Integrated Care: WHAT YOU NEED TO KNOW TO GET STARTED · SouthEast Lancaster Health Services, (SELHS), Lancaster 2011-present –Co-located - bilingual BH clinician .5FTE –groups

Integrated Care:WHAT YOU NEED

TO KNOW TO GET STARTEDOctober 9, 2015

Rehabilitation and Community Providers Annual Conference

Types of Integrated Care

Behavioral Health in Primary Care Practices

Behavioral Health in FQHC’s

Behavioral Health in Pediatric Practices

Behavioral Health in Medical Units/ER’s

Primary Care in BH Outpatient Centers

BH Staff leased to FQHC, PCP’s, other Teams

ACO Integrated Team/Multi-Partner Teams

Development of Relationship w/PCP

This is the starting point, takes patience

Finding a PCP that is:

collaborative, willing to take risks

a effective leader, move barriers

willing to learn about integrated care

willing to change work flows

willing to change office layout, BH in middle

Starting the Journey – Co-Location

Often starts with co-location, ½ day a week

Develop relationships w/MD, RN’s, Billing, front desk

Develop work flows for intake & scheduling

Procedures for concierge services – SPMICMHC

Develop EHR communication processes

Brief problem solving therapy 6 – 10 session

Emergency protocol when BH specialist not in clinic

Mid Way – Some Integration

BH Specialist increases time in the clinic 2-3 days

Warm Hand Offs implemented

Some screening – Depression/Unhealthy Sub Use

Available for more high utilizers

Access to consulting psychiatrist possible

Trust Grows, Partnership is Evolving

Phone follow up, motivational interviewing by BH

Integrated Care

100% screening of Depression/Unhealthy Sub Use

BH Specialist available 4-5 days/week

BH Specialist extenders: Case Mgrs, Peer Specialist

Proactive services – phone reminders

Outreach to high utilizers

All staff trained in Motivational Interviewing

MD’s use SBIRT

Could be a Health Home

Fully Integrated Systems

FQHC and CMHC merge – one system

CMHC builds a health clinic within

One EHR across BH and medical services

BH and Medical staff are from one organization

One system for billing and accounting

Could be a Health Home

Cross System Integrated Teams

RN, LCSW, Case Mgr, Nutritionist, Peer Specialist

Works for ACO, Health System

Identifies High Utilizers who are in “pain” ER, Inpt

Funding – Global Budget – multiple sources

Interventions are non-traditional, out of the box

Boundaries between team members diffuse

Maybe able to be a Health Home

Mission, Vision and Values

Triple Aim – Improve patient experience

Reduce cost/Improve efficiency

Improve patient/client outcomes

Provide one stop shop, no wrong door

Highly coordinated care, less fragmented care

Treat the whole person

Improved life expectancy

Diversion from high cost services/Reduce high utilizers

Improve population health of the practice

Outcomes from Integrated CareAdult Practices

Significant reduction in PHQ-9 scores (depression)

Pediatric Practices

Pts referred for BH intervention enter BH service 2.0 yrs earlier

when service is on-site

PCP’s provide 50% more BH interventions themselves

Referrals to specialty MH services have decreased 1.2%

over four years -- a net savings of $2,128,359 – Children’s

Hospital network.

Lowers cost/patient of providing primary care - $63 per

patient annually

Pediatric Outcomes Continued

Average time from referral to appointment was under 1 week and show

rate was 96%- improved access meaning better patient experience

Show rate is 85% - improved engagement

Average Length of treatment episode = 6 months - decrease cost

26% of children did not require behavioral health treatment at 6 month

follow-up - improved health

During that time a significant improvement in children's functional

outcomes using the SDQ- improved health

Behavioral Health in

Adult Medicine

Stephen Christian-Michaels, Family Services of W. PA

Susan Blue, Community Services Group

Behavioral Health in Adult Medical Clinics:

