Posted By Becky Boober, Neil Korsen,
Thursday, July 2, 2015
This is the second in a five part series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the first post.
Almost 50% of primary care practices in Maine now offer some level of behavioral health integration. Integrated care is an expected component of the Patient Centered Medical Home (PCMH) and Health Home initiatives in Maine, thanks in large part to the work of two statewide organizations.
The Maine Health Access Foundation (MeHAF), whose mission is to increase access to quality health care and to improve the health of all people in Maine, launched its 12-year, $14 million Behavioral Health Integration Initiative in 2005 to increase access to behavioral health services and to reduce stigma. MeHAF awarded 42 integrated care grants to projects involving over 150 partnering organizations. One-year planning and three-year implementation grants were awarded in three rounds of funding for both clinical practice and systemic transformation levels. MeHAF also supported technical assistance, evaluation and research, and a robust learning community. A self-assessment tool was developed to help practice teams examine their level of integration. MeHAF also engaged key stakeholders in a five-year public policy effort to embed integrated care into state funding and health care reform initiatives. Because of an emphasis on sustainability by MeHAF, most of those organizations are still integrated and have expanded their integrated care services, according to a follow-up evaluation completed in 2014. Stories about a few former grantee organizations are shared below.
Parallel to the MeHAF funded efforts, Maine Quality Counts, a statewide quality improvement organization, worked with other key organizations to start the multipayer PCMH pilot. As part of a grant from MeHAF, Maine Quality Counts included the integration of behavioral health and primary care as one of the 10 core expectations for pilot participants in the PCMH. Over 200 primary care practices are working to increase their level of integration as part of their engagement as PCMH, Health Homes (Medicaid version of PCMH) , or Behavioral Health Homes (mental health agencies working on better integration of physical healthcare).
Embedding integrated care into statewide practice improvement and payment reform pilots, such as PCMH and Health Homes, proved instrumental to being able to sustain the work in practices across the state. Both public and private payers expanded support of integrated care through enhanced payments, opening of reimbursement codes, and allowance of same-day services. Use of the per-member-per-month enhance payments were sometimes used by the practices to support needed services such as care/case management and consultations. The State continues to support integrated care as a core element of its State Innovations Model initiative.
A six-year evaluation of integrated care in Maine identified factors that facilitated successful implementation, including:
top administrative and clinical leadership support,
adequate infrastructure such as reimbursement and shared electronic health records,
behavioral health specialists who are flexible and who market their potential contributions to the team,
integration of behavioral health specialists in all primary care team functions (morning huddles, warm hand offs, case reviews), and
tracking and using data for continuous improvement.
Another lesson learned was the extensive work required to build trusting relationships that bridge the cultural variances between the behavioral health and medical professions. Developing a framework was essential to guide discussions about how differently the professions perceive use of time, relationship with patients (or what to call patients/consumers/clients), confidentiality requirements, and definitions of phrases such as care/case management. Professional flexibility facilitated this process of integrating the different professional cultures. Because of issues such as this, the complexity of integrating care requires a long-term view and concerted efforts to build both relational and organizational infrastructure to support the work over time.
Because of all the support provided for practices to integrate, there are many stories to be told about the successes of integration in Maine. A few examples include:
MaineHealth has created a partnership between hospital-owned primary care practices and the regional Maine Behavioral Healthcare system to place behavioral health specialists, mostly LCSW’s, in those practices. Thanks to a number of years of MeHAF funding, MaineHealth was able to pilot a variety of approaches to integration in twenty different practices and learn a lot about what works and what doesn’t. Using that knowledge, an approach has been spread that places the LCSW at least half time in the primary care practice, uses warm handoffs or other provider referral, a focused treatment model, and includes regular (and as needed) psychiatric consultation. There are now more than 30 FTE’s of behavioral health clinicians in more than 60 different practices. Developing population health pathways that target behavioral health services to priority populations is a next important step for the program.
Tri-County Mental Health Services and Central Maine Healthcare developed a sustainable contract model between the community mental health system and the local health care system’s primary care practices. Using two MeHAF integrated care grants, Tri-County implemented integrated care by fully embedding its Licensed Clinical Social Workers (LCSW) as the behavioral specialists Central Maine Healthcare primary care practices. The LCSW participate as equal members of the care team activities, such as morning huddles, team meetings and case reviews, warm hand offs, follow up to electronic screening, brief interventions and transitions of care.
Tri-County also developed a toolkit for other sites interested in this model. The integrated care contracting arrangement has been so successful that it has now spread to 25 Central Maine Healthcare primary care sites and is being spread to other health care systems. It is also a critical component of the area’s developing Accountable Care Organization (ACO).
Penobscot Community Health Care used MeHAF grant funding to pilot integrated care in a low-income housing setting in Bangor, Maine. Since then, they have expanded integrated care into its homeless health clinic and into all 12 of its primary care clinics. Staffing includes a licensed MHP, substance abuse clinicians, psychologists, psychiatrists, 10 psychiatric nurse practitioners, 18 licensed social workers/counselors, peer specialists, care managers and Behavioral Health Homes case managers.
When they build or renovate clinics, behavioral health specialists share office pods with primary and specialty care and are fully integrated into all clinical functions. Screening tools are built into the electronic health record to facilitate warm hand offs and other integrated care strategies.
