PRIMARY AND BEHAVIORAL
HEALTHCARE INTEGRATION
PRACTICAL APPROACHES TO
IMPLEMENTATION
Les Stratford, RN, BSN, MA, Program Director
Coastal Behavioral Healthcare, Sarasota, Florida
Anthony R. Bichel, Ph.D.
Apalachee Center Inc., Tallahassee, Florida
Rick Hankey, Senior V. P. and Hospital Administrator
LifeStream Behavioral Center, Leesburg, Florida
Coastal Behavioral Healthcare
LEARNING OBJECTIVES
PROVIDE
AN OVERVIEW OF INTEGRATED BEHAVIORAL
HEALTH AND PRIMARY CARE
INCREASE
KNOWLEDGE OF THE IMPLEMENTATION
PROCESS AND SUSTAINABILITY
DESCRIBE
LESSONS LEARNED
Coastal Behavioral Healthcare
OUTLINE
• History
• Define The Problem Today
• What Changed? Why Now?
• What Is Integrated Care?
• The Implementation Process
• Sustainability
• Lessons Learned
Coastal Behavioral Healthcare
HOW DID PHYSICAL AND
MENTAL HEALTH BECOME
SEPARATED?
Coastal Behavioral Healthcare
HISTORY
1950 – 1960: Most people with mental illness
were living in asylums.
In the 60s: Due to John F. Kennedy and advances
in medical thinking, changed from
institutional care to community based
system.
1980 – 1990: Number of people living in taxfunded institutions was reduced by 50%.
Today: Approximately one-fifth of the 1950s
number reside in institutional care.
Coastal Behavioral Healthcare
PROMISES MADE AND
PROMISES BROKEN
Money was intended to follow consumers into
community programs. This didn’t happen.
Employer paid insurance had no reason to pick up
the bill. Most didn’t.
Operating two systems: state and community. Never
had enough money to fund both.
Community based mental health system has always
been underfunded.
Coastal Behavioral Healthcare
TODAY PEOPLE WITH SMI DIE
ON AVERAGE 25 YEARS
SOONER THAN THE GENERAL
POPULATION
Coastal Behavioral Healthcare
OF THE SIX MAJOR CAUSES OF DEATH
IN THE UNITED STATES,
THERE IS AN INCREASED RISK OF DEATH
AMONG THE SERIOUSLY MENTALLY ILL
MAJOR CAUSE OF DEATH
INCREASED RISK OF DEATH
CARDIOVASCULAR
3.4 X
LUNG CANCER
STROKE
3X
2 X IN THOSE LESS THAN
50 YEARS OF AGE
RESPIRATORY
5X
DIABETES
3.4 X
INFECTIOUS DISEASES
3.4 X
Bob Sharp, Fl Council For Community Mental Health
Coastal Behavioral Healthcare
FACTORS INCREASING
HEALTH RISK
Less likely to be screened
Poverty
Poor access to Primary Care
Self-Care
Capacity/Resource
Disconnectedness
of “Physical” &
“Mental” health
care systems
Cognitive,
Affective
and Behavioral
symptoms
Weight Gain
System Navigation Barriers
Tobacco and Substance Abuse
Medications
Coastal Behavioral Healthcare
WHAT'S CHANGED AND
WHY CHANGE NOW?
4-Year Grant from The Substance Abuse And Mental Health
Services Administration (SAMHSA) – $500,000 Per Year
The Purpose Of The Grant Is To Improve The Physical Health
Status Of People With Serious Mental Illness
The Challenge Is To Establish A System That Bridges The Gap
Between Mental Health Care And General Medical Care
“It’s the right thing to do!”
