The document summarizes the accomplishments of the Detroit Wayne Mental Health Authority (DWMHA) in integrated healthcare initiatives in 2015. Key accomplishments include: 1) Implementing a standardized integrated bio-psychosocial assessment across providers. 2) Increasing coordination between behavioral health providers and primary care providers, with 13 providers having on-site primary care and 75% of providers at the highest level of integration. 3) Training 95% of providers on an assessment tool to evaluate their level of integrated care capabilities.

1. DWMHA 2015 Accomplishments in Integrated Healthcare Initiatives Page | 1
Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016
Mission
To facilitate and create an infrastructure for coordinated and integrated mental health, substance use,
and physical health care for persons with serious persistent mental illness (SPMI)/Co-occurring mental
illness and substance use disorders, intellectual/developmental disabilities (I/DD), and serious
emotional disturbances (SED).
Vision
DWMHA Consumers will be able to enter at any door and receive recovery oriented services and
supports from health care professionals who are welcoming and trained to deliver integrated health
care that meets their mental health, substance use, and physical health care needs.
Overview
The DWMHA Integrated Healthcare Department has collaborated with other Departments of
DWMHA for several accomplishments over the past year to advance the infrastructure of DWMHA in
support of an integrated delivery system. The accomplishments are in the following areas:
I. Standardized Integrated Bio-Psychosocial Assessment (BPS)
August 15, 2015 was the implementation date of the standard Bio-Psycho-Social
Assessment (BPS) in the EMR’s of MCPNs and Providers in the DWMHA network. With
the Dual-Eligible Project we recognized the BPS as the "Level-2" intake assessment to be
completed with a referral from the Integrated Care Organizations (ICOs). Our first step
was to develop the BPS in MHWIN so that we had at least one shared system for the
Providers to access the document. PCE has been busy delivering the new BPS Assessment
in EMRs for their client’s systems.
The implementation of the "Behavioral Health-TEDs" (BH-TEDs) record is a project that is
being driven by the Michigan Department of Health and Human Services (DHHS) and
DWMHA Information Technology Department. The BPS document collects some of the
BH-TEDs data and is also one of the triggering events for the submission of the BH-TEDs
record from the Providers and MCPNs. For these reasons the implementation of the BH-
TEDs project was linked to the delivery of the BPS Assessment. In addition, a “standard”
form presents a consistent representation across DWMHA in Care Coordination with
Physical Healthcare.

2. DWMHA 2015 Accomplishments in Integrated Healthcare Initiatives Page | 2
Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016
II. Coordination with Primary Care Providers/Levels of Integration in Behavioral Health
Centers
DWMHA Integrated Healthcare Department has worked diligently with providers to
increase the level of integrated healthcare delivery. Thirteen (13) comprehensive provider
have primary care provider presence on site to address the physical health needs of their
consumers with chronic medical needs. Seventy five percent (75%) of the comprehensive
behavioral health providers are at a level four (4). Level four means primary care and
behavioral health providers share the same facility and have some of the same systems in
common. Face-to-face communication or shared treatment plans may occur. Next steps
are to improve the actual practice of integrating primary care needs into the person centered
planning process in behavioral health.

3. DWMHA 2015 Accomplishments in Integrated Healthcare Initiatives Page | 3
Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016
III. The Integrated Care Capability in Behavioral Health Treatment instrument
(ICCBHT) aims to assess the extent to which mental health service providers provide their
consumers with integrated/coordinated care. Developed by Martena Reed and Detroit
Wayne Mental Health Authority.
a. Approximately ninety-five percent 95% of providers (MI, IDD, SUD) were trained and
implemented the DWMHA Integrated Healthcare Capability in Behavioral Health
Treatment Tool. The results from providers that implemented the ICCBHT indicate
that providers review of their level of integration at a slightly higher level compared to
the SAMHSA level of care integration.
b. To further support all providers in their journey to implementing integrated healthcare
practices DWMHA Clinical Practice Improvement Department supported the
development of the Integrated Health Care Tool Kit.
 The Integrated Healthcare Tool Kit for providers to deliver integrated care:
http://www.dwmha.com/Portals/0/Documents/IntegrationOfCare/2015-05-
26_Tool%20Kit%20Format%20V2.0-sw.edits-052115.pdf
IV. DWMHA Integrated Healthcare Learning Collaborative- DWMHA held several
Integrated Healthcare Learning Collaborative for DWMHA Providers, facilitated by the
National Council. The purpose of the Learning Collaborative is to assist our providers:
a. Understand elements of the MI Health Link Program and performance of providers
b. Update on the progress of DWMHA Integrated Healthcare Initiative
c. How to use the results of the Integrated Care Capability in Behavioral Health
Treatment Assessment Tool
d. How to use MI Care Connect to support integrated healthcare delivery
e. Sharing of information and refinement of organization goals toward advancing its
level of integrated healthcare delivery

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Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016
V. Coordination with Medicaid Health Plans, MCPNs and PIHPs
DWMHA Integrated Healthcare staff are actively engaged with six (6) of eight (8)
Medicaid Health Plans (MHP) in Wayne County. The expected outcomes of this data
sharing and care coordination project are: Improved Gaps in Care; Reduction in Inpatient
utilization and cost; Reduction in ER utilization and cost; Improve care coordination.
DWMHA, MCPNs and Providers work collaboratively with the MHPs to address high ER
utilizers that have behavioral health diagnosis and consumers who have not had an office
visit within the last 12 months and other gaps in care. CMT population health tools have
been used to support coordination of care with Medicaid Health Plans (see chart below).
The following chart describes outcomes related to utilization costs.

