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Presented by: Diana Knaebe, Heritage Behavioral Health Center. Macon County Initiative Integrating Behavioral Health and Primary Care. Integration Partnership Background. Description/History of Partnerships Rationale for involvement Evolution of Partnerships and programs – services offered

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Presented by diana knaebe heritage behavioral health center

Presented by:

Diana Knaebe, Heritage Behavioral Health Center

Macon County Initiative Integrating BehavioralHealth and Primary Care

Integration partnership background
Integration Partnership Background

  • Description/History of Partnerships

  • Rationale for involvement

  • Evolution of Partnerships and programs – services offered

  • Next Steps

Heritage and CHIC Integrated Care Project

Heritage Behavioral

Health Center

Community Health Improvement Center

Integration partnership background1
Integration Partnership Background

Description/History of Partnership

Community Health Improvement Center and Heritage

  • Have had working relationship for the past fifteen years; initially, there were cooperative efforts with mutual referrals to assure that clients received needed primary care/mental health services.

  • Early on the entities worked cooperatively with a local pharmacy, and developed a system utilizing bubble cards containing daily prescribed dosages of medications for medical and psychiatric problems which could be taken by the client on a daily basis.

Integration partnership background2
Integration Partnership Background

  • In July 2006, the United Way funding allowed Heritage to provide an adult psychiatrist on-site at CHIC. This psychiatrist provided psychiatric care, support, and follow up to patients, and consultation to medical physicians 9 hours per month. The CHIC physicians were so pleased with the immediate psychiatric consultation available that the pediatric providers requested on-site psychiatric availability.

  • Consequently, in April 2007, a child and adolescent psychiatrist was added. He provides mental health services to the primary heath center 4 hours per month, direct care to patients, and consultation and education to the medical physicians.

Integration partnership background3
Integration Partnership Background

  • United Way funding allowed CHIC to provide a APN as well as a liaison on-site at a Homeless Day Center operated by Heritage. This allowed access to health care by individuals many of whom had not received health care in years.

  • Both organizations have attended the National Council’s Integrated Care Sessions for past 5 years.

  • Participated in National Council’s Integrated Collaborative Care Project in 2007

  • Participated in MHCA Integrated Healthcare Learning Community August 2009-November 2010

Reasons rationale for partnerships
Reasons/Rationale for Partnerships

Ultimately to Implement a patient centered medical home – true integration of care

  • Better Overall health outcomes.

  • Improved access and retention of clients

    • Joint referral process and records access

    • Clinical processes defined for collaboration and joint education for staff

    • Nurse practitioners and/or Physician Assistants at both CHIC and Heritage

    • Clients only seen at one site for all needs – as much as possible unless need specialty care

    • Maximizing revenue (current and new services)

    • Efficient/effective/efficacious care

    • Non-duplication of care and services

    • Education sharing component for staff and clients

Cultural issues differences
Cultural Issues/differences

Term-language Differences

How patients/clients are seen – length of time for visit and follow up

Funding Streams and Mechanisms often very different

Determination of “hand-offs” and/or referrals

Releases – Medical Records

The Four Quadrant Clinical Integration Model For the Adult Population/ Heritage & CHIC Adaptation

Integration partnership expansion
Integration Partnership - Expansion Population/ Heritage & CHIC Adaptation

The Administrative and Clinical Collaborative Committees continue to meet on the existing collaboration as well as expanding to additional behavioral health services on site at CHIC and with an intention of continuing to work towards the provision of primary health care in a behavioral health care setting. This project is the logical extension of efforts currently underway between Heritage and CHIC. Heritage and CHIC meet regularly to plan, coordinate, and implement our existing collaboration of integrating behavioral and primary health care. This collaboration is progressive and moving forward.

The MCMHB joined the Administrative Committee in late 2009 when we began a “pilot project” to add expertise, additional funds with Medicaid billing through them plus the matching local dollars.

