Care Integration Requires Blending Cultures

Confidentiality a concern for patients with care integration

KANSAS CITY, Mo. — There are bureaucratic and technological hurdles to overcome when meshing medical and mental health services, but getting staff workers to embrace the integration is the tallest task, according to a panel of safety net officials who met Wednesday for a presentation at the Mid-America Regional Council.

“The biggest problem is just blending the cultures — making people think more broadly,” said Jason Wesco, chief executive of the Health Partnership Clinic, which has sites in Johnson and Miami counties in Kansas.

He and Dennis Dunmyer, vice president of behavioral health and community programs for the Kansas City CARE Clinic, said it was particularly hard to get mental health workers and patients to share information with medical providers because of concerns about confidentiality.

The secrecy around mental health diagnoses starts with clinicians and passes on to clients, who are sometimes surprised that a primary care doctor in a clinic knows the mental health information that’s stored in the clinic’s electronic medical record system, they said.

Proponents of better coordination of patient care say information sharing is a key way to improve treatment and reduce costs in the health care system. For instance, primary care doctors can better tailor their prescriptions if they know a patient is taking psychotropic drugs.

Toniann Richard, executive director of the Health Care Collaborative of Rural Missouri, which serves communities east of Kansas City, joined Wesco and Dunmyer on the panel.

Wednesday’s presentation was the fourth in a series this year by the Metropolitan Mental Health Stakeholders, a group that is part of the MARC Regional Health Care Initiative.

The idea for the sessions grew from a survey the stakeholders group did last year to determine the extent of integration and identify barriers to collaboration. Committee members chose the session topics based on the responses about the barriers.

Previous presentations in the series have covered: practice-improvement suggestions for mental health centers; a presentation on “health home” initiatives in Missouri and Kansas; and views from the medical community.

The stakeholders’ group expects to hold a wrap-up session in December.

The panelists also said that electronic medical record systems lack features that could help integration.

No product, they said, adequately handles both the black-and-white data on the medical side along with the narrative, case-management needs on the behavioral health side.

“You can kind of make what is out there work,” Dunmyer said.

But, Richard said, clinics must be mindful of patient privacy laws even when only sharing data among providers within the same office.

“We live in a data era,” she said. “People want privacy.”

She also said it can be costly and time consuming to get staff properly credentialed with the various health plans that pay for patient services.

“Medicaid alone will almost drive you crazy,” Richard said.

Outsourcing that work, she said, had cost her organization between $30,000 and $40,000.

All three panelists said their integration models included staff members that can either provide on-the-spot therapy in exam rooms or arrange for support services.

It usually takes grant funding to add those positions, but in the long run, they said, patient revenue generated by the positions can make them self-supporting.

When everything is clicking, the panelists said, the provider staff should be meeting ahead of time to anticipate patients’ potential behavioral health needs.

“Our next step is to go back and say, ‘OK, let’s look at our patients for the day. We know that the 10:30, 1:30, and 4:30 are all here for a Xanax refill, so we want our behavioral health consultant to somewhat be on standby,’” Richards said.

It also helps for the clinic to develop a list of instances that should prompt a primary care physician to request behavioral health support, such as when a patient is newly diagnosed with a chronic disease, Wesco said.

That can simplify the life of physicians who are focused on medical diagnoses.

“They have enough to think about,” Wesco said.

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