Dedicated to promoting the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings.
The primary care, mental health, and addiction fields each have their own, and when working together, differences often bubble to the surface. If unaddressed, this barrier can hamper care coordination and, ultimately, the care individuals receive
People may change involuntarily, but this is often short lived unless they go through the above process. Once the external pressure is relieved, often people go back to familiar behavior.So then the question is, how do we engage people in a conversation about change so that they are free to consider why they would be motivated to change their behavior?
OARS Help: Focus on MI Spirit Provide the framework (the how-to skills) for the MI Guiding Principles. Build relationship with Consumer Increase/highlight ambivalence Elicit change talk Help avoid the Common Traps
Making Integrated Care Work
Making Integrated Care Work MI Primary Care Association September 28, 2012 Laura Galbreath, MPPDirector, Center for Integrated Health Solutions
Agenda-About the Center for Integrated Health Solutions-Lessons Learned from Grantees and Others• PC/BH Partnership - Communication• Workforce Development• Health Homes• Health Behavior Change• Operations and Administration• Financing and Billing
About the Center In partnership with Health & Human Services (HHS)/Substance Abuse and Mental Health Services Administration (SAMHSA), Health Resources and Services Administration (HRSA).Goal: To promote the planning, and development and of integration of primary and behavioral health care for those with serious mental illness and/or substance use disorders and physical health conditions, whether seen in specialty mental health or primary care safety net provider settings across the country.Purpose: To serve as a national training and technical assistance center on the bidirectional integration of primary and behavioral health care and related workforce development To provide technical assistance to PBHCI grantees and entities funded through HRSA to address the health care needs of individuals with mental illnesses, substance use and co-occurring disorders
The Center for Integrated Health Solutions is dedicated to increasing the number of: Individuals trained in specific behavioral health related practices Organizations using integrated health care service delivery approaches Consumers credentialed to provide behavioral health related practices Model curriculums developed for bidirectional primary and behavioral health integrated practice Health providers trained in the concept of wellness and behavioral health recovery
Center for Integrated Health SolutionsTarget Populations SAMHSA Primary & Behavioral Health Care Integration (PBHCI) Grantees HRSA Grantees General PublicServices Training and Technical Assistance Knowledge Development Prevention and Health Promotion/Wellness Workforce Development Patient Protection and Accountable Care Act Monitoring and Updates
SAMHSA Primary and BehavioralHealth Care Integration (PBHCI) Grant Program
PBHCI ProgramProgram purpose: To improve the physical health status of people with SMI by supporting communities to coordinate and integrate primary care services into publicly funded community-based behavioral health settingsExpected outcome: Grantees will enter into partnerships to develop or expand their offering of primary healthcare services for people with SMI, resulting in improved health statusPopulation of focus: Those with SMI served in the public behavioral health systemEligible applicants: Community behavioral health agencies, in partnership with primary care providers
SAMHSA PBHCI Learning Communities West Region (1) Northeast & 14 Grantees Mid-Atlantic Region (5) Central Region (2) 17 Grantees 9 Grantees VT WA Midwest Region (4) ME 15 Grantees MT NH ND OR MN NY MA ID WI SD MI CT RI WY PA NJ CA IA NV NE DE OH UT IL IN WV DC CO MO MD KS KY VA OK NC AZ NM AR TN SC AK MS AL GA HI TX LA Southeast Region (3) 9 Grantees FL
