Linda Rosenberg - Texas Council of Community Centers

www.TheNationalCounci l .org

R oadmap to E quity:A c hieving P arity in the Healthc are

S afety NetTexas Council of Community Centers

May 31, 2012Linda Rosenberg

President and CEONational Council for Community Behavioral Healthcare


“The future is already here –it’s just not very evenly distributed.”

–William Gibson


Members hip*

*Mental health, substance use, hospitals, state and local governments, child welfare, health centers serving safety net population of 8 million



The old comic strip, that said about Fred Astaire: “Sure he was great, but don’t forget that Ginger Rogers did everything he did, backwards…and in high heels.”

We are the Ginger Rogers of the healthcare world, dancing backward in high heels


The future of American healthcare…


T oday … R eimagining what is pos s ibleForces in play…experimentation; demand for impact; liberation of information; branding causes not organizationsPreparing for the future…1. Policy 2. Service Delivery 3. Workforce4. Technology 5. Public Education


1) L et’s talk P olicy…

• ACA - 50 m. behavioral-primary care integration grants

• ACA - Mental illness & substance Use Disorder eligible chronic illness for Medicaid health homes(state plan option); and behavioral healthcare organizations (BHOs) eligible providers

• Parity in the Affordable Care Act (ACA) – Exchanges and Essential Benefit Packages; and the expansion of Medicaid by more than 15 million


…A nd the current Healthcare L ands cape

Environment of ExperimentationImpact of the deficit debate on MH/SUD• Rapid expansion of Medicaid managed care for

all populations • Dual-eligible planning and implementation• ACOs and health homes• From fee for service to case rates, bundled

payments and capitation – shared risk


T he 2012 E lec tions …

• Entitlements on the chopping block - Medicare, Social Security, Medicaid

• Much of the legislative business for the year will be pushed off until after November 6. Lame duck session – that is, the period of time after the election but before the new Congress is sworn in – could be critically important

• The National Council Public Policy Institute and Hill Day on June 25-26 is opportunity to speak up for behavioral health in the halls of Congress and lays groundwork for success during the lame duck session!


J oin us in Was hington, DC

B ehavioral Health IT A c t of 2011 (S . 539)

> Extends federal health IT incentive payments to CBHOs and certain behavioral health providers

> Currently 14 Senate co-sponsors

> Working on House introduction


E xc ellence in Mental Health A ct S .2257

• Parity in the safety net• Creates criteria for Federally Qualified

Community Behavioral Health Centers (FQCBHCs), as entities designed to serve individuals with serious mental illnesses and addiction disorders

• Improves Medicaid reimbursement for FQCBHC

• Creates a loan fund to support the modernization and construction of community-based mental health and addiction treatment facilities.

Senator Jack Reed, co-author of the 2012 Excellence in MH Act


S upreme C ourt A C A C hallenge• Healthcare is the single biggest

category of government spending in America

• Ongoing issues with the sustainability of U.S. health spending…

states and the federal government will continue to search for solutions regardless of the Supreme Court decision


A tul G awande: T es ting, T es ting

• Insurance Reform and Coverage Expansion are “technical fixes”

• Payment Reform and Service Delivery Redesign is now the focus … “bending the cost curve”


2) L et’s talk service delivery?Demand for Impact- Integration - Care Management


C an good primary c are s olve everything?

• Think of the person with heart failure, diabetes, asthma

• Think of the mom with depression and diabetes who’s on the verge of homelessness

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B i-Directional Integration...Clinical Design for Adults with Low to Moderate and Youth with Low to

High BH Risk and Complexity

Primary Care Clinic with Behavioral

Health Clinicians

embedded, providing

assessment, PCP

consultation, care

management and direct

service

Partnership/Linkage with

Specialty CBHO for persons who need their care stepped up to

address increased risk and complexity with ability to step back to Primary Care

Clinical Design for Adults with Moderate to High BH Risk and

Complexity

Community Behavioral Healthcare Organization with an embedded

Primary Care Medical Clinic with ability to address the full range of

primary healthcare needs of persons with moderate to high

behavioral health risk and complexity

Food Mart

CBHOFood MartCBHO

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B i-Directional Integration -T echnical A s s is tance

