Promoting Improved Integration: An Examination of Collaborative Health Care Models

1. Promoting Improved Integration: An Examination of Collaborative Health Care Models Council on Advocacy and Government Relations Peter Martin, MD, MPH John Lusins, MD Marilyn Griffin, MD Margaret Balfour, MD, PhD

2. Disclosure Statement Drs. Martin, Griffin, and Balfour are all APA Public Psychiatry Fellows, sponsored by Bristol Myers-Squibb Dr. Lusins is an APA Psychiatric Leadership Fellow

3. Access to Slides Viewable slideshow: http://www.slideshare.net/collaborativehealthcaremodels/ Downloadable PDF: http://sites.google.com/site/ collaborativehealthcaremodels/

4. Workshop Objectives Identify different models of integrative health care Explore the concept of the medical home and discuss how it can be incorporated into the mental health realm Examine examples of different integrative models, utilizing examples from the adult and pediatric realms, as well as discussing health care coordination models as seen in different countries and cultures Discuss various payment models to ensure the success of integrative health care

5. Collaborative Care: Overview Peter S. Martin, MD, MPH Child and Adolescent Psychiatry Fellow University of Rochester

6. Conceptual Models Provider-centered

7. Conceptual Models for ProvidersTraditional

8. Conceptual Models for ProvidersCoordinated Care

9. Conceptual Models for ProvidersCo-Location

10. Conceptual Models for ProvidersCo-Location in Reverse

11. Conceptual Models for ProvidersIntegrated Care

12. Levels of Integration BASIC On-site CLOSE Fully Integrated MINIMAL BASIC at a Distance CLOSE Partly Integrated Collaboration Continuum Doherty, W. The Why’s and Levels of Collaborative Family Health Care.

13. Conceptual Models Patient-centered

14. The Four Quadrant Clinical Integration Model Quadrant II ↑ BH ↓ PH Quadrant IV ↑ BH ↑ PH Behavioral Health Risk/Status Quadrant III ↓ BH ↑ PH Quadrant I ↓ BH ↓ PH Physical Health Risk/Status Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices

15. Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home.

16. Joint Principles of the Patient-Centered Medical Home Personal physician Physician directed medical practice Whole person orientation Care is coordinated and/or integrated Enhanced access Quality and Safety Payment National Center for Medical Home Implementation

17. Suggested Resources Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009. Pautler, K., and M.-A. Gagne. 2005. Annotated Bibliography of Collaborative Mental Health Care. Mississauga, ON: Canadian Collaborative Mental Health Initiative. http://www.ccmhi.ca/en/products/documents/03_AnnotatedBibliography_EN.pdf Smith, TE and Sederer, LI. A new kind of homelessness for individuals with serious mental illness? The need for a “mental health home.” Psychiatric Services. 2009;60:528–533. http://ps.psychiatryonline.org/cgi/reprint/60/4/528

18. ReferencesCollaborative Care: Overview Doherty, W. The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine. 1995;13(3–4):275–81. Mauer, B. Behavioral health/primary care integration: The four-quadrant model and evidence-based practices. National Council for Community Behavioral Healthcare. 2006. Mauer, B. Behavioral health/primary care integration and the person-centered healthcare home. National Council for Community Behavioral Healthcare. 2009.

19. Towards Integrated Health Care in Northern WV John Lusins, MD Chief Resident WVU Department of Behavioral Medicine Morgantown, WV

20. Conflicts I owned 0.5% of Lime Medical LLC and had on-going consulting relationship. Closed as of May 13th 2011 No further conflicts

21. Theory 4 Quadrant Model Where do we fit? Two Locations Valley Community Mental Health Centers Chestnut Ridge Center

22. Valley CMHC Founded in 1969 by West Virginia University, Valley Counseling Services united with The Human Resources Association and incorporated as Valley Community Mental Health Services in 1972. Doing business as Valley HealthCare System, a nonprofit corporation. Spurred by the federal government, funds became available through the passage of the Community Mental Health Center Act of 1963, introduced by President John F. Kennedy and Valley was able to establish itself as one of 13 federally-funded mental health centers in the state in the early 1970’s.

