Behavioral Health Integration
Pearls for Managing Depression in Primary Care
Video discusses valuable techniques
Dennis Novack, MD, Professor of Medicine and Associate Dean of Medical Education at Drexel University College of Medicine, and Damara Gutnick, MD, Medical Director at Montefiore Hudson Valley Collaborative, discuss the diagnosis and management of depressed patients in primary care, based on their many years of experience. Listen to these experts discuss the high prevalence of depression in patients with co-morbid chronic disease and how routine screening can help identify patients and potentially save lives; time effective strategies that allow quality care to be delivered more efficiently; the importance of self-management support for patient engagement; and effective communication strategies, including active listening and recognizing non-verbal signs of depression. The annotated version of this video can be seen here.
Integrated Primary Care and Behavioral Health
WHY WE CHOSE THIS PROJECT
The Behavioral Health Integration project is designed to ensure that patients are treated holistically and both their medical and Behavioral Health (BH) needs are met. In our resident survey, mental health and schizophrenia were rated among the top five health issues in the community, and more than 20% of consumers did not know where to go to obtain mental health services, substance abuse services, or alcohol abuse services in their county. BH disorders are one of the top five Medicaid inpatient conditions in the Hudson Valley. Given the prevalence and coordination of care needed to treat BH, this data indicate that there is a significant opportunity to resolve this gap in care.
Those with BH diagnoses have marked disparity in health outcomes when compared to the general population. One of the reasons for these poor outcomes is related to lack of primary care access. Staff at medical clinics may not have experience in working with members with serious mental illnesses, and these members may not have the ability to advocate for themselves. Co-location and integration of care is a primary means of addressing this issue.
Our research also revealed provider and community resource gaps that will benefit from the active involvement of peer organizations in this integrated model of care. MHVC will leverage the over 1,300 community organizations in the Hudson Valley to address this gap. In addition to resources, there are gaps in the infrastructure that prevent sharing treatment plans and Electronic Health Records (EHRs) across provider sites. These gaps can be closed with systems for sharing treatment plans and EHRs across provider sites, including community-based crisis stabilization services.
The project objective is integration of mental health and substance abuse with primary care services to ensure coordination of care. The goals of this project can be achieved through three different models:
- Model 1: Integration of BH specialists into primary care clinics
- Model 2: Integration of primary care services into established BH sites such as clinics and Crisis Centers
- Model 3: IMPACT (Improving Mood - Promoting Access to Collaborative Treatment) Model, BH specialists integrated into primary care coordination teams using collaborative care standards
To meet the varied needs of BH clients with co-morbid conditions, we plan to implement all three models within MHVC, and plan to explore both real and innovative virtual integration models.
We will leverage the significant experience of our partners, as well as maintain the strong involvement of community based resources, since peer resources and social supports are key components of recovery.
When Co-Location is Not Enough: How Astor and CMG Created a Seamless Process
MHVC BH Learning Collaborative facilitated collaboration, development of templates
Before DSRIP, Astor Clinics of Ulster and Dutchess County moved into the Children’s Medical Group building, anticipating that co-location would be the future of providing care for their mutual clients. Astor was in the building almost five years, but although they were co-located, some of the clinicians were still siloed while others had good relationships.
This was the perfect project for Michelle Blackmore, PhD, Project Director at the Montefiore Medical Center’s Care Management Organization, which leads the Behavioral Health Integration Learning Collaborative (BHLC) for MHVC. Working with Amie Adams, LCSW-R, Regional Director of Outpatient Clinics for Astor Clinics of Ulster and Dutchess County, and Dr. David Fenner, President of the Children’s Medical Group (CMG), the BHLC helped foster collaboration and communication, launching new interactions and work flows between these two partners.
“We brought them to the table and they talked about their mutual and separate needs and frustrations,” said Blackmore. “Simple yet profound actions resulted, from developing health assessment templates that allowed medical and behavioral health providers to update each other on shared patients, to just having a meet-and-greet with each other’s new staff to begin collaboration.” MHVC and Blackmore, as part of the BHLC, now have monthly calls with the teams, but they are mostly brief check-ins and an opportunity to brainstorm through any challenges as the teams advance their integration efforts. “We have been so impressed with what they were able to do in such a short time,” said Blackmore. “Many changes didn’t necessarily require expense or infrastructure transformation, just caring and care coordination on each side.”
“The BHLC got leadership to the table and we were able to identify meaningful and realistic changes,” said Adams. “We could also address the basics, such as, ‘In the pediatric world, this is how we function’ and ‘in the behavioral health world, this is how we do things.’” Astor and CMG implemented a liaison protocol on each side.
The model is so successful that MHVC and the BHLC are now introducing it to other partners. The health care assessment template is a tool to help medical and behavioral health providers communicate and collaborate on shared patients. It is used instead of a chart, providing a more efficient way to share patient information, treatment plans, progress, etc. "Reviewing a full chart isn't always practical, so without the assessment template, providers weren't sharing information regularly," said Blackmore.
The template creates a 1-2 page summary with vitals, chief complaint, scales, etc., and makes it much easier and efficient to obtain and share client information. The key points are in narrative form, very user-friendly, and easy to get into the electronic health record and send out to the liaison. Since Astor represents the behavioral health (BH) side, and CMG pediatrics, there are two complementary forms -- the BH Assessment Form and the Medical Assessment Form.
“When we know we are going to collaborate on a patient or client, we can quickly fill out the form and get it to the right clinician -- and CMG can do the same,” said Adams. Astor has two full-time clinicians in the CMG Hyde Park location, and one full-time clinician in Rhinebeck, five days a week. Both offices are fully co-located with CMG: they share a front door at Hyde Park, and have an office in the pediatrician’s office in Rhinebeck. “Nurses often walk families over to Astor-a warm handoff,” said Adams.
Astor provides outpatient mental health services for ages 2-21. It is an open access model, so families can walk into its Hyde Park office from 9 AM-5 PM, and crisis appointments during working hours prevent trips to the emergency department. “Importantly for this population, the collaboration of mental health and pediatrics should be physically prominent in a child’s health care,” said Adams.
That is the joint goal of Astor and CMG, according to Dr. Fenner, a pediatrician. “A lot of people present in our primary care offices. In some cases, we refer to a therapist and there is never communication back and forth. With Astor in some of our offices, we have that communication and so much more.” The CMG Care Coordinators and Astor act as “matchmakers” between providers. Astor and CMG started with simple questions: If CMG has providers on site Tuesday, Thursday, Friday, and the Astor therapist is there on Wednesday, how and when do they speak? “We asked, ‘What is our work flow? Their work flow? How does it work with a busy primary care doctor and a busy therapist?’” “The goal is to create times for meaningful, deliberate communication,” said Fenner. “We schedule a call -- it is not ad hoc and in the middle of my primary care appointment.”
This high level of collaboration and coordination has allowed CMG and Astor to address critical problems together. “There is so much need for mental services for kids,” said Fenner. Child and adolescent mental health needs and ways to deliver it are different from those of adults, just as the pediatric world differs from adult primary care. “Working with Astor, we ask ourselves, ‘How do we integrate child and adolescent mental health with the pediatric world?’”