Altarum Institute Policy Roundtable Integrating Primary and Behavioral Health Services: A Community Health Center Paradigm July 21, 2010 Washington, D.C

Altarum Institute Policy Roundtable

Integrating Primary and Behavioral Health Services: A Community Health Center Paradigm

July 21, 2010

Washington, D.C.

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Refining the Integration Paradigm:A Challenge to Policy Makers

Dennis S. Freeman, Ph.D.Chief Executive Officer

Cherokee Health Systems

© 2010 Cherokee Health SystemsAll Rights Reserved

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The Press for Integration -- Why the Future is Now

▲Widespread acceptance of the “concept” of integration

▲Tantalizing outcome studies are appearing

▲Health status of persons with serious mental illness

▲Increased appreciation of behavioral factors in chronic disease management

▲Emergence of the concept of the Healthcare Home

▲Diminished scope of CMHC system

▲Expansion of the FQHC system


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New Paradigms Emerging Across the Safety Net

Paradigm Shift at the Systems Level▲Primary Care-locus of most mental health intervention

▲ Increased mental health service capacity at FQHCs

▲FQHC/CMHC collaborations

Paradigm Shift at the Clinical Level▲Primary Care Provider focus on behavioral factors

▲Mental Health Provider focus on general health status

▲New service role for Behaviorists in primary care


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A Few Nagging Questions About Integration

▲What is it?

▲How do we do it?

▲Who can do it?

▲How do we pay for it?

▲What are the results?


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Integration: Beyond Co-Location

Integrated Care

▲Embedded member of

primary care team

▲Patient contact via hand off

▲Verbal communication

predominate

▲Brief, aperiodic interventions

▲Flexible schedule

▲Generalist orientation

▲Behavior medicine scope

Co-Located Mental Health▲Ancillary service provider

▲Patient contact via referral

▲Written communication

predominate

▲Regular schedule of sessions

▲Fixed schedule

▲Specialty orientation

▲Psychiatric disorders scope


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Cherokee Health Systems:Cherokee Health Systems:Merging the Missions of Merging the Missions of CMHCs and FQHCsCMHCs and FQHCs


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Corporate Profile

Founded: 1960

Services:Primary Care - Community Mental Health - Dental - Corporate Health Strategies

Locations:21 clinical locations in 14 Tennessee Counties

Behavioral health outreach at numerous other sites including primary care clinics, schools and Head Start Centers

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

Cherokee Health SystemsCherokee Health SystemsA Federally Qualified Health Center and A Federally Qualified Health Center and

Community Mental Health CenterCommunity Mental Health Center

Number of Employees: 538

Provider Staff: Psychologists - 40 Master’s level Clinicians - 59 Case Managers - 29 Primary Care Physicians - 31 Psychiatrists - 13 Pharmacists - 9 NP/PA (Primary Care) - 17 NP (Psych) - 7 Dentists - 2


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Blending Behavioral Health into Primary Care

Cherokee Health Systems’ Clinical Model


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Blending Behavioral Health into Primary CareCherokee Health Systems’ Clinical Model

Behaviorist on the Primary TeamThe Behavioral Health Consultant (BHC) is an embedded, full-time member of the primary care team. The BHC is a licensed Health Service Provider in Psychology. A Psychiatrist is available, generally by telephone, for medication consults.

Service DescriptionThe BHC provides brief, targeted, real-time interventions to address the psychosocial aspects of primary care.

Typical Service ScenarioThe Primary Care Provider (PCP) determines that psychosocial factors underlie the patient’s presenting complaints or are adversely impacting the response to treatment. During the visit the PCP “hands off” the patient to the BHC for assessment or intervention.


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The Behavioral Health Consultant (BHC) in Primary Care

▲Management of psychosocial aspects of chronic and acute diseases

▲Application of behavioral principles to address lifestyle and health risk issues

▲Emphasis on prevention and self-help approaches, partnering with patients in a treatment approach that builds resiliency and encourages personal responsibility for health

▲Consultation and co-management in the treatment of mental disorders and psychological issues


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Cherokee’s Patient-Centered Healthcare Home

▲Embedded Behavioral Health Consultant on the Primary Care Team

▲Real time behavioral and psychiatric consultation available to PCP

▲Focused behavioral intervention in primary care

▲Behavioral medicine scope of practice

▲Encourage patient responsibility for healthful living

▲A behaviorally enhanced Healthcare Home


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Outcomes of Cherokee’s Behaviorist Enriched Healthcare Home

