SAN BERNARDINO COUNTY: AN INTEGRATED BEHAVIORAL HEALTH CAPACITY ASSESSMENT

SAN BERNARDINO COUNTY: AN INTEGRATED BEHAVIORAL HEALTH CAPACITY ASSESSMENT Community Clinic Association of San Bernardino County Integrated Safety Net Partnership Prepared by: Karen W. Linkins, PhD, Jennifer J. Brya, MA, MPP, and Alaina Dall, MA

2 Vision "The shared vision of the Integrated Safety Net Partnership (ISNP) is to achieve a regional public safety net system that is integrated, cost effective, and patient centered."

3 Project Goals San Bernardino County safety net partners work together to create a streamlined, accessible continuum of care that puts the patient and their goals at the center of care across all systems, and advances a whole health orientation across the community. Outcomes if the Vision is achieved: Enhanced access to evidenced based, quality care Reduced silos and fragmentation Families and communities have the knowledge, tools and community support to stay healthy Patients are empowered and health literacy improved Shared accountability across agencies -- care coordination for whole person centered health Families and communities will view healthcare as a priority and utilize community services.

We gathered information from county, state and national data sources. 4 County County data Local periodicals Community Vital Signs State California Department of Health Care Svcs OSHPD National Census American Community Survey Health Resources and Services Administration (HRSA)

5 We conducted key informant telephone interviews with representatives from: County Department of Behavioral Health County Department of Public Health Inland Empire Health Plan High Desert Child, Adolescent and Family Services Center Social Action Community Health System

6 Analysis of Provider IBH Capacity Surveys CCASBC assisted with administration of a provider survey with their clinic members. Responses were received from the following: Redlands Community Hospital Inland Empire Health Plan Riverside-San Bernardino County Indian Health, Inc. City of Montclair Medical Clinic Bloomington Community Health Center

COMMUNITY PROFILE 7

8 About San Bernardino County It is the largest county in the contiguous U.S., covering 20,000 square miles of land. 80% of the county is vacant land; 15% is used for military purposes. 81% of the land is outside the governing control of the County Board of Supervisors or local jurisdictions; it is primarily owned and managed by federal agencies.

9 The county is divided into 3 distinct areas: The Valley Region, which is divided into the West and East Valley Region, has the majority of the cities and is the most populous region. The Mountain Region is mostly public lands owned and managed by federal and state agencies. Source: Land Use Services Department, cited in 2014 Community Indicators report The Desert Region is the largest region (93% of the county s land area) and includes parts of the Mojave Desert.

Most cities are concentrated in the Valley Region in the Southwest Corner. Valley Region Mountain Region Desert Region Bloomington* Angelus Oaks* Adelanto Chino Big Bear City* Apple Valley Chino Hills Big Bear Lake Baker* Colton Crestline* Barstow Fontana Lake Arrowhead* Big River* Grand Terrace Lytle Creek* Bluewater* Highland Oak Glen* Fort Irwin* Loma Linda Running Springs* Hesperia Source: Land Use Services Department, cited in 2014 Community Indicators report 10 Mentone* Wrightwood* Homestead Valley* Montclair Joshua Tree* Muscoy* Lenwood* Ontario Lucerne Valley* Rancho Cucamonga Morongo Valley* Redlands Mountain View Acres* Rialto Needles San Antonio Heights* Newberry Springs* San Bernardino Oak Hills* Upland Phelan* Yucaipa Piñon Hills* Searles Valley* * = Unincorporated Silver Lake* Spring Valley Lake* Twentynine Palms Victorville Yermo* Yucca Valley