Many Mainers now expect that when they enter the primary care practice, they will receive integrated screening, care, and follow up. Sites report improved consumer and provider satisfaction. This increased satisfaction, improved consumer health outcomes, bending health care costs, and infrastructure support across the payers and the State have made the spread of integrated care in Maine not only possible, but inevitable.
Becky Hayes Boober, PhD, Senior
Program Officer at Maine Health Access Foundation (MeHAF), leads initiatives
that transform health care systems to provide Patient-Centered Care. In 2013,
MeHAF established the community-based Thriving in Place initiative to keep
persons with chronic health conditions, including older persons, in their
homes. She also oversees MeHAF’s $14+ million investment to integrate behavioral
health and primary care. Starting with 42 grants involving over 150 partnering
organizations, integrated care has now spread to about 46% of primary care
practices in Maine. Dr. Boober is a member of the Grantmakers In Health Behavioral Health Funders’ Network Steering Committee. Prior
to joining MeHAF, Dr. Boober retired from the State of Maine with over 20 years
in public policy and administrative leadership working in the Commissioners’
Offices of three state departments (Education, Health and Human Services, and
Corrections). She assisted with interagency, systemic improvement initiatives.
Korsen, MD, MSc is a family physician/geriatrician with 18 years of practice
experience, mostly in small towns in Maine. Since 2001, he has worked for
MaineHealth, an integrated delivery system in southern and central Maine. He is
the medical director of the Behavioral Health Integration program for
MaineHealth. He has received funding support for this work from the MacArthur
Foundation, the Robert Wood Johnson Foundation and the Maine Health Access
Foundation. He has a number of peer
reviewed publications related to behavioral health integration and depression
in primary care, and has spoken extensively on these topics regionally and
nationally. Dr. Korsen is a member of the AHRQ National Integration Academy
Council, an expert panel working with AHRQ to develop resources related to
behavioral health integration in primary care. He is principal investigator for
the AHRQ Atlas of Integrated Behavioral Healthcare Quality Measures. Dr. Korsen
received his undergraduate degree from Dartmouth College in 1975, his medical
degree from Hahnemann Medical School in 1979, and a Masters of Science from the
Center for the Evaluative Clinical Sciences at Dartmouth (now the Dartmouth
Institute) in 2002.
This post is the first of a five part series highlighting states across the US that support integrated care initiatives. Check back later for more posts.
Every so often, an opportunity comes along in healthcare that must be pursued. These opportunities often build off the recognition that there is: a) a problem; and, b) a solution, that while difficult, could be pursued to address the problem. The state of Colorado is currently in the process of pursuing an innovative solution to a longstanding problem; however, before I get to that, let me start with some context.
"The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization.”
Colorado has decided to integrate behavioral health into 400 primary care practices. Yes, I said 400. This is no goal to balk at, but what would you expect from a state whose lowest elevation is 3,315 feet? We live a mile high and aim our healthcare goals even higher. This "State Innovation Model” (SIM) is just another innovation in an already innovative state around healthcare. But unlike other healthcare initiatives, SIM, at its core, is about payment reform. Payment reform that can support integration through practice transformation.
And no, it is not just like riding a bike. You see, like unlearning how to ride a bike, Colorado has to literally unlearn how to deliver fragmented care. We have to set aside all our culture, history, politics, and antiquated protectionist tendencies to do what’s right for people. For some, mainly our communities, this will change lives. For others, like some of the special interests who love to protect their pot of the pie, there will be "much rejoicing.”
As we all know, to truly transform healthcare, we have to change it clinically, operationally, and financially. We have to look at the state policy levers that enable change and pursue them with reckless abandon.
Make no mistake, Colorado’s reputation as a leader in healthcare is cemented through such forward thinking ideas as that of the SIM. With strategic partners, including health plans, Colorado has a chance to successfully create an approach to healthcare that is person-centered, remains focused on the whole, and is committed to seeing that investment reap positive benefits from all who participate.
So can Colorado right a wrong when it comes to separating out behavioral health from the larger health system? Possibly. But for SIM to be a success it will require a fundamental departure from legacy systems and antiquated ways of delivering and paying for healthcare. Because after all, isn’t the notion of integrating behavioral health into primary care just another example of good care? Regardless, you will be hard press to find another state that is leading the way like Colorado.
Dr. Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. He leads the Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral and Primary Care project as well as the Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) project in Colorado and Oregon. He is the co-creator of the National Research Network’s Collaborative Care Research Network and is the past President of the Collaborative Family Healthcare Association. He is the section editor for Health and Policy for Families, Systems and Health and reviews for several academic journals. Dr. Miller is a technical expert panelist on the Agency for Healthcare Research and Quality Innovations Exchange and on the International Advisory Board of the British Journal of General Practice. Dr. Miller’s research interests include models of integrating mental health and primary care, health behavior interventions, primary care practice redesign, using practice-based research networks to advance whole person healthcare, and healthcare policy.
“Population health.” It is a term that is widely used in the health care world, but not universally understood. Some definitions of population health emphasize outcomes. Others focus on measurement. Still others emphasize accountability. So what does population health truly mean? Who is responsible? What impact does it have on our current health care environment?