Linda Rosenberg of The National Council
Coastal Behavioral Healthcare
SAMHSA
GRANT PROGRAM
$28 MILLION DOLLARS GIVEN TO 56
COMMUNITY BEHAVIORAL HEALTH CARE
AGENCIES TO INTEGRATE PRIMARY AND
BEHAVIORAL HEALTH CARE SERVICES
FIVE REGIONS
FLORIDA IS IN REGION 3
West Region (1)
10 Grantees
Northeast &
Mid-Atlantic Region (5)
17 Grantees
Central Region (2)
8 Grantees
WA
MT
ND
OR
ID
NY
WI
SD
MI
IA
NE
NV
UT
IL
CO
AZ
AK
HI
OK
NM
TX
IN
MO
KS
MA
CT RI
NJ
PA
DE
OH
DC
WV
KY
VA
MD
NC
TN
AR
LA
ME
NH
MN
WY
CA
VT
Midwest Region (4)
13 Grantees
SC
MS
AL
GA
Southeast Region (3)
8 Grantees
FL
West
Region 1
Central
Region 2
AK: Wrangell Community
Services
CA: Mental Health
Systems
CA: Alameda Co
Behavioral Health Care
Services
CA: Asian Community MH
Services
AZ: CODAC Behavioral
Health Services
CO: Mental Health Center of
Denver
TX: Austin-Travis CO MH/MR
Center
FL: Coastal Behavioral Healthcare IL: Human Service Center
CA: Glenn County Health
Services Agency
CA: Tarzana Treatment
Centers, Inc.
OR: Native American
Rehab Assoc of the NW
WA: Asian Counseling and
Referral Services
WA: Downtown
Emergency Service Center
Southeast
Region 3
Midwest
Region 4
NE & MidAtlantic
Region 5
CT: Bridges - A Community Support
System
CT: Community MH Affiliates
FL: Lifestream Behavioral Center
IL: Trilogy Inc
FL: Miami Behavioral Health
Center
IL: Hertiage Behavioral Health MA: Community Healthlink Inc
Center
TX: Montrose Counseling
Center
FL: Community Rehabilitation
Center
IN: Adult & Child Mental Health ME: Community Health and
Center
Counseling Service
OK: North Care Center
FL: Apalachee Center, Inc
OK: Oklahoma Dept of
MH/SA
UT: Weber Human Services
IN: Southlake Community
Mental Health Center
FL: Lakeside Behavioral Healthcare IN: Centerstone of IN
NH: Community Council of Nashua
GA: Cobb/Douglas Community
Service Board
SC: State Dept of MH
KY: Pennyroyal Regional
MH/MR Board
MI: Washetenaw Community
Health Organization
NJ: Catholic Charities, Diocese of
Trenton
NY: VIP Community Services
OH: Center for Families and
Children
OH: Shawnee MH Center
NY: Postgraduate Center for Mental
Health
NY: Bronx-Lebanon Hospital Center
NJ: Care Plus NJ
OH: Southeast Inc.
NY: International Center for the
Disabled
OH: Greater Cincy BH Services NY: Fordham Tremont CMHC
WV: Prestera Center for MH
Services
PA: Milestone Centers
PA: Horizon House
RI: Kent Center for Human/Org
Development
RI: The Providence Center
MD: Family Services, Inc
Coastal Behavioral Healthcare
IT IS A TEAM-BASED MODEL
WITH MEDICAL AND MENTAL
HEALTH PROVIDERS
PARTNERING TO FACILITATE THE
DETECTION, TREATMENT, AND
FOLLOW-UP OF BOTH MEDICAL
AND PSYCHIATRIC DISORDERS IN
A COMBINED SETTING.
Coastal Behavioral Healthcare
SAMSHA GOALS
REDUCE HEALTHCARE DISPARITIES
ELIMINATE THE EARLY MORTALITY GAP
REACH PEOPLE WHO CANNOT OR WILL NOT ACCESS
PRIMARY HEALTHCARE SERVICES
EARLY INTERVENTION AND DETECTION
BEFORE ISSUES DEVELOP OR WORSEN
Coastal Behavioral Healthcare
ACHIEVING THE GOALS
IMPROVE
HEALTH AND
WELLBEING BY
• Regular screenings and registry tracking
• On-site integrated primary care
prevention, screening, and treatment
services
• Wellness education and support
activities
• Referral and follow-up
INCREASE
CONSUMER
PARTICIPATION
THROUGH
• Peer involvement in the delivery,
planning and evaluation of services
• Advisory Committee involvement and
feedback
Coastal Behavioral Healthcare
STEP 1 – SUCCESS THROUGH PARTNERSHIPS
STEP 2 - UNDERSTANDING DIFFERENCES
STEP 3 - INTEGRATION MODELS
STEP 4 – CRITICAL STEPS
Primary Care
Grant Evaluator
Laboratory Vendor
Medical Supply Company
Health Educators
Community Stakeholders
Business Alliances
Coastal Behavioral Healthcare
MANATEE COUNTY RURAL HEALTH SERVICES – Primary Care
UNIVERSITY OF SOUTH FLORIDA – Grant evaluators
SWEETBAY PHARMACY Healthy Saver Plus Program
• $7 annual enrollment fee for entire family
• 450 generics at $4 per 30-day supply
DIABETIC STAFF AND PATIENT EDUCATION
• Dave Joffe, Sweetbay Pharmacist,
• and Diabetes- in-Control, Editor in Chief
PHARMACIST INTERNSHIP PROGRAM
• Student Rotation Affiliation with
• Lake Erie College Of Medicine
PFIZER MEDED GRANTS
• Application for funding of a Wellness Peer Advocate
Coastal Behavioral Healthcare
They’re different! Acknowledge & Embrace it!
