Ceu pdf 211 by Brett Johnson

Laurie Alexander, PhD Alexander l d BH Consulting

Karl Wilson, PhD Crider Health Center

Audience Poll: How do you self-identify?       

Consumer Family member Mental health or substance use provider Primary care provider Ad t Advocate Policymaker Funder 2

BIDIRECTIONAL INTEGRATED CARE 101: WHAT YOU NEED TO KNOW Laurie Alexander Alexander, Ph Ph.D. D Alexander Behavioral Healthcare Consulting laurie alexander09@gmail com laurie.alexander09@gmail.com

For today – The basics 4



Definition of bidirectional integrated care



Rationale for integrated care



Approaches pp to integrated g care



State & national activities



How you can get involved & learn more

Bidi Bidirectional i l IIntegrated dC Care 101

What is bidirectional integrated care?

Integrated health care 6



“…in …in essence integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems p ob e s o often te occu occur at tthe e sa same e ttime. e Integrating services to treat both will yield e bes best results esu s a and d be the e most os the acceptable and effective approach for g served.” Hogg gg Foundation for Mental Health,, those being Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S., www.hogg.utexas.edu

Bidirectional integration 7

Integrating PC services into MH/SU settings AND Integrating MH/SU services into PC settings **In both cases, the services are not just provided, but coordinated with other care delivered in that setting *PC = primary care; *MH = mental health; *SU = substance use

A word of clarification 8



Focus is on the integration of services



This may or may not involve the integration, or merging, of organizations (often not)  NOTE:

Will not cover organizational / structural integration or payment / financing today today, but useful information on those topics in resource list later in presentation

Bidi Bidirectional i l IIntegrated dC Care 101

Why y integrate g p physical y and behavioral health care?

Seeking BH care in primary care 10



Most people seek help for BH problems in PC settings



~1/2 of all care for common psychiatric g disorders happens in PC settings



Populations of color are even more likely t seekk or receive to i care in i PC th than iin specialty BH settings *PC = primary care *BH = behavioral health (i.e., MH + SU)

Why seek MH care in PC settings? 

Uninsured or underinsured



Limited access to public MH services



Cultural beliefs and attitudes



Availability y of MH services,, especially p y in rural areas *PC = primary care *MH = mental health

BH p problems in primary p y care 12



Mild to moderate BH issues are common in PC settings Anxiety, y, depression, p , substance use in adults  Anxiety, ADHD, behavioral problems in children  Prevention and early intervention opportunity 



People with common medical disorders have high rates of BH issues 

E.g., Diabetes, heart disease, & asthma + depression  Worse outcomes & higher costs if both problems aren’t addressed

Usual care in PC settings g 13



MH problems often go undetected and untreated d iin PC



When PCPs do detect MH problems, they tend to undertreat them



Populations of color, color children and adolescents, older adults, uninsured, and low-income p patients more often receive inadequate care for MH problems



SU care involves same issues issues, if not worse *PCP = primary care provider; *SU = substance use; *MH = mental health

Medical issues in BH settings g 14



People p with serious mental illness ((SMI)) are dying 25 years earlier than the general population.



2/3 of premature deaths are due to preventable/treatable medical conditions such as cardiovascular, pulmonary, and infectious diseases.



44% of all cigarettes consumed nationally are smoked by people with SMI SMI.

See www.nasmhpd.org for Morbidity And Mortality In People With Serious Mental Illness report (2006)

Medical issues in BH settings g 15

ď&#x201A;¨

Oregon state study found that those with coco occurring MH/SU disorders had worst early mortality gap ď&#x201A;¤ Average

age of death for those with co-occurring MH/SU = 45 years (vs. 53 for those with SMI)

B. Mauer & C. Weisner (2010) California Institute for Mental Health webinar The Case for Integrated Care: www.cimh.org/LinkClick.aspx?fileticket=AK6sNXKyXo%3d&tabid=804

Usual care in PC settings g 16



BH consumers in PC settings:  Are

less likely to receive effective medical care, including preventive services

 Report

difficulties establishing relationships with

PCPs Time

limitations and stigma

Usual care in MH settings g 17



2007 survey of National Council members (CMHCs) revealed limited capacity to screen and provide medical care:  2/3

can screen for common medical problems.

 1/2

can provide treatment or referral for those conditions.

 1/3

can provide some medical services on-site. * CMHCs = Community mental health centers Druss, et al (2008). Psychiatric Services, 59:917-920.

Key y opportunity pp y 18



Integrating care offers an important opportunity to reduce disparities:  Eliminate

the early mortality gap

 Reach

people who cannot or will not access specialty BH care

 Intervene

worsen

early before issues develop or

Bidi Bidirectional i l IIntegrated dC Care 101

What is effective integrated g care?

Integrating g g BH into PC 20



Helpful but not sufficient Helpful,  Physician

training

 Screening  Referrals  Co-location

of services

*PC = primary care *BH = behavioral health (i.e., MH + SU)

Strongest g evidence base 21



Collaborative care  >25

years of research  >38 randomized controlled trials trials, including IMPACT 

Adaptation of Wagner’s chronic care model www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Mod el&s=2

IMPACT Study: J Unutzer, JAMA. 2002;288:2836-2845; and AIMS Center http://impact-uw org/

Collaborative care’s key ingredients 22



Care management – Patient education & empowerment, ongoing monitoring, care/provider coordination



Evidence-based treatments – Effective medication management, psychotherapy



Expert consultation for patients who are not improving



Systematic y diagnosis g and outcome tracking g



Stepped care



Technology support – registries

J. Unutzer, 2010, www.cimh.org/LinkClick.aspx?fileticket=84F6JQndwg8%3d&tabid=804

Screening, Brief Intervention, and Referral to Treatment (SBIRT) 

Identification of behavioral problems (alcohol, other drug, tobacco, depression, anxiety) & level of risk



Low risk: Raise awareness and motivate client to change



Moderate risk: Provide brief treatment (cognitive behavioral, medications)) with clients who acknowledge g risks and are seeking help



High g risk: Refer those with more serious or complicated p MH/SU conditions to specialty care



Used in primary p a y care ca e centers, ce e s, hospital osp a ERs, s, trauma au a ce centers, e s, a and d other community settings See http://sbirt.samhsa.gov/ for more information

Integrating PC into BH settings 

Same p principles p appear pp to apply pp y



Beginning steps  Screening

and tracking of basic health indicators for everyone on psychotropic meds  Glucose, Glucose

lipid levels levels, blood pressure pressure, weight weight, BMI BMI, etc

 Identification

of & coordination with the PCP



Wellness programs, including peer-led



C ll b ti care Collaborative *PCP = primary care provider

Bidi Bidirectional i l IIntegrated dC Care 101

Where does the Medical Home fit in?

The Medical Home 26



Patient-Centered Medical Home (PCMH) Ongoing relationship with a PCP  Team with collective responsibility for ongoing care  “Whole Whole person” person orientation 

 PCMHs

need MH and SU capacity – i.e., MH and SU services need to be integrated into the medical home



P Person-Centered C dH Healthcare lh H Home  Healthcare

home may be a PC or BH setting depending on a person’s person s preference

See www.thenationalcouncil.org for more info on the person-centered healthcare home and the role of MH/SU in medical homes. See www.pcpcc.net site for more about medical homes.

Bidi Bidirectional i l IIntegrated dC Care

How do people receiving g integrated services feel about their care?

Consumers’ take on integration 

People receiving integrated services report higher quality of life and greater satisfaction with:  Access  Attention

to their treatment preferences

 Courtesy  Coordination  Overall

& continuity of care

care Druss et al, Arch Gen Psychiatry. 2001; 58(9): 861 8 861-8. Unutzer et al, JAMA. 2002; 288(22): 2836-2845. Ell et al, Diabetes Care. 2010; 33(4): 706-713.

