[PC-BH-Integration] PC-BH-Integration program implementation obstacles

Thu Jan 5 16:11:21 EST 2012

Great points Larry. The more time I am spending with the PC physician leaders struggling with costs, health risk appraisals, patient activation and engagement and effective behavioral engagement in managing the huge population with chronic disease, much co morbid with mh and sa, the more  I am clear how marginalized most  collaborative care continues to be.  I am engaged in a large institutional project with a focus on COPD Diabetes and Cardiac disease. My role will be to identify the behavioral  processes that patients and providers engage in that don’t work cause poor care and excessive cost, and identify, operationalize and implement those procedures with evidence based behavioral basis, including systematic identification and response  to  interfering mh and sa issues. The barriers to integration are old school and medium but not long visioned. Barriers to effective primary care is the viewable and achievable frontier…  The Triple Aim rules. Thoughts?? R

From: pc-bh-integration-bounces at lists101.his.com [mailto:pc-bh-integration-bounces at lists101.his.com] On Behalf Of Larry Cesare
Sent: Thursday, January 05, 2012 3:28 PM
To: [National Council's Behavioral Health - Primary Care Integration Listserve]
Subject: Re: [PC-BH-Integration] PC-BH-Integrationprogram implementationobstacles

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.

Clearly, 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

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
219-736-7232

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
301-634-9525

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
http://www.IntegratedPrimaryCare.com<http://www.integratedprimarycare.com/>
http://www.umassmed.edu/fmch/faculty/Blount.cfm

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)

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Message: 1
Date: Wed, 4 Jan 2012 04:23:36 -0900
From: "Bradley, Wendy D" <wdbradley at SouthcentralFoundation.com<mailto:wdbradley at SouthcentralFoundation.com>>
To: "'[National Council's Behavioral Health - Primary Care Integration
Listserve]'" <pc-bh-integration at lists101.his.com<mailto:pc-bh-integration at lists101.his.com>>
Subject: Re: [PC-BH-Integration] One more plea for failures
Message-ID:
<F7D46789D91A08489F0CC2629550F0481D39E2EA19 at SCFExch3.southcentralfoundation.com<mailto:F7D46789D91A08489F0CC2629550F0481D39E2EA19 at SCFExch3.southcentralfoundation.com>>

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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<mailto: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> [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<mailto: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<mailto:john.kern at regionalmentalhealth.org>

John S. Kern, M.D.
Chief Medical Officer
The Regional Mental Health Center
8555 Taft Street
Merrillville, IN 46410
219-736-7232

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