Access to Mental Health Services Through Primary Care Clinics. Making the Connection

Transcription

1 Access to Mental Health Services Through Primary Care Clinics Making the Connection

2 Presenting Today Katy Schalla Lesiak, MSN/MPH, CPNP Child Health Consultant Minnesota Department of Health Casey Ladd, MSW, LICSW, LMFT Director of Family/Child Services The Human Development Center Heather Winesett, MD Pediatrician St. Luke s Pediatric Associates Glenace Edwall, PsyD, PhD, LP Director of Children s and Adult Mental Health Divisions Minnesota Department of Human Services

3 Learning Objectives 1. Identify national & state trends impacting socialemotional & mental health screening in primary care. 2. Identify current and emerging statewide resources for children s mental health. 3. Identify specific strategies to link with primary care for improved access to mental health services. 4. Explore links and collaboration between families, schools (early intervention services), public health, clinics, and mental health providers.

4 A day in the life of a primary care provider Time / clinic flow Does not compute: infant mental health Pandora s box and the door knob My patient is my patient a limited perspective Missing step on the algorithm: what next?

5 American Academy of Pediatrics As of March 2014: Periodicity Schedule Psychosocial/Behavioral Assessment at every well visit birth 21 years Depression screening at every well visit years using PHQ-2 or others

6 National Pediatric Mental Health Screening Guidelines & Measures US Preventive Services Task Force Screen for depression ages years when systems in place for diagnosis, treatment and follow-up NCQA HEDIS (health plans) Screen for depression by age 13 and 18 years using standardized tool (depression only) Physician Quality Reporting System (PQRS) Medicaid includes payment incentives Screen for depression age 12 and older using defined list of tools; follow up plan documented

7 State Clinical Quality Measures Minnesota Community Measurement approved 3/2014 as full measure after pilot: Percentage of pediatric patients ages 12 to 17 who have a documented mental health and/or depression screening using one of the listed validated tools at a well child visit during the measurement period.

8 Child and Teen Checkups (Well child checks for children in MN eligible for Medicaid or MinnesotaCare) Added recommendations as of 8/2013: Social-emotional/mental health screening at 6, 12, 18 months and every checkup 2 to 21 years Maternal depression screening during infant s 1 st year of life

9 Early Childhood Mental Health Grants

10 Screening instrument recommendations Social-emotional/mental health screening 0 up to 6 years: Interagency Developmental Screening Task Force 6 up to 21 years: Task Force Instruments: Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) Pediatric Symptom Checklist (PSC) Patient Health Questionnaire (PHQ-9) Kutcher, Global Appraisal of Individual Needs (GAIN-SS), Beck (BDI), Children s Depression Inventory (CDI)

11 MN Early Childhood Comprehensive Systems (ECCS) Grant Goals Promote healthy development Promote early detection & intervention Coordinate across sectors Expand screening & referral in health care & child care Support RTT online screening initiative Coordinate training on development, screening, referral Explore centralized access point for existing services Explore data systems to better coordinate across sectors

12 Opportunities More measures and recommendations More awareness (?understanding) More referrals How to better connect? One community s story Working toward integrated care in MN

13 Duluth/Proctor/ Hermantown Thrive Initiative ABCD III The Depression Care Project Post Partum Depression Screening

14 Research is showing that psychopathology is not something you have, but is an outcome of interactions between biology, genetics, and experiences In fact, poor early care can change the architecture of a child s brain ( es/reports_and_working_papers/) Early consistent, responsive and sensitive care is generally required for healthy development. M. Casey Ladd, MSW, LICSW, LMFT 5/5/2014

15 While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? Yes No If yes enter 1 2. Did a parent or other adult in the household often or very often Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes No If yes enter 1 3. Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? 4. Did you often or very often feel that Yes No If yes enter 1 No one in your family loved you or thought you were important or special? oryour family didn t look out for each other, feel close to each other, or support each other? Yes No If yes enter 1 5. Did you often or very often feel that You didn t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No If yes enter 1 6. Were your parents ever separated or divorced? Yes No If yes enter 1 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? Yes No If yes enter 1 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No If yes enter 1 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes No If yes enter Did a household member go to prison? Yes No If yes enter 1 Now add up your Yes answers: This is your ACE Score.

16 ACE Category* Women (N = 9,367) Men (N = 7,970) Total (N = 17,337) Abuse Emotional Abuse Physical Abuse Sexual Abuse Neglect Emotional Neglect Physical Neglect Household dysfunction Mother Treated Violently Household Substance Abuse Household Mental Illness Parental Separation or Divorce Incarcerated Household Member

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18 Ace Score Women Men Total or more

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20 20

21 Capability Intellectual & employable skills Self regulation self control, executive function, flexible thinking Ability to direct & control attention, emotion, behavior Positive self view, efficacy Attachment & Belonging Bonds with parents and/or caregivers Positive relationships with competent and nurturing adults Friends or romantic partners who provide a sense of security & belonging Community, Culture, Spirituality Faith, hope, sense of meaning Engagement with effective orgs schools, work, prosocial groups Network of supports/services & opportunity to help others Cultures providing positive standards, expectations, rituals, relationships & supports