In recognition that there is no uniform definition of this important and emergent concept, we sought out to create a new dialogue featuring a variety of thought leaders in the field. We reached out to over 100 health care leaders and asked them to define the term “population health.” What follows are their responses.
What We Learned
The concept of population health first came about in 2003 when David Kindig and Greg Stoddart defined it as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.” While accurate, some complain this definition focuses strictly on the measurement of health outcomes without explaining or acknowledging the role that health care providers must take to impact those outcomes.
Our survey reflected that notion. Of the 37 leaders who participated, only two people directly cited Kingdig and Stoddard’s original definition. While interpretation and understanding of the phrase “population health” differed greatly in the responses we received, many did view it as an opportunity for health care systems, agencies and organizations to work together in order to improve the health outcomes of the communities they serve. Two other key trends and questions we observed include:
A question of responsibility. Do the health outcomes of a specific population rely on the behaviors of the population? The actions of the provider? Or both?
A take on Triple Aim. Several participants referenced the Triple Aim Initiative, an approach developed by the Institute for Healthcare Improvement for optimizing health system performance.
While we may not have reached a universal consensus on what “population health” means, we discovered that now is the time to think differently — not only about the definition of population health — but also about the way health care is delivered. In our ever-evolving health care environment, perhaps the “traditional way” may not be the right answer.
We welcome discussion regarding the ideas we present here and look forward to creating an ongoing, open dialogue about the role population health plays in the health care industry today.
Wayne Brackin, Chief Operating Officer and Executive Vice President, Baptist Health South Florida
Paul Brashnyk, MPH, Interim Director of Clinic Operations, UW Neighborhood Clinics
The comparative flood of new users of opioid medication and heroin in the population has led to a crisis. That it is a crisis is agreed to by politicians, medical professionals, substance abuse professionals, and the public in general. I am told that the Chinese character for “crisis” is made up of a combination of the characters for “danger” and “opportunity.” I recently heard a report from Beth Tanzman, the Assistant Director of the Vermont Blueprint for Health, that Vermont has taken the opportunity presented by this danger to respond with a distinctive approach to creating integrated behavioral health in primary care. Instead of small changes in payment or regulation, they simply funded salaries for behavioral health clinicians in primary care. The chief duty of these clinicians is to address substance abuse concerns, but they are inevitably addressing a broader array of behavioral concerns.
I think there are two important points that this example brings to mind.
1. Whether the impetus for adding behavioral health in primary care is to treat people with serious depression, to provide better care for people with trauma histories, to attempt to intervene before people are involved in the criminal justice system, or to address serious substance abuse is a choice based on administrative and funding opportunity, because as a population THEY ARE MOSTLY THE SAME PEOPLE.
2. If you only target serious substance abuse with your behavioral health resources, you are seeking to intervene in the process too far downstream. Unless you are offering behavioral alternatives in chronic pain therapy, so that physicians have some way of helping their pain patients other than opioid pain medications, you are not helping stem the tide of new addicts.
(To see a 24 minute interview with a patient who got off narcotic pain meds after 18 years with the help of behavioral health in primary care - go to: click on “watch in Vimeo” and use “pillman” for the password. http://umassmed.edu/cipc/resources/videos/ )
And, today only, you get 50% more important points than promised:
3. If you define the behavioral health clinician that you put in a primary care practice (a “general medical setting”) as only addressing substance abuse, you make your program fall under the strictures of 42 CFR (the federal statute regulating the exchange of information about a patient’s substance abuse care). The clinician and physician cannot exchange information without further releases. If you define the role as a behavioral health generalist, though they may do a good deal of work with substance abuse, 42 CFR does not apply. (Your state may have other regulations that do apply.)
Posted By Jacqueline Williams-Reade,
Thursday, May 21, 2015
This is the second in a two-part series on which personality type (extrovert or introvert) works best in collaborative care. Click here for Part 1.
To all my fellow introverts, tell me if this sounds familiar. You’ve probably heard all your life that introverts are people who don’t like being around people, like to spend their free time in a cave, and are shy and withdrawn. While that is often society’s definition of introversion (I’m looking at you, extroverts!), this is not the case. Introverts don’t have problems being around people, but, in general, introverts need alone time to recharge while extroverts recharge through being around others. Susan Cain clarifies that introverts "prefer to devote their social energies to close friends, colleagues and family,” in her bookQuiet: The Power of Introverts in a World That Can't Stop Talking. "They listen more than they talk, think before they speak, and often feel as if they express themselves better in writing than in conversation.”
So introversion and extroversion are really about where we get our energy and the type of environments we prefer. Just because someone is outgoing, doesn’t mean they’re an extrovert. Similarly, just because an extrovert can be quiet or get tired of being around people doesn’t mean they’re an introvert. There is no clean line between extroversion and introversion – we all reside along a spectrum of these personality traits. In fact, some people who can’t seem to agree on which "side” of the spectrum they fall are labeled "ambiverts” as they have traits of both sides fairly equally.
While a job at a fast-paced integrated care setting can appear to run counter-cultural to the introvert’s preferred, not overstimulating environment, I think there are a few key things to keep in mind that can help introverts take their place as a valued and successful team member in these settings. For me, this process involves examining the typical challenges faced by introverts and re-defining and re-framing them in a way that provides a way to elicit my inborn traits that are both useful and deeply valuable in any setting. Let me show you what I mean…
Everybody’s talking a mile a minute!
