Integrating Medical Care into the CMHC setting

Integrating Medical Care into the CMHC settingKirk Morton, RN, BSNPresentation to the VACPNMay 8, 2014

What is the medical home model?

The medical home relies on a team of providers—such as physicians, nurses, nutritionists, pharmacists, and social workers—to meet a patient’s health care needs. Studies have shown that the medical home model’s attention to the whole-person and integration of all aspects of health care offer potential to improve physical health, behavioral health, access to community-based social services and management of chronic conditions.

Grantee: RICHMOND BEHAVIORAL HEALTH AUTHORITY Richmond, VA

Program: PBHCI Grant SM060927

Congressional District: VA-03FY 2013 Funding: $400,000 Project Period: 07/01/2013 - 06/30/2017

The Richmond Behavioral Health Authority (RBHA) proposes to expand and enhance the quality of behavioral health and medical services for Richmond, Virginia residents with serious behavioral health conditions through the Richmond Integrated Community Health (RICH) Recovery Initiative. The RICH Recovery Initiative will involve partnering with a local federally -Qualified Health Center, a local university health system, and a local advocacy organization to establish RBHA as a Health Home by expanding an on-site primary medical care clinic as well as client health navigation services. It is anticipated that approximately 1,700 total clients will benefit from the services offered through RICH Recovery. Annually, the project will serve 250 clients in Year 1, 375 in Year 2, 475 in Year 3, and 600 in Year 4. The RICH Recovery's goals are to: 1) Improve overall health, wellness and recovery in a high-risk, underserved behavioral health population of the City of Richmond by establishing RBHA as their Health Home integrating primary and behavioral care using a multi-disciplinary team, including peer-based services; 2) Contain and reduce overall health care costs, specifically by reducing inappropriate use of emergency room services and reducing overall hospitalizations; 3) Utilize Health Information Technology (HIT) to improve client care, expand services, improve client and organizational outcomes, and lower costs; 4) Implement health promotion activities and continuous service linkages by employing an innovative Peer Recovery Coach Navigator workforce; and 5) Ensure the availability of bi-directional referral and data sharing linkages with specialty care clinics to provide the most appropriate type and level of client care.

Metrics and OutcomesSection H Indicator Number of Valid Cases At-risk at Baseline At-risk at Second Interview Outcome Improved

Blood Pressure - Systolic 730 41.90% 42.20% 15.60%Blood Pressure - Diastolic 730 31.80% 33.30% 10.70%

Blood Pressure - Combined 730 48.20% 49.50% 17.30%BMI 701 73.90% 73.20% 44.90%Waist Circumference 245 46.90% 47.80% 35.50%Breath CO 73 69.90% 71.20% 30.10%Plasma Glucose (fasting) 135 32.60% 38.50% 29.60%HgbA1c 116 56.90% 55.20% 35.30%HDL Cholesterol 221 24.40% 27.60% 32.60%LDL Cholesterol 211 24.60% 26.10% 34.60%Tri-glycerides 220 33.60% 38.60% 33.60%

RBHA’s Answer:

Domain 1: Environment - What does our external environment require of us?

Key Item

Rank Importance 1-5

Sustainability Factors

Do you know the implications of Medicaid expansion in 2014 on your agency? Are you participating in your state’s health home discussions? Are you in contact with likely Accountable Care Organizations in your area? Specific Action Step (including who, by when)

Domain 2: Strategy - What gives us direction?

Key Item

Rank Importance 1-5


Is integration embedded in your strategic plan? What is your agency’s vision & mission? Does it need to change to include

integration elements? Do you have a business plan for growing your integration business? Have you

quantified the impact of Medicaid expansion on your business plan in 2014? Do you know how much money your organization needs to make in order to

support your integrated care vision? Is integration part of the service every client receives? Are wellness programs

part of your service array? Are clients trained in peer support and wellness coaching programs??

Does your organization support the health and wellness of your employees? Specific Action Step (including who, by when)

Domain 3: Leadership Practices, Culture and Communication

Key Item

Rank Importance 1-5


Have you formed a change team that is empowered to influence integration in your clinic?

Is your governing board engaged and knowledgeable about integration? Are supervisors supporting staff during integration, including reviewing client

health goals during supervision? Specific Action Step (including who, by when)

Domain 4: Administrative and Policy - Are we capable?

Key Item

Rank Importance 1-5


Do your administrative policies support integration? (Confidentiality policies, Billing and Reimbursement policy, Ethics policy)

Do your clinical policies regarding care coordination, annual lab work, prescribing, smoking, treatment planning, etc, require elements related to integrated services?