22 1. The developing capacity of the child from birth to five to experience, regulate, and express emotions ZERO TO THREE: National Center for Infants, Toddlers and Families M. Casey Ladd, MSW, LICSW, LMFT 5/5/2014

23 2. The ability of the child to form close and secure interpersonal relationships ZERO TO THREE: National Center for Infants, Toddlers and Families M. Casey Ladd, MSW, LICSW, LMFT 5/5/2014

24 3. The drive of the child to explore the environment and learn ZERO TO THREE: National Center for Infants, Toddlers and Families M. Casey Ladd, MSW, LICSW, LMFT 5/5/2014

25 4. All within the context of family, community, and cultural expectations for young children ZERO TO THREE: National Center for Infants, Toddlers and Families M. Casey Ladd, MSW, LICSW, LMFT 5/5/2014

26 Elevated Edinburgh Is it Autism? No it s PTSD Is it ADHD? No it s MI/CD Heart stricken

27 New Service Delivery and Payment Models for Integrated Care MINNESOTA ASSOCIATION FOR CHILDREN S MENTAL HEALTH DULUTH, MN APRIL 28, 2014

28 Health Care Reform and Integration Minnesota Health Care Plan (MHCP) changes, small and large New benefits Expansion of psychiatric consultation Behavioral Health Homes State Innovation Model Pearls for providers

29 New Benefits: Family Psychoeducation Five new or expanded benefits added to MHCP in 2013 legislative session: 1. Family Psychoeducation A children s mental health benefit to provide help to families in understanding symptoms, the impact of mental health disorders on child s development, the roles of treatment and skills development, and ways to promote resilience and prevent co-morbidities and relapse

30 New Benefits: Clinical Care Consultation 2. Clinical Care Consultation A children s mental health benefit to allow reimbursement for mental health professions communicating with other providers and educators; necessary for integrating care across systems and settings State Plan Amendment in preparation

31 New Benefits: Mental Health Service Plan Development 3. Mental Health Service Plan Development Limited to Children s Therapeutic Services and Supports (CTSS) providers for financial reasons; DHS interested in expansion to outpatient providers in Providers reimbursed for development, review and revision of individual treatment plans, including time spent completing assessment and outcome measurements and meeting with parents/caregivers

32 New Benefits: Intensive Treatment in Foster Care 4. Intensive Treatment in Foster Care Revision of Section 256B.0946, first enacted in 2005 and delayed on fiscal basis Targeted for children and youth through age 20 in foster care; includes trauma assessment, clinical services, 24/7 phone support; may be provided by CTSS or outpatient providers under contract with DHS

33 New Benefits: In-Reach Services 5. In-Reach Services Previously available to all MHCP recipients, but 2013 legislation explicitly expanded to children and adolescents, with lower usage thresholds (ED> twice in past 3 months or hospitalization > twice in past 4 months or discharge to shelter). Provides for working in ED or hospital to arrange for community services and supports prior to discharge

34 2013 Rate Increase Mental health professionals will have reimbursement under MHCP increased 5% beginning 9/1/14

35 Expansion of Psychiatric Consultation MHCP previously covered psychiatric consultation by a psychiatrist to primary care providers; in 2013, service was expanded to include consultation by a licensed psychologist or advanced practice nurse certified in mental health. DHS is seeking federal approval of new tiered rate structure in which both psychologist/apn and physician can be reimbursed for consultation.

36 Minnesota Behavioral Health Homes (BHH) Section 2703 of the Affordable Care Act allows for Medicaid State Plan Option to reimburse health homes 2 years of 90% federal match for enhanced integration and coordination of primary, acute, behavioral health and long-term supports for persons across lifespan with chronic illness Minnesota s first SPA will be for behavioral health: children and youth with serious emotional disturbance and adults with severe mental illness

37 BHH, continued Population chosen due to barriers to health care access, high co-occurrence of chronic health conditions and early mortality State currently has planning grant, including advisory council Framework for BHH intended to be used in future for other populations with complex needs, e.g., substance abuse, foster care, autism, physical disabilities

38 BHH, continued Services which must be delivered by BHH: Comprehensive Care Management: designed to manage medical, social and mental health conditions more effectively based on population health data and tailored to individual patient needs; based on patient registry Care Coordination: development, implementation and monitoring of Health Action Plan

39 BHH, continued Health Promotion Services: encourage and support patients in adopting healthy behaviors and better managing their health and wellness, including smoking cessation, weight management and fitness, management of chronic conditions Comprehensive Transitional Care: specialized care coordination services focused on movement of individuals within or between different levels of or settings for care; focused on movement to more integrated settings and preventing gaps in services

40 BHH, continued Referral to Community and Social Services: identification and referral to medical and behavioral health care, entitlements and benefits, respite, housing, educational and employment supports, transportation, etc. Individual and Family Supports: help clients and their significant supports to increase health literacy and self-efficacy skills and improve health outcomes

