INVESTING IN INTEGRATED CARE The Maine Health Access Foundation s 12 year journey (2005 2016) to improve patient centered care in Maine through the Integrated Care Initiative.
Table of Contents The MeHAF Journey Overview MeHAF Activities 2005 2016 Expected Outcomes Evaluation Results Reach and Outcomes of Clinical Implementation Grants Clinical Grantee Program Snapshots DFD Russell Medical Centers Downeast Health Services Rosscare Nursing Home Network Amistad Fi Accomplishments and Lessons Learned Systems Impact of Work Lessons Learned Policy Makers Clinicians Organizations Payers Grant Makers Integrated Care Going Forward
The MeHAF Integrated Care Initiative People tell us that too often the health care system lacks organization, is difficult to navigate, and is hard to understand. This is particularly an issue for those who are uninsured or medically underserved. MeHAF promotes more patientcentered and seamless care, particularly through the coordination and integration of primary care, behavioral health, dental care, specialty care, and other services. A centerpiece of our work is the Integrated Care Initiative, a twelve year, over $14 million commitment to promote better patient centered care by improving coordination between behavioral health and primary care. This is an overview of this initiative, the key components, and what has been learned during the journey. Care Integration: Comprehensive, coordinated, and continuous health relationships that are patient centered, safe, timely, efficient, effective, equitable, and accessible to everyone in Maine.
Integrated care from the patient s perspective I have a team that covers it all - rehab counselor, a case worker, a psychiatrist. They coordinated everything. They made sure I got dental, medical, and blood work.
Short and long term expected outcomes of the initiative Short Term Outcomes Long Term Outcomes MeHAF Create models/culture of patient centered care and integration Identify and leverage trends, issues and opportunities Stimulate systems change MeHAF is viewed as Partner by grantees Maine s health system becomes more integrated (including among non grantee providers) Increased percentage of Maine s population receives integrated care Non grantee providers take up integrated approach Grantees Increase understanding and level of patient centered care and integration Change delivery systems Improve patient outcomes Serve priority populations Patients and families become advisors/advocates Data systems support integrated care Sustainable integration created at practice and systems levels Reduce barriers to systems change: Reimbursement Regulation Licensing Demonstrate value of integrated care Avoid unintended effects
Evaluation Results
Overview of clinical implementation grant evaluation MeHAF awarded 42 grants across the state of Maine to develop integrated behavioral health programs. This included 21 clinical implementation grantees that were diverse in terms of types of organization hospitals, primary care, consumer advocacy; and in the patients they served adults, children, and elderly. The evaluation provided an opportunity to learn from diverse organizations and approaches to integration that work in different contexts and for different populations. The evaluation used the framework of RE AIM to analyze the Reach, Effectiveness, Adoption, Implementation and Maintenance of the program. The following infographic provides a snapshot of the data that describes the reach of the programs, in terms of whom was served and the impact on access to care and clinical outcomes for patients. The full discussion of the findings of this evaluation can be found at: LINK Evaluation Questions: Did the services provided by MeHAF s Clinical Implementation grantees become more integrated and more patient centered as a result of the initiative? What approaches/structures/ components of primary care/behavioral health integration and patientcentered care worked at the patient, provider and organizational levels? What were the key factors related to integration and patient centered care that made them work or not work? What were the considerations for replication (e.g., what circumstances populations/settings/ environments optimize the probability of successful replication)?
