Jane Hamel-Lambert, MBA, PhD

Karen Montgomery-Reagan, DO, FAAP, FACOP

Sherry Shamblin, PCC-S

Dawn Murray, DO

March 20, 2009

Overview

IPAC: A Rural Health Network Integration Efforts

Developmental Screening and SurveillanceCo-Locating Mental Health in Primary Care

Co-Location Interagency PartnershipsUniversity Medical Associates, IncTri-County Mental Health & Counseling ServicesFamily Healthcare, Inc.

Introductions Jane Hamel-Lambert, MBA, PhD

President, IPAC; Department of Family Medicine, Ohio University’s College of Osteopathic Medicine

Karen Montgomery-Reagan, DO, FAAP, FACOPChair, Pediatrics, Ohio University College of

Osteopathic Medicine; University Medical Associates, Inc.

Sherry Shamblin, PCC-SEarly Childhood Mental Health Consultant, Clinical

Supervisor, Tri-County Mental Health & Counseling Services, Inc.

Dawn Murray, DOMedical Director, Family Healthcare, Inc.

Integrating Professionals for Appalachian Children

IPAC: A Rural Health Network Interdisciplinary collaboration hinges on

interagency cooperation

MHPSA. Retention/recruitment

Thank you to Office of Rural Health Policy (P10 RH06775, D06RH07920)

Integration Goals

Adoption of routine developmental surveillanceImproves early identification Alternative to “wait and see”

Co-location of Mental Health ProvidersImproves accessImproves quality through care coordination

Improves patient outcomes Developing common language

AAP guideline

Developmental Surveillance and Screening Algorithm9, 18, 30 months give screening tool If at risk, refer for further evaluation

http://www.medicalhomeinfo.org/Screening/DPIP%20Follow%20Up.html

Adoption of the Ages and Stages Questionnaires

ASQ & ASQ:SE

Childcare programs Primary care settings

Shift away from clinical impressions (watch and listen) to using formal parent-completed, normed screening tool.

Reassurance and Risk

SCREENS ASQ Screens 5 Domains• Communication• Gross Motor• Fine Motor• Problem solving• Personal-social

ASQ:SE• Social-Emotional development

Why ASQ Tools?

CHEAP!CHEAP! ASQ – 3 (May 2009) … $249 and

ASQ:SE… $149.00

Low cost alternative—annual cost of $25-50 for following children

Permission granted to photocopy

Quick and Easy

Utility Parent satisfaction survey (N=731) (publisher data)

• How long did it take to complete the questionnaire? 70% Less than 10 minutes 28% 10-20 minutes 2% More than 20 minutes

• It was easy to understand the questions? 97% Easy 3% Sometimes 0% Not easy

Accurate: ASQ

  Normative sample of over 8000

questionnaires, high reliability (> 90%), internal consistency, sensitivity, and specificity

See www.brookespublishing.com for ASQ User’s Guide Technical Report for complete psychometric data.

Parent Report: ASQ Research

As accurate as formal measures for identifying cognitive delay (Glascoe, 1989, 1990; Pulsifer, 1994)

As accurate as formal measures for identifying language delay (Tomblin, 1987)

As accurate as formal measures for identifying symptoms of ADHD and school related problems (Mulhern, 1994)

More accurate than Denver for predicting school-age learning problems (Diamond, 1987)

Physicians trust it

Catches kid earlier than she may have Opens up conversations with parents

regarding observations Monitoring

Billable Generate Revenue

Billing

CPT Code: 96110 (limited evaluation)

E/M Modifier – 25: Significant Separately Identifiable Evaluation and Management Service by the Same Physician or the Same Day of the Procedure or Other Service Document administration, interpretation (normal,

abnormal, parent discussion and referral/action)

Medicaid Relative Value (staff admin) = $13.64 (2005)

Generalizability

Depression for adults: PHQ -9Patient Health Questionnaires

Improves identification Tool for communication

Co-location of Mental Health Providers in Primary Care

UMA is a multispecialty group dedicated to serving southeastern Ohio. Affiliated with Ohio University College of Osteopathic Medicine

Karen Montgomery-Reagan, DO, FACOP, FAAP

Motivation for Co-Location Program Practice Group has a need for mental health

services Difficulty with referrals; seems like a black hole..

Making appointment calls CMHC required in person to schedule appointment

Families need access to service Waiting for appointments

Communication Did they go, what was the dx, were they discharged from

care? What was the Primary Doc role?

Family Benefits Clients familiar with surroundings and

comfortable with office staff/patients Ease of scheduling for patient and

physiciansReferral sheet to receptionFamilies provided intake paperwork Appointment scheduled right then and there

Parents/patients more willing to try mental health services provided at our office

Family Quotes

Patient: I’ve tried counseling before I have individuals that will fit your personality…

(choice)I will speak with the provider individuallyIf it doesn’t work, I have other avenues

Patient: If you think this person will help, I will give it a try…

Patient: How soon? It always take so long to get it

Physician Benefits Physicians find mental health a benefit for their patients Physician have direct contact with provider

Curbside consults, guides diagnostics, treatment planning

Communication easy on site, no phone messageDon’t wait until it’s a disaster---crisis

Appointment info is charted I know if they are going and continuing care

Physicians are able to directly discuss cases with the mental health professional on site

