack of protocols and clarity in delineation of roles, balancing workflow Lack of common integrated care model Involvement of ERs Sustaining provider use of integrated care strategies
Making the Business Case
Clinical (outcomes, processes of care) Organizational (fidelity) Economic (costs) Social (satisfaction, stories)
Making the Business CaseMomentum and Lessons Learned
RWJF Depression in Primary Care National Demonstration Program Linking clinical and economic strategies 8 organizations: 4 Medicaid
Washington Circle Indicators Bringing performance measurement to
consumers, purchasers VA Primary Care-Mental Health
Integration Initiative
Clinical Performance Measures
No-show rates % achieving remission (PHQ-9) % on pharmacotherapy >=6 months % receiving recommended toxicity monitoring
tests for medications # hospitalizations/ER visits % receiving follow-up care post-hospitalization
Making the Business Case
WIIFM?Benefits depend on audience Practice Plan State
Counts towards QI activity √ √
Empowers providers √
Reduces costs (inpatient, etc.) √ √ √
Reduces duplicative care (Rx) √ √ √
Applicable to other populations √ √
Attractive to purchasers √ √
Summary: 6-P Framework: Summary: 6-P Framework: Strategies to Reduce BarriersStrategies to Reduce Barriers
Patient/Consumer
Practices/Clinical
Purchasers (State/Private)
• Education on privacy issues and confidentiality• Evaluate preferences, promote self-management
• Opinion leaders from PC, BH• Provide guidelines, communication with care manager
• Invest in care management (NP, MSW, RN)• Improve information systems – establish registry
• Comprehensive outcomes data (claims, consumer)• Develop a business case
• Return-on-investment (State-level data)• Persistence in light of “crisis du jour”
Populations and Policies
• Engage community stakeholders• Increase demand for quality care, enhance advocacy
Providers
Plan/Organization
Pincus et al. 2003; Kilbourne et al. 2008