This webinar highlighted ways to fully integrate behavioral health care into primary care. The role of nurses, medical assistants, behaviorists, lay health workers, and primary care providers was discussed along with the use of clinical dashboards and warm hand-offs. This webinar was presented May 19, 2016 3:00 p.m. Eastern Time

1. Welcome
The National Cooperative Agreement on
Clinical Workforce Development
WEBINAR 7: Achieving Full Integration of Behavioral Health and
Primary Care
May 19th, 2016
Presented by the
the Community Health Center, Inc.
& the MacColl Center for Health Care Innovation

2. Speakers
From MacColl Center for Health Care Innovation, Group Health Research Institute:
Ed Wagner, MD, MPH, Director Emeritus
Brian Austin, Deputy Director
Katie Coleman, MSPH, Research Associate
From Leibig-Shepherd, LLC:
Carolyn Shepherd, MD
From Old Town Recovery Center:
Shanako DeVoll, CSWA, QMHP, CADC III, IHART Program Manager
Erika Armsbury, MSW, QMHP, Director of Clinical Services
From Community Health Center, Inc.:
Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director
Kerry Bamrick, MBA, Senior Program Manager
Tim Kearney, PhD, Chief Behavioral Health Officer
Veena Channamsetty, MD, Chief Medical Officer

3. LEARNING COLLABORATIVE APPLICATIONS NOW
OPEN!
o Participation in the Learning Collaborative is FREE for health
centers.
o 9-month intensive learning collaborative provided by CHCI,
it’s Weitzman Institute and partners
o Team Based Care or Post-Graduate Residency Program
How to apply?
-Visit www.chc1.com/nca
-PDF of the application is available on our website
-Applications due May 31st

4. Learning Objectives:
1. Participants will be able to describe the features that distinguish effective
behavioral health programs.
2. Participants will be able to describe ways that expanded care team members
can work with core team members to provide seamless, non-fragmented
care to patients.

5. Get the Most Out of Your Zoom Experience
• Send your questions using Q&A function in Zoom
• Look for our polling questions
• Live tweet us at @CHCworkforceNCA and #primarycareteams and #HRSAnca
• Recording and slides are available after the presentation on our website within one week
• CME approved activity; requires survey completion
• Upcoming webinars: Register at www.chc1.com/nca

6. Integrating Behavioral Health
and Primary Care
Learning from Effective Ambulatory Practices
MacColl Center for Health Care Innovation
Group Health Research Institute
May 19th , 2016
Ed Wagner, Director Emeritus
Katie Coleman, Research Associate | Brian Austin, Deputy Director

7. The Key Functions Of Excellent Primary Care

8. The challenges of caring for the patient with
behavioral health problems
Diverse clinical problems and care/staff needs
• Acute distress needing assessment and short-term therapy
• Established mental health disorder needing chronic therapy and management
• Substance abuse
Added care complexity
• Psychiatric disorders and substance abuse problems:
• require specialized assessment and treatment competencies
• respond slowly to treatment
• Interfere with patient empowerment and self-management competence
• often involve complicated pharmacologic issues
Why manage in primary care?
• The PC team’s relationships with and knowledge of the patients are often key to recovery.
• A PCMH is better able to track and follow patients than most mental health providers.
• Only 50% of patients who receive a referral for specialty mental health care ever follow
through with the referral. Among those who do, many do not have more than one visit.

9. Providing effective care for behavioral health
problems in primary care requires:
• Full implementation of the patient-centered medical home.
• Integrated behavioral health expertise; co-location alone is not
enough.
• Primary care clinicians willing and able to be accountable for BH care.
• Shared or integrated care: sharing (interactive communication*) of
care planning and care management between primary and mental
health care;
• Clinical care management services integrated with primary care
* Foy et al. Ann Int Med 2010; 152:247-258

