BH Integration: from the ordinary to the extraordinary Beverly Hammerstrom MPCA Conference Traverse City, Michigan September 17, 2007

Overview History Define the problem today Why now? Exactly do we mean by integrated care? Examples of models Next steps

History

Define the problem today

Why now?

Exactly do we mean by integrated care?

Examples of models

Next steps

Let’s first look at insurance……. Group health insurance first offered in 1910 by Montgomery Ward Became readily available in the US in the late 1930’s Prior to this primarily offered on lives, houses, cars, etc. Covered only catastrophic losses In-patient, emergency room Employer-sponsored health insurance became popular in the 1950’s after the IRS ruled it was a tax-deductible business expense 1960 – Private Sector (75%); Public Sector (25%); but most private sector plans did not cover MH (carve outs)

Group health insurance first offered in 1910 by Montgomery Ward

Became readily available in the US in the late 1930’s

Prior to this primarily offered on lives, houses, cars, etc.

Covered only catastrophic losses

In-patient, emergency room

Employer-sponsored health insurance became popular in the 1950’s after the IRS ruled it was a tax-deductible business expense

1960 – Private Sector (75%); Public Sector (25%); but most private sector plans did not cover MH (carve outs)

Federal Health Insurance Policies By early 1960’s clamor began for federal health insurance policies, primarily to aid poor and elderly Medicare Medicaid By end of 1960’s – federal share = 40%

By early 1960’s clamor began for federal health insurance policies, primarily to aid poor and elderly

Medicare

Medicaid

By end of 1960’s – federal share = 40%

How did physical and mental health become separated? 50 years ago – most people with mental illness were living in asylums more than 20,000 people in Michigan were living in state or county-operated facilities 1960’s – due to efforts of John Kennedy and advances in medicine thinking began to change Michigan PA 258 of 1974 – “tipping point” from institutional care to community-based system 1980-1990 – reduced by 50% number of people living in tax-funded institutions Today only less than 2000 patients in state facilities

50 years ago – most people with mental illness were living in asylums

more than 20,000 people in Michigan were living in state or county-operated facilities

1960’s – due to efforts of John Kennedy and advances in medicine thinking began to change

Michigan PA 258 of 1974 – “tipping point” from institutional care to community-based system

1980-1990 – reduced by 50% number of people living in tax-funded institutions

Today only less than 2000 patients in state facilities

Promises Made; Promises Broken Money was intended to follow consumers into the community programs Employer-paid insurance had no reason to pick up the bill; most didn’t Operating two systems – state & community; never enough money to fund both Community-based mental health system has ALWAYS been under funded

Money was intended to follow consumers into the community programs

Employer-paid insurance had no reason to pick up the bill; most didn’t

Operating two systems – state & community; never enough money to fund both

Community-based mental health system has ALWAYS been under funded

Shift in state’s directions Decreasing revenues have led to a shift in direction to maximize federal dollars and draw down more Medicaid match funds Incentives put in place in 1995 to encourage CMH’s to become authorities; froze county match Most treated in county-based systems today for mental illness are Medicaid Few general fund dollars available to treat other populations Guidelines specify they must treat the most severe first

Decreasing revenues have led to a shift in direction to maximize federal dollars and draw down more Medicaid match funds

Incentives put in place in 1995 to encourage CMH’s to become authorities; froze county match

Most treated in county-based systems today for mental illness are Medicaid

Few general fund dollars available to treat other populations

Guidelines specify they must treat the most severe first

Just How Big is the Problem Nearly 44 million Americans (26% of the population) experience a mental health problem annually Only 5% of those suffering from a mental health problem receive treatment from a mental health professional Community Mental Health Centers (CMHC) are not required to serve the uninsured population

Nearly 44 million Americans (26% of the population) experience a mental health problem annually

Only 5% of those suffering from a mental health problem receive treatment from a mental health professional

Community Mental Health Centers (CMHC) are not required to serve the uninsured population