Consumers’ take on integration “It is great having my two providers in the same building because they talk with each other at the time of the problem rather than me having to wait until I see my provider for psych meds and/or my therapist.” – Jackie, Pathways Community Behavioral Healthcare, Clinton, MO

Consumers’ take on integration “Around the time that my bipolar condition was identified, I was diagnosed with kidney disease. Between the two disorders, it was a pretty upsetting time in my life… My doctors, dialysis clinic staff, and mental health case manager are wellll connected. t d They Th take t k a team t approach, h and d they each check on the status of my health... Today I have control over my health; it doesn doesn’tt have control of me. The coordinated care allows me to feel like I can go out and be a part of the community.” – Cassandra McCallister, Board Member, Washtenaw Community Health Organization, Ypsilanti, MI

Consumers’ take on integration …I’m not saying y g everything y g is p perfect because it isn’t. I’m still working hard with the CBT to change my negative way of thinking. Living with my blindness isn’t easy. As Rachel (care manager) says, “It’s not for sissies.” But I can’t imagine where I’d be now if it weren’t for the great team that pulled together to make sure I didn’t fall th through h the th cracks. k – Joann Gilbert, Project Vida Health Center, El P Paso, TX Videotaped at Hogg Foundation’s 2008 conference Integrated Health: C ti B d & Mi d R b t L S th l d S i XV Vid

Bidi Bidirectional i l IIntegrated dC Care

What is going on around the nation?

Local / regional g activities 33



Thousands of BH & PC providers partnering       



Mid-State Health Center (NH) Meridian Behavioral Healthcare (FL) Volunteer Behavioral Health Care Services (TN) ( ) Verde Valley Guidance Clinic (AZ) People’s Community Clinic (TX) Navos (WA) Sierra Medical Center (CA)

Integrated systems    

Crider Health Center (MO) Cherokee Health Systems (TN) Washtenaw Community Health Organization (MI) Intermountain Healthcare (UT & ID)

State-level work 34



State efforts via Transformation and block grant funds in AL, MI, PR, WV, MO, OK, OH, NM, & WA



National N ti lC Council-led il l d statewide t t id llearning i communities in TX, ME, & IL 

Funded by Hogg Foundation, Foundation Maine Health Access Foundation, & Community Behavioral Healthcare Association of Illinois



Minnesota DIAMOND



California’s CalMEND initiative

National / federal efforts 35



Health reform – PCMH payment reform via Medicaid; PC in BH demonstration grants



SAMHSA PC BH Integration grants



HRSA behavioral health expansion grants



Patient-Centered Primary Care Collaborative



SAMHSA/HRSA TA Center (upcoming)



AHRQ resource center (upcoming)

Bidi Bidirectional i l IIntegrated dC Care

How do I g get involved?

Where to start 37

ď&#x201A;¨

Learn more

Learning g more 38



National Council – listserv & website



Hogg Foundation for Mental Health – resource guide



California Institute for Mental Health – webinars



IBHP - CA Endowment/Tides E d t/Tid C Center t – tool kit



AIMS Center – Universityy of Washington g – training g



Patient-Centered Primary Care Collaborative



Collaborative Family Healthcare Association

Where to start 39



Start conversations with local providers or your own PCP  Raise

awareness  Share information 

Get involved in advocacy  Financing

issues  Incorporation of recovery principles  Training and other workforce issues

Getting g started as a provider p 40



Map core functions on to staffing resources  What

are the basic activities your center needs to accomplish?

 Who

is doing them currently? If no one, who could ld ttake k th them on? ?

 What 

additional resources are necessary, if any?

AIMS Center planning tools http://uwaims.org/implementation_tools.html

CONTACT INFORMATION Laurie Alexander, Ph.D. g Alexander Behavioral Healthcare Consulting laurie.alexander09@gmail.com

 

Community Mental Health Center since 1979 Community Health Center since 2006 ◦ Vi Vision: i Full, F ll productive, d ti h healthy lth li lives ffor everyone ◦ Mission: To build resilience and promote health through community partnerships ◦ Became FQHC in 2007



Service area:

◦ 520,000 people ◦ Four Missouri counties outside St. Louis



Children and Families

◦ School-based prevention/ mental health promotion and early intervention (53 (53,000 000 children and youth/year) ◦ School- and home-based interventions (system of care))



Adults with serious mental illness ◦ Community Support Teams ◦ Two ICCD certified clubhouses

 Transitional and supported employment

◦ Housing

 Supported community living  Psychiatric group home  Crisis beds

 HUD apartments



General p public through g three integrated g care sites Primary health care P Psychiatry hi and d mentall health h l h supports Pediatrics One includes dentistry and oral health school outreach ◦ One includes Ob/Gyn

◦ ◦ ◦ ◦

Overcoming the Barriers



Financing (capital Fi i ( it l and d operating) ti ) Cultural barriers between primary care/mental / health delivery y systems/practitioners. Lack of practitioner training in the health service area that is not their own area of expertise. Information sharing



Space

 



◦ Issues of confidentiality ◦ Electronic Health Record

ď ˝

ď ˝ ď ˝

Partners with physicians to address behavioral b h i l health h l h needs d identified id ifi d in i the h primary care setting. Develops joint plans with medical providers on behavioral health aspects of patient care. Provides crisis intervention, brief assessment and referral, behavioral interventions, and education for primary care patients with mental health health, substance abuse, and issues of medical compliance.

BHS Model vs. Traditional MH Model >population mgmt. >specialty care >15-25 min. visits >45-60 min. visits >1-3 visits >5 or more visits >no limit l on # off >5-7 patients/day d patients per day

BHS Model vs. >open access >any medical issue >BHS interruptible >Goal: G l enhance h overall health

Traditional MH Model >waiting list >mental health issues >â&#x20AC;?do not disturbâ&#x20AC;? >Diagnose and d treat DSM disorder



Community Support Workers, Care Coordinators, School C di S h l Based B d Mental M l Health H lh Specialists, Clinical Case Managers and Peer Specialists

◦ Supports clients in meeting their treatment plan goals identified in the primary care, mental health and dental health service settings settings. ◦ Interacts with Behavioral Health Specialist, Medical Case Manager, and Nurse Liaison as needed needed. ◦ New role: Health Coach – Health Navigator



Moving to a Wellness Model ◦ Nutrition ◦ Exercise ◦ Healthy Living



Maintaining a Recovery Orientation ◦ Independent Living ◦ Work



Enhancing Cultural Competence

Contact Information Laurie Alexander, PhD laurie alexander09@gmail com laurie.alexander09@gmail.com Karl Wilson, PhD KWilson@cridercenter.org

6/1/2011

Introduction to Effective Behavioral Health in Primary Care Alexander Blount, EdD Miguel g Olmedo,, DNP University of Massachusetts Medical School This session was coordinated by the National Association of Community Health Centers a Partner in the Center for Integrated Health Solutions

Session Objectives At the close of the presentation, participants will have gained: • An increased understanding of what effective primary care and behavioral health integration looks like in practice • An increased understanding of the evidence base and promising practices • Knowledge of practical steps primary care teams can take to improve the identification of behavioral health problem in primary care setting • Knowledge of practical steps primary care teams can take to improve the treatment of behavioral health problems in primary care setting

6/1/2011

Characteristics of Primary Care First Contact – When you need to “go to the doctor”, come see us. Continuous – We are you over time time. We can put today’s today s concerns in the context of your life. Comprehensive – We’ve got what you need Coordinating – And if we don’t have it, we’ll help you find it. Care for the “undifferentiated” patient – Whatever it is, you’ve come to the right place.

Primary Care is the future. Primary care is our best venue for improving population health and for controlling medical cost. Primary Care is the only thing you can do MORE OF and get lower cost and better care The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care: A Report from the American College of Physicians January 30, 2006

6/1/2011

Mortality Outcomes Primary care: 1 per 10,000 (20%) increase in primary care physicians results in 5% decrease in mortality or 40 fewer f deaths d th per 100 100,000 000  Family Physicians: 1 per 10,000 (33%) increase results in 9% decrease or 70 per 100,000 fewer deaths

• Specialists: 1 per 10,000 (8%) increase in specialist physicians results in 2% increase in mortality or 16 2003;16:412-22. more deaths per 100,000 Shi. J Am Board Fam Pract 2003;16:412Certificate Program in Primary Care Behavioral Health

Primary Care is rewarding to providers Being THE doctor “Driving the bus” Mastery of a broad field Caring for whole people (and families) Connectedness Making a difference Preventive care Other examples from physicians at the sites Certificate Program in Primary Care Behavioral Health

6/1/2011

Primary Care is stressful for providers Pace Responsibility  We all know the stories of a missed dx.  Need to coordinate care in an uncoordinated system

Often up against the edge of their knowledge Other examples from physicians at the sites  Get the person at your site with the laptop to either “raise a hand” or type your answer on the chat. Certificate Program in Primary Care Behavioral Health

The New Math of the 15 Minute Primary Care Visit  A primary care provider with a panel of 2500 average patients would spend:  7.4 hours per day to deliver all recommended preventive care – [Yarnall et al. Am J Public Health 2003;93:635]

 10.6 hours per day to deliver all recommended chronic care services – [Ostbye et al. Annals of Fam Med 2005;3:209]

6/1/2011

What’s Next?