Description

Family Practices

Adult Medicine Practices

Federally Qualified Health Centers

Rural Health Centers


Description – Family Services of W. PA

Family Practice New Kensington, St Margaret UPMC

2003 – 2007 – Co-located – part time staff

2008 – 2011 – Integrated – 1 FTE, part time psychiatrist, pharmacist

IMPACT – 100% screening

FQHC added to Agency Outpatient License, FSWP Bills, FSWP EHR

Community Health Ctr, New Kensington – FQHC – 127 patients

2011 – 2013 – Co-located – ½ day, LCSW

2014 – 2015 – Integrated Team with HRSA funding

LCSW, Case Manager, Peer Specialist purchased from Family Services

100% screening, Daily Huddle, IMPACT model

Staff use FQHC EHR, FQHC bills

Outreach to most complicated patients in 2nd year


Description – Community Services Group/FQHC’s

SouthEast Lancaster Health Services, (SELHS), Lancaster

2011-present – Co-located - bilingual BH clinician .5FTE – groups & individual

Satellite MH out-patient license for clinician services

2011-2013 – 4 hours per week of on-site CRNP psychiatric time, discont.

2013 - present – Integrated Services, 1 FTE bilingual LCSW in BH consult model

PHQ is being used as part of the FQHC’s processes

Susquehanna Community Health & Dental Center, Williamsport

2012 Integrated Services - BH Consult model & medical social worker

2014 Psychiatric consultation (telepsych) 4 hours per week

2015 Community Navigator

PHQ is utilized for tracking for a stepped care project with the MCO


Shared Vision: Is the primary focus on:

Crisis intervention – keeping PCP’s on schedule

Brief therapy

Screening all patients for BH disorders

Outreach to high utilizing patients


Financing Strategies

Fee for Service

Capitation – Health Plan (when BH not carved out)

PCP Practice or Hospital pays to improve efficiency

CMHC paid for BH staff to be embedded in practice

Shared Savings with an Accountable Care Organ.


Billing

BH bills – CMHC bills their contracted payers

FQHC bills – BH insurers billed

FQHC Uninsured – HRSA funds/Grants


Billing Issues - BH Provider Bills

BH Provider utilizes their main office PROMISe Number

FQHC provides multiple specialties, BH Provider can

request PROMISe #

Currently OMHSAS/OMAP don’t allow two services at the

same PROMISe #

Can request a waiver, but it is taking many months,

many not approved

This barrier is being addressed and maybe removed


Billing Issues – PCP Bills

BH provider assists PCP set up their billing system

BH provider assists PCP get into BH payer

networks

FQHC will need a new PROMISe # for BH services


Regulatory Expectations

BH in Medical Clinic

CMHC includes clinic on OMHSAS Outpt license

All OMHSAS and MCO expectations same

BH in FQHC and BH Bills for BH Services

CMHC includes clinic on OMHSAS Outpt license

All OMHSAS and MCO expectations same


FQHC - Regulatory Expectations

BH in FQHC, FQHC bills using FQHC EHR

FQHC regs are silent on BH services – like other services

HRSA demands same day documentation

BH MCO expectations are the same

FQHC provides BH services internally

FQHC needs HRSA to expand their scope to BH

FQHC needs to get in BH MCO provider networks

Same day documentation is required by HRSA


Electronic Health Record Strategies

Parallel EHR’s – Double Documentation

Integrated Care Plan, Encounter documentation

Cross EHR data exchange difficult at this time

Documentation in the EHR that Bills, brief notes in the other

Patient Registries

Can combine data across EHR’s to get unduplicated counts

Export of data to patient registries – Depression – IMPACT Model

Used to Treat the Target – Compare against average

improvement

Behavioral Health in Adult Medical Clinics

Limitations:

2 copays with Warm Handoffs, BH often has to “eat” copay

Lessons Learned:

Warm Handoff BH Intervention PCP intervention

Train Medical and BH Staff simultaneously

Motivational Interviewing

Integrated Care Model

SBIRT

Short Term focus of treatment

Engagement strategies – bilingual staff, peer specialists

Questions

Primary Care in BH Clinics

Ken Wood, Milestone Centers, Inc.