▲Penetration rate

▲Efficient management of utilization

▲ Improved health outcomes

▲Focus on patient responsibility and behavioral change

▲Provider and patient satisfaction


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Spec

ialty

Car

e

Hos

pita

l Car

e

Cost

ER V

isits

Prim

ary

Care

Vis

its

x utilization level for other regional providers


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Payment Policy Disincentives for the Integration Paradigm

▲Mental health carve-outs

▲Excessive documentation requirements

▲Same day billing prohibition

▲Encounter-based reimbursement

▲Antiquated coding requirements


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Refining the Integration Paradigm: The Policy DilemmaObvious Questions, Challenging Answers, Controversial Solutions

▲ Since most mental health problems are treated only in primary care, why do most behaviorists practice elsewhere?

▲ Is the academic health manpower pipeline generating the workforce for tomorrow’s healthcare system?

▲ Since so much of primary care is behavioral in nature, why is treatment primarily bio-chemical in response?

▲ Why do we have 2 separate, community-based safety net systems when most patients of each system need the services of both?

▲ Since primary care/behavioral health integration enjoys such acclaim, why is there so little of it in existence?


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Contact Information:

Dennis S. Freeman, Ph.D.Chief Executive Officer

[email protected]

Cherokee Health Systems2018 Western Avenue

Knoxville, Tennessee 37921Phone: (865) 934-6711

Fax: (865) 934-6780


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The Patient-Centered Medical Home: The Role of Behavioral Health

Alexander Blount, EdDProfessor of Family Medicine and PsychiatryUniversity of Massachusetts Medical School

Director of Behavioral ScienceDepartment of Family Medicine and Community Health

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The Patient Centered Medical Home “Defined”ACP, AAFP, AAP, AOA

▲ Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

▲ Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

▲ Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

▲ Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner

▲ http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

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How Much Does it Cost Us?

Identified in multiple states that on average extreme uncoordinated care pts (<10%) account for approximately:

30% of all medical costs,

45% of all drug costs and

32% of total plan costs and for older pts even more

At least 35% of costs for the uncoordinated care groups represent potential savings

Approx. 10% of total direct care costs can be saved if the most extreme uncoordinated care patients are better coordinated via medical homes, health information exchange of data , targeted interventions and other combined strategies

Slide from Owens, Focusing Care Coordinationhttp://www.pcpcc.net/content/care-coordination

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Traditional Disease/Utilization/Care Management Program Approaches

▲Voluntary pt enrollment

▲Target all pts with a major chronic disease-same interv.

▲Assume all high cost and high utilizers are cost & quality impactable

▲Focus resources on contacts with high cost and high utilizers

▲Often rely on pt reported behavior instead of actual claims or medical chart data

▲Assume chronic and/or complex disease drives majority of all costSlide from Owens, Focusing Care Coordination http://www.pcpcc.net/content/care-coordination

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The Complex “Medical-only” Patient is Rare Among Complex Patients

▲The more somatic illnesses a person has, the more they are likely to have one or more psychiatric diagnoses

▲Low income and “neuroticism” correlate with more somatic diagnoses as well as more psychiatric diagnoses

Neeleman, J., Ormel, J. AND Bijl, R. V (2001). The distribution of psychiatric and somatic ill health: associations with personality and socioeconomic status, Psychosomatic Medicine 63:239–247

▲Finding similar to large pilot done by Boeing Corporation www.integratedprimarycare.com

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The Story of “Joan”Medical Diagnoses:

▲1. Chronic thrombocytopenia probably secondary to chronic ITP

▲2. Coronary artery disease. Status post CABG in 1993

▲3. Chronic obstructive pulmonary disease. The patient is intermittently oxygen dependent (and a smoker)

▲4. Insulin requiring diabetes associated with neuropathy

▲5. Osteoarthritis

▲6. Bipolar disorder

▲7. Recurrent urinary tract infections

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The Story of “Joan”

Medications:

▲Norvasc, famotidine, furosemide, metformin, Neurontin, diazepam, fluconazole, insulin, and Mellaril.

