REVERSE CO-LOCATION: INTEGRATING PRIMARY CARE INTO A BEHAVIORAL HEALTH SETTING

Philadelphia DBHiDS June 2013

Lawrence A. Real, MDMedical Director

Horizon House Inc

WHAT IS “REVERSE CO-LOCATION”?

Primary care located within a behavioral health setting

Because our people are dying!

WHY BRING PRIMARY CARE INTO THE BEHAVIORAL HEALTH SETTING?

INCREASED MORBIDITY AND MORTALITY

People with serious mental illness (SMI) die on average 25 years earlier than the general population

Though suicide and injury account for maybe 1/3 of this, 60% of premature deaths are due to preventable medical conditions, and most of those due to cardiovascular disease

These preventable medical conditions are linked to high rates of modifiable risk factors

Parks et al, Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors, October 2006

Reversing Early Mortality Due to Obesity and Cardiovascular Risk Factors in Mental Illness: What Works in Changing Health Behaviors Bartels Feb ‘12

MODIFIABLE RISK FACTORS

High incidence of smoking Individuals diagnosed with psychiatric

disorders smoke ~ ½ the cigarettes smoked in U.S.

Sedentary life style High rates of obesity, poor

nutrition Over 42% of people with SMI are obese**

Co-morbid substance use disorders

Limited access to quality healthcare?

*National Epidemiologic Survey on Alcohol & Related Disorders, 2002

**Dartmouth Health Promotion Research Team, 2012

SPECTRUM OF COLLABORATIVE CARE MODELS

“COLLABORATIVE” vs “INTEGRATED”

Collaborative care involves behavioral health working WITH physical health… [or vice versa]

Integrated care involves behavioral health working WITHIN, and as a part of, physical health… [or vice versa]

In collaborative care, patients perceive behavioral health care as a separate service received from a specialist…[or vice versa]

In integrated care, patients perceive behavioral health care as a routine part of primary care…[and vice versa]Strosahl, in Integrated Care: the Future of Medical and Mental Health Collaboration, 1998

Bottom Line on Co-location

Co-location does not equal integration!

It does, via physical proximity, create an opportunity for improved collaboration

The devil is very much in the details, i.e., how well you plan and execute

How are we attempting to integrate care at Horizon House?

Our Journey to Integrated Care

September 7, 2010 –Horizon House partners with Delaware Valley Community Health, and the Fairmount Primary Care Center at Horizon House opens at our 30th St location

September 30, 2010 – Horizon House receives a 4-year Physical and Behavioral Health Care Integration grant from SAMHSA

June 2013– Over 600 patients have received primary care on site

SAMHSA Grant Results in Expanded Staffing

Full-time certified Physician Assistant

Supervising physician, 1/2 day/wk } DVCH

Team leader/ Medical assistant

Billing clerk/administrative assistant

Project Manager (HH)

Data Coordinator (HH)

Health Integration Specialist (HH)

Health Educator (DVCH)

Certified Peer Specialist (2)

Services Offered as of Opening Day

•Insurance eligibility assistance•Adult primary and preventive care and health education*•TB Testing •Lung function testing (Spirometry)•EKGs•Immunizations•Onsite lab services•Referrals to specialists/help in making appointments •Physician available by phone

after hours•Appointment Reminders

•OB/GYN Dental, Podiatry and Health Education Group Services (at DVCH’s Health Center at 1412 Fairmount Avenue) • Prescriptions: filled through patients’ current pharmacy.• Psychotropic medications: prescribed by behavioral health providers.

Ophthalmology and/or optometry services: Referrals to Wills Eye Hospital.

THREE KEY TASKS

1. Can you increase access to primary care, and thereby improve the management of chronic illnesses?

2. Can you improve the early detection and/or prevention of other disease states?

3. Can you “create health” by engaging people in wellness activities before, during or after the emergence of serious medical co-morbidities?

What do you need?

Who Will Provide Primary Care?

1. Facilitated referral (coordination) BH organization coordinates referrals and shares

information with PCPs offsite

2.Partnership-based models (reverse co-location)

Primary care embedded in community-based BH organization

3. Fully integrated models Staff from a single organization provide primary

care and behavioral health care—i.e., do it yourself!

