Integrating Physical Health Care in Behavioral Health Agencies in Rural Pennsylvania

Executive Summary

January 2014

Background

Individuals with serious mental illnesses (SMI) have high rates of chronic physical health conditions, including metabolic disorders and cardiovascular disease (De Hert et al. 2011; Newcomer 2007; Newcomer and Hennekens 2007; McEvoy et al. 2005). Unfortunately, the delivery of behavioral and physical health care for people with SMI is fragmented and poorly coordinated (Collins et al. 2010). In response, the Substance Abuse and Mental Health Services Administration, state Medicaid programs, health plans, and mental health systems are making efforts to integrate care for this population. Embedding or co-locating physical health providers in specialty behavioral health care settings (often referred to as reverse co-location) is one of several strategies proposed to improve the integration of services for people with SMI (Collins et al. 2010). Even though interventions that incorporate the co-location of physical health providers in behavioral health care settings has yielded some promising results (Druss et al., 2010), relatively little is known about how behavioral health agencies incorporate physical health services into their organizations and workflows.

Under the leadership of Community Care Behavioral Health (CCBH), the Behavioral Health Home Plus(BHHP) program was implemented in two community behavioral health agencies that serve five rural counties in Pennsylvania. BHHP aimed to improve the integration of physical and behavioral health services for Medicaid beneficiaries with SMI through several activities: (1) embedding a registered nurse in each behavioral health agency to develop an interdisciplinary care team and address consumers' physical health conditions; (2) training case managers and peer specialists within the behavioral health agencies to become wellness coaches, thereby helping consumers identify and address physical health and wellness goals; (3) tracking consumers' progress in reaching wellness goals, including their use of a web-based portal; and (4) strengthening collaborations between behavioral health agencies and primary care providers (PCPs) in the community. The program targeted Medicaid beneficiaries with SMI (including schizophrenia, bipolar disorder, major depression, or borderline personality disorder) who received services through the Columbia, Montour, Snyder, and Union counties and Northumberland County behavioral health agencies.

Methods

The study presents the early implementation experiences of BHHP in order to explain: (1) how the agencies integrated physical health care into routine practice; (2) the types of training and support needed to co-locate nursing staff and orient agency staff to physical health care; (3) the strategies used to identify consumers in need of physical health care and wellness services; (4) the approaches for strengthening collaborations with PCPs in the community; and (5) consumers' perception on this new model of care. We used a qualitative case study approach to generate in-depth information about BHHP's early implementation and to gather real-world experiences with the model from staff, consumers, and other key stakeholders. We collected qualitative information during two rounds of site visits that included discussions with agency staff and stakeholders, consumer focus groups, observations of the program environment, and document reviews. We used inductive and deductive analytic techniques to identify themes from the qualitative data.

Results

The development of BHHP involved an extensive planning process that included stakeholders from several counties and input from consumers. Findings suggest that the behavioral health agencies successfully trained their staffs in wellness coaching and integrated registered nurses into agency functions. Other short-term outcomes that emerged include the development of care planning processes that incorporate physical and behavioral health goals and an increased awareness and knowledge of physical health and wellness among behavioral health staff and consumers. Given the complexity of introducing new processes of care to behavioral health agencies, they experienced several challenges during the program's early implementation. These challenges included, staff role confusion, difficulty establishing new procedures and communication protocols among staff members, discomfort among case managers and peer specialists in identifying and addressing physical health concerns, difficulty building collaborative relationships with PCPs, and slower-than-expected uptake of web-based tools for tracking consumer outcomes.

Agency staff and CCBH developed several strategies to overcome the challenges of integrating nurses and expanding the roles of case managers and peer specialists. CCBH worked with agency leaders to clarify roles and develop written job descriptions for both nurses and case managers to help delineate their roles and responsibilities. A high-risk care manager from CCBH initiated meetings with nurses on a weekly basis to assist with role clarification, provide a resource for information, and discuss ongoing wellness activities. In an effort to improve communication and coordination across the care team, leaders from one agency included the nurse in daily meetings with supervisors and invited her to attend weekly meetings with case managers to discuss consumers engaged in wellness activities.

Some case managers and peer specialists struggled to assume their new role as wellness coaches. At the program's outset, their discomfort contributed to their tendency to refer almost all consumers with physical health problems, even relatively minor problems, to the nurse. Some case managers also expressed concern about whether consumers would be comfortable with case managers functioning as wellness coaches--not because of concerns related to privacy but rather because some consumers did not perceive that physical health or wellness fell within case managers' scope of practice.

Agencies and consumers experienced difficulty in tracking consumers' progress toward physical health and wellness goals. Consumer and staff use of the web portal was much more modest than expected; some staff noted the challenges of technology use in a rural setting, including the lack of Internet connectivity and/or computer access. Agencies needed to create more formal mechanisms for tracking processes of care to monitor who received wellness coaching and what the coaching included.

Engaging PCPs was challenging for agencies; barriers included the competing demands of primary care staff and their limited familiarity with behavioral health services, case management, and peer services. Nurse attendance at PCP appointments with consumers was cited as an effective way to interact with PCPs and demonstrate the value of the wellness program to primary care staff.

Consumers in the focus groups were uniformly positive about their experience in receiving care from the nurse. However, some consumers noted that they were not comfortable disclosing physical health information to case managers, but other consumers welcomed and expected their case managers to communicate with other agency staff about their physical health and wellness goals.

Discussion

Developing a service setting that integrates primary care and behavioral health services is a long-term process that requires substantial investment in staff training and other resources (Heath et al. 2013; Kim et al. 2012). As with other complex interventions, changing staff roles and responsibilities and adapting well-established workflows involve trial and error (Campbell et al. 2007). The study highlighted early implementation challenges as well as key successes of the agencies in incorporating wellness coaching into their regular routines, integrating registered nurses into agency functions, developing care planning processes that incorporate physical and behavioral health goals, and increasing awareness and knowledge of physical health and wellness among behavioral health staff and consumers. Findings suggest that training case managers to function as wellness coaches, integrating a nurse into a behavioral health agency, implementing web-based health assessment tools for people with SMI, and strengthening collaborations with PCPs are ambitious tasks that require a significant culture shift for both providers and consumers. Based on the successes and challenges of BHHP, similar efforts would benefit from: (1) adequate planning to clarify the team's roles and responsibilities and to establish mechanisms for regular communication; (2) committing to ongoing training to help staff become more comfortable in addressing physical health needs and implementing wellness coaching; (3) obtaining ongoing input from consumers and staff to guide program development; and (4) developing mechanisms to track physical health and wellness activities and consumer outcomes.