11 The SB County population grew by 21.5% between the 2000 and 2010 censuses. Source: U.S. Census Quick Facts

12 Aside from the unincorporated areas, the largest populations were in SB City, Fontana, Rancho Cucamonga and Ontario. Valley Region 2013 Est. Population % of County Chino 80,988 3.8% Chino Hills 76,572 3.6% Colton 53,243 2.5% Fontana 203,003 9.6% Grand Terrace 12,337 0.6% Highland 54,291 2.6% Loma Linda 23,704 1.1% Montclair 38,027 1.8% Ontario 167,500 7.9% Rancho Cucamonga 171,386 8.1% Redlands 69,999 3.3% Rialto 101,910 4.8% San Bernardino 213,708 10.1% Upland 75,413 3.6% Yucaipa 52,536 2.5% Mountain Region 2013 Est. Population % of County Big Bear Lake 5,124 0.2% Desert Region 2013 Est. Population % of County Adelanto 31,304 1.5% Apple Valley 70,924 3.4% Barstow 23,219 1.1% Hesperia 92,147 4.4% 29 Palms 25,768 1.2% Victorville 121,096 5.7% Yucca Valley 21,132 1.0% Remainder of County - Unincorporated 327,288 15.5% Source: U.S. Census, State and County Quickfacts. http://quickfacts.census.gov/qfd/states/06/0630658.html

More than half of the county population identifies as Hispanic or Latino The estimated breakdown of races/ethnicities in 2013 is: 77.5% White alone 9.5% Black or African American alone 2.0% American Indian and Alaska Native alone 7.1% Asian alone 0.5% Native Hawaiian/Pacific Islander alone 3.4% Two or more races 51.1% Hispanic or Latino (could be of any race above) 31.4% White alone, not Hispanic or Latino 41% of people spoke a language other than English at home. (2009-2013 averages) (California = 44%) Sources: US Census QuickFacts 13

14 SB County has more poverty than California counties on average. 15% of families had incomes below the federal poverty level at some point in a given year. (California = 12%) 19% of individuals had incomes below FPL within the given year. (California = 16%) $54,090 was the estimated median household income. (California = $61,094) Source: American FactFinder 2009-2013 5-year estimates for Selected Economic Characteristics.

In 2013, SB County had higher uninsured rates in almost all groups (Pre-ACA). Uninsured Populations California SB County % of total population that was uninsured 17.2% 19.0% % of 18-64 year-olds that were uninsured 24.0% 26.4% % White alone, not Hispanic/Latino 10.0% 12.2% % Hispanic or Latino (of any race) 26.3% 24.8% % of Native born 12.4% 14.8% % of Non-citizens (not naturalized or undoc) 43.9% 48.8% % of Employed 20.6% 22.0% % of Unemployed 41.7% 42.6% % Under 200% FPL 54.9% 54.2% % 200% and over FPL 11.3% 12.8% Source: U.S. Census Bureau, 2013 American Community Survey, 1-year estimates, Health Insurance Coverage Status. 15

16 Uninsured Population Pre ACA An estimated 389,227 individuals (19% of population) were uninsured in San Bernardino County in 2013. Source: U.S. Census Bureau, 2013 American Community Survey, 1-year estimates, Health Insurance Coverage Status.

More than 27% of the uninsured have gained coverage since ACA implementation* 1 st Covered California Open Enrollment Period Medi-Cal managed care (transitioned from LIHP to Inland Empire Health Plan) 2nd Covered California Open Enrollment Period # gained coverage Oct 2013 March 2014 53,623 January 1, 2014 38,796 Nov 2014 Feb 2015 12,157 SUBTOTAL 104,576 * Does not include the newly eligible who gained coverage in the adult Medi-Cal expansion, or those that were previously eligible for Medi-Cal but not enrolled, because data has not yet been made available from DHCS. Sources: California Healthline, Medi-Cal Enrollment Jumps to 11.3 million, by David Gorn, 11-12-2014; Covered California Highlights How Coverage is Improving the Health of Enrollees and Changing Lives Across the State, Covered California Daily News, 2-6-2015; Community Clinic Association of San Bernardino County: The California Endowment s Prevention Plan for the Inland Empire. 17

Enrollment increased 51% between September 2013 and March 2015. Medi-Cal Managed Care Enrollment 18 700,000 600,000 500,000 77,511 83,750 400,000 63,123 300,000 53,741 467,288 517,476 200,000 272,625 335,458 100,000 - Sept 2012 Sept 2013 Oct 2013 Sept 2014 Mar 2015 Inland Empire Health Plan Molina Healthcare Source: DHCS Medi-Cal Managed Care Enrollment Reports. n = 398,581 in Sept 2013; and 601,226 in Mar 2015.

