Integrated Care Challenges in a Public Health Setting

1. Integrated Care Challenges in a Public Health Setting Collaborative Family Healthcare Association 10th Annual Conference Denver, CO Nov. 7, 2008 Ashley Lester, LCSW; Stephen Snow, PhD, LPC Integrated Care Clinicians Buncombe County Health Center RHA Health Services, Inc. Asheville, N.C. 28801

2. Introductions • Ashley • LCSW, University of Denver, 1996 • Integrated Care, RHA/BCHC Primary Care Clinic • Bilingual (Spanish/English) Therapist • Certified Yoga Teacher • Steve • PhD, Counseling, UNC Charlotte, 2005 • Private practice (family violence/complex trauma) • Integrated Care, RHA/BCHC Primary Care Clinic • Executive Director, CFHA • Previous careers: journalism, telecommunications

3. Overview • Introduction • Overview of BCHC’s population • Integrated care interventions • Challenges and creative responses • Case examples • Final comments and questions • Resources

4. Buncombe County Health Center • 36,000-40,000 patient visits annually • 12 medical clinicians • 3 integrated care clinicians • Safety net for indigent care in Buncombe County, (150,000 people) • 1 of 2 primary care clinics out of 100 Health Departments in NC (county funded)

5. Our Beginnings • Duke Depression Grant • 5 full time integrated care clinicians • Budget cuts, county contracted out positions

6. RHA Health Services, Inc. • RHA Behavioral health established in 1995; not-for-profit company serving people with mental illness, substance abuse, and developmental disabilities. • RHA Health Services and RHA Howells provide residential, vocational, and educational programs for more than 1500 infants, children, adolescents, and adults in North Carolina and Tennessee • More than 700 employees deliver a wide variety of care, from community support to intensive in-home and crisis management. • $200 million in revenue; $23 million in free services

7. Clinic Population • 13% latino (adult) 54% latino (child) • Latino population has increased 210% in past 10 years • .01 % Ukrainian/Russian speaking • .002% Other languages • 11% African American • 76.9% Caucasian

8. Public Health Population • Largely indigent, some homeless, little money, little education, disorganized, chaotic lives • % uninsured • % medicaid/medicare • % insured - other

9. Low-Income Patients • Living in poverty is a health risk. The stresses of the lives of people in poverty take a greater toll on their bodies than is true for people with adequate financial resources. • Low-income and underserved populations are less likely than the general public to accept a mental health definition of their problem. If they do accept a referral for mental health services, they have much greater difficulty with travel and scheduling.

10. Low-Income Patients • Garrison, et. al., (1992), in a study in Springfield, MA, found that while low income patients have higher levels of psychosocial needs, medical providers are less likely to address psychosocial needs in this population than in more affluent populations. • Lower institutional trust, clinicians’ lack of assertive treatment. • Physicians were more likely to try to deal with parents’ concerns if the payment type was anything except Medicaid and more likely to try to refer Medicaid patients to specialty mental health services. Garrison, W., Bailey, E., Garb, J. & Ecker, B. (1992). Interactions between parents and pediatric primary care physicians about children's mental health.  Hospital & Community Psychiatry 43: 489-493.

11. Clinic Population • Most common issues presented • Lethargy, headaches, chest pain, chronic pain, etc. • Translates into: • Depression • Anxiety/panic • PTSD • Substance Abuse • Complex trauma • Unresolved grief • Physical / sexual trauma • Bipolar disorder • Personality disorder • Somatized disorders

12. Integrated Care Interventions • Triage • Short-term therapy • Telephone counseling • Clinical case management • Psychiatric consultation • Follow up clinic visits • Groups

13. Triage • When medical clinician suspects mental health issue, therapist is paged. • Assessment time – avg. 20 minutes • BHQ • Differential diagnosis • Risk for self-harm or harm to others • Motivational interviewing, stages of change, psychoeducation • Referral out or follow-up with integrated care clinician • Ruling out resources • Eligibility for speciality mental health system Advocacy Concrete needs * Challenge – NC Mental Health Reform

14. September 2008 Triages • Unduplicated PT Count: 170 • Total # of PT Visits: 362 • Total # of Triages: 101 • Total hours in Svc. Del.: 250.2 (15,025 minutes in direct contact) • Average Productivity: 78.3%

15. 2007-2008 Contacts

16. Behavioral Health Questionnaire (BHQ) • One-page, two-sided brief assessment questionnaire. • Depression questions • Nine weighted questions, including SI/HI • CAGE • Four-question Substance Abuse measure • Bipolar questions • Mania, irritability, problems because of periods of hyper-alertness • Anxiety questions • General & immediate symptoms • Domestic/family violence questions • Still to be designed

17. Options After Triage • Short-term (@ 8 sessions/meetings) therapy • Phone counseling • Clinical case management • Follow up while in clinic

18. Examples/Cases • L.S.: Bipolar-disordered/dually diagnosed woman • J.H.: Depressed man with chronic illnesses (depression, COPD, diabetes) • S.H.: Woman with trauma, anxiety, depression and unresolved grief • J.S.: Chronic back pain, depression, Hep C, med-seeking behavior

19. Institutional Challenges • North Carolina mental health reform in chaos • Rising numbers of uninsured adds stress to system • Lack of therapy guidelines (evidence-based) • Legal barriers to communication among providers • Organizational and professional culture differences between PC and BH • Clinical and fiscal separation of physical and mental health care -- adapted from presentation in 2006 by Susan Mims, Buncombe County Medical Director

20. With Challenges, Creative Responses • Psychiatric consultation • Groups – specifically stress reduction • Close professional relationships w/ therapists in private practice • Connections in community w/ Spanish speaking providers • Education for clinicians • Do not bill

21. Final Comments • This model has some significant benefits, especially creative flexibility. • This model also has some significant limitations, including limited referral options. • All in all, the model is additive and still developing.

22. A Few Resources • Books • Blount, A. (1998). Integrated primary care: The future of medical and mental health collaboration. Norton: New York • Gatchel, R & Oordt, M. (2003). Clinical health psychology and primary care: Practical advice and clinical guidance for successful collaboration American Psychological Association: Washington, D.C. • Web sites • http://www.integratedprimarycare.com/ • http://www.primarycareshrink.com • http://www.mahec.net/ic/ • http://www.thenationalcouncil.org/

23. A Few More Resources • www.depression-primarycare.org The MacArther Foundation • Institute for Healthcare Improvement (IHI) www.ihi.org/collaboratives • RWJ Project: Depression in Primary Care www.wpic.pitt.edu/dppc • National Council for Community Behavioral Heathcare www.nccbh.org/html/learn/primary.htm • Developmental Behavioral Pediatrics Online www.dbpeds.org • http://cartesiansolutions.com ( Financial information) • http://www.cfha.net • http://www.parc.net.au • http://www.shared-care.ca • http://www.behavioral-health-integration.com/news.php • http://www.shepscenter.unc.edu/index.html • http://www.icarenc.org/

24. The End Thanks for listening. For a free copy of this presentation: CFHA Members: http://www.cfha.org Non-members: http://www.commcure.com/cfha1108.ppt Please provide credit for any material you use. For more information on this and other trainings, workshops and consultations, please go to www.commcure.com. Contact us at: Ashley: ashley.lester@buncombecounty.org 828-250-5340 Steve: ssnow@rhanet.org 828-250-5254