[PC-BH-Integration] PC-BH-Integrationprogram implementationobstacles

Larry Cesare lacesare at ymail.com
Thu Jan 5 15:27:33 EST 2012

What a
superb grassroots effort this string has been to disseminate the hard-earned
knowledge from real world experience!  I'm impressed
with the firsthand knowledge that comes from setting up actual integrated service
delivery operations, not to mention the depth of insight into barriers encountered and the commitment to sharing both what has and hasn't worked so far.
I am
especially grateful to those willing to openly describe some of their
struggles.  Thomas Edison said "I have not failed.  I've just
found 10,000 ways that won't work."  Maybe this explains why,
after decades of consensus over the need for bi-directional integration of
medical and behavioral care, our current healthcare system continues to be
bifurcated, creating avoidable inefficiencies, waste and suboptimal outcomes. 
I would only suggest that, while there is much to be learned from failures,
perhaps we can reduce the necessary number of them by collectively adopting a classic
Deming-like TQM approach to systematically identifying, prioritizing and, insofar as is possible, eliminating, minimizing or avoiding the barriers we face.  If we, instead, simply rush to impose "fixes" at the operational level, we may remain slaves to trial-and-error and wind up investing money, time and energy into integration efforts of limited effectiveness and/or generalizability.
Future research, policy and program development need to
be aimed at mitigating the barriers that block the path toward integration, some that may be manifest at a functional level, some that may transcend daily operations to include broader, longstanding interprofessional, socioeconomic and/or political issues.  But if we agree that a comprehensive "root cause analysis" should preceed any plan of corrective action, a starting list of barriers that could form the branches of a fishbone diagram might include:  (a) limited generalizability of the medical offset
research to date, (b) differences in models of collaberation and degrees of
integration, (c) continued reimbursement models that provide little incentive for
integration, (d) failure to distinguish among different subpopulations with
comorbid medical and behavioral issues, (e) narrow definitions of the term “behavioral”
that only consider severe and persistent psychiatric or substance abuse
disorders, (f) disregard for the full range of non-pharmacologic,
evidence-based behavioral interventions, (g) failure to reliably measure
meaningful clinical outcomes, (h) gaps in assumptions, values and even language
between medical and behavioral “cultures”, etc. and (i) failure of professional
training programs to produce medical and behavioral providers equipped to work
within an integrated environment.
if we are to shake off the status quo and take healthcare to the next level, we
shall need to overcome a multitude of far-reaching and well entrenched
system-level barriers.  This will require ongoing collaberation among those who, like those on this listserve, are committed to advancing integration of primary medical and behavioral care as a critical element to any successful patient-centered medical home model, ACO-type organization or overarching health reform plan.  Through our dialogue, we need to define a well-articulated "big picture" of what the ideal integrated care system would look like and what results it will produce (i.e., the "value story").  But, just as importantly, we need a common appreciation of the obstacles in our way and an organized, systematic approach for overcoming them.
Keeping an eye on the prize...

Larry A. Cesare, Psy.D.
877 Greensview Drive
Wooster, Ohio  44691
Phone:  330-264-5495
Email:  lacesare at ymail.com
Website:  http://www.linkedin.com/in/larrycesare

From: John Kern <john.kern at regionalmentalhealth.org>
To: '[National Council's Behavioral Health - Primary Care Integration Listserve]' <pc-bh-integration at lists101.his.com> 
Sent: Thursday, January 5, 2012 9:08 AM
Subject: Re: [PC-BH-Integration] PC-BH-Integrationprogram implementationobstacles