SAMHSA PBHCI GranteesWest Region (1)AK: Alaska Islands Community Services (III)AK: Southcentral Foundation (IV) Southeast Region (3) Northeast & Mid-AtlanticCA: Alameda County Behavioral Health Care Region (5) Services (II) FL: Apalachee Center, Inc(III)CA: Asian Community Mental Health Services (III) FL: Coastal Behavioral Healthcare (III) CT: Bridges...A Community SupportCA: Catholic Charities of Santa Clara County (IV) FL: Community Rehabilitation Center (III) System (I)CA: Glenn County Health Services Agency (III) FL: Lakeside Behavioral Healthcare (III) CT: Community Mental HealthCA: Mental Health Systems, Inc (I) FL: Lifestream Behavioral Center (III) Affiliates (III)CA: San Francisco Department of Public Health (IV) FL: Miami Behavioral Health Center (III) MA: Community Healthlink ,Inc (III)CA: San Mateo County Health System (III) GA: Cobb/Douglas Community Services Board (III) MD: Family Services, Inc (III)CA: Tarzana Treatment Centers, Inc. (III) SC: South Carolina State Department of Mental Health (III) ME: Community Health & CounselingOR: Native American Rehabilitation Association of VA: Norfolk Community Services Board (IV) Services (III) the Northwest (II) NH: Community Council of Nashua (I)WA: Asian Counseling and Referral Service (III) NJ: Care Plus NJ (I)WA: Downtown Emergency Service Center (III) NJ: Catholic Charities, Diocese ofWA: Navos (IV) Trenton (III) Midwest Region (4) NY: Bronx-Lebanon Hospital Center (III) IL: Heritage Behavioral Health Center (III) NY: Fordham Tremont CMHC (III) IL: Human Service Center (I) NY: ICD-International Center for theCentral Region (2) IL: Trilogy, Inc(III) Disabled (II) IN: Adult & Child Mental Health Center (III) NY: Postgraduate Center for MentalAZ: CODAC Behavioral Health Services (I) IN: Centerstone of Indiana (II) Health (III)CO: Mental Health Center of Denver (I) IN: Health & Hospital Corporation of Marion County (IV) NY: VIP Community Services (I)LA: Capital Area Human Services District (IV) IN: Regional Mental Health Center (II) PA: Horizon House (III)OK: Central Oklahoma Community MH Center (I) KY: Pennyroyal Regional MH/MR Board (I) PA: Milestone Centers (II)OK: NorthCare Community Mental Health Center (III) MI: Washtenaw Community Health Organization (III) RI: Kent Center for Human &TX: Austin-Travis County Integral Care (III) OH: Center for Families & Children (I) Organizational Development (III)TX: Lubbock Regional MH & MR Center (II) OH: Community Support Services (IV) RI: The Providence Center (II)TX: Montrose Counseling Center (II) OH: Greater Cincinnati Behavioral Health Services (III)UT: Weber Human Services (III) OH: Shawnee Mental Health Center (I) OH: Southeast Inc. (I) WV: Prestera Center for Mental Health Services (III)
Integrated health care11 “…in essence integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served.” Hogg Foundation for Mental Health, Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S., www.hogg.utexas.edu
12 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 well connected. They take a team approach, and they each check on the status of my health... Today I have control over my health; it doesn’t 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
Primary Care and Behavioral HealthIt goes together like Peanut Butter and Jelly!
Communication with Your Partners“The Four Agreements,” Don Miguel Ruiz• Be impeccable with your words. Clarify your partnership’s goal and recognize that you have created a process that requires constant nurturing and communication.• Don’t take anything personally. Disagreements will occur. Learn to manage the process, not the personality, and recognize and understand your differences.• Don’t make assumptions. Involve both boards, schedule weekly administrative meetings, hold regular treatment team meetings, communicate between team meetings, and create a specialized data collection position.• Do your best. Involve state and local stakeholders, seek training for staff in care coordination, bring in outside experts such as CIHS for guidance, and engage other organizations that do similar work.
