Integrating Behavioral Health Care: A Providers PerspectiveBarbara C. Zeller, M.D.Chief Clinical Officer

Our historic experience with HIV care informed our development of an integrated care model • The Bronx, New York City 1990

• Face of HIV/AIDS had changed in New York City

• Brightpoint began with residential care

Our History

Our Integrated Care Model: A Provider’s Nirvana

All aspects of physical,

behavioral and social care

coordinated and customized to each

patients needs.

Shelter

Resident

Food

Art Therapy

Health Education

Modified TC• Individual Counseling• Group Sessions• Structured Daily Schedule• Housing Structure• Assignments

Social Services• Case Management• Legal Liaison• Family Program

Therapeutic Recreation

Acupuncture

Medical Care

Nursing Care 24/7

PT/OT

Evidence Base For Integrated Care

Prevalence of co-occurrence of behavioral health, substance abuse disorder (SUD) and chronic medical conditionsInteracting effects between behavioral and physical healthBiological, psychological and social factors play a significant role in human functioning and disease

Developing an Outpatient Model: Patient-Centered Medical Home

Integrated Care Remains Best Means to Attain Our Vision:Improved health outcomes for people, families and communities challenged by health disparities caused by poverty, discrimination and lack of access.

The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms and ineffective patterns of health care utilizations.

Defining Integrated Care

Source: Agency for Healthcare Research and Quality

Tackling Comorbidities: Integrated care is critical for people living with HIV

Source: Brightpoint Health Data 2014-2015

2011 2012 2013 2014 2015 YTD0%

10%

20%

30%

40%

50%

60%

70%

% of HIV Patients with Comorbidities

HIV and Substance Abuse HIV and Behavioral Health DX HIV and Substance Abuse and Behavioral Health DX

Complex conditions require coordination and follow up.

Tackling Comorbidities: Why our integrated care model is especially effective

The right hand must know what

the left hand is doing

Patient’s life

depends on it

Medication interaction. Do you know all of yours?

Now imagine you are homeless, hungry and dealing with multiple health challenges.

Are you going to look them up?

Social determinants Shelter as a public health issue

Nutrition

Our Patients 2014

61%

39%

Men Women 20-29 30-39 40-59 60+

AgeGender

75%

25%

Housing Status

Homless/Unstably Housed

Perm. Housing

White Black Unreported Hispanic0%

10%

20%

30%

40%

50%

60%

Race/Ethniticy

Our Outpatient Model: Homeless FQHC Patient-Centered Medical Home

Patient

Outreach(Transportation)

Mental Health(Article 31/28)

Care Coordinator(Health Home)

Dental Services

Out PatientDrug Treatment(Article 822)

Nutrition/Meal Service

Office-Based OpioidReplacement Therapy(Buphenophine)

Primary Care(Article 28)

Medical Case Management

Pain Management

Primary Care Team

Patient

Med Tech RN

Medical Case Manager

Behavioral Health Provider

Medical Provider

Care Manager(Health Home)

Start from existing programs and locations. Two models, both have their advantages

Challenges and Barriers: Moving from co-location to integration

Virtual Integration• Services at different physical

locations, integrated through HIT• Health Information Technology• Providers communicate on their own

schedules. No need to make time for meetings.

Bricks and Mortar Integration• Services at the same locations

• Providers can communicate and huddle in person

Challenges and Barriers To True Integration

Discipline Specific Silos

Development of Integrated

EHR

Work Flows Work Force Development

Change is always hard.

Breaking the Barriers: Institute for Healthcare Improvement Collaboration

May June July3.9

4

4.1

4.2

4.3

4.4

4.5

Patient Experience: For today's visit, your care team was well organized, efficient, and did not waste your time? Brightpoint

Collaborative AverageGoal

Key

Breaking the Barriers: Institute for Healthcare Improvement Collaboration

BrightpointCollaborative AverageGoal

Key

May June July60

65

70

75

80

85

Improvement in Blood Pressure Control

Breaking the Barriers: Institute for Healthcare Improvement Collaboration

BrightpointCollaborative AverageGoal

Key

May June July3.80

4.00

4.20

4.40

4.60

4.80

Patient Satisfaction: I was able to get all of my health needs met by my health care team.

Breaking the Barriers: Institute for Healthcare Improvement Collaboration

BrightpointCollaborative AverageGoal

Key

May June July0

20

40

60

80

100

Depression Screening Follow Up

Overall Results: Integrated care increases access for hard to reach patients

Source: Brightpoint Health Data

2011 2012 2013 20140

1,000

2,000

3,000

4,000

5,000

6,000

7,000

1,831

2,988

4,738

5,941

1,407

2,235

3,304

4,246

1,2701,457

1,648 1,726

Increasing Access To Services

Primary Care PatientsBehaviorial Health PatientsHIV+ Patients

Creating Efficient Systems of CareJessica Diamond, MPA, CPHQSenior Vice President, Organizational Culture and Quality

Past Decade Represents More Change In Health Care Delivery Than Any Time In History

Stimulus Act of 2009

Authorized CMS to offer financial incentives for

“meaningful” use of Electronic Health Records (EHR)

Affordable Care Act (ACA) 2010Most significant overall of the US health system

since 1965Increases the quality and affordability of health insurance

Reduces the number of uninsured AmericansLowers health care

costs for individuals and government

Cutting Costs is Half the

Equation, Increasing Quality is Equally

Important

Aligning on Quality…What Really Matters

National Committee for

Quality Assurance (NCQA) driving

quality improvement

Promotes accountability for care integration, access, patient satisfaction and reducing health

care costs

Builds consensus by working with policymakers,

employers, providers, patients

and health plans

Moving from episodic care to coordinated care supporting population medicine. Asking a new set of questions:

Health Care Transformation = Workforce Transformation

Old question:What services do

you provide?