• 64 + grantees including Austin Travis County Integral Care, StarCare Specialty Health System, Montrose Counseling

http://www.integration.samhsa.gov/


New Medicaid S tate Option for Healthcare Homes• State plan option allowing Medicaid beneficiaries with

or at risk of two or more chronic conditions (including mental illness or substance abuse) to designate a “health home”

• Community behavioral health organizations are included as eligible providers

• Effective Jan. 2011• MO (2); RI (2); NY; OR; NC• Several states have submitted State Plans

– Iowa, Oregon, Washington


Integration = A cces s ible• National Council has worked with 149 pairs of CBHOs and

FQHCs• Can schools, child welfare, ACOs and healthcare homes get

their clients/patients into specialty MH/SU care with same day/next day access, especially for high risk, high need patients?

New Patient’s first Visit to PCP includes

behavioral health screening

Possible BH Issues?

Behavioral Health Assessment by BH

Professional working in primary care

Need BH Svcs?

Clients with Low to Moderate BH need enrolled in Level 1; to be case managed and served in primary care by PCP and BH Care Coordinator with support from Consulting Psychiatrist and

other clinic-based Mental Health Providers

Clients with Hi Moderate to High need referred to Level 2 specialty care; PCP continues to

provide medical services and BH Care Coordinator maintains linkage; this is a time-

limited referral with expectation that care will be stepped back to primary care

YES

YES

Referrals to other needed services and supports (e.g. CSO, Vocational Rehabilitation)

Superb Access to Care

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A n A cces s ible Organization: C arls bad Mental Health C enter (NM)

Nationwide, same-day access initiatives:• Consumer wait times from

six months to zero days; staff time saved 40 percent; average annual savings of $222,000 per agency

• Practice change – control the schedule; only 2 appts out; concurrent documentation; reminder calls


S ervice Delivery… C as e Management to C are Management

23


• Jeffrey Brenner - COMPSTAT >> HEALTHSTAT• Two most expensive city blocks, 900 people,

accounted for 4000 hospital visits, 200 hundred million in healthcare costs over a 5 year period.

• 1% of 100,000 people used 30% of costs

C OMS T A T C omes to Healthc are

24


Mis s ouri…

25


C are Management…

• Do you have the ability to identify patients with MH/S UD who repres ent the top 5% to 10% of high c os t c ons umers of health c are and provide effec tive c are management s ervic es to help them manage their MH/S U dis orders A ND their c hronic health c onditions ?

• Do you know your c os ts ?• C an you negotiate with health plans ?• Is you workforc e prepared?

Care Coor-

dinationTeam Care

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3) L et’s talk workforc e …. Health Worker S hortage?

• Too few health works being training• and

• Too few health workers willing to work in the health system


It’s Not J us t Us …. T here is a G lobal Workforc e S hortage

• The World Health Organization (WHO) estimates that 4.3 million more health workers are required to meet the need by 2015

• Health workforce shortages have replaced system financing as “the most serious obstacle” to realizing the right to health within countries

• Source: Milbank Memorial Fund 2011 Report


A G rowing S ervic e E c onomy =A G rowing Demand for S killed

C ons umer Oriented s taff


T he V alue

of Money


B ehavioral Health… A direct care worker in a 24-hour residential treatment

center has a lower median salary than an assistant manager at Burger King ($23,000 vs. $25,589)

A social worker with a master’s degree employed in a mental health-addictions treatment organization earns less than a peer at a general healthcare agency ($45,344 vs. $50,470)

A registered nurse working in behavioral health earns less than the national average for nurses ($42,987 vs. $66,530)

The VA and FQHCs• Source: National Council for Community Behavioral Healthcare 2011 Salary

Survey


Workforce Initiatives …

There is only on way to eat an elephant; one bite at a time


National Health S ervic e C orp• The below quick tips can help you begin the process of becoming an

NHSC-approved site.

Read CIHS’ new manual Understanding the National Health Service Corps to learn about the program and its application process.

Determine if you are located in a Health Professional Shortage Area (HPSA) by entering your address in HRSA’s HPSA Locator.

Contact your State Primary Care Office (PCO). PCO will walk you through the application process and answer any of your questions.

