Nancy Paull MS LADC I Slide 2 Summary of Talk 1. Overview of
integrated care, SSTARs model of primary care behavioral health
integration 2. latest initiative through the NIATx Accelerating
Reform Initiative - 3. Billing, IT issues impacting integration-
Slide 3 Founded in 1977 as a private, not for profit organization.
Original programs included: a 20 bed alcohol detoxification
program, an outpatient alcohol treatment program, an education
program for persons convicted of driving under the influence of
alcohol Slide 4 SSTARs programs have been developed by listening to
and trying to meet the needs of the clients we serve. Slide 5 From
the very early days of operation, it was clear that our clients
were medically compromised. High rates of diabetes, Asthma Liver
disease Nutritional deficiences Slide 6 Our community has
consistently had a high rate of opioid addiction. The first cases
of HIV/ AIDS came to SSTAR very early in the epidemic; and there
were no infectious disease specialists in our community. SSTAR
became the first provider in the state to have a counseling/testing
site in their drug treatment facility Slide 7 When the first wave
of individuals tested positive, we had push-back from the local
private physician community, who didnt want us integrating those
patients into their private practices. SSTAR staff had to refer
most patients to Providence and Boston. Slide 8 SSTARs Medical
Director Frank Lepreau said: These are our patients- they deserve
to be treated well within their own community Slide 9 SO.. 1.Dr
Lepreau sought help from Brown University Infectious Disease
Specialists 2.Simultaneously, we started looking at state
regulations for clinics and licensing requirements Slide 10 We
became a licensed clinic; licensed by the Massachusetts Department
of Public Health; hired staff; and utilized our medical director
and volunteer Docs from Browns program. In the first year of
operation, we lost a staggering; $250,000. Slide 11 We then decided
to apply for FQHC status to the Bureau of Primary Care. Our
application was rejected. Slide 12 We then went to our local
community Health Center Assn for help. Initially they were not
thrilled to see us. The state had recently started a free care pool
for community health centers and they did not want drug treatment
agencies stealing their money. Slide 13 The ASSN suggested we first
apply for a Look-a Like Clinic and after much work we were awarded
that status. We became eligible for the states free care pool and
our rates for Medicaid/ Medicare increase significantly. We started
working our way back to financial health. Slide 14 We then applied
with another health center in town to be an FQHC. Since only 1
would be funded, SSTAR agreed to be the sub-recipient in this
agreement. Slide 15 We won FQHC status. We now have a grant which
assist us with basic infrastructure costs. Our Health center
doctors are covered by Federal Malpractice Insurance. However, it
does not cover any inpatient work in our detox; or other services
that our not in our scope of practice. Slide 16 Slide 17 Building
relationships with the local medical community; preparing for
Medical Homes An Approach other organizations could use to link
with Primary Care Slide 18 Prepare for medical home payment reform
by increasing collaboration with community primary care providers.
Mobilize the local medical community to identify, treat, and
improve outcomes for addicted individuals and their families. Slide
19 2. CHANGE /DO Build on relationships with community medical
providers Partner with St. Annes Hospital Convene meeting of S-A
primary care providers 3/31 Slide 20 3. Results/ Study Two primary
care providers who attended the meeting engage in collaboration.
Referral/release of information form developed and implemented Both
practices institute drug and alcohol screening (CAGE-AID) for
annual physicals and new admits. Slide 21 Results contd SSTAR
Family Health Care Center begins tracking CAGE results in their
EHR. Hotline cell phone established for instant referral access to
SSTAR case manager by participating medical providers. One of the
two participating providers links us to third medical practice that
agrees to participate meetings at SSTAR and at the practice,
adoption of referral form. Three referrals made Slide 22 4. Next
Steps/ Act Establish baseline CAGE results plus tracking of
referral outcomes. Form a change team to improve referral outcomes.