While at first glance, a day filled with quick interventions with patients and brief reports to colleagues may sound antithetical to an introvert’s values, I’d like to reframe these interactions as a way to bring out the best of an introvert’s personality. For instance, while this way of talking can often be interpreted as being difficult for introverts as they typically don’t like to interrupt or speak off the top of their head, I like to re-frame this as an interaction which can be a boon for introverts in that you can skip the small talk (which introverts typically dislike) and go straight to the substance of an interaction. In essence, communication in integrated care is often about getting to the essential point quickly and introverts have the capacity and skills to do this well.
Rush, rush, rush
Granted, most any integrated care setting keeps a pretty fast pace due to the busy nature of the medical setting. While on the surface, this seems like a way to quickly drive an introvert mad by presenting them with interruptions and an unbridle pace of work, I find this to be an excellent opportunity for introverts to practice their preferred way of feeling centered and calm. While there may be a rush around you, an important aspect of maintaining your ability to do and think your best is to not allow people to make you feel rushed. An introvert who can practice their natural preference of calm, mindful interactions can be a valuable asset to his or her colleagues and the medical setting at large. There, of course, will be times when you have to speed up your natural rhythm, but harnessing your ability to find your sense of calm within the busy-ness is something that will help an introvert survive and thrive in this kind of setting.
I don’t fit in here
If you ever find yourself awash in what feels like a sea of extroverts, look around and you might be surprised to find other introverts in your midst. There are varying statistics regarding how many introverts there are in the general population (somewhere between 25 and 40%) so I bet if you look around the typical integrated care setting you will find physicians, PA’s, nurses, schedulers, managers, etc. who identify as introverts and are making integrated care a better place. You are never as alone as you think and this is important to remember when you can feel like you’re swimming against the current of the preferred, extroverted way of being in an integrated care setting.
"Stay true to your own nature.” (Cain)
For introverts in integrated care, we need to figure out how to take care of ourselves as the environment can often stretch our natural boundaries and use up our reserves. To re-charge, introverts need alone time and it is important to know how much you personally need and when. Do you need an hour after work each day? Do you need a weekend day devoid of people plans? Do you need to log off all social media for a certain amount of time? It’s important to take care of yourself and it’s a mandatory part of thriving in a setting that can work against our innate nature and preferences.
Overall, I think the most important aspect of being an introvert in integrated care is to be happy with who you are. It is important to believe that you can be different and still be liked. If you are agitated at your introverted nature, you will fight against the very things that are your greatest assets by trying to be someone you’re not. However, if you appreciate your indelible strengths of introversion, you will believe your skills are valuable and look for ways to let those skills shine through – even in the midst of a busy medical clinic.
Jackie Williams-Reade is an Assistant Professor and Director of Medical Family Therapy at Loma Linda University. If she had a quarter for every time she was either 1) told she was definitely not an introvert after a delightful conversation with someone new or 2) told she was definitely an extrovert after giving a well received public presentation or 3) mistaken for being aloof or distant when using her deep listening super-power or 4) mistaken for not having any ideas simply because she feels everything has been said already and why waste words, she would be filthy rich... and still an introvert.
This is the first in a two-part series on which personality type (extrovert or introvert) works best in collaborative care. Check back next week for Part 2.
I have been asked by my esteemed colleagues at CFHA to submit a blog post explaining why I feel that being an extrovert is beneficial when working in integrated care. They have asked me to go first because they are still trying to convince my introverted counterpart to participate. I will do my best to represent my fellow extroverts, but if I get something wrong please let me know. I would love to talk about it!
(Side Note: How do you know if you are an extrovert? You have to ration how many exclamation marks you use in written communication!!)
As a behavioral health consultant, I am well aware of the need to initiate interactions in order to work as a team in primary care. It’s not that primary care providers don’t want to work together; they just don’t always have time to stop long enough to bring me in. Occasionally they forget I’m available unless I remind them. These dynamics of primary care have helped me to develop some of my potentially dysfunctional character traits in order to further the cause of integrated care.
In my opinion, the best personality type for integrated care is an extrovert who is mildly hypomanic, somewhat inattentive, and has a touch of OCD. My hope is to convince you to develop some of these traits in yourself in order to better work together as a team. In preparation for this blog entry I talked to everyone I know… not about what to write, but because I’m an extrovert and like to talk to people. Now it is getting late so I should probably start writing something.
Anyway, back to my formula. In order to establish a new integrated care function you have to be willing and able to talk to anyone and by that I mean, anyone! No shrinking violet when it comes to talking to the grumpy provider, the resistant patient, or the reluctant administrator. Sometimes you have to just keep talking to them until they agree with you, right? It also helps if you do not mind looking ridiculous from time to time. Communication can get a bit muddled sometimes and you may end up going into the wrong exam room – turn that into an introduction to the service and move on!
