CPCA Behavioral Health Survey 2014 Responses reflect 89 organizations representing more than 500 sites across California Mental Health Services available Mental Health & Substance Use Disorder Services available No Mental Health or Substance Use Disorder Services County Boundary Lines Map reflects only those health centers that responded to the CPCA 2014 Behavioral Health Survey. Not all respondents answered all questions on the survey. Health center identifying information has been removed from the examples. 1 P a g e
Models of Care Integration (N = 80) Models of Care & Service Integration 75% integrate behavioral health services into primary care 45% provide behavioral health services onsite, but separate from primary care 16% provide behavioral health services at a site separate from primary care services 15% provide substance use disorder services at a site separate from primary care services 9% do not provide mental health or substance use disorder services onsite Mental health (MH) services offered onsite include (N = 78): Individual counseling - 95% Traditional therapy (30-50 minute counseling sessions) - 78% Family counseling - 77% Cognitive behavioral therapy - 74% Medication management - 69% Case management services - 65% Psychiatric services for adults - 62% Universal mental health screening for adults - 58% Group counseling - 53% 15 minute behavioral health coaching within primary care physical health visit - 47% Chronic pain management - 44% Classes and workshops - 44% Psychoeducational groups - 41% Support groups - 40% Psychiatric services for children - 38% Universal mental health screening for children - 32% Peer model groups - 19% 25% offered other MH services in addition to those above, including: Additional screening services (Intimate Partner Violence Screening and Intervention, PHQ-2 depression screening, etc.) The Every Child Bright Beginnings Initiative Psychiatry consults for children Crisis management Stepped care Parenting classes Psycho-education courses Support in substance abuse Support in seeking safety Tele-psychiatry School-based and home-based therapy services 2 P a g e
Life rehabilitation Substance Use Disorder (SUD) services offered onsite include (N = 71): Individual therapy - 68% Screening, Brief Intervention, Referral to Treatment (SBIRT) - 61% Medication Assisted Treatment Services - 31% Group treatment - 28% General outpatient services (2-10 hours per week) - 24% Adolescent services - 23% Suboxone clinic - 18% Intensive outpatient services (11 hours per week or more) - 13% Opioid and stimulant outpatient detox - 8% Residential services - 4% 31% offered other SUD services in addition to those above, including: Prescription options for psychotropic medication Referral to inpatient detox and residential treatment Intensive Outpatient Treatment (Matrix Model) Prevention education and support for parents Early and Periodic Screening, Diagnostic and Treatment (EPSDT) for adolescents A pilot program for medication management Narcotic treatment programs (Methadone) Support for seeking safety targeted for persons with mild drug issues and history of trauma Harm reduction counseling Motivational enhancement treatment Methadone maintenance 3 P a g e
Grants and Awards 27% (N = 79) received a Health Resources Services Administration (HRSA) Behavioral Health Integration Grant. Health center awardees are using their grants for expansion activities that include hiring additional staff, integrating SBIRT into primary care, integrating mental health records into the electronic health record (EHR) system, and funding group education. 44% (N = 78) receive Mental Health Services Act (MHSA/Prop 63) funding for behavioral health programs or services. Examples of how this funding is used include: Integrated psychiatry Integrated behavioral health service cultural brokers Targeted integrated care models focused on Latinos, homeless, elderly, friends and families of individuals with mental illness, and populations at-risk of incarceration Peer recovery support programs Implementing the IMPACT Model for teens and adults Providing field capable clinical services to transitional age adults of Asian Pacific heritage Prevention and Early Intervention (PEI) services embedded in senior housing Case management services in supportive housing Subcontracts with community based organizations for an embedded Assertive Community Treatment (ACT) Team to serve homeless adults with severe mental illness (SMI) Medical case management and psychiatry services targeting homeless seniors with SMI Funding for Triple P (Positive Parenting Program) classes 19% (N = 75) co-locate county specialty mental health services at one or more of their primary care sites. Examples include co-location to provide services such as: Case management Parent support groups Specialty mental health outpatient services Private mental health providers (each have a county contract) A county-funded, non-profit Latino Mental Health community based organization out-stationed at the clinic site Children's Specialty Mental Health Services (EPSDT) Onsite nurse intake with a county liaison nurse and nurse practitioner Substance abuse provider intake and group sessions 4 P a g e