Other Statistics:

▲Rank in calls to on call line: #1

▲Rank in ER utilization (out of 22,000 pts): #1

▲Rank in eliciting frustrated comments from nurses and residents: #1

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“Joan” Gets a Case Manager

▲Blue Cross, trying desperately to contain costs, assigns her a telephone case manager

▲She tells the case manager how verbally abusive her husband is to her, initiating a referral for elder abuse. It is not substantiated.

▲The case manager stops calling

▲ER use unchanged

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When depression is an important factor in a complex presentation, many care managers

are a poor fit▲ “Nurses, practice assistants, and HCAs complain of the

psychological burden of providing mental health services in depression care. To avoid exhaustion, they prefer to work part-time. Reports of HCAs working in innovative depression care programs are still rare." Genschen, J, et al, Health Care Assistants in Primary Care Depression Management: Role Perception, Burdening Factors, and Disease Conception. Annals of Family Medicine, Vol 7, no.6. 2009.

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Why Should Behavioral Health Be a Core Service of PCMH?

▲ Access – At least 50% better access to MH care if offered in primary care. (different from managing care across medical specialties) (Bartels, Coakley, Zubritsky, et al. Am J Psych, 2004)

▲ Complex patients with chronic illnesses needing behavioral health care are more likely to be designated for Medical Home level of care.

▲ Care in medical setting is a better cultural fit for many patients.▲ Behavioral Health Clinicians free up time for PCPs to spend with

other patients, while enhancing patient satisfaction and self-efficacy.

▲ Care management is more effective when done by professionals with behavioral health skills. (Pincus, Pechura, Keyser, et al. Administration & Policy in Mental Health. 33(1):2-15, 2006

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A Change of Pattern for “Joan”▲Family systems models teach us that recurrent patterns can be

understood as circular

▲ If they seem unidirectional, look for the hidden influence going the other direction

▲Arthur was always taking care of Joan, with more or less success

▲How could it be seen as the other way around?

▲Joan and Arthur engage in occasional couples visits. ER visits down after meetings. Strategies for night call devised, though not consistent across residents. Relapse after daughter killed in MVA.

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The need for Behavioral Health services in the PCMH is becoming clearer all the time

▲NCQA increases the expectation of behavioral health services (mental health, substance abuse, health behavior change) in each successive version of the accreditation requirements for PCMH

▲URAC has a larger role for behavioral health services than NCQA in its accreditation requirements for PCMH

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Options arise when we develop new descriptions or stories of familiar events

▲When the health system is stuck in recurrent unhelpful patterns with a “complex” patient, we need to look for another story

▲The details that support a new story could be anywhere in the interactions of the person in their social network, but their family is usually the richest source

▲PCMH care managers need access to skills in family interviewing and systems thinking in addition to skills in CBT, relaxation therapies and Motivational Interviewing

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How can the necessary skills be broadly available?

▲Behavioral Health Clinician in Primary Care practices

▲Properly trained clinician (usually psychiatrist or health psychologist) provides supervision for care manager who has some behavioral health training (IMPACT model)

▲Special training programs for mental health professionals to become primary care behavioral health professionals. (e.g., Certificate Program in Primary Care Behavioral Health, Univ. of Mass. Medical School)

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Let’s talk some more:

[email protected]

www.IntegratedPrimaryCare.com

Certificate Program In Primary Care Behavioral Health

www.umassmed.edu/FMCH/PCBH/welcome.aspx

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Health Care Reform and Integration:A Federal Perspective

Peggy Clark, MSW, MPANancy Kirchner, MSW

Disabled and Elderly Health Programs GroupCenter for Medicaid, CHIP, and Survey & Certification

Centers for Medicare & Medicaid Services

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Medicaid Facts and Figures

▲ In 2009, over 65 million people were enrolled in Medicaid

– 5.8 million were enrolled on the basis of being age 65 or older

– 9.5 million were enrolled on the basis of being blind or disabled

– 31.3 million were enrolled as eligible children

▲ In 2008, Federal and State government gross Medicaid outlays were $351.8 billion

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CMCS and Behavioral Health

▲Medicaid is the largest payer for mental health services in the United States

▲Comprehensive services available through Medicaid; many are optional under Medicaid so State’s have considerable flexibility in benefit design

▲ In 2007, Medicaid funding comprised 58% of State Mental Health Agency revenues for community mental health services

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Mental Health Service Users

10.9%

Substance Abuse Service

Users0.7%

All Other Medicaid

Beneficiaries88.3%

Medicaid MH/SA Service Users

Source: SAMHSA

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Medicaid Expenditures for MH/SA Service Users