19 UNMET BEHAVIORAL HEALTH NEEDS

The prevalence of SMI is estimated to be higher in SB County than the state. 20 SED = Severe emotional disturbance; SMI = serious mental illness; AOD = alcohol and other drug SMI - broader definition = more types of depression and anxiety than the standard SMI diagnosis, and conditions may be chronic or not. (See detailed list of criteria in Appendix A, Section 1, Table 1 on page 5 of the California Mental Health Prevalence Estimates.) Source: DHCS California Mental Health and Substance Use System Needs Assessment Appendices, Tables 1b-1e.

61% of youth with severe emotional disturbance (SED) were unserved. 21 ADP = the former CA Department of Alcohol and Drug Programs; DMH = the former CA Department of Mental Health. Source: DHCS California Mental Health and Substance Use System Needs Assessment Appendices, Tables 1b-1e.

22 68% of adults with serious mental illness were unserved, increasing to 94% when a broader definition was used. Source: Source: DHCS California Mental Health and Substance Use System Needs Assessment Appendices, Tables 1b-1e.

93% of adults with an alcohol or drug diagnosis were unserved in 2009. 23 Source: Source: DHCS California Mental Health and Substance Use System Needs Assessment Appendices, Tables 1b-1e.

Notes about behavioral health services penetration rates: The number served are not unduplicated (if served by Medi-Cal and ADP counted twice.) There is no measure for whether a person received enough services. A person seen once is still included as served. Private insurance or self-pay clients are not included, however very few persons with SMI receive services in the private sector. 24 Conclusion: Despite data limitations, it is clear that the extent of unmet need is considerable!

25 Patients/Needs Difficult to Serve Complicated medical cases; hard to get timely care. Patients needing psychiatry services who are not in crisis. Patients needing complex care management; with health plans it can take several referrals Homeless patients; shortage of temporary shelter and linkage to permanent housing. Long waiting lists. Veterans who may be homeless People who have difficulty finding affordable housing. People needing outpatient SUD services KI = Findings from key informant interviews

26 Patients/Needs Difficult to Serve PC clinic patients who receive medical care but have mild-moderate care MH needs. (Tier 1 and 2) Individuals with severe mental health conditions who need coordinated primary and specialty medical care (Tier 3) Patients dependent on prescription pain medication; need more intervention/treatment options for opioid addiction Undocumented immigrants not covered by ACA BH Services for low income and cash paying patients IEHP members whose BH needs are carved out to other agencies resulting in the health plan not being able to coordinate care SM KI = Findings from key informant interviews SM =Findings from Survey Monkey

27 Workforce Challenges Insufficient access to PC services across the region Resistance from old school providers not willing to embrace integration Very few FQHCs and CHCs with integrated BH capacity given geography and population size PC staff ability to assess and treat patient with BH needs Need to increase provider ability to use technology Need pediatric MH services and staff High Desert needs to focus on filling and funding MFT or LCSW positions County BH needs more case managers KI = Findings from key informant interviews

28 Workforce Challenges Psychiatry shortage; need to consider solutions such as e-consults and tele-psychiatry. County BH lost 4-5 psychiatrists due to better salary offers elsewhere. County uses telehealth services, i.e. in Needles. They are have an RN development program in which they are working on developing psychiatric NPs. Need more BH providers since more people have coverage. They have MFTs through Loma Linda but not LCSWs. There is a 2-3 month wait to see a PCP (DPH).

29 Other Barriers and Challenges Lack of adequate reimbursement and financing Need reimbursement for same-day primary care and behavioral health visits in health centers IPA structure --- many small PCP practices with limited capacity to build IBH programs Poor coordination of care; not having a key contact; not knowing if referral worked and patient was seen. Inadequate system for transferring health information between agencies (not Excel); E.H.R. implementation in progress.

