9/13/2017. Integrated Behavioral Health (IBH) MHCF Focus Areas. A little about myself

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1 Integrated Behavioral Health (IBH) (406) MHCF Focus Areas Three focus areas: 1. Behavioral Health o Integrated behavioral health initiative o Strengthening the Substance Use Disorder System 2. American Indian Health 3. Partnerships for Better Health Website map and description of prior grantees A little about myself Eastern Montana Roots Background Gratitude 1

2 Screening Questions Who s in the room? Level and comfort with IBH? Main reasons for being here? Goals for Today 1. Review Behavioral Health Challenges in MT and need for IBH 2. Examination of key IBH elements and how this translates to your settings Explore how to plan, enhance, or implement IBH into your setting Analysis of funding opportunities and financing models for IBH Review Clinical models and frameworks for delivery of IBH 3. Explore how current state and federal initiatives (PCMH, CPC+, etc.) relate to IBH 4. Explore current and future delivery of IBH in Montana 5. Review case examples from two different Montana settings with early outcomes explored. Goals for today in simple terms 1. If you are not planning or implementing IBH, hopefully you re very excited or very uncomfortable. 2. If you are planning or implementing IBH, hopefully you re very excited or very uncomfortable. 3. You know what options and resources are available to start or improve. 2

3 If you have come to help me, you are wasting your time. If you have come because your liberation is bound up with mine, then let us work together. Lilla Watson The consequences of untreated behavioral health and chronic disease issues are devastating Montana s suicide rate is consistently double that of the US as a whole. Montana has the second highest rate of alcohol related deaths in the US. Source: Montana Vital Statistics. Montana s Behavioral Health Workforce All of Montana s Counties except Yellowstone are HRSA designated Healthcare Professional Shortage Areas for Mental health Only 25% of Montana s mental health care professional need is met (bottom 5 of all states) 78% of Montana s behavioral health workforce resides in only 8 of our 56 counties Extreme shortage of prescribers (long waiting lists for psychiatrists and Psychiatric Nurse Practitioners) Source: Kaiser Foundation, MCCB Workforce Map, HRSA 3

4 There are 599 Licensed Addiction Counselors (LACs) in the state. 18 counties have no LACs. There are 708 Licensed Clinical Social Workers (LCSWs) in the state 15 counties have zero LCSWs Behavioral Health is everyone s business Only 20% of patients started on anti depressant in usual primary care show substantial clinical improvements % of patients need at least one change in treatment. Most patients with common mental health conditions like depression and anxiety are treated in PCP settings. 70% of all antidepressant prescriptions are written by a PCP. Specialized Providers for Behavioral Health are not enough and there is not enough of them. 93% of Montanan s with substance use disorder are not receiving treatment 10% of ER hospital claims in MT had SUD diagnosis. Mental Health or substance abuse listed as one of top concerns for all 56 counties. Burnout and wellness of workforce 4

5 What is Driving the Movement for Integrated Behavioral Health? The 53 year lifespan for people with Serious Mental Illness is comparable with Sub Saharan Africa NASMHPD 2006 Study: Morbidity and Morality in People with Serious Mental Illness 5

Biggest Driver for IBH What is IBH IBH= Good Care Reconnection of the Head and the Body Behavioral Health Physical Health Healthcare Integration is just

6 Biggest Driver for IBH What is IBH IBH= Good Care Reconnection of the Head and the Body Behavioral Health Physical Health Healthcare Integration is just rediscovering the Neck Partners in Health Primary Care/County Mental Health Collaboration Toolkit, Integrated Behavioral Health Project (IBHP), October

Integration Terms Some Integrated Health Term Sources: Research Literature Collaborative Care Policy Health Home Accrediting Bodies Patient Centered Medical Home Performance Based: CPC+ Demystifying

7 Integration Terms Some Integrated Health Term Sources: Research Literature Collaborative Care Policy Health Home Accrediting Bodies Patient Centered Medical Home Performance Based: CPC+ Demystifying IBH Defining Integrated Behavioral Health A practice team of primary care and behavioral health clinicians working together with patients and families, using a systematic and cost effective approach to provide patient centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress related physical symptoms, and ineffective patterns of health care utilization. Source: Peek CJ. The National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus [AHRQ Publication No. 13 IP001 EF] Rockville, MD: Agency for Healthcare Research and Quality;

Need for IBH The concept of IBH aims to shift clinicians & managers to thinking more about the 'patient journey IBH aims to have: the right people, in the right order, doing the right thing, at the