Coastal Behavioral Healthcare
PRIMARY CARE
MENTAL HEALTH
PACE
15 minute appointment
50 minute session
SETTING
An exam room
A comfortable office
LANGUAGE
Diagnosis, medical
terminology, complaints
Assessment, mental health
terminology, issues
HIERARCHY
Clear – Doctor in charge
Diffuse – Administrator in Charge
with Medical Director
FLOW
Flexible patient flow
Scheduled client flow
Coastal Behavioral Healthcare
Integration Model
Level of
Integration
Attributes
MINIMAL COLLABORATION
I
SEPARATE SITE & SYSTEMS
MINIMAL COMMUNICATION
BASIC COLLABORATION FROM
A DISTANCE
II
ACTIVE REFERRAL LINKAGES
SOME REGULAR COMMUNICATION
BASIC COLLABORATION ON
SITE
III
SHARED SITE; SEPARATE SYSTEMS
REGULAR COMMUNICATION
IV
SHARED SITE; SOME SHARED
SYSTEMS
COORDINATED TREATMENT PLANS
REGULAR COMMUNICATION
V
SHARED SITE, VISION, SYSTEMS
SHARED TREATMENT PLANS
REGULAR TEAM MEETINGS
COLLABORATIVE CARE
PARTLY INTEGRATED
FULLY INTEGRATED SYSTEM
Coastal Behavioral Healthcare
Organizational Buy-in and Plan
Establish Contracts
Hire Staff
Billing – Opportunities for Sustainability
Data Tracking and Collection
Before admitting the
first patient, consider:
Space
Policies & Procedures
Documentation
Registration and Scheduling
Primary Acute Care Services –
Offerings and Expense
Coastal Behavioral Healthcare
Physical
History
Personal Risk
Factors
Family Risk
Factors
Height
Weight
BMI
Blood
Pressure and
Pulse
Fasting
Plasma
Glucose
Total
Cholesterol
Triglycerides
LDL
HDL
Cholesterol /
HDL Ratio
Complete
Metabolic
Panel
A1C
Abdominal
Circumference
TSH
Medication
Review
Liver Function
Studies
CBC with
Differential
Co-Occurring
Risk of Harm
Depression
Screening
NOMS
Physical Exam
Coastal Behavioral Healthcare
NUTRITIONAL EDUCATION
ILLNESS SELF-MANAGEMENT
FOOD TOURS
STRESS MANAGEMENT
HEALTHY COOKING
PEER SUPPORT
DIABETES EDUCATION
RECOVERY ACTIVITIES
PHYSICAL ACTIVITY ED
EXERCISE INSTRUCTION
MEDICATION MANAGEMENT
SMOKING CESSATION
Coastal Behavioral Healthcare
SUSTAINABILITY
WHEN THE FUNDING STOPS
COMPLICATED
REIMBURSEMENT –
CPT AND ICD-9 CODING
SAMSHA’S TARGET
POPULATION MUST BE
EXPANDED IN ORDER TO
SUSTAIN INTEGRATION
MODEL
TARGET POPULATION
• 18 YEARS OR OLDER
• SMI-12MONTH
DURATION
• GAF BELOW 60
• UNINSURED
LACK OF SAME DAY
SERVICES
REIMBURSEMENT UNDER
MEDICAID
Coastal Behavioral Healthcare
Coastal Behavioral Healthcare
• SENIOR LEADERSHIP INVOLVEMENT IS CRITICAL
• SET GOALS … DEVELOP A ROAD MAP
• FORCE INTEGRATION AT EVERY OPPORTUNITY
• BROAD BASE HOLISTIC CARE … NO SILOS
• HIRE AT LEAST ONE EXPERT IN PRIMARY CARE
• COST OF PROVIDING PRIMARY CARE IS MORE
EXPENSIVE THAN THAT OF MENTAL HEALTH CARE
Coastal Behavioral Healthcare
• WORK ON SUSTAINABILITY IMMEDIATELY … YEAR ONE
• FOSTER PARTNERSHIPS … CAN INCREASE OFFERINGS
WITH LITTLE COST
• EDUCATING AND ASSISTING PATIENTS IN MANAGING
THEIR HEALTH CARE IS VITALLY IMPORTANT. PROVIDING
THE SAME ASSISTANCE TO THEIR CARE GIVERS IS
ESSENTIAL!