All of this response to the “send me your failures” plea has been fantastic – I am also especially interested in the experience of folks attempting to roll out primary care services in MH sites: “reverse collocation” or SAMHSA grantees – to me it feels earlier in the game for this effort, and shared experience more valuable.
So to kick off, this is what I did: failing to get PBHCI grant in Cohort I, I decided to go ahead and open a clinic with NorthShore HealthCenters, our FQ partner, located in the CMHC site.  Over a number of months, we saw a single-digit number of patients, and our partner had to reluctantly pull out, at least for a while. Why? 
·         Separate registration for the FQ really burdensome and we just did not do enough to smooth it out.  Though we thought we had.
·         The CMHC staff, including me, not encouraging enough of the clients to get the medical care they needed, AND 
·         I wildly underestimate the amount of drum-beating and PR needed to engage our psychiatrists and MH staff to refer.
​​​​​Other struggles with primary care services in MH sites?
John S. Kern, M.D.
Chief Medical Officer
The Regional Mental Health Center
8555 Taft Street
Merrillville, IN 46410
From:pc-bh-integration-bounces at lists101.his.com [mailto:pc-bh-integration-bounces at lists101.his.com] On Behalf Of Eric Goplerud
Sent: Wednesday, January 04, 2012 10:40 PM
To: [National Council's Behavioral Health - Primary Care Integration Listserve]; [National Council's Behavioral Health - Primary Care IntegrationListserve]
Subject: Re: [PC-BH-Integration] PC-BH-Integrationprogram implementationobstacles
I agree with Rodger.   We completed a survey for NACHC of integrated behavioral health services in FQHCs.   Integration was either mental health only or, the minority, mental health and substance use.   There was only one instance of a health center that had a substance use treatment provider on staff and no mental health staff.  
Eric Goplerud
Senior Vice President
Substance Abuse, Mental Health and Criminal Justice Studies
NORC at the University of Chicago
4350 East-West Highway, 8th Floor
Bethesda, MD 20814
From:pc-bh-integration-bounces at lists101.his.com on behalf of Kessler, Rodger S
Sent: Wed 1/4/2012 12:31 PM
To: [National Council's Behavioral Health - Primary Care IntegrationListserve]
Subject: Re: [PC-BH-Integration] PC-BH-Integrationprogram implementationobstacles
Sandy, Obviously agree completely. That said, the other side of the coin is also concerning. The field and survey data I am collecting suggests that in integrated primary care, it is really integrated mental health, with little or no attention to substance abuse. That does not work either. Rodger
From:pc-bh-integration-bounces at lists101.his.com [mailto:pc-bh-integration-bounces at lists101.his.com] On Behalf Of Blount, Alexander
Sent: Wednesday, January 04, 2012 12:10 PM
To: [National Council's Behavioral Health - Primary Care IntegrationListserve]
Subject: Re: [PC-BH-Integration] PC-BH-Integration program implementationobstacles
This actually raises another "don't do it" and that is:  don't integrate only substance abuse services and not behavioral health even if the most acute need is around substances.  There was a conference recently in Washington sponsored by the White House Office of Substance Abuse (I don't have the name exactly right) and SAMHSA.  It included physicians and behavioral health folks, both from the specialty substance abuse field and from primary care. Some of the folks from the specialty world thought that integrating substance abuse into primary care as a program was a good idea.  None of the people, physian or behavioral health professional, who work in primary care thought that was a tenable idea.  It just continues the dichotomizing of patients, using a different dichotomy.  I hope you are in touch with the folks at the Hogg Foundation who have done so much work in promoting integrated care in Texas.  I suggest you look at starting again with a
 generalist approach and SA can be a part of that.
Alexander Blount, EdD 
Director, Center for Integrated Primary Care 
Professor of Family Medicine and Psychiatry 
University of Massachusetts Medical School 
Director of Behavioral Science 
Department of Family Medicine and Community Health 
Editor,Families, Systems, & Health 
55 Lake Ave, N 
Worcester, Massachusetts 01655 
O. 774.443.2147,  F. 774.441.7799 
alexander.blount at umassmemorial.org 
From:pc-bh-integration-bounces at lists101.his.com [mailto:pc-bh-integration-bounces at lists101.his.com] On Behalf Of Linda Benitez Tavel
Sent: Wednesday, January 04, 2012 11:01 AM
To: pc-bh-integration at lists101.his.com
Subject: Re: [PC-BH-Integration] PC-BH-Integration program implementationobstacles
Good Morning Dr. Kern and colleagues,  I am in Texas and recently collaborated with a group of pain management physicians who reported concerns with their patients who exhibit drug seeking behaviors for other than pain management.  We discussed a co-located behavioral health care model whereby a behavioral health component could be co-located within their clinics to add substance abuse screenings, assessments, prevention, intervention and treatment services as part of their health care management plans, including drug screenings and breathilizers at each visit.  Due to the high incidence of prescription abuses that occurs within this population, and in our society, the doctors thought this would be a great idea.  Many obstables occurred with existing medical facilities policies and once we consulted with an attorney specializing in the area of health care law, it appeared that present Texas laws will not allow for this concept.  There are a couple
 of integrated primary care-mental health care models in Texas among non-profit entities but none with a primary care-substance abuse integrated model.  Within the area of substance abuse, co-occurring disorders often emerge and management of these mental health disorders have to occur simultaneously while treating addiction. 