Evaluation Results (info graphic)
Clinical Grantee Program Snapshots A few grant projects and their results. Selected grantee projects, key characteristics, and results. DFD Russell Medical Centers- Collaborative care in an FQHC Downeast Health Services- Integrated care for at risk children and family support Rosscare-Older adult integrated care services Amistad- Support for healthy lifestyles for those with severe and persistent mental illness
DFD Russell Medical Centers FEDERALLY QUALIFIED HEALTH CENTER LOCATED IN LEEDS, MONMOUTH, ANDTURNER, ME DFD Russell has a long history of co location of behavioral health providers. The purpose of DFD Russell s grant was to move beyond co location to a more collaborative integrated approach. Service characteristics Standardized Screening Co located behavioral health LCSW, psychologist, professional counselor, and two case managers Follow up by case managers on PHQ 9 (depression screening), missed appointments, and emergency room and hospital visits Focus on medication adherence and side effects education by case managers Results Patients with major depression (133/167 with complete data) had a drop in symptoms (average of 5.6 PHQ 9 points). The drop of PHQ 9 points indicates a reduction from severe or moderate depression to mild or minimal depression. 48% of patients achieved a 50% or more reduction in symptoms or a score of 5 or less (remission)
Downeast Health Services MULTI SERVICE ORGANIZATION LOCATED WASHINGTON COUNTY, ME Washington County has one of the highest rates of substance abuse in the state and in the nation, with substantial impact on the health of young children and mothers. Given the limited number of pediatricians in the county Downeast Health Services in collaboration with the Community Caring Collaborative (CCC), a group of health, social, and other community service organizations, developed a program to address the early intervention and developmental needs of children in the county. Service characteristics Identify high risk children age 0 8 (due to drug or alcohol exposure, pre term, born of teen parents, trauma or violence exposure, or attachment disorder) Co locate in primary care a Family support specialist to provide developmental assessment, shared treatment plans, parent skills education, referrals and linkages to community services Family Support Specialist worked with family to develop goals to address risks, health and developmental needs of children Results Over one third of patients/families attained all of their goals, and 75 percent improved or attained at least one goal. The types of issues addressed in the treatment plan included issues relating to child behavior (21 percent), case/care management (29 percent), family dynamics/home environment (16 percent), prenatal health or child birth (4 percent), or general mental or physical health issues (30 percent).
Rosscare Nursing Home Network HOSPITAL AND NURSING HOME PARTNERSHIP WITH EASTERN MAINE HEALTH SYSTEMS IN BANGOR, ME One of the challenges faced by Eastern Maine Health Systems was that several elderly patients with mental health and/or dementia diagnoses were staying in the hospital for extended periods of time after their acute medical issues were resolved. Nursing homes didn t have the ability to appropriately care for patients with mental health issues. Further, patients in the nursing home did not have adequate access to behavioral health services. Service characteristics Co located licensed clinical social worker in hospital and nursing home settings Licensed clinical social worker created plans for care transitions between hospital and nursing home Training of nursing home staff on management of difficult behaviors of residents, and clinical staff on prescribing and use of anti psychotics Psychiatrist consultation on site and via telehealth (remote phone and video access) Results Reduced hospital length of stay from 45 days to 6 days Reduced use of anti psychotic medications on a routine basis in the nursing homes. No anti psychotic medications were used as needed during the period of January 2010 through June 2011. Patients were depressed fewer days and had fewer depressive symptoms
Amistad CONSUMER DRIVEN MENTAL HEALTH ORGANIZATION IN PORTLAND, ME Amistad is a consumer run organization (100 percent of its board members are consumers) serving persons living with mental illness in Portland, Maine since 1982. Individuals with severe mental illness often have significant and multiple chronic medical conditions and poorer access to medical care, contributing to a 25 year shorter life span, on average, than those without severe mental illness. The purpose of Amistad s grant was to address this discrepancy by assisting its members to access medical care services more effectively and by encouraging and teaching wellness and self management. Service characteristics Peer patient navigator attended medical visits with patients Healthy Amistad program focused on healthy eating options, goal setting for weight, and provided physical activity support and programs Results Over the course of six months, 50% of clients had a substantial weight change in the preferred direction, either gaining more than 5 pounds (2 of 4 clients) or losing more than 5 pounds (9 of 18 clients).
