This book presents evidence and strategies for assessing psychiatric issues in severe obesity and uses common psychiatric presentations to feature the impact on bariatric surgery and key assessment features for weight loss. Concluding chapters focus on evidence-based psychosocial treatments for supporting patients with weight loss and bariatric surgery and includes educational tools and checklists for assessment, treatment, and care.
Experts on non-pharmacological interventions such as mindfulness, cognitive-behavioral therapy and nutrition education describe treatment approaches in each modality, concluding with pharmacological approaches for psychiatric conditions and eating pathology. Additional tools in the appendices support clinicians, making this the ultimate guide for managing psychiatric illness in patients suffering from severe obesity.
As obesity continues to grow in prevalence as a medically recognized epidemic, Psychiatric Care in Severe Obesity serves a vital resource to medical students, psychiatrists, psychologists, bariatric surgeons, primary care physicians, dietitians, mental health nurses, social workers, and all medical professionals working with severely obese patients.
It is a much-needed resource for professionals managing the emotional well-being of this patient group, especially given the prevalence of mental ill health within this cohort. Its broad swath of topics ranging from bariatric surgery to mindful eating and everything in between makes it a unique and helpful resource for anyone providing care to patients with severe obesity.
Psychiatric Care in Severe Obesity : An Interdisciplinary Guide to Integrated Care - honavurakowy.tk
Finally, while administrators and providers were optimistic that Medicaid Health Homes have potential to improve access to care for adults with serious mental illness, the newness of the initiative made it difficult to assess the degree to which Health Home networks would meet these goals. We conclude with recommendations to state policymakers, clinical providers, and technical assistance providers and recommendations for future research, all designed to strengthen New York state's integrated care initiatives for adults with serious mental illness.
This report describes the RAND Corporation's examination of approaches to integrated care implemented by New York state community mental health centers for adults with serious mental illness. The purpose of the project was to generate information that will help state policymakers streamline the adoption of promising approaches to improving the overall wellness and physical health of people with serious mental illness by making primary medical services available in or coordinated by staff in the mental health settings where this population already receives care.
To do this, we characterized, compared, and contrasted three integrated care initiatives operating in the state. From this information, we generated recommendations to state policymakers, clinical providers, and technical assistance providers, as well as suggestions for future evaluation to further strengthen initiatives ongoing in New York state. Adults with serious mental illness have a wide range of medical, behavioral, social, and other service needs see Table 1.
Consequently, comprehensive care for this population is best achieved by a system of care in which providers of multiple types work together to ensure that all of these needs are met. In this report, we focus on a modest, but critical, piece of this systems and services puzzle: the integration of primary medical and mental health services.
We focus on the integration of primary medical and mental health services for adults with SMI because the excess morbidity and mortality in persons with SMI is a public health crisis. Compared with people without mental illness, individuals with SMI e. Numerous factors contribute to the excess burden of general medical conditions among persons with SMI, including low levels of self-care, medication side effects, substance abuse comorbidity, unhealthy lifestyles, and socioeconomic disadvantage Burnam and Watkins, ; CDC, ; Druss, Within the health care system, attention is focused on barriers to care that result from the organizational and financial separation of behavioral and general health care sectors.
These barriers, it is widely believed, contribute to disparities in access to and the quality of general medical care for people with SMI Alakeson, Frank, and Katz, ; Bao, Casalino, and Pincus, ; Druss, ; Horvitz-Lennon, Kilbourne, and Pincus, Consequently, integration of care, in particular the integration of primary care into mental health settings, has become a focus of several state and federal policy initiatives. Some different perspectives on and approaches to integrated care are reflected in three recent initiatives promoting the integration of primary care and mental health services for adults with SMI being implemented in New York state.
These include:. The PBHCI grants program provides a solution to the one-time costs associated with establishing a new program of integrated care through finances to support infrastructure development e.
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It also provides short-term grant period financing for other nonbillable services such as peers and wellness services that may be of particular value to consumers. At the time of this report, more than PBHCI grantees have been awarded, with another cohort of unknown size scheduled for funding in fiscal year The New York state OMH Medicaid Incentive is designed to encourage the provision of primary care services in mental health clinics using a market incentive mechanism.
