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Integrating Primary Care and Behavioral Health: Lessons From a Ground View to 1,000 Feet Integrating Behavioral Health Project September 11, 2008. Larry Mauksch, M.Ed Department of Family Medicine University of Washington. Principles for success in practice change.

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larry mauksch m ed department of family medicine university of washington

Integrating Primary Care and Behavioral Health: Lessons From a Ground View to 1,000 FeetIntegrating Behavioral Health Project September 11, 2008

Larry Mauksch, M.Ed

Department of Family Medicine

University of Washington

principles for success in practice change
Principles for success in practice change
  • Build relationships through experiential team training on clinical and operational topics
  • Have regular huddles and meetings
  • Create team ownership of change, challenges, and successes
  • Find out what is important to patients in life, in problem focus, in treatment, and in relationships
principles for success in practice change1
Principles for success in practice change
  • Figure out what to change first, don’t change everything at once, be patient but persistent
  • Do not let staff turnover cause system decay
  • Track Progress: patient, team, system, cost
  • Create back-up systems to optimize clinical success:
    • multidisciplinary transdisciplinary
principles for success in practice change2
Principles for success in practice change
  • Conserve resources and intensify care for patients with greater complexity (stepped care)
  • CELEBRATE SUCCESS!!!
slide5

Person

Family

Obesity

Depression

Substance abuse

Diabetes

slide6

Patient

Primary

Care Provider

Care

Management

Beh Health

Consult or Tx

Self

Management

Group

Psychiatric

Consult or Tx

Biopsychosocial patient centered care

slide7

Shared Space

Financial

Incentive

To Work

Together

Patient

Primary

Care Provider

Organizational Features Promoting Integration

Integrated Information

System:

Electronic Medical Record

Provider communication

Patient tracking for f/u

Hallway

Updates and

consults

3-way meetings

Case

Management

Leadership

Shared Mission / Vision

Team Training

Ongoing Training

Beh Health

Consult or Tx

Self

Management

Group

Psychiatric

Consult or Tx

marillac clinic background
Marillac Clinic Background
  • Primary care clinic:
    • medical, dental, mental health, optical
  • Only serves people:
    • at or below 200% Fed poverty guidelines
    • uninsured (no Medicaid or Medicare)
  • Grand Junction, Colorado
    • 2004 population of Mesa Country = 127,000
  • Private, non profit, not an FQHC
  • In 2004: 9700 visits from 3100 patients
collaborative care phases of integration at marillac
Collaborative Care: Phases of Integration at Marillac
  • Preliminary work (1994-1996)- Therapist leaves at 6 mo
  • Phase 1 (1997-1998) Building a conceptual and physical commitment in the clinic and community
  • Phase 2 (summer, 1998 - summer, 1999) Intensive training
  • Phase 3 (spring 1999 – spring 2002) Building the Marillac system and design of interagency model
  • Phase 4 (2002-2006) Quality improvement within Marillac and across agencies
  • Phase 5 (2006…) Decay, retraining and transformation towards a medical home
principles of change
Principles of change
  • Lasting collaboration requires an educational and training process that builds relationships between disciplines
    • A new culture
  • Meaningful and sustainable changes in service require change in system design
    • Chronic care model: Information systems, provider training, promotion of self management, expert consultation and decision support, community involvement
essential ingredient organizational structural
Essential Ingredient:Organizational / Structural
  • Strong board and executive director support
  • Providers co-located for better communication
  • Combined medical record (paper going to EHR) with full access to MH and PC providers
  • Inter-agency collaboration
    • Funding
    • Shared training
    • Inter-agency communication and referral systems
essential ingredients clinical
Essential Ingredients: Clinical
  • Staff and interdisciplinary team training
    • Clinicians and staff
    • Clinicians and staff from community agencies
  • Patient tracking and follow-up
  • Assessment of population needs and quality of care
clinical training
Clinical training
  • Didactic topics (evidenced based)
    • Patient and family centered communication skills
    • Primary care counseling skills
    • Collaborative care communication skills
  • Experiential approaches
    • Shadowing
    • Regular interdisciplinary case conferences
collaborative tips behavioral health provider
Adherence