Accomplishments and Lessons Learned Impact on systems of care Policy, Clinical, Organizational, Payer, and Grant Maker perspectives
Systems Impact of Work Patient Centered Medical Home Payment Measurement Health Information Exchange Workforce Integration becomes a core principle of Maine s Patient Centered Medical Home Model reaching over 200 practices including Health Homes Health and Behavior Codes improve the ability for providers to bill for integrated services The Site Self Assessment Tool is developed to support practices in assessing and planning for integrated services and becomes recognized and used at a national level An implementation toolkit supports behavioral health electronic health records connection to Health Information Exchange (HIE) to support integrated services and behavioral health records being added to the Health Information Exchange Integrated care workforce development is expanded through an Integrated Care Preparation program at University of New England, and a practicum established between Husson College and Penobscot Community Health Center
Development of the State Integrated Care Policy Committee A multi stakeholder committee convenes at a state level to develop an agenda and workplan for policy changes that support integrated care. Key accomplishments: Collaboration with state initiatives: Maine DHHS includes integrated care as foundational component of its ACA Section 2703 Health Homes and Behavioral Health Homes waivers and the State Innovation Model initiative National leader engagement: Maine hosts CMS Region I Administrators on site visits to integrated care practices to enhance understanding and commitment to integrated care. National representation: Maine is represented at the AHRQ Integrated Care Academy by Neil Korsen, who lead the effort to write and publish AHRQ Integration Quality Measures Atlas Payer engagement: Anthem piloted first in Maine the use of Health and Behavioral codes to financially support behavioral health services in primary care settings. This was then spread to other states. It was clear from the outset that in addition to grant making, systemic changes and policy enhancements were needed to facilitate sustainability of integrated care as an important component of patient centered care. Participants State government officials Payers Employers MeHAF grantees Patients Statewide leaders in mental health and primary care MeHAF Staff
The lessons learned from the MeHAF initiative apply to many different stakeholders in the healthcare community. Progressing towards a model of integrated care is a collaborative effort involving many! Here we have summarized key lessons learned for the following audiences.
Lessons Learned for Policy Makers Health Information Exchange (HIE): The issue of different standards for treating mental health Information and substance abuse information under State and Federal law require complex processes of separating mental health from substance abuse information to support HIE efforts. Through 2011, Maine statutes related to consent for release of medical records were a barrier to bringing mental health records into HealthInfoNet, Maine s Health Information Exchange. HealthInfoNet and other partners worked as a coalition to change this law, and were successful, such that patients can now opt in to release their information. Payment Reform: Payment for behavioral health is complicated and difficult for providers to navigate. Policy can support convening forums for better understanding how to use current payment models to support integrated care and design improved systems for the future. MeHAF convened conversations with payers and developed in state expertise on payment mechanisms for integrated health that was then offered as technical assistance to providers. Alignment of State Programs: Engaging and aligning work with the state health and human services department furthered the statewide impact. MeHAF supported work on alignment of state programs and services for the severely mentally ill (SMI). The Maine Department of Health and Human Services (DHHS) worked to convene DHHS departments and consumers and to inform a better integrated care model for those with SMI. This laid the groundwork for future federal funding under the Medicaid State Plans Amendment Health Homes program.
Lessons Learned for Clinicians Promoting adoption among primary care providers(pcp). The transition to integrated care requires PCPs to learn and adapt to work with a new behavioral health team member. Several tips to engage physicians in the process include: Include PCPs in planning process for behavioral health integration Include PCPs in hiring of behavioral health providers Building relationships between Primary Care and Behavioral Health providers: There are several strategies that encourage the team building critical to move from co location of services to an integrated care model. Have behavioral health providers (BHPs) shadow PCPs during visits. BHPs and PCPs can then later discuss how they could have teamed to address patient needs and concerns Adapting behavioral health providers to the integrated care setting: Behavioral health providers adapt to providing care in shorter visits from the traditional 60 minute to 15 30 minute appointment. The following strategies help identify and transition the behavioral health provider. Before recruiting, write BHP job descriptions that clearly explain practice s approach to integrated services and related expectations. Engage other PCPs, either internally or externally to talk about their experience and benefits of integrated care Schedule the BHP and PCP to work during the same days so that warm hand offs are possible If the BHP has an administrative desk, locate it next to the PCP s so informal interactions are facilitated Assess relationships between providers by tracking referral patterns from each PCP to the behavioral health provider to assess differences among providers. Include BHP in PCP meetings and huddles
Lessons Learned for Organizations Identify the value of integrated care for the practice. Successful organizations have clearly articulated what integrated care will bring to the practice in way that is meaningful to its staff and patients. Some of the values articulated among MeHAF grantees included: Ability to provide holistic care Better manage care for complex patients Supporting mental health will support the overall health of our patients Teaming up with a behavioral health provider frees up time of the medical provider to focus on complex medical needs Training: An asset to start up and sustainability of a program is training of staff. The costs of training based on internal budgets can be prohibitive so organizations should look for outside funding and prioritize training for both primary care and behavioral health staff at the outset of the program. Measurement: The measurement of outcomes of the integrated care program assists staff in understanding and measuring progress. Organizations should not only collect data but share and discuss data across peers. Alignment with organizational values: Primary care organizations found implementation more successfull if they were able to align integrated care to the organizational values.
