When you walk through the halls of an integrated care agency, you might hear something like: “The treating PCP is an APRN, but she needs to consult the DO about any contraindications between the DPP-4 inhibitor, the SSRI, the Levothyroxine, and the naltrexone. The patient is slightly agitated and started taking Prozac five days ago. The MA needs to check Lipids and A1-C, then the patient needs to meet with the BHOT to go over the functional plan and review any recent behavioral activations of pain. Patient has her MAT visit next week with the MD and follow-up one week after with the PA. Remember to put in the schedule for the LPN to do vitals.” This workshop explains the various disciplines working in an integrated primary care behavioral health settings, including an overview of common medical terms used in this environment. It looks at everyday practices in a collaborative primary care behavioral health agency and explains how to better promote alignment of services, integration, and care coordination of patients with medical, mental health, and substance use issues. The presenter will describe common psychotropic medications, classes and indications used in primary care and how to collaborate with medical care providers about these medications. The presenter uses case study and personal experience to describe how he came to provide clinical care in an integrative, collaborative Federally Qualified Health Center.
Presenter: David Ferruolo, MSW, LICSW, MLADC, EdD.
David Ferruolo is a Clinical Social Worker at Health First. He has over four years direct practice experience at this fully integrated primary care & behavioral health Federally Qualified Health Center providing co-occurring counseling and MAT/Suboxone treatment clinic. In this role he provides supervision of other Social Workers, Occupational Therapists, and Counseling interns as part of HRSA integrated care model grant. David holds a Doctoral of Education degree from Plymouth State University and a Master of Social Work degree from the University of New Hampshire. His NH licenses include: Social Work and a master’s level Licensed Drug and Alcohol Counselor.
Using the case study of a client with chronic disease and a behavioral health diagnosis, Tracy Tinker will provide chronic disease information for behavioral health providers. She will describe the intersection of chronic disease and behavioral health as well as the bidirectional impact of chronic disease on behavioral health and behavioral health impacts on chronic disease management. She will review issues such as different languages used by multidisciplinary providers/misaligned objectives and potential barriers to integration. The latest statistics and guidelines related to Diabetes, Hypertension, and Dyslipidemia are included. At the completion of this workshop participants will be able to list at least 2 potential barriers to integration, identify and utilize strategies to overcome identified barriers, and understand the intersection of behavioral health and chronic disease management.
Presenter: Tracy Tinker, RN, MSN, CDE, CNL
Tracy Tinker is a Quality Assurance Nurse and Chronic Disease Coordinator at the Health Center for the Homeless in Manchester.
She has a Masters of Nursing and is a Certified Diabetes Educator with nine years’ experience. Tracy received her MSN from the University of New Hampshire and is licensed as a RN through the NH Board of Nursing. Additionally, she is a Certified Nurse Leader through the American Association of Colleges of Nursing.
This workshop will provide an overview of the key competencies needed to practice as a behavioral health clinician in primary care. National efforts to describe these competencies have been completed in the last few years. These will be described as well as the unique methods of developing these competencies. At the completion of this workshop, participants will be able to: describe the key attitudinal, knowledge and behavioral competencies needed to work as a team member in primary care. The will also be able to identify local methods that could be successful in developing these competencies in both continuing education and "on the job" training as well as identify ways of evaluating success at the individual and practice levels.
Presented by William Gunn, Jr., PhD
Dr. William (Bill) Gunn, Jr is a self-employed consultant contracted with the for Region Six Integrated Delivery Network (the Seacoast/Strafford region). Bill has thirty years of working in Primary Care Behavioral Health setting and has written two books on integrated care. He is also an Adjunct Clinical Professor in the Family Therapy Department at the University of New Hampshire. Bill received his PhD from Virginia Tech University; his master’s in education through James Madison University and is licensed in NH as a Clinical Psychologist.
This presentation uses case studies from a variety of target populations to highlight challenges and successes when serving clients in an integrated healthcare environment. This workshop will include an enhanced care coordination panel representing various Integrated Delivery Network (IDN) Regions.
Region 1 will explain how their copilot team serves a specific Medicaid population with a combination of complex medical needs, complex basic needs (housing, food, transportation), and mental health support needs.
Region 2 will share their Family Choices program which uses the NH Wraparound intervention model and is available to pregnant and parenting families with children through age 6.
Region 3 will present their Integrated Dual Diagnosis Treatment project to treat those with co-occurring SUD and mental health diagnoses.
Region 7 will describe a Community Health Workers’ role as the bridge between the patient in the community and the providers and services they need to access.
At the end of this session, participants will be able to describe different approaches to care coordination and identify barriers and mitigations that occur while providing care coordination for various target populations as well as describe at least 2 approaches to sustainability of care coordination models.
Panel Presentation (see below for speaker information)
Region 1: Jennifer Seher BS is the Program Director of the Aging and Disability Resource Center (ServiceLink) in the southwestern part of NH. She has worked collaboratively with NH BEAS and UNH to pilot U.S. Administration on Community Living (ACL) funding pilot for the current implementation of the NH Family Caregiver Program. In 2013 she worked in collaboration with NH BEAS, UNH CACL, and Cheshire Medical Center-Dartmouth Hitchcock Keene to pilot the Coleman CTI model for high risk patients transitioning from hospital to home. She is currently working in collaboration with Monadnock Family Services, Cheshire Medical Center-DHK, and other community partners to implement a program named Copilot which builds on the success of the ServiceLink care transition work with CMC-DHK.