According to NIDA MED, prescription abuse is quickly becoming a significant health care issue.  Present laws in Texas do not support the integration of private primary care, speciality care clinics with behavioral health care.

Linda Benitez Tavel
Vice President
Amexica International Consultants
Tel: 210-446-4606 ext 102
Fax: 210-446-4549
On Jan 4, 2012, pc-bh-integration-request at lists101.his.com wrote:
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>Today's Topics:
>1. Re: One more plea for failures (Bradley, Wendy D)
>Message: 1
>Date: Wed, 4 Jan 2012 04:23:36 -0900
>From: "Bradley, Wendy D" <wdbradley at SouthcentralFoundation.com>
>To: "'[National Council's Behavioral Health - Primary Care Integration
>Listserve]'" <pc-bh-integration at lists101.his.com>
>Subject: Re:
 [PC-BH-Integration] One more plea for failures
><F7D46789D91A08489F0CC2629550F0481D39E2EA19 at SCFExch3.southcentralfoundation.com>
>Content-Type: text/plain; charset="us-ascii"
>Great lists so far....
>I will add
>1) The best thing we ever did was to have the BHCs sit with the providers in the same space. They end up sharing work rather quickly because BHCs are able to show providers where they can be helpful and consults happen naturally throughout the day. Also, it reinforces that BHCs are part of the team and shifts the BHCs perception from traditional BH to the primary care culture.
>2) I also cannot stress enough the importance of finding the right "fit' for this position. We have
 found that flexibility, strong communication skills (confidence), ability to be a team player and having a systems, solution-focused approach in clinical work is imperative.
>3) Spend time making sure PCPs know how and are comfortable introducing BHCs to patients. (not as a saying therapist, social worker etc.)
>4) Make sure there are "triggers" that get BHCs into the room. (i.e. screeners). This gets PCPs used to using BHCs.
>5) Spend enough time training BHCs in the beginning. We have found "shadowing" is most helpful. Have them shadow all members of the PCP team (especially PCPs) to help them understand the culture. They should shadow BHCs and then be shadowed to ensure stated competencies.
>I attached a few tools we use.
>Wendy D Bradley, LPC
>Improvement Advisor-Clinical
>Organizational Development
>Southcentral Foundation
>Anchorage, Alaska
>wdbradley at scf.cc
>work 907 729-3378
>cell 907 250-9325
>From: pc-bh-integration-bounces at lists101.his.com [mailto:pc-bh-integration-bounces at lists101.his.com] On Behalf Of John Kern
>Sent: Friday, December 30, 2011 8:20 AM
>To: 'pc-bh-integration at lists101.his.com'
>Subject: [PC-BH-Integration] One more plea for failures
>My final act of 2011 will be to reach out again to all of you to share with me / us any experiences of failures so far in the implementation
 of your
 programs, things that you would recommend that others not do, to spare them your own personal agony.
>I am collecting these for a training presentation, and PROMISE that I won't use any identifying information without permission. AND that my own failures will be well-documented in the presentation - that's what makes it fun.
>Thanks in advance. Happy New Year!
>BTW, if you are willing to share, but not to the listserv, I am at john.kern at regionalmentalhealth.org
>John S. Kern, M.D.
>Chief Medical Officer
>The Regional Mental Health Center
>8555 Taft Street
>Merrillville, IN 46410
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