23. Valley CMHC Currently located in Monongalia, Marion, Preston and Taylor Counties

24. Valley CMHC

25. Valley CMHC Services Chemical Dependency Developmental Disabilities Mental Health

26. Valley CMHC Suicide Hotline 24/7 staffing Outpatient services Daily clinics by MD’s Now NP’s with MD supervision Therapists Case Coordinators Crisis Unit ACT team

27. Valley CMHC Primary Care Over the last year, push by MD’s staffing to have FP/IM MD’s to join staff Non-compliance with out-sourced PCP appointments Immediate non-acute health concerns Coordination of care

28. Valley CMHC Added two Family Practitioners in last year 1 day/week at 4 BH locations New clinic Metabolic Program Well-received primary care visits (172) Reported increase in patient satisfaction No change in show-rate for BH 2 MD positions to NP’s

29. Chestnut Ridge Hospital Home of WVU Department of Psychiatry Free-standing hospital with 65 inpatient beds Over 50,000 outpatients seen last year

30. Chestnut Ridge Hospital Specialty Clinics Memor y Disorders Thought Disorders Sleep Disorders Geriatric Psychiatry All patients previously referred to main hospital outpatient for Primary Care needs

31. Chestnut Ridge Hospital 2010 WVU Family Medicine/Psychiatry Graduate hired to create Integrated Care clinic Thought Disorders Clinic Chronic severe mental illness with low-moderate primary care needs Patients given option of continuing care at Main Outpatient clinic vs. seen as part of scheduled clinic Care coordinated by BH Physicians and Social Workers

32. Chestnut Ridge Center Results (prelim) Patient adherence to primacy care recommendations increased: BP medications Glucose control Weight loss Patient satisfaction increased Physician satisfaction increased Decreased No-Show rate

33. Quadrant II PCP: Provides primary care services and collaborates with the specialty BH providers BH: Provide BH assessment and arrange for/deliver specialty BH services Assure case management (housing, community supports) Assure access to health care Create a primary care communication approach that assures coordinated service planning

34. Future Expand Primary Care integration to all specialty clinics Measure results at Valley and WVU Hospitalizations? Integrate FP into ACT team

35. References and Resources “Valley MCHC Annual Report”- 2010-2011 Collins, C et al. Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf

36. Regards APL Fellowship CAGR Committee Co-presentors

37. “Hello Primary Care, I’m home!” An Overview of Behavioral Health and Pediatric Primary Care Integration Marilyn Griffin, MD PGY 5 Triple Board Resident APA Public Psychiatry Fellow APA Council on Advocacy and Government Relations May 18, 2011

38. Outline “Houston, we have a problem” Creative solutions Successful models Change Discussion

39. “Houston, we have a problem…”

40. The Facts 2001: Surgeon General’s Report on Children's Mental Health indicated the mental health of children and adolescents was a public crisis

41. The Facts, Cont. ≈ 1 in 5 children in US with diagnosable mental health disorder ≈ 80% of mentally ill children are not identified or treated Suicide is the 3rd leading cause death in 10-24 yo Mental Illness is the 2nd leading cause of disability and premature mortality in the U.S. Burden of untreated mental illness on various systems of care

42. The Facts, Cont. Source: Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (2009 pg 246). Adapted from Eisenberg and Neighbors (2007).

