From the Field

Examples of Primary Care and Behavioral Healthcare Integration

Community Support Services Collaborates to Add Primary Care to Mental Health Services
Frank Sepetauc PCC, CRC, Vice President of Rehabilitation Services, Community Support Services, Akron, Ohio

Akron, Ohio’s Community Support Services (CSS) serves adult residents of Summit County with severe mental illnesses. The agency also serves individuals who are homeless, involved in the criminal justice system, or have a co-occurring mental illness and substance abuse problem.

Clinic staff come from many sources and includes a nurse practitioner through the University of Akron and a primary care physician contracted through Summa Physicians, Inc. Nurse practitioner students from the University of Akron rotate through the clinic. Klein’s Pharmacy, with which CSS has a 20-year association, provides staffing for the pharmacy. Additionally, the pharmacy will be a site for students from the College of Pharmacy at NEOUCOM.

CSS’s information technology staff developed an electronic record for primary care. The goal is the establishment of a totally integrated electronic record that is shared among the primary care clinic, the pharmacy, and behavioral health providers at CSS.

Planning is in process to develop outcome measures to assess short-term and long-term improvement in the health and longevity of clients with severe and persistent mental illness. Research will include emphasis on disease management, wellness activities, and nutrition. The goal is to determine the effect of coordinated medical and psychiatric care on a person’s length of life. This longitudinal study will last more than 10 years.

In implementing this clinic, we learned the importance of cooperation and collaboration between the medical and psychiatric communities. Regular meetings were vital as we organized this effort. Also, the presence of a project manager with knowledge and skills in both medical and psychiatric care is essential. It is important that the manger be from outside the agencies involved to ensure that his or her other duties do not undermine the effort. Time must be allocated to “credential” medical providers in a distinct location to include an outpatient behavioral health center.

Hoboken University Places Medical Nurses in Partial Care Teams
Michael Swerdlow, PhD, Executive Director, Primary and Behavioral Health Services, Hoboken University Medical Center?{Community Mental Health Center, Hudson County, NJ

Our goal was to provide primary medical care to 250 clients in four mental health partial care programs and to develop mechanisms to maintain program sustainability after the 3-year funded period.

We hired a primary care advanced practice nurse to provide the direct care at the four partial care sites. The APN was supervised by one of the attending family physicians in our family medicine residency program and spent 1 day a week at each partial care site and 1 day a week in the residency program to link any of the partial care clients who required specialized or more intensive physician-based care. The nurse conducted physical health assessments and provided direct patient care at the partial care sites.
A key component of our program was the development of a joint-care service delivery model in which the APN worked as part of the partial care team. The nurse attended partial care treatment team meetings to ensure that mental health staff were aware of the patients’ medical conditions.

Of the 250 patients enrolled in the partial care programs, 225 received complete physical health assessments and follow-up treatment. The conditions treated included hypertension, dermatological problems (e.g., psoriasis, seborrhea, rosacea, warts), lipid disorders, diabetes mellitus Type 2, asthma, urinary tract infections, hepatitis C, and gastroesophageal reflex disease.

Age- and gender-specific testing protocols were developed. The protocols covered Pap smears, breast self-exams, digital rectal exams, and screening for hepatitis C and HIV for high-risk clients. A number of patients were referred to specialists for care

What We Learned

Pacing of care 
Initially, many of our clients were resistant to receiving medical care. It was essential for the nurse practitioner to get to know the clients before an actual assessment or treatment started. To gain client trust, the APN also needed to participate in some of the regular partial care activities.

Joint care delivery model 
Ideally, having the primary care provider meet with mental health providers to plan and discuss specific clients is effective and greatly enhances the coordination of care. An unanticipated outcome of this delivery model was that the mental health staff became more comfortable in dealing with the medical system.

Linkage to family medicine residency program
These programs generally have a community health orientation and are intended to expose residents to different patient populations. Also, behavioral health organizations can provide required educational programming to residents in exchange for medical access.