8 Need for IBH The concept of IBH aims to shift clinicians & managers to thinking more about the 'patient journey IBH aims to have: the right people, in the right order, doing the right thing, at the right time, with the right outcomes, & all with attention to the patient experience. Source: WHO, The Four Quadrant Model Conceptual framework for designing integrated programs. Offers guidance to determine which setting can provide the most appropriate care Defines what care people need and where care is best delivered based on the severity of the person s behavioral health and physical health needs. Describes the need for a bi directional approach, addressing the need for primary care services in behavioral health and visa versa. 8

9 Standard Framework for IBH Referral Co-Located Integrated Key Element: Communication Level 1 Level 2 Minimal Collaboration Basic Collaboration at a Distance Key Element: Physical Proximity Level 3 Level 4 Basic Collaboration Close Collaboration On-Site On-Site with Some System Integration Key Element: Practice Change Level 5 Level 6 Close Collaboration Full Collaboration in a Approaching an Transformed/ Merged Integrated Practice Integrated Practice Behavioral health, primary care and other healthcare providers work: In separate facilities. In separate facilities. In same facility In same space In same space In same space not same within the same within the same within the same offices/clinic facility but facility regular facility, sharing (e.g., separate separate work teaming & cross all practice waiting areas). flows/teams. staffing. space (one clinic/one team). Standard Framework for Integration Level 1 Minimal Collaboration Level 2 Basic Collaboration at a Distance Level 3 Basic Collaboration On-Site Separate systems Communicate about cases only rarely and under compelling circumstances Separate systems Communicate periodically about shared patients Separate systems Communicate regularly about shared patients, by phone or e- mail Communicate, driven by provider Communicate, driven by specific need patient issues Collaborate, driven by need for each other s services and more reliable referral May never meet in person May meet as part of larger community Meet occasionally to discuss cases due to close proximity Have limited understanding of each other s roles Appreciate each other s roles as Feel part of a larger yet illdefined resources team Standard Framework for Integration Level 4 Close Collaboration On-Site with Some System Integration Share some systems, like scheduling or medical records Level 5 Close Collaboration Approaching an Integrated Practice Actively seek system solutions together or develop work- a- rounds Level 6 Full Collaboration in a Transformed/ Merged Integrated Practice Have resolved most or all system issues, functioning as one integrated system Communicate in person as needed Collaborate, driven by need for consultation and coordinated plans for difficult patients Have regular face-to-face interactions about some patients Have a basic understanding of roles and culture Communicate frequently in person Collaborate, driven by desire to be a member of the care team Have regular team meetings to discuss overall patient care and specific patient issues Have an in-depth understanding of roles and culture Communicate consistently at the system, team and individual levels Collaborate, driven by shared concept of team care Have formal and informal meetings to support integrated model of care Have roles and cultures that blur or blend 9

10 Value Based Approaches Comprehensive Primary Care Plus Patient Centered Medical Homes Accountable Care Organizations Collaborative Care Codes Others?... Name of Program Health improvement features Cost savings mechanism Patient Centered Medical Home (PCMH) Comprehensive care: Coordinated care: Accessible services: Quality and Safety: Various models exist Comprehensive Primary Care Plus (CPC+) Accountable Care Organization (RACO) Comprehensive care: Patient centered care: Coordinated care: Accessible services: Quality and Safety: Analytical system: Strong referral system: Consortium of Providers: Accountability: Coordinated care: Continuous quality improvement: Care management fee (CMF): Prospective (PBPM) payment for CPC+ Medicare beneficiaries to cover care management (R3,R9) 3,9 Performance based incentive payment: Prospective (PBPM) payment for CPC+ Medicare beneficiaries to incentivize quality healthcare delivery (R3,R9) 3,9 Comprehensive primary care payment: Prospective payment of a percentage (10% 65%) of the expected E&M payment for Medicare patients Shared Savings Program: Rewards ACOs that lower their health care costs while meeting CMS quality performance standards by sharing 50 60% of the generated savings Perspectives on Care Coordination Patient & Family ask How easy is it for me to get the care I/my loved one needs? Healthcare Provider asks How easy is it for me to do my work? System Representatives ask How easy is it for me to know care is effective & efficient? Source: McDonald KM, Schultz E, Albin L, Pineda N, Lonhart J, Sundaram V, Smith Spangler C,Brustrom J, and Malcolm E. Care Coordination Atlas Version 3 (Prepared by Stanford University under subcontract to Battelle on Contract No ). AHRQ Publication No EF. Rockville, MD: Agency for Healthcare Research and Quality. November