Introduce ARISE family interventions as strategy to increase
treatment engagement? Document successes and use to market the
value of screening and SSTAR referrals to other community providers
Slide 23 5. Impact New and strengthened partnerships with community
medical providers; increased focus on addressing the problems
associated with managing addicted patients in community medical
settings. Slide 24 Understand the customer: community medical
providers want solution to problem of their drug-seeking patients.
We have TA to provide as well as treatment resources. Understand
the customer: their referred patients dont necessarily want
treatment or believe they need it. Change team needs to devise
interventions to increase success of referrals by recognizing where
patient is in stages of change model. Slide 25 Outcomes Three
community medical provider practices engage in project
Referral/Release of Information form developed to improve
coordination of care for shared patients Meetings/conference calls
Hotline cell phone set up for community providers to make direct
contact with SSTAR case manager for referrals and warm handoffs Two
practices initiate use of CAGE AID for initial and annual physicals
Each of the three practices makes at least one referral to the
hotline Slide 26 Slide 27 Reimbursement and IT Issues M
ASSACHUSETTS ! Slide 28 Slide 29 Provider Type A community health
center provider type usually cant bill to a behavioral health MCO
carve out. They arent part of the provider network. Primary care
cant bill for a behavioral health diagnosis to a medical payor
theyll say that should be billed to the BH carve out Slide 30
Performance Standards - Billing Under Mental Health Clinic
licensure regulations and payor standards, full psychosocial
assessment must be completed and billed for in order to be eligible
for reimbursement for other BH services such as individual
counseling, group counseling, etc. If counselor meets with patient
for a crisis session or patient drops in on a group, service isnt
billable because full intake/assessment hasnt been processed first.
Slide 31 Credentials and Reimbursement BH Billing in primary care
setting limited to LICSW, PhD licensed psychologist, psychiatrist,
NP Services provided through our mental health clinic depending on
payor, reimburses for addiction counselors, LMHC, unlicensed
Masters, etc Slide 32 Staffing Issues BH staff of the Health Center
are shared with the BH clinic to maximize reimbursement 2
addictions counselors, 1 LMHC, 1 LICSW Part of their salary paid
from HC budget. They are not on the salary+productivity pay system
that BH clinic staff are on so they have more flexibility in their
schedules to respond to situations. When they provide a
reimburseable service, its billed through the BH Clinic; Slide 33
Varying payor credentialing requirements can contribute to
uncollectible claims. Example: Suboxone group led by an addictions
counselor; client with UBH attends the group and that particular
insurance wont reimburse for that level provider. Its not
cost-effective to have separate group for people with that
insurance. Slide 34 Your memo raises concerns that FQHCs are
experiencing difficulty in obtaining Medicaid payments for
behavioral health services by clinical psychologists, clinical
social workers and nurse practitioners. .. Therefore as long as
these Practitioners are practicing within their scope of practice
under state law, the FQHCs payment should reflect the services
provided to Medicaid eligible Beneficiaries by these types of
practitioners. CMS MEMO Sept 23, 2003 Slide 35 Integrated
Documentation For those BH services provided and billed through the
Health Center, there will be notes in the primary care chart /
electronic health record in Nextgen But most of the BH care because
of the reimbursement issues - happens through the BH clinic and is
recorded in the BH electronic health record. This is a different
software application because there are special needs not met by
primary care applications. Barrier to integrated care Slide 36 HIT-
options for BH-PC Integration/Interoperability Find one application
that meets the needs of BH and Primary Care Create a software
bridge to share/dump certain fields into the other application: for
example medication lists, progress notes Develop a data warehouse
storing information from both systems that would allow sharing
Intranet to access the clinical information from each application
Slide 37 SUMMARY: It is difficult and expensive to start an FQHC
Billing for Behavioral Health in an FQHC is complex IT systems are
not yet integrated in a way that is acceptable to each type of
provider and probably not acceptable to payers and
accreditation/licensing bodies. Slide 38 BUT: Patients can get
better, more complete care. We are excited to be working to
transform systems of care for our patients. SSTAR believes with
Medical Homes and Accountable Care Organizations coming we need to
ready ourselves for the changes