Integration partnership background4
Integration Partnership Background Population/ Heritage & CHIC Adaptation

  • Integration: Partnering Agencies 2011

    • The Community Health Improvement Center (CHIC), a primary health care center – Federally Qualified Health Center,

    • Heritage Behavioral Health Center (Heritage), a community behavioral health center – Mental Health, Substance Abuse, Homeless and Housing Services

    • The Macon County Mental Health Board (MCMHB), a public taxing body that funds MH/SA/DD services

    • The Macon County Health Department, public health department (MCHD)

Integration partnership expansion two
Integration Partnership – Expansion Two Population/ Heritage & CHIC Adaptation

Macon County Health Department

MCHD entered into partnership with IDPA ABCD II (Assuring Better Child Health and Development Initiative) project in 2005. State level partners included:

Illinois Chapter, American Academy of Pediatrics ( ICAAP) and Illinois Academy of Family Physicians

Ounce of Prevention Fund (OPF)

Illinois Department of Human Services (IDHS) Office of Family Health (OFH)

IDHS Office of Mental Health (OMH)

Illinois Department of Children and Family Services

Illinois Primary Health Care Association (IPHCA

Local partners included:

AOK Network


WIC/FCM Coordinator

Pediatric/Family Practices:

Early Intervention/CFC:

Heritage Behavioral


Edinburgh postnatal depression scale epds
Edinburgh Postnatal Depression Scale (EPDS) Population/ Heritage & CHIC Adaptation

  • Possible Depression is indicated at score of 10 or above. Referral provided for all scores of 10 or higher


  • Edinburgh’s Completed :

    • May 05 – September 05 = 434

    • Scores of 10 or higher = 100

    • Result=25% rate of at risk women in need of referral !

    • Current screening rates maintain average of 100 screens completed /month with 10-20% rate of need for referral

Hopes screams from mchd
Hopes & Screams from MCHD Population/ Heritage & CHIC Adaptation

MCMHB Board Director enlisted local mental health providers to provide counseling services for clients with positive screening scores

Referral rates outnumbered available resources

MCMHB providers had long waiting times for client entry

Some MCMHB providers were charging clients for services against project agreement

Some providers requested clients not be referred if in prenatal state

Some OB providers declined to accept screening results

MCHD staff expressed frustrations and concerns related to referral inconsistencies

Mchd request to mcmhb fall 2010
MCHD Request to MCMHB Fall 2010 Population/ Heritage & CHIC Adaptation

  • Invited MCMHB Director to Maternal Child Health staff meeting to address staff concerns related to the counseling referral system

  • Staff relayed numbers of underserved clients

  • Gave examples of referral difficulties with MCMHB paid agencies

  • Requested on site services and to include home visits for clients with barriers such as daycare, transportation, work/school schedules

    • Goal= to achieve through partnership timely and adequate service delivery and follow up for at risk women and families

Mcmhb reasons for involvement
MCMHB Reasons for Involvement Population/ Heritage & CHIC Adaptation

  • New Medicaid by billing through the MCMHB – directly to DHFS

  • Local Funds Initiative - matching Medicaid with County dollars means more money for the community

  • Quicker access to behavioral health services

  • Captive Audience at CHIC – linkage & need from MCHD

  • Eligibility – changes in eligibility over the years in mostly only target population defined by DHS-OMH – this allows an Expansion of eligibility wider range of individuals than current and potential

    • Still meeting medically necessity

  • More holistic care - hopefully better clinical outcomes/people improving/getting better

Integration partnership expansion two continued
Integration Partnership – Expansion Two Continued Population/ Heritage & CHIC Adaptation

Administrative Team established and meeting to work through challenges, barriers, referral processes, medical record – computer

Members from MCHD, MCMHB, Heritage

Clinical Teams also providing feedback through their supervisors – funnels up to Administrative Team and back to clinical teams/supervisors to smooth the processes

Mchd happy days are here
MCHD, “ Population/ Heritage & CHIC AdaptationHappy Days Are Here!”

January 2011-Part time MCMHB funded Heritage Counselor begins accepting onsite referrals at MCHD and completing home visits.

40 referrals received in the first month! Whew!