Educate primary care providers
Offering education to primary care providers on how to work with the mentally ill is critical. Medical education provides little or no training in this area.

In Missouri, Data Analytics and Primary Care Nurses Reduce Gaps in Medical Care
Paul Stuve, PhD, Account Manager, CNS Care Management Technologies, Morrisville, NC

Missouri implemented a statewide disease management and primary care/behavioral healthcare integration initiative; the plan used data analytics to reduce the fragmentation and gaps in medical care in combination with adding primary care nurses on site in community mental health organizations. In 2005, the Missouri Department of Mental Health partnered with Missouri Medicaid (now MO HealthNet) to implement Comprehensive NeuroScience’s Health Care Optimization program.

Designed for patients with severe mental illness and co-occurring physical illness, the HCO program alerts and informs both psychiatric and medical caregivers of the patient’s potential health risks and present patterns of service so that providers can proactively focus appropriate clinical interventions.

A detailed integrated health profile based on claims data is delivered bimonthly to medical and psychiatric providers, case managers, nurse liaisons, community mental health organizations, and other key contacts. The report provides a comprehensive picture of the patient’s treatment history, including diagnoses; important health and pharmacy alerts; current medications and medication adherence information; and a list of recent hospitalizations, emergency room visits, and outpatient services. Key caregivers are identified, and contact information is provided in a Key Contacts list.

Prescribing patterns that do not reflect best practice standards are highlighted and related educational information is provided to prescribers. Information on the patient’s level of treatment engagement is also included. Further adherence information is provided to designated care contacts through twice-weekly email reports on failure to refill critical medications. The process allows for rapid intervention to minimize adherence-related relapse. Finally, the HCO offers outreach and care coordination through a health liaison and designated nurse managers to ensure linkage across providers, case managers, and CMHOs.

The HCO pilot project enrolled 2,000 patients and provided caregivers with more than 6,400 integrated health profiles during its first year. Training was provided to CMHO case managers and supervisors throughout the state, and an active health liaison maintained contact with each agency’s executive and clinical staff to ensure optimum use of the information provided. The results were impressive: the number of HCO patients who lacked a psychiatric treatment home decreased over the first year from 36% to 9%. Psychiatric inpatient days also decreased by an average of 50%, for an estimated savings of more than $6 million. More recently, nurse liaisons have been hired for most CMHOs to further ensure the best possible outcomes for enrolled patients. Missouri is currently planning to expand the HCO program to a population of children in state custody who are living in residential care facilities.

Navos and Neighborcare Evolve from Colocation to 2-Way Integration
Wayne Webster, MD, MPH, Physician; Debra Morrison, Behavioral Health Program Manager, Neighborcare Health, Seattle Washington

In Seattle, Washington integration activities are successfully addressing both sides of the mental health and primary care interface. The collaborative work between NAVOS and Neighborcare Health demonstrates the power of partnership to address the full health continuum and provides valuable insights for primary care providers serving a traditionally dispirited population.

The collaborative relationship between NAVOS and Neighborcare began with colocation — NAVOS sends a mental health professional to the primary care center for a set number of clinical hours and helps facilitate needed referrals to specialty mental health services. This helped to improve care and develop a more truly integrated curbside consultation in the exam room.

Neighborcare also hired a behavioral health program manager to develop a more cohesive and purposeful program and to focus on increasing integration with primary care. The organization provides services based on the IMPACT model of stepped care (see www.impact-uw.org). Neighborcare’s goal is to provide maximum support to primary care physicians as they deal with increasing numbers of patients needing treatment for depression, anxiety, posttraumatic stress disorder, and bipolar disorder.

NAVOS serves a large number of individuals transitioning out of psychiatric hospitalization, homelessness, and the criminal justice system. Staff decided to focus on a client population with co-morbid psychical and mental health conditions living in housing on or near the NAVOS campus. 

