The Register Report, Fall 2007 Working Together: Integrated Health Care The Role of the Psychologist in Intermountain's Mental Health Integration Program by Brenda Reiss-Brennan, MS APRN, Dennis Van Uitert, Ph.D. and Quincey Atkin, Ph.D. Return to Table of Contents

As a nonprofit organization, Intermountain Healthcare (Intermountain) combines the financial, administrative and delivery aspects of health care into one integrated network committed to providing clinical excellence, quality, and innovation. It currently has 26,000 employees, 21 hospitals, and 440,000 covered lives in its health plan, Select Health. The medical group has 300 primary care providers (PCPs) and 216 secondary care providers, located in 99 clinics. Primary care providers serve all families regardless of their health plan or their ability to pay.

The mission of Intermountain is excellence in the provision of health care services to communities in the Intermountain region. Intermountain is organized into key clinical integration programs. The mission of the primary care clinical program is to improve outcomes for the patients we serve in primary care offices by making it easier for physicians and staff to provide evidence-based treatments and to be more efficient in the care they provide.

MENTAL HEALTH INTEGRATION

In 1999, a key group of Intermountain leaders became increasingly concerned that primary care medical resources were not being used effectively to treat patients with depression and other mental health conditions. These leaders were influential in establishing the Mental Health Integration (MHI) quality improvement program to ease the burden of physicians in managing these conditions and to build a business case for integration. Consumers, providers, hospital and physician administrators, community partners, and research staff worked together to bring about this integration. Sustained results demonstrate that collaborative primary and mental health care leads to improved functional status in patients and improved satisfaction and confidence among physicians in managing mental health problems as part of routine care at a neutral cost.

The goal of MHI is threefold: 1) to provide timely and appropriate mental health services as a part of routine primary care delivery 2) to reach as many families as possible and 3) to reduce the burden of primary care providers.

The MHI program has been tested in over eight primary care clinics, which includes teams of well-respected family practice, pediatric and internal medicine providers. These groups of Intermountain physicians provide collaborative care for conditions such as diabetes and asthma, and they encouraged Intermountain leadership to redesign the clinic workflow in order to integrate mental health care as part of everyday practice. Following successful pilot tests, an MHI leadership team was next established at each regional site to design, implement, and evaluate the MHI model across all clinic sites using standard quality improvement principles and a tested economic pro forma approach. Team membership included key stakeholders such as lead physicians, regional nurse consultants, mental health practitioners, receptionists, clinic administrators, a quality researcher, consumers and onsite nursing care managers. MHI accountability is aligned to the region and each clinic manager, who is responsible for recruiting and hiring the MHI team and designing a MHI operational workflow that supports their PCPs and support staff. PCP champions, regional medical directors and nurse consultants sustain the cultural changes by engaging their peers in ongoing practice detailing and outcome review.

At the clinic site, the roles of PCPs, consumers and families, mental health providers (APRN, PhD, LCSW) and care managers are redesigned and reorganized into a consultative and collaborative treatment team model to improve patient and family centered care for mental health conditions in the primary care setting. MHI teams and tools training is required of MHI clinics and staff. It includes: team roles (who does what); how to use and score the MHI packet; updates on the science of MH conditions; how to engage patient and family and match level of resource needed to their health management capabilities; EMR team documentation, communication and follow-up tracking; patient and family education, and links to community resources. The baseline assessment (e.g., the MHI packet) is introduced by the PCP or designated support staff. The front page introduces the patient and family to the team concept and identifies a wide range of measures (from patient’s health risks, available family/relational support, depression, anxiety, ADHD, bipolar disorder, as well as functionality in school/workplace). MHI packets have been designed for both adult and pediatric patients/families, and include baseline and follow-up measures. The purpose of the MHI assessment packet is to help the clinical provider assess the patient’s and family’s overall health risk level of need. Online web-based training material and packets have been developed to ensure ease of provider training and collection of patient’s information. Clinics decide how this training should be integrated into practice workflow, and who on their staff is best matched to provide team role functions. Clinics also determine how MHI tools are made available to both providers and consumers.

The MHI program is administered by regional leaders who decide with their primary care providers and clinic managers if their clinic is ready for MHI and how they will account for implementation protocols in their budget. Once this decision is made the mental health specialist and care manager are recruited to meet the needs of the clinic patient population based on a tested economic model. Psychologists and APRNs have performed well in the specialty role and have proven to be excellent team players exemplifying the communication and flexible adoption skills necessary to work in the primary care setting.

Psychologists are well trained to provide the diagnostic consultation and brief CBT needed for the MHI interventions. Our MHI psychologists are both full time and part time depending on the needs of their region. Currently our part time psychologists work in both the MHI clinics and they compliment these hours with part time in Intermountain’s secondary care or university psychology programs. All psychologists hired for MHI clinics participate in standardized MHI training with their clinic PCP’s, care managers and support staff. They also shadow experienced MHI specialists to help them orient to their new role and the world of primary care. Ongoing MHI staff meetings and PCP training provide opportunity for collegial support and continuous feedback to improve the MHI process.

Provided below are two regional examples of how the role of the psychologist has evolved as MHI has been adapted to their region. These psychologists reports represents the most mature MHI clinics which have been implementing MHI for over eight years. Their clinics have provided the cost, functional improvement and satisfaction data that has promoted MHI diffusion throughout the Intermountain Medical Group.

THE PSYCHOLOGIST EXPERIENCE

MHI Case Example: Urban North Region. [Four primary care family practice clinics]

During my 23 years at Intermountain Healthcare as a psychologist, I have seen, participated in and in some cases helped develop many attempts designed to improve coordination of care with MDs and the quality of care for our patients. One of the reasons I enjoy working for Intermountain is the support that such efforts have received on every level of the corporation. The MHI program has proven leadership commitment that has resulted in decreasing barriers and improving access to evidence-based care. The MDs at the various health centers have been enthusiastic about MHI and having care managers and psychologists in their clinics. They have referred many patients and seem to appreciate the ongoing collaboration and consultation. continued

 

Page 1

Page 1 2