What does this mean for Primary Health Care Providers? More and more needing behavioral health services are seeking it through primary care providers 95% seek treatment from a family physician – many for physical complaints 92% of all elderly patients receive MH care from PCP 90% of most common complaints have no organic basis 70% of federally-funded health centers report on-site mental health treatment and counseling; 50% provide substance abuse treatment and counseling (2003)

More and more needing behavioral health services are seeking it through primary care providers

95% seek treatment from a family physician – many for physical complaints

92% of all elderly patients receive MH care from PCP

90% of most common complaints have no organic basis

70% of federally-funded health centers report on-site mental health treatment and counseling; 50% provide substance abuse treatment and counseling (2003)

Prevalence of Psychiatric Disorders in Low-income PC Patients 7% 10% Eating Disorder 7% 17% Alcohol Abuse 11% 36% Anxiety Disorder 16% 33% Mood Disorder 28% 51% At least one psych DX General PC Low-income Disorder

More facts……….. 70-80% of all psychotropic medications are prescribed within primary care settings, sometimes inappropriately 67% of psychoactive agents prescribed by PCP 80% of antidepressants prescribed by PCP About ½ the time, mental health problems go undetected in primary care settings Even when diagnosed, these problems tend to be under-treated MH outcomes in primary care patients only slightly better than spontaneous recovery

70-80% of all psychotropic medications are prescribed within primary care settings, sometimes inappropriately

67% of psychoactive agents prescribed by PCP

80% of antidepressants prescribed by PCP

About ½ the time, mental health problems go undetected in primary care settings

Even when diagnosed, these problems tend to be under-treated

MH outcomes in primary care patients only slightly better than spontaneous recovery

Compliance Issues As few as 1 in 4 patients referred to specialty MH or CD make the first appointment Nationally = 45-75% “no shows” from 5-15% at first integrated clinic in Washtenaw County 50-56% non-adherence to psychoactive medications within first 4 weeks

As few as 1 in 4 patients referred to specialty MH or CD make the first appointment

Nationally = 45-75%

“no shows” from 5-15% at first integrated clinic in Washtenaw County

50-56% non-adherence to psychoactive medications within first 4 weeks

Untreated/Under-treated Patients Over-utilize medical services Visit physician twice as often as those receiving appropriate care Seek treatment in emergency rooms when in crisis People with persistent depression have annual adjusted medical costs 70% higher than those without depression

Over-utilize medical services

Visit physician twice as often as those receiving appropriate care

Seek treatment in emergency rooms when in crisis

People with persistent depression have annual adjusted medical costs 70% higher than those without depression

Why Patients Seek Mental Health Services in Primary Care Settings Limited access to specialty service providers Lack of adequate insurance coverage Cultural beliefs Eligibility requirements for public mental health services Trust their own physician Stigma

Limited access to specialty service providers

Lack of adequate insurance coverage

Cultural beliefs

Eligibility requirements for public mental health services

Trust their own physician

Stigma

Primary Care Concurs Committee on the Future of Primary Care The committee recommends the reduction of financial and organizational disincentives for the expanded role of primary care in the provision of mental health services. It further recommends the development and evaluation of collaborative care models that integrate primary care and mental health services more effectively. These models should involve both primary care clinicians and mental health professionals.

Committee on the Future of Primary Care

The committee recommends the reduction of financial and organizational disincentives for the expanded role of primary care in the provision of mental health services. It further recommends the development and evaluation of collaborative care models that integrate primary care and mental health services more effectively. These models should involve both primary care clinicians and mental health professionals.

Prevalence of Psychiatric Disorders in Low-income PC Patients 7% 10% Eating Disorder 7% 17% Alcohol Abuse 11% 36% Anxiety Disorder 16% 33% Mood Disorder 28% 51% At least One Psychiatric Dx General PC Population Low-income Patients Psychiatric Disorder

Low-income Patients with Psychiatric Dx 35% saw their PCP in the past 3 months 90% of low-income patients with psychiatric Dx preferred integrated care

35% saw their PCP in the past 3 months

90% of low-income patients with psychiatric Dx preferred integrated care

Morbidity and Mortality Rates People with serious mental illness are dying nearly three decades earlier (on average) than general population High prevalence of obesity, diabetes and cardiovascular disease Newer medications for bipolar disorder and schizophrenia can exacerbate metabolic risks BH Providers less likely to screen and monitor regularly

