Integrating Public Health and Mental Health

State: NY Type: Neither Year: 2015

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Livingston County is a rural area located in Western New York.  According to the Census, the size of the Livingston County Department of Health's jurisdiction is 65,070.  The target population for this practice is Livingston County residents who are in need of mental health services.  Similar to other rural areas, in Livingston County, there are many barriers to accessing care including mental health.  Traditional health care models approach mental and physical health separately, ignoring the strong connection between the two areas. Fortunately, health care is evolving towards a more progressive model of integrated care. The primary role of the public health system is to monitor and improve the health of the community, with emphasis on prevention, early detection and access to care for all residents. To ensure the triple aim approach is achieved, focus must be placed on wellness, prevention and early intervention. The integration of mental and public health provides a sound infrastructure to meet the needs of residents and improve the health of the community.  Mental health issues often affects individuals’ physical health in many ways, including chronic disease, and poor health and lifestyle choices.   Goal Increase public awareness of Mental Health and promote change to improve Mental Health services and capacity. Objectives  1. Identify public health tools needed to accomplish MH promotion and MI prevention goals regarding surveillance, epidemiology, prevention research, programs, and policies 2. Improve physical health and functioning of patients 3. Improve efficiency of clinic operations  4. Develop strategies for integrating MH and MI and public health systems  The practice was implemented as a result of a Community Health Assessment (CHA), which occurred in 2013.  A CHA Leadership Team reviewed results of various assessments and identified mental health promotion and chronic diease prevention as priorities for Livingston County.  Upon further assessment, it was evident that a cohesive public and behavioral health infrastructure was needed to better serve the needs of individuals diagnosed with mental health issues. Utilizing the collaborative care model of the health home, it was evident that to build an infrastructure in which clients could receive a health check up while at their behavioral health appointment to provide improved coordinated service and to reduce overall no show rates for therapy visits.  To implement this practice, the Department canvassed public health staff for their interest in working in a behavioral health environment. We then presented our idea to the local governing authority. The concept was approved as nursing services are billable and the net cost to the county was zero. The next step was assessing the time of day and how to approach patients, as well as a policy, assessment tool and protocol. We offered this as a voluntary part of the therapy appointment. Once we found an appropriate candidate, we informed and trained staff on the new protocol. We  updated patient records to incorporate the integrated system change. We conducted an enhanced assessment to identify the synergy of integrating additional areas of the departments.  We now have one catalyst for payroll and staff sharing of clerical work, which resulted in increased efficiency and allowed for the reallocation of funds to better serve the needs of the target population. Staff leveraging was integral to the success of this practice as a nursing position was created at Mental Health.  The nurse’s role is to provide an assessment of the individual seeking mental health services by checking vital signs, providing education regarding various public health issues and linking them to needed health services. This is a true example of systems integration between public and mental health, which proved to be extremely successful. The objectives of systems integration were met at the clinic. One full time nurse provides services to the community members served in the Department. This created better linkages to the public health system.  We continue to work on other objectives including increased leveraging from staff.  Specific factors which lead to the success of this practice was staff leveraging, utilizing billable services to maintain services, staff buiy in and empowerment, comprehensive staff orientation, and extensive internal communication regarding the new position and its impact on patients’ health. This practice addresses health disparities as individuals with mental health diagnoses often have physical health issues and difficulty accessing health care and closes the gaps mental health patiets; therefore, the health of the individuals served is improved in all aspects. The website for LCDOH is www.livingstoncounty.us/doh.htm.
Many individuals who have mental health diagnoses also have physical health issues such as chronic diseases.  Historically, public health and mental health have been two separate systems, with each focusing on specific health issues.  While each system meets the specific needs of the individuals served in the realm of their practice, there are limitations in meeting all of their needs.  When there is fragmentation of the two systems, many of the individual’s needs are not met which affects their health and the health of the community. The Collaborative care programs are one approach to integration in which primary care providers, care managers, and psychiatric consultants work together to provide care and monitor patients’ progress.  The New York State Office of Mental Health estimates that in 2011 approximately 441 adults and 129 children/youth from Livingston County accessed MH services every week. Among these adults, 54% accessed outpatient services; 49% accessed community support services; and 8% accessed residential services.  Among these children and youth, 78% accessed outpatient services and 28% accessed community support services. In addition, according to the Behavior Risk Factor Surveillance Survey, in 2009, 8.5 Livingston County residents reported 14 or more days with poor mental health in the last month.  We have reached almost 35% of the mental health population in Livingston County To date, we have screened 199 patients since the inception of the system change in clinic operations starting in August, 2014 of the nurse at the clinic.  In the past, the clinic relied heavily on referrals to primary care. The issue was getting transportation to the health care facility and the no show rate due to anxiety and having to travel, and scheduling separate appointments. In addition, the health care issue was not addressed in a timely manner due to wait times on accessing primary care.  The current practice is better as it better serves the disparate population through the collaboration of mental and public health systems. Silos of care have been removed to provide better care to the target population. Taking vital signs and even measuring height and weight for individuals with high body mass index (BMI) sends a message that behavioral health providers care about a consumer’s overall health. Screening for something as basic as obesity can indicate which individuals may be at higher risk for co-morbid conditions such as hypertension and diabetes. Timely care can be provided, and often issues can be identified sooner through regular vital sign checks, so that patients are more proactive in terms of their health and can improve prevention efforts. This practice has also effected community groups like weight watchers and chronic disease self- management groups by increasing participation at the mental health clinic. The practice is a creative use of existing practices as the integration of physical and mental health care is an important aspect of the health home model. Collaborative care programs are one approach to integration in which primary care providers, care managers, and psychiatric consultants work together to provide care and monitor patients’ progress. The collaborative care approach, which is used as a basis for this integration, has been recognized as evidence-based practice by Substance Abuse and Mental Health Services Administration and recommended as a best practice by the Surgeon General’s Report on Mental Health and the President’s New Free Commission on Mental Health.  
