Building Better Care: Behavioral Health Integration

State: OR Type: Model Practice Year: 2008

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The primary goal of this project is the full integration of behavioral health services into the county’s primary care delivery system. The objectives are as follows: By 8/31/08, increase access to behavioral health services in selected primary care clinics by increasing the number of same-day appointments by 50 percent. By 8/31/08, increase the overall number of “warm hand-offs” (introduction of the behavioral health provider by the primary care provider in the exam room) in selected primary care clinics by one to two appointments per day. By 8/31/08, increase the number of times a behavioral health provider has contact with a primary care patient (“touches”) on selected primary care panels (group of patients assigned to a single primary care provider) to 50 percent.

The goal of this project and the public health issue the project addresses are both behavioral health integration in primary care settings. The objectives of the project are linked to the goal in that (1) access to behavioral health services is required in order to achieve behavioral health integration; (2) the “warm hand off” links the patient directly to the behavioral health provider via the primary care provider; and (3) the number of “touches” that occur in any given panel of patients is a direct measure of the level of contact between the patient and the behavioral health provider in that panel.

The project intends to accomplish full integration of behavioral health services in primary care clinics in order to improve health outcomes in the population. Two other objectives that do not yet have available data are as follows: 1) By 12/31/08, use the PHQ 2 depression screening tool on 85 percent of new adult patients and 85 percent of existing adults patients accessing services in primary care 2) By 12/31/08, achieve a 50 percent reduction in PHQ 9 scores in 50 percent of adult patients with a depression diagnosis.

Collecting data on these measures will allow the project to assess the impact that behavioral health integration is having on mental health outcomes in our population. Increases in the percentage of patients screened, diagnosed, and treated for a mental illness will have a positive impact on the ability to manage chronic disease in the population.

