Mental+Health+Trouble+Shooting+2-2015

Dear providers, **This is a Behavioral Health Integration update regarding the status of mental health and substance use services in the ten county clinics.** As you must know, everything is in its pilot stage. The main clinic "laboratories" are Concord Health Center 1 and 2 as well as the new Miller Wellness Center but all clinics are rolling out Behavioral Health Integration. There is a large cross-divisional team involved in this effort.

__1) How are behavioral health patients identified for intervention?__ **In addition to chief complaints and roster huddles, we also have an annual screen called the SBIRT** which screens for depression (PHQ-9), alcohol (AUDIT) and drugs (DAST). There is a large effort underway by registration, nursing, CHWs, providers and IT people to move this forward systematically. The screen has minimal impact on workflow if patient is negative on the initial screen. **If they screen positive, the nurse will go through the full screen with the patients during the intake process. The hope is that the nurse will then be able to report the score and assessment of risk to the patient ("You scored a __. This means you have moderate depression") and then alert the provider as well as any behavioral health staff at your site.** We are working to make this part of the "standard workflow" for all clinics. As clinic staff gets more training on brief intervention and resources for referral, more can be expected.

__2) What are possible interventions after patient need is identified?__ There has been so much effort to get the screen going in all the clinics that we are still working on standardizing the interventions for screen positive patients. Eventually, I would like to send an update that lets you all know the algorithm for mild versus moderate versus severe patients and then make this part of standard workflow so that your role is clear as part of an overall team flow. Until then, I will list the **possible interventions available to you depending on severity of patient and the resources in your region.** This is in addition to a possible brief intervention discussing screen results which is itself a meaningful intervention **:** **For mild to moderate patients:** **1) Referral to a LCSW or psychologist for therapy.** **ALL Medi-cal patients with mild to moderate mental health needs are eligible for therapy and it is paid for.** No more lists of low-fee or sliding scale providers. It is now a mandated benefit. **You need to fill out the "MH INT REF--Access Line".** This referral is now electronic so there is no fax vortex and you can instead **track what happens to this referral under the referral tab.** The Access Line will then try to contact the patient and give them a list of 3 names of therapists in the community to call to set up their own appointment. About 34% of those referrals still end in patient not being able to be contacted. So, this is still a work in progress. **Please ensure the patient phone number is correct and patient is willing. If you feel there are persistent issues with this referral, please let me know.** **2) If you work at WCHC, MHC1, MWC or PHC, then you also have the option of calling the Wright Institute psychologists for a warm handoff and short-term therapy. A warm handoff is preferred for these patients rather than a referral** **out** as it increases the likelihood of continuing with their follow-up Wright appointments and increases communication between providers in clinic. The Wright Institute has been crucial to integration and team work in real-time at these sites and you are lucky if you have them.

**For severe patients or patients refractory to mild to moderate interventions:** P**lease make a referral to county MH for severe patients using the same "MH INT REF"** and pressing the med management button. In addition, there are at least five ways to get support or increase linkage: 1) **Call the new, seasoned and very friendly Consult Liaison psychiatrist Vince Perez from county MH. He is on-call for you M-F 8:30-4:30pm and his number is on Amion.** You can call him for help with med management on patients that are refractory to your first-line SSRI treatment or who need help with med management before they get into county MH. There is no strict criteria--you can call him for help just like you would call any other consult. 2) **Send** **severe patients who are already known to the three county MH clinics but are having trouble with appointments/meds to WALK-IN to the MH clinic via the new "Rapid Access" program between 10am-3pm M-F**. Keep in mind this is still being standardized across sites but is especially tailored to patients recently discharged from PES and 4C. 3) **Inbasket your local MH program manager. This will be a good name to put in your contacts**. I have included the phone number as well. West Adult--Matthew Luu (510)215-3700 ; West Children--Chad Pierce (510)374-3261 ; Central Adult--Guillermo Cuadra (925)646-5480 ; Central Children--Jan Cobaleda-Kegler (925)646-5468 ; East Adult--Beverly Fuhrman (925)431-2621 ; and East Children--Eileen Brooks (925)427-8664 . <span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;">4) **If you work in WCHC, MHC1, MWC, CHC2 then you can also call the behaviorist** to help with linkage to county MH as well as other CBOs and AOD providers in community. Again, **the warm handoff here makes all the difference** **and the behaviorist can contain crisis with short-term therapy and linkage to MH**. They are MH employees and have insider access to the MH electronic record and MH staff to help providers and patients. We are in the process of hiring 2 more behaviorists for East County clinics. <span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;">5) Do not forget **PHN and CCHP case management referrals** also are very helpful for all patients with behavioral health needs as well as basic needs.

<span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;">__3) So, what do I really need to know and who can help me meet the needs of a patient with a behavioral health problems?__ <span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;">**I strongly believe our county providers are amazing and have been unintentional therapists and psychiatrists in addition to primary care providers for many years. This can change if you need it to--please use the above services. For mild to moderate patients, think about therapy via warm handoffs and referrals. For severe patients, think about warm handoffs, referrals, walk-in or inbasket to local MH clinics. For all patients with behavioral health needs, remember you can call the Consult Liaison psychiatrist on Amion and make referrals to Case Management.** <span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;">Also know that I am acutely aware: 1) strict definitions/criteria for resources based on severity does not capture the spectrum of need for our patients, 2) there is inequality between services available between different clinics sites, 3) the clinics will benefit from more resources for patients with substance use disorders and, 4) the more we can systematize and standardize integration in clinic workflow and IT infrastructure, the less we need to depend on provider memory of this email or the contacts list on your phone.

<span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;">__4) How can you help__ __Natasha__ __help you?__ <span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;">****This is a work-in-progress. Your feedback on where the system is breaking down for you is crucial. Please inbasket/email me with any patient cases**. Specific patient cases are MUCH more helpful to me than general feedback because then I can pursue solution in real-time with appropriate division/staff with something tangible. Any success stories are also helpful.**

<span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;"> Natasha Pinto, MD <span style="display: block; font-family: Helvetica,Arial,sans-serif; font-size: 16px;">Behavioral Health Integration Physician Coordinator

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