43. “It is easier to build strong children than to repair broken men.” Frederick Douglass

44. Workforce Shortage

45. Workflow Shortage, Cont. Prevention training standards & programs Training resources Medical and graduate medical education curriculum changes

46. Creative Solutions

47. http://www.medicalhomesummit.com/past2010/past.html

48. The Patient - Centered Medical Home 1967 AAP introduced the medical home concept 2002-2006 expanded definitions of medical home and creation of other models 2007 AAFP, AAP, ACP, AOA, developed: Joint Principles of the Patient-Centered Medical Home

49. The Patient - Centered Medical Home: Joint Principals Personal physician Physician directed medical practice Whole person orientation Care coordination/integration Enhanced access to care Quality and safety Appropriate payment National Center for Medical Home Implementation

50. The Patient - Centered Medical Home: Benefits Unique opportunity to engage in services without stigma Improved access to specialty care Appropriate level of care by providers in familiar environment

51. Bridging Medical Home and Integrated Care Patients designated for medical home care represent those potentially targeted for integrated care The medical home has the potential to shift costs from acute care to preventive, chronic care management, and recovery

52. Bridging Medical Home and Integrated Care, Cont. Medical home will provide more comprehensive approach to primary care more holistic and integrated care a more collaborative physician-patient relationship

53. Collaboration +/- Integration = Confusion Terms not used consistently in the field Engel (1977) biopsychosocial model theory at the root of collaborative and integrated care Strosahl (1998) collaborative care involves behavioral health working with primary care integrated care involves behavioral health working within and as a part of primary care (you say tomato, I say tomhato)

54. Successful Models

55. Child and Family Counseling Center(CFCC) Pittsburgh, PA

56. Child and Family Counseling Center (CFCC) Based on patient centered medical home model Unmet behavioral health service need Provide evaluation and treatment: Mood disorders Anxiety disorders Attention-deficit and disruptive behavior disorders Adjustment disorders http://www.chp.edu/CHP/counseling

57. CFCC Partnership Children’s Community Pediatrics Children’s Hospital of Pittsburgh Western Psychiatric Institute and Clinic

58. CFCC: Children’s Community Pediatrics 110 Pediatricians Several mid-level providers 19 practices 28 offices 8 counties http://www.cc-peds.net/main/index.shtm

59. CFCC: Children’s Hospital of Pittsburgh Only children’s hospital serving Western PA Level 1 Pediatric Trauma Center One of 8 pediatric hospitals in US named to: U.S. News & World Report's Honor Roll of America’s “Best Children’s Hospitals” for 2010–2011 http://www.chp.edu/CHP/Home

60. CFCC: Western Psychiatric Institute and Clinic Largest psychiatric facility in Western PA Serves over 25,000 patients and families/yr Full continuum of services including 24 hour psychiatric emergency room Residency training site for Triple Board Program and Family Practice/Psychiatry Program http://www.upmc.com/HospitalsFacilities/Hospitals/wpic/Pages/default.aspx

61. CFCC Partnership Mission Statement “ …a collaborative effort between pediatricians, licensed clinical social workers, psychologists and psychiatrists to provide timely access to high-quality, empirically-supported behavioral health assessments, behavioral interventions, and psychiatric interventions to children and families in an integrated model of care provided within the pediatric primary care office.”

62. CFCC: 2007 Pilot Project BH specialist in 1 CCP office 2 days/week (therapist, child & adolescent psychiatrist) Referral indications and exclusions identified Clinical treatment protocol outlined Training sessions for all staff Centralized registration and billing Electronic Medical Records

64. ADHD/Comorbid anxiety mood sx

65. Anxiety/phobia/OCD

66. Chronic illness

67. Depression/mood sx

68. Defiance/opposition

69. Disordered eating

70. Encopresis/enuresis

71. Grief/Loss

73. Homocidality

74. Severe substance abuse

75. Violence

76. CYF report

78. Mild adjustment issues

79. Mild anxiety or depression

80. Parenting/child development education

81. Family supportReferral to Behavioral Health Therapist for assessment and possible treatment Pediatrician refers to Emergency Dept. or appropriate community agency Managed by the Pediatrician Non-behavioral concerns are not referred to behavioral provider: Custody Issues CYF/child welfare issues Learning/school evals Financial/housing, etc. If no symptoms resolution or specialized care required (bipolar disorder, psychosis, etc.) Referral to child psychiatrist Pediatrician refers to appropriate community agency Therapists/psychologist collaborate with psychiatrist and pediatrician G.Crum/A.Schlesinger 5-13-08