41 BHH, continued States must track avoidable hospital readmissions, calculate cost savings and monitor the use of health information technology Behavioral health homes must demonstrate a true integration with primary care States must avoid duplication of services/payments Integrate existing services into health homes Allow beneficiaries to choose between programs, e.g., Targeted Case Management Sufficiently differentiate service to avoid duplication, e.g., Clinical Care Consultation

42 The BHH Team Clients and their identified supports Care Manager Care Coordinator Qualified Health Home Specialist Team Leader Partner Providers [other health professionals; may be particularly important for comprehensive health assessments]

43 Eligible BHH Entities Behavioral Health Providers Sufficient infrastructure to incorporate team functions; incorporate or coordinate with primary care; health information technology including registry, outcome reporting Primary Care Providers Sufficient infrastructure to incorporate team functions; embed or closely coordinate with behavioral health providers; HIT as above; may be certified Health Care Homes

44 BHH Timeline SPA must be submitted to SAMHSA before CMS; anticipated July, 2014 SPA submitted for Tribal review August Submit SPA to CMS September; CMS review September-November and final negotiations November December Provider certification following SPA approval; anticipated January June, 2015 Services slated to begin July, 2015

45 BHH Reading SAMHSA-HRSA Center for Integrated Health Solutions (2012). Behavioral Health Homes for People with Mental Health and Substance Use Conditions: The Core Clinical Features. Pires, S. (2013). Customizing Health Homes for Children with Serious Behavioral Health Challenges. Prepared for U.S. Substance Abuse and Mental Health Services Administration.

46 Strategic Innovation Model (SIM) Minnesota awarded largest testing grant in U.S., February 2013: $45.3 million Five other states received SIM testing grants: AR, MA, ME, OR, VT 16 states received design grants

47 SIM Vision Every patient receives coordinated, patient-centered primary care; Providers are held accountable for the care provided to Medicaid enrollees and other populations, based on quality, patient experience and cost performance measures; Financial incentives are fully aligned across payers and the interests of patients, through payment arrangements that reward providers for keeping patients healthy and improving quality of care; and

48 SIM Vision, continued Provider organizations effectively and sustainably partner with community organizations, engage consumers, and take responsibility for a population s health through Accountable Communities for Health that integrate Medicare, mental/chemical health, community health, public health, human services, schools and long term supports and services

49 What is SIM Testing? Can we improve health and lower costs if more people are covered by ACO models? If we invest in data analytics, HIT, practice facilitation and quality improvement, can we accelerate adoption of ACO models and remove barriers to integration of care (including behavioral health), especially among smaller, rural and safety net providers?

50 SIM Testing, continued How are health outcomes and costs improved when ACOs work with Community Care Teams and Accountable Communities for Health to support integration of health care with non-medical models, compared to those who do not adopt these models?

51 SIM Vision 60% of fully insured population in ACO/ACH models, + 200,000 Medicaid enrollees 67% of primary care clinics are Health Care Homes 15 Accountable Communities for Health (ACH) ACO/ACHs integrate behavioral health (and other services) $111M in savings to Medicaid, Medicare and commercial payers

52 SIM Drivers and Funding 1. HIT/HIE: Providers will have the ability to exchange data in a safe and secure manner for treatment, care coordination, QI and population health. $9M (20%) 2. Data Analytics: ACOs have analytic tools to systematically manage cost/risk and improve quality. $10.4M (23%) 3. Practice Transformation: Expanded number of patients served by patient-centered, team-based, integrated/coordinated care. $5.9M (14%)

53 SIM Drivers and Funding 4. Accountable Communities for Health: Provider organizations partner with communities and engage consumers, to identify health and cost goals and take on accountability for population health. $6.8M (16%) 5. ACO Standardization: Development and standardization of ACO performance measurement, competencies and payment methodologies; focus on complex populations. $3.2M (7%)

54 General ACH Criteria Broad populations may apply for ACH grants Community-led leadership team that represents community and broad section of providers Includes at least one ACO that provides primary care to a threshold percentage of population and has financial accountability for outcomes Includes a community-based care coordination services delivery team or system Population-based prevention component Priorities on advancing health equity Participates in measurement/testing/evaluation

55 ACH Grant Timeline ACH Advisory Subgroup meeting Feb April, 2014 Contract with existing Community Care Teams for technical assistance, summer, 2014 Statewide community engagement through June, 2014 (and beyond) Competitive RFP to be posted July, 2014 Implementation begins October, 2014

56 SIM Information, Questions Visit Request speakers at questions to

57 Pearls for Providers Integration requires relationship building and interprofessional skills, particularly in relation to primary care Emphasize top of license skills, e.g., for psychologists, including program design, outcomes measurement, QI Prepare for HIT/HIE and increased measurement needs Apply clinical and analytical skills to issues of prevention and population health

58 Contact Information Glenace Edwall, Psy.D., Ph.D., LP, M.P.P. Director, Children s Mental Health and Adult Mental Health Divisions Minnesota Department of Human Services P.O. Box St. Paul, MN glenace.edwall@state.mn.us