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AtlantiCare Health Services Mission Health Care. Region II Conference Integration of Behavioral Health in Primary Care June 2, 2010. What is Primary Health Care?. “Essential health care” Universally accessible to individuals and families In a community

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AtlantiCare Health Services Mission Health Care

Region II Conference

Integration of Behavioral Health in Primary Care

June 2, 2010

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What is Primary Health Care?

  • “Essential health care”

  • Universally accessible to individuals and families

  • In a community

  • Provided as close as possible to where people live and work

  • Care based on the needs of the population

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Providing behavioral health in primary care involves

  • Diagnosing and treating people with mental disorders

  • Putting in place strategies to prevent mental disorders

  • Ensuring that primary health care workers are able to apply key psychosocial and behavioral science skills

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For example:

  • Interviewing

  • Counseling

  • Interpersonal skills

  • In their day to day work in order to improve overall health outcomes in primary care (WHO, 1990)

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Integration of Behavioral Health in Primary Care

  • Integrating specialized health services – such as mental health services – into PHC is one of WHO’s most fundamental health care recommendations (WHO, 2001)

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Rationale for Integrating Behavioral Health Services into PHC

  • Reduced Stigma -

    • Patients are more comfortable in discussing mental health issues with PC provider

    • Because primary health care services are not associated with any specific health conditions, stigma is reduced

    • In general they have an established relationship with primary care provider because they are more inclined to follow up on medical care

    • “ I am not crazy “

    • less stigma walking into a PHC setting than a behavioral health setting

  • Improved Access to Care

    Patients are more likely to keep appointments where multiple issues are being addressed

    Better coordination of care

  • Treatment of co-morbid physical conditions

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Co Morbidity

  • Behavioral health is often co-morbid with many physical health problems such as:

  • Heart Disease


  • Diabetes

  • Tuberculosis

  • Chronic Pain

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Co Morbidity

  • When primary health care workers have received some behavioral health care training they can attend to the physical needs of people with behavioral health disorders as well as the behavioral health needs of those suffering from infectious and chronic diseases. This will lead to BETTER health outcomes

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Morbidity and Mortality in People with Serious Mental Illness

  • Persons with serious mental illness (SMI) are dying 25 years earlier than the general population

  • While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006)

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Improved Prevention and Detection of Behavioral Disorders

  • Primary health care workers are frontline formal health professionals

  • First level of contact of individuals, the family and the community

  • Equipping these workers with behavioral health skills promotes a more holistic approach to patient care and ensures both improved detection and prevention of behavioral disorders

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Treatment and Follow –up of Behavioral Health

  • People who are diagnosed with a behavioral health disorder are often unable to access any treatment for their mental health problems

  • Providing behavioral health services in a PHC, more people will be able to receive the services and care they need because:

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Treatment and Follow –up of Behavioral Health

  • Better physical accessibility

    Primary health care is the first level of contact, usually the closest and the easiest to access for individuals, the family and the community

  • Better financial accessibility

    340b program

  • Better acceptability

    Linked to reduced stigma and easier communication with health care providers

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Integrated Care

  • Most effective approach to treat mental health in PC settings

  • Comprehensive

  • Multidisciplinary approach

  • Fully integrated with information available to all practioners

  • Cost-effective

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Why Integrate?(

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Challenges to Overcome for Successful Integration

  • Integration of mental health services requires a lot of careful planning and there are likely to be several issues and challenges that will need to be addressed.