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Multnomah County Health Department
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Building Better Care: Behavioral Health Integration
The primary goal of this project is the full integration of behavioral health services into the county’s primary care delivery system. The objectives are as follows: By 8/31/08, increase access to behavioral health services in selected primary care clinics by increasing the number of same-day appointments by 50 percent. By 8/31/08, increase the overall number of “warm hand-offs” (introduction of the behavioral health provider by the primary care provider in the exam room) in selected primary care clinics by one to two appointments per day. By 8/31/08, increase the number of times a behavioral health provider has contact with a primary care patient (“touches”) on selected primary care panels (group of patients assigned to a single primary care provider) to 50 percent. The goal of this project and the public health issue the project addresses are both behavioral health integration in primary care settings. The objectives of the project are linked to the goal in that (1) access to behavioral health services is required in order to achieve behavioral health integration; (2) the “warm hand off” links the patient directly to the behavioral health provider via the primary care provider; and (3) the number of “touches” that occur in any given panel of patients is a direct measure of the level of contact between the patient and the behavioral health provider in that panel. The project intends to accomplish full integration of behavioral health services in primary care clinics in order to improve health outcomes in the population. Two other objectives that do not yet have available data are as follows: 1) By 12/31/08, use the PHQ 2 depression screening tool on 85 percent of new adult patients and 85 percent of existing adults patients accessing services in primary care 2) By 12/31/08, achieve a 50 percent reduction in PHQ 9 scores in 50 percent of adult patients with a depression diagnosis. Collecting data on these measures will allow the project to assess the impact that behavioral health integration is having on mental health outcomes in our population. Increases in the percentage of patients screened, diagnosed, and treated for a mental illness will have a positive impact on the ability to manage chronic disease in the population.
Multnomah County has been designated as a Health Professional Shortage Area for mental health professionals by the Health Resources and Services Administration. Several census tracts have also been designated as medically underserved areas by the Bureau of Health Professions. State funding cuts have dramatically reduced the funding for the amount and types of services for the county’s uninsured populations and forced Medicaid-funded agencies to focus only on seriously mentally ill patients with crisis needs. This lack of available services, combined with an ever expanding group of Medicaid and uninsured patients, have made the services offered by the County vital to the populations served by the County. The public health issue addressed by this practice is behavioral integration in primary care settings. The relevancy of this issue to the population was determined in part through the participation by Dr. Susan Marie, the Director of Mid-Level Practice for the health department, on the Multnomah County’s Mental Health and Substance Abuse Advisory Committee and the Governor’s Mental Health Task Force. Both bodies identified behavioral health integration as a public health priority. Also, the need for behavioral health services dramatically increased when the services offered by the health department became the only resource for the county’s low-income and uninsured populations after a state funding cut in 2005 eliminated all behavioral health services except crisis intervention and inpatient hospitalization. The goal of this project and the public health issue the project addresses are behavioral health integration in primary care settings. The objectives are linked to the goal in that (1) access to behavioral health services is required in order to achieve behavioral health integration; (2) the “warm hand off” links the patient directly to the behavioral health provider via the primary care provider; and (3) the number of “touches” that occur in any given panel of patients is a direct measure of the level of contact between the patient and the behavioral health provider in that panel. The project intends to accomplish full integration of behavioral health services in our primary care clinics in order to improve health outcomes in the population we serve. There is evidence that behavioral health integration improves chronic disease and health outcomes. A study of the effect of a team-based primary care model that included a psychiatrist and a depression care manager found that the model not only reduced depressive symptoms but also resulted in outcomes such as decreased pain in patients with osteoarthritis, improved physical functioning in diabetic patients, and improvement in overall quality of life. The project also found evidence of improved chronic disease outcomes. In the data collected from one pilot team in which behavioral health integration has been implemented, preliminary results have indicated an improvement in diabetic outcomes, including an increase from 58 percent to 72 percent in the number of diabetic patients with an A1C done in the last six months and an increase from 24 percent to 37 percent of diabetic patients with an A1C of less than seven.
Agency Community RolesBehavioral health integration is a project of the Multnomah County Health Department for implementation throughout its primary care system. Stakeholders’ role in planning and implementing the project involved obtaining input from the behavioral health and primary care pilot team members on a variety of issues related to planning and implementation, engaging management teams in the planning to address specific challenges around implementation, and forming a steering committee to guide the planning and implementation process. The health department fosters cooperation and participation within the agency through a variety of mechanisms, including regular communication with all levels of management and staff, staff and management training, and dedicated staff and provider meetings that focus on the healthcare teams’ relationship with each other and the patient. A steering committee meets regularly to guide the implementation of the project, and collaborative meetings are attended with other agencies in the community that are also adopting the practice. The goal of behavioral health integration is furthered through these relationships by keeping integration a high priority in the care the primary care teams provide. Costs and Expenditures$80,400 for start-up and implementation and $110,047 for in-kind costs. Note: These numbers reflect the costs associated with the entire Building Better Care project. This amount cannot be separated from the cost of implementing the behavioral health component of the project. Also, the in-kind costs reflect the entire year of 2007. ImplementationTasks taken to achieve the goals and objectives of the project include: Integration of behavioral health services (time frame: 1/07-present): 1) Developed a vision consistent with the organization’s mission statement 2)Developed organizational goals and objectives for integrated services 3) Provided orientation and training for leadership and frontline staff 4) Identified organizational champions to develop and pilot integrated services 5) Assessed current system design 6) Developed an implementation plan to overcome barriers 7) Piloted implementation   Access to behavioral health services (time frame: 4/07-present: 1) Hired an LCSW to increase capacity 2) Problem-solved with behavioral health staff and other primary care team members 3) Co-located behavioral health staff to be physically located with the other members of the primary care team 4) Adjusted the schedules of the behavioral health staff to allow for more same day appointments 5) Provided training to all social workers providing behavioral health services, including training in the chronic disease self management model Numbers of “warm hand offs” and “touches” (time frame: 4/07-present): 1) Opened the schedules of behavioral health staff to allow for the flexibility needed to accommodate the warm hand off and increase the number of touches
The project has improved access to behavioral health services by creating greater capacity, strengthening the link between behavioral health and primary care services via the warm-hand off, and reinforcing the relationship between patients and behavioral health providers by increasing patient touches.
Stakeholder commitment to perpetuating the project is high. The commitment is ensured by providing all levels of management and staff with regular communication about the project. Continued support to the primary care teams around the integration of behavioral health services will also be provided. Information about the improvements in behavioral health and chronic disease outcomes will be distributed regularly to all stakeholders along with the results of quality improvement efforts. The funding agency will be informed of progress as the implementation of the practice unfolds. Plans for sustainability include the following: 1) The state of Oregon recently approved use of the Health Behavior and Assessment codes, which will help to sustain the practice by providing funding for behavioral health services delivered within the primary care setting. 2) Reallocation of funds to allow for additional behavioral health staffing, thereby increasing capacity for providing services 3) Training in the behavioral health integration will be provided to future behavioral health staff through a training DVD that has been developed for distribution across the Department’s clinics. 4) A monthly report that includes several behavioral health measures will be provided to each primary care team for the purpose of measuring performance against the targets set for each measure, making behavioral health providers aware of improvements in care.
 
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