Speaker Names, Credentials, Full Title Melissa Merrick, LCSW, CDC I, Administrator

1. Expanding Behavioral Health Integration: Consultative Psychiatry and Immediate Access Behavioral Health Consultants (BHCs) Session # B4b October 18th, 2014 Speaker Names, Credentials, Full Title Melissa Merrick, LCSW, CDC I, Administrator Brian McCutcheon, Administrator Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure Please include ONE of the following statements: • We have not had any relevant financial relationships during the past 12 months. OR

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Review differences of and value between co-located and consultative psychiatry models. • Define the role of a BHC working in a medical clinic and behavioral health clinic • Leave the session with a list of next steps to consider in implementing a co-located and consultative psychiatry model, and in expanding BHC role beyond a medical clinic setting.

4. Bibliography / Reference • Izard, T. (2005) Managing The Habitual No-Show Patient, Family Practice Management. 12(2), 65-66 • 2. Lacy, N.L., Paulman, A., Reuter, M., & Lovejoy, B. (2004). Why We Don’t Come: Patient Perceptions on No-Shows, Annals of Family Medicine, V. 2(6), 541-545. • 3. Patteson, T.J., Brenna, M., Schobitz, R. (2013). Concurrent and Co-Located Early Intervention for Concussion and Acute Stress Reaction, Psychiatric Annals, V.43 (7), 313-317 • Concurrent and Co-Located Early Intervention for Concussion and Acute Stress Reaction • 4. Roy-Byrne, P., et al. (2009). Brief Intervention for Anxiety in Primary Care Patients, Journal of American Board of Family Medicine, 22(2) 175-186, • 5. Sederer, L.I., Ellison, J, & Keyes, C. (1998). Guidelines for Prescribing Psychiatrists in Consultative Collaborative, and Supervisory Relationships, Psychiatric Services.

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Integration at SCF • Introduced Behavioral Health Consultants (BHCs) in 2004 • Need for Behavioral Health & Access to services • First Attempt Failed; learned from each integration experience • Work as part of the Integrated Care Team (PCP, RN CM, CMA, BHC, RD, RPh) • BHCs within SCF System: • 14 Primary Care ~ Anchorage • 5 Pediatrics ~ Anchorage • 4 Primary Care ~ Wasilla • 4 Behavioral Health Clinics (Adult & Child/Adolescent) • 1st Attempt of Co-Located Psychiatry 2012

7. Behavioral Health Redesign • Continuous evaluation and QI related to behavioral health services • Partnership with the Triple Aim ~ guided thinking • Considered interagency services and sought to not duplicate services

8. Behavioral Health Redesign Principles • Same day Behavioral Health access to all customer-owners regardless of point of entry into the system • Reduce burden on customer-owners when accessing services • Clinical staff working at the top of their license; primary care vs. specialty care • Group learning circles primary service line for behavioral health care

9. Core Redesign Elements • New position created called Community Case Manager • Behavioral Health Consultants (BHC) working in BSD-PCC clinic to meet C-Os same day needs, aligning MSD and BSD • Enhanced range of treatment and support services through Learning Circles • Enhanced integration of psychiatric specialists into primary care

10. Enhanced Integration Behavioral Services Co-location with Medical Services Primary Care • more consultations between Behavioral Health Consultants (BHC) and Primary Care Providers (PCP) to Psychiatrists • shared pool/population of customer-owners cared for in cooperation w/ PCP’s • increased access/capacity with reduced wait time

11. Co-Located Psychiatry • Office in or nearby primary care setting ~ could include pediatric setting • Designated time built into daily schedule for consultation • Consults generally result in medication recommendations or referral recommendation

12. Co-Located Psychiatry • What worked for us: • Providers used consult time • Most consults routed through BHCs • What we struggled with: • Providers had difficult with limited consult time • Visibility in primary care clinic was difficult with full caseload • Referrals for medication stayed the same for those PCPs/BHCs who were not sitting directly next to psychiatry

13. Consultative Psychiatry Model • Stepped Approach to Care • (1) Routine psychiatry medication handled by PCP • (2) Complex antidepressants/anxiety meds consult with psychiatry • (3) Complex medication needs – psychiatry takes over care. Stabilizes with goal of returning care to PCP with ongoing support • (4) Medication needs that require on-going psychiatry will be managed by psychiatry • BHC or PCP can consult, but BHC always involved

14. Consultative Psychiatry Model • Challenges with this model: • Reducing psychiatry caseload to support this model • Ratio of Primary Care Teams to psychiatry staff • Implementing this model secondary to Behavioral Health Consultants • Adding on additional responsibilities/tasks • Supervision of BHCs • EHR Documentation • Who documents consults/recommendations • Financial Implications

15. Behavioral Health Consultants • Routinely considered part of the primary care team • Provide consultation to primary care teams on routine mental and behavioral health care • Utilize screening instruments in conjunction with primary care visits • Provide brief intervention on behavioral and mental health needs • Assess motivation for counseling/psychiatry and refer as approprite

16. Changes to Existing Model • Added Behavioral Health Consultants to outpatient behavioral health clinics • Refined referral process for specialty behavioral health services • Therapy services • Psychiatry services

17. Behavioral Health Consultants • Did not want to duplicate services-> Extension of BHC services • Sees all customer-owners walking in for services • Provides support to customer-owners who assigned clinician is out • Works to connect c-o to Primary Care Team or psychiatry as needed

18. Behavioral Services Redesign Concept Model

19. Behavioral Health Consultants Medical Clinics Behavioral Health Clinics • Brief Intervention on a range of behavioral issues • Part of the Primary Care Team • Access to full medical record • Chart in medical record • Brief Intervention on a range of behavioral issues • An extension of the Primary Care Team • Access to full medical record • Chart in medical and behavioral health record

20. Referrals to Specialty Behavioral Health • All referrals go through BHCs • Strong emphasis on c-o motivation and ability to engage in specialty services • Assessment of needs and where c-o’s need would best be served • Cases for referral are staffed weekly with specialty clinic to ensure best fit • Psychiatry cases are staffed via Stepped Approach

21. Referrals to Specialty Behavioral Health • Advantages of this model: • Customer-owners do not sit on a “waiting list” • Decreased no show rate • Increased & timely access • Streamlines care and decreased duplication in a large system • Provides built in follow up care when moving out of specialty care

22. Referrals to Specialty Behavioral Health • Challenges of this model: • Too many cooks in the kitchen • Clinicians feel their clinical decision making is questioned • Less autonomy in referrals to specialty care • Primary Care Clinic BHCs holding onto customers longer decrease their access for curbside consultations

23. Would this work in your organization? • Take 5 Minutes and work with a partner to discuss: • Is there room for co-located or consultative psychiatry? • What does access to specialty behavioral health look like in your organization? • What would be your next steps to increase access to: • Psychiatry • Therapy Services

24. Questions???

25. ThankYou! Qaĝaasakung Aleut Quyanaq Inupiaq ‘Awa'ahdah Eyak Mahsi' Gwich’in Athabascan Igamsiqanaghhalek Siberian Yupik Háw'aa Haida T’oyaxsm Tsimshian GunalchéeshTlingit Quyana Yup’ik Chin’an Dena’ina Athabascan Tsin'aen Ahtna Athabascan Quyanaa Alutiiq