People with serious mental illness are dying nearly three decades earlier (on average) than general population

High prevalence of obesity, diabetes and cardiovascular disease

Newer medications for bipolar disorder and schizophrenia can exacerbate metabolic risks

BH Providers less likely to screen and monitor regularly

Recommendations……. Promote Coordinated and Integrated mental Health and Physical Health Care for Persons with SMI Promote integration of general health and mental health records Revise laws and policies to support communication between providers

Promote Coordinated and Integrated mental Health and Physical Health Care for Persons with SMI

Promote integration of general health and mental health records

Revise laws and policies to support communication between providers

And……… Adopt a Policy that Mental Health and Physical Healthcare should be Integrated Implement Care Coordinated Models Assure financing methods for service improvements. Include reimbursement for coordination activities, case management…….. Establish rates adequate to assure access to primary care by persons with SMI

Adopt a Policy that Mental Health and Physical Healthcare should be Integrated

Implement Care Coordinated Models

Assure financing methods for service improvements. Include reimbursement for coordination activities, case management……..

Establish rates adequate to assure access to primary care by persons with SMI

New Freedom Commission Chapter on Integration in the Final Report as well as several Action Agenda activities related to integration Recommended development of a comprehensive state plan across all mental health activities that should include a requirement to address primary care integration issues

Chapter on Integration in the Final Report as well as several Action Agenda activities related to integration

Recommended development of a comprehensive state plan across all mental health activities that should include a requirement to address primary care integration issues

Why Now? “ Research demonstrates that mental health is key to overall physical health. Therefore, improving services for individuals with mental illness requires close attention to how mental health care and general medical care interact. While mental health and physical health are clearly connected, a chasm exists between the mental health and general health care systems in financing and practice.

“ Research demonstrates that mental health is key to overall physical health. Therefore, improving services for individuals with mental illness requires close attention to how mental health care and general medical care interact. While mental health and physical health are clearly connected, a chasm exists between the mental health and general health care systems in financing and practice.

The Recommendation……. “Commission suggests that collaborative care models should be widely implemented in primary health care settings and reimbursed by public and private insurance.”

“Commission suggests that collaborative care models should be widely implemented in primary health care settings and reimbursed by public and private insurance.”

Goal #5: The Commission recommends that Medicare, Medicaid, and the Department of Veterans Affairs, and other Federal and State-sponsored health insurance programs and private insurers identify and consider payment for core components of evidence-based collaborative care including: case management, disease management, supervision of case managers, consultations to primary care providers by qualified mental health specialists that do not involve face-to-face contact with clients

The Commission recommends that Medicare, Medicaid, and the Department of Veterans Affairs, and other Federal and State-sponsored health insurance programs and private insurers identify and consider payment for core components of evidence-based collaborative care including: case management, disease management, supervision of case managers, consultations to primary care providers by qualified mental health specialists that do not involve face-to-face contact with clients

Changes at the Federal Level Omnibus Budget Reconciliation Acts (OBRA) of 1987 and 1989 expanded Medicare and Medicaid reimbursements to include clinical psychologists and master’s level social workers practicing in rural areas HRSA has provided grant funding to FQHC’s to increase behavioral health staff (no longer available)

Omnibus Budget Reconciliation Acts (OBRA) of 1987 and 1989 expanded Medicare and Medicaid reimbursements to include clinical psychologists and master’s level social workers practicing in rural areas

HRSA has provided grant funding to FQHC’s to increase behavioral health staff (no longer available)

And……….. PIN 2004-05 – Medicaid funding for BH in FQHC’s All new FQHC applications must include HRSA is offering grant funds for Developing Integrated Networks in rural areas and for developing networks

PIN 2004-05 – Medicaid funding for BH in FQHC’s

All new FQHC applications must include

HRSA is offering grant funds for Developing Integrated Networks in rural areas and for developing networks

Michigan Task Force Concurs Mental health and physical health should be more integrated…….. An ideal system is integrated; for consumers entering a confusing array of services, there is no wrong door. Develop specific sustainable models of collaboration at the state and local levels maximizing resources earmarked for providing mental health services.

