Brenda Reiss-Brennan, MS, APRN, Dennis Van Uitert, PhD,
and Quincey Atkin, PhD
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.
The psychologists who provide direct care to patients and consultation and coordination of care with the MDs are skilled, dedicated and excited about the process. We currently have 3 psychologists providing MHI in various Intermountain Health Centers. Each has more than 20 years experience (a total of more than 70 years) working in a variety of mental health settings (Psychologist One: outpatient therapist, provider of psychological testing, adult inpatient program director, child adolescent inpatient program director, director of the ER crisis intervention team, provider of hospital consultation liaison services, and now MHI; Psychologist Two: outpatient therapist, provider of psychological testing, director of outpatient substance abuse treatment, director of substance abuse treatment for the US Naval Reserve, provider of hospital consultation liaison services, and now MHI; and Psychologist Three: an outpatient therapist, provider of psychological testing, school counselor, consultant/supervisor of school counseling services, and now MHI). These individuals were recruited to participate in the MHI program because of their interest in this initiative, the breadth of their experience and their history of positive relationships and interactions with the physicians at the participating health centers in the past. Psychologists were chosen for this initiative because of the breadth of experience and training that their preparation as a psychologist provides and because payers reimbursed psychologists at more favorable rates.
The relationship between a patient and the therapist is the key variable in predicting how helpful therapy will be. It is our experience that a similar phenomenon takes place in developing a program to improve the detection of mental health issues, to improve the quality of the care provided to patients and to increase the coordination of care between physicians and mental health providers. If the relationship between the MDs and the psychologists is positive and mutually supportive the process works.
The MHI process employed in our region includes the following elements:
1) All new patients at the health center, all patients with depression or another mental health diagnosis on their problem list and any other patient that is identified by the MD and/or his/her staff receive a two question screen about possible depressive symptoms when they arrive at the health center for their appointments.
2) If the patient responds yes to either question he/she is asked to complete a PHQ-9. The PHQ-9 is scored and given to the MD at the beginning of the visit. The PCP decides based on his or her assessment whether the patient is suffering form a (mild, moderate, or severe) condition and if they need to refer to the care manager or the psychologist.
3) The MD reviews the results with the patient and may prescribe medication, introduce care management or ask the patient to schedule an appointment with one of the psychologists who will see the patient in the same health center. The patient completes the MHI packet before their appointment with the psychologist.
4) The care manager may also facilitate helping the patient complete the packet and schedule their mental health appointment.
The psychologist role in this process goes far beyond psychotherapy with the patient. The psychologist scores MHI packets and provides written feedback about the results to the MD, consults about cases, sits in with the MD during office visits as requested, works with the RN case manager, meets with patients on a scheduled and/or crisis basis, and facilitates referrals to other providers or services in the secondary behavioral health system. The goal is to have an integrated, coordinated plan of care rather than two separate silos that happen to be located in the same building.
We currently have a psychologist placed at three health centers for one day per week each and at three other sites for 1/2 day each (These psychologists spend the rest of the time carrying out other duties – mostly seeing outpatients at the Center for Counseling). MDs talk about how much they appreciate the communication and coordination of care. Patients talk about the ease of access and how seeing a psychologist at their MD’s office decrease the stigma of seeking mental health treatment.
It is my personal goal to talk with each physician about each encounter I have with their patients in person (1st choice) or by phone. Communication is further enhanced because psychologists chart in the same electronic record as the MDs, which allows the psychologist to have access to the physicians’ notes and visa versa. It is further my goal to foster my relationship with each physician by finding a reason to talk with each MD each day I am in the health center.
I find participation in this process of care delivery fulfilling because of the relationships I have with other team members and because of the improved quality of care provided to our patients.
MHI CASE EXAMPLE: URBAN CENTRAL REGION[Three Primary Care Clinics (Internists, Family Practice, Pediatric) One Uninsured Clinic] One of the biggest strengths, in my opinion, of MHI is indeed doing what it purports, integrating mental and medical health to provide the best care possible for patients and increasing patient satisfaction. Psychologists are hired from within the Intermountain Health Centers as well as from the community of private practitioners. Most mental health practitioners hired are seasoned providers and are generally able to quickly adapt to the needs of the population they serve within the clinics. If additional clinical training is needed, whether it is in brief focused therapy or more specialized clinical disorders they are encountering, mental health providers generally identify trainings within and outside of the state they can attend to increase their skills and knowledge. Patient referrals for psychologists come directly and only from the PCPs with whom they work at each clinic. The purpose of this is to fit in the model of mental health integration, meaning that PCPs have a direct person with whom they can communicate about their patients and refer them to directly within the clinic. As a result, the priority is to support PCPs and their patient populations and be available for them to be seen within a short amount of time (i.e., within 2 weeks). Services provided by a psychologist mainly include intake/consultation and brief therapy (often cognitive-behavioral) for a variety of general childhood and behavioral disorders.
As a psychologist working within MHI, there are several benefits which seem a little different than general private practice. First, the communication and interaction with PCPs is greatly facilitated through this model. Having the psychologist in each of the medical clinics helps increase communication with the PCP, and there is an electronic record which both the psychologist and PCP have access to and and a form of messaging is also available. Also, patients often seem more likely to receive services within a clinic they know and feel comfortable. Having a care manager is also another major benefit to help support psychologists in reducing the burden of responsibility when providing services for patients and their families. Care managers support the mental health practitioner by helping with follow-up phone calls, working with the school system, educating parents, and helping with medical and mental health referrals outside of the clinic. This partnership between care manager, mental health specialist, and PCP may help practitioners feel like they are working with a team to improve mental health functioning for patients, instead of feeling isolated, overwhelmed, and alone. In Summary, MHI has provided a venue for psychologists to use their exceptional training and skill as a member of heath care team committed to quality care. They have increased the attention to behavioral health as part of every day health care practice. They have accomplished this by their ability to develop positive working relationships, use of scientific decision making in their clinical judgment and commitment to meeting the needs of the patients and families they serve.
Brenda Reiss-Brennan, MS, APRN, CS is Mental Health Integration Leader, Primary Care Clinical Programs, IHC.
Dennis Van Uitert, PhD, is a psychologist at the McKay-Dee Center for Counseling in Ogden, Utah. Dennis received a Ph.D. in counseling psychology from the University of Minnesota in 1984 and has worked at McKay-Dee Hospital Center providing various psychological services since.
Quincey Atkin, PhD, is a clinical psychologist who has been working with both adults and children for Intermountain Medical Group as part of the Mental Health Integration program for almost two years.