10/4/2017. County/FQHC Collaborations to Improve Behavioral Health Continuum of Care. FQHCs in SUD/SMH

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1 County/FQHC Collaborations to Improve Behavioral Health Continuum of Care Allie Budenz, MPA Associate Director of Quality Improvement, CPCA FQHCs in SUD/SMH California has a tri-furcated behavioral health system. Specialty Mental Health services are for moderate to severe clients run by the county Mild to moderate behavioral health services are provided through Medi-Cal managed care plans or their subcontractors (Beacon, Optum) Drug Medi-Cal run by the state, potentially now through the counties under the Drug Medi-Cal Organized Delivery System Waiver (DMC-ODS) FQHC s cannot deny services based on diagnosis or acuity. Figure: Role of FQHCs in the behavioral health delivery system Specialty Mental Health CountytMHPo Mild to Moderate BH Severe MCOs County MHP FQHC Services Determined by statute, paid by MCOs and State DMC State/County Patients often caught in the grey space which lead to billing issues Duplication of services. Audits and investigation challenges. 1

2 SB 323 (Mitchell) Authorize FQHCs and RHCs to elect to enroll as a DMC certified provider or an SMH provider contracted with a specialty mental health plan and provide SMH and DMC services pursuant to the terms of a mutually agreed upon contract. Prohibits the costs associated with those services from being included in the FQHC s or RHC s per visit PPS rate. Separate staff and separate facilities Increase timely access to behavioral health care needs across California and reduce expensive and less effective avenues, such as emergency rooms. Reduce care coordination burden between entities Improved patient centered, integrated patient care Models of Partnership to Improve Consumer Access 1. Contractual Arrangements for County Specialty Mental Health and DMC-ODS Services; SB Creating New Health Center Entities Outside of the FQHC to Provide Specialty Mental Health Services; 3. Bidirectional Co-location with Specialty Mental Health and SUD Partners; and 4. Medication Assisted Treatment for OUD at FQHCs Arrangement 1: Contractual Arrangements for County SMH and DMC-ODS Services 2

3 Arrangement 2: Creating New Entities Outside of the FQHC to Provide SMH/DMC Services FQHC New Entity New provider entity is established and collaborates closely with the FQHC and other local partners to provide mental health and SUD services to individuals and families in the community. The new entity is not an FQHC; it is a separate entity that is owned and governed by the FQHC. Arrangement 3: Bidirectional Co-location with SMH/SUD Partners MH / SUD Provider FQHC FQHC MH / SUD Provider Model 1. Mental health or SUD services offered by a separate provider organization, co located within a FQHC. Model 2. FQHC primary care services colocated within a mental health or SUD provider organization. There is no arrangement for payment between the co locating entities. While the provider organizations share physical space, they remain separate for administrative and reimbursement purposes. This arrangement allows for a bi directional extension of services and the opportunity for greater care coordination without necessitating any payment transaction between the FQHC and the partner organization. Arrangement 4: MAT for OUD MAT in FQHCs: March 2016: 36 CA CHCs receive Substance Abuse Service Expansion Awards July 2017: DHCS Hub and Spoke Services: <$5 million in each of 19 regions September 2017: 150 CA CHCs receive Access Innovations in MH and SUD Services (AIMS) MAT in/out of PPS 3

4 Contact Us Allie Budenz Associate Director of Quality Meaghan McCamman Assistant Director of Policy BUILDING EFFECTIVE RELATIONSHIPS TO IMPROVE CARE: A COUNTY/FQHC COLLABORATIVE Ian Evans, LMFT Alcohol and Drug Administrator Forensic Program Coordinator Yolo County Health and Human Services Agency (HHSA) Sara Gavin, LMFT, LPCC Director of Behavioral Health Services CommuniCare Health Centers (CCHC) 4

5 Why is this Important and Why now? Funding opportunities and legislative push Drug Medi-Cal Organized Delivery System Waiver Senate Bill 323 Federally Qualified Health Centers Stepping Up Initiative Improve our client s lives CommuniCare Health Centers Federally Qualified Health Center Established in 1972 Substance use services have been part of legacy Serves one in every nine Yolo County residents CommuniCare Health Centers 20% of CommuniCare s annual budget is behavioral health/substance use services 27% of FTEs at CommuniCare are behavioral health/substance staff FTE at CommuniCare Primary Care 42% PN 8% Dental 11% Behavioral Health 27% Admin 12% 5

6 Jail/Reentry Probation Dispositional Court Initial Detention First Court Appearance Jail - Pretrial Prison/Reentry Parole Specialty Court 10/4/2017 CommuniCare Health Centers Primary provider of outpatient substance use treatment in the County Primary provider for juvenile justice youth in the County Primary provider for Woodland Joint Unified School District Primary provider of behavioral health/substance use services to CalWORKS families in the County Therapeutic Continuum of Care Connecting People to Community-Based Treatment and Initial Services Law Enforcement Contact with Law Enforcemen t Law Enforcement Jail-based Arrest Outpatient Treatment Intensive Outpatient Treatment Court-based Integrated MH & SU Services Peer Support Services Pretrial Supported Employment Case Management Court-based Jail-based Crisis Services Supportive Housing Psychoph armacology 6

