Post on 30-Dec-2015
transcript
How to Crash the Party: Bringing Behavioral Health Specialists to
the Care Coordination Team
Mary Jean Mork, LCSW
Director of Integration
MaineHealth and Maine Behavioral Helathcare
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session B5aOctober 18, 2014
Faculty Disclosure
I have not had any relevant financial relationships during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to: Identify barriers and success factors for care coordination. Identify a “success factor” to immediately address. Create a plan for addressing this factor upon return to work.
Learning Assessment
A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
Agenda
Description of Care Coordination (CC) Team Challenges for Behavioral Health Specialists (BHS) Role and value of BHS on the team Success factors and strategies for maximizing team
effectiveness Activity – Developing Action Plans Question and answer period
Patient Centered Medical Home (PCMH) – the Concept
From deGruy 10.10
(Behavioral Health)
Internet Citation: Figure 1. Family tree of terms in use in the field of collaborative care: A National Agenda for Research in Collaborative Care. June 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/collaborativecare/collab3fig1.html
Care Coordination
The deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the
appropriate delivery of health care services.
From: Safety Net Medical Home Initiative. Care Coordination: Reducing Care Fragmentation in Primary Care. Implementation Guide. May 2013
“If a person doesn’t have a roof over their head, if they don’t have a meal, if they’re a victim of physical or sexual abuse if
their household has a lot of stress in it, if their kids’ school is not safe, then that's going to impact their health…..that health is
more than just the pill that we’re giving you or the hospital that we put you in. It’s all the other parts of your life and whether
they’re working in harmony.”
Dr. Jeffrey Brenner in interview “What Primary Care has to Learn from Behavioral Health”. National Council for Behavioral Health.
Meet George
Barriers to Care Coordination:
RolesRules
ArrangementsTurf
Who is involved?
Care Managers Case Managers Behavioral Health Clinicians Care Coordinators Transition coaches Peer navigators Health coaches RN’s in the practice Primary care providers Primary care staff Family and community supports Other?
Mental Health Primary Care
Treatment Team•Case Manager
•Team Leader – LCSW•Peer/Youth Support
•Psychiatry•Medical Director
Care Team•Provider
•Nurse•Medical Assistant
•Integrated BH Clinician•Nurse Care Manager
•Health coach/navigator
Preventative and Acute Care
Chronic Care
High Utilization
Chronic Care with MH Dx
Substance Abuse
High Utilization with MH Dx
“We're all going to have to give up some turf. After all, it's actually the
patient's turf.”
Robert McArtor, MD, CMO MaineHealth
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Specialty Mental Health Care
Coordinated Care Team (Potential Team Members)
Care ManagerBehavioral Health Clinician
Care CoordinatorEngagement Specialist
Health GuideResource SpecialistTransitions Coach
Peer NavigatorBHHO Case Manager
CCT social worker
Complex Care
Mgmt
Primary CareSpecialty Medical Care
Hospital
Patients
Psychiatric Consultation
Other Complex Patients
Care Plan Team
Care Coordination System Management
Patient PopulationCrisis and ED High Utilizers
PCP and Clinical Care
Team
Powered by
Care Coordination and Behavioral Health Saturday, September 20, 2014
Q1: Describe your involvement on the care coordination team
Q2: I If you have tried to have more involvement in care coordination activities, what barriers have you experienced?
Q3: If you are presently involved in care coordination activities in your practice, what has been most successful in helping be part
of these activities?
What else did I hear?
“It was horrifying. We don’t have anything in our practice.”
“We can’t coordinate unless there’s a mistake in scheduling, because she (the care manger) uses the office when I’m not there.”
“Who is my team?” “I didn’t fill it out because it doesn’t pertain to me.”
Complex Care Teams(Social, behavioral and medical complexities)
Behavioral HealthNeeds
Complex
Coordination Needs
Medication Access
Community
Resource
Needs
Providing:
•A multidisciplinary approach to complex
care coordination;
•Team collaboration;
•Community resource partnerships, and
•Standardized best practice interventions
BHS’s value on CC team
Direct service to Patient Link to specialty MH and SA treatment Liaison to psychiatric services “Triage” role with psychiatry referrals. Consultation to CC team System perspective
Behavioral lens for medical system Medical system lens for behavioral health
Expertise with individualized care plans tailored to patient Patient and family centered focus
Common Challenges for BHS
Population health Using data to inform work Understanding nuances of different care
management roles Clarifying roles around behavioral change,e.g.
with health coaches Ability to access specialty MH, SA and psych
services
CC Success Factors
Clarity, connection and non-duplication of: Roles Functions Responsibilities
Clarity about population being coordinated Timely and accurate data Tracked and shared outcomes “Partnership” approach to care Individualized patient centered planning process for care plans Shared Care plans and “alerts” throughout system Standardized coordination of care
“Team” members have assigned tasks based on individual care plan “Team” lead to manage complex care situations
Strategies to Improve CC
Identify who is coordinating care Identify leaders Multidisciplinary case presentations Target specific patients, design services around individual’s
goals, coordinate care, track results Identify impact measures, e.g. ED usage for specific
populations Make connections with community providers and continuum
of care
Additional considerations for CC
Funding – are there: New funding streams that support this work? Cost savings and medical cost offsets?
Honor the patient voice in development of the care plans
Value and nurture the team relationships!
Resources
Websites http://integrationacademy.ahrq.gov/ - AHRQ Academy for Integrating Behavioral Health and
Primary Care www.uwaims.org - Advancing Integrated Mental Health Solutions – resources for implementation
from University of Washington www.integratedprimarycare.com – National clearinghouse site for information on integrated care
from University of Massachusetts. www.integration.samhsa.gov - SAMHSA-HRSA Center for Integrated Health Solutions www.thenationalcouncil.org – the National Council for Community Behavioral Healthcare.
Publications IHI Innovation Series 2011. Craig, et.al. Care Coordination Model: Better Care at Lower Cost
for People with Multiple Health and Social Needs. http://www.improvingchroniccare.org/downloads/reducing_care_fragmentation.pdf Reducing Care Fragmentation: A Toolkit for Coordinating Care
Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!