Through this mechanism, clinics add primary care services to their operating certificate, thereby expanding their billable scope of practice. New Medicaid billing codes were introduced for this purpose, and to qualify to use these codes, clinics had to first apply to OMH for permission and demonstrate that they had the personnel and facility resources to provide the services.
Clinics could be approved at two levels of care intensity: A low-intensity level defined as health monitoring ; and a high-intensity level that includes both health monitoring and health physicals. At both levels, the Medicaid Incentive program removes some barriers to providing physical health services in settings where adults with severe mental illness interact with the health care system most frequently.
Under this program, physical health services are reimbursed on a fee-for-service basis, do not require referral, and can be billed on the same day as a mental health service. How providers and consumers perceive this shift in practice is one of the questions that we address in this study. New York state Medicaid Health Homes are integrated networks of diverse health care providers designed to provide seamless multidisciplinary care to patients with complex medical needs. Health homes are managed by lead organizations, generally large health care provider agencies. Care for individual patients is managed by community-based organizations that have subcontracted with the lead organization to provide care coordination services.
The care coordinators work with the network of health care providers and community providers of services such as supportive housing, legal assistance, and food assistance to provide comprehensive, integrated care to health home enrollees. Health Homes are designed to facilitate consumer access to care through coordination of services at the system level, within a network of existing providers. This is in contrast with the programs described above that aim to integrate care at the setting level, within behavioral health clinics.
The aim of this study is to describe the operation of each of three ongoing approaches to integrated care for adults with serious mental illness implemented by community mental health centers operating in New York state. In particular, we emphasize the mental health clinic perspective on integrated services either offered or coordinated by the mental health agency, because the mental health clinic is often the gateway through which adults with SMI access the health care system Bao, Casalino, and Pincus, Readers should note that this is a descriptive, qualitative study in which we aim to learn from the experiences of clinics that were strategically selected due to their efforts to provide primary care services to adults with SMI.
The study is not an evaluation of mental health—based primary care overall or of any of the three models that we examined, and we cannot address evaluative questions about impacts of initiatives on outcomes or total health care costs.
Instead, this study is designed to highlight institutional, regulatory, and design features that help or hinder current policy efforts in New York state, on the presumption that the goals and strategies of these policies will remain a priority for policymakers. Readers should also note that while the perspectives of substance use providers are not systematically included in this study substance use services are overseen by a separate, third regulatory agency in New York state and are therefore beyond the scope of this project , we strongly encourage decisionmakers to consider how those services can also be integrated for adults with serious mental illness, given their high rates of comorbidity and considerable impact on the outcomes of any mental health or medical care that consumers receive.
Data for this project come from two sources: visits to sites investing in innovations in the delivery of mental health—based integrated care, and surveys of mental health clinics and affiliated providers. Sites were selected with three goals in mind: 1 geographic diversity, representing New York City as well as rural and urban upstate areas; 2 representation of all three of the integrated care initiatives available to clinics currently ongoing throughout the state; and 3 active and innovative efforts to improve the provision of primary care services to their adult clients with SMI.
We strategically visited innovative sites in order to identify solutions and other promising practices from clinics, administrators, and clinicians who are actively working on the challenge of mental health—based integrated care. As a result of this selection strategy the clinics in this study are not representative of mental health clinics in the state and may be biased toward clinics that have more effective service delivery systems overall.
Site visits were conducted between October and March The overarching goal for the site visits was to gain a broad understanding of how primary care services fit into the mental health service delivery system. During visits, we toured facilities and conducted interviews with as many different types of clinic staff as time and scheduling allowed. We also met with groups of consumers at most sites. Topics covered during site visits included but were not limited to clinic structures, range of services provided, composition of the care team, target population and consumers served, clinical work flow, Health Information Technology HIT , use of data for practice management and continuous quality improvement, clinic culture of integration, and sustainability, as well as policy impacts, barriers to integration, and promising integrated care practices being developed by the clinics.
We also fielded two separate yet complementary surveys to 1 mental health clinic administrators, and 2 providers affiliated with mental health clinics providing or coordinating integrated care. A stratified, random sample of remaining clinics was selected from a list of all licensed Article 31 clinics in the state provided by OMH. The sample was selected to have equal numbers of clinics with and without OMH Medicaid Incentive licenses and to be equally distributed across regions of the state. Survey topics were the same as those covered during site visits.