Colleen Zane, Horizon House Inc.

Primary Care in BH Clinics:

Descriptions – Milestone Centers

Partners: Squirrel Hill Health Center

FQHC to provide primary care services using a mobile van

at two Milestone locations 280 patients

PCP is on site weekly to provide care

Milestone staffing:Registered Nurse - on site daily -- medical needs of SHHC patient, wellness

Care Navigator - facilitates medical linkages and benefits coordination

Peer Specialists - provides peer support to consumers

Wellness programing is a significant component


Descriptions – Horizon House 750 patients

Partner: Delaware Valley Community Health (DVCH)FQHC to provide primary care services in a satellite site located with Horizon House

DVCH Staffing:* PCP is on site 4 days week * Medical Assist/Office Manager: 5 days

* Physician Assistant: 4 days * Medical Doctor/Director: .5 days

Horizon House Staffing:Program Manager (Occupational Therapist)

Health Mentor (Personal Training)- implements InSHAPE program

Peer Specialist: provide peer support to consumers

Wellness program funded separately by SAMHSA’s PBHCI

Wellness Room

Primary Care in BH Clinics

Financial Models

SAMHSA in 5 Year Grants or other Grants ******

Billing by PCP – Medicaid, Medicare, Medicare

Advantage, Insurance – FFS - Capitation

FQHC in BH – Medicaid, Medicare, Medicare

Advantage, Insurance and HRSA for uninsured

when Scope is Expanded to CMHC

Fee for Service

Capitation

HRSA Cost Reconciliation


Medical Regulations

CILA License from Department of Health maybe

required for a number of the lab tests

FQHC will have to apply for a Scope Expansion

Nothing Else


Billing Issues

DVCH: Billing as usual, usually out of main medical clinic

Horizon House

Specialty population limitations

Productivity

Visit Strategy

Regular visits focused on targeted concern

Involvement of behavioral health staff

Billing

May be possible to bill for additional time spent for SBIRT or Tobacco Treatment

Currently PA can bill for same day visits


Electronic Health Records Strategies




Continuity of Care Document (CCD) does not provide enough info


Horizon House

Double documentation

Systems can not communicate and fall short of meaningful use


Limitations – difficult to convince BH clients to change MD’s

Lesson Learned:

Building it does not mean they will come.

Wrapping supportive services improve physical health

Cultural differences are a significant and ongoing challenge

“Lifestyle Diseases” require wellness interventions--take longer

Sustainability is a challenge with no simple solutions

Behavioral Health Staff Expertise

Building Skills

Creating Culture Change

Questions

Pediatric Integrated CareTammy Marsico, Wesley Spectrum Services

Doug Henry, Western Psychiatric Institute & Clinic (WPIC)

Pediatric Integrated Care:

Description - WPIC

Began in 2007 when CCP pediatricians met with us:

1/3 of their pts had BH challenges

Pts rarely followed through on BH referral and when they did:

they often had trouble accessing o/p services

PCP’s often did not receive any info relative to dx/treatment plan

First: 1 LCSW full-time into large practice site & .25 FTE child psychiatrist

Now: * 14.0 LCSW, LPC, PhD therapists and

* 2.0 FTE child and adolescent psychiatrists

providing integrated access to 34 CCP practices serving more than180,000 youth.