Source: SAMHSA

Mental Health Service Users29.9%

Substance Abuse Service Users1.8%

All Other Medicaid

Beneficiaries68.3%

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Costly Physical Conditions – 22-64

21.4%

5.3% 5.0% 5.2%3.2% 3.2% 2.2%

14.3%

3.5% 3.4% 3.3%2.0% 2.0% 1.9%

0%

5%

10%

15%

20%

25%

Any CostlyPhysical

Condition

Diabetes Cardiovascular Renal Gastrointestinal Pulmonary Cancer

Mental Health Services Users Ages 22 through 64

All Medicaid Beneficiaries Ages 22 through 64

Source: Medicaid Analytic eXtract (MAX), 2003, 13 states

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MH/SUD: DEHPG Goals

▲Federal policy supports the offer of effective services and supports

▲ Improved integration of physical and behavioral health care

▲Person-centered, consumer-directed care that supports successful community integration

▲ Improved accountability and program integrity to assure Medicaid is a reliable funding option

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Key Points—Medicaid Mental Health1986-2005

▲Medicaid funded a growing share of MH treatment—from 17% (1986) to 28% (2005)

▲However, MH remained a small share of all Medicaid spending (just 10% in 2005)

▲Medicaid spending on MH prescription medications increased rapidly—from 7% (1986) to 27% (2005) of all Medicaid MH spending

▲Hospital and LT MH treatment financed by Medicaid declined as a share of Medicaid MH spending

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Key Points—Medicaid Substance Abuse Spending 1986-2005

▲Medicaid funded a rising share of SA treatment—from 12% (1986) to 20% (2005)

▲However, SA remained a very small and falling share of all Medicaid spending (just 1% in 2005)

▲Share of Medicaid SA spending for hospital care fell and the share for SSACS and MSMHOs* rose from 1986 to 2005

▲Medications currently played no significant role in SA treatment

▲Share of all Medicaid SA spending in outpatient settings more than doubled; inpatient and residential settings share fell from 1986 to 2006

* Center-based care in specialty substance abuse centers (SSACs) and multi-service mental health organizations (MSMHOs).

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Medicaid State Plan Benefits

MANDATORY- Physician services- Laboratory & x-ray- Inpatient hospital- Outpatient hospital- EPSDT- Family planning- Rural and federally-qualified

health centers- Nurse-midwife services- NF services for adults- Home health

OPTIONAL- Dental services- Therapies –

PT/OT/Speech/Audiology- Prosthetic devices, glasses- Case management- Clinic services- Personal care, self-directed

personal care- Hospice - ICF/MR- PRTF for <21- Rehabilitative services- Special services in waivers and

demonstrations

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Some State Plan Options for Mental Health Services

▲ Inpatient hospital services [other than those provided in an Institution for Mental Diseases (IMD)]

▲ Outpatient Hospital Services

▲ Physicians’ Services

▲ Medical/Other remedial care furnished under State law, provided by other licensed practitioners

▲ Home Health Services

▲ Clinic Services

▲ Rehabilitative Services

▲ Services for individuals 65+ in IMDs

▲ Intermediate Care Facility Services for the mentally

retarded /related conditions (ICFs/MR)

▲ Inpatient psychiatric facility services for individuals <22

▲ Case management services

▲ Section 1915(i)

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Waiver and Demonstration Authorities

▲Section 1915(a) – voluntary contract with organization that agrees to provide care

▲Section 1915(b) – managed care that restricts providers, selective contracting, locality as central broker, additional services generated through savings

▲Section 1915(c) – home and community-based long term services and supports

▲1115 demonstrations – managed care, expand eligibility, impose cost-sharing, provide different benefits, budget neutral

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Managed Mental Health CareSection 1915(b) waivers that cover mental health services:▲ California▲ Colorado▲ Florida▲ Georgia▲ Iowa▲ Kansas▲ Michigan▲ Minnesota▲ Nebraska▲ New Jersey▲ New Mexico▲ North Carolina

A federal team of reviewers including representatives from SAMHSA, the Health Resources and Services Administration, CMS, and OMB works together during the approval/renewal process

▲ Texas▲ Utah▲ Washington

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States with 1915(c) Waivers Related to Mental Health▲ Approved waivers that serve persons aged 18 and older:

