Primary Care/Behavioral Health INTEGRATION. Neal Adams, MD MPH Deputy Director California Institute for Mental Health

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1 Primary Care/Behavioral Health INTEGRATION Neal Adams, MD MPH Deputy Director California Institute for Mental Health

2 Why Integrate BH & PC? BH disorder burden is great BH and physical health problems are interwoven Treatment gap for BH conditions is enormous PC settings for BH services enhance access

3 California Context: Dual Eligibles One third live in L.A. County Two thirds are age 65 and older Roughly 14% of Medi-Cal population but are 25% of cost 20% enrolled in Medi-Cal managed care $7.6 billion in state Medi-Cal costs ($20 billion with Medicare) $3.2 billion in LTC costs = 75% of Medi-Cal total LTC spending 52% have a psychiatric disability

4 Proposed Demonstration Model 10 Counties proposed in 2013 Current State Authority for Four Counties: Los Angeles (370,000) Health Net and LA Care Orange (71,000) CalOptima San Diego (75,000) Molina, Care 1st, Community Health Group, Health Net San Mateo (15,000) Health Plan of San Mateo Six Proposed, pending further authority and readiness: Alameda, Sacramento, Contra Costa, Santa Clara, San Bernardino, Riverside

5 Demonstration Goals 1. Coordinate state & federal benefits; access to care across care settings; improve continuity of care; and use a person-centered approach. 2. Maximize the ability of beneficiaries to remain in their homes/communities with appropriate services & supports in lieu of institutional care. 3. Increase the availability and access to home- and communitybased alternatives. 4. Preserve/enhance ability of consumers to self-direct their care and receive high quality care. 5. Optimize the use of Medicare, Medi-Cal and other State/County resources.

Overarching Recommendation 1 Health care for general, mental, and substance use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and

6 Overarching Recommendation 1 Health care for general, mental, and substance use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body. Overarching Recommendation 2 The aims, rules, and strategies for redesign set forth in Crossing the Quality Chasm should be applied throughout M/SU health care on a dayto day operational basis but tailored to reflect the characteristics that distinguish care for these problems and illnesses from general health care.

7 Issues and Challenges Improved care coordination and integration is a critical concern. shame of the 50s was institutionalization the shame of today is patients with SMI dying 25 years early because of co occurring illness This is supported both in literature and by what observed in daily practice and systems operations. Critical questions include: How do we improve access to physical health care for those with co occurring mental and physical illness? What is the motivation for primary care physicians to continue seeing mental health clients?

8 Mental Health's View There is often the impression of once a patient enters the mental health system, we own the patient and we have not been able to convey that, at a certain point, care needs to be transferred. This is not conveyed to patients or staff no point of transfer is part of the mental health treatment culture. In addition, patients are apprehensive because they have never been told that exiting the system is an option.

10 The Four Quadrant Model Addresses the needs of the population and appropriate targeting of services Organizes our understanding of the potential approaches there is no single method of integration Clarifies the respective roles and locus of PCP and BH providers, depending on levels of severity and co-morbidity Identifies system tools and clinician skill and knowledge sets needed and how they vary by subpopulation Developed by National Council for Community Behavioral Healthcare

11 The Four Quadrant Clinical Integration Model Quadrant II BH PH Quadrant IV BH PH Low High Behavioral Health (MH/SA) Risk/Complexity Low Behavioral health clinician/case manager w/ responsibility for coordination w/ PCP PCP (with standard screening tools and guidelines) Outstationed medical nurse practitioner/physician at behavioral health site Specialty behavioral health Residential behavioral health Crisis/ED Behavioral health inpatient Other community supports PCP (with standard screening tools and guidelines) Outstationed medical nurse practitioner/physician at behavioral health site Nurse care manager at behavioral health site Behavioral health clinician/case manager External care manager Specialty medical/surgical Specialty behavioral health Residential behavioral health Crisis/ ED Behavioral health and medical/surgical inpatient Other community supports Persons with serious mental illnesses could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration. Quadrant I BH PH PCP (with standard screening tools and behavioral health practice guidelines) PCP-based behavioral health consultant/care manager Psychiatric consultation Physical Health Risk/Complexity Quadrant III BH PH PCP (with standard screening tools and behavioral health practice guidelines) PCP-based behavioral health consultant/care manager (or in specific specialties) Specialty medical/surgical Psychiatric consultation ED Medical/surgical inpatient Nursing home/home based care Other community supports High

