Session # D5a Statewide Behavioral Health and Primary Care Integration Implementation: Challenges and Successes in Missouri Ronald B. Margolis, PhD, CEO St. Louis Behavioral Medicine Institute Dawn Prentice, LCSW, Director of Integrated Care and Health Psychology St. Louis Behavioral Medicine Institute CFHA 19 th Annual Conference October 19-21, 2017 Houston, Texas
Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.
Conference Resources Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=resources_2017 Slides and handouts are also available on the mobile app.
Learning Objectives At the conclusion of this session, the participant will be able to: Describe the barriers to statewide implementation of primary care behavioral health integration Discuss why integrated healthcare delivery requires workforce training and systematic change Identify various levels of training and consultation approaches for enhancing statewide implementation of behavioral health integration into primary care settings
Bibliography / Reference 1. Nielsen, M. Olayiwola, J.N., Gundy, P., Grumbach, K. (ed.) Shaljian, M. The Patient-Centered Medical Home s Impact on Cost & Quality: An Annual Update of the Evidence, 2012-2013. Patient-Centered Primary Care Collaborative (2014). 2. Dow, A.W., DiazGranados, D., Mazmanian, P.E., & Retchin, S.M. (2013). Applying Organizational Science to Health Care. Academic Medicine, 88(7), 952-957. DOI: 10.1097/acm.0b013e31829523d1 3. Hoge, M.A., Morris J.A., Laraia M., Pomerantz A., & Farley, T. (2014). Core competencies for Integrated Behavioral Health and Primary Care. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions 4. Ader, J., Stille, C.J., Keller, D., Miller, B.F., Barr, M.S., Perrin, J.M. (2015). The Medical Home and Integrated Behavioral Health: Advancing the Policy Agenda. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). DOI: 10.1542/eds.2014-3941 5. Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 Building Blocks of High-Performing Primary Care. The Annals of Family Medicine, 12(2), 166-171. DOI: 10.1370/afm.1616
Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.
Missouri s Timeline of Integration Initiatives 2007 FQHC/CMHC Integration Initiative State Partners MO Department of Mental Health MO Primary Care Association MO Coalition for Community Behavioral Healthcare 2008 7 FQHC/CMHC Partnerships BHC Training in FQHCs 2011 CMS Approval Health Home SPA in Missouri -CMHC Health Homes -PC Health Homes
Challenges with PCHH integration 35 organizations = over 100 clinic sites Staffing FTE based on # of enrolled PCHH patients Specific criteria for enrolled patients PMPM payment model PCHH patients small percentage of patient population Outcomes assessment vs. process assessment
Successes of the MO Health Home Initiative % 40 35 30 25 20 15 Baseline Yr1 % of patients with at least 1 hospitalization (non-duals, 9+ attestations) Yr2 Y3 Baseline Yr1 Yr2 Y3 10 5 0 CMHC Primary Care Reduction in Hospitalization 9
Successes of the MO Health Home Initiative Initial 18 Month Estimated Cost Savings CMHC Health Homes 20,031 persons total served (includes dual eligibles) Total cost reduction $15.7 M PC Health Homes 23,354 persons total served (includes dual eligibles) Total cost reduction $7.4 M Health Home Total 43,385 persons total served (includes dual eligibles) Total cost reduction $23.1M 10
Successes of the MO Health Home Initiative From compliance to enthusiasm Helped organizations meet the Triple Aim Helped organizations become NCQA PCMHs Prompted HBAI code reimbursement by MOHealthnet 11
Barriers to Statewide Integration at the clinician level Variance in clinical skill Recruitment difficulties, especially in rural areas Retention issues Being the right fit for the PCBH model Comfort in mental health vs. medical
Barriers to Statewide Integration at the clinic level Infrastructure that supports integrated care delivery Various levels of PCP buy-in of the BHC role Lack of clinic and community resources Multiple clinic sites Team care defined in a traditional sense
Barriers to Statewide Integration at the system level Variance in Leadership Support of the BHC role Supervision for BHCs Fiscal health of organization varies Funding source drives BHC practice Ethical considerations for various levels of care Sustainability concerns
Lessons Learned from Statewide Integration All Politics is Local
Lessons Learned from Statewide Integration Collaboration and Culture osignificant effort is required for FQHCs and CMHCs to collaborate at the clinical level othe differing cultures between Primary Care and Behavioral Health care must to be recognized and addressed at the organizational & clinical level
Lessons Learned from Statewide Integration Workforce training and systematic change key to success oadding new & additional staff does not (necessarily) create change oprotected time is a precious commodity ointegrated Care Core Competencies are more useful than job descriptions oteam based care is not the default practice
A Team of Experts is not an Expert Team
Focus on Effective Team Practice Working Group Strong, focused leader Individual accountability Runs efficient meeting Performance measured indirectly Discusses, decides, delegates Team Shared leadership Individual & mutual accountability Specific team purpose Collective work Discusses, decides, works together Team training of medical students in the 21st century: Would Flexner Approve? Morrison G, Goldfarb S, Lanken PN. Acad Med. 2010;85:254-259
Training and Consultation strategies for a Statewide Integration Initiative Engage ALL involved State Leadership to Administration to Individual Clinicians Understand individual system strengths/limitations Strategically challenge status quo thinking
Training and Consultation strategies for a Statewide Integration Initiative Use Integrated Care Core Competencies to address multiple barriers Listen for needs and requests of participants Use organizational science to develop system change Offer flexible training/consultation opportunities
Training and Consultation strategies for a Statewide Integration Initiative Training and Consultation Format Delivery Didactic training of integrated primary care Ongoing BHC consultation Site Visits at individual clinics Administrative Phone Consultations Regional Meetings Statewide Conferences and Team Based Learning Webinars
Discussion
Contact Information RONALD B. MARGOLIS, PH.D. CEO and Professor Emeritus Saint Louis Behavioral Medicine Institute Department of Family & Community Medicine Saint Louis University 314-289-9401 www.slbmi.com Ronald.Margolis@uhsinc.com DAWN PRENTICE, LCSW Director of Integrated Care & Health Psychology Saint Louis Behavioral Medicine Institute 314-881-3457 www.slbmi.com Dawn.Prentice@uhsinc.com
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