Description - Wesley SpectrumPediatric Alliance Wesley Spectrum

Prepare for HCR and Triple Aim

Seek PH partnerships

Expand Continuum of BH for children

Primary and Secondary Prevention-Early Identification and Intervention

Holistic philosophy

Family centered

Move toward true integration

4 FT Therapists in 5 Ped Offices

Access to MH treatment through a collaborative relationship with providers

50% of patients with BH challenge

Fear of risk and liability

Seeking Medical Homeaccreditation

Increase doc time workflow

Holistic care- body and mind connection

Efficient and timely communication exchange

Children’s Institute

Developmental Pediatric

Clinic pts with unmet BH needs

Care Coordination priority

Holistic Care

Medical Home development

for children with special health

care needs

Seeking BH Partnership

Family centered

Enhance ease of access to BH

services

Pediatric Integrated Care: Wesley Spectrum Start Up

Partnership with AHCIWorkflow processes

Evaluation tools Outcomes

Needs Assessment conducted:

Screening practices

Population –age, Dx, high risk behaviors, time doc spends on

BH issues

Volume

Communication Process

EstablishedReferral Process

Information Exchange

Discharge and Follow-up

RecruitmentPredictive Index

Survey

AHCI

Motivated, flexible, creative,

self reflective

Pediatric partner choice of

candidates


Financing

WPIC bills – CMHC bills their contracted payers

We started this way but found the same financial challenges for o/p LOC that afflict CMH clinics – you lose $

Much better to pursue “incident to” billing on the medical side. Yields 1.5x better reimb on average.

Challenge – therapists must be “owned” by the practice

Wesley Spectrum handles billing through BH


Financing Strategies

Fee for Service – Performed on the medical side except for

psychiatry which necessarily is billed to BH carve-outs

Capitation – Health Plan (when BH not carved out)

Looking forward to case rates – likely to accelerate the

movement toward integration. Same if PA carves in

PCP Practice or Hospital pays:

Improves PCP efficiency

Creates competitive edge – differentiates practices

PH provider pays for non-billable therapist time


Staffing, Productivity, and Smooth Integration

Therapists see 5.9 patients/day to pay for themselves

Psychiatric time/# Therapists I WPIC-CCP is 6-7:1.

WS allots up to 3 hrs of psychiatric time for every 4 therapists.

PCPs/practices must be comfortable with BH staff therefore they are involved in selection process

Physicians need to be educated in some MH basics Black-box warnings

Malpractice actions are far more common in PC than in BH care

PCP’s comfort w/prescribing & managing psychotropics


Regulations

WPIC - CCP

BH staff governed by DOH regulations and MCO standards

Starting to do D & A screening and brief intervention – brings up question of BDAP

WS is not a PA satellite outpt site and is not governed by OMHSAS licensing regulations.


Billing Issues

BH Provider utilizes their main office PROMISe Number

FQHC provides multiple specialties

BH Provider can request PROMISe #

Currently OMHSAS/OMAP don’t allow two services

at the same PROMISe #

Can request a waiver, but it is taking many months, many not approved

This barrier is being addressed and maybe removed

Pediatric Integrated Care: Triple Aim

Better Health

ID Functional Outcomes

Better Experience

(96% Show rate first appt. and 90% thru Treatment Episode

Access within 5 days to first appt.

Absence of Stigma – comfort with Ped office as ‘HOME’

Enhanced Collaboration

Cost Savings

PH side – improved workflow, less diagnostic tests

BH side – Early engagement results in reduced intensity of Tx


Electronic Health Record





Patient Registries

Can combine the data across EHR’s to get unduplicated counts

Export of data to patient registries – Depression – IMPACT Model

Used to Treat the Target – Compare against average improvement

Continuity of Care encrypted document customized with information to meet needs of both Pediatrician and BH transmitted via email for upload into EHRs


Limitations

Children with Complex needs referred to other LOC

Barriers to integrated EHR

Lessons Learned:

Huge opportunity for prevention-close mortality gap

for adults with BH disorders

Importance of Partnerships- need to now connect

with schools

Significance of Culture Shift

Right clinicians with fit for specific office team

Questions

Behavioral Health

Outreach in Medical Units Sherry Shaffer, Community Care Behavioral Health

Anthony Lucas, Allegheny HealthChoices, Inc.