82. CFCC: Beyond the Pilot 2 Child and Adolescent Psychiatrists 2 Triple Board trained Physicians Therapists at 14 different locations Non CCP patients seen at central location (Pine Center, Wexford Office)

83. CFCC: Beyond the Pilot, Cont. > 1500 patients seen since Aug 2008 Ave approx 600 visits/month Approx 10% no show rate 80% diagnoses = anxiety, depression, or ADHD Comorbidity Depressive & Anxiety d/o Anxiety d/o & ADHD

84. CFCC: Strategies for Success Buy in by all invested parties Monthly meetings Provide staff with appropriate tools/support Centralized billing

85. Communication is the key Office Managers Nurses Operations Scheduling Staff Front desk Triage Staff Families

86. “Nothing changes, if nothing changes” - Earnie Larsen

87. Policy Implications 2010: Patient Protection and Affordable Care Act Demonstration Projects Medicaid Medical Home Pilot: Sec 2703 Medicaid Accountable Care Organization Pilot Program: Sec 2706 Co-location of Primary and Specialty Care in Community-Based Behavioral Health: Sec 5604

88. Policy Implications, Cont. Improve reimbursement rates Improve incentives for screening and prevention Recommend collaboration among Department of Health and Human Services agencies (HRSA, SAMHSA, etc)

89. Thank You! Kenneth Thompson, MD Abigail Schlesinger, MD Norman Cohen, MD Roberto Ortiz-Aguayo, MD Art Kovel, MD Carl Bell, MD Kristin Dalope, MD Lynn Malec, MD Sheree Shafer Gretchen Crum WPIC Triple Board Program APA Public Psychiatry Fellowship

90. References AACAP Committee on Health Care Access and Economics, AAP Task Force on Mental Health. Improving Mental Health Services in Primary Care. Pediatrics Volume 123, Number 4: 1248-1251, April 2009 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. Elk Grove Village, IL: American Academy of Pediatrics; 2007. Available at: http://www.medicalhomeinfo.org/Joint%20Statement.pdf. Capko J., Practice Points: Home Sweet Medical Home. Repertoire, January 2011;19: Collins C, Hewson DL, et al. “Evolving Models of behavioral Health Integration in Primary Care. Milbank Memorial Fund. May 2010 Doherty, W. The Why’s and Levels of Collaborative Family Health Care. Family Systems Medicine. 1995;13(3–4):275–81. Goinik A, et al. Medical Homes for Children with Autism: A Physician Survey. Pediatrics Volume 123, Number 3: 966-971, March 2009 Horowitz L.M, Ballard ED, Pao M. Suicide screening in schools, primary care and emergency departments. Current Opinion in Pediatrics. 2009; 21 (5): 620-627 Holt, W. “The Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment in Primary Care, A Case Study by the Commonwealth Fund,” March 2010. Lake, Raymond. How academic psychiatry can better prepare students for their future patients. Part I: the failure to recognize depression and risk for suicide in primary care; problem identification, responsibility, and solutions. Behav Med. 2008 Fall;34(3):95-100. Martin P., Griffin M., Krasnik C., “All in the Family: The Benefits and Challenges of Collaborative Health Care Models.” APA 62nd Institute on Psychiatric Services. October 15, 2010 Merikangas KR, He J, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication-adolescent Supplement (NCS-A). JAACAP . 2010; 49 (10): 980-989

91. References, Cont. O'Connell ME, Boat T, Warner KE. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. The National Academies Press 2009. Policy Statement- The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care. Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Pediatrics Volume 124, Number 1:410-417,July 2009 Sarvet B., Gold J., Bostic, J.Q., et al., “Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project,” Pediatrics, December2010; 126;1191-1200 U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 199 The President’s New Freedom Commission on Mental Health. Achieving the Promise: Transforming Mental Health Care in America. July 2003 http://www.ahrq.gov/ http://www.mcpap.com/index.asp http://www.nacronline.com/recovery-issues/dealing-with-your-dark-side-part-4 http://www.nih.gov http://samhsa.gov www.aap.org www.aacap.org www.psych.org www.thenationalcouncil.org