30 Other Barriers and Challenges Inadequate networking; need to strengthen relationships between social service agencies and primary care (referral contacts) Lack of adequate public transportation, esp. in mountains and high desert (Morango Basin) Geographic size of the county creates challenges for agencies to come together to share strategies/best practices Community providers have limited knowledge of programs, services and activities going on across the county

31 BEHAVIORAL HEALTH DELIVERY SYSTEM

32 San Bernardino County has 26 Hospitals Including psychiatric hospitals 24 Primary Care Clinics (OSHPD) Excluding county clinics Source: OSHPD List of Clinics in SB County; List of Hospitals in SB County

33 The County Hospital and Clinics Arrowhead Regional Medical Center (456 Beds) SB County Department of Public Health Arrowhead Fontana Family Health Center Adelanto Community Health Center (FQHC) Arrowhead McKee Family Health Center Hesperia Health Center (FQHC) Arrowhead Westside Family Health Center Ontario Public Health Center (Primary Care) Internal Medicine Primary Care Needles Health Center (Primary Care)

34 Hospitals providing acute psychiatric services Acute Psychiatric Hospitals Canyon Ridge Hospital, Chino 106 acute psychiatric beds General Acute Care Hospitals Community Hospital of San Bernardino 74 acute psychiatric beds Loma Linda University: Behavioral Medicine Center 71 acute psychiatric beds 18 chemical dependency recovery beds Redlands Community Hospital 18 acute psychiatric beds Source: OSHPD List of Hospitals in San Bernardino County, and facilities description, accessed 6/2/2015

Not a single California county meets the goal of 50 psychiatric beds per 100k population. Table: Acute Care Inpatient Psychiatric Bed Distribution, Counties over 1 million, OSHPD 2011 data County Adult Child/ Adol Chem/ Dep Beds per 100k* Population Alameda 277 50 74 23.16 1,554,720 Contra Costa 84 24 8 10.00 1,079,597 Los Angeles 1,810 217 411 21.21 9,962,789 Orange 463 32 62 16.02 3,090,132 Riverside 183 12 131 8.99 2,268,783 Sacramento 297 68-25.93 1,450,121 San Bernardino 304 76 38 18.26 2,081,313 San Diego 548 76 95 24.39 3,177,063 Santa Clara 166 - - 9.03 1,837,504 Notes: Beds per 100k were calculated based on more types of beds than those listed. To see all elements of calculation, refer to full report. Beds per 100,000 residents goal is 50. Source: California s Acute Psychiatric Bed Loss, California Hospital Association, p.4, Rev. 9/27/2013. 35

The following FQHCs and look-alikes provide BH services for the Medi-Cal population. Number of Patients Receiving Mental Health or Substance Abuse Services in 2013 Medi-Cal and Uninsured 36 Health Center Inland Behavioral and Health Services (FQHC) Mission City Community Network (FQHC) Mental Health Substance Abuse Total Patients - BH Total Patients - All Svcs 480 705 1,185 10,632 2,263 0 2,263 16,561 SAC Health System (Look-alike) 428 0 428 11,449 Total 3,171 705 3,876 38,642 Note: No data was available for Adelanto or Hesperia county FQHCs. Source: HRSA Uniform Data System (UDS) reports, 2013, the most recent data available

The majority of AOD treatment programs are non-residential co-ed programs. Table: California DHCS Licensed Residential Facilities and/or Certified Alcohol and Drug Programs in SB County, February 2015 Co-Ed Men Women Women + Children Families Total Private Treatment Non-Residential 22 1 1 0 1 25 Residential 4 7 1 1 0 13 Residential with Detox 8 6 0 1 0 15 County Treatment Non-Residential 4 0 0 1 0 5 Total 38 14 2 3 1 58 37 One private provider offers non-residential for individuals with a dual diagnosis. Aegis Treatment Centers in Hesperia is licensed by California DHCS to provide Narcotic Treatment. Source: http://www.dhcs.ca.gov/documents/status_report_february_2015_ada.pdf

38 Additional Prevention, Wellness, and Health Education programs aim to prevent serious problems from developing. County MHSA Prevention and Early Intervention (PEI) programs DPH received a $250k grant from HRSA for integrated behavioral health; they want to strengthen link between the county psychiatrist and primary care BH. (M Ellis, DPH)

39 CROSS-SYSTEM COLLABORATION

40 Many examples of cross-system collaboration are already in progress. High Desert Child, Adolescent and Family Services Center A therapist from this site works for the County Crisis Response Team. Referrals from probation are streamlined. The referral process to County Behavioral Health is working well. A partnership with Barstow Community College to educate or train parolees is working well.