Mental health and physical health should be more integrated……..

An ideal system is integrated; for consumers entering a confusing array of services, there is no wrong door.

Develop specific sustainable models of collaboration at the state and local levels maximizing resources earmarked for providing mental health services.

Goal #5 “Coordinate the delivery of mental health services by both federally qualified health clinics and community mental health programs.” The writing’s on the wall, folks! and it’s the right thing to do

“Coordinate the delivery of mental health services by both federally qualified health clinics and community mental health programs.”

The writing’s on the wall, folks!

and it’s the right thing to do

NCCBH Goals for Integration Every provider of public BH services assures assessment of health status as well as mental status and has specific protocols in place for medically monitoring all consumers receiving second generation antipsychotic medications. An integral part of their service for consumers is to assure that each person is connected to a primary care medical home and there are specific mechanisms between the BH and PCP for coordination of services.

Every provider of public BH services assures assessment of health status as well as mental status and has specific protocols in place for medically monitoring all consumers receiving second generation antipsychotic medications. An integral part of their service for consumers is to assure that each person is connected to a primary care medical home and there are specific mechanisms between the BH and PCP for coordination of services.

NCCBH Goals continued…….. The safety net population in every community served by providers of public BH services and by CHC’s has seamless access to both BH and physical health care. There is a strong working partnership among these providers, with roles defined, referral protocols in place and cross-placement of clinical staff.

The safety net population in every community served by providers of public BH services and by CHC’s has seamless access to both BH and physical health care. There is a strong working partnership among these providers, with roles defined, referral protocols in place and cross-placement of clinical staff.

What is Integrated Care? Not simply placing a MH specialist inside a medical setting Medically oriented; pace fits with the ecology of the medical setting Covers problems not typically seen in specialty mental health care Focuses on population management and on supporting and enhancing the PCP who leads the integrated care team

Not simply placing a MH specialist inside a medical setting

Medically oriented; pace fits with the ecology of the medical setting

Covers problems not typically seen in specialty mental health care

Focuses on population management and on supporting and enhancing the PCP who leads the integrated care team

Integrated care……… Includes a treatment plan containing behavioral and medical elements rather than two separate treatment plans Is a health care model in which physical health and mental health clinicians partner to manage the treatment of mental health disorders in the primary setting

Includes a treatment plan containing behavioral and medical elements rather than two separate treatment plans

Is a health care model in which physical health and mental health clinicians partner to manage the treatment of mental health disorders in the primary setting

Elements of BH Integration Financial or structural integration does not assure clinical integration Clinical integration helps focus on what consumers need Public sector efforts focused on financial integration (carve-ins) have had limited success Clinical integration requires financial and structural supports Public sector financing is a major barrier to achieving clinical integration in most settings

Financial or structural integration does not assure clinical integration

Clinical integration helps focus on what consumers need

Public sector efforts focused on financial integration (carve-ins) have had limited success

Clinical integration requires financial and structural supports

Public sector financing is a major barrier to achieving clinical integration in most settings

Benefits of Integration Improved detection of behavioral health disorders Significant increase in patients receiving recommended care and positive clinical outcome Higher levels of patient adherence to treatment Better clinical outcome than by treatment in either sector alone

Improved detection of behavioral health disorders

Significant increase in patients receiving recommended care and positive clinical outcome

Higher levels of patient adherence to treatment

Better clinical outcome than by treatment in either sector alone

More benefits…….. Improved consumer and provider satisfaction Improved PCP skills in medication prescription practices Increased confidence in PCP in managing BH conditions

Improved consumer and provider satisfaction

Improved PCP skills in medication prescription practices

Increased confidence in PCP in managing BH conditions

And it saves money…….. More cost effective treatment Can reduce overall cost and reduce over-utilization of the medical system Between 20 and 40% of total medical care cost savings Up to 70% saved in treating older Americans