92. Promoting Improved Integration: An Examination of Collaborative Health Care ModelsPresented by the APA Council on Advocacy and Government Relationsat the 2011 Annual Meeting of the American Psychiatric AssociationMay 17, 2011 | Honolulu, HawaiiPaying for Integration Margaret Balfour, MD, PhD APA/BMS Public Psychiatry Fellow Public Psychiatry/T32 Postdoctoral Research Fellow University of Texas Southwestern Medical Center at Dallas

93. Integration can be… How services are organized, infrastructure, etc. Payment mechanisms and policies What the consumer experiences

94. Foundations of clinical integration Clinical integration is the ultimate goal. Financial and structural integration don’t automatically result in clinical integration. But it’s difficult to have clinical integration without financing and infrastructure that support collaboration.

95. Many barriers to financial integration http://www.thenationalcouncil.org/galleries/resources-services%20files/BHCoverage_onSameDay_byState_9_14.BMP

96. Lack of Medicaid reimbursement for: Same-day visits Undermines the concept of “warm-handoffs” and co-location Care management and provider communication Which is the centerpiece of collaborative models PCPs coding primary mental health diagnoses Screening and prevention SAMHSA. Reimbursement of Mental Health Services in Primary Care Settings. 2008. http://download.ncadi.samhsa.gov/ken/pdf/SMA08-4324/SMA08-4324.pdf

97. Health plan barriers Carve-outs: lack of reimbursement for PCPs outside the health plan no financial incentive for coordination of care with physicians in other panels Medical cost savings not on the radar No reimbursement for consultation, team meetings or phone calls Even if one health plan has a perfect reimbursement model, most practices have patients on many different plans AHRQ. Integration of Mental Health/Substance Abuse and Primary Care, 2008. http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf

98. Looking to the literature Many programs are grant funded, and extra FTEs and services may not be sustainable outside the pilot/clinical trials environment Studies usually don’t go into detail about funding mechanisms Many studies compare different clinical and structural models, but none directly compare financial models Mostly have to rely on case studies at this point But groups are starting to study “real-world” implementation/financing issues. AHRQ. Integration of Mental Health/Substance Abuse and Primary Care, 2008. http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf

99. RWJF Depression in Primary Care Program Goal is to identify and implement economic and organizational strategies that will sustain care improvements. Identified seven reimbursement models for care management Differ in where the care managers are based and how they’re funded. J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288

100. Care management funding models Practice-based care management on a fee-for service basis Care managers are employees of the practice and located on-site Revenue flows from insurer to practice based on billing Depends on insurer/state policies and coverage Requires knowledge of covered CPT and HBAI codes J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288

101. Care management funding models Practice-based care managers under contract to health plans Health plans contract with practices to provide CM to targeted plan members CMs can be employees of either the practice, the health plan, or a 3rd party entity Revenue for their services based on historical estimates of service costs and numbers served and paid in yearly or monthly retrospective payments J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288

102. Care management funding models Global capitation Fully capitated HMOs have the flexibility to allocate resources They may choose to fund CMs internally Example: Kaiser Permanente Care Management Institute: www.kpcmi.org J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288

103. Care management funding models Pay for Performance (P4P) Health plans offer financial incentives for meeting pre-defined performance improvement targets Revenue is re-invested to support care managers and other quality improvement initiatives J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288

104. Care management funding models Health-plan based care management Care managers are employees of the health plan Provide services in the form of utilization review and care coordination with patients, behavioral health providers, PCP. Usually have little face-to-face contact with the patients Funded through administrative overhead paid to the health plan Works best when health plan is in close geographical proximity to providers so relationships can be developed. J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288