• ELECTRONIC HEALTH INFORMATION RECORDS ARE
GREAT! PAPER CHARTS ARE NOT!
Coastal Behavioral Healthcare
CASE STUDY
56-YEAR-OLD WHITE FEMALE
MAJOR COMPLAINT: Acute leg ulcers
MEDICAL HISTORY:
Major Depressive Disorder
Generalized Anxiety
Diabetes
Hypertension
Asthma
Hyperlipidemia
MEDICATION REGIMEN:
No Change In More Than 1 Year
CASE STUDY
PHYSICAL EXAM:
Weight 302: height 5’1”
Blood Pressure: 148/90
Pulse 88 bpm; resp. 22 per minute
Lungs clear; no wheezing, rales or rhonchi
Lower extremities: + 2 pitting edema bilaterally; pulses fair
LABS: ABNORMAL OR RELEVANT LABS ONLY
Hemoglobin A1C: 9.2 (normal range 5.9-7)
Creatinine: 0.7 mg/dl (normal range: 0.7-1.4 mg/dl)
Blood Urea Nitrogen: 18mg/dl (normal range: 7-21)
Sodium: 140 mEq/l (normal range 135-145mEq/l
LIPID PANEL:
Total Cholesterol: 211 mg/dl (normal range<200 mg/dl)
LDL, Triglycerides: 10% Above normal in all three
Liver function panel: within normal limits
ASSESSMENTS
Poorly Controlled, Severe, Persistent Asthma
Foot Ulcer On Left Foot
Dyslipidemia : Elevated LDL Despite Statin Therapy
Persistent Lower-extremity Edema Despite Diuretic Therapy
Hypokalemia
Hypertension Elevated
Coronary Artery Disease Stable
Obesity Stable
Financial Constraints Affecting Medication Behaviors
Insufficient Patient Education Regarding Purpose And Role Of Medications
Wellness, Preventive And Routine Monitoring Issues
OUTCOMES
REFERRAL TO ENDOCRINOLOGIST
SAME–DAY APPOINTMENT
PATIENT REFERRED BACK TO INTEGRATED PROGRAM
WITH MEDICATION CHANGES AND MONTHLY
FOLLOW-UP APPOINTMENTS WITH ENDOCRINOLOGIST
AMPUTATION AVOIDED - ENDOCRINOLOGIST REPORTED
THAT LEFT FOOT AMPUTATION WOULD HAVE RESULTED
IF NOT FOR IMMEDIATE REFERRAL
RESOURCES
Aetna Depression In Primary Care
Cherokee Health Systems – Training Programs
Commonwealth Of Pennsylvania Screening, Brief Intervention, Referral And Treatment
Hogg Foundation For Mental Health – Resource Guide
Integrated Behavioral Health Project (IBHP) – Tool Kit
Integrated Primary Care, Inc.
Intermountain Behavioral Health Program
John A. Hartford Foundation- Improving Mood: Promoting Access To Collaborative Care
National Council For Community Behavioral Health Care
Substance Abuse And Mental Health Services Administration SAMHSA
University Of Massachusetts Certificate Program In Primary Behavioral Health Care
HRSA- Starting A Rural Health Clinic – A How To Manuel
Coastal Behavioral Healthcare
Les Stratford, RN, BSN, MA, Program Director
Coastal Behavioral Healthcare, Sarasota, Florida
lstratford@coastalbh.org 941-331-2530 ext. 1110
Anthony R. Bichel, Ph.D.
Apalachee Center Inc., Tallahassee, Florida
anthonyb@apalacheecenter.org 850-459-7025
Rick Hankey, Senior Vice President and Hospital Administrator
LifeStream Behavioral Center, Leesburg, Florida
rhankey@LSBC.net 352-315-7810
Coastal Behavioral Healthcare