With the collaborative care model of the health home, it was evident that to build an infrastructure in which clients could receive a health check-up while at their behavioral health appointment. This in turn, provides enhanced coordinated services and reduces overall no show rates for therapy visits.  To implement this practice, the Department canvassed public health staff regarding their interest in working in a behavioral health environment. We then presented our idea to the local governing authority. The concept was approved, being that nursing services are billable, the net cost to the county was zero. The next step was assessing the time of day and how to approach patients. We offered this as a voluntary part of the therapy appointment. Once we found an appropriate candidate, we advertised and trained staff on the new protocol. We also updated patient records. In addition to this measure, we did a better canvassing at the synergy of other separate areas of the departments becoming one.  We now have one catalyst for payroll and staff sharing of clerical work. These concepts have resulted in increased efficiency and allowed for the reallocation of funds to better serve the community.  We included internal and external stakeholders in this endeavor. In addition, outreach and education was provided to community partners including the rural health network and local healthcare providers. Staff leveraging was integral to the success of this practice as a nursing position was created at Mental Health.  The nurse’s role is to provide an assessment of the individual seeking mental health services by checking vital signs, providing education regarding various public health issues and linking them to needed health services. This is a true example of systems integration between public and mental health, which proved to be extremely successful in meeting the needs of the target population. To implement this practice, the Department canvassed public health staff regarding their interest in working in a behavioral health environment. We then presented our idea to the local governing authority. The concept was approved, being that nursing services are billable, the net cost to the county was zero. The next step was assessing the time of day and how to approach patients. We offered this as a voluntary part of the therapy appointment. Once we found an appropriate candidate, we advertised and trained staff on the new protocol. We also updated patient records. In addition to this measure, we did a better canvassing at the synergy of other separate areas of the departments becoming one department.  The nurse’s role is to provide an assessment of the individual seeking mental health services by checking vital signs, providing education regarding various public health issues and linking them to needed health services. This is a true example of systems integration between public and mental health, which proved to be extremely successful in meeting the needs of the target population. The timeframe for the practice was 6-9 months for planning. Currently the LCDOH is implementing and evaluating the practice. Various stakeholders were involved through a Community Health Assessment Leadership Team and an Integration Team that met monthly to work on the objectives. The LCDOH continues to collaborate with stakeholders through ongoing communications which include discussions at external meetings and written correspondance such as, emails. We have branded and mobilized other community stakeholders to integrate mental health into other health care areas. Since the inception of this program, our local community hospital has added office space on site for behavioral approaches. In addition a primary care provider has added limited behavioral health service on site. The start up was in-kind space at the mental health clinic as well as staffing time equating $58,000 with fringe benefits. However, units of service were billed to equal a cost neutral endeavor. 
We were able to successfully implement their models and have a significant and positive impact on patients. We have improved the mental and physical health of patients and provided effective strategies for containing/reducing costs. Perhaps the most notable accomplishment is that they assessed their communities, identified unmet needs, and created a system of care that uniquely addressed those unmet needs. We assessed data from electronic patient records and utilized patient satisfaction surveys as well as team discussion. No secondary data sources are currently being utlized. We required and compared units of services, versus units of service in behavioral care. Results were analyzed through qualitative analysis and discussions at team meetings.   Short term success has been demonstrated though a effective systems change process. These indicators include vital sign checks including blood pressure checks, diabetes education and linkages . Implementing this protocol and policy affected 80% of clients at the clinic. The Department will continue to monitor and analyze vital signs, provide client based education and referrals to other services to evaluate the effectiveness of this practice. Some modifications to this practice that were made were adjusting the time that the nursing team met with MH clients in order to best serve the appointment. We had initially had the health assessment done at the beginning of the appointment rather than the end of the appointment, but now have inverted that approach. While the organization has been successful in achieving integration, eliminating payment, regulatory and data silos would help make the process more systematic and streamlined.
A truly integrated delivery system requires combining different kinds of services and supports, including behavioral and physical health care. With the Affordable Care Act (ACA) expansions bringing coverage to a population with a range of behavioral and physical health needs, integration of the two has never been more important and therefore needs to be a better understood resource in the community. Finding competent staff/providers and those who are committed to collaborative care is essential.  Staff and community partner input is vital to the success of this practice.   LCDOH worked through the cost per unit of service vs. staffing time with a cost neutral outcome. The practice has been sustained and is utilized in other clinic settings in the county. Morevover, staff buy in and empowerment led to the success of this practice. To continue to be sustainable, data sharing across providers is key to integration and to identify risk scores for patients based on predictive modeling, which consolidates information and data from across systems to support care management interventions for high-risk beneficiaries. 
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