The survey response rate to the provider survey was acceptable for a web-based survey 69 percent. Although survey respondents broadly represented the array of clinics and providers meant to be included in the study, the overall response rate to the clinic survey was low 20 percent. All participating mental health clinics were Health Home affiliated and typically affiliated with more than one Health Home.
Clinics of all types offered on-site screening and monitoring of physical health conditions, and at almost all clinics, mental heath care records were maintained in an electronic format; few of these records, however, were integrated with records from primary care or other physical health care providers.
Providers of all disciplines described closer collaborative relationships at clinics offering a broader scope of physical health services on site even when the scope of these services was limited, as in Medicaid Incentive clinics , suggesting that providers who work together in the same space may have more opportunities to build trust and respect related to the provision of integrated care. Overall, providers from all clinic types reported that they perceived that their integration efforts were improving consumer access to physical health care services and outcomes.
The PBHCI clinics were larger, serving more adults with SMI than other clinic types, and more likely to be situated within agencies with a medical hospital affiliation potentially facilitating access to primary and other medical services, plus other infrastructure to support physical health care such as HIT. Importantly, PBHCI clinics were more likely than other clinic types to have obtained on their own or via a partner organization a Department of Health Article 28 license to provide comprehensive, on-site primary care. Licenses and availability of grant funding likely affected staff membership on the care team: PBHCI clinics were more likely to employ case managers, peers, and wellness specialists.
PBHCI clinic administrators described a broader role for case managers than at other clinics, and perhaps relatedly, PBHCI clinic staff also reported greater success enrolling consumers in integrated care initiatives, including Health Homes. In contrast, Medicaid Incentive clinics tended to be smaller, free-standing non-hospital-affiliated entities. Medicaid Incentive clinics provided only the limited scope of primary care services health monitoring, health physicals permitted by their licenses.
Participation in the incentive did not typically alter clinic infrastructure e. For instance, primary care services were often provided by existing mental health staff e. Medicaid Incentive clinic administrators also reported a comparatively narrow role for case managers in consumers' overall care.
Finally, mental health clinics participating in Health Homes but not PBHCI or the Medicaid incentive program were varied, including academic medical center—affiliated clinics and free-standing clinics of varying resources, capabilities, and size. Among these clinics, overall, we observed that participation in the Health Home did not alter the clinic's scope of practice. As intended by the program, participation in Health Homes appeared to be associated with increased reliance on case managers and networks of agencies to get consumers access to primary care.
Overall, clinic staff reported that state-level investments in integrated care infrastructure, such as Psychiatric Services and Clinical Knowledge Enhancement System PSYCKES , the Regional Health Information Organizations RHIOs , and state drug databases, were helpful for characterizing and tracking consumer status and care outside of their immediate system of care.https://senjouin-renshu.com/wp-content/69/2132-rastrear-numero-de.php
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Several differences across integrated care initiatives were also observed. The scope of services supported by the grants including staff trainings regarding their expanded role at the clinic helped to create an integrated care culture. In contrast, integrated care culture change was not observed in the clinics that were using the Medicaid Incentives, despite the fact that the administrations of these clinics were committed to the same goal of whole person consumer care albeit many of them with fewer resources to support integration from the outset.
Specifically, Medicaid Incentive services were provided as part of a clinic routine, e.
Psychiatric Care in Severe Obesity
For instance, aside from those who were providing the specific Medicaid Incentive services, staff did not receive trainings on the importance of, or steps toward addressing consumers' physical health care needs. Overall, we found that consumers placed little value on the Medicaid Incentive—supported services because services did not address their desires for improved access to acute treatment services for physical health conditions such as headache or flu.
Health Homes represent a different approach to integration, focusing on coordinating care within a network of providers rather than developing a new or modifying a specific, existing clinical setting. The Health Home has the potential to complement any scope of primary care offered in, or coordinated by, the mental health clinic including PBHCI and the Medicaid Incentive because case managers are meant to be able to link consumers to any needed additional services elsewhere within the network.