Monitor dose

Monitor side effects

Monitor beliefs

Assess symptoms

Consult with MD/PA/NP

Medication

Successes

Obstacles

Share therapeutic info

Family, cultural issues

Strategies

Monitor overall health quality of life

Note physical symptoms

Health maintenance

Chronic illness mgmt

Chronic illness beliefs

Collaborative Tips: Behavioral Health Provider
collaborative tips medical nursing provider
Share concerns about adherence with MHP

Share psychosocial information about patient and family

Encourage participation in psychotherapy

Assess patient beliefs about psychotherapy

Ask what psychotherapeutic goals you can support

Communication skills

Cognitive changes

Behavioral changes

Emotional awareness

Share concerns about other health care issues

Collaborative Tips: Medical/Nursing Provider
collaborative tips care manager
Monitor the gaps-- “interstitial thinking”

Track patients using systems “owned” by the team.

Adapt communication to varying styles of behavioral health and primary care providers

Track

Side effects

Adherence

Outcomes

Facilitate

Referrals

Needed visits

Defining shared goals

Community connections

Collaborative Tips: Care Manager
a proxy for integration hallway consults
A Proxy for Integration:Hallway consults

Averages in 2003 and 2004

  • 1034 consults between primary care providers and case managers or mental health therapists
  • 405 three way meetings between patients, behavioral health providers and primary care providers
quality of care improvement
Quality of Care Improvement
  • Chart review comparison
    • All charted mental illnesses
  • 500 consecutive patients in 1999
  • 500 consecutive patients in 2004
slide30

Number of Mental Health Contacts with

Health Professionals in1999 and 2004

essential ingredients financial
Essential Ingredients: Financial
  • Commitment of core organizational resources
  • Multi-organizational support
  • Development of new financial resources
    • Public and private grants
    • State health programs
    • New insurance relationships
    • State policy changes
donated fte and funding in lieu of decreased uncompensated care
Donated FTE and Funding in Lieu of Decreased Uncompensated Care
  • From Local hospitals
  • Local mental health centers
research team
Research Team

Larry Mauksch, M.Ed*

Stephen Hurd, Ph.D#

Randall Reitz, Ph.D#

Susie Tucker, Ed.D#

Wayne Katon, MD†

Joan Russo, Ph.D†

* University of Washington Department of Family Medicine

# Marillac Clinic, Grand Junction, Colorado

† University of Washington Department of Psychiatry

and Behavioral Science

marillac papers
Marillac Papers
  • Mauksch, L. B., Tucker, S. M., Katon, W. J., Russo, J., Cameron, J., Walker, E., & Spitzer, R. Mental illness, functional impairment, and patient preferences for collaborative care in an uninsured, primary care population. J Fam Pract 2001, 50(1), 41-47.
  • Cameron, J. and Mauksch, L. Collaborative Family Health Care in an Uninsured Primary Care Population: Stages of integration. Families, Systems and Health, 2002, 20(4) 343-363.
  • Mauksch, LB. Katon, W., Russo, J., Tucker, S., Walker, E Cameron, J. The content of a low income, uninsured primary care population: Including the patient perspective. Journal of the American Board of Family Practice, 2003, 16,:278-289.
  • Mauksch, L., Reitz, R., Tucker, S., Hurd, S., Russo, J., Katon,W. Improving Quality of Care for Mental Illness in an Uninsured, Low Income Primary Care Population, General Hospital Psychiatry, 2007, 29, 302-309
remember
Remember
  • Build relationships through experiential team training on clinical and operational topics
  • Have regular huddles and meetings
  • Create team ownership of change, challenges, and successes
  • Find out what is important to patients in life, in problem focus, in treatment, and in relationships
more to remember
More to Remember
  • Figure out what to change first, don’t change everything at once, be patient but persistent
  • Do not let staff turnover cause system decay
  • Track Progress: patient, team, system, cost
  • Create back-up systems to optimize clinical success:
    • multidisciplinary transdisciplinary
still more to remember
Still more to remember
  • Conserve resources and intensify care for patients with greater complexity (stepped care)
  • CELEBRATE SUCCESS!!!