Neighborcare’s High Point Clinic began sending a primary care practitioner, Dr. Webster, and a medical assistant one afternoon each week to a NAVOS facility that serves patients coming from three different residential facilities in the area. Patients come to the same building where they would normally see their case manager or therapist; the PCP has an exam room there, with remote access to Neighborcare’s electronic medical record system.

In a typical afternoon, the PCP sees 10 to 15 patients. Although patients may come initially about an acute illness or injury, the PCP works with all the patients to establish an ongoing relationship and deals with their chronic illnesses, such as diabetes and hypertension, which affect a large number of patients who have chronic mental illness. The goal is to create a medical home for these patients.

All appointments for the primary care clinic located at NAVOS are handled through the HighPoint clinic. Walk-ins are accepted as well and can be quickly registered via High Point’s electronic medical record.

On many occasions the case manager stays in the room as consumers consult with the PCP. Case managers, who spend a lot of time with consumers and get to know the issues in their lives, provide support to recommended health changes and help coordinate care. The case manager can also help when a client’s mental illness impedes his or her ability to communicate.
 
NAVOS and Neighborcare found that two major obstacles to coordination were information sharing and billing. The organizations use different information systems, which made information exchange difficult. For instance, obtaining blood work results and medication information was a big obstacle but through dialogue and exchange, they developed protocols to work within their restraints. They now use patient tracking sheets that include information on an individual’s diagnosis and medications. 

Individuals seen at the primary care clinic located on the NAVOS campus are registered as patients with Neighborcare. All services performed at the clinic are billed to appropriate public/private insurance the client may have (same day billing). When they started the partnership, Neighborcare had to add NAVOS to their malpractice rider in order to see clients off site.

Verde Valley Works with Consumers Who View Behavioral Health System as Primary Healthcare Source
Robert D. Cartia, MBA, MA, CEO, Verde Valley Guidance Clinic, Inc., Cottonwood, AZ

In April 2009, the Verde Valley Guidance Clinic, a private, nonprofit community behavioral health organization that has served the Verde Valley/Sedona area of north central Arizona since 1965, intends to open a full-service integrated care program that will colocate primary care physicians and behavioral healthcare medical staff. The project intends to provide services to adults with serious mental illness who are enrolled in both the behavioral health system and the Arizona Health Care Cost Containment System (Medicaid).
 
Our clinic’s perception is that SMI clients enrolled in the behavioral health system tend to be more connected with that system, with which they interact frequently, than with the primary care system, with which they interact on an as-needed basis. Consumers therefore tend to view the behavioral health system as their primary system of healthcare. As a result, the idea to colocate physicians at the clinic became a critical core value for successfully integrating services. 
 
The clinic developed a relationship with a local physicians’ group, which enthusiastically agreed to staff a primary care office in the clinic’s new building. This group of physicians had input into the floor plan and medical office needs. Because of this collaboration, SMI consumers will receive psychiatric and medical care at the same location — and neither service will be “watered down.” Program sustainability is enhanced, because the physicians’ group bills for its services separately from behavioral health services. 

The clinic has constructed a 14,000-square-foot, two-story facility specifically to meet the needs of this project. On one side of the bottom floor is a fully functional primary care office that includes three exam rooms, a doctors’ office, a triage room, a lab draw room, and a supply room.  Behavioral health psychiatric staff offices are housed on the other side of the first floor. In addition, a full retail pharmacy will be adjacent to the waiting room. We are establishing protocols for doctor-to-doctor communication to maintain the highest level of collaboration and information sharing.

Another important feature of the project is electronic health information sharing. The clinic is working with the primary care physicians to provide direct electronic input into the client’s behavioral health electronic medical record and for the primary care physicians to have access to minimal data sets of behavioral health information (primarily medical) so they can efficiently and safely provide care. The primary care physicians will also use Netsmart Technologies’ InfoScriber, which is the clinic’s current e-prescribing module.