Because of the pace at which we work it’s helpful to keep your energy up. You can do that by developing a nasty caffeine habit or regularly raiding the candy drawer (admit it; we all have one – or 5 - somewhere in the clinic). I have found it is easier to just nurture my hypomanic tendencies. It keeps things light and really helps to burn off the extra calories from the coffee and candy. Just make sure you are not experiencing distress or impairment and you are free and clear. It’s not just the artists that can benefit from hypomania anymore!
The next component, inattentiveness, is a bit blurry in that it is a fine line between hypomania and hyperactivity but just humor me on this; a formula with only two components is not as interesting. Integrated care, especially in the early days of forming a new service requires a person to wear many hats. Because of this, you have to be able to switch sets at the drop of a hat. You think you are going to lunch but then you are doing a crisis intervention because a patient might be suicidal. Of course, the down side is that you can sometimes find yourself getting ready to go to lunch and trying to remember what you were going to do a couple hours ago…then you remember that you were headed to the bathroom.
I have found it is easier to just nurture my hypomanic tendencies
Lastly, it helps to have a little OCD. When you are going from patient to patient you need to be able to keep track of all those little details like what you saw them for the last time and what interventions you have already tried. Being able to find handouts on the fly is important (you need to move on to talk to more people!) so a good filing system comes in handy. Of course, at the end of the day when you are trying to remember what happened after you set your coffee down that morning, being a bit anal retentive about paperwork is really helpful. For those who need some help developing these tendencies I recommend putting tape outlines for everything on your desk…then just for fun put the objects outside of the lines and see who squirms! Another fun strategy is to start making super complex spreadsheets for everything. Once you have created a spreadsheet to manage your spreadsheets, you have made it!
Now I think it is time to stop as I may be drifting into more introverted pastimes. I certainly do not want my readers of the introverted variety to be uncomfortable…though I suppose it is too late for that at this point. You know the saying: "We’re here, we’re uncomfortable, we want to go home” but alas one of you must speak out. Do not panic! We are here to support you and if you will only speak up to the rest of the group…wait, that can’t be right. For all of my teasing, I will concede that an introvert can function in integrated care but I suspect it would require a lot of naps. We will all have to tune in to hear what the next post will be about…
Juliette Cutts is a licensed clinical psychologist and Behavioral Health Consultant at Salud Medical Center in Woodburn, Oregon. She is a native Californian and got her PsyD from John F. Kennedy University in Pleasant Hill, California in 2010. After graduation she completed a post-doctoral fellowship in Health Psychology at the University of Wisconsin in Madison. After post-doc, she stayed on at Access Community Health Centers as a Behavioral Health Consultant to provide services to underserved patients in the Madison area. In 2012 she moved back to the West Coast to join Yakima Valley Farm Workers Clinic as the Behavioral Health Consultant at Salud Medical Center. At Salud she works with predominantly migrant workers who are not well served by traditional mental health.
The APM pilot is testing the idea that a per-member-per-month (PMPM) fee to care for a population can support comprehensive care. Integration of physical and behavioral health care is a great case for examining alternative payment methodologies, and it gives us a peek into what Oregon’s APM is (and isn’t) achieving.
Integration of behavioral health and primary care by health care systems is one of the most robust examples of patient-centered, comprehensive care that I have observed in this model. We know that emotional and behavioral issues commonly compound physical health risks and lead to worsening health outcomes. We also know that primary care is where most people struggling with these commonly co-occurring conditions are seen by health care professionals.
Our research team at Oregon Health & Science University have had the incredible opportunity to observe 25 practices across the nation, including six in Oregon that are working to deliver integrated, whole-person primary care. Integrated care is a practicing team of primary care and behavioral health clinicians, working together with patients and families, to address the spectrum of behavioral healthconcerns that present in primary care, including mental health disorders as well as psychosocial factors associated with physical health, at-risk behaviors, or health behavior change (e.g., smoking, diet). In some cases, a case management team also facilitates enabling services (such as transportation to appointments) or connects patients with community resources.
We have visited these practices through our work on three studies:
Advancing Care Together, a demonstration project in Colorado supported by The Colorado Health Foundation to advance integration in 11 practices;
a workforce competencies assessment supported by the Agency for Healthcare Research and Quality, CalMHSA, and Maine Health Access Foundation to study integrated care workforce in practices across the U.S.; and
TEAM-UP, a study funded by the National Institute of Mental Health to identify the health IT needs of integrated teams. Two practices participating in TEAM-UP are also participating in APM.
Through this work, we have learned that the transition to practice that delivers integrated care is an enormous undertaking. It involves structural, process, and cultural changes that are not for the faint of heart.
For some practices in Oregon, the APM pilot is allowing experimentation with embedding behavioral health professionals on their teams. In many of these clinics, physicians can now immediately refer patients to these behavioral health clinicians in a "warm handoff,” meaning the physician introduces the patient to the specialist in the clinic at the end of the visit.
Let’s look at an example. The primary care clinician determines that her patient is suffering from depression and this is impacting how the patient manages his diabetes. The clinician suggests that the patient meet another member of her team. The clinician invites the behavioral health clinician to join the visit, and the primary care clinician explains, with the patient’s help, what the patient is experiencing. The primary care clinician leaves the examination room, and the behavioral health clinician and patient begin addressing the patient’s depression right away. These introductions can help reduce the stigma of receiving mental health care and ensure access to the appropriate behavioral health care provider.
