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:

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 a co-located and consultative psychiatry model, and in expanding BHC role beyond a medical clinic setting.

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:• 14 Primary Care ~ Anchorage• 5 Pediatrics ~ Anchorage• 4 Primary Care ~ Wasilla• 4 Behavioral Health Clinics (Adult & Child/Adolescent)

1st Attempt of Co-Located Psychiatry 2012

Integration at SCF

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

Behavioral Health 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 BSD-PCC clinic to meet C-Os same day needs, aligning MSD and BSD

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 Psychiatristsshared pool/population of customer-owners cared for in cooperation w/ PCP’sincreased 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 Assess motivation for counseling/psychiatry and

refer as approprite

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 who 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

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:

PsychiatryTherapy Services

Would this work in your organization?

Questions???

Thank You!

Qaĝaasakung

Aleut

QuyanaqInupiaq

Háw'aa Haida

‘Awa'ahdah

EyakMahsi'Gwich’in

Athabascan

Igamsiqanaghhalek

Siberian Yupik

Tsin'aenAhtna Athabascan

T’oyaxsmTsimshian

Gunalchéesh Tlingit

QuyanaYup’ik

Chin’anDena’ina Athabascan

QuyanaaAlutiiq