Lessons Learned for Payers Providers need assistance in understanding the appropriate billing codes, and acceptable provider types to bill for integrated services Education on proper billing for behavioral health is welcomed and desired by practices. A major stumbling block is location restrictions for billing. Consider removing restrictions on where and who can bill for integrated behavioral health services, as this provides more flexibility to ensure patients are receiving the services in the location that best meets their needs. Accountable Care Organizations (ACOs) will be the laboratories for developing and testing quality metrics and payment innovations related to behavioral health and primary care integration In Maine, there has been a high level of participation in the CMS funded ACO Pioneer (three in Maine) and shared savings (one in Maine) pilots. 1 Payment through per member per month programs such as patient centered medical home can support integrated care by supporting care and case management Engage multiple stakeholders in understanding the impact on total cost of care There is interest among provider systems, and public entities to use claims data to better understand the impact of integrated services on total cost of care. Under the Maine State Innovation Model grant, partnerships are forming to analyze these data. 1 Maine Pioneer ACOs: Beacon LLC Shared Savings ACOs: MaineHealth, Maine Community Accountable Care, Central Maine
Lessons Learned for Grant Makers Supporting clinical and systems grants Diversity in funding of grants at clinical and systems levels supports building relationships and connecting lessons learned across the system and at the practice level. Consumer engagement Encouraging and requiring patient engagement as part of grant making can ground the work and ensure it is accountable to the community it is intended to benefit. Technical assistance on data measurement Data management assistance is needed by grantees of all levels of sophistication, and supporting and teaching organizations how to use data can have a lasting impact on their work. Engage in supportive policy and system changes The simultaneous existence of a policy committee is a forum for discussion of strategy to address systems issues identified at the practice and community level that require policy change. When key decision makers are part of the learning process, they become champions for integrated care. A learning community develops sustainable relationships Developing a learning community supports education and creates a broad base of support and relationship building which forges relationships for continued peer learning and support. Identify and nurture your champions Deliberately develop champions in many stakeholder sectors and look for unlikely partners such as in housing, transportation, and business individuals who may have a professional or personal reason to support integrated care. Let champions and decision makers know when they have made a difference.
Integrated Care Going Forward Growth Sustainability and Accelerating Integrated Care
Growth of Integrated Care Sites
New funding after MeHAF
Sustaining Integrated Care: Factors that impact sustainability for an organization A financial model that supports an integrated approach The following support organizational financial stability: 1) Regulations match practice and provide consistency across settings 2) Clear guidelines on how to code visits, particular those that use existing codes 3) Mechanisms exist to provide integrated care without penalties or the requirement of a specific diagnosis. Clinical and staff support The level of knowledge, buy in and engagement among clinicians is critical, and in the words of one organization makes all the difference. Data demonstrating benefits and value Positive outcome data or cost data are needed to help make a persuasive argument for sustaining this approach and describing its value to decision makers. Organizational leadership, support and commitment Organizations that establish integrated care as a agency wide priority are perceived as more likely to maintain the program and monitor its efforts.
Accelerating Integration
Desired outcome: People s health, daily lives, and functioning improve as a result of engaging with a health care system that treats them as whole persons. The system integrates behavioral health and primary care and is cost effective.
Additional Resources Evaluation and Policy Reports Maine Health Access Foundation Integrated Care Initiative: Cross Site Evaluation of Clinical Implementation Grantees Final Report Bridging the Digital Divide: Using Health IT to Integrate Behavioral and Physical Health Care in Maine Integration Moving Forward Issue Brief Maine Integrated Care Policy Committee Strategic Work Plan and Accomplishments: 2013 2015 Case Studies Healthy Amistad Northeast Integrated Geriatrics Care: Supporting Primary Care in Long Term Care Settings Patient Engagement: Practical Strategies to Engage Patients in Integrated Care Working Toward Collaborative Care. Borkowski, N and Deckard, G eds. Organizational Behavior in Healthcare: Case Studies. 2013. Jones and Bartlett Publishers Tips for Implementation Tips for Implementing Integrated Care: Lessons Learned from MeHAF Clinical Implementation Grantees