7 CommuniCare Behavioral Health Programs CommuniCare Substance Use Programs Prevention Early Intervention PC1000/Drug Court Schools SBIRT Outpatient Services OSARP Path to Recovery Day Treatment Services Perinatal Day Treatment Residential Detox/MAT services Buprenorphine Vivitrol CalWORKs Davis Mild-Moderate Specialty MH Adult Psychiatry MAT Family/Couples Latino Outreach Nav Center- new! West Sacramento Mild-Moderate Specialty MH Adult Psychiatry Child Psychiatry MAT Family/Couples Outpatient SUD Perinatal Day Treatment Supervised Visitation Dual Diagnosis TFCBT Parenting Latino Outreach PC1000 Woodland In Home Schools Mild-Moderate Specialty MH Adult Psychiatry Child Psychiatry MAT Family/Couples Outpatient SUD Supervised Visitation Dual Diagnosis TFCBT Parenting Latino Outreach PC1000 Wraparound Specialty MH MAT FFT Supervised Visitation Parenting Latino Outreach Assessment Groups Individual therapy TFCBT Mild-Moderate Youth Specialty MH Juvenile Hall Assessments Group Therapy Day Reporting Centers Mild- Moderate Outpatient SUD Imbedded at County Assessment Individual Groups Family/Couples Supervised Visitation 7

8 CommuniCare Funding Streams for Behavioral Health Services Drug Medi-Cal Probation Perinatal Medi-Cal Self Pay/Sliding Scale Perinatal State block grant School Districts Beacon/Wrap Partnership- Expanded benefit CalWorks Other County funds Child Welfare Services HRSA (MAT) SAMHSA grants MHSA County Private Insurance Sacramento Office of Education Department of Education EPSDT- Specialty mental health Medi- Cal Schools Services 8% MAT Services 14% Child Welfare Services 20% Partnership SAT 1% IBH 18% Dept. of Education 1% Probation 7% EPSDT 11% CalWORKS Services 6% MHSA 5% Medi-Cal SUD 3% SAPT 6% SBIRT/Warm Hand-offs Challenges CommuniCare providers call behavioral health front desk and warm hand-off initiated Substance use screening/brief intervention and referral to treatment all under one roof Outpatient substance use services Youth substance use services Medication assisted treatment (vivitrol/suboxone) 8

9 Perinatal Day Treatment Intensive day program (3 hours/day, 5 days/week) Pregnant and parenting women Gender Specific Gender-specific intervention, individual and group therapy Evidenced based practices Transport to/from Mom Trauma- Informe d Free of cost transportation Child development program Individu al and group therapy Parentin g and childcare Specialty Youth Mental Health BH Programs Trauma Focused Cognitive Behavioral Therapy Functional Family Therapy Wraparound Other Evidence Based Practices Seeking Safety Trauma Focused Cognitive Behavioral Therapy Dialectical Behavioral Therapy Rational Emotive Behavior Therapy Moral Reconation Therapy Functional Family Therapy Illness Management and Recovery In-Home Cognitive Behavioral Motivational Interviewing Therapy (Moving Beyond Cognitive Behavioral Interventions Depression) for Substance Abuse 9

10 How Did We Get Here? Yolo County contracts all substance use services out to community-based organizations Yolo County contracted out Youth EPSDT Services in: Starting in 1999, all Children s Services contracted out over the next several years CommuniCare historically offered substance use services within Yolo County Request for proposals in 2014 How did CommuniCare get there? Passion for serving underserved/stigmatized Social determinants of health Developed relationship with county, schools, child welfare services, and community Hired clinicians who had experience with substance use (or desire to learn) CommuniCare Outcomes Perception of Access CommuniCare asked clients about the perception regarding access to services Examples: Convenient locations/ Frequency of Services/ Staff promptly returned calls 84% of clients reported satisfaction 3% of clients reported dissatisfaction 13% of clients were neutral Disagree Strongly 3% Disagree Neutral 1% 16% Agree 33% Strongly Agree 47% 30 10

11 Current Outcomes - Access Day Reporting Center Time to Assessment 0% 0-14 Days 100% CalWORKS Time to Assessment Days 6-14 Days 1% 1-5 Days 52% 47% Perinatal Day Treatment Time to Assessment 8-14 Days 8% Days Days 21% 71% CommuniCare Outcomes Perception of Improvement CommuniCare asked clients about the perception regarding improved outcomes, as a direct result of services received Examples: Effectively deal with daily problems/do better in social situations/improved housing situation 80% of clients reported satisfaction 4% of clients reported dissatisfaction 14% of clients were neutral Disagr Strong ee ly Neutr 3% Disagr Strong al ee ly Agree 14% 1% Agree 33% 47% 32 CommuniCare Outcomes Perception of Functioning CommuniCare asked clients about the perception regarding functioning, as a direct result of services received Examples: Able to take care of my needs/ Better able to handle things when they go wrong/ Doing things that are more meaningful to me Disagre Strongly 82% of clients reported satisfaction e Disagre e 4% of clients reported dissatisfaction 14% of clients were neutral Neutral 2% 14% Agree 34% 2% Strongly Agree 48% 33 11

