SYNCHRONIZATION

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ASystemic Integration

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ofBehavioral Health

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into the Medical Continuum

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T. C. O S N E R & A S S O C I A C A T E S

I didn’t pick my illnesses

To my endocrinologist,I’m a diabetic

To my PCP,I have Crohn’s

Disease

To my OB-GYN,It’s a recurring

infection

To my Oncologist,I have breast CA

To my Hospitalist,I’m someone to

stabilize

To the ED doc,I’ve got panic attacks

What’s the one thing they

all have to deal with?

The reason I have to see them

more than I should ?

My Depression . . .

My Depression . . .

. . . my socialstressors . . .

. . . and my addiction

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Behavioral health issues . . .

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. . . the pervasive co-morbidity

By now, we’ve all seen the stats

But we still suffer from . . .

STEREOTYPES

“Will someonePlease get thisPsych patient

outof my ED?”

A partial solution . . .

. . . adding much needed serves

Behavioral health in Oncology

. . . Creating medical homes

But it’s a systems problem . . .

Behavioral Health Integration,

like the rest of Healthcare,

has been stitchedtogether into a

Monster

An arm here . . . . . . a leg there . . .

and last – The Brain

Developing in silos . . .

Independent

Uncoordinated

Uncooperative

disconnected

duplicative

protective

“MyProgram”

A philosophy of integration . . .

. . . based on new assumptions

Behavioral Health is inclusive of promoting well-being . . .

. . . preventing and intervening in harmful behaviors . . .

. . . and the treatment of mental health and addictions disorders

It is a primary service firstand a specialty service second

It engages all behavioral healthmatters regardless of location

Treatment occurs at the siteof the most frequent medical

utilization

Treatment is synchronizedacross the medical continuum

The systems engages with the patient rather than patients having to engage with

departments

Behavioral heath integrationIs defined on three levels

Substance abuseand mental health

Internal integrationof core services

External integrationinto the medical continuum

Realigning and repurposing resources

to be FTE neutral

How to build an integrated service: From primary to specialty care

Assessment & ReferralAnchor Service(licensed SW/Registrar/Hybrid ClinicianCall Center/Database-EMR/Inter-departmental)

From routine to acute

Embedded Hybrid PracticesIn Primary Care

Embedded Hybrid Practicesin Specialty Care(cardiology, oncology, endocrinology, etc.)

Reprogramming of BHUandRealignment of psychiatry

Realignment of existingHospital-base outpatientinto hybrid MH/CD programs

Hospital-based Behavioral Health

All integration effortsboth in internal and externalbegin with the developmentof the Hybrid Clinician

Creating . . .

Creating . . .

E T H O S

As every Marine is a rifleman . . .

. .. every clinician is a Hybrid

Hybrid Clinician profile

• Licensed Masters – level Clinician in social work, psychology or marriage/family

• Licensed or Certified Alcohol/Drug Counselor

• Conceptual/systems thinker

• Flexible team player

• Strong diagnostic skills

Hybrid Clinician profile

• Experienced in different levels of care

• Entrepreneurial

• Desire to be more than just “a therapist”

Hybrid Clinician skillset

• Knows the entire system

• Functions at any level of care

• Interventionist: CBT/SFBT/MI

• High Risk case management

• Utilization management

• Registrar

Hybrid Clinician skillset

• Versed in Lean Principles

• Certified in Primary Behavioral Health Care

Financial sustainability is achieved

through existing payment mechanisms

and creative partnershipswith payers

Creating an organic system .

Embed infrastructure

rather than a service

Creating an organic system .

Embed infrastructure

rather than a service

Hybrid skillsets –

No Wrong Front Door

Creating an organic system .

Hybrid skillsets –No Wrong Front Door

Treatment is synchronizedand flows through

the system

Creating an organic system .

Treatment is

synchronizedand flows through

the system

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

SpeciallyTrainedHybrid

Clinicians

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

PreviouslyUnidentified

Psych Drivers

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

PreviouslyUnidentified

Psych Drivers

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Integrate intoSystemPCPs &

Specialties

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

Single Hospital System

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Integrate intoSystemPCPs &

Specialties

Challenges & Hurdles

“You can’t do that”

Challenges & Hurdles “Our system is too big”

Challenges & Hurdles “You can’t do it all at

once”

Challenges & Hurdles “What about HIPAA”

Challenges & Hurdles

“We can’t afford additional FTES”

F

Fi

Fir

Firs

First

First S

First St

First Ste

First Step

First Steps

Diagnose the System

First Steps

Diagnose the System

“If you want to truly understand something (like your organization), try to change it”

Kurt Lewin

First Steps

Diagnose the System

• the Infrastructure

• the Culture

• the Continuum connectivity

• its nimbleness

• current employee fit

Diagnose the System

• the Infrastructure

• the Culture

• the Continuum connectivity

• its nimbleness

• current employee fit

Identify administrator

and physician Champions!

Identify administrator

and physician Champions!

Train 1st generation Hybrids and their leader.

(Hybrid boot camp)

Educate Payers regarding the model

and haveHybrids credentialed

on all panels

Engage Finance for all Proper Support

Engage IT for all Proper Support

Identify PCP/SpecialtyBeta Sites

Then . . .

Tell the story

Tell the story

Tell the story

First Steps are bothsequential and simultaneous

efforts

Playing in old Yankee Stadiumwhile building

New Yankee Stadium

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Single Hospital System

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Single Hospital SystemOne

Department

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Single Hospital SystemOne

DepartmentOne Identity

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Single Hospital SystemOne

DepartmentOne IdentityMultifaceted

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Single Hospital SystemOne

DepartmentOne IdentityMultifaceted

Revenue generating

Across the

Continuum of Care

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Single Hospital SystemOne

DepartmentOne IdentityMultifaceted

Revenue generating

NoWrongDoor

ICU

PCP PCP

PCPPCP

PCPPCP

SpecSpec

SpecSpec

Spec Spec

SPECIALTYMED/SURG

EDBHU

SpecialtyMentalHealth

SpecialtyMentalHealth

A&RC.C.

Supplemented by billable

Web-basedCBT

Web-basedCBT

What it is and what it does . . .

• Embeds infrastructure, not just a service

• Coordinates systems rather than clinicians

• Delivers treatment where the patients are

• Reduces stigma and impacts compliance

• Impacts costs

• Not the typical Hub & Spoke system