Does your annual lab assessment include metabolic syndrome indicators? Are blood pressure and BMI measurements completed at each medical visit? Are health and wellness goals in your treatment plans? Do you have organization-wide policies regarding tobacco use? For services you will be unable to sustain , how will you assist clients to find other

providers of those services? Specific Action Step (including who, by when)

Domain 5: Billing (Are we maximizing our billing potential?)

Key Item

Rank Importance 1-5


Are you billing for all possible behavioral health services provided? Primary care visits?

Are your Medicaid and Medicare numbers appropriately linked to the service provided?

If partnering with an FQHC, do you understand FQHC billing rules and regulations?

If partnering with an FQHC, do they understand your billing rules and regulations?

If partnering with an FQHC, do you have a contract outlining payment. clinical services, and operations expectations?

Have you walked through your workflow and identified who can pay for each step of your process - with your clinical and billing staff at the same time?

Do you know what existing billing codes for integrated health are billable in your state and to which third party source?

Specific Action Step (including who, by when)

Domain 6: Technology (Do we have the technology in place necessary to support integrated services?

Key Item

Rank Importance 1-5


Are you using a certified EHR? Can your system generate registries for staff to use to support integration? Can you generate a Coordination of Care Document (CCD)? Does your clinical record support documentation of physical health related

services? Are you connected to the State HIE? Can your system generate an electronic bill after the completion of a

documented event? Specific Action Step (including who, by when)

Domain 7: Quality Improvement (Do we have a structured approach for engaging in integration-related quality improvement efforts?)

Key Item

Rank Importance 1-5


Do you have automated methods for understanding the health and wellness of the people you serve at a population-level?

Do you routinely use clinical and client-level data to make policy and practice decisions?

Does your quality improvement program include benchmarks for integration activities?

Does your quality improvement data drive change processes? Specific Action Step (including who, by when)

Domain 8: Structure - Are roles and responsibilities clear? Are we organized so we can meet strategy?

Key Item

Rank Importance 1-5


Do your job descriptions for case managers, therapists, nurses and doctors include key tasks associated with integration?

Are your integrated teams meeting routinely and often (daily, weekly, etc) to discuss integration efforts and client issues?

Have nurses transitioned from “behavioral health nurses” to “integrated health nurses”?

Is the treatment team required to monitor BOTH physical health and behavioral health issues?

Have you identified the baseline caseloads for both primary care and behavioral health clinicians?

Are your clinicians seeing enough clients to meet the financial need? Specific Action Step (including who, by when)

Domain 9: Skills - Are staff able to do the desired work?

Key Item Rank Importance 1-5


Does your staff development program include iterative integration trainings?

Are staff trained on evidence based programs and tracked regarding fidelity to those approaches?

Have case managers and therapists been trained on health navigation/care coordination?

Are your billing staff trained on correct billing procedures such as the proper CPT code, linked with the proper diagnostic code and the proper credential?

Are you as an agency and your providers empanelled with all of the appropriate managed care plans?


Domain 10: People - How do we attract and develop our talent?

Key Item

Rank Importance 1-5


Do your performance evaluations include integration tasks? Does your new staff orientation include information on integrated care? How do you ensure that new staff have an integration “mindset?” Specific Action Step (including who, by when)

Domain 11: Rewards – How do we recognize people for supporting the change towards an integrated system?

Key Item

Rank Importance 1-5


How engaged are staff in your transition to integrated services? How well designed and aligned are incentives and informal rewards to drive

needed behaviors necessary for achieving the strategy? Specific Action Step (including who, by when)

Domain 12: Marketing – How do we tell the story of both the need for integrated care and the success of our efforts?

Key Item

Rank Importance 1-5


Are you capturing client stories that demonstrate complex needs and successes? Are you able to generate clear short reports for varied audiences (board, staff,

elected officials, health and community partners, additional funders) with your data and stories?


Where We Are To Date Build out complete Target population identified and data

collection begun Workflow modifications EMR adjustments Building “Super Bill” (We haven’t starting yet, looking at spending some of

grant money for consultant.)

Some staff hired (All staff hired now)

Challenges And Successes Hiring of Full-Time FNP is proving to be more

difficult than expected (Now hired) Hiring MD likely to be less challenging but issues

remain around utilization (Now hired) Optimal billing will likely require the consultation of

some experts (looking at options now) Credentialing of Staff as insurance companies

aren’t themselves prepared for new modalities (still in process)

New focus on integrated care has already shown benefits to consumers

Documents

Integrating Medical Care into the CMHC setting