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