Warm handoffs don’t routinely happen in the typical primary care practice for a number of reasons. First, many primary practices cannot afford to employ a behavioral health clinician. Second, in those practices that do employ a behavioral health clinician, primary care clinicians often cannot find the behavioral health clinician because s/he is located on another floor or part of the building. This is a huge barrier, and renovating space to support integrated care costs money.
Third, behavioral health clinicians may be busy, particularly if a practice is employing a traditional model of 50-minute behavioral health therapy sessions for referred patients. In the traditional model, behavioral health clinicians focus on patients who need long-term therapy, who go through a formal intake. The clinician is paid for services rendered. If successful, a behavioral therapist will have a full schedule, making it prohibitively expensive to hire enough traditional behavioral health professionals to meet a clinic’s patient demand. This model leaves no room on their schedule for warm handoffs, particularly if these handoffs are not reimbursed. The result is that these professionals are inaccessible to the primary care team and their patients.
One of the clinics in the APM Pilot estimated that nearly half of the patients in its population has either depression or some other health issue with a behavioral health-related diagnosis. For many patients, long-term therapy and a 50-minute visit is not needed to help with their mild to moderate emotional or behavioral problem. In these cases, behavioral health clinicians can offer brief, problem-focused therapy. In this model, the behavioral health clinicians become familiar with the clinic’s panel of patients, and the team moves to a truly population-based approach. As of yet, however, this level of integration still remains the promise of a new care model rather than the current reality.
The Role Of Payment Reform
All of the practices we have visited are early adopters, and while money is not the motivating factor for these practices (how could it be?), financing must be addressed to sustain integration efforts. If the primary way a health provider is paid is through physician visits (which is how providers were paid under the Fee-for-Service model), then it’s extremely hard to finance an integrated health care model. The APM pilot is one step toward a payment system that better enables health systems to implement integrated care in a financially viable way.
While APM is not specifically funding primary care-behavioral health integration, it is freeing up practices to look more broadly at how they treat their patients.The practices in the APM pilot do not have requirements for how to they spend their PMPM fee. Therefore, instead of needing to generate a high number of physician-patient primary care visits, they now have the flexibility to spend some of their fees on behavioral and mental health services. As long as the net effect is budget-neutral, they can treat patients in new ways and with new combinations of providers.
Integrated care is comprehensive primary care. To make it common practice will require leadership to push further on paying for services that are central to comprehensive primary care, align payment across payers to reduce complexity, and support system-wide practice change.
Deborah Cohen, PhD, is an Associate Professor in the Department of Family Medicine at Oregon Health & Science University. She has been developing her skills in qualitative methods for more than 20 years, and has spent more than a decade studying primary care practices, with a focus on clinician-patient communication, practice change and improvement and health information technology use. Dr. Cohen has expertise in a range of qualitative methods and approaches, including interviewing, observation, and conversation analysis. In addition to her research, Dr. Cohen mentors and teaches on the topics of qualitative methods and practice change and improvement.
Posted By Matt Martin, Cathy Hudgins, Barry J. Jacobs,
Wednesday, April 22, 2015
On April 7th, the Washington Post reported on a case involving Henry Rayhons, a former member of the Iowa House of Representatives, and criminal charges of third-degree sexual abuse. State prosecutors charged Mr. Rayhons for having sex with his wife, Donna Lou Rayhons, in August 2014 while she was incapacitated by dementia and living in a care facility. Jury deliberations began on Monday April 20th, 2015.
Henry and Donna Lou married after their longtime spouses had died. A few years into the marriage, Donna Lou was diagnosed with dementia. In May 2014, two of Donna Lou’s daughters met with care facility staff members to create a care plan for their mother. They, along with a doctor, decided that mom was no longer able to consent to sex. Henry was informed of this decision.
Donna Lou died in a nursing home in August 2014 after a four-year battle with Alzheimer’s. Henry was arrested and charged with sexual abuse a week later. According to law experts, this is the first case of its kind regarding capacity and dementia. At what point in dementia does a spouse or partner lose the right to say yes? Cathy Hudgins and Barry J. Jacobs provide commentary below. Click here for another viewpoint on this case.
CATHY HUDGINS: After reading this article and accompanying documents, I had more questions than I had answers. Early in my career as a Marriage and Family Therapist, I practiced at an adult day services center that served participants with various types of dementia and cognitive impairment. In working with these older adults and their families, I gained an appreciation for the extreme feelings of loss and confusion related to how to proceed with relationships and basic life issues. I worked with many family members and caregivers who had little guidance or experience prior to the onset of the disease. I remember giving these folks some room to learn and make small mistakes as they navigated the decline of their loved one. However, we taught our families that there were lines that no one would be allowed to cross, and those lines were drawn by the state’s definition of elder abuse.
Mrs. Rayhon’s disease progression was determined by the provider team, which included her family, at the facility through a validated screening tool and through the expertise of the providers and staff. As a way to educate and draw the line for Mr. Rayhon, it was conveyed overtly that she would no longer be able to consent to sex. From what Mr. Rahyon’s family wrote in rebuttal to his case, they believe (and I assume in concert with his belief and actions) that there should be no such restrictions to protect patients in a nursing home – even those that score a 0 on a dementia assessment. It is this kind of thinking that actually initiated protective services for vulnerable populations many years ago. The bottom line is that Mr. Rayhon knew that she could not consent, and he decided that his right to have sex with his wife trumped the law and the boundaries drawn for her based on an assessment of her capacity.