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For example :

  • Training of Staff

  • Uncomfortable in dealing with mental disorders

  • Overall reluctance of primary health care workers

  • Availability of time

  • Adequate supervision of primary care staff

  • Human resource management issues-competencies

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Clinical Barriers to Integrated Care

  • Traditional separation of mental health issues from general medical issues

  • Lack of awareness of mental health screening tools in the primary care setting

  • Physician’s limited training in psychiatric disorders and their treatment

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Financial Barriers

  • Lack of insurance parity for psychiatric disorders

  • Medicaid’s low reimbursement rates

  • Billing restrictions

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The following challenges are examples that policymakers should consider:

  • Reimbursement for mental health services from Managed Behavioral Health Care Organizations

  • Reimbursement after an initial mental health screening or diagnosis

  • Limitations in reimbursement for non-physician providers, i.e case management

  • Limitations on billing for mental health services and an additional medical visit on same day

  • Coding and provider combinations that generate adequate reimbursements from Medicaid/Medicare

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Policy Barriers

  • Health and Mental Health funding streams

  • Difficulty in sharing information due to HIPPA regulations

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  • Shortage of mental health professionals

  • Limited communication between medical and mental health providers

  • Lack of agreement between medical and mental health provides

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AtlantiCare’s Journey

  • Established 330h center in 2003

  • Grant requires mental health and substance use services

  • Psychiatric APN through NHSC until May 2009

  • Introduced PhQ-9 to medical staff

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  • CIP grant dollars – satellite site

  • MHC – AIS program

  • Open July 2009

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Adult Intervention ServicesAtlantiCare Behavioral Health

A unique pilot program developed by Atlanticare Behavioral Health to address the needs of the residents of Atlantic County

One of two services of this type in the state. Atlanticare Behavioral Health developed the program at the request of the state.

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  • To provide comprehensive short-term interventions to individuals who are experiencing significant and distressing symptoms due to mental illnesses

  • To bridge the gap between the onset of acute symptoms and on-going treatment

  • To reduce the number of mental health clients inappropriately treated in the ER

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  • To provide accessible early and urgent intervention, support services,and ongoing recovery supportsto individuals, families, and consumers in acute distress

  • To maintain or enhancethe quality of lifeof the consumers and their families

  • To provide community based crisis intervention through the development of acommunity walk in center and the provision of early intervention outreach services

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  • Adults – 18 years of age or older

  • Experiencing acute psychiatric symptoms

  • Co-Occurring substance use disorders

  • All of whom are in a community setting and can be safelystabilized, and subsequently provided ongoingindividualized supports

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MHC-AIS Integrated Services

  • Monthly meetings established with Directors, medical and clinical staff and case management

  • Weekly case management meetings between AIS-MHC to review progress on mutual patients and develop action plans for high risk patients

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Case Study-Billy E 61 year old African American male

Medical History

  • Diabetes,COPD,Hypertension,GERD,

    Glaucoma, Hepatitis C, Obesity, Osteoarthritis, Asthma, Muscle weakness, Congestive heart failure

    Psychiatric History

  • Major Depressive Disorder, Anhedonia, past hx of alcohol abuse (5 yrs sober)

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Case study

  • Patient of MHC since 2007

  • Treated for medical and psychiatric issues

  • May 2009 , psychiatric APN resigned

  • APN referred Billy to behavioral health services

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Case study

  • Billy does not follow through with behavioral health referrals

  • Non-adherent to psychiatric medications and behavioral health services

  • No follow through with appointments and specialty referrals (pulmonologist, nephrology, ID clinic)

  • Decline in self esteem, feelings of hopelessness, lacks ability to function in social settings

  • Difficulty trusting people

  • Isolating

  • Feels he has no one in his corner advocating for him

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Case study

  • Encourage referral to AIS program

  • co-located with MHC

  • Intake and Psych evaluation on 3/10/2010

  • Chief complaint- “I stopped taking my meds, ran out of them, I can’t sleep, I worry a lot, I can’t handle my stress. I feel depressed”

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Case study

  • Billy accepted to the AIS program

  • Begins medication and treatment on 3/10/2010

  • Attends 5 groups per week, 1:1 counseling weekly, case management services and medication monitoring

  • Follows through with 90% of appointments

  • Adherent to psych medication

  • Successfully follows through with specialty appointments

  • Involved in social functions – CODI, fashion show, support groups, computer class

  • Increase in confidence and self esteem

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Case study

  • Remained with AIS for 2 months , discharged on 5/6/2010 and referred to ABH outpatient program

  • Highest PhQ-9 score was 18

  • Recent score 2

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