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transcript
Expanding Behavioral Health Integration:
Consultative Psychiatry and Immediate Access Behavioral
Health Consultants (BHCs)Speaker Names, Credentials, Full Title
Melissa Merrick, LCSW, CDC I, AdministratorBrian McCutcheon, Administrator
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session # B4bOctober 18th, 2014
Faculty Disclosure
Please include ONE of the following statements:
We have not had any relevant financial relationships during the past 12 months.
OR
Learning Objectives
At the conclusion of this session, the participant will be able to:
Understand the elements of SCF’s Behavioral Services Redesign
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 and/or in expanding access to behavioral health services
Bibliography / Reference
1. 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.
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
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:• 15 Primary Care ~ Anchorage• 5 Pediatrics ~ Anchorage• 5 Primary Care ~ Wasilla• 4 Behavioral Health Clinics (Adult & Child/Adolescent)
1st Attempt of Co-Located Psychiatry 2012
SCF Behavioral Health Integration
Three primary treatment tracks: • Scheduled individual therapy• Medication management• BURT (psychiatric crisis)
Anticipate growth in need for services creates a challenge in how to continue current model and accommodate expanded services
We have learned some things to consider for changes and expanding services
Pre-Redesign ~ Behavioral Health
SCF needs to continue aligning and integrating services (when possible) to serve population-based health needs
Feedback from Customer-owners is that they want quicker access to services and services specific to their needs
There may be additional service needs we are not meeting
in the current model
Consistent rapid growth in Anchorage/MatSu Region
Why the Changes? Future Needs
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
Cultural relevant & population based services
Considerations for BH Redesign
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
Behavioral Health Redesign Principles
New position created called Community Case Manager
Behavioral Health Consultants (BHC) working in outpatient behavioral health clinics to meet C-Os same day needs, aligning Medical & Behavioral Divisions
Enhanced range of treatment and support services through Learning Circles
Enhanced integration of psychiatric specialists into primary care
Core Redesign Elements
Behavioral Services Co-location with Medical ServicesPrimary 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
Enhanced Integration
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
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
Co-Located Psychiatry
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
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
ConsultantsAdding on additional responsibilities/tasksSupervision of BHCs
• EHR DocumentationWho documents consults/recommendations
• Financial Implications
Consultative Psychiatry Model
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 Address complex customers in the primary care setting Assess motivation for counseling/psychiatry and refer
as appropriate
Behavioral Health Consultants
Added Behavioral Health Consultants to outpatient behavioral health clinics
Refined referral process for specialty behavioral health services• Therapy services• Psychiatry services
Changes to Existing Model
Did not want to duplicate services-> Extension of BHC services
Sees all customer-owners walking in for services
Provides support to customer-owners when assigned clinician is out
Works to connect c-o to Primary Care Team or psychiatry as needed
Behavioral Health Consultants
Behavioral Services Redesign Concept Model
Customer-owner meets with Clinician
Customer-owner wants more?
Customer-owner ready for LC?
Clinician makes appointment or
referral or connect with appropriate service and
provider
Clinician gives Customer-owner Learning Circle
information to schedule
Done
Welcome Customer-owner
Specialized Treatment Individual Therapy
Medical Management
MD/ANP
Crisis or Urgent?
No
Yes
No
Yes
No
Yes
Education Learning Circles
Open Learning Circles
Closed Learning Circles
FWWI type events
Case Management (Intensive and
General)
Clinician connects Customer-owner directly to BURT
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
Behavioral Health Consultants
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
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
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
• Walk in vs. prescheduled appointments
Referrals to Specialty Behavioral Health
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:
PsychiatryBehavioral Health Services (brief intervention and/or specialty therapy
services)
Would this work in your organization?
Questions???
Thank You!
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