10. The Principles of Integrated BH Care
10
Team care Primary care and behavioral health providers, whether
co-located or not, share care.
Population-based The care team shares a defined group of patients tracked in a
registry to ensure no one ‘falls through the cracks.’ Practices
track and reach out to patients who are not improving.
Treat-to-Target Each patient’s treatment plan clearly articulates personal goals
and clinical outcomes that are routinely measured. Treatments
are modified until the clinical goals are achieved.
Evidence-based care Patients are offered treatments for which there is credible
research evidence to support their efficacy in treating the target.
Adapted from: Behavioral Health Implementation Guide: www. aims.uw.edu

11. Acute distress assessment and short-term therapy
• Behavioral Health Specialist – usually an LCSW or
licensed therapists or counselors
• Available for warm hand-offs – 60-70% of day
unscheduled
• Provides short-term therapy only
• Documents in EHR
• Provides or supports care management services for
patients treated for major depression, anxiety, bi-
polar, etc.
• May provide SBIRT services

12. Established mental health disorder needing
chronic therapy and management
Collaborative Care
• Proven effective in 75+ randomized trials for anxiety,
depression, PTSD
• PCP, BHS and patient discuss and select therapy. If drugs,
PCP prescribes. If psychotherapy, sent to BHS for treatment
or referral.
• Patients tracked in a registry and followed by care manager
(BHS or RN).
• Care manager discusses patients with psych. consultant.
• Treatment adjusted if patient is not improving or therapeutic
target is not achieved.

14. Behavioral Integration and the Primary Care Team
Screening for depression Medical assistant or Receptionist
Care management for depression RN, Behavioral Health specialist
Referral for longer-term psychotherapy BH Specialist, Referral Coordinator
Crisis management Behavioral Health specialist
Brief Psychotherapy Behavioral Health specialist
Psychotropic Medication PCP or Psych NP
Psychiatric Consultation Consulting Psychiatrist
SBIRT Trained staff to screen, treat, refer

15. www.improvingprimarycare.org

16. Resource Spotlight #1

17. Resource Spotlight #2
www.improvingprimarycare.org

18. Carolyn Shepherd, M.D.
Behavioral
Health
Integration

19. Clinica Family Health Services
2015
47,000 Patients
210,000 Ambulatory visits
5 sites, 15 clinical teams

20. • Began in 2002
• 15 teams of 3.0 in-clinic provider:1.0 BHP
• Assigned a panel of approximately 3600 patients
• Licensed Clinical Social Worker, Licensed Marriage and
Family Counselor, PsyD
• Sit in a co-located space with the team and see patients in
the same patient care rooms, IMPACT model
• Four 20-minute recheck slots a day
• Majority of patients seen on any day are patients being
seen by the team for medical complaints
Behavioral Health Integration

21. • BHPs chart in the same chart as the primary care clinicians and
the rest of the team
• We have built BH templates that support SFT and CBT
• The concatenated document is in the same e-file as all other
notes so the team can communicate and coordinate care
effectively
• BHPs attend the huddles, and strategize which patients they will
see that day using EHR huddle reports
• BHPs are introduced to new patients with warm handoffs.
Sometimes they see the patients first.
• BHPs run our chronic opioid group visits as well as depression
group visits and anxiety group visits
Behavioral Health Integration

22. 1. BHPs need a lot of training in solution focused therapy and
cognitive behavioral therapy to feel comfortable in a fast moving
primary care team (no "50 min. hours").
2. Streamlining the paperwork burden for BHPs is important, this is
done at the leadership and state level.
3. Help the BHPs learn to decrease their charting volume, it is
critical if other team members are going to be able to confirm
the diagnosis and find important data points quickly. We did
extensive "best practice charting" training in our EHR for the
BHPs.
4. Not all BHPs are cut out for the primary care team. It is helpful
to normalize this at the time of hire, and let people "try on" the
model without fear of being terminated. We talk about this at
hire, and we let applicants shadow our existing BHPs.
Lessons Learned

23. 5. Sometimes it is best to let the BHP go in and talk to a
patient with a long list of somatic complaints before the
physical provider sees the patient. Often the visit is much
shorter for the PCP, and the patient is happier because they
did not feel rushed.
6. Continuity and relationship are just as critical for the
patient and the BHP as the physical health
provider. Reception, call center, MAs, physical health
clinicians all need to drive continuity for BHPs.
7. BHPs can communicate with psychiatrists on patients who
are not doing well.
8. BHPs who are comfortable in this environment are a
phenomenal addition to the primary care team.
Lessons Learned