The Role of Leadership Main point: Leaders who employ research informed approaches are more likely to activate the organization to support a change initiative: Communicating for buy in (what is the message? Who delivers the message? How do we know if the workforce understands and values the message? What practical actions can the workforce take that promotes engagement of consumers? How does an organization insure that the workforce supports the aims of the integration initiative? How does the organization insure that the primary care partners understand, value and act in ways that are likely to engage consumers.16
8.Make the Changes Stick Steps leaders take to 7. Don’t Let Up successfully implement change 6. Short Term Wins 5. Empower Action 4. Build the Right Team 3. Communicate for Buy In 2. Get the Vision Right 1. Build a Sense of Urgency Based on the work of J. Kotter (2002) The Heart of Change.17
Workforce ConsiderationsAdministrative Staff and Board of Directors – data including prevalence, clinical and productivity outcomesClinical Team – screening, clinical protocols, motivational interviewing, how to deal with upset patients smoothly, effectively, empatheticallyBehavioral Health Clinicians – UMass training, motivational interviewing, Psychiatric ConsultationFront Desk, Security - Mental Health First Aid
The Right TemperamentPersistenceCreativity and flexibilityEnthusiasm for learningStrong patient advocateWillingness to be interruptedAbility to work in a team
Focus on Behavioral HealthIncorporating attention to behaviors affecting health, mental health and substance abuse• PCMH 1: Enhance Access and Continuity – Comprehensive assessment includes depression screening, behaviors affecting health and patient and family mental health and substance abuse• PCMH 3: Plan and Manage Care – One of three clinically important conditions identified by the practice must be a condition related to unhealthy behaviors (e.g. obesity) or a mental health or substance abuse condition – Practice must plan and manage care for the selected condition• PCMH 4: Provide Self-Care and Community Resources – Self-care support includes educational and community resources and adopting healthy behaviors• PCMH 5: Track and Coordinate Care – Tracks referrals and coordinates care with mental health and substance abuse services• PCMH 6: Measure and Improve Performance – Preventive measures include depression screening Achieving NCQA Recognition as a Patient-Centered Medical Home 22 RI Statewide Learning Collaborative February 5, 2011
Why Do People Change?Individuals change voluntarily when they. . . Become interested in or concerned about the need for change Become convinced that the change is in their best interests or will benefit them more than cost them Organize a plan of action that they are committed to implementing Take the actions that are necessary to make the change and sustain the change
Person-Centered Skills:The BasicsUtilize O.A.R.S. • Ask Open-ended questions (not short-answer, yes/no, or rhetorical) • Affirm the person/commitment positively on specific strengths, effort, intention • Reflect feelings and change talk • Summarize topic areas related to changing
Formal Business Process Analysis SupportsClear, Precise, Accessible Communication• Step-by-step financial, clinical and practice management activities• Promotes cross-discipline understanding of each step• Connects multiple dimensions –billing, data collection and reporting, clinical services, practice management, etc.• “Requirements Traceability Matrix” - what you do and why you do it
Analysis Examples• Timing • How long are activities within the process taking? • How much time passes between activities? • How long are the patient contact intervals within Intake? Between Intake and Re-assessment?• Billing • What are the billable/non-billable events? • Is there a way you can make non-billable events billable? • How do these events match up to the appropriate license/credential of the role? Are you maximizing the amount of reimbursement?• Role License and Credentials • Where and how are you meeting credentialing requirements? • Do they match the billable activities?
Billing and Coding Infrastructure• Staffing – Sample of needed expertise • Chief Financial Officer • Payables and Receivables staff • Claims Processers• Knowledge of Payer Requirements • Private Payers • Medicaid • Medicare• Technology supports• Accurate, good documentation of services
The Health and Behavior Assessment/Intervention Codes(96150 - 96155)• Approved CPT Codes for use with Medicare right now• Some states are using them now for Medicaid• Behavioral Health Services “Ancillary to” a physical health diagnosis Diabetes COPD Chronic Pain
Maximizing Who Can Bill, for What, and ByWhom – Interim Billing Worksheets• Point in time review of each states Medicaid program on what may or may not be reimbursable in your state for integration using currently available codes• Point in time review of Medicare reimbursement• Link CPT, Diagnostic Code and Credential• One of many tools – a place to start the conversation and billing locally and in a state• Do not GUARANTEE you will be paid based on the worksheet Worksheets Available at: www.integration.samhsa.gov
The resources and information needed to successfully Integrate primary and behavioral health careLaura Galbreath, MPPOnline: integration.samhsa.govPhone: 202-684-7457, ext 231Email: firstname.lastname@example.org