More cost effective treatment

Can reduce overall cost and reduce over-utilization of the medical system

Between 20 and 40% of total medical care cost savings

Up to 70% saved in treating older Americans

Oahu Study……… 126,000 patients 40% reduction of costs by a sample of high utilizers Reduced medical utilization by 21%

126,000 patients

40% reduction of costs by a sample of high utilizers

Reduced medical utilization by 21%

McDonnell-Douglas Corp. 1989 Provided in-house counseling for substance abuse, depression, family problems for employees – 20,000/4 years Lowered health care cost of not only employees but also dependants 34-44% reduction in absences 60-80% lower attrition rate Saved $4 in health, absences, and attrition for every $1 spent

Provided in-house counseling for substance abuse, depression, family problems for employees – 20,000/4 years

Lowered health care cost of not only employees but also dependants

34-44% reduction in absences

60-80% lower attrition rate

Saved $4 in health, absences, and attrition for every $1 spent

PCP prefer integrated care: PRISM-E Study of Elderly Better communication between PCP and MHP (93%) Less stigma for patients (93%) Better coordination of care (92%) Better care of depression (64%) Better care of anxiety (76%) Better care of alcohol problems (66%)

Better communication between PCP and MHP (93%)

Less stigma for patients (93%)

Better coordination of care (92%)

Better care of depression (64%)

Better care of anxiety (76%)

Better care of alcohol problems (66%)

Hypothesis: Better identification of behavioral health needs and better targeting and managing of treatment to those needs using collaboration will lead to more cost-effective treatment, higher compliance and better patient outcomes. It should be a slam dunk……

Better identification of behavioral health needs and better targeting and managing of treatment to those needs using collaboration will lead to more cost-effective treatment, higher compliance and better patient outcomes.

It should be a slam dunk……

Getting there is not a “walk in the park” Financial Barriers Not reimbursed for collaborative work Revenue silos Billing requirements; record-keeping regulations Firewalls in communication systems Legal landmines Stigma and discrimination associated with mental health problems Lack of resources Human (providers; staff) Funding Time/Space Interest Proper tools Language and Cultural Differences

Financial Barriers

Not reimbursed for collaborative work

Revenue silos

Billing requirements; record-keeping regulations

Firewalls in communication systems

Legal landmines

Stigma and discrimination associated with mental health problems

Lack of resources

Human (providers; staff)

Funding

Time/Space

Interest

Proper tools

Language and Cultural Differences

The Great Cultural Divide…….. Primary Care Docs 10-15 minute blocks Deal one-on-one w/other physicians Find it difficult to deal with interdisciplinary team Medical records short, concise summaries of the diagnosis, treatment and outcome Language = patients Psychiatrists Language = clients or consumers 45-60 minute sessions Time with consumers considered sacrosanct Behavioral health records are long and complex Contain goals and objectives Variety of provided services; may be re-evaluated over time Contain consumer input

Primary Care Docs

10-15 minute blocks

Deal one-on-one w/other physicians

Find it difficult to deal with interdisciplinary team

Medical records short, concise summaries of the diagnosis, treatment and outcome

Language = patients

Psychiatrists

Language = clients or consumers

45-60 minute sessions

Time with consumers considered sacrosanct

Behavioral health records are long and complex

Contain goals and objectives

Variety of provided services; may be re-evaluated over time

Contain consumer input

Training………… Most primary care physicians receive little training in psychiatry Most psychiatric specialty training does not provide much training in primary care issues Neither receives significant training in collaborative, integrated practices arrangements

Most primary care physicians receive little training in psychiatry

Most psychiatric specialty training does not provide much training in primary care issues

Neither receives significant training in collaborative, integrated practices arrangements

Barriers Identified by Michigan FQHC’s Funds to employ staff Limited availability of behavioral health providers Limited space and staff Staff resistance Ownership of medical records; HIPPA Sharing of revenue sources

Funds to employ staff

Limited availability of behavioral health providers

Limited space and staff

Staff resistance

Ownership of medical records; HIPPA

Sharing of revenue sources

Three World View: Three Languages Clinical “Achievement” of health goals Goal of care = quality Financial Bottom line Price/value Structural/Operational Productivity Efficiency