11 Isn t Care Coordination Someone s Job? Some agency s do have a position but it is still the responsibility of all. Care Coordination duties should be made explicit in all job descriptions/scope of work/practice documentation. Care Coordination must have target measures. Care Coordination measures must be monitored and brought back into specification if targets are not met using CQI methods. IBH Outcomes Benefits of Integration Research clearly highlights benefits to patients who receive care under integrated behavioral health models. Positive return on investment Reductions in hospital stays Improve health outcomes Reduced healthcare costs 11

IBH works Integrated Care can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings, and they provide a robust clinical and policy

12 IBH works Integrated Care can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings, and they provide a robust clinical and policy framework for care integration. Source: Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, & Behavioral Health Care Settings: Systematic Review and Meta Analysis. Am J Psychiatry 2012;169: Over 30 RCT s showing IH improves health outcomes. See: Blount: Patients and Providers Like IBH Approaches Older adults reported greater satisfaction with mental health services integrated in primary care settings than through enhanced referrals to specialty mental health and substance abuse clinics. Patient engagement helps to drive health literacy and ultimately patient ownership /responsibility for health behavior change. In the new marketplace the patient has more choice about who to see, so customer satisfaction matters Providers report greater satisfaction, ability, continuity, quality etc. Source: Chen H, Coakley EH, Cheal K, et al. (2006). Satisfaction with mental health services in older primary care patients. Am J Geriatr Psychiatry. Apr;14(4): Outcomes: Reducing Hospitalization Primary Care Health Homes CMHC Healthcare Homes Source: Parks, J See: 12

IBH in Montana Types of Healthcare Sites Responding to

Community Mental Health Center and Substance Use

health center 25% Community Mental Health Center 22%

Indian Clinic or Tribal Clinic 5% Rural Health Clinic,

25% IBH landscape in MT Self reported level of

Sites, 2015 [CATEGORY NAME] [PERCENTAGE] Minimal 29% Co

13 IBH in Montana Types of Healthcare Sites Responding to Baseline Integration Assessment Dually Licensed Community Mental Health Center and Substance Use Disorder Treatment Program 16% Federally qualified health center 25% Community Mental Health Center 22% Substance Use Disorder (SUD) Treatment Program 7% Urban Indian Clinic or Tribal Clinic 5% Rural Health Clinic, Hospital Affiliated Clinic or other Private Primary Care 25% IBH landscape in MT Self reported level of behavioral health integration at Montana Healthcare Sites, 2015 [CATEGORY NAME] [PERCENTAGE] Minimal 29% Co Location of behavioral and primary care services 12% Integration coordinated with outside agencies 28% 13

14 MHCF Integrated Behavioral Health Initiative Summary Grant Opportunities: Integrated Behavioral Health Initiative (In 2nd year of initiative). One Year Planning Grants for up to $50,000 Implementation Grants (invited) for up to $ 150,000 Training and Technical Assistance with National Council for Behavioral Health Webinars, Coaching Calls, Learning Communities, Steering Committees Revenue and Business Planning core to assistance Clinical Model, IBH elements, and levels of integration Substance Use Disorders part of IBH IBH Grantees by Region & Facility WESTERN 9 Grantees NORTH CENTRAL 5 Grantees NORTH EASTERN 3 Grantees STATEWIDE 2 Grantees FACILITIES 3 BH Providers 3 County 3 FQHC 4 Health Dept. 11 Hospital 1 Psych. Hospital 2 Student Health Center 2 University Dept. SOUTH CENTRAL 9 Grantees EASTERN 1 Grantees MHCF Integrated Behavioral Health Initiative Summary Metrics and Outcomes: Steering Committee Developed and Convening IBH Core elements document Planning and Implementation grantee metrics developed Infrastructure: webinars, learning communities, listserv, steering committee, financing Sheets being finalized. Proforma and Revenue Cycle 14

15 Mental health and SUD screening standards Establish & achieve mental health & substance use disorder screening & treatment services targets 100 Percent Complete (0%, 25%, 75%, 100%) Baseline 6 12 Month Follow up Entity A Entity B Entity D Implement SBIRT Care Pathway 100 Implement Screening, Brief Intervention & Referral to Treatment (SBIRT) care pathway 90 Percent Complete (0%, 25%, 75%, 100%) Baseline 6 12 Month Follow up Entity A Entity B Entity D MHCF Integrated Behavioral Health Initiative Summary Lessons Learned: Executive and Medical Leadership is required not assumed Community Based versus Facility Based IBH SUD is an afterthought and SBIRT is just an acronym Yes, you can actually do this and not lose money 15