12 Improved Quality Outcomes and Lower Cost

13 Vision: Integrated Model of Care Initial health risk assessments Person-Centered shared care plans Care coordination teams Health plans responsible for providing seamless access to a full continuum of services Strong consumer rights Joint state-federal oversight

14 Successful Integration is a CHALLENGE Common source of frustration for both consumers and providers includes lack of: interaction, access and appropriate referral co management of conditions that require integrated/coordinated care outcomes As well as: operational inefficiencies

15 Barriers to Integration BH & PC providers operate in separate silos Information sharing rare & difficult Economic crises lead to budget cutbacks; inertia mitigates against system reform. Workforce capacity and competency limitations Financial (revenue/billing) impediments Parity for BH not fully implemented/resolved

16 Bi-Directional Integrated Care

17 The Continuum of Integration Model Separate space & mission Desirability Attributes Traditional BH Specialty Model 1:1 Referral Preferred + relationship provider/some information exchange Co-location On-site BH unit/ ++ separate team Collaborative care On On-site/shared cases w/ BH specialist Integrated care PC Team Member +++++

18 Levels of Integration Minimal Collaboration Continuum at a distance on-site partly integrated fully integrated

19 NZ Stepped Care 20

20 Mental Health Integration Treatment Cascade Model: Transformation of Delivery and Cost at Intermountain Healthcare Clinically Informed Consensus Guidelines for Improved Integration of Primary Care and Mental Health Services in California

21 Collaborative Care MH/SU Continuum for the Safety Net Population Mild MH/SU Complexity Moderate MH/SU Complexity Primary Care Specialty MH Serious MH/SU Complexity Serious and Persistent MH/SU Complexity

23 Model 1: Improving Collaboration Between Separate Providers Minimal BH & PC providers work in separate facilities, have separate systems, and communicate sporadically Private practices; settings w/ active referral linkages Q 1 & 3 (Low BH needs)

24 Model 2: Medical Provided BH Care Basic at a distance Providers in separate systems at separate sites, but engage in periodic communication about shared patients Private practices; settings w/ active referral linkages Q 1 & 3 (Low BH needs)

25 Model 3: Co-Location Basic on-site Providers have separate systems but share same facility, allowing for more communication HMO settings; PC clinics that employ therapists or care managers Q 1, 2, & 3

26 Model 4: Disease Management Close, partly integrated Share same facility, have some systems in common, e.g., scheduling or records; physical proximity allows for regular faceto-face communication HMO settings; PC clinics that employ therapists or care managers Q 1, 2, & 3

27 Model 5: Reverse Co-Location Close, partly integrated Share same facility, have some systems in common, e.g., scheduling or records; physical proximity allows for regular faceto-face communication HMO settings; PC clinics that employ therapists or care managers Q 2 & 4 (High BH needs)

28 Model 6: Unified PC & BH Close, fully integrated BH & PC providers part of same team Large practices and medical systems Q 1-4

29 Model 7: Collaborative System of Care Close, partly or fully integrated Specialty BH services integrated w/ PC services; may be partly or fully integrated depending on degree of collaboration HMO settings; PC clinics that employ therapists or care managers Q 2 & 4 (High BH needs)

30 Lack of Clinical Consensus When is it appropriate for someone to be referred to specialty mental healthcare? What level of severity and complexity of mental health needs should be cared for in the primary care setting? When should someone receiving specialty mental health care be referred back to primary care for ongoing treatment and monitoring? Clinically Informed Consensus Guidelines for Improved Integration of Primary Care and Mental Health Services in California

32 1. Continuum of Care Each community should establish a continuum of collaborative care across primary care and mental health with mechanisms for stepped care back and forth across the continuum. The continuum should range from basic care of mental health needs by the primary care provider to specialty mental health services traditionally provided by the public mental health system. The continuum should include multiple levels of care with increasing availability of a range of mental health specialist in the primary care setting that are responsive to the changing complexity and severity of patients needs.

