MENTAL HEALTH INTEGRATION PROJECT

1
MENTAL HEALTH INTEGRATION PROJECT

• ENHANCING MENTAL HEALTH PRACTICE
• IN PRIMARY CARE
• through improved education and communication.

Dr. Ken Casimir MD Affinity Medical
Group Dr. Mark Marnocha PhD UW-SMPH Family
Medicine Dr. John Mielke MD Appleton
Cardiology/Community Foundation Dr. Doug Moard
MD Thedacare Family Medicine Dr. Mark Rovick
DO Fox Valley Childrens Psychiatric/MCW
2
Setting

• Fox Valley region Third largest urban
  population area in Wisconsin
• Larger Cities Oshkosh, Neenah, Menasha,
  Appleton. Green Bay
• Smaller Towns Chilton, New London, Shawano,
  Hortonvlle, Kimberly, Kaukauna, Little Chute,
  Freedom.
• Limited Scope contiguous communities, and those
  with linkage via health systems x 2.
• Region/Community/Practice driven rather than
  state-level or discipline-specific.

3
Weaknesses/Threats

• Serious shortage of Pediatric Psychiatry
• Inadequate Adult Psychiatry Access
• Nation-wide shortage of psychiatry
• Strong Family Medicine practices, though majority
  not full-scope. (no inpatient medicine or Ob)
• Family Medicine forced to assume wider scope of
  MH practice.

4
Strengths/Opportunities

• Community interests in compassion, education,
  health-care, and youth services.
• Community Foundation w/physician voice.
• Connections with MCW and UW-SMPH Medical
  residency and consultation programs.
• Involved psychiatrists with community, primary
  care, and youth expertise.
• Community aim to improve MH access, align
  pediatric MH resources, and upgrade MH
  prevention.

5
Relevant Literature

• Diverse studies of upgrading MH care skills among
  primary care physicians.
• No clear gold standard as far as methods with
  well-documented and replicated results.
• Recent statewide initiatives to bolster primary
  care MH care skills, notably New York,
  Massachusetts, Nebraska.
• Pediatric MH concerns increasing, eg, ADHD
  overdiagnosis, proper use of atypicals, suicide
  prevention, emerging drug use, cyber issues.

6
MHIP Task Force

• 630 am meetings begun in 2011
• Coffee stat and prn
• Prior history of diverse connections among MHIP
  group members.
• Ongoing alignments with health systems, community
  initiatives, educational resources.
• Initial literature review.
• Questions about regional needs physician
  interest?
• Development of mixed Quantitative/ Qualititative
  semi-structured interview format.

7
Interview Format

• 11 Likert or other numeric items.
• 5 yes-no or other forced choice items.
• 4 open-ended questions.
• Comments solicited after all items.
• Interview responses transcribed by interviewers.
• Numeric and content summaries by 1st author.

8
Physician Survey InformationMHIP

• 21 semi-structured face-to-face interviews
• 12 female / 9 male regional physicians
• Snowball/Convenience Sample
• MD/DO mix
• Most Early-Middle career (3-20 years post
  residency)
• 17 Family Medicine, 3 Pediatrics, 1 Internal
  Medicine
• 8 Affinity 7 Thedacare 2 Kaukauna Clinic 1
  each FCCHC, PCA, UW, Independent
• From Appleton, Chilton, Greenville, Kaukauna, New
  London, Oshkosh, Shawano, Waupaca

9
General Numerical Findings

• 57 do not feel proficient caring for MH
  problems.
• 67 do not feel counseling is sufficiently
  accessible.
• Only 29 identify an MD partner w/special
  interests in MH care.
• Only 20 find MH care reimbursement to be a
  problem.

10
Physician Views about MH Changes

• BAD NEWS
  More Psychiatrists is most needed change,
  but least practical.
• GOOD NEWS
  More PCP training is 2nd most needed change,
  and the most practical.
• More Counseling is moderate in need and
  practicality.
• Reimbursement Change is least needed, and
  2nd least practical.
  

11
Need for MH Changes

• 5 change areas rated from 4 Great Need to 1
  Minimal Need

12
Practicality of MH Changes

• 5 change areas rated from 4 Highly to 1
  Minimally Practical

13
Physician Interest in MH Training

• 95 indicated they are either Very amenable -
  Sign me up or else Interested-Have some
  questions.
• Only 1 MD (later career) not interested!
• Only 24 (5 Physicians) said they need any
  compensation for such training.
• EXTENSIVE ideas from physicians for training
  content, AND for in-depth group training
  face-to-face with primary care peers and
  psychiatry / MH resource people.

14
Interview Content Summaries

• Mental Health Care Concerns Lack of
  communication w/psychiatry poor access to
  general MH resources access to psychiatry
  resources unfamiliarity.
• Suggested Training Areas Refractory depression
  Younger children Bipolar Schizophrenia
  Suicide ADHD Managing meds Algorithms for
  treatment, diagnosis Listening/counseling.

15
Initial MHIP Conclusions

• Additional psychiatric training is clearly
  identified by PCPs as both necessary and
  practical
• 95 of surveyed PCPs were either interested or
  very interested in structured psychiatry CME
  training
• Only 24 of surveyed PCPs identified a need for
  reimbursement for CME time

16
Conclusions (continued)

• PCPs identify their relationships with
  psychiatrists as less than satisfactory
• Communication regarding available mental health
  resources is inadequate
• Improvement of MD-MD relationships, along with
  readily accessible network re available
  resources is essential

17
Current status of project

• Community Funding
• Initial curriculum per ASCP, with augmentation
  prn
• 9 monthly evening sessions
• Emphasis on complex cases, minimal basic review,
  and current evidence/practice updates
• 2.5 hours with dinner
• 50 registrants including NPs and
  students/residents. Future iterations may
  include office staff involved in MH case
  management
• Session eval forms pretest and posttest
  assessment of comfort with aspects of complex OP
  MH care.