16 MHCF Integrated Behavioral Health Initiative Summary Looking Ahead: Investments in IBH education and workforce (Centers of Excellence) Continued alignment with value based approaches (CPC+) Strategic engagement based on region, community, and facility Continue to strengthen IBH foundation and framework for future Don t forget about past grantees. Case Examples Providence Health System: Grant Creek Clinic (Jody Haines) Livingston Health Center: Critical Access Hospital (Bren Lowe) Behavioral Health Integration September

17 Process Recruit and hire LCSW Build EHR components to support behavioral health Staff and provider education Relationship building Reimbursement and data tracking Current State Screening with PHQ 2 PHQ 9 Warm Hand Offs LCSW provider template schedule Average daily scheduled visits Tracking no shows Patient Tracer 17

18 Next Steps ED referrals Standardized F/U with no shows Crisis management and training Community collaboration Increase screening at Primary Care Visits Build consultation model with psychiatry Case conferences A Case Study in Integrated Behavioral Health Grant Creek Family Practice Missoula MT Grant Creek Family Medicine Family Practice X ray; Lab; Walk in clinic; Foster care clinic; Pediatrics; Care Management 9 providers Patient centered care; team based care model = medical home NCQA PCMH Level 3 First NCQA PCMH in state of Montana 9 Providence Level 3 NCQA recognized clinics in region CPC+ 7 Providence clinics participating 18

19 Goals 1. Provide the right care in the right place, and at the right time. Plan developed and implemented for episodic/crisis and longitudinal behavioral health 2. Embed LCSW into clinic setting successfully Serve as an addition to clinic care teams additional resource 3. Enhance patient continuity 4. Reduce stigma of behavioral health by serving patients in their medical home Improve patient outcomes There is no wrong door for behavioral health care Success & Challenges to Date Successes LCSW & care team integration cultural context Clinical care pathways established Example: PHQ2 PHQ9 algorithm Developed, intertwined, and matured a crisis response program to supplement Intra development Cross continuum support, collaboration, management, and oversight Neurobehavioral health service line Urgent Mental Health Psychiatry ED & Crisis Response NBMI (direct admission from PCMH or ED) Telepsychiatry Spine and Pain Clinic (w/ tele option) Success & Challenges to Date, con t Challenges If you build it, they will come. = Access constraints (already!) Physical space limitations Ensuring sustainability Billing/coding efficiencies 19

20 Outcomes to Date October 2016 November 2016 December 2016 January 2017 February 2017 March 2017 April 2017 May 2017 June 2017 July 2017 August 2017 September 2017 ACCESS Clinic % Same Day Appts. 18.8% 21.5% 22.0% 29.5% 22.4% 20.4% Clinic 3rd Next Available 52.5% 42.3% 37.3% 33.0% 35.3% Clinic % No Shows 9.7% 7.1% 6.1% 9.6% 6.6% 8.9% Eden % Same Day Appts. 16.7% 10.9% Eden % No Shows 0.0% 12.3% Eden # of Patient Visits CLINICAL QUALITY Depression Screening 45.0% 48.1% 50.7% 55.2% 59.7% 60.7% UTILIZATION ED Utilization (all) ED Utilization (behavioral dx) PATIENT SATISFACTION MHCF 2017 Funding Opportunities and Beyond We plan to give more than $5 million in 1 2 year grants 2 types of grants: Rapid Response: $10,000 $75,000; 1 step application (Active) Large Grants: $75,000 $150,000; 2 step application (Done) 2018: IBH Models in OB practices/hospitals willing to consider implementing IBH for prenatal/nursery patients. Questions? Scott Malloy, LCSW Senior Program Officer Montana Healthcare Foundation 777 E. Main St., Suite 206 Bozeman, MT (406) info@mthcf.org 20

Request for Proposal. Promoting Integrated Behavioral Health and Primary Care in New Hampshire

Request for Proposal. Promoting Integrated Behavioral Health and Primary Care in New Hampshire One Pillsbury Street, Suite 301 Concord, New Hampshire 03301 603-228-2448 KFirth@endowmentforhealth.org Purpose: 1 P a g e Request for Proposal Promoting Integrated Behavioral Health and Primary Care in