Infrastructure Scheduling

On site facilitates follow throughSooner access is easier to negotiate

Office SpaceLocation mattersShape, size and absence of medical gear

Private practitioner vs CMH clinicians MH Practitioner Billing

Providers are doing their own billing Record Keeping

Doc charts have mental health progress note

Real Numbers Three Providers

2 ½ days of service combined

Numbers of Families 78 families have been provided service

Numbers of VisitsOver 250 appointments (Jan08/May08)

No Show ratesMedicaid (approx 29%) NS rate > than

privately insured NS rate (approx 10 – 12%)

TCMH-CS is a licensed Community Mental Health Center serving four counties in southeastern Ohio

Recovery Model

Focuses on resiliency while reducing symptoms

All people have strengths to overcome challenges

Individuals are the experts in their experiences so have the voice and choice in services

Values unconditional acceptance of the individual

Implications of Differences in Practice Models

Professional Culture Patient/Client Implications for Assessment/ Diagnosis Organizational Structure Physical Office Space Communication

Practitioner Work Style Consultation

Info goes back and forth

Physician manages case

Mental health

Has time efficiencies

CollaborationFuse ideasJointly develop

treatment plan “our” patient

Time to develop relationship

Build in communication strategies

Billing and Paperwork Procedures Medicaid/Insurance

Medicaid matchReimbursement by insurer, by who is

delivering servicesElecting to serve

Modifying structure of intake paperwork and documentation

Difficult to merge systems even when there is duplication because of ODMH requirements

Evaluate Your Practice Needs Age Family Care versus Pediatric Practice Payee source Mental Health Needs

Laying a Good Foundation Choose the right mental health partner

for your practice Build a working relationship Build time for communication/interaction Be prepared to develop joint vision and

goals for the partnership

Behavioral Health Integration …a work in progress

Dawn Murray, DO

MISSION of FHI (Family Healthcare, Inc.)

The Mission of Family Healthcare, Inc. is to provide access to high quality, affordable, healthcare to everyone without discrimination.

All Community Health Centers have a similar mission.

Family Healthcare, Inc FQHC (federally Qualified Health Center) Six sites in six counties in Southeastern Ohio Behavioral health considered a core service,

provided on site or through referral agreement Investigated many models of behavioral

health/primary care integration. IPAC (Integrating Professionals for

Appalachian Children) involvement was springboard for our current journey.

FQHC Federally Qualified Health Centers AKA

Community Health Centers Receive 330 grant from federal government which

provides for uninsured care. (For FHI, this is about 20% of budget)

Sliding fee scale based on income Accept most insurances including medicaid (and

Medicaid HMO’s), medicare. Enhanced reimbursement through medicaid and

medicare. Considered safety net providers FTCA malpractice coverage Different funding stream than Community Mental

Health centers

Behavioral Health/Primary care Integration models in FQHC’s Referral Agreements with Private Psychiatrists or

Community Mental Health Centers (no integration) Complete in house Mental Health program with

psychologists, social workers, and psychiatrists as FQHC employees.

In house Behavioral Health Program with Clinical psychologists, LISW’s, counselors under supervision of PCP’s

FQHC contracting with Community Mental Health Agency for mental health personnel

All possible combinations of these.

IPAC-Colocated Providers Involvement in IPAC allowed more

collaboration between agencies for ideas to develop.

We started with the original plan of a Tri County counselor in one of our sites.

Quickly saw limitations of this arrangement: Only available for kids. Not as many kids

as predicted. Bigger need for adult services. Better if billing is through FQHC due to another funding stream.

Began contract with Tri County, but still kept IPAC involvement

Behavioral Health/Primary Care model LISW can triage for PCP’s which increases

everyone’s efficiency LISW will keep people for counseling at FQHC and

work with PCP to address goals to enhance medical outcomes.

If patient is outside of PCP scope for mental health issues, LISW can start intake paper work, make psychiatric referral and expedite patient care. She can continue counseling at FQHC with support from PCP. This is very important given the long wait times we sometimes have for psychiatrists, especially in rural areas. We can keep people from falling through the cracks.

Concerns

Competition for patients/clients Supervision Reimbursement Integration

Win-Win

At a time when Mental Health funding is being cut, it is good to have other revenue streams. By contracting for services of the LISW, she actually increased her productivity at the Mental Health Center. FHI is breaking even on the deal, and getting excellent services for our patients.

Next Steps We are working on streamlining our

communication between the PCP and the LISW.

Developing a protocol and system to triage more urgent psyche referrals into the Mental Health Center.

We are planning to spread to our other sites.

Continuously communicating between Community Mental Health center, and providers to foster trust, and better integrate our cultures for improved access to quality healthcare for all patients.

CoLocation toward Integration Shift referring “my clients” to jointly taking care of

families Co-Learning

Understanding diagnostic paradigmsUnderstanding professional biases MH builds medical knowledge; Doc gains mental

health knowledge Communication Goals

Shared languageParticipation in routine meetings Access to medical charts

Lessons Learned Health delivery system dichotomizes MH and

HealthCarve out billingsDifferent govt oversight agencies (ODH, ODMH);

Mission and mandatesDiagnostic tools are differentPhilosophies of care

Communication nourishes partnerships Tensions teach Build the relationships

Contact Information

Jane Hamel-Lambert hamel-lj@ohio.edu

Karen Montgomery-Reaganmontgomeryreagan@oucom.ohiou.edu

Sherry Shamblin sshamblin@tcmhcs.org

Dawn Murray murraydoc@yahoo.com