The Patient Centered Medical Home • http://www.pcpcc.net/ p p p • Team takes some of the work • Address patient problems in best way for the patient and the problem, not all by office visits • New payment models to pay for health, not for visits A central concept in Health Reform First approach to get support from large employers, health plans, provider groups and consumer groups. Currently pilots (most successful) in just about every state. Copyright: Certificate Program in Primary Care Behavioral Health

Why Should Behavioral Health Be a Core Service of PCMH? Access – At least 50% better access to MH care if offered in primary care. (different from managing care across medical specialties) (Bartels, Coakley, Zubritsky, et al. Am J Psych, 2004) Complex patients with chronic illnesses needing behavioral health care are more likely to be designated for Medical Home level of care. Care in medical setting is a better cultural fit for many patients. Behavioral Health Clinicians free up time for PCPs to spend with other patients, while enhancing patient satisfaction and selfefficacy. efficacy Care management is more effective when done by professionals with behavioral health skills. (Pincus, Pechura, Keyser, et al. Administration & Policy in Mental Health. 33(1):2-15, 2006 Copyright: Certificate Program in Primary Care Behavioral Health

6/1/2011

Behavioral Health Needs Assessment in Primary Care Mental Health (of every level of severity) Substance Abuse Health Behavior Change â&#x20AC;&#x153;Ambiguousâ&#x20AC;? Illnesses Chronic Illness Culturally Syntonic Approaches

Prevalence of Behavioral Health Problems in Primary Care PHQ-3000 Merillac 500 Major Depression = 10% 24% Panic Disorder = 6% 16% Other Anxiety Disorders = 7% 21% Alcohol Abuse = 7% 17% A Mental Any M t lH Health lth D Dx = 28% 52%

6/1/2011

Prevalence of Behavioral Health Problems in Primary Care Unhealthy Behaviors Smoking Obesity Sedentary lifestyle Non-adherence

= 25% = 30% = 50% = 20 - 50%

â&#x20AC;&#x153;Ambiguous Illnessâ&#x20AC;?

The vastt majority Th j it off primary i care complaints are related in some way to behavioral factors but not to diagnosed mental disorders. Kroenke, K. & Mangelsdorff, A. D. (1989). Common symptoms in ambulatory care: Incidence, evaluation, therapy and outcome. American Journal of Medicine, 86, 262-266 Copyright: Certificate Program in Primary Care Behavioral Health

6/1/2011

10 most common complaints in adult primary care - 15% x organic pathology found (Kroenke & Mangelsdorff, 1989)

chest pain

back pain

fatigue

shortness of breath

dizziness

insomnia

headache

abdominal pain

swelling

numbness Copyright: Certificate Program in Primary Care Behavioral Health

Chronic conditions that require behavioral health component in standard of care protocols: Asthma Diabetes CVD Irritable Bowel Syndrome Obesityy Substance Abuse Copyright: Certificate Program in Primary Care Behavioral Health

6/1/2011

Depression with Chronic Illnesses: Increased rates of depression in patients with:  Congestive g Heart Failure  Diabetes  COPD

Patients with chronic illness and depression 2-5x the healthcare cost of patients with chronic illness alone Depression is the common factor in patients disabled (compared with pts equally sick but not disabled) by hypertension, asthma, arthritis, ulcers. Bachman, J. http://www.wpic.pitt.edu/dppc/downloads/Depression_in_Disease_Management_ Practices_for_Chronic_Conditions_FINAL.doc Copyright: Certificate Program in Primary Care Behavioral Health

Culture Impacts “Depression” Culturally Syntonic Approaches Signs of Depression found Signs of Depression found Cross-Culturally Cross Culturally in “Western” Western Cultures Appetite changes Sleep changes Psychomotor agitation or retardation Decreased energy Decreased libido Diminished ability to think or concentrate

Self-deprecation Hopelessness Guilt Suicidality Pfeiffer, W. (1968). The symptomatology of depression viewed transculturally. Transcultural Psychiatry Research Review 5: 121-123. Copyright: Certificate Program in Primary Care Behavioral Health

6/1/2011

Underserved and Minority Populations are Particularly Affected “…racial and ethnic minorities are less inclined than whites to seek treatment from mental health specialists. Instead, studies indicate that minorities turn more often to primary care.” Surgeon General’s Report on Mental Health, 1999. Supplement on Culture,, Race and Ethnicityy

Interlude

6/1/2011

Categories of Relationship between Collaborating Medical and Behavioral Health Services • Coordinated = Behavioral services by referral at separate location with formalized information exchange. • Co-Located = By referral at medical care location • Integrated = Part of the “medical” treatment att medical di l care llocation ti Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems & Health: 21, 121-134, 2003.

Population Receiving Collaborative Care Targeted = Defined by disease or problem Non-targeted = Any patient requesting or referred for service

6/1/2011

Behavioral Health Service

Specified = received by all pts. Unspecified = depends on clinician

Coordinated Care Coordinated care elements: • • • •

appointment arrival notification clinical information exchange protocols coordinated treatment planning Example of eating disorder care.

Originally the model advocated for PCMH for behavioral health. Bartels et al. found “enhanced referral” still 50% less effective than co-location for access. (Bartels, Coakley, Zubritsky, et al. Am J Psych, 2004) Phone outreach programs (Wang, et al, JAMA, Sept 26, 2007, 14-1-1411.) Massachusetts Child Psychiatry Access Program  Built on a consultative model

6/1/2011

Moving along the continuum achieves improvement in: Access Patient Satisfaction Provider Satisfaction Patient Adherence Cost Effectiveness Cost Offset Clinical Outcome Improvement Clinical Outcome Maintenance

Physicians Love I. P. C. ANECDOTAL reports indicate: Docs feel less isolated Bolder in “can of worms” situations Enjoy treating “complex” patients more Better job satisfaction Better provider retention

6/1/2011

The type of Behavioral Health service does make a difference. HAWAII HEALTHCARE UTILIZATION STUDY is i Coordinated and Targeted and compares the cost of Specified and Unspecified Behavioral Health care

Chosen to be included in study: 1. Top 15% of health care users 2. Sufferers from chronic airway di disease (COPD (COPD, asthma) h ) 3. Sufferers from diabetes 4. Sufferers from hypertension 5. Sufferers from ischemic heart disease 6 Patients in mental health treatment 6. 7. Patients with chemical dependency HAWAII HEALTHCARE UTILIZATION STUDY

6/1/2011

For Medicaid study patients with chronic medical disease: Unmanaged treatment lead to a slight increase in overall cost. Targeted Focused Treatment saved 26% with an average of 7.5 outpatient visits

HAWAII HEALTHCARE UTILIZATION STUDY

Studies of Collaborative Care Co-Located Non targeted Non-targeted Unspecified Improved Access – 2 Patient Satisfaction – 9 Provider Satisfaction – 4 Improved Adherence – 1 Cost Effectiveness – 7 Cost Offset - 2 Clinical Improvement – 13 No Clinical Improvement – 12 (UK studies)

6/1/2011

At the very beginning: PCPsâ&#x20AC;&#x2122; perceptions Until they have worked with a BHP, physicians tend to think of mental health clinicians as uncommunicative. When they do communicate, mental health folks want to say too much. Mental health folks sometimes make confidentiality a way of protecting turf. Physicians not sure what happens in therapy, maybe some kind of catharsis or paid friendship Are they psychoanalyzing me? Others? PCPs please chime in. Copyright: Certificate Program in Primary Care Behavioral Health, UMass Medical School

Making Co-Location Work BHP in health center - 7 sessions/wk.

Patients attending first visit w. BHP when scheduled by physician w/o introduction: 40% Patients attending first visit w. BHP when scheduled after introduction by physician: 76% N=80, p= <.01 Apostoleris, N. & Blount, A. In preparation.