Review NHSC Service Site Reference Guide for details about what it means to be an NHSC site before you begin application process.

Apply online at the NHSC website (you must first created an online account).

http://www.integration.samhsa.gov/workforce/Understanding_the_National_Health_Service_Corp_A_Guide_for_Community_Behavioral_Health_Providers_and_Primary_Care_Partners.pdf�

http://www.integration.samhsa.gov/workforce/Understanding_the_National_Health_Service_Corp_A_Guide_for_Community_Behavioral_Health_Providers_and_Primary_Care_Partners.pdf�

http://datawarehouse.hrsa.gov/GeoAdvisor/ShortageDesignationAdvisor.aspx�

http://bhpr.hrsa.gov/shortage/hpsas/primarycareoffices.html�

http://www.nhsc.hrsa.gov/downloads/sitereference.pdf�

http://programportal.hrsa.gov/extranet/site/login.seam�


B y and F or C ons umers …

Whole Health Action Management (WHAM): • Preparing consumers to serve as health educators

and coaches. • Guiding participants through person-centered

planning process to health and resiliency goal with weekly action plan for success.

• Designed to support the emerging peer workforce to move into new health integration service models like health homes.


P s ychiatris ts …• Curriculum: 6 Modules designed to increase

psychiatrists’ capacity to practice and/or consult in integrated health settings. – Module 1: Introduction to Primary Care Consultation

Psychiatry– Module 2: Building a Collaborative Care Team– Module 3: Psychiatrist Consulting in Primary Care– Module 4: Behavioral Health in Primary Care– Module 5: Medical Patients with Psychiatric Illness– Module 6: The role of the Psychiatrist in the Public

Mental Health System


C as e Managers to C are Managers • Transforming traditional mental health case management

programs into assuming responsibility for the whole health of the individuals they serve.

• Topics include:• Conceptual framework for change: health homes, chronic

care model• Physical health of people with behavioral health diorders• Diabetes and heart disease: key issues and key

interventions• Exercises in motivational interviewing for health behavior

change• Self-assessment of individual practice


G raduate S oc ial Work E ducation…

• Integrated Healthcare Curriculum for Schools of Social Works:

A competency-based curriculum and curriculum modules to prepare Masters of Social Work students for behavioral health practice focused on integrative and collaborative primary/behavioral health care.

Will prepare future MSWs to enter the workforce with the needed competencies to provide and lead integrated healthcare. Curriculum offerings will be paired with field placement opportunities committed to integration and collaboration.


• National Council Middle Management Academy• Psychiatric Leadership /Executive Leadership***• Emerging Leaders and Health Disparities***

L eaders hip…


Harvard B us ines s R eview S kills for the 21s t C entury L eader

• Serial Attention Skills - There is no point in trying to limit distractions. The key is to learn to be successful in a distraction-rich world.

• Cross-cultural Communication - the ability to modify behavior in specific situations to accommodate varying cultural norms…requires capacity to manage psychological challenges that arise...

• Mastery Of Digital Influence - Health care (after pornography) most frequent subject of on-line searches. E-mail replacing physician office visits. On-line platforms (Twitter, Facebook, LinkedIn) for recruiting, market research, and customer service – now job requirement.


4) L et’s talk tec hnology?

Information L iberation• Mainframes to Minicomputers• Personal Computers to

Laptops• Cell Phones to Smart Phones

– NY Times - smart phone eliminates need for camera, camcorder, music player, alarm clock, and GPS units

– Assisted Treatments– Social Media

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T echnology – as healthcare organizations we mus t …

• Promote collaboration, coordination and integration of care

• Ensure staff competent in practices based on newest scientific evidence

• Use standardized instruments/registries • Bill and report data to multiple payers• Ensure compliance• Measure outcomes • Market – to consumers, potential staff and communities

Does your organization us e an E lectronic Health R ecord?


Dis eas e R egis tries …What G ets Meas ured and Monitored, G ets Done

• Metabolic Syndrome– Blood pressure - weight– Cholesterol - height– Triglycerides - blood sugar

• Disease registry with results maintained on cyber access


Screening Tools as “Vital Signs”

Behavioral health screeners are like monitoring blood pressure!- Identify that there is a problem- Need further assessment to understand the

cause of the “abnormality”- Ongoing monitoring to measure response to

treatmentIf we don’t measure it…we can’t manage it…we can’t improve it…and we won’t be paid for it!