---adapted from Druss, 2011

Lessons Learned: Partnering

You have to either find a partner, or hire your own primary care staff—each comes with its own unique challenges

FINDING A PARTNER: Compatibility

Characteristics of the “right” partner

Experience with /commitment to serving ‘safety net’ populations

Belief in holistic, client-centered services

Willing to give up preconceived notions

Creative, flexible--willing to try new things

Team players, develop concept jointly

Able to quickly establish services

Lessons Learned: Business

You need a business plan that, before too long, projects the primary care operation to at least break even—while maintaining quality of care

FINDING A PARTNER: Feasibility Is there sufficient traffic at the site

Payor mix of potential participants

Willingness of participants to change primary care provider

Can you get Board approvals?

Can you get HRSA, other approvals for change of scope [for FQHC]?

“Show Me the Money!”

Need to take the ‘long view’, see initial commitment as consistent with your agency’s service mission

Creative and assertive in pursuing grants, ‘freebies’, collaborations

Sustainability still will likely require parallel changes in service reimbursement

How Will You Engage Consumers?

Presumption: utilize their engagement with and trust in behavioral health team (‘warm handoffs’)

Make co-located service a preferred choice for primary care (via screenings, wellness activities, incentives, good customer service)

Certified Peer Specialists key members of the team trying to integrate care

Motivational interviewing

Who Will Coordinate Care?

Traditional “case managers”—add this task to services already being provided

Create/ hire/ train specialists in healthcare integration

Combination of existing personnel (with additional training) and integration specialists

Assumes coordination of primary/ medical specialty care via PCP

Lessons Learned: Blending Cultures

You need to work with your primary care providers to merge and adapt the different cultures that define each of you

Two different worlds?

FINDING A PARTNERChallenge of Information Sharing

Two different and independent charting systems

More stringent state regulations re sharing of BH info

Participant concerns about sharing BH information with primary care providers (and vice versa)

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Lessons Learned: Transforming Yourself

You need to persistently work on changing the culture of your organization so that it sees itself as one that provides integrated health care, not just behavioral health care

Lessons Learned: Choices

You need to consciously balance your desire that all your participants choose primary care on site with with your desire to insure they can freely choose where to receive primary care

Fairmount Primary Care Center at Horizon House: Accessing Care

Fairmount PCC available to ALL HH staff and program participants

Fairmount PCC must be selected as primary care provider

Consistent with FQHC rules, Fairmount PCC will see people without health insurance

Lessons Learned: Systems

You need to create and monitor systems that support the collaborative care you intend to provide, especially if you have gone the ‘partner’ route

Lessons Learned: “Show Me the Data!”

You need to create a ‘clinical registry’ that enables you to track both individual and population health outcomes

Lessons Learned: Ownership of One’s Health

Your processes need to allow for participants to progress to assuming charge of their own disease management and wellness activities

Lessons Learned: Consumer Involvement

Consumers and their supports need to actively involved in design and execution of your plan: Peer specialists on the team Peer advisory council Consumer feedback via surveys and focus groups

Lessons Learned: Wellness Matters

A substantial amount of your effort needs to be devoted to wellness programming, aimed both at the management of chronic illness and at some combination of illness prevention and health promotion

Samples of Wellness Activities

Meditation group Walking group Smoking Cessation Wake and Move FIT Club (Finding Inspiration Together) Yoga Whole Health, Wellness, & Resiliency Taking Charge of Our Health Community Inclusion-YMCA and

Farmer’s Markets

Lessons Learned: We’re all in this together!

Learning communities enable us to learn from each others successes and failures

Each of us can use, modify, and develop new EBP’s

How can we make effective collaboration easier for each other?

Lessons Learned:“Ya Gotta Believe”

Major Challenge?

Our own nihilism/pessimism

The question remains: Can you really make a difference?

Health Promotion Programs for Persons with Serious Mental Illness: What Works?

A Systematic Review and Analysis of the Evidence Base in Published Research Literature on Exercise and Nutrition Programs

Prepared for SAMHSA-HRSA Center for Integrated Health Solutions by the Dartmouth Health Promotion Research Team, Project Director Stephen Bartels, MD February 2012

Health Promotion Programs for SMI: Key Findings

Interventions that last > 3 months are superior; the intensive phase of programs should last at least 6 months

Programs that combine education and activity-based approaches are more sucessful than those that focus on non-specific wellness education

Programs that incorporate nutrition education and exercise are superior in inciting weight loss than those that focus on nutrition alone

Reversing Early Mortality Due to Obesity and Cardiovascular Risk Factors in Mental Illness: What Works in Changing Health Behaviors? Bartels Feb ‘12

Thank you very much!