6/1/2011

Studies of Collaborative Care Co-Located Targeted Specified Access - 1 Improved Adherence – 2 Cost Effectiveness – 1 Clinical Improvement – 10 No Clinical Improvement – 1 Maintained Improvement - 2

Studies of Collaborative Care Integrated Targeted Specified Improved Access – 1 Patient Satisfaction - 5 Provider Satisfaction - 3 Adherence – 6 Cost Effectiveness – 2 Cost Offset – 1 Clinical Improvement – 8 Maintained Improvement - 3

6/1/2011

Group Health Studies Integrated Targeted Specified Intervention + Patient education + alternating 4 4-6 6 visits with PCP and:  a) psychiatrist to manage antidepressants (or)  b) psychologist to provide C-B therapy Results:  74% of depressed patients effectively treated – (40% in control group)  No effect for minor depression Average Cost / successfully treated case  Collaborative C ll b ti C Care - $1750  Usual Care - $2000 (Katon et al, 1995, 1996)

Depression Care Management Protocol

Depression in primary care, RWJ and MacArthur programs.  http://www.depression-primarycare.org/ – Toolkit – Help in re-engineering practices Develop screening for depression in collaboration with providers (usually PHQ-9)  Who  When  What triggers Assure that assessment/diagnosis protocol is in place for positive screens and that all assessed positive are on a registry. Protocol  Assures Ass res that patients kno know ttypes pes of care offered  Makes phone calls to assess medication effect and side effects  Tracks visits  Re-screening/outcome c. Certificate Program in Primary Care Behavioral Health, UMass Medical School

6/1/2011

Advantages of Creating an Integrated Primary Care Program by Starting with Care Management: g Quick start up  Start up to model program in about 3 years

Care management for MH problem treated as chronic illness. Easiest for PCPs to understand and accept get used to a high g volume brief intervention BHCs g service Buncombe County Health Center a good example c. Certificate Program in Primary Care Behavioral Health, UMass Medical School

The IMPACT Treatment Model Collaborative care model includes:  Care manager: Depression Clinical Specialist – Patient education – Symptom and Side effect tracking – Brief, structured psychotherapy: PST-PC

 Consultation / weekly supervision meetings with – Primary care physician – Team psychiatrist (or psychologist)

Stepped protocol in primary care using antidepressant medications and / or 6-8 sessions of psychotherapy (PST-PC) Unützer et al, JAMA 2002; 288:2836-2845

6/1/2011

Substantial Improvement in Depression (≥50% Drop on SCL-20 Depression Score from Baseline) Response (³50% drop on SCL-20 depression score from baseline

60 P< 0001 P<.0001

P<.0001

40 P<.0001

30 20 10 0 3

Unützer et al, JAMA 2002; 288:2836-2845.

month Usual care

Intervention

Behavioral Health Consultant Management of psychosocial aspects of chronic and acute diseases Application of behavioral principles to address lifestyle and health risk issues Consultation and co-management in the treatment of mental disorders and p psychosocial y issues Model developed by Kirk Strosahl, PhD

6/1/2011

CBT in the Exam Room 1) CBT picture 2) Thought stopping or behavioral activation

Integration: Beyond Co-Location Integrated Care Embedded member of primary care team Patient contact via hand off Verbal communication predominates Brief, aperiodic interventions Flexible schedule Generalist orientation Behavior medicine scope

Co-Located Mental Health Ancillary service provider Patient contact via referral Written communication predominates Regular schedule of sessions Fixed schedule Specialty orientation Psychiatric disorders scope ÂŠ 2010 Cherokee Health Systems All Rights Reserved

6/1/2011

Cherokee Health Systems A Federally Qualified Health Center and Community Mental Health Center

Corporate Profile Founded: 1960 Services: Primary Care - Community Mental Health - Dental - Corporate Health Strategies

Locations: 21 clinical locations in 14 Tennessee Counties Behavioral health outreach at numerous other sites including primary care clinics, schools and Head Start Centers

Number of Clients: 58,561 , unduplicated p individuals served - 24,958 , Medicaid (TennCare) ( ) New Patients: 19,829 Patient Services: 442,626

Number of Employees: 538 Provider Staff:

Psychologists ‐ 40 Master’s level Clinicians ‐ 59 Case Managers ‐ 29 Primary Care Physicians ‐ 31 Psychiatrists ‐ 13 Pharmacists ‐ 9 NP/PA (Primary Care) ‐ 17 NP (Psych) ‐ 7 Dentists ‐ 2 © 2010 Cherokee Health Systems All Rights Reserved

117%

78%

Cost

63%

Hospital Care

32%

Speciialty Care

58%

ER Visits

Primary Care Visits

% of Average Utilization n

x utilization level for other regional providers

Figure 1: Comparison of CHS utilization with regional providers

6/1/2011

Relationship with “Specialty Mental Health” Still important p for longer g term care IPC makes referrals to SMH more likely to be successful Specialty MH able to better target high need populations Consultation backup to PCP I some systems In t SMH has h developed d l d specialized i li d teams to support generalist PCBH clinician

Designing a Program of Bi-Directional Integrated Primary Care PCP (NP or MD) is part of a primary care practice.  Sees some patients in the PC practice and some in CMHC  As patients become bonded to the PCP and team, they can move to Primary Care setting when ready  It is about passing relationships, face to face. Primary care in CMHC serves the purpose of fostering healthy behavior, initiating care and preparing consumers for how to succeed at “going to the doctor.” 48

6/1/2011

How will the numbers break down? Mature program in Maine 500 people categorized as SMI 35% get care in CMHC primary care 50% get care in CHC or other primary care site coordinated with CMHC. 15% get no care.

Organizational Partnerships Leadership buy-in at the top is crucial  Continued administrative involvement in meetings is needed because each new innovation needs administrative support.

– Regular clinical case discussions teach everyone about the difference in cultures.  Without regular discussions, the stresses of each group will be under recognized by the others and each will feel the others are not pulling their weight.  Opportunities to help make each other’s work easier will be missed. – Look for ways to help with “tough” patients/consumers for the other. – Each side will have a different experience of who is tough.

– Both partners will change substantially. • •

FQHCs will need to move toward being very patient centered to serve SMI population effectively. CMHCs will need to move toward being true healthcare providers by delivering the full spectrum of care.

6/1/2011

Combined Model A feature of the CIHS partnerships – Different consumers will have different services depending on needs. Coordinated for consumers with specialty mental health, case management and health behavior change in CMHC and primary care in FQHC -Regular routines of communication Co-located for consumers getting MH and primary care in CMHC or FQHC -Routine and unplanned communication opportunities (MH and primary care in different parts of the building with separate intake, separate records, no regular communication is not Coordinated, Co-located or Integrated.) Integrated for consumers getting all care in same place with one treatment plan, one team, one record, all “healthcare”.

So, do we have a “best” model defined for the future? Was the Model T the “best” best model car? Experimentation at some point creates an innovation that fits the environment. Innovation reshapes the environment and creates the context for new innovation. Different populations have enough difference in needs that models should be different. What does the FQHC population need?