33 1. Continuum of Care Each community should establish a continuum of collaborative care across primary care and mental health with mechanisms for stepped care back and forth across the continuum. The continuum should range from basic care of mental health needs by the primary care provider to specialty mental health services traditionally provided by the public mental health system. The continuum should include multiple levels of care with increasing availability of a range of mental health specialist in the primary care setting that are responsive to the changing complexity and severity of patients needs.

34 1. Continuum of Care Each community should establish a continuum of collaborative care across primary care and mental health with mechanisms for stepped care back and forth across the continuum. The continuum should range from basic care of mental health needs by the primary care provider to specialty mental health services traditionally provided by the public mental health system. The continuum should include multiple levels of care with increasing availability of a range of mental health specialist in the primary care setting that are responsive to the changing complexity and severity of patients needs.

35 2. Care Settings Primary care, with appropriate staffing and resources, is usually the most appropriate setting for the large majority of mental health care when mental health specialists are integrated into the primary care team and service delivery system. Specialty mental health is the appropriate setting for individuals who require intensive case management, psychosocial rehabilitation, inpatient, crisis services and residential psychiatric care.

36 2. Care Settings Primary care, with appropriate staffing and resources, is usually the most appropriate setting for the large majority of mental health care when mental health specialists are integrated into the primary care team and service delivery system. Specialty mental health is the appropriate setting for individuals who require intensive case management, psychosocial rehabilitation, inpatient, crisis services and residential psychiatric care.

37 3. Clinical Care Guidelines There are many available guidelines for providing mental health care in the primary care setting for a range of diagnoses/conditions including not only depression, but also schizophrenia, bi polar disorder, attentions deficit disorder and many others. Guidelines for the general scope of medical care to be provided in the specialty mental health setting (e.g. treatment of simple medical conditions, laboratory screening/monitoring, preventive services, etc) should be adopted or created Clinically Informed Consensus Guidelines for Improved Integration of Primary Care and Mental Health Services in California

38 3. Clinical Care Guidelines There are many available guidelines for providing mental health care in the primary care setting for a range of diagnoses/conditions including not only depression, but also schizophrenia, bi polar disorder, attentions deficit disorder and many others. Guidelines for the general scope of medical care to be provided in the specialty mental health setting (e.g. treatment of simple medical conditions, laboratory screening/monitoring, preventive services, etc) should be adopted or created Clinically Informed Consensus Guidelines for Improved Integration of Primary Care and Mental Health Services in California

39 3. Clinical Care Guidelines Each community (e.g. county) should select and consistently use one of the existing guideline sets or locally agree on what guidelines they will use. Determination of the appropriate level or step of care should be made based on the severity and complexity of the individual s needs not on the basis of diagnosis or specific pharmacotherapy.

40 3. Clinical Care Guidelines Each community (e.g. county) should select and consistently use one of the existing guideline sets or locally agree on what guidelines they will use. Determination of the appropriate level or step of care should be made based on the severity and complexity of the individual s needs not on the basis of diagnosis or specific pharmacotherapy.

41 4. Bi-Directional Transitions The determination of the appropriate level of step of care should anticipate changes in need over time and the bidirectional transition of patients between levels/steps. There is general agreement that the level of functional impairment, more than symptoms, complexity of care or diagnosis, should determine the need for specialty mental health services outside of the primary care setting. Transitions between primary care and specialty mental health are best facilitated by the mental health specialists in the primary care setting based on local conditions, resources and relationships.