Jennifer is a Critical Time Interventionist certified through the Center for the Advancement of Critical Time Intervention and a Master Social Work candidate through the University of NH.
Region 1: Glen Lawrence, MA is the Director of Adult Services at Monadnock Family Services.
He is responsible for the administrative and clinic leadership of a wide range of clinical services including adult clinical services, the Dialectical Therapy Program, and the Assertive Community Treatment Team. Along with the Medical Director, he oversees all aspects of intake, clinical programming and program development. He holds a Master of Arts degree in clinical psychology from Antioch New England Graduate School.
Region 2: Maryann Evers, LICSW is the Director of Family Support and Home Visiting at Child and Family Services. She has held clinical programmatic administrative positions in outpatient mental health and child welfare for over 30 years. Her expertise includes working with clients' experiencing substance use disorder and early childhood mental health. She has participated in multiple interdisciplinary projects focused on improving health outcomes for families and children. Maryann has a Master of Social Work degree in Reflective Practice from BU and is certified as an Early Childhood Mental Health clinician.
Region 3: Marie Macedonia, MS, PsyD is the Integrated Dual Disorder Treatment Team Coordinator at Greater Nashua Mental Health Center where she provides high level of care to individuals with serious and persistent mental illness and severe substance use. Since 2015, she has worked with individuals suffering from co-occurring disorders. She began working with adolescents struggling with substance related disorders during her pre-doctoral internship. Dr. Macedonia has a doctoral degree in Psychology from Antioch University New England.
Region 7: Annette Carbonneau is the Program Manager at the North Country Health Consortium where she is responsible for oversight and development of the Ways2Wellness Community Health Worker Program. This program is based on researched and evidence- based practices around the country. Annette has 14 years of non-profit experience managing projects that provide family, provider and community education.
Understanding and Addressing Substance Use Disorders as Chronic Medical Conditions
This workshop will address the neurobiological and psychosocial contributors to substance use disorders and general approaches to management. At the end of this session participants will be able to describe the roles of psychobehavioral and pharmacologic therapies in treatment of substance use disorders as well as the unique and common features of opioid, alcohol, cannabis and tobacco use disorders and their treatment.
Presented by Seddon Savage, MD, MS; & Mary Brunette, MD
Seddon Savage, MD, MS - Dr. Seddon Savage is an Assistant Professor of Anesthesiology at the Geisel School of Medicine at Dartmouth and a member of the NH Governor’s Commission on Alcohol and Other Drugs. She has more than 30 years clinical practice as a physician in the field of addiction and pain medicine. She has published, teaches and is a leader in policy and advocacy at the State and National levels on addiction for more than three decades . She received her Medical Degree from Dartmouth Medical School and is certified in Addiction Medicine through the American Board of Addiction. She also holds a Master of Science degree from Columbia University College of Physicians and Surgeons.
Mary Brunette, MD - Dr. Brunette is an Associate Professor of Psychiatry, Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock. As a board-certified addiction psychiatrist, she has been involved in research, clinical care, and service administration for people with co-occurring addiction and mental illness for 20 years. She has taught students, trainees and community clinicians on topics related to addiction in many venues locally and nationally. Mary received her medical degree from Oregon Health Sciences University. She is Board Certified in Addiction Psychiatry from the American Board of Addiction Psychiatry.
The alignment of multiple dynamic, highly diverse health and social service delivery systems is an ever-evolving endeavor. In this session, we review the Community Care Team (CCT) model that has been developed in the Region Six Integrated Delivery Network (IDN). The CCT is a working group comprised of decision-making representatives from over 50 clinical and non-clinical agencies and organizations that serve the most vulnerable members of our communities. The CCT is a functional exposition of “the network” in which service and support systems operate, and that creates a space in which those systems can be concurrently observed, understood, and aligned in real time. After describing the structure and functions of the CCT, we review cases that demonstrate its value for enhancing the accessibility to, and integration of behavioral, medical and social service assets to improve the health and wellbeing of the people we serve. Likewise, we describe CCT value to service providers in cultivating shared awareness and enhancing coordination through reducing systems gaps, redundancies, and incongruities, while building network awareness, resilience, and capacity to meet the ever-changing priorities and needs of consumers. At the end of this session, participants will be able to: provide a basic description of the CCT Model; describe the key tasks required to start and develop a CCT; describe the basic operations and tools used in a CCT; describe the value of a CCT for coordinated and integrated care models across a network of clinical/non-clinical entities; describe the value of the CCT for network development and systems alignment. This presentation may include breakouts where small groups engage with real CCT cases as a way to demonstrate the different types of value of the CCT.
Presented by Sandra Denoncour, BA, ASN, RN & Tory Jennison, PhD., RN
Sandra Denoncour, BA, ASN, RN Sandra recently moved from Lamprey Health Care to become Director of Care Coordination at the Region 6 IDN. While at Lamprey Health Care she was a Practice Manager in an integrated primary care behavioral health and OB/GYN services practice. Sandi has a Bachelor of Arts Degree from UNH and an Associate Degree in Nursing from Great Bay Community College.
Tory Jennison, PhD., RN Tory is the Director of Population Health/ Region 6 (Seacoast/Strafford) Integrated Delivery Network. She has 21 years of experience working in, designing, leading, and evaluating clinical and administrative coordination of multi and interdisciplinary teams across acute, primary, and home-based health care including integration of social non-clinical supports. Additionally, she has many years’ experience building resilient community-based systems of care across diverse populations. Ms. Jennison holds a PhD in Public Affairs from the University of Central Florida and a MS in Nursing Administration from UNH.