6/1/2011

Considerations in Adding a Behavioral Health Provider Provider skill set and fit Financial Information exchange between providers Charting Scheduling S Space c. Certificate Program in Primary Care Behavioral Health

Provider Skill Set and Fit Someone who has taken our course should have the orientation necessary to learn on the job. Good at making relationships with all of the roles in primary care They must do well in ambiguous situations, dive in rather than wait for an invitation. Handle new situations with assurance and confidence without misrepresentation knowledge. c. Certificate Program in Primary Care Behavioral Health

6/1/2011

Financial Medical billing:    

Increases number of patients seen by physicians. (1/sess.) Up-code a visit: Level 3 to Level 4 or 5 Some integrated g funding g (SBIRT) ( ) can support broader engagement g g Health and Behavior codes: 96150-96155 – Medicare, many Blues, some Medicaid, some privates

Mental Health billing:  Bill for small bits of time  If panels are a problem, primary care docs may help  Some MH services (CSP) can support integrated case management

For medical people, Behavioral Health billing is a nightmare. This is why administrative staff need to feel some buy buy-in in to integrated care. PCMH may turn all this around. Expect to pay something for the increase in medical providers enjoyment of the practice and better outcomes. c. Certificate Program in Primary Care Behavioral Health

Information Exchange Between Providers Medical and mental health cultures have very different approaches to confidentiality. The medical approach is the goal, in compliance with local regulations. Blanket information release with the goal of enhancing primary care Curbside consultations Forms for email or EMR updating p g Behavioral health or “troubling patient” rounds c. Certificate Program in Primary Care Behavioral Health

6/1/2011

Charting Patient must give permission for unified charting Unified charting means social hx and previous medical hx already done for MH rules. Unified charting may not need to be undifferentiated charting Coming of EHR will make much of this moot. Check off notes for the brief interactions of PC Tracking BH values in EMR (eg PHQ-9 as vital) Health and Behavior codes charted in medical record as medical services. c. Certificate Program in Primary Care Behavioral Health

Scheduling Medical scheduler keeps BHPâ&#x20AC;&#x2122;s book Sh t time Shorter ti periods, i d 30, 30 20, 20 15 min. i Consider an Open Clinic as a way of learning to work differently Schedule some free time for introductions and curbside consultations Schedule time for conjoint interviews

c. Certificate Program in Primary Care Behavioral Health

6/1/2011

Back to the Patient Centered Medical Home (Person Centered Healthcare Home) • Care coordination/management is a piece of all of the versions. • Important new role, though not new to everyone. • Some people will be right in saying that they have been doing most of what is thought to be needed for years. g it all. • Few have been doing

The impact of the 2011 standards • New 2011 Guidelines from NCQA require behavioral health services, including one of three care programs for chronic illness being a behavioral illness (level 3). • Each practice must arrange or provide for mental health care. •

The difficulty with referral will create pressure for every practice to bring in behavioral health.

• Every practice must provide patient and family activation for healthy behavior. • Every practice must provide care coordination, whether or not there is a care coordinator. Copyright: Certificate Program in Primary Care Behavioral Health, UMass Medical School

6/1/2011

So, what does all this mean? The PCMH model is going to be everywhere, even in mental health centers. Bits from all the heritages, case manager, care manager for depression, behavioral health consultant and care coordinator will probably be recognizable in the future version of the job. It is likely to be a role for which we will need thousands of properly trained people and no discipline seems to be preparing people for all the pieces of this work. Modular training, such as the Certificate Program in Primary Care Behavioral Health, is needed to get people ready to do the whole job. http://umassmed.edu/FMCH/PCBH/welcome.aspx

Change like this is scary but it can be fun. While the grants and pilots look very good, the main stream system is not set up p to support pp integration g of behavioral health and p primary y care in most states. It is about administrative and fiscal change as much as clinical change. Currently it is a field of entrepreneurs and advocates which will soon give way to the systems builders and data producers. Specialty mental health will continue to be necessary, but it may have to become defined as a part of health care to survive. Anyone who produces good health outcomes with patient and family engagement at reasonable cost will always have a place at the table.

6/1/2011

If you dialed in to this webinar on your phone please use the “raise your hand” button and we will hand open up your lines for you to ask your question to the group. (left) If you are listening to this webinar from your computer speakers, please type your questions into the question box and we will address your questions. (right)

Please be in touch. Alexander Blount, EdD. – Alexander.Blount@umassmemorial.org Miguel Olmedo, Olmedo DNP, DNP FNP – Miguel.Olmedo@umassmed.edu Miguel Olmedo@umassmed edu Certificate Program in Primary Care Behavioral Health Email for information: PCBH@umassmed.edu Center for Integrated Health Solutions http://www.thenationalcouncil.org/cs/center p g _for_integrated g _health_solutions Dr. Blount’s website

http://www.IntegratedPrimaryCare.com

Integration Models Lessons From the Behavioral Health Field Presenters:

Karen Bassett, Weber Human Services Kathy Bianco, Care Plus NJ, Inc Jennifer DeGroff, AspenPointe

The Wellness Clinic Weber Human Services Midtown Community Health Center Karen Bassett, LCSW Clinical Supervisor II and Project Director

Our Program Weber Human Services (WHS) is located in Ogden, Utah and serves a growing urban population. WHS is currently co-located with Midtown Community Health Center to provide physical health services in the Wellness Clinic. We provide a medical clinic, behavioral health clinicians and prescribers, a pharmacy, and a laboratory adjacent to one another.

Level of Integration • WHS is moving towards an integrated Healthcare Home • Although mental health and primary care staff are employed by two different agencies, care is seamless to the consumer • WHS and Midtown use the same waiting area, customer care staff, laboratory, and pharmacy • Joint bi-weekly case staffings include: • RNs, MDs, APRNs, Case Managers, Project Director, Care Coordinator, and Wellness Coordinator

• Monthly planning meetings include: • Administration from both agencies • Wellness Clinic staff

Services Provided—Physical Health • • • • • • •

Health & preventative screenings Immunizations Treatment for acute & chronic Illness Medication management Referrals to specialty providers Prescription Assistance Prenatal care, family planning and birth control • Sexually transmitted disease testing and treatment

Services Provided—Behavioral Health • 21 MH clinicians providing Evidence-Based Practices • • • • •

• • • •

Motivational Interviewing Psycho-Educational Multifamily Group Therapy Dialectical Behavioral Therapy Adult Outcome Questionnaire Dual Diagnosis Treatment

Skills Development Case Management Medication Management with 3 Prescribers and 4 RNs New peer support specialist program to provide 30 hours/week

Other Services Provided • Free NAMI education groups for consumers and families • Education Center in lobby • Fully equipped on-site laboratory

• Pharmacy • Advisory Board of clients and family members • Services not provided: • Chronic pain management, court-ordered treatment, or prescriptions for controlled substances

Wellness Clinic

NAMI Pharmacy

Uninsured Prescriber

Behavioral Health Physical Health

Wellness Coordinator

Laboratory

Care Coordinator

Wellness Clinic Team WHS Project Director Quality Assurance/IT Wellness Coordinator 21 BH Therapists 1 Psychiatrist 2 APRNs

Midtown Clinic Manager 2 PH Providers Care Coordinator APRN (Uninsured) 4 RNs 3 Medical Assistants

Lessons Learned – Recruiting • 50% of those who no-show to a 1st appointment will reengage if called and offered another appointment • Care managers of local hospitals are a great referral source

• Convenience: • Clinicians must be sold on the benefits of the clinic and have an easy process for referrals; monthly reminders are key; give clinicians a “cheat sheet” with a spiel for referrals • BH Med Mgt staff are a great source for referrals • The layout of the Wellness Clinic with all services in one wing is helpful for both recruiting and communication between PC and BH staff

Lessons Learned—Recruiting Part II • Open house = great initial numbers, but retention issues • Involvement with community partners (letters, visits, brochures) has not significantly increased referrals • No difference (with recruiting) between our fancy brochure and a very inexpensive one • Recruit dual diagnosis from substance abuse team • Monthly drawing for clinician/med team/CC staff referrals

Lessons Learned—EHR--Junction • Vendor: WHS Internal Software Development Team – 6 FTE • Costs shared equally with 3 other BH providers • Benefits of Internally Developed Software • • • • •

Flexibility Set own IT priorities Quickly implement priorities Customization without increased costs Technically support internal initiatives

Lessons Learned – Wellness • Magnetic wall with Wellness Calendar publicizes wellness tips and activities • Food of any kind (even healthy) is a great motivator for getting individuals involved in the wellness classes • “Bring a friend to Wellness” helps increase numbers in both the clinic and the Wellness Center activities.