24. Behavioral Health Integration
https://clinica.org/innovations/clinica-videos-our-model-care/

25. Veena Channamsetty, MD Chief Medical Officer
Tim Kearney, Ph.D. Chief Behavioral Health Officer

26. Behavioral Health Integration
Behavioral
Health from the
Beginning
Separate
Buildings, Paper
Charts
Integrating
Facilities
Integrated Care
Record
Innovate Practices:
Changing the Way
We Operate
Next Steps
Collaboration Continuum
CHC’s Journey

27. The Components of Integration
Evaluation
Training
Workflow/Processes
Facilities/Systems
Leadership Structure

28. Facilities and Physical Model
• Interdisciplinary Pods that Promote Team-Based Care
• Open office structure
• Collaboration throughout the workday

29. • Exam rooms and therapy
rooms
• Reducing stigma of seeing
behavioral health provider –
no longer sent “over there”
• Seamless transition between
medical and behavioral health
Facilities: One Corridor Care

30. Systems and Technology
Integrated EHR
• Up-to-date patient medical and behavioral health information available.
• Pain scores and access to other data – bi-directional information sharing
• Shared Care Plans
• Electronic referral and recall process
• Collaborative Care Dashboard

31. Planned Care Dashboard
PHQ > 15 8/24/15

32. Systems and Technology and Process
Collaborative Care Dashboard
 Planned Care in Behavioral Health
 Delivery of Integrated Services

33. Rethinking the warm hand-off process: Proactive vs Reactive
Processes
• Medical initiated warm hand-off and behavioral
health initiated warm hand-off
• Staggered vs. consecutive visits – make our
presence known
• Criteria:
• No BH services and PHQ above 15
• No BH services and BH Diagnosis
• No BH services and chronic pain patient

34. • Seamless Scheduling
Processes

35. • Instant access to behavioral
health services via messaging
service while with patients
facilitating:
• Immediate and seamless
warm-hand offs to BH
• Transition to nursing for
controlled substances
• Transition to dental
hygienist for dental
treatment
• Behavioral health crisis
calls handled by large
regional groups of
providers
Systems of Integration: Instant Assistance Technology

36. • Clinical Metrics
• Screening for BH need
• UDS measure
• Improved BH Outcomes
• Practice Metrics
• Patients enrolled in BH
• Wait time to see BH
• ED utilization
• Avoidable Hospitalization
• Experience/Feedback Metrics
• Patient experience
• Staff experience
• Real Time Operational Data
Evaluation of the Model

37. Initiative BH Medical Nursing Dental
Integrated Care Meetings r r r
Recalls r r r r
BH Groups r r
Shared Medical Visits r r r
Warm Hand-Offs r r r r
Prenatal-Dental Project r r r
Shared Care Plans r r r
Complex Care Management r r r
Trauma Screening & TFCBT r r
Standing Orders r r r r
Fluoride Varnish r r r r
SBIRT r r r r
BH Dashboard r r r r
Appointment Allocation r r r r
00/00/00
Interdisciplinary Care Initiatives

38. IHARTIntegrated Health and Recovery Treatment
Behavioral Health Home
Shanako DeVoll,
CSWA, QMHP, CADC
III
IHART Program
Manager
Erika
Armsbury,
MSW, QMHP
Director of
Clinical
Services
http://www.centralcityconcern.org/

39. Central City Concern
• Central City Concern is a nonprofit agency serving single adults and
families in the Portland metro area who are impacted by
homelessness, poverty and addictions.
• Provides a comprehensive continuum of housing options integrated
with direct social services including healthcare, recovery and
employment.
• CCC currently has a staff of 700+, an annual operating budget of $47
million and serves more than 13,000 individuals annually.