12 CommuniCare Outcomes Incarceration (November 2016 April 2017) CommuniCare began tracking incarceration data in November 2016 Average days incarcerated prior to treatment was compared to 0.13 days during treatment 99.95% reduction in days incarcerated CommuniCare will continue to track post graduation to determine whether gains are sustained Prior to Treatement During Treatment Days Incarcerated Looking Ahead CommuniCare DHCS Grant CA H&SS Model Intensive Outpatient Certified Look to expand services under the DMC-ODS waiver Navigation Center Looking Ahead - County RFP all substance use disorder contracts in FY Continue to support CommuniCare efforts DMC ODS Requirements Regular review of data and engagement in quality improvement efforts as needed Increased collaboration/communication between Agency and Providers to ensure availability of comprehensive performance data 12

13 Why Partner with a County? Opportunity Hiring flexibility Expand services to meet the needs of your clients outside of the prospective payment system rate Provides flexibility and diversified funding streams Better for patients, services under one roof Improve health outcomes Agency/non-profit flexibility Why Partner with an FQHC? FQHC fundamental concepts Health care as a right Community control Population-based care Universal access and quality Local economic development Community action Cultural competency Relationship Strength Ongoing communication and problem solving Mutual trust Collaborating whenever appropriate Accessibility Willingness to merge cultures 13

14 Collaborative Meetings Provider Stakeholder Workgroup Monthly Substance Use Disorder Provider Meetings Monthly CommuniCare/Probation/Health and Human Services Meeting Quarterly Medical Directors Collaborative Public Health Collaboratives Community Corrections Partnership MHSA Stakeholder meeting Cultural Competency Committee Quality Improvement Committee Homeless Multidisciplinary Team Meetings Health Council Stepping Up Intercept subcommittees System Utilization Review Upcoming with Drug MediCal ODS system Know Your Partners! Questions? Ian Evans, LMFT Alcohol and Drug Administrator Forensic Program Coordinator Yolo County Health and Human Services Agency (HHSA) (530) Sara Gavin, LMFT, LPCC Director of Behavioral Health Services CommuniCare Health Centers (CCHC) (530)

15 blue shield of california foundation We believe all Californians can be healthy and safe Our mission: Improve the lives of all Californians, particularly the underserved, by making health care accessible, effective, and affordable, and by ending domestic violence. About us: Total Grantmaking since 2002: Over $383 million 2016 Grantmaking: $29.6 million, 422 grants Independent Board: 9 Trustees, 5 from Blue Shield of California Total Number of Staff: 24 Source of Funding: Annual contributions from Blue Shield of California Advancing Behavioral Health Integration through Community Collaboration Presenter: Rachel Wick Senior Program Officer, Health Care and Coverage blueshieldcafoundation.org rachel.wick@blueshieldcafoundation.org California Primary Care Association Conference October 12, 2017 slide 44 the need and the treatment gap (2014) Needed to talk about a behavioral health issue (among low-income Californians) If needed to talk, actually spoke with a healthcare professional (among low-income Californians) slide 45 15

16 interest vs. availability (2014) barriers to seeking help (2014) Percent saying each item is a reason for not speaking with a healthcare professional about behavioral health issues (among low-income Californians) slide 47 many policy opportunities March 2010 January 2014 July 2015 December 2015 Affordable Care Act (ACA) signed into law Medi-Cal mental health benefits expanded 1915(B) Waiver for specialty managed county mental health plans extended Section 1115 Medi-Cal 2020 waiver approved October 2008 Mental Health Parity and Addiction Equity Act (MHPAE) signed into law November 2010 Section 1115 Medi-Cal Bridge to Reform Waiver Approved April 2014 Cal MediConnect Implemented September 2015 Counties plan to implement DMC-ODS pilot September counties DMC-ODS implementation plans approved Federal Californi a slide 48 16

17 a no wrong door system of care? Who pays? Medi-Cal Managed care plans Managed Behavioral Health Care Organizations County Mental Health Plans Mild to Moderate Serious Community health centers School s Hospitals Substance use treatment providers Mental health providers Who provides? slide 49 integration grantmaking approach Community Engagement and Equity Local Collaboration & Care Integration State Policy & Financing Opportunities Align accountability and measurement page 50 working together to understand access gaps Santa Cruz Integrated Behavioral Health Action Coalition slide 51 17

18 working together to address access gaps Merced County Whole Health Partnership slide 52 working together to coordinate care slide 53 working together to expand the workforce Sonoma County and Redwood Community Health Coalition slide 54 18

19 working together to expand the workforce Alameda County and Community Health Center Network LINK TO VIDEO slide 55 whole person care No wrong door; timely access Trust in providers and systems Quality care slide 56 what could your health center --and its patients-- gain from a partnership with county? what could county gain from a partnership with you? where could you start? how might it evolve? slide 57 blueshieldcafoundation.org 19

20 thank you! tools, resources and reports at stories of community collaboration and leadership blueshieldcafoundation.org slide 58 20