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Transforming Clinical Care through Integration of Physical and Behavioral Health
June 27 , 2013
Rick Ybarra, MA Program Officer
Hogg Foundation for Mental Health
Austin, TX
28th Annual Conference Dallas, Texas
Annette Gary, PhD, RN Associate Chief Executive
Officer for Programs STARCARE Specialty
Health Systems Lubbock, TX
A. Camis Milam, MD Executive Vice President
Medical Services Center for Health
Care Services San Antonio, TX
Learning Objectives
Participants will be able to:
identify three principles and components in the delivery of integrated health care
describe three national innovations advancing integrated health care
identify three innovated examples of integrated health care based on two case studies
Persons with serious mental illness (SMI) are now dying 25 years earlier than the general population.
Their increased morbidity and mortality are largely due to treatable medical conditions that are caused by modifiable risk factors such as smoking, obesity, substance abuse, and inadequate access to medical care. (60% of premature deaths in persons w/SMI are due to natural causes). Source: NASMHPD, 2006
1. Overall health is essential to mental health.
2. Recovery includes wellness.
Why integrate?
Silos of Care
Social
Services
Psychiatry
Primary
Care
Community
Based
Services
Clinical
Social Work
&
Psychology
Unutzer, 2009
Integrated Health Care: Definition
Systematic coordination of physical and behavioral health services.
It may involve coordinating behavioral health care services with other services provided in a primary care setting, or coordinating physical health care services with other services provided in a behavioral health setting.
Integrated Health Care: Principles
Patient: Understands the diagnosis
Collaborates! Chooses treatment in consultation with provider(s):
e.g., medications and / or brief psychotherapy
Team-based care comprised of: Psychiatrist
Care manager/care coordinator
Behavioral health specialist
Nurse practitioner
Primary care provider (PCP)
Use of standard measurements (PHQ-9; Depression Inventories) pre- and post- at every encounter adapted from Unützer et al, Med Care 2001; 39(8):785-99
Integrated Health Care: Components
Patient registry
Use of screening tools
Provider education and training
Use of EBP guidelines
Referral to specialty providers
Co-location
Combination of above
Integrated Health Care: National Movements
ACA
Agency for Healthcare Research and Quality (AHRQ): Academy for Integrating Behavioral Health and Primary Care Lexicon
Atlas
SAMHSA’s Primary and Behavioral Health Care Integration (PBHCI) Program Austin-Travis County Integral Care
Lubbock Regional MH & MR Center
Montrose Counseling Center
CMS Health Care Innovation Awards Center for Health Care Services
Integrated Health Care: National Movements
Maricopa County RBHA – AZ
Mercy Maricopa will implement “Recovery Through Whole Health”
Mercy Maricopa and AHCCCS health plans to coordinate all physical and behavioral healthcare services.
SHAPE (Sustaining Healthcare Across integrated Primary care Efforts)
A western Colorado payment reform initiative to support integrated behavioral health in primary care settings - expanded to Oregon • Aims to SHAPE the way care is delivered;
• Aims the SHAPE the way care is paid for; and,
• Aims to SHAPE the way a community receives care.
Global payment model
“Providers are not trapped in a workflow designed to generate volume-based payments. Instead, the payment system supports integrated, coordinated, patient-centered care.”
Why now?
The train is leaving has left the station! Affordable Care Act driving system change
Increased demand for cost effectiveness/ outcomes
TRIPLE AIM! Improve outcomes, enhance the patient experience of care, and decrease cost
What does this mean for LMHAs? Is your organization on the train?
What have you moved forward? Challenges?
1115T Waiver
Opportunity to be a part of a new system of care to address the “whole health” needs of patients/consumers
Integrated Health Care Resources
AHRQ http://integrationacademy.ahrq.gov/
AIMS Center – University of Washington http://uwaims.org/
California Institute for Mental Health http://www.cimh.org/
Collaborative Family Healthcare Association – http://www.cfha.net/
Hogg Foundation for Mental Health http://www.hogg.utexas.edu/
IBHP - CA Endowment/Tides Center http://www.ibhp.org/
SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) http://www.integration.samhsa.gov/
Patient-Centered Primary Care Collaborative http://www.pcpcc.net/
SHAPE http://sustainingintegratedcare.net/
StarCare Specialty Health System Sunrise Canyon/Combest Clinic
Annette Gary, PhD, RN
Associate Chief Executive Officer for Programs
Lubbock, TX
Objective
This session will provide an update on the partnership between The Combest Center, an FQHC, and StarCare Specialty Health System, a community mental health center operating as an integrated care clinic in Lubbock, Texas.
The Partnership
The partners StarCare Specialty Health System
(Sunrise Canyon)
TTUHSC SON, Larry Combest Community Health and Wellness Center
SAMHSA Status - submitted 2009, funded 2010, in year 3
New Access Point (NAP) Application
The Grant Dollar$
Funding YEAR 1: $500,000
YEAR 2: $400,000
YEAR 3: $350,000
YEAR 4: $330,000
Grant dollars primarily utilized for salary support, supplies, wellness activities, and evaluation.
StarCare receives the grant dollars, but internally the budget is split between the two organizations.
“Population Served” 1300 adults from 5 counties
Demographics
51% Female, 49% Male
27% Hispanic
20% African American
14% aged 18-27
39% aged 28-44
43% aged 45-64
Financial Status
93% below 200% FPL
47% Medicaid
18% Medicare
31% uninsured
Challenges/Barriers
Sustainability
Different EMRs
Billing & Sliding Scale
Changes in Psychiatric Staff
Evolving Vision
Variables Monitored by SAMHSA
Sustainability: What are the options?
Continue as we are today
StarCare “owns psychiatric services and bills”
FQHC “owns primary care services and bills”
One organization could provide both services
StarCare could provide both services
LCCHWC could provide both services
What is the BEST option?
A Recovery-Oriented Approach to Integrated Behavioral and Physical Health Care for a High-Risk Population
A. Camis Milam, M.D.
Executive Vice President, Medical Services
The Center for Health Care Services
San Antonio, TX
Target Population Characteristics
Episodically or chronically homeless
Serious mental illness
Substance use disorders
Currently have or are at risk for chronic physical illness
Currently using ERs as their primary care source
Program Goals
Improve individuals’ capacity to participate and self-manage
Improve health outcomes by delivering the right care (first behavioral, then physical) at the right time (sobriety and stability first) in the right place (behavioral health clinic).
Lower the cost of care with implementation of a streamlined, bundled payment structure that proportionately values behavioral, primary and tertiary care.
Challenges
Even though our primary care and behavioral health care providers are both “in house” we have discovered that we speak different languages.
Few working models to follow.
Payers do not yet have adequate reimbursement structures.
CMHCs do not yet have talent in support areas (coding and billing, e.g.).
Resistance to change with payers, governmental agencies, staff and (perhaps surprisingly) consumers of care.
Lessons Learned
Integration is really about coordination of care.
CMHCs are the current leaders in experience with care coordination.
Definitions are crucial and need to be agreed upon in advance and stakeholders need to be involved in deciding what services will be provided.
Ongoing communication with all involved parties is crucial – there WILL be misunderstandings.
Dialogue!
Transforming Clinical Care through Integration of Physical and Behavioral Health
28th Annual Conference Dallas, Texas
Contact Information
Rick Ybarra, MA rick.ybarra@austin.utexas.edu
Annette Gary, PhD, RN
agary@starcarelubbock.org
A. Camis Milam, MD CMilam@chcsbc.org
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