• Monthly newsletter with health tips and calendar • Advisory Board is a great recruiting tool

Lessons Learned • Relationships are what keep our people engaged • Health Navigator Training gets case managers motivated • Encourage consumers to come in for all primary care needs and recognize when to use ER and InstaCares • Monitor TRAC* numbers weekly • Walk-through by staff of intake process to identify processes that need modification • Satisfaction surveys also indicate areas for improvement *TRansformation ACcountability System web-based data entry and reporting system that provides a data repository for CMHS program performance measures

Care Plus NJ Center for Primary and Behavioral Health Kathy Bianco, APRN Vice President, Clinical Services

Who We Are: • Care Plus NJ has been providing community based mental health services for over 33 years • Our service continuum includes a full range of acute care, sub-acute and community services • We have over the past 20 years tried different models of addressing our clients multiple medical conditions

Our History With Primary Care Time Frame

Model

What We Did

1991-1995

Enhanced collaboration with outpatient hospital based medical clinics

CPNJ nursing staff met with and developed positive collaborative relationships with clinic nurses

What Worked Nursing staff enjoyed collaboration

Appointment were tracked by CPNJ nursing staff so they Consult requests could ensure would be sent consult requests with dx, psych were prepared meds and and given to the reason for client referral

What Did Not Work Long wait for appointments

Clients would get to the clinic and go to the hospital coffee shop Consult requests were not returned Any labs or testing would need to be â&#x20AC;&#x153;Chasedâ&#x20AC;? Frequent clinic staff turnover

Our History With Primary Care Time Frame 1996-2002

Model

What We Did

What Worked

What Did Not Work

Collaboration with outside PCP’s to provide services on site

Nursing staff would assist PCP’s onsite and provide needed follow up

Documentation and lab/medical testing were available quickly

Nursing staff were unable to attend to other duties while assisting PCP onsite

They billed for the service on their own

Labs were drawn onsite so results were returned directly

Medications were entered into a central database and a bit easier to reconcile

Consumer often needed care on “off days”, which resulted in ER use

Our History With Primary Care Time Frame 2002-2008

Model Added a Medical APN to CPNJ staffing This position did not become the primary care provider of record, however, provided sick care and assisted when consumers were â&#x20AC;&#x153;falling through the cracksâ&#x20AC;?

What We Did

What Worked

What Did Not Work

Re budgeted for the position

Consumers utilized the ER less frequently

We were unable to refer to specialty care

Prepared a small examining room Included this positions as part of the behavioral health team

This position served as a good liaison to inpatient medical units and for discharge planning

Consumers would become confused about who was treating them External testing (clinic) continued to be difficulty to track

Our Model • We hired our own primary care staff

• Bi-Directional and Embedded Care • Primary care within the mental health center • Mental health care within the primary care center

• Integrated and Multidisciplinary Treatment Team • Wellness Services are a Central Component

• Focus on: • Nutrition • Exercise • Stress Reduction

Our Transformation is ongoing…. • Developed a primary care practice • Integrated teams

• Blended cultures • Cross trained staff • Blended treatment planning • Built enthusiasm over outcomes

Team Roles • • • • • • • • • • •

Nurse Care Manager/Liaison Advance Practice Nurse Collaborating Primary Care Physician Psychiatrist Case Manager Clinician Peer Counselor Certified Diabetes Educator Nutritionist Dentist Podiatrist

Functional Areas of Integration Access – “No Wrong Door” • Psychiatrist, Therapist, or Mental Health Worker can bring client over as a warm hand off • Reworking our ACCESS center to develop primary care skill set for new admissions

Services • One treatment plan developed with our higher levels of care ie: partial care and residential services – Our goal is to integrate ALL treatment plans utilizing an EMR platform

Functional Areas of Integration cont. Funding • Billing will become integrated per project plan • Funding/staffing will continue as blended for now • Moving forward into a fee for service environment will require re-work of current system with maximization of all billing opportunities

• Advocacy efforts at the State level with Medicaid, HMO’s, DMHS, and DMHSS

Functional Areas of Integration cont. Governance • One Board

• Strong project support from the Board of Directors

Functional Areas of Integration cont. Evidence Based Practices • Treatment team meeting include behavioral health and primary care

• Wellness programming is a large component of our programming; this takes time to build • Very complex cases can be reviewed at a “higher level” if team is anxious – There is an opportunity weekly for this review

Functional Areas of Integration cont. Data • We have purchased an EMR for primary care • Conducting due diligence for the behavioral health EMR needs • GOAL – systems talk in real time

• Working with an HIE is underway to ensure systemwide sharing of data

Workflow CLIENT PRESENTS

STAYS WITH CURRENT PCP

OPTS-IN APPOINTMENT MADE OR CLIENT SEEN IMMEDIATELY

RN CASE MANAGER RN ASSESSMENT VITALS

1ST APPOINTMENT

APN HISTORY & PHYSICAL LABS EKG

REFERRALS

NEEDED

BEHAVIORAL HEALTH TEAM

RN CASE MANAGER MEETS WITH OR EMAILS CASE MANAGER

BEHAVIORAL HEALTH TEAM

SCHEDULES FOR WELLNESS ACTIVITIES COMPLETES REFERRALS FOR EXTERNAL FOLLOW-UP MAKES APPTS FOR EXTERNAL SPECIALTY CARE

NUTRITIONIST

DIABETES EDUCATOR WELLNESS PROGRAMMING

PEER COUNSELOR

Outcomes • 39% Initially Diagnosed with Hypertension • 92% are now Normotensive

• 48% Initially Diagnosed as Obese • Lost an average of 11 pounds (national average ~6-9 pounds)

Outcomes: LDLs “Bad Cholesterol” decreased for clients through use of Statins Goal: LDL <100 80%

72%

70% 60% 50% 40% 30%

22%

20% 10% 0% PRIOR

RECENT

Outcomes: HDLs “Good Cholesterol” increased for clients through TLC (Therapeutic Lifestyle Changes) Goal: HDL>40 74% 73% 73% 72% 71%

70% 69% 68% 67% 67% 66% 65% 64% PRIOR

RECENT

Outcomes: HDLs Triglycerides decreased for clients through TLC (Therapeutic Lifestyle Changes) Goal: TRG <150 80%

73%

70% 60% 60% 50% 40% 30% 20% 10% 0% PRIOR

RECENT

Group Name

No. of Groups Per Week

Average No. of Attendees per week

Exercise Group

Walking Group

YMCA

YOGA

Weight Management

Wellness

Health Issues

Healthy Choices

Nutrition & Healthy Living

Cooking, Kitchen

Smoking Cessation/Holistic Welness

Diabetes Education

Meditation & Relaxation

Breaking Unhealthy Habits

WRAP

Total

298

Client Satisfaction â&#x20AC;˘ Ranked Number 1 among all MHCA agencies with 5 or more programs â&#x20AC;˘ Rated higher than the MHCA national database across all dimensions

AspenPointe and Peak Vista Community Health Center Jennifer DeGroff, PhD AspenPointe Health Services Director of Outpatient & Integrated Care Services

AspenPointe – Peak Vista Story The First Integration Project (2001) • Vision: Co-located and partially integrated model • Staffing: Therapist only

• Location: Peak Vista CHC Women’s Health Center • Buy-In: Initially present for staff and leadership, but waned over time.

• Funding: Medicaid funding for some; no funding for non-Medicaid (generally un/underinsured) • Project fell apart

The Second Integration Project (2006) • Drivers that brought us together again: • CEO’s had many concerns regarding future of Mental Health and Physical Health

• Vision: Close Collaboration and Partially Integrated System • • • • • • •

Common scheduling Treatment team meetings Separate funding, shared on-site expenses 2 governing boards Sharing of EBP’s across systems Separate data sets Collaboration around individual cases

The Second Integration Project (2006) • Started with a Therapist and then added Psychiatrist time • Location: Peak Vista CHC Family Health Center @ Union • Buy-In: Clinical and administration, BUT Increased Commitment to Success by Leadership • Regular corporate and management meetings • Clear the path attitude • This project will not fail!