– Colorado

– Montana

– Wisconsin

– Connecticut

▲ Approved waivers that serve children with serious emotional disturbances:

– New York (2)

– Kansas

– Michigan

– Wyoming

– Wisconsin

– Texas

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Health Reform and Medicaid Mental Health

▲Health home, chronic conditions (1-1-2011)– Enhanced FMAP

– Collaboration with SAMHSA

▲Amendments to 1915 (i) – HCBS type services offered under State Plan (10-1-2010)– Allows waiver of comparability

– Prohibits waiver of statewideness

– Adds additional service options

– Increases income option

– Eliminates option to limit number of participants

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Mental Health Parity▲Wellstone-Domenici Mental Health Parity and

Addiction Equity Act of 2008 was passed by Congress in October 2008 as part of the Bush stimulus package

▲02/02/2010: Federal Departments of Treasury, Labor, and HHS publish Interim Final Regulation in the Federal Register– 05/03/2010: Public comment period closed

– 07/01/2010: Regulation effective

▲MHPAEA also applies to Medicaid managed care plans (MCOs), CHIP State Plans, and benchmark plans– Further guidance from CMCS will be forthcoming

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Where Are We Going?

“A sustainable, person-driven long-term

support system, in which people with

disabilities and chronic conditions have

choice, control and access to a full array of

quality services that assure optimal

outcomes, such as independence, health

and quality of life.” – DEHPG Vision Statement

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Treating the Whole Person While Reducing Costs:

Practical Lessons from the California Integrated Behavioral Health Project

Mary Rainwater, L.C.S.WProject Director

Integrated Behavioral Health Project

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Outline

▲Brief Overview of Our Initiative

▲Key Findings

▲The “Business Case” – Quality and Cost Improvements

▲The Challenges in Moving from Business Case to Policy and Financing Reforms

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In Support of the Field: IBHP Background and Goals

Launched in 2006 by the Tides Center and The California Endowment to accelerate the integration of behavioral health services at primary care community clinics throughout California

Goals:

▲ Improve behavioral health treatment access

▲Reduce stigma of seeking mental health services

▲ Improve patient outcomes

▲Strengthen collaboration between mental health and primary care providers

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Building and Supporting Connections Across the Field

▲Grants

▲Build and Support a Learning Community

▲Policy and Advocacy Work

▲Training and Technical Assistance

▲Partnerships and Collaborations

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Lessons Learned:

▲Clinical:– Higher Quality

– Improved Access

▲Operational:– Requires Customization

– Not One-Size-Fits-All

▲Financial:– Lower Health Care Costs

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1115 Medicaid Waiver Behavioral Health Group’s Menu

▲Five Core Elements– Care Management

– Data Management and Information Exchange

– Consumer Engagement

– Clear Designation of Person-Centered Health Care Home

– Performance Measures

▲Five Domains to Track Best Practices– Clinical

– Operational/Administrative

– Financial

– Oversight

– Population-Specific Considerations

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Integrated Care’s Bottom Line:

Lower Overall Health Costs

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6-Step Integration Game Plan:

▲Design Clinical Model

▲ Identify and Address Funding Barriers

▲Craft Integration Budget

▲Revise Business Processes and Obtain Necessary Approvals

▲Design Implementation Plan

▲Monitor and Adjust

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Identify and Address Funding Barriers

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Alignment of Current Funding

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Health Care Reform

Three Components of Health Care Reform:

▲Universal Coverage

▲Delivery System Redesign

▲Payment Reform

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The “Big Fix”

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California’s Puzzle

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Health Care Reform and Parity Changes Everything…

…How services are organized

…How mental illness/substance abuse are addressed

…How mental health/substance abuse treatment are funded

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Thank you

Please visit www.ibhp.org for more information, tools and trainings.

Contact information:

Mary Rainwater: [email protected]

References:

“The Business Case for Integrated Care; Mental Health, Substance Use and Primary Care Services”, June 2010; Barb Mauer and Dale Jarvis, MCPP Healthcare Consulting

“Paying for Integrated Services: FQHC, Medi-Cal and Other Funding Strategies”, June 24, 2010; Dale Jarvis, CPA, MCPP Healthcare Consulting

Documents

Altarum Institute Policy Roundtable Integrating Primary and Behavioral Health Services: A Community Health Center Paradigm July 21, 2010 Washington, D.C