41 Many examples of cross-system collaboration are already in progress. County Behavioral Health (Integrated Health Program) BH staff work in two primary care clinics Arrowhead McKey Family Health Center and Arrowhead Westside Family Health Center. They serve as a conduit between primary care and specialty mental health. There are no joint meetings with primary care providers yet but there is more and more pressure to work together!

42 Many examples of cross-system collaboration are already in progress. The Interdisciplinary Care Team (ICT) meets monthly to manage clients transitioning between agencies, esp. for Tier 2 and 3 clients. Healthcare Reform/ACA Committee: There is a current high-level monthly meeting of county departments and other agencies. One initiative is working with jails on assigning inmates eligible for Medi- Cal to primary care before getting released. Cal Medi-Connect Committee meets quarterly with internal programs and health plans; facilitated by IEHP and Molina. Consider adding Clinic Association to meeting

Many examples of cross-system collaboration are already in progress. Social Action Community Health System (FQHC Lookalike) New campus opening in 2015 with integrated care teams Has a close relationship with Loma Linda since it served as their community health clinic up to 2010, and staff are predominantly from there. Have a good working relationship with the County; regularly works with the mobile crisis team for their patients. Are trying to follow the Cherokee Model of Integration in which a BH team is embedded in primary care and patients also have access to specialty MH. Cherokee offered an onsite 3-day training about two years ago. 43

44 Many examples of cross-system collaboration are already in progress. Redlands Community Hospital coordinates care with ARMC and community psychiatric services IEHP utilizes health risk assessments, claims data, and referral information to identify members who require care coordination by a care management team. City of Montclair Medical Clinic coordinates to improve transitions for people with complex BH or health needs with: ARMC Al Shifa Clinic Bloomington Community Health Center H Street Clinic SM = Findings from SurveyMonkey SM

Several efforts are underway to develop shared consent forms and to share data. Implementation of a universal consent is in progress (County counsel reviewing it) The IEHP provider network can share information via a web portal in order to better coordinate between PCPs, BH, and other specialists. IEHP compiles a common care plan across multiple providers and keeps it updated. It is housed in the Health Plan Medical Management System. 45 SM Note: a $4.8 million technology grant was used to upgrade broadband capability.

46 E.H.R. implementation is a work in progress. ARMC has E.H.R. County Primary Care Clinics have E.H.R. County BH rolling out in July 15 starting with billing County BH can view ARMC E.H.R., i.e. discharge plan, and print copy to give to psychiatrist. BH staff use Excel to track demographics, diagnosis, where client was sent, or if referred for other services (SSI, transportation, drug and alcohol).

47 RECOMMENDATIONS TO INCREASE INTEGRATION

48 Strategies to Advance Integrated Care in San Bernardino County Expand strategic partnerships Disseminate foundation elements of IBH 101 to build capacity across PC network Prioritize populations and issues Build capacity for BH within PC clinic settings Build capacity for PC within BH settings Improve referral pathways and care coordination processes

Strategies to Advance Integrated Care in SB County Implement regular multi-agency meetings for clients transitioning between agencies Increase information sharing between agencies Identify liaisons at all agencies involved in transitions Get all primary care and behavioral health agencies on an E.H.R. Define and understand care coordination and how to staff it; clarify CC capabilities with SUD population (42-CFR) Focus on duals population and IEHP online portal; overlapping population between county, FQHCs and IEHP. 49

50 Strategies to Advance Integrated Care in SB County Offer patient incentives for behavioral health change Create local access to a secure MH facility; anyone with 5150 is taken out of area to Arrowhead Hospital or Loma Linda Hospital. The community needs an inpatient treatment program for youth in addition to the one they already have for adults. (Now youth have to go to LA for services). Enhance coordination of overlapping duals population between county, FQHCs and IEHP. Improve care coordination for most complex PC/BH patients and be sure they have a health home