Clinical

“Achievement” of health goals

Goal of care = quality

Financial

Bottom line

Price/value

Structural/Operational

Productivity

Efficiency

Minkoff’s View (Medical Director of Choate Integrated Behavioral Care, Woburn, MA) Clinical integration Dually trained clinicians or interdisciplinary teams Clinical practice integration Formal collaboration and consultation mechanisms, required screening practices, collaboration practices built into service protocols

Clinical integration

Dually trained clinicians or interdisciplinary teams

Clinical practice integration

Formal collaboration and consultation mechanisms, required screening practices, collaboration practices built into service protocols

Balance clinical integration with….. Programmatic integration Structural integration Behavioral and primary care services under a common administrative authority which can create standards for collaboration and clinical integration Physical integration Co-location of services in either direction

Programmatic integration

Structural integration

Behavioral and primary care services under a common administrative authority which can create standards for collaboration and clinical integration

Physical integration

Co-location of services in either direction

And……….. Fiscal integration Mental health and primary care services under a common funding stream which can be utilized to promote any of the other’s activities

Fiscal integration

Mental health and primary care services under a common funding stream which can be utilized to promote any of the other’s activities

Doherty’s FIVE LEVELS OF COLLABORATION Doherty’s Five Levels, FULLY INTEGRATED ELECTRONIC HEALTH RECORD; NEED-TO-KNOW ACCESS FOR ALL PRACTITIONERS SHARED ALLEGIANCE TO BIOPSYCHOSOCIAL SYSTEMS PARADIGM NO COMMON LAN-GUAGE OR UNDER-STANDING OF OTHERS’ CULTURE LITTLE UNDERSTAND-ING OF OTHERS’ CULTURE SHARED VISION BASIC APPRECIA-TION OF OTHERS’ ROLE & CULLTURE APPRECIATION OF OTHERS’ ROLES LITTLE SHARED RESPONSIBILITY LIMITED COMMUNICATION REGULAR COLLABORATIVE TEAM MEETINGS SOME DATA SHARING BUT SEPARATE DATA SETS NO SYSTEMIC APPROACH TO COLLABORATION LINE STAFF WORK TOGETHER ON SOME CASES SEPARATE DATA SYSTEMS; LIMITED SHARING INTEGRATED FUNDING WITH RE-SOURCES SHARED ACROSS NEEDS; MAXIMIZATION OF BILLING AND SUPPORT STAFF SEPARATE FUNDING WITH SHARED ON-SITE EXPENSES; SHARED STAFFING & INFRASTRUCTURE COSTS PRIMARY CARE PHYSICIAN WORKS WITH CLINICIAN ON SITE RATHER THAN PSYCHIATRIST SEPARATE FUND-ING SYSTEMS SEPARATE FUND- ING SYSTEMS; NO RESOURCE SHARING SAME SYSTEMS; SEAMLESS; ONE TREATMENT PLAN; ON-GOING CONSULTATION COORDINATED TREATMENT PLAN; REGULAR FACE-TO-FACE INTERACTION TWO PHYSICIANS; TWO TREATMENT PLANS; SOME INTERACTION DUE TO PROXIMITY OCCASIONAL PLAN SHARING; SEPARATE & DISTINCT SERVICES SEPARATE AND DISTINCT TREATMENT PLAN AND SERVICES ONE FRONT DOOR; SHARED SITE; ONE VISIT FOR ALL NEEDS SHARED SITES SHARED FACILITY; MAY SHARE RECEPTION AREA TWO FRONT DOORS; SEPARATE FACILITIES TWO FRONT DOORS; SEPARATE FACILITIES CLOSE-FULLY INTEGRATED CLOSE-PARTLY INTEGRATED BASIC ON SITE BASIC AT DISTANCE BASIC

Bureau of Primary Health Care Model……….. Model I Referral Relationship Model II Co-location Teams working separately Model III On-site; shared cases between BH and PCP Model IV Integrated Care; BH specialist an active member of primary care team