Health Homes' potential, however, is not yet clear since the program is in its early stages, and medical providers expected to accept SMI adult referrals contacted by Health Home case managers were often unaware that the program existed at all. We observed several clinic features that appeared to be associated with program success across initiatives. Such clinics were also able to use existing groups to offer wellness services, contributing to centerwide shifts towards a culture of health and shared accountability for mental and physical health care.
Clinics described having increased access to consumer information about hospitalizations, discharges, and other significant events that wasn't previously available, thereby increasing their ability to do timely follow-ups and target case management resources to consumers most in need. Third, successful clinics were eager to take advantage of the information-sharing privileges associated with the Health Home. While the newness of some of the Health Home networks made the ultimate impact of this feature difficult to assess, clinics anticipated that information sharing within the Health Home would streamline their current processes for connecting consumers to services not available on site while also supporting continuity of care.
Fourth, as with many health care reforms, we observed that institutional champions were often credited for enabling clinics to implement integrated care in institutions and communities where it otherwise did not exist. In this case, champions were often individuals with particular expertise in health systems and finance who could navigate a complex policy context and leverage or flex existing resources to accommodate integration. Relatedly, some of these champions created legacies sustained through the creation of training programs e.
Administrators described challenges integrating services at the systems e. At the systems level, challenges to integration included access to licenses that facilitated integrated care, maximizing existing infrastructure e. While administrators from all clinic types reported the belief that forthcoming managed care programs would impact sustainability potentially in positive or negative ways , in general, financial concerns were different across clinic types.
Within PBHCI clinics, administrators were concerned about the sustainability of wellness, peer, and care management services following the end of the grants. In some cases, administrators expressed concerns that payers were not keeping pace with policy and that claims for legitimate integrated services e. At Medicaid Incentive clinics, sustainability concerns were more moderate and related to perceptions that current reimbursement rates defrayed but did not cover health physicals and health monitoring costs and were not available to support any related medical needs such as follow-up on referrals to physical health treatment.
Finally, sustainability was a major concern among Health Home clinics and providers. In particular, concerns were widespread that changes in reimbursements e. At the clinic level, clinics of all types reported concerns related to information sharing among providers on the care team, including those at affiliated agencies, and accessing appropriate and timely social services particularly transportation and housing to enable consumers to take advantage of integrated primary and behavioral health offerings.
Clinics of all types developed unique and innovative approaches to the delivery of integrated care. They included innovations in work flow, such as weekly, interdisciplinary case conferences and a web-based care coordination platform allowing providers to communicate routinely in a virtual space, including a dashboard and real-time alerts regarding changes in consumer status e. Case managers using the virtual space also used the platform as a clinical registry, generating lists of consumers with specific identified needs including information drawn from the local RHIO.
However, a challenge of this system was that providers with only a few consumers enrolled in the Health Home were unlikely to use the system, since it required them to go outside of their local EHR. Clinics also created innovations in the structure and composition of the care team, such as leveraging the experience of peers to model healthy lifestyle changes and engagement in wellness programs, plus creating new positions i.
Some clinics also restructured their care teams in accordance with the Health Home model, putting the case manager at the head of the care team.
Finally, we also observed innovations in sustainability planning in clinics with Article 28 full primary care licenses; typically PBHCI but also select Health Home clinics such as opening medical clinics to consumers' family members and care givers, in order to increase census and increase provider opportunities to bill.
Our research has several limitations. Briefly, site visits were conducted at a small, select sample of sites and do not represent the large and diverse population of mental health clinics in New York state. The response rate to the project survey was low, limiting the extent to which results can be widely generalized. Perspectives of clinics not participating in integrated care were not included.
Finally, since the clinics that implemented each of the integrated care initiatives are likely to differ from other clinics in ways that we were not able to measure, our observational design precludes us from definitively disentangling effects of the models from underlying features of the clinics that implemented them. To meet this end, we recommend the following actions or changes:. New York state's mental health clinics are implementing a range of integrated primary medical services for their adult consumers with SMI with support from a range of initiatives.
These initiatives provide varying levels of financial and technical support to clinics and staff, and these different levels of investment are reflected in the scope and intensity of services that are made available to consumers, plus the extent of work flow and culture change occurring within clinics. Alakeson, V.