Operations and Billing Managed Care Plan Arrangements 73% (N = 75) had a contract with their managed care plan or behavioral health subcontractor for behavioral health services at the time of the survey Among those health centers that indicated they were billing for mental health services (N = 67), 67% had received payments for 2014 claims at the time of the survey Concerns about the billing process included the following: Confusion around how to bill the managed care plan for services done by non-pps billable providers without risking loss of payment in reconciliation Concern over whether billing for patients who go beyond the mild/moderate criteria would continue to be paid for by the State Lack of clarity around which claims managed care plans would deny and how to determine whether to bill the State directly Lack of clarity on how to distinguish between mild/moderate vs. severe Inconsistency with billing procedures between managed care plans (e.g. some managed care plans are requiring a pre-authorization, while others are not) Same day billing and restrictions on billable providers continues to prevent patients from accessing care Becoming a Drug Medi-Cal provider is difficult and there are not many providers to refer patients to Often unclear where to refer patients with substance use disorder needs DHCS is unclear in advising policies and protocols on billing practices. DHCS staff do not seem to understand their own policies, which has a profound impact on the clinics Some managed care plans are not accepting electronic claims, so it takes a long time to receive payment Some Medi-Cal managed care plans do not credential licensed clinical social workers Would like social determinants of health to play a larger role 34% (N = 76) were offered provider training on the managed care plan assessment tool used to determine whether the patient should be referred to the county for services. 21% were unaware that this tool existed. Training on this tool was offered by the following: LA Care and the Los Angeles Department of Mental Health San Francisco Health Plan Central California Alliance for Health Beacon Certain county specialty mental health plans 5 P a g e
Workforce 32% (N = 76) currently use or employ Marriage and Family Therapists (MFTs). Of those that responded to the question of how MFTs were paid for (N = 37): 35% used grant funding 24% received managed care FFS 22% included costs in their health center budget Other methods of payment included: o County Contracts o Ryan White grants o Partnerships with local universities o Volunteers (no payment) 36% (N = 76) use or employ Community Health Workers (CHWs) for work relating to behavioral health services. CHWs were used for: Facilitating peer advisory groups Health education Case management and referrals Cultural linkages Group education Screening Community outreach and engagement Developing patient centered plans with providers Motivational interviewing Scheduling appointments Certified Enrollment Counselors for Covered California Some health centers (N = 70) use providers that are funded by supplemental payments from the managed care plan on a fee for service (FFS) basis. Provider types include: Marriage and Family Therapists 11% Licensed Professional Clinical Counselors 3% Drug counselors 3% Associate Clinical Social Workers 17% Psychological Assistants - 3% Peer providers 3% Interns 19% 6 P a g e
Substance Use Disorder Treatment 46% (N=76) have implemented the Screening, Brief Intervention, Referral to Treatment (SBIRT) managed care plan benefit. The types of providers administering the benefit include: Physicians - 53% Nurse Practitioner - 51% Licensed Clinical Social Worker - 51% Physician Assistant - 43% Medical Assistant - 32% Psychologist - 21% Registered Nurse - 15% Substance abuse counselor - 11% Marriage and Family Therapist - 9% Health educator - 6% 54% (N=76) have not yet implemented the SBIRT Benefit. Reasons for not implementing SBIRT included: Not enough staff - 37% No training - 22% Reimbursement - 20% Unclear what is covered under the benefit - 33% 55% cited other reasons for not implementing SBIRT in addition to those above, including requirements for workflows and documentation, lack of clarity on the ratio and types of providers needed, lack of training staff available, feeling overwhelmed by other initiatives and changes, lack of EHR compatibility, time required for training, and not having enough providers that meet the SBIRT qualifications. 80% (N=75) were screening for drug use in additional to alcohol. Patients that screen positive for drug use are: Referred to county alcohol and drug treatment services Referred to community substance use disorder services Assigned to an internal substance use counseling team Connected with a care coordinator Substance Use Disorder (SUD) services provided in the FQHC setting include: Note: Not all SUD services are built into PPS rates SUD screening Culturally specific SUD prevention groups Referral to community and county resources Suboxone clinic Sobriety groups 7 P a g e
Medication management Motivational interviewing Motivational enhancement therapies Dual diagnosis treatment Harm reduction counseling Driving Under the Influence (DUI) Programs Ryan White funded programs 8 P a g e
