An Environmental Scan of Behavioral Health

Integration in OregonPRESENTED BY JEN HALL, MPH

Family Medicine, OHSU

Proposal #5805870 / Session # D2b Collaborative Family Healthcare Association October 15-17, 2015 Portland, Oregon U.S.

FACULTY DISCLOSURE

The presenters of this session have NOT had any relevant financial

relationships during the past 12 months

LEARNING OBJECTIVES

At the conclusion of this session, the participant will be able to:

• Describe the stages of behavioral health and primary care integration observed in Coordinated Care Organizations

• Identify contextual factors that shape behavioral health and primary care integration

• Identify and discuss key drivers and strategies for supporting behavioral health integration

REFERENCES1. Cohen DJ, Davis MM, Hall JD, Gilchrist EC, Miller BF. A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration: Observations from Exemplary Sites. Rockville, MD: Agency for Healthcare Research and Quality; 2014.

2. Cubic B, Mance J, Turgesen JN, Lamanna JD. Interprofessional education: preparing psychologists for success in integrated primary care. J Clin Psychol Med Settings 2012;19(1):84‐92.

3. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative; 2011

4. McDaniel SH, Grus CL, Cubic BA, et al. Competencies for psychology practice in primary care. Am Psychol 2014;69(4):409‐29

5. Rozensky R. Implications of the Affordable Care Act for education and training in professional psychology. Train Educ Prof Psychol 2014;8(2):83‐94.

LEARNING ASSESSMENT

• A learning assessment is required for CE credit

• A question and answer period will be conducted at the end of this presentation

BACKGROUND

Coordinated Care Organizations (CCOS) are networks of health care providers and organizations (physical health care, addictions, mental health, oral health) who work together under one global budget, to delivery care to Medicaid beneficiaries

• First CCOs formed in 2012

• 16 CCOs in Oregon

• Operate under global budget

BACKGROUND: CCOs

• Accountable for patient health outcomes (17 metrics)

• Governance

• Governing Board• Community Advisory Council• Clinical Advisory Panel (optional)

BACKGROUND: CCOs

• Integration is a cornerstone of Oregon’s vision for CCOs

• A number of CCOs are piloting behavioral health integration in their practices

• 23 Transformation Fund projects focus on behavioral health integration

BEHAVIORAL HEALTH INTEGRATION

Care that results from a practice team of primary care and behavioral health clinicians, working together to provide patient-centered care

May address mental health, substance use, health behavior, life stressors and crises, stress related physical symptoms, and ineffective patterns of utilization

BEHAVIORAL HEALTH INTEGRATION

A new model of care

• Not just PC + MH

• Requires a new kind of provider (or retrained provider)

• New infrastructure

“It’s a whole new language. It’s a whole new way of communicating and a whole different focus, which is very different and non traditional from when you truly think mental health therapy. I mean, it’s a different model. It’s short term. It’s solution focused.”

-Behavioral Health Organization Leader

BEHAVIORAL HEALTH INTEGRATION

THIS STUDY

We conducted a survey of CCOs to better understand behavioral health integration efforts in Oregon

METHODS

Sample: 5 of the 16 CCOs• Membership size• Geography• Experience with integration

33 semi-structured interviews • CCO leaders• Behavioral health clinicians• Primary care clinicians

METHODS

• Data analyzed by a multi-disciplinary team using crystallization-immersion approach

• Preliminary findings vetted with CCO-wide BH organization and refined

• Study protocol approved by the OHSU IRB

FINDINGS: HISTORY &EARLY ADOPTION

• Some practices and organizations in CCO network were integrating before CCO formation

• Early adoption also meant that partners often had experience and a history of working together

“Probably ten years ago, I sat in with a

group called the mental health

integration workgroup. […] We met with

the Medical Director. We would talk about

cases. We would talk about individual clients.

And we weren’t the only ones involved.

There was a number of people from our

community.”

FINDINGS: EARLY ADOPTION

-BEHAVIORAL HEALTH CLINICIAN

FINDINGS

CCOs in various stages of behavioral health integration implementation

Major Implementation

PilotPlan

FINDINGS: PLANNING STAGE

•Site visits•Learning from others•Collecting data•Surveying providers•Determining interest

“Right now we’re gathering that

information and doing the

foundation. We’re taking in formation

from folks who currently have integration

efforts around what’s working and

what isn’t, so we can look at how we

can generalize that to our provider

panel.”