The Current Model • • • •

Partially Integrated / Fully Integrated Staffing: 9 licensed BHCs from AspenPointe Referrals: Directly to the BHC by the primary provider 39,762 BH visits since 2006 • • • • • •

2006: 3 staff 2007: 4 staff 2008: 6 staff 2009: 6 staff 2010: 7 staff 2011: 9 staff

Total # of Visits 12000 10000

8000 6000

Total # of Visits

4000 2000 0 2006 2007 2008 2009 2010 2011

MH/Primary Care Integration Options

Function

Minimal Collaboration

Basic Basic Collaboration Collaboration On- Close Collaboration/ from a Distance Site Partly Integrated THE CONSUMER and STAFF PERSPECTIVE/EXPERIENCE

Two front doors; consumers go to separate sites and organizations for services Separate and distinct services and treatment plans; two physicians prescribing

Two front doors; cross system conversations on individual cases with signed releases of information Separate and distinct services with occasional sharing of treatment plans for Q4 consumers

Funding

Separate systems and funding sources, no sharing of resources

Separate funding systems; both may contribute to one project

Governance

Separate systems with little of no collaboration; consumer is left to navigate the chasm

Two governing Boards; line staff work together on individual cases

EBP

Individual EBP’s implemented in each system;

Data

Separate systems, often paper based, little if any sharing of data

Two providers, some sharing of information but responsibility for care cited in one clinic or the other Separate data sets, some discussion with each other of what data shares

Access

Services

Separate reception, but accessible at same site; easier collaboration at time of service Two physicians prescribing with consultation; two treatment plans but routine sharing on individual plans, probably in all quadrants; Separate funding, but sharing of some on-site expenses

Same reception; some joint service provided with two providers with some overlap

Two governing Boards with Executive Director collaboration on services for groups of consumers, probably Q4 Some sharing of EBP’s around high utilizers (Q4) ; some sharing of knowledge across disciplines Separate data sets; some collaboration on individual cases

Two governing Boards that meet together periodically to discuss mutual issues

Q1 and Q3 one physician prescribing, with consultation; Q2 & 4 two physicians prescribing some treatment plan integration, but not consistently with all consumers Separate funding with shared on-site expenses, shared staffing costs and infrastructure

Fully Integrated/Merged One reception area where appointments are scheduled; usually one health record, one visit to address all needs; integrated provider model One treatment plan with all consumers, one site for all services; ongoing consultation and involvement in services; one physician prescribing for Q1, 2, 3, and some 4; two physicians for some Q4: one set of lab work Integrated funding, with resources shared across needs; maximization of billing and support staff; potential new flexibility One Board with equal representation from each partner

Sharing of EBP’s across systems; joint monitoring of health conditions for more quadrants

EBP’s like PHQ9; IDDT, diabetes management; cardiac care provider across populations in all quadrants

Separate data sets, some collaboration around some individual cases; maybe some aggregate data sharing on population groups

Fully integrated, (electronic) health record with information available to all practitioners on need to know basis; data collection from one source

How do we fund it? • AspenPointe pays staffing; Peak Vista pays building costs • AspenPointe receives Medicaid units for services provided: • Peak Vista bills the medical visit but does not bill for Mental Health encounters • AspenPointe adjudicates against BH Medicaid

• Peak Vista does not bill indigent, Medicare, or 3rd party due to payor restrictions

What’s Next for our Model? • Increased focus on Health and Behavior issues, not just Mental Health issues • Improved client transition back to Peak Vista once specialty MH care is done at AspenPointe (i.e., “back door”)

LESSONS LEARNED

Access – Must involve: • Quick screening and assessment • Brief focused interventions on same day • Occasional return appointments for brief focused tx, but this cannot impede co-visits • Ability to refer to higher levels of care when needed

Staff Match to Site and Project needs: • Skill and temperament match • Tendency to turn back to prior habits of care • BHC must be eager to get out and connect – many times sell services to rest of primary care team until team understands the value the BHC brings to the team

Services: • Service model must be well defined • Both sides of the house must have familiarity with the Integrated Model

Funding: • Funding often trips or halts the process – there are not a lot of ways to fund this yet! • Must be open to looking for alternative sources of funding. Federal, state, private grants, billing code shifts with current payers, braided funding, win-win funding, staff sharing • Make a decision to invest in your future healthcare opportunities even if there is not a clear funding stream at the start

Governance: • Boards must be educated on Integrated Care models • Board knowledge of Health Care Reform trends gives buy-in towards Integrated Care projects and conceptual support • Board can influence strong ties to other healthcare partners in the community to explore new Integrated Care opportunities

Each organization has its own bureaucracy: • Each organization needs to understand the organization of the other, including funding streams and restrictions as well as state and federal requirements around their services • Each organization needs to determine who liaisons with whom at each organizational level

Leadership • There must be CEO and C-Level buy in and support for human resources, finances, space, etc. • Senior leadership must understand the role of Integrated Care and the importance of this approach to our future

• Once the project begins there is a strong gravitational pull to move toward old ways of practice. • Corporate leaders and managers need to meet and cross inform beyond just the start up time period. • A clear-the-path mentality is essential for success • Integrated care must become the standard for many of our staff

Culture – Corporate, Medical/Psych: • Calendar challenges – holidays • Standard work hours • Terminology • Pace of medicine vs. mental health practice • Roles of MD vs. NP vs. Therapists • Having the team believe that this model will have the best outcome on patients/clients

Thank you! Please feel free to contact me with questions: Jen DeGroff 719-572-6241 Jennifer.DeGroff@AspenPointe.org

Q&A

Please type your questions into the dialog box

Thank you For more information about the SAMHSA-HRSA Center for Integrated Health Solutions visit our website:

www.integration.samhsa.gov

Preparing for Bidirectional Integration: Lessons from the Field June 14, 2012 2:00 â&#x20AC;&#x201C; 3:30 pm ET

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June 14, 2012 â&#x20AC;&#x201C; IHP Learning Collaborative Project Management Model and Outcomes Achieved MTM Services Faculty

Integrated Health Providers Learning Collaborative: Powerful learning collaborative process that: 1. Each of the 15 centers in the collaborative (8 MH/SU and 7 SU only) were at different stages of readiness to move to integrated healthcare delivery. All 15 had expressed the desire to move forward with integration efforts, however, each center has specific/somewhat unique challenges to overcome. 2. Therefore, the project management challenge was to develop a learning collaborative process that would facilitate each center starting the integration of healthcare process at different places and different focus areas… That would include:  

Support for peer sharing of positive changes being made to move other cohort teams beyond the “realm of impossibility”… Support the use of a CQI change process that can continue to provide implementable solutions into the future..

Integrated Health Providers Learning Collaborative: Powerful learning collaborative process that: 3. Provide clinical service delivery process changes that support enhanced consumer engagement in the areas of: 1. 2.

Enhanced access to treatment timelines to reduce wait times and enhance consumer retention Integrated information gathering in the access to treatment process to reduce redundant information gathering from consumers Shift the clinical documentation process to a more personcentered collaborative documentation model which included providing consumer satisfaction survey support to measure the enhanced engagement (survey results will be presented based on 483 consumer responses).

IHP Learning Collaborative Cohort 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

APT Foundation, New Haven, CT Brandywine Counseling and Community Services, Wilmington, DE Centennial Mental Health Center, Sterling, CO Community Health Resources, Windsor, CT Community Services Northwest, Vancouver, WA Connections - Healthâ&#x2C6;&#x2122;Wellnessâ&#x2C6;&#x2122;Advocacy, Beachwood, OH Edgewater Systems, Gary, IN Journey Mental Health Center, Madison, WI Mecklenburg County Provider Services, Charlotte, NC Mosaic Community Services, Baltimore, MD New Age Services, Chicago, IL Operation PAR, Pinellas Park, FL Phoenix Houses of Mid-Atlantic, Arlington, VA Seven Counties Services, Louisville, KY View Point Health, Lawrenceville, GA

Provider Learning Collaborative Goals 1. 2. 3.

5. 6.

Provide basic information about the new integrated service delivery models being developed. Provide an opportunity for each collaborative member to assess its readiness to participate Provide technical assistance/support to collaborative members to facilitate their addressing the typical service delivery challenges that have historically created barriers to providing value enhanced services. Develop a Rapid Cycle Change Plan for each member that will address specific change goals and objectives and a specific timeline to accomplish the changes needed. Support a continuous quality improvement based learning experience for each member. Provide an opportunity for collaborative members to share their attainment outcomes with other CBHOs

Consultation and Technical Support Summary for Each Collaborative Member 1.

Healthcare Reform Readiness Assessment was completed by each team to confirm the level of readiness to develop the capacity to provide primary care in each center. The MTM Faculty used each teamsâ&#x20AC;&#x2122; information to design the goals/objectives in an individualized Rapid Cycle Change Plan for each team Monthly Internet based Rapid Cycle Change Plan technical assistance support was provided to each team to support each center in the development and implementation of integrated primary and MH/SA service delivery models One (1) onsite consultation and training day was provided by identified members of the MTM Faculty based on the focus of the technical assistance needed. The topic focus and agenda for each day was customized to the specific identified needs of each member A series of nine two hour monthly webinars were provide so that all learning collaborative members and their respective change teams could receive support on areas of change or curriculum that was identified in the readiness assessment outcome.