Strategies to Advance Integrated Care in SB County Continue to expand networks to include more MH/SUD treatment providers Adopt a universal release of information form that will allow PCPs and others to share information with BH specialists. Utilize tele-psychiatry to leverage scarce BH provider resources. Leverage existing efforts related to BH integration that are about to launch with IEHP, County BH, County PH and SACHS 51 SM

52 BEHAVIORAL HEALTH INTEGRATION INITIATIVE (BHI-I) FUNDED BY IEHP Inland Empire Health Plan is set to launch a 2-Year, multi-million dollar investment in BH integration August 2015

53 IEHP Behavioral Health Integration Initiative (BHI-I) IEHP is set to launch an initiative that will invest in infrastructure development, practice coaching and evaluation to support bidirectional BHI in key provider sites in both Riverside and San Bernardino counties. Pilot sites will span 12 Provider Partners, with 34 diverse clinic sites including: Primary care/fqhcs County behavioral health Children s clinic Substance Use treatment facility Board and Care Adult day health care center

54 IEHP Behavioral Health Integration Initiative (BHI-I) San Bernardino Partners for the BHI-I Pilot: Arrowhead Regional Medical Center Family Medicine Clinics (Public Hospital Clinics) Fontana McKee Westside San Bernardino County Public Health Hesperia Clinic (FQHC) San Bernardino County Behavioral Health Adult Residential Services Mesa Community Counseling Phoenix House

IEHP Behavioral Health Integration Initiative (BHI-I) San Bernardino Partners for the BHI-I Pilot: Social Action Community (SAC) Health System (FQHC Look Alike) Orchid Court (Board and Care Center) San Bernardino Adult Day Health Care (Community based adult day health service provider) Telecare Corporation (BH clinic, providing PC services in collaboration with SACHS) 55

56 IEHP Behavioral Health Integration Initiative (BHI-I) BHI-I Systems Change Goals: Support practice transformation and infrastructure development across health and BH providers to provide whole health care to patients Provide care that assesses the full range of health, BH and social service needs of patients Develop comprehensive care plans in collaboration with the patient that include patient goals related to physical, behavioral and social conditions Create a systematic method for tracking operational and clinical performance

IEHP Behavioral Health Integration Initiative (BHI-I) BHI-I Framework Targets 5 Key Areas of Change: 1) Assessment Processes 2) Care Planning 3) Service Delivery Practices 4) Health Care Management (Population Health) 5) Health Promotion & Patient Experience 57

IEHP Behavioral Health Integration Initiative (BHI-I) Key Domains of Competency Development for Pilots: Team Based Care Comprehensive Care Management & Coordination Utilization of Health Information Technology Health Promotion and Self-Management Support 58

59 IEHP Behavioral Health Integration Initiative (BHI-I) BHI-I Timeline Pilot Sites Selected May/June 2015 Pilot Implementation (Practice Coaching): August 2015 through September 2017 Future plan is to spread successful practices and models within the IEHP provider network

60 IEHP Behavioral Health Integration Initiative (BHI-I) Pilot Site Selection Process Following site visits and interviews, IEHP selected sites who met the following criteria: Existing integrated BH capacity to build from Executive leadership committed to a vision of whole health care History of innovation Patient centered care philosophy Interest/engagement in service delivery redesign Receptivity to practice coaching Commitment to performance measurement, quality improvement and outcome-based care Willingness to invest in long term, sustainable change Strong partnership with the health plan

IEHP Behavioral Health Integration Initiative (BHI-I) Health plan role in supporting systems change Committing substantial financial resources to build infrastructure and capacity across the network Building a vision and shared understanding of the benefits of an integrated system Organizing and convening the provider partners to disseminate models and best practices Advancing Health Information Exchange across the network Analyzing the claims/cost data to build the business case for ongoing support of integration efforts 61

62 Conclusion What are your thoughts? What surprised you about these findings? What are some possible next steps?