Drug Medi-Cal 8% (N=73) of health centers have Drug Medi-Cal contracts, including contracts for: Outpatient drug free Intensive outpatient day treatment prevention Perinatal intensive day programs Methadone detox and maintenance Adolescent and youth services Narcotic treatment program psychosocial counseling Major concerns relating to Drug Medi-Cal included: Lack of capacity to see patients that are referred to the program Length of time to get a license can take more than two years Lack of clarity on how to contract with Drug Medi-Cal as an FQHC Poor rates of reimbursement Overwhelming regulatory requirements Lack of workforce to handle demand Inadequate language capacity No funding for detox outside of inpatient Lack of coordination with mental health Abstinence focus instead of a harm reduction philosophy 9 P a g e
County Contracts and Relationships 22% of respondents (N=76) were offered training on the county specialty mental health plan assessment tool (used to determine whether the patient should be referred to the county for services). 17% were unaware that this tool existed. 19% of respondents (N=76) have a contract (e.g. Short Doyle) with the county to provide specialty mental health services beyond the county assessment. This included contracts for full service partnerships for severely and persistently mentally ill and serious emotional disturbance, Drug Medi-Cal, Prevention & Early Intervention programs, intensive case management, and medication support. For CCHCs that are interested in contracting with the county mental health plan to provide county mental health services, but have not done so: 22% were not interested in contracting with the county 22% said the county was not willing to contract 20% could not meet the required scope of services 20% could not integrate with the county EHR system 20% cited documentation requirements/administrative burden 17% had trouble hiring qualified staff 19% (N=74) work with counties to co-locate specialty mental health services at one or more of the CCHC s primary care sites. 11% (N=76) co-located clinic staff at the county specialty mental health services site. 26% (N=74) have a county-appointed liaison that works with the health center to assist with access to county programs. However, respondents indicated that liaisons were not always helpful. 13% (N=75) of health center/consortia and county mental health services agreed upon shared quality measures. These included: Shared measures with Mental Health America (MHA) and Pacific Asian Counseling Services (PACs) Standardized assessment tools for behavioral health conditions 28% negotiated an agreement with the county for the return of patients from the county specialty mental health system once stable. Most arrangements were informal agreements, though some arrangements were through Memorandums of Understanding (MOUs). Respondents overwhelmingly indicated that there was no way to tell when patients stabilized in the county system and when/how to follow up with them. Other types of county/health center collaborations in behavioral health included: Behavioral Health Integration through Community Collaboration Blue Shield Foundation grant Learning communities through the consortia 10 P a g e
The Shasta Health Alignment & Redesign Collaborative Behavioral Health Integration Project 3 agencies co-located to provide services to populations with no funding, including adults with severe mental illness, uninsured adults, and children ages 0 to 3 Telemedicine through contracted psychiatrists Ryan White funding to support behavioral health for HIV/AIDS patients Collaboration with Doctors without Walls to provide behavioral health access to the homeless Dialogue with PathPoint in the provision of behavioral health services to the community Pediatric behavioral health services providers shared with county Pilot programs to help patients access help for depression in conjunction with prescription drugs Stigma reduction resources shared by the county Collaboration with social services agencies Cultural services through Asian Community Mental Health Services (ACMHS), a countycontracted community based provider Patient navigators 92% (N=72) of respondents reported that the county specialty mental health plan offered services in languages other than English. 81% (N=75) did not have a dispute resolution process in place to help patients that were unable to access county services. Those that did used managed care contract mechanisms, grievance forms, and informal discussions with county staff. Existing Barriers to Care through the County Specialty Mental Health Plan included: Transportation Waiting time between referral and appointment Excessive wait times for psychiatry services Language (particularly Spanish) Presence of alcohol or other drugs usually results in county denial Patients not meeting criteria for county services Stigma from patients and their families Lack of referral sites for uninsured patients Difficulty tracking homeless individuals Difficulties for patients in navigating the county system Availability of beds No psychotherapy services 11 P a g e