MENTAL HEALTH
INTEGRATION PROJECT
ENHANCING MENTAL HEALTH PRACTICE
IN PRIMARY CARE…
through improved education and communication.
Dr. Ken Casimir MD
Affinity Medical Group
Dr. Mark Marnocha PhD
UW-SMPH Family Medicine
Dr. John Mielke MD
Appleton Cardiology/Community Foundation
Dr. Doug Moard MD
Thedacare Family Medicine
Dr. Mark Rovick DO
Fox Valley Children’s Psychiatric/MCW
Setting
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Fox Valley region: Third largest urban population
area in Wisconsin
Larger Cities: Oshkosh, Neenah, Menasha, Appleton.
[Green Bay]
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Smaller Towns:
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Limited Scope: contiguous communities, and those
with linkage via health systems x 2.
Region/Community/Practice driven rather than
state-level or discipline-specific.
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Chilton, New London, Shawano,
Hortonvlle, Kimberly, Kaukauna, Little Chute, Freedom….
Weaknesses/Threats
Serious shortage of Pediatric Psychiatry
 Inadequate Adult Psychiatry Access
 Nation-wide shortage of psychiatry
 Strong Family Medicine practices, though
majority not full-scope. (no inpatient
medicine or Ob)
 Family Medicine forced to assume wider
scope of MH practice.
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Strengths/Opportunities
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Community interests in compassion, education,
health-care, and youth services.
Community Foundation w/physician voice.
Connections with MCW and UW-SMPH Medical
residency and consultation programs.
Involved psychiatrists with community, primary
care, and youth expertise.
Community aim to improve MH access, align
pediatric MH resources, and upgrade MH
prevention.
Relevant Literature
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Diverse studies of upgrading MH care skills
among primary care physicians.
No clear ‘gold standard’ as far as methods with
well-documented and replicated results.
Recent statewide initiatives to bolster primary
care MH care skills, notably New York,
Massachusetts, Nebraska.
Pediatric MH concerns increasing, eg, ADHD
overdiagnosis, proper use of atypicals, suicide
prevention, emerging drug use, cyber issues.
MHIP Task Force
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630 am meetings begun in 2011
Coffee stat and prn
Prior history of diverse connections among MHIP
group members.
Ongoing alignments with health systems, community
initiatives, educational resources.
Initial literature review.
Questions about regional needs & physician interest?
Development of mixed Quantitative/ Qualititative
semi-structured interview format.
Interview Format
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11 Likert or other numeric items.
5 yes-no or other forced choice items.
4 open-ended questions.
Comments solicited after all items.
Interview responses transcribed by interviewers.
Numeric and content summaries by 1st author.
Physician Survey Information
MHIP
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21 semi-structured face-to-face interviews
12 female / 9 male regional physicians
Snowball/Convenience Sample
MD/DO mix
Most Early-Middle career (3-20 years post residency)
17 Family Medicine, 3 Pediatrics, 1 Internal
Medicine
8 Affinity; 7 Thedacare; 2 Kaukauna Clinic; 1
each FCCHC, PCA, UW, Independent
From Appleton, Chilton, Greenville, Kaukauna,
New London, Oshkosh, Shawano, Waupaca
General Numerical Findings
57% do not feel proficient caring for
MH problems.
 67% do not feel counseling is
sufficiently accessible.
 Only 29% identify an MD partner
w/special interests in MH care.
 Only 20% find MH care reimbursement
to be a problem.
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Physician Views about MH Changes
BAD NEWS =
“More Psychiatrists” is most needed change, but
least practical.
 GOOD NEWS =
“More PCP training” is 2nd most needed change,
and the most practical.
“More Counseling” is moderate in need and
practicality.
“Reimbursement Change” is least needed, and 2nd
least practical.
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Need for MH Changes
5 change areas rated from 4 = ‘Great Need’ to 1 = ‘Minimal Need’
4
3.95
3.45
3
3.28
3.17
2.65
2
1
More
Psychiatry
Physician
Training
More
Counseling
Community Reimbursement
Education
Changes
Practicality of MH Changes
5 change areas rated from 4 = ‘Highly’ to 1 = ‘Minimally’ Practical
4
3
3
2.95
2.87
2
1.65
1.38
1
Physician
Training
Community
Education
More
Reimbursement
More
Counseling
Changes
Psychiatry
Physician Interest in MH Training
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95% indicated they are either “Very amenable - Sign
me up” or else “Interested-Have some questions.”
Only 1 MD (later career) not interested!
Only 24% (5 Physicians) said they need any
compensation for such training.
EXTENSIVE ideas from physicians for training
content, AND for in-depth group training face-toface with primary care peers and psychiatry / MH
resource people.
Interview Content Summaries
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Mental Health Care Concerns: Lack of
communication w/psychiatry; poor access to
general MH resources; access to psychiatry;
resources unfamiliarity.
Suggested Training Areas: Refractory
depression; Younger children; Bipolar;
Schizophrenia; Suicide; ADHD; Managing
meds; Algorithms for treatment, diagnosis;
Listening/counseling.
Initial MHIP Conclusions
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Additional psychiatric training is clearly
identified by PCPs as both necessary and
practical
95% of surveyed PCPs were either “interested”
or “very interested” in structured psychiatry
CME training
Only 24% of surveyed PCPs identified a need
for reimbursement for CME time
Conclusions (continued)
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PCPs identify their relationships with
psychiatrists as less than satisfactory
Communication regarding available mental
health resources is inadequate
Improvement of MD-MD relationships, along
with readily accessible network re: available
resources is essential
Current status of project
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Community Funding
Initial curriculum per ASCP, with augmentation prn
9 monthly evening sessions
Emphasis on complex cases, minimal basic review,
and current evidence/practice updates
2.5 hours with dinner
~50 registrants; including NPs and
students/residents. Future iterations may include
office staff involved in MH case management
Session eval forms; pretest and posttest assessment of
comfort with aspects of complex OP MH care.