105. Care management funding models Third-party based care management under contract to health plans Health plans subcontract for CM services with disease management organizations, managed behavioral healthcare organizations, or CMHCs Payments typically capitated with a PMPM payment based on historical estimates of costs and numbers served J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288

106. Care management funding models Hybrid models Combinations of all the above For example: CMHC care managers placed in primary care, partly funded via fee-for-service billing, and partly through health plan contracts J. Bachman et al. Funding mechanisms for depression care management: opportunities and challenges. General Hospital Psychiatry 28 (2006) 278–288

107. Coding tips: Diagnosis and CPT E&M Study of depression claims in primary care settings to evaluate reasons for denials Found that most were coding errors not necessarily specific to MH policy issues http://www.machc.org/

108. Coding tips: HBAI codes Health and Behavior Assessment/Intervention Codes for non-physicians in primary health settings American Psychological Association online tool http://flash1r.apa.org/apapractice/hbcodes/player.html

109. State-by-state variability http://www.thenationalcouncil.org/galleries/business-practice%20files/Map_of_Available_HBAI_CPT_Codes1.pdf

110. Other tools To assess funding environment Kaiser Commission Report on Medicaid and the Uninsured State by state description of covered services and reimbursement methods, available Level II HCPCS codes, etc. http://www.kff.org/medicaid/benefits/service.jsp?nt=on&so=0&tg=0&yr=2&cat=7&sv=40 NCCBH Environmental Assessment Tool State Level Policy and Financing Questionnaire to assess whether state polices will promote or act as a barrier towards integration http://www.thenationalcouncil.org/galleries/business-practice%20files/PC-BH%20Environment-State%20Policy.pdf Lots of other resources: SAMHSA-HRSA Center for Integrated Solutions http://www.thenationalcouncil.org/cs/center_for_integrated_health_solutions

111. The future? PPACA creates new Center for Medicare and Medicaid Innovation (CMI) Funds payment reform pilots that promote payment for value rather than payment for volume. Case-rate: bundled payments for an individual for an episode of care Global payments: bundled payments for an individual for a period of time Removes barriers, creates more flexibility, incentives for prevention and integration models Dale Jarvis, The Business Case for Bidirectional Integrated Care. 2010. http://www.thenationalcouncil.org/galleries/policy-file/CiMH%20Business%20Case%20for%20Integration%206-30-2010%20Final.pdf

112. Further in the future? Move away from our “sick care” system Towards Patient-Centered Medical Homes supported by Accountable Care Organizations (The following slides were gratuitously stolen (with permission) from a presentation at the recent NCCBH conference by Dale Jarvis and Andy Keller.)

113. Typical Current “Wiring Diagram”

115. Effective

116. Efficient

117. Personalized

118. Timely

119. EquitableACO delivery organizations that facilitate the work of patient- centered teams The Fix: There is an emerging consensus about how to fix the health care system. The Institute of Medicine describes the fix with the following diagram. In order to achieve desired outcomes, the delivery system must organize itself into high performing patient-centered teams supported by health care organizations that facilitate this work. This requires: Person-Centered Healthcare Homes Supported by Accountable Care Organizations. These organizations, in turn, must be supported by the payment and regulatory system.

120. Which requires the Customization of the Accountable Care Organization

121. And Organizing the Safety Net Payors Washington State’s fledgling two-part effort: A Regional Health Authority to organize the payors to create a supportive payment and regulatory system That will, in turn, support organizing the delivery system into accountable systems of care

122. KEY IDEA: Get the payors working together in the same way we’re expecting the providers to work together

123. Questions? Viewable slideshow: http://www.slideshare.net/collaborativehealthcaremodels/ Downloadable PDF: http://sites.google.com/site/collaborativehealthcaremodels/ Contact Information Peter Martin: psmartin@gmail.com John Lusins: drjlusins@gmail.com Marilyn Griffin: griffinm3@upmc.edu Margaret Balfour: margaret.balfour@gmail.com