BH Outreach in Medical Units:

Description of Outreach Models

Allegheny General Hospital Model

Using SBIRT in the emergency room (ER) and inpatient (IP) medical units

Hospital social workers assisting with referrals to substance use disorder (SUD) Tx

UPMC Hospital Model

Modeled after Project Engage initiative - Christiana Care Health System

Embedding peers in SUD recovery in select UPMC hospitals via WPIC and UPMC

partnership

Community Care Behavioral Health

Community Outreach Recovery Specialists (CORS) – using peers in SUD recovery to

do outreach, engagement and transition with ER/IP unit referrals

BH Outreach in Medical Units

Financing

Current:

Grant through CMS

Commitment of support from PA

DHS/OMAP/OMHSAS and local PH/BH-MCOs

Future:

Accountable Care Organization

Hospital systems – to help reduce readmission rates


Important Components

Hospitals:

Staff are oriented to the goals/challenges of the initiative

Staff are trained in SUDs and BH systems of care

Identify internal “champion”

Peers in SUD recovery working in the hospital:

Receive intensive pre-service training, on-going training/technical

assistance and clinical supervision

Part of the IP treatment team for members with SUD problems

Coordination of care between PH/BH-MCOs and hospitals


Outcomes of Interest

HEDIS Measure: Initiation and Engagement in AOD

Treatment

Engagement/referral rate

Satisfaction survey

Readmission rate

Emergency department visit rate

Per Member Per Month (PMPM) Costs


Limitations & Lessons Learned

Limitations:

Funding designed to serve HC population (only)

Experimental model – emerging practice

Lessons Learned:

Staff recruitment – peers in SUD recovery are an

emerging workforce

Importance of hospital leadership participation in

all aspects of implementation

Questions

The Future – Global Budgets Accountable Care Organizations

Integrate Care Teams

Stephen Christian-Michaels, Family Services of W. Pa

Noreen Fredrick, Western Psychiatric Institute and Clinic


Description

Integrated care team (maybe from different agencies):

Registered Nurse

Licensed Clinical Social Worker

Care Manager

Nutritionist

Peer Specialist/Health Educator

Outreach in ER or Medical Units

Accountable Care Organizations

Financing

Integrated Care Team funded by the ACO network

Behavioral Health and Medical Revenues

Services paid for savings from reductions in high utilizers

Accountable Care Organizations

Billing and Documentation

Depends on detail that the ACO wants


Electronic Health Record

May be a combined health record across the ACO

May utilize a regional health information exchange

Data from team’s record is uploaded at least daily

Behavior Health Home Plus Expansion

Nurse driven case management model

Focus: wellness and physical health challenges in BH setting

Integration of physical and behavioral health services

Service Coordinators and Peer Specialists as Health Navigators

Approach:

Wellness Coaching model

Self- management strategies

Lead Nurse Navigator

coordinates the services and

provides guidance to the Health Navigators

Behavior Health Home Plus ExpansionSuccesses

Smoking Cessation

Weight Loss

Medication adherence

Increased physical activity

Connections with Health Care Providers

117 individual completed wellness plans & coaching

23 wellness coaches have been trained

Nurse navigator completed 161 health assessments

Barriers to Integrated Care

Getting a PROMISe # for settings w/Medical/BH

Two co-pays for first session with warm handoff

Billing for 2 services on same day for Medicare

D&A counseling at PCP site – confidentiality

Flow of information between BHBH EHR’s

Savings from integration doesn’t come back

Wellness Activities by Case Mgr, Peer unbillable

Medicare credentialing only allows PhD & LCSW

Workforce – few trained, few interested

Cultures very different, requires focus on change

Questions?

Documents

Integrated Care: WHAT YOU NEED TO KNOW TO GET STARTED · SouthEast Lancaster Health Services, (SELHS), Lancaster 2011-present –Co-located - bilingual BH clinician .5FTE –groups