Integrated Health Readiness Assessment Completed in Summer 2011 â&#x20AC;˘ Evaluated 12 Domains: 1. 2. 3. 4.

5. 6. 7. 8. 9. 10. 11. 12.

Access to Services Centralized Scheduling & Cancellation Protocols Key Performance Indicators & Rate Standards LOC Benefit Package Design & Caseload Management No Show/Cancellation Management Collaborative Documentation Process Outcome Assessment Capacity Internal UM Community Awareness, Branding & Market Share Revenue Management Measurement of KPI Capacity Change Management & Decision-Making Culture

Readiness Assessment Aggregate Results

Color Key: Red (1) = High Concern/RCCP Focus

Yellow (2) = Consider Change Needs Green (3) = No Change Recommended

Integrated Health Readiness Assessment Results Based on a Three Point Scale (1 = High Concern, 2 = Concern, and 3 = Commendation)

• Identified specific level of concern in each of 12 domains for each of the 15 centers • Provided each of the 15 centers an average readiness score • Prioritized needs for each center • Informed development of goals and recommendations for individualized Rapid Cycle Change Plans

Learning Collaborative Team: APT Foundation

Brandywine Counseling Centennial MHC Community Health Resources Community Services Northwest Edgewater Systems Mecklenburg County SASC Mecklenburg County - Shelter MHC of Dane County Mosaic Community Services New Age Services Northeast Ohio Health Services

Operation PAR Phoenix Houses Seven Counties - MH Services Seven Counties - Developmental Services View Point Health

Average Rating: 2.1 1.9 1.9 2.0 1.8 2.3 1.8 1.9 1.9 2.1 1.6 1.9 1.9 1.8 1.5 1.3 1.7

Rapid Cycle Change Goal Recommendations Based on Readiness Assessment Findings 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Enhance Access to Treatment Timeliness Develop and implement Centralized Schedule Management including Will Call and Back Fill Support Develop and implement No Show/Cancellation Management including Scheduling Templates and Engagement Specialist Design and Implement re-engagement/transition procedures for current cases not actively in treatment. Provide Training and Implement Collaborative Concurrent Documentation Design and implement Levels of Care/Benefit Package Designs to support appropriate utilization levels. Develop and implement an enhanced Outcome Assessment Capacity (i.e., PHQ-9, DLA-20, etc.) Develop and implement integrated primary care services. Develop and implement Cost Based Key Performance Indicators (KPIs) Develop and implement Capacity to Measure KPIs to support coaching/mentoring activities by supervisors/managers Develop and implement payer mix enhancements including Third Party Payers Design and implement internal utilization management functions including Credentialing Support for Clinical Staff; PreCerts, authorizations and re-authorizations; and referrals to clinicians credentialed on the appropriate third party/ACO panels 13. Develop and implement enhanced Revenue Cycle Management including co-pay collections and claim submission 14. Develop and implement enhanced community awareness support including collaboration with medical providers

Of 15 Centers 9 12 11 10 10 11 12 13 8 9 13 11

10 11

Rapid Cycle Change Plan Sample

Monthly Cohort Webinar Topics â&#x20AC;&#x201C; Based on Readiness Assessment and Center Evaluations

MTM Services Faculty and Focus Areas

Gap AnalysisCompleted Summer/Fall of 2011 Centennial MH & Psychiatry– Access Flow Chart

•

• • • •

At each agency, Gap Analysis Teams (GATs) convened consisting of 2 direct service staff from each level of service along intake continuum

Clients Call or walk-in for Care

Professional Referrals No – A - 15% B – 15% E- 15% F 15% H 15% L 13% S 40% W 15% Y 15%

Support Staff Available? Yes – A – 85% B – 85% E- 85% F- 85% H – 85% L - 87% S – 60% W – 85% Y - 85%

Wait Time – 1-3 days % of calls are lost Cris Locates & Calls the Client Back Client Back to schedule appointment Completes – Svc req., demographics, svc hx, education, pregnancy status, PCP, veteran status, referral source, Medicaid status, emer contact, IV drug user?, financial info, schedule appt (A) Forms: Initial Contact Registration Form (e, or paper) 5-6 min Client and Staff Time S - 3 min client and staff time Post Session: complete log – 10-15 min Staff Time Only

Initial Call

Individual internet meetings scheduled with each GAT Measured First Client Contact, through completion of Treatment Plan Gap Analysis with 15 Centers resulted in 193 Individual Process Flows Goal: Identify Process Redundancy and Wait Times

Client in Crisis? No – A 98% B 97% E 98% F – 95% H 97% L 97% S 5% W 98% Y 98%

LOCATIONS/ Services: AMH CMH SA – Adult and Youth Psychiatry – meds only Case Management Criminal Justice- CM Akron (A) Burlington (B) Elizabeth (E) + CSP + Outreach (IOG) coordinated care Fort Morgan (F) + CSP + vocational supported employment Holyoke (H) - CM Limon (L) + DV - OP Sterling (S) + residential + SPMI + day treatment (CSP) + vocational supported employment Wray (W) Yuma (Y)

Yes – A- 2% B- 3% E – 2% F - 5% H - 3%

L -3% S - 5% W - 2% Y – 2%

Crisis Flow

Client Appropriate for Care?

No – 1%

Refer Client Out

Yes –99%

End of First Contact Wait Days – A 2-7 / B 2-7 / E 2-14 / F 2-7 / H 2-7 / L 2-7 / S 2-7 / W 2-7 / Y 2-7

Intake Assessment –orScreen (H-10%)*no charge –orEvaluation (A- 5%)

INTAKE ASSESSMENT: Pre-Session: Support Staff - Forms – Consent, fee acknowledge, insurance info, collect payment (opt) 5-10 Client and Staff S – Initial Contact form 5-10 min Client time / 5-10 Client and Staff H – MH 10-15 Client and staff / Session: Therapist (MA+) - Forms: Assessment, ROIs, CCAR (MH), Mental Status Exam, psychosocial hx, brief physical/med screen, provisional dx, 90-120 min Client and Staff Time Post Session: Therapist – 60-120 Staff Time Only H - SCREEN: Clinician 30-50 client and staff Post-Session: 15 min staff only time EVALUATION: Pre-Session (support staff): 5-10 Client and Staff. Session (clinician) 120 min client and staff. Post-Session: 120-240 min staff time only

End of Second Contact C

Access to Treatment Process Flows â&#x20AC;&#x201C; Measurement Process Summary 193 Processes

Access Process - Wait time by Organization and Division

Intake Cost Analysis Example

Initial Access Flow Cohort Outcomes 1. Measurement of current processes from first call for routine help to treatment plan completion 2. Measurement processes provided indicate that the cohort of 15 centers have 193 different flow processes 3. Number of staff hours needed range from .5 hours to 11.7 hours â&#x20AC;&#x201C; Cohort average is 5 hours of staff time 4. Cost of processes range from $11 to $855 â&#x20AC;&#x201C; Cohort average cost is $369 5. Total days wait to treatment range from less than one day to 150 calendar days â&#x20AC;&#x201C; Cohort average wait time is 31.30 calendar days for all divisions/programs

Access to Treatment National Best Practice Target Averages 1. Access to Treatment processes within each center:  

Gold Standard – Standardized Process for the center Silver Standard – No more than one per division

2. Number of staff hours needed from first call for help to treatment plan completion range from 2 hours to 2.5 hours which will require staff to use collaborative documentation process 

Assessment process target is one hour using CSR support

3. Cost of processes range from $150 to $200 4. Total days wait to treatment for therapist/case manager is 8 calendar days or less and to MD/APRN is 10 total calendar days or less from Intake/Assessment

Change Measurement

RESULTS 21

Pilot / Implementation Phase for RCCP Efforts

Integrated Care Outcomes for RCCP Efforts

Improved Timeliness of Access to Care 1. Multiple Teams reported a complete restructuring of Access/Intake Processes, removing redundancies and unnecessary steps resulting in cohort average reduction in calendar wait days to care from 25 days to 14 days. 2. Centralized Scheduling  implemented by 26% of Teams  Indicated by one Team as “Most Notable Achievement” for increasing productivity

3. Open Access  Piloted/Implemented by 46% of all Cohort  Open Access was highlighted by 5 Individual Centers as their “Most Notable Achievement”.