Model I

Referral Relationship

Model II

Co-location

Teams working separately

Model III

On-site; shared cases between BH and PCP

Model IV

Integrated Care; BH specialist an active member of primary care team

A very basic on-site integrated model Physicians remain in charge of patient’s physical health Mental health professionals assess for mental illnesses and link clients with appropriate services Co-location provides “single point of entry”

Physicians remain in charge of patient’s physical health

Mental health professionals assess for mental illnesses and link clients with appropriate services

Co-location provides “single point of entry”

Collaboration – Contact & Communication Therapists read medical charts and notes Physicians read therapy notes Providers talk in the hallway Physicians join therapy sessions Therapists join medical sessions Conjoint family meetings Unified treatment team working to best assist patient in physical and mental care

Therapists read medical charts and notes

Physicians read therapy notes

Providers talk in the hallway

Physicians join therapy sessions

Therapists join medical sessions

Conjoint family meetings

Unified treatment team working to best assist patient in physical and mental care

Continuum of Integration BH specialists primary care team members +++++ Integrated Care On-site/shared cases With BH specialist +++ Collaborative Care On-site BH Unit but Separate Team ++ Co-location Preferred Provider Some info exchange + Referral Relationship Traditional BH Specialty Model -- Separate Location and Mission Attributes Desirability Model

Components of an Integrated Model Behavioral Health Triage Comprehensive Behavioral Health Assessment On-site Behavioral Health Treatment Referral Consultation Care monitoring and chronic disease management protocols

Behavioral Health Triage

Comprehensive Behavioral Health Assessment

On-site Behavioral Health Treatment

Referral

Consultation

Care monitoring and chronic disease management protocols

On-site Behavioral Health Treatment May include an array of services Individual, group, family counseling Psychotherapy Psychopharmacological assessment and treatment Limited by available behavioral health staffing and budgetary capacity

May include an array of services

Individual, group, family counseling

Psychotherapy

Psychopharmacological assessment and treatment

Limited by available behavioral health staffing and budgetary capacity

Referrals Internal referral back to PCP or other BH staff External referral to specialty BH providers Other social service components Housing Employment

Internal referral back to PCP or other BH staff

External referral to specialty BH providers

Other social service components

Housing

Employment

Care monitoring Chronic psychiatric conditions that can be managed effectively in PC setting Less complicated cases of depression Chronic health problems that are result of or complicated by co-morbid psychiatric conditions Difficulty adjusting to diabetes or cancer

Chronic psychiatric conditions that can be managed effectively in PC setting

Less complicated cases of depression

Chronic health problems that are result of or complicated by co-morbid psychiatric conditions

Difficulty adjusting to diabetes or cancer

Cherokee Health Systems Both a community health clinic and a community mental health provider in Tennessee Opened its first co-located, integrated primary care and behavioral health clinic in 1984 Today Cherokee has 21 sites

Both a community health clinic and a community mental health provider in Tennessee

Opened its first co-located, integrated primary care and behavioral health clinic in 1984

Today Cherokee has 21 sites

Cherokee’s Patient Base 40,000 in 2001 44% sought primary health care 56% sought behavioral health services 57% of population is Medicaid reimbursed on a capitation basis 12% are covered by Medicare 9% covered by federal and state grants

40,000 in 2001

44% sought primary health care

56% sought behavioral health services

57% of population is Medicaid reimbursed on a capitation basis

12% are covered by Medicare

9% covered by federal and state grants

Core Objective = Integration Entire staff is committed All staff (accounting, front-line, supporting) are considered essential players in providing integrated care Weekly case management meeting include the entire clinical staff Primary care providers are paid for time required for collaboration

Entire staff is committed

All staff (accounting, front-line, supporting) are considered essential players in providing integrated care

Weekly case management meeting

include the entire clinical staff

Primary care providers are paid for time required for collaboration

And……… Cherokee offers 12-month, 2000-hour internships to provide “an intensive and diverse clinical training experience within a community health setting”

Cherokee offers 12-month, 2000-hour internships to provide “an intensive and diverse clinical training experience within a community health setting”

According to Cherokee…….. ……….placement of a behaviorist on each primary care team is crucial to their mission to help ensure that the patients will get the appropriate behavioral care prescribed and recommended.