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Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016
VI. Care Connect/Adult Mental Health Block Grant Achievement- DWMHA was awarded
the Adult Mental Health Block Grant to support the development and implementation of a
health information exchange, MI Care Connect, that will provide secure technological
platform where providers have easy access to both physical and behavioral health encounter
and medication data for Medicaid enrollees. MI Care Connect supports the CMS ”Triple
Aim: ” Improving the patient experience of care (including quality and satisfaction);
Improving the health of population; Reducing the per capita cost of health care. DWMHA
Integrated Healthcare and Information Technology staff have successfully accomplished
the following:
1. Rolled out of MI Care Connect to providers and MCPNs.
2. Successfully integrated data into MI Care Connect from Care Connect 360,
Medicaid physical and behavioral health encounter data. Successfully engaged Care
Management Technologies (CMT) that provides analytical tools for individual and
population care management.
3. DWMHA standardized assessment documents documents (Biopsychosocial
assessment, SIS, LOCUS) have been successfully loaded into MHWIN from the
provider organization’s electronic health record.
4. Staged roll-out in the 4th
quarter to a set of six (6) “Early Adopter” Providers. Data
Use Agreements, user IDs, and passwords have been created for six (6) early
adopter organizations. User IDs and passwords have been provided to
approximately 100 behavioral health clinicians. The users represent ACT teams, MI
Health Link Case Managers and Supports Coordinators, and Integrated Care Teams
with Primary Care Providers.
5. Identifies early adopter provider organizations. The organizations invited
represented providers that are at a variety of integrated healthcare levels and
disability populations. Providers were asked to identify teams that will use MI
Care Connect. Providers that partner with FQHCs are included in the early adopter
group. Clinicians are using MI Care Connect in the morning huddles, during
intakes, and population based health management. MI Care Connect is being
refined to be more user friendly. The Care Team functionality is being tested with
the Early Adopter group.

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Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016
VII. Implementation of the MI Health Link Program (Integrated Care for Persons with
Medicare and Medicaid)
As of November 30, 2015, DWMHA has received approximately 3,522 Level I referrals
from five (5) ICOs. DWMHA is considered a PIHP leader in the MI Health Link Program
in Michigan. DWMHA Integrated Healthcare staff continue to work with contracted and
non-contracted providers to train on the MI Health Link program, provide technical
assistance in completing the Level 2 Assessment, and continue to work with the ICOs to
improve the processes for the MI Health Link program and improve the health outcomes for
the enrollees. DWMHA has taken lead in implementing the Behavioral Health Consent
form for the exchange of 42 CFR Part 2 data. The electronic exchange of health
information for referrals between the ICOs and the PIHP is functioning well. The
following charts that provide analysis of eligible persons in Region #7 Wayne County and
those actually enrolled in the MI Health Link Program:
DWMHA staff has provided continued stay reviews and transition of care services to
approximately 444 MI Health Link inpatient admissions. Ninety-one percent (91%) of
discharges have been connected with outpatient services within seven (7) days of discharge.
Twenty-one (21%) of admissions were readmitted within thirty (30) days of initial
discharge. DWMHA Integrated Healthcare staff continue to work intensively with the ICO
Care Coordinators, MCPNs, and contracted providers to reduce readmissions.
Duplicate/
Misdirected
Referral to
PIHP, 1,299
, 37%
Not Linked
to
Consumer,
153 , 4%
Pending
Screening,
58 , 2%
Not able to
Contact/Decli
ned PIHP
Serices at
Access, 534 ,
15%
Pending
Level 2
Assessment
, 199 , 6%
Not able to
Contact/De
clined PIHP
Serices at
Level II
Provider,
173 , 5%
Sent to ICO,
1,106 , 31%
MI Health Link- Status of All ICOs Referrals
from Start of Program - November 30,
2015
N=3,522
0
100
200
300
400
500 444
403
94
MI Health Link- Inpatient Admissions and
Transitions of Care Activity from Start of
Program through November 30, 2015
Admissions
91%
21%

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Prepared by Audrey E. Smith, Director, Integrated Healthcare Initiatives 1/5/2016
VIII. Summary Accomplishments in Integrated Healthcare at DWMHA
 Implementation of the MI Health Link Program
 Increased Level Of Integrated Healthcare Delivery- DWMHA Providers to 75 %
 Case To Care Management Training
 DWMHA Integrated Healthcare Learning Collaborative Meetings
 Data Sharing Care Coordination Project with Medicaid Health Plans- Improved
Outcomes and Savings
 MI Care Connect/ Health Information Exchange
 Integrated the Provision of SUD Treatment, Prevention, and Recovering Services
 Standardized Integrated Processes & Assessments- Including SUD Providers
IX. Future Goals
1. Develop in implement departmental practices and policies that meet NCQA standards
2. Continue to improve the delivery of integrated health care with providers in the
development of care plans and care coordination.
3. Continue to managed the implementation of the MI Health Link program and improve
the outcomes of care and service utilizations.