T reat to T arget – treatment dec is ion s upports

Do you have defined assessment processes and levels of care based on clinical pathways, functioning, symptom severity, service volumes, etc. to match clients with type, location, and duration of evidence-based care so consumers get needs met in timely, effective manner?

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Technology – Citizen Science

• Online health information seekers account for 59% of all U.S. adults.

• Four out of five Internet users research health info on the web.

• Healthcare is — after pornography —the most frequent subject of online searches.


T op 5

Mental health

Cardiology

Diabetes

Respiratory Care

Wound Care

1

2

3

4

5


T elehealth Is E xploding

• 13,000 health apps for smartphones• 200 telehealth networks connecting

2,000 institutions• Email use with consumers for service

has tripled• Telehealth industry is projected to grow

to $8 billion in 4 years• Home telehealth will grow at six

times the rate of the face-to-face clinical market (56% compared to 9.9%)


T elehealth in A ction: Health B uddy and S mart P hones

• Everyday, the Bosch Health Buddy System gathers vital signs, reviews symptoms, educates, and reinforces positive behavior.

• Data from the device is sent to and reviewed by the health provider to identify need for intervention.

• Smart phone – substance use


5) L et’s talk public educ ation? Winning the hearts and minds of A meric ans - branding a c aus e not an organizationWith T reatment P eople R ec over Recovery rates with treatment and/or medication: Bipolar disorder 80%Major depression 65-80%Schizophrenia 60%Addiction 70%

$1 invested in substance abuse treatment has a return of $7 in cost savings from social benefits

Recovering people work, pay taxes, have homes and relationships, volunteer, contribute, vote


P ublic Health C ris is …– 60% of people who experience MH problems & 90% of

people who experience SU problems and need treatment donot perceive the need for care

– Almost as many people need SU treatment as diabetes, butonly 18.3 percent vs. 84 percent receive care

– Suicides are almost double the number of homicides– Mood disorders rank 1st in U.S. work loss costs; & most

common reason for going on social security disability– ¼ of U.S. hospital stays involved mental/substance use

disorders– Mental illness leading cause of military hospitalizations*


What A meric ans K now• Most Know or Are Taught:

–Basic First Aid and CPR for physical health crisis–Universal sign for choking; and basic terminology to

recognize blood/other physical symptoms of illness & injury–Basic nutrition and physical health care requirements–Where to go or who to call in an emergency

• Most Do Not Know and Are Not Taught:–Signs of suicide, addiction or mental illness or what to do

about them or how to find help for self or others–Relationship of behavioral health to individual or community

health or to health care costs–Relationship of early childhood trauma to adult physical &

mental/substance use disorders


T ragedies


P ublic E vents L ead to Inac c urate P ublic Dialogue

• Individual Blame Based on Misunderstanding–E.g., moral judgment, discrimination, prejudice, social exclusion

OR• Attention to symptoms

–E.g., homelessness; drug-elated gangs; child welfare issues due to addiction and mental illness; amount of jail time by persons with M/SUDs; institutional, provider, or system failures

LEADING TO• Insufficient responses

–E.g., increased security & police protection; tighter background checks; controlled access to weapons; legal control of perpetrators & their treatment; more jail cells, homeless shelters, institutional/system/provider oversight)


S o, how do you c reate a dialogue…

• On the role of BH in public life• With a public health approach that:

–Engages everyone – elected officials, schools, parents, churches, health professionals, persons affected by mental illness/addiction & their families

–Based on facts, science, common understandings–Focused on prevention (healthy communities)–Committed to the health of everyone (social inclusion)


Mental Health F irs t A idPartnership with Maryland and MissouriState Governments

• 50,000 trained – Texas in top 5 • 2000 instructors• Youth and Spanish adaptations – 2012• National policy and media attention


P olic y, s ervic e delivery, workforc e, tec hnology and public educ ation…c hange is c ons tant• Making use of existing

tools…• Applying them

conscientiously…• And holding ourselves

to a high standard



Documents

Linda Rosenberg - Texas Council of Community Centers