Disrupting the Status Quo: Dismantling Silos in Integrated Training

1. Session #H1a Friday, October 11, 2013 or Saturday, October 12, 2013 Disrupting the Status Quo:Dismantling Silos in Integrated Training Colleen Clemency Cordes, Ph.D. Assistant Director, Nicholas A Cummings Doctor of Behavioral Health Program Wendy Danto Ellis DHEd, MC, LPC DIRECTOR – Behavioral health, SCOTTSDALE HEALTHCARE FAMILY PRACTICE RESIDENCY Collaborative Family Healthcare Association 15th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives 1) Describe how current educational systems continue to promote the silos of medical and behavioral healthcare 2) Identify three strategies for transforming our healthcare programs 3) Describe a unique collaborative partnership between a behavioral health and medical residency training program and how this has led to increased provision of collaborative primary care and enhanced provider satisfaction

4. Learning Assessment Audience Question & Answer

5. “Including IPE enables the professions to learn with, from, and about each other. Then, and only then, may they develop critical appreciation of what each other contribute to collaborative practice in response to [the] increasingly compound and complex needs presented by individuals, families, and communities” (Barr, 2012, p. 2)

6. Evolution of Medical Paradigms WHOLE PERSON/ INTEGRATED BIOMEDICAL BIOPSYCHOSOCIAL

7. CULTURE OF COUNSELING/BEHVIOR CHANGE Blending Cultures CULTURE OF MEDICINE • Pathology based • Values certainty; dislikes ambiguity or change • Expert/ knowing stance • Goal is for doctor to diagnose and “fix” the problem • Functions with a system of assess, diagnose and treat • Evidence based • Outcome oriented • Training models are rooted in tradition and power differentials • Resource, resiliency and strength based • Values change, differences and possibilities • Embraces “not knowing’ stance • Goal is to connect with the “patient” and collaboratively define outcomes/objectives • Functions within a paradigm of conversation and collaboration • Values evidence based in addition to personal experiences • Multiple outcomes are acceptable/valued • Training models cross over disciplines and are evolving

8. EVEN THE IOM AGREES:Institute of Medicine’s Ten Rules to Redesign and Improve Care • Care based on healing relationships • Customization based on patient’s needs and values • The patient as the source of control • Shared knowledge and the free flow of information • Evidence-based decision making • Safety as a system property • The need for transparency • Anticipation of needs • Continuous decrease in waster • Cooperation among clinicians

9. TRANSFORMING OUR HEALTHCARE TRAINING AND EDUCATION PROGRAMS PUTTING IT INTO PRACTICE

10. HOW?We need to break down the silos at multiple levels • Educational institutions • Undergraduate, graduate and post-graduate levels (e.g. medical school, residency programs, psychology and counselor training etc) • Vocational training programs • Medical assistant or dental assistant training programs • Governmental and regulatory level • Licensing boards, reimbursement policies etc.

11. Interprofessional Education (IPE) • Any type of educational, training, teaching, or learning session in which two or more health and social care professions are learning interactively • Family medicine + psychology most common iteration in U.S. • But psychologists are only a small percentage of the BHC workforce

12. FQHCs Serving as Training Sites for Specialty Behavioral Health Staff, by Provider Type * From: Nachc 2010 assessment of behavioral health services in federally qualified health centers

13. IPE Outcomes • IPE has led to positive outcomes in: • Collaborative interactions • Working culture in emergency departments • Patient satisfaction • Decreases in medical errors • Management of care for IPV survivors • Knowledge and skills of professional providers • Most IPE occurs after licensure, but increasingly looking at benefits pre-licensure (Barr, 2012)

14. Implications for Training & Education FOR PHYSICANS and DENTISTS FOR MID-LEVEL PROVIDERS (PAs, NPs,PTs, OTs, RNs, etc.) FOR MENTAL HEALTH AND BEHAVIORAL HEALTH CLINICIANS FOR SUPPORT STAFF (MAs, Billing, Referral, front office support)

15. Goals for Workforce Development • Expand the role of consumers and their families to participate in, direct, or accept responsibility for their own care (provide tools for doing so) • Expand the role and capacity of communities to identify local needs and promote health and wellness (to meet local needs) • Implement systematic federal, state, and local recruitment and retention strategies • Increase the relevance, effectiveness, and accessibility of (Inter-professional) training and education • Actively foster leadership development among all segments of the workforce • Enhance available infrastructure to support and coordinate workforce development effort • Implement a national research and evaluation agenda on workforce development

16. Multiple layers…Our Partnership DBH INTERN

17. Practical issues to address… Process for referring BH patients from provider Scheduling of BH patients; follow-up Fees for BH services; billing Record keeping; shared EHR or not Psych medications outside the practice scope of providers Referrals to ancillary services; community resources (process & follow-up) BHC communication with other center staff (front office, billing, nursing, providers, care managers etc) BHCs at different sites are isolated from each other; how to maintain esprit du corps Coverage for vacations/training/etc. Language/translation services Each site has its own “cast of characters”; different personalities, different team members (e.g. dental)

18. Accreditation ChallengesACGME vs. FQHC • Program and Institutional Guideline for Using a Community Health Center as outpatient clinic site include: • Behavioral science education must be integrated into the residents’ experiences in the CHC • The appointment & assignment of faculty preceptors in the CHC must be under the control of the program director and in the presence of a qualified faculty … • The program director must have authority and responsibility for the educational program of the residents. • *Example of conflicting regulations, cultures and barriers to integration.

19. ASU’s Doctor of Behavioral Health ProgramInterdisciplinary Training in Action • Evidence-based interventions for mental health and chronic illness • Medical literacy for enhanced collaboration • Systems awareness and redesign • Entrepreneurship • Health behavior change • Mental health assessment & treatment • Group medical visits & psycho educational programs • Program evaluation • Physician consultation • And much more!!

20. DBH in action: Partnership with SHC • Heuser NOAH – Non-medical pain intervention project – An excellent example of a successful integration and overcoming barriers of two cultures. • Barriers overcome: different definitions of desired outcomes, VERY different attitudes toward chronic pain patients & change; office work flow challenges; provider awareness of and utilization of BHC • Gains received: Increased patient satisfaction, increased provider satisfaction; still pending – lower PCP utilization for non-medical issues; education of providers, resident physicians and staff on non-medical interventions for chronic pain; revision of pain policy and pain contract; less need for patient referral to pain specialists = enhanced patient centered care within PCMH

21. Best Advice for Successful Implemtnation: KISS • “DON’T ASK…DO TELL” (Scripted statements for doctors e.g. DIABETES – NEWLY DIAGNOSED OR POORLY CONTROLLED DIABETICS “I’m going to invite in another member of the NOAH health care team who has special skills in helping people to adjust to the new diagnosis of________.” ) • ONE EASY TO USE STEP… ALL BH REFERRALS MUST GO THROUGH BEHAVIORAL HEALTH DIRECTOR OR BEHAVIORAL HEALTH CONSUSLTANT (includes group visits, psych NP) ONE STOP SHOPPING… WE DO ALL THE REST AND REPORT BACK TO YOU

22. QUESTIONS ? COMMENTS?

23. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!