42 4. Bi-Directional Transitions The determination of the appropriate level of step of care should anticipate changes in need over time and the bidirectional transition of patients between levels/steps. There is general agreement that the level of functional impairment, more than symptoms, complexity of care or diagnosis, should determine the need for specialty mental health services outside of the primary care setting. Transitions between primary care and specialty mental health are best facilitated by the mental health specialists in the primary care setting based on local conditions, resources and relationships.

43 4. Bi-Directional Transitions The determination of the appropriate level of step of care should anticipate changes in need over time and the bidirectional transition of patients between levels/steps. There is general agreement that the level of functional impairment, more than symptoms, complexity of care or diagnosis, should determine the need for specialty mental health services outside of the primary care setting. Transitions between primary care and specialty mental health are best facilitated by the mental health specialists in the primary care setting based on local conditions, resources and relationships.

44 4. Bi-Directional Transitions Establishing and maintaining effective communication and ongoing relationships between administrators and clinicians in primary care and mental health is often a key ingredient of success. This can be accomplished by the identification of a change champion within systems and/or communities. Developing shared access to clinical data can facilitate transitions Clinically Informed Consensus Guidelines for Improved Integration of Primary Care and Mental Health Services in California

45 4. Bi-Directional Transitions Establishing and maintaining effective communication and ongoing relationships between administrators and clinicians in primary care and mental health is often a key ingredient of success. This can be accomplished by the identification of a change champion within systems and/or communities. Developing shared access to clinical data can facilitate transitions Clinically Informed Consensus Guidelines for Improved Integration of Primary Care and Mental Health Services in California

46 4. Bi-Directional Transitions Establishing and maintaining effective communication and ongoing relationships between administrators and clinicians in primary care and mental health is often a key ingredient of success. This can be accomplished by the identification of a change champion within systems and/or communities. Developing shared access to clinical data can facilitate transitions Clinically Informed Consensus Guidelines for Improved Integration of Primary Care and Mental Health Services in California

47 5. Determining Levels of Care There is a need for a standardized objective method or approach for determining the level of complexity/severity and/or functional impairment to assist in the determination of the most appropriate level of care. However, at this time there is not general agreement within or across service systems about what that method should be used. There should be explicit agreement on referral/acceptance criteria for facilitating integration of patient care across primary care and specialty mental health systems, based upon a level of care instrument that can be easily applied in all settings. Ease of use of any method must be balanced with reliability and validity. Candidate measures/instruments/tools that show promise

48 5. Determining Levels of Care There is a need for a standardized objective method or approach for determining the level of complexity/severity and/or functional impairment to assist in the determination of the most appropriate level of care. However, at this time there is not general agreement within or across service systems about what that method should be used. There should be explicit agreement on referral/acceptance criteria for facilitating integration of patient care across primary care and specialty mental health systems, based upon a level of care instrument that can be easily applied in all settings. Ease of use of any method must be balanced with reliability and validity. Candidate measures/instruments/tools that show promise

49 5. Determining Levels of Care There is a need for a standardized objective method or approach for determining the level of complexity/severity and/or functional impairment to assist in the determination of the most appropriate level of care. However, at this time there is not general agreement within or across service systems about what that method should be used. There should be explicit agreement on referral/acceptance criteria for facilitating integration of patient care across primary care and specialty mental health systems, based upon a level of care instrument that can be easily applied in all settings. Ease of use of any method must be balanced with reliability and validity. Candidate measures/instruments/tools that show promise

50 5. Determining Levels of Care There is a need for a standardized objective method or approach for determining the level of complexity/severity and/or functional impairment to assist in the determination of the most appropriate level of care. However, at this time there is not general agreement within or across service systems about what that method should be used. There should be explicit agreement on referral/acceptance criteria for facilitating integration of patient care across primary care and specialty mental health systems, based upon a level of care instrument that can be easily applied in all settings. Ease of use of any method must be balanced with reliability and validity. Candidate measures/instruments/tools that show promise

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