FINDINGS: PLANNING STAGE

-CCO LEADERSHIP

FINDINGS: PILOTING STAGE

• Integration efforts in one or more practices, but not part of a systematic CCO effort

FINDINGS: MAJOR IMPLEMENTATION

• Dedicated resources• Major focus area, part of vision• Integrated care available to most

members

FINDINGS: SUPPORTING INTEGRATION

ONGOING LEARNING & SUPPORT

GOVERANANCE

STRUCTURETRAINING

BUY-IN & ENGAGEMENT

FINANCING & RESOURCES

FINDINGS: GOVERNANCE

• Behavioral health representation on:

• Governing board• Finance committees• Clinical advisory panel

• Behavioral health provider organizations have strong connection and relationship with CCO

FINDINGS: TRAINING

• Learning Summits, Conferences, & Workshops• SBIRT• Tobacco cessation• OPAL K

• Consulting with integration leaders in other states

• CCO provided/coordinated training on integration• Primary care practices• Behavioral health clinicians• Primary care providers

It’s such a culture shift from doing the

traditional mental health kind of therapy, move

from 50 minute treatment hours and tons of

sessions to 20 to 30 minutes and two to three

sessions. It’s an entirely different vocabulary, a

different focus, and a different way of meeting

the needs of the patient. So [the intensive

integration training] was helpful, that

week of intense adoption of a new lens.

That made a difference.”

FINDINGS: TRAINING

-BEHAVIORAL HEALTH CLINICIAN

FINDINGS: ONGOING LEARNING & SUPPORT

• Ongoing support and training to new BHCs

• Learning collaboratives for BHCs to share and learn from each other

• Learning collaboratives for integrated practices

“[The coordinator] goes around and visits the clinics and provides onsite consultation, as well as leads a learning collaborative group that meets twice a month to talk about issues related to integrated care. […] I thought it was important for the [BHCs] to continue to discuss issues, identify what works, what doesn’t.”

-CCO PARTNER, CAP MEMBER

FINDINGS: ONGOING LEARNING & SUPPORT

FINDINGS: BUY-IN & ENGAGEMENT• CCO leaders with expertise or hired

consultant(s) met with practice leaders:

• Provided integration readiness assessment

• Discussed how to begin behavioral health services in their practices

FINDINGS: BUY-IN & ENGAGEMENT• Started in practices that were

interested and ready

• Started in practices with a high number (or proportion) of Medicaid beneficiaries

FINDINGS: BUY-IN & ENGAGEMENT

• Clinical Advisory Panels (CAPs) (clinician leaders)• Create buy-in in practices and local

communities• Key resource for engagement

• Clinician “change champions” at in a PC clinic or MHC can stimulate change and push integration forward

• Clinician word-of-mouth

“We knew [they] were going to be interested because they had been talking for a long time about really liking to have more access [to behavioral health.] And then there is some word of mouth that happens in the medical community. As people are happy with what’s happening, they talk about it with other practitioners. And then they either call us or bring it up to us in meetings [to] see if [they] can get something going in [their]practice.”

FINDINGS: BUY-IN & ENGAGEMENT

-CCO LEADERSHIP

FINDINGS: PILOTING & EXPERIMENTING

FINDINGS: PILOTING & EXPERIMENTING

FINDINGS: FINANCING& RESOURCES

• Allocated Transformation Fund dollars to behavioral health integration projects

• Invest CCO dollars in integration pilots and initiatives

• Developing alternative payment methodologies for primary care reimbursement

LIMITATIONS

• CCOs and state policies change quickly

• Sample • Only included 5 CCOs• Did not include substance use providers• Did not include patients

• The extent to which these findings are generalizable to other states is unknown

CONCLUSION

• State leaders play a role in shifting the environment to support an integrated health care system

• Providing guidance on effective strategies and sharing knowledge from Coordinated Care Organizations and their practices that are integrating care may accelerate integration efforts

THANK YOU!

Thank you to the CCO leaders and providers who participated in our study.

We appreciate the contributions of our collaborators who participated in this work:

• Integrated Behavioral Health Alliance of Oregon• Oregon Health Authority Transformation Center • Deb Cohen, PhD• Jason Kroening-Roche, MD• Ruth Rowland, MA• David Cameron

SESSION EVALUATION

Please complete and return the evaluation form to the classroom

monitor before leaving this session.

Thank you!