……….placement of a behaviorist on each primary care team is crucial to their mission to help ensure that the patients will get the appropriate behavioral care prescribed and recommended.

Next steps………. Determine where you are on the continuum of care and where you want to be Might require a stepped approach Might be different at each location Will depend upon resources available Staff, space, time, funding

Determine where you are on the continuum of care and where you want to be

Might require a stepped approach

Might be different at each location

Will depend upon resources available

Staff, space, time, funding

Don’t reinvent the wheel…. Lots of model programs that have proven successful Look at them, but then tweak them to meet the individual needs of your center

Lots of model programs that have proven successful

Look at them, but then tweak them to meet the individual needs of your center

Washtenaw County WCHO Delonis Homeless Shelter Small health clinic open 35 hrs. per week Nurse Practitioner Clinic Services to consumers at CMH facility, including smoking cessation classes Packard Community Clinic Full-time MSW and 4 hrs. of psychiatric time per week Ypsilanti Family Practice ½ day per week adult and child psychiatrist on site for consultation and resident training Corner Health Center Mental health staffing at center for persons 12-21 and children

Delonis Homeless Shelter

Small health clinic open 35 hrs. per week

Nurse Practitioner Clinic

Services to consumers at CMH facility, including smoking cessation classes

Packard Community Clinic

Full-time MSW and 4 hrs. of psychiatric time per week

Ypsilanti Family Practice

½ day per week adult and child psychiatrist on site for consultation and resident training

Corner Health Center

Mental health staffing at center for persons 12-21 and children

National Models That Already Exist MacArthur IMPACT RWJ Depression Disparities BPHC Health Disparities Program Washtenaw County Michigan Model Cherokee Health Systems - Tennessee

MacArthur

IMPACT

RWJ Depression Disparities

BPHC Health Disparities Program

Washtenaw County Michigan Model

Cherokee Health Systems - Tennessee

A rose by any other name…. If you’ve seen one integrated care program, you’ve seen one integrated care program Each program should be designed to address the needs in the community and be consistent with the mission and objectives of primary care Different models lead to different costs and outcomes

If you’ve seen one integrated care program, you’ve seen one integrated care program

Each program should be designed to address the needs in the community and be consistent with the mission and objectives of primary care

Different models lead to different costs and outcomes

Look for ways to partner…. Shared staffing arrangements Shared services Don’t overlook opportunities through telemedicine Opportunities to co-locate Three Rivers Health St. Joseph CMH Dental practice

Shared staffing arrangements

Shared services

Don’t overlook opportunities through telemedicine

Opportunities to co-locate

Three Rivers Health

St. Joseph CMH

Dental practice

Look for funding opportunities HRSA Grants Foundations RWJF Hogg Foundation Funding CMH Staff at Primary Care Clinics When the number of shared consumers is >40 (average case load size at CMH), and existing CMH professional and 5 hours of psychiatric time can be allocated to that clinic for the provision of on-site mental health services

HRSA Grants

Foundations

RWJF

Hogg Foundation

Funding CMH Staff at Primary Care Clinics

When the number of shared consumers is >40 (average case load size at CMH), and existing CMH professional and 5 hours of psychiatric time can be allocated to that clinic for the provision of on-site mental health services

Legislation may be needed…. Reimbursement codes Federal state Insurance Laws Public/Mental Health Code Changes Allow for partnerships/shared funding streams Governance It’s not impossible…….

Reimbursement codes

Federal

state

Insurance Laws

Public/Mental Health Code Changes

Allow for partnerships/shared funding streams

Governance

It’s not impossible…….

What’s on the Horizon……… National Learning Collaboratives National Learning Communities National Council for Community Behavioral Healthcare Statewide Learning Communities Statewide Pilot Projects Local Ideas

National Learning Collaboratives

National Learning Communities

National Council for Community Behavioral Healthcare

Statewide Learning Communities

Statewide Pilot Projects

Local Ideas

“ There is no try; only do.” Yoda Thank you.