I do have several questions about this case, however. Does Mr. Rayhon have some type of cognitive decline or mental health problem that would make someone in his position as a law-maker disregard the law? While it does not sound like he had time with her prior to the sexual encounter to interpret her ability to consent at that time (I have seen several patients with dementia experience short windows of clarity), did he interpret something she did as consent?
Finally, I am not sure what Dr. Pearson meant by "at what point in dementia do you lose the right to say yes?” In my opinion, the ability to consent, if even possible at her stage of the disease, is transient, and the limitations associated with those moments of clarity are inconsistent at best. This fact is why the line must be drawn to protect vulnerable individuals, even from those who love them. There is no doubt that physical closeness can be curative and comforting. Nevertheless, there are other ways to satisfy this human need in lieu of an act that requires consent.
BARRY J. JACOBS: Some landmarks cases—whether legal or clinical—help us forge ahead into new territories of understanding and knowledge. Others, like signposts at the edge of frontiers, delineate the outer edge of the known world beyond which we are lost in cloudbanks and quicksand. The Rayhons case—about marriage, dementia and sexual consent—catapults us into a wilderness of clinical fuzziness, moral ambiguities, and legal murk.
We are all in agreement that sex should be consensual between intellectually capable adults. But determining exactly the point at which a person with a progressive dementia loses the capacity for informed sexual consent is not scientific at this point. It’s often clinical guesswork, based on wildly inappropriate measures (e.g., using memory test results to calculate degree of sexual understanding). The "line” that my colleague, Dr. Hudgins, refers to is not so clear; it is a legal construct, based on clinical impressions, extrapolations and opinions. This idea of a "line” is sometimes used to prevent people in nursing homes from engaging in sex, as if they lose that right once they enter the institution. The "line” was used in this case as a weapon by step-daughters in a power struggle with their step-father for control over their mother’s last months.
That is quite familiar in this family-and-illness drama (at least in the more detailed Bloomberg news story). Mr. Rayhons wanted to take care of his wife with dementia at home. Her daughters from her first marriage decided that he was in denial about her degree of impairment and, with the collusion of a family physician, placed her in a nursing home one day against Rayhons’ wishes while he was at a state legislative session 30 miles away. (As her husband, he should have had the legal right to make decisions about where she would reside. How did her daughters usurp that right?) After that, it appears that they sniped at one another and struggled over details of Mrs. Rayhons’ care at the nursing home. When the daughters took steps to protect their mother through limiting the privacy that their step-father would have with her, he responded by flouting the rules they set up. Seen from this perspective, his alleged act of having intercourse with his wife was, as much as anything else, a gesture of defiance toward his step-daughters.
A family-oriented professional could have helped these warring parties find some compromises and accommodations before the story’s climax (so to speak). Unfortunately, the professionals seem to have banded together to demonize the husband. He may have acted rashly or even naively but I don’t believe he’s a demon. And I don’t think an Iowa jury will determine he’s a criminal—just a lost and angry man who wandered into the poorly charted landscape of dementia and the law.
Matt Martin, PhD, LMFT, is Blog Editor for the Collaborative Family Healthcare Association. When he is not blogging or editing he teaches behavioral science to family medicine residents at the Duke/SR-AHEC residency program. Interested in writing for the blogs? Email Matt at email@example.com
Cathy Hudgins, PhD, LMFT, is the Director of the Center of Excellence for Integrated Care under the North Carolina Foundation for Advanced Health Programs. Dr. Hudgins has experience in Integrated Care management and development, crisis assessment and intervention, community-based and college-based outpatient counseling, in-patient assessment and intervention, and community mental health consulting. She has practiced in community mental health agencies, hospital and healthcare settings, as well as in private practice. She has also held a variety of posts in higher education administration and student affairs. She is an active member of the Collaborative Family Health Association and AAMFT and presents locally and nationally on Integrated Care.
Barry J. Jacobs, Psy.D. is the Director of the Behavioral Sciences for the Crozer-Keystone Family Medicine Residency and the lead faculty member for its super-utilizer program, the Crozer Connections the Health Team, and the Camden-Cooper-Crozer Hot-Spotting and Super-Utilizer Fellowship Program. He is also the author of The Emotional Survival Guide for Caregivers (Guilford, 2006).
A colleague said he needed a slide on the history of integrated of behavioral health and could I give him a few high points. This is what I wrote.
The first integrated behavioral health program that I know about that was a large implementation and not just a couple of practitioners working together was the Gouverneur Health Program in New York in the 70’s. There is a chapter in my book about it, Integrated Primary Care: The Future of Medical and Mental Health Collaboration, Norton, 1998. There was a fully integrated program at the first HMO which was in New Haven that is described by Coleman, et al. In 1994 I published a paper in which the term "integrated primary care” was used for the first time.