40. IHART
• All clients check in with a registered nurse before their
psychiatric medical provider (PMP) appointment.
• Behavioral health assistant is a Qualified Mental
Health Associate (QMHA) and does both
administrative tasks as well as behavioral health
related support for the team.
• A 30 minute morning huddle is conducted daily to
focus on: coordination of care, crisis intervention,
linkage to medical appointments and/or follow up, and
an overview of clients needs for the day.
• The care team coordinator and/or the behavioral health
assistant remain in the team room at all times to
manage day to day and to support the team.
• CCC’s Health Services consists of: Old Town Recovery Center (OTRC), Old
Town Clinic (OTC) & Central City Concern Recovery Center (CCCRC) IHART
is one of 4 care teams located within the Old Town Recovery Center (OTRC)
• OTRC & Old Town Clinic (OTC) are co-located in the heart of downtown
Portland
• OTC & OTRC use a shared Electronic Health Record
• IHART structure is modeled after medical homes, but tailored to fit the needs of
behavioral health (BH) clients and BH systems. For example:

41. Who are IHART clients?
• Behavioral Health Home with a focus on integration with primary care.
• Capacity to serve 300.
• Clients are paneled at the Old Town Clinic (OTC) for primary care.
• Our clients have tri-morbidity, including Severe and Persistent Mental
Illness, homelessness, medical issues and addiction.
• 30% of all intakes to OTRC are from OTC. The majority of those are
referred to IHART.
• Clients can also be enrolled on IHART through intake due to complex
medical needs & no current primary care provider.

42. Sustaining IHART roles
• Development & definition of roles was a crucial part in sustaining
IHART.
• Team roles & workflows were defined to support staff in working to the
top of their skill set/license.
• 10 staff with different disciplines share a team room with the majority
serving in extender roles to the Mental Health Counselors
• Support from a program manager, psychiatric providers, registered
nurses and a pharmacist.
• Putting systems in place to track the health of the population
• Education & training for behavioral staff on ‘Primary Care 101’
• Training & supporting behavioral health staff on integrating medical
coordination into behavioral health appointments

43. Sustaining IHART roles
10 roles in the IHART team room
Care team coordinator, QMHP- Day to day coordination and consultation within the
team, supervision of QMHA’s, carries a small caseload of 20 clients, and coordinates daily
crisis interventions and follow up.
4 Mental health therapist, QMHP- Carry a caseload of 62 clients and are scheduled for
individual therapy 60% of the time, the other 40% is spent doing crisis intervention,
clinical coordination/case management, groups and documentation.
Substance abuse and mental health counselor, QMHA/QMHP, CADC - Facilitation of
dual diagnosis groups, carries a case load of 25 clients and provides alcohol and drug case
management for the entire population.
Behavioral health assistant, QMHA- Is in the team room at all time, answers phone call,
triages crisis situations, all administrative coordination, referrals to respites and outside
agencies.
Case manager, QMHA- Works with the entire population on case management needs,
gets assigned daily tasks from therapist and team, coordination and linkage to outside
services, housing support and medical appointment coordination.
Peer Wellness Coach, QMHA, PWC- Our peer works with individuals to support them
in reaching their treatment goals. Attends medical appointments, support around daily
living skills and health coaching strategies.
Employment specialist, QMHA- Works with 20 IHART clients around supportive
employment.

44. IHART Projects
• Metabolic Monitoring Project (MMP) - Supporting
clients on 2nd generation antipsychotics to get their labs
completed every 3-6 months.
• Coordination with OTC care teams - Care team
managers from OTC attend our morning huddles weekly
to coordinate client needs and to brainstorm strategies to
best serve mutual clients.
• Wellness Program - 16 week Road to Wellness course
that focuses on making small changes in health
practices. Two days per week peer run walking group
and a weekly check in with our registered nurses.
• Targeted Primary Care – Small group of individuals
whose basic medical needs are being addressed by our
team with the supervision of their PCP.
• IHART’s third year will focus on data collection.

46. Q & A, Discussion

47. Reminders
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Dissolving the Walls: Clinic Community Connections
Thursday, June 2nd, 3-4 p.m EST
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