Initially ,frustration expressed regarding delayed contact time vs referral numbers …However …

Counselor provides assistance with multiple scenarios

Clients and staff express 100% satisfaction with follow up services

Next steps mchd
Next Steps MCHD Population/ Heritage & CHIC Adaptation

Expansion into Seniors

Plan to use Geriatric Depression Screen

One full-time mental health staff beginning July 2011 might expand to another part-time assigned to the MCHD clients/patients

Specific changes implemented in the last year
Specific Changes Implemented in the Last Year Population/ Heritage & CHIC Adaptation

Lost the psychiatrist that worked so well for both organizations as a result have added Psychiatric Nurse Practitioner to FQHC

Added Mental Health Therapist to the FQHC site with MCMHC Board Funding

Screening to determine who can be better served at the FQHC as primary – Medical Home

Have received SAMHSA Integrated Primary Care Grant which will allow us to emphasize wellness with SPMI population added Physical PA on site at the Mental Health Center.

MCHD has become 2nd site funded by MCMHB for therapists to see identified by MCHD staff in need of services – primarily an outreach, in-home model though which is different than that at CHIC

Lessons learned things to consider when establishing collaborations for integration of care
Lessons Learned – things to Consider when establishing Collaborations for Integration of Care

Can take much more time to work through because our systems are often actually complicated

Are the right people at the table for discussions?

Licensure of Sites – Scope of Practice Changes

Written Agreements

Joint Contracts for purchasing of staff or services

Who is billing for what?

Samhsa program goals
SAMHSA Program Goals Collaborations for Integration of Care

  • Heritage Behavioral Health Center received a SAMHSA Grant in September 2010 for its Primary and Behavioral Health Care Integration (PBHCI) program.

  • Our project focuses on:

    • individuals with Serious Mental Illness who are on antipsychotic medications and….

    • have co-occurring metabolic syndrome or a chronic medical condition

    • Establishment of a primary care clinic at Heritage Behavioral Health Center

    • Provision of wellness activities/programs

    • Working with 500 SMI adults by the end of the 4th year

Samhsa program goals1
SAMHSA Program Goals Collaborations for Integration of Care

Health and Illness Background Information

  • Used both as a screening and as a means of documenting diagnoses (PH and BH) as well as important medical/health history variables SF-36 (short form)

  • Person Centered Healthcare Home Fidelity Scales and Protocols

    • Developed by our evaluator, TriWest

    • Based on the conceptual work of Barbara Mauer and collaborators

    • 2-day collaborative assessment process

  • Accomplishments
    Accomplishments Collaborations for Integration of Care

    In 5 months, established a Health & Wellness Suite, including a Primary Care Office at Heritage

    Contracted with CHIC Primary Care Clinic to place a Primary Care Physician/Assistant on site

    Developed a Clinical Registry

    Admitted 57 clients to Health and Wellness Program since Mid March 2011

    Accomplishments Collaborations for Integration of Care

    • Received 87 referrals to the program since program began in February 2011

      Success Stories:

      • In one month, one client lost 20#, another lost 11#, a third lost 14#. No one enrolled in the program has gained weight.

      • Two partially immobile clients are now mobile and continuing to improve

    Health and wellness activities
    Health and Wellness Activities Collaborations for Integration of Care

    • Food Pyramid Education weekly

    • Healthy Cooking Classes weekly

    • Chair Zumba twice per week

    • Modified Yoga weekly

    • Daily Walking Activity

    • Healthy Food Shopping As Needed

    • 1:1 Food Counseling and Review of Food Tracker as needed

    • Weekly Off Site Exercise

    Plans for the future
    Plans for The Future Collaborations for Integration of Care

    • Expand hours and responsibilities of P/A to provide all primary care for individuals in the program

    • Provide fully certified smoking cessation classes to clients

    • Staff will become certified in smoking cessation, diabetes education, yoga, and zumba

    • Provide physical illness management education to case managers

    • Add Peer Support/Mentors to program

    • Wellness Model throughout organization

    Key contact person s and contact information
    Key Contact Person(s) and Contact Information: Collaborations for Integration of Care