1995 was a big year for integrated care. It was the publication of Katon, et al’s big JAMA article with the evidence for integrated care for depression and it was the first meeting of the Collaborative Family Healthcare Association, the first organization made up of physicians and behavioral health folks focused on collaborative care www.cfha.net. After that it was sort of a steady development for a while. The work in Seattle kept on, supported by RWJ and MacArthur, building to the IMPACT model and beyond. The Behavioral Health Consultant model also build out of the Northwest, from Kirk Strosahl and Patty Robinson’s work. You can see it almost formulated in Kirk’s chapter in my book.
Various pieces fell in place. The military picked up integration as did HRSA in the early 2000’s. Centers of excellence were built at Health Partners in Minneapolis by CJ Peek and at Sharp Health in San Diego. Lots of different reports fell into place. The next monumental moment was the passage of the ACA. That kicked integrated care into actuality all over the country. That was the start of the AHRQ Academy for the Integration of Behavioral Health and Primary Care. The BPHCI grant program of HRSA and SAMHSA juiced the mental health guild organization called NCCBH into creating the Center for Integrated Health Solutions which is trying to be sure that integration doesn’t marginalize the mental health centers by being a great source of information for the entire field.
Now we are at the point where the leaders are seeing the impetus behindthe movement begin to push it out in front of them. We find ourselves having to define what counts as integration so that the term doesn’t get applied to whatever people are doing that they want to be sure is in on the action. We see people placing mental health clinicians from mental health centers into primary care who don’t realize that what they have been trained in is specialty mental health care and what is needed is primary care behavioral health. That is why we started our training program to make sure folks can get the rigorous orientation they need to succeed. We have to keep reminding each other not to ask does integration work?, does the PCMH work?, can integration save money? We have to ask what form of integration works in what context? How are they doing the PCMH in what regulatory and payment environment so that it works? What sort of integration or camre management program targeted at which patients, accounted by looking at what parts of the system works financially?
Our current success and rapid development great, but it is a movement that is much bigger than all of the pioneers now. We have to keep reminding ourselves that integrated primary care, or integrated behavioral health, or whatever else we call it, is not important. Better care for patients is important. If we keep our eyes always on that, integration will evolve and be durable for a long time.
Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA. At UMass he has developed training programs in Primary Care Behavioral Health and Integrated Care Management that have already trained 2000 people for the workforce needs of the transformation of healthcare. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’. He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.
In the small primary care office where I work as an embedded behavioral health specialist we are metrics savvy. We have graphs showing numbers of patients completing depression screenings, shared decision-making tools, and data to demonstrate the health care team effectiveness with reducing emergency room visits. With all of our analytics and quality improvement efforts, we don’t measure how the hospitality of the front desk staff positively impacts a patients’ sense of well-being and engagement. The relational skills of the front desk make a daily impact on all who observe and interact with them.
Observing the front desk staff interactions reminds me of Miles, a classmate of one of my sons, who decided that he wanted to make a difference by opening one of the high school front doors - every school day for four years. He arrived early and greeted each student by name as they journeyed through his open door into the school. Miles’ entryway was well traveled. Did his greeting make a difference in the learning of students, in the community health of the school, or in the decisions students made throughout their day? When I observed him holding the door open I smiled more, listened with increased attunement, and felt a little softer in spirit.
When patients check-out after an appointment, they have brief conversations of caring with the front desk staff. These meaningful conversations invite the patients to consider that they are more than their presenting problem or illness. "How is your grandson doing with his new job?” "Have you started planting your garden yet?” "Are you continuing to volunteer at Hospice?” The whole person is cared about. Greeting patients by name, welcoming with eye contact and an attentive smile may provide a needed healing balm and invitation to care for oneself.
Patients can consider that they are more than their presenting problem or illness
Front Desk Ladies at Foresight Family Physicians Clinic
The attentiveness of the front office staff gives a "we’re here to help” message to patients. Changes in spirit and self-care occur with experiences of kindness rather than criticism. Common feelings of vulnerability and fears coming into a doctor’s office may ease with consistent affirming interactions.
Why is this important other than the front desk feel good take away? In my role as the behavioral health specialist I ask patients about what they value in life to highlight motivation for improving a specific aspect of health. Carrying the initial warm welcome, a patient may become more engaged when discussing health changes with a medical provider. If the initial interactions with the front desk staff were invalidating, the response with health care team members may lack some motivation. Courage and fortitude to move into new health behaviors are more likely to occur when we feel cared about and safe.
Measuring kindness is not a clinical data point. Warm and brief conversations encourages values of kindness and trust. When asked about their motivation for quality service, the reply from the front desk reflects that they know they make a difference in patients’ lives. With smiles they discuss observing serious faces relax, laughing with the lonely, being trusted with a reflection of the visit, and hearing that they are called by name. Sandi, Cassi and Jennipher positively impact patient’s health care experience. Where ever we serve in our office, we have the common goal of helping patients with their health.
Patient-centered hospitality by the front office staff offers a significant gateway to health engagement; "you matter” is the message; the patient response of "I value myself” can be the result.
Lisa Barnes, LCSW, has transitioned from an over twenty-five year Clinical Social Worker in private psychotherapy practice to Integrated Health Specialist at Foresight Family Physicians in Grand Junction, CO. This career change has been enabled through CFHA mentors, part-time hospital and physician office work experiences, and many webinars! Lisa’s mission is to promote health in a health care system.
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