New questions:

How do we reduce costs AND improve population health?

How do we best use resources for better outcomes?

It’s Not, “What’s the Matter With You, It’s What Matters to You.” - Maureen Bisognano, IHI

Paramount paradigm shift for

providers

Focus on reducing/

eliminating inequality and

disparities

New Approach Requires New Tools

Partnership between

providers and payors

Redesigned IT including

integrated data support

Non-traditional health care work force

New care management

models

Sharing financial risk

for the populations

served

Measurement and

accountability tools

Example: Provider Dashboard

2015 Q2 PRIMARY CARE PROVIDER DASHBOARD, 4/1/2015 - 6/31/2015Measure Types Primary Prevention Secondary Prevention Tertiary Prevention  

Reporting Entity   UDS, HEDIS,

MU UDS, MU UDS, HEDIS, MU,QIP

UDS, HEDIS, MU, QIP

UDS, HEDIS, MU

DOH Sexual Health

Screening Project

DOH Sexual Health

Screening Project

UDS, MU UDS, HEDIS, MU UDS UDS, MU HIVQUAL, QIP MU

    Flu Vaccination

Tobacco Assessment

Cervical Cancer

Screening

Colorectal Cancer

Screening

Adult Weight Screening and

Follow upGonorrhea Screening HIV Screening

Tobacco Cessation

Intervention

Controlled HTN (Last BP <

140/90)

Diabetes HbA1c > 9 % or not tested

Diabetes HbA1c <7%

VL Suppression(Last VL< 200 copies/mm3)

Meaningful Use

2014 NYS Target Goal   42% 90% 62% 36% 53% 95% 95% 69% 68% 25% 45% 76% 100%

2015 Q2 Brightpoint

Health Average  31% 97% 32% 14% 92% 72% 73% 87% 70% 26% 51% 65% 100%

Provider Panel Size (by PCG)                          

1 196 43.75% 96.89% 52.94% 1.12% 68.60% 16.98% 26.96% 97.48% 56.25% 38% 37.93% 68.42% 85%

2 587 28.22% 94.27% 24.10% 15.23% 91.28% 76.66% 78.66% 97.35% 77.50% 25% 56.96% 61.46% 88%

3 326 19.05% 98.90% 29.85% 4.82% 94.53% 89.42% 82.44% 48.19% 65.38% 23% 53.85%   N/A

4 491 32.42% 98.84% 45.60% 10.24% 97.99% 87.70% 77.74% 96.41% 73.15% 25% 49.12% 63.83% N/A

5 644 36.91% 99.42% 37.34% 21.25% 97.89% 58.96% 74.19% 92.77% 62.39% 30% 47.89% 56.52% 85%

6 581 23.65% 95.17% 16.76% 1.77% 89.17% 85.86% 82.35% 92.64% 68.29% 19% 46.55% 63.64% 100%

     

  Met or Exceeded Target Goal

  Approaching Target Goal (within 10% of Target Goal)

  Has not met Target Goal (>10% from Target Goal)

Example: Provider Progress

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2015 Q12015 Q2Target Goal

Example: Health Center Dashboard

Successful efficient Systems of Care must:

Understand the needs of your patient population

Utilize population

health management tools improve

quality

Understand the true barriers

preventing patients from

engaging in care

Fiscal Concerns: How Do We Pay For Integrated CarePaul D. Vitale, MA, FACHEPresident and Chief Executive Officer

Challenge: Shifting from HIV to FQHC-H had funding implications

Potential to lose grant funding for

HIV only programs.

More reliant on government reimbursement for operating

revenue.

Board

Challenge: Change Is difficult for all stakeholders

Staff Patients

Capacity issues• Maximum of 30% of visits to primary care

centers can be for behavioral care

Challenge: True integration of behavioral health is particularly challenging

Provider issues• Shortage of qualified mental health providers who

want to work with our population• Expansion of services and populations means

finding new providers• Pediatric specialists• Bi-lingual providers

• Strategic planning• State reform program• Managed care and value based payments• Health home care management programs• Growth through strategic acquisitions and affiliations• Hospital system partnerships• Fiscal management

• FQHC Status• Grants • Making very tough decisions

Complex Challenges Require Multiple Solutions

• All major initiatives pay off these objectives

—or they don’t happen

1. Grow through organic growth, new

locations, acquisitions, affiliations and

mergers

2. Expansion of our population, services and

integrated care models

3. Embrace and flourish within a value-

based health care environment

4. Re-creation of our identity through

branding, marketing, development and

communications

5. Enhancement of our organizational

effectiveness to support our direction

Solution: Effective Strategic Planning

• Brightpoint concluded first strategic plan cycle in 2013

• 2014-17 Strategic plan based on five pillars

Reform was desperately needed in New York State. In 2010:• Medicaid costs per recipient were double the national average• Ranked 50th in country for avoidable hospital use• Ranked 21st for overall Health System Quality

Governor Cuomo created the Medicaid Redesign Team (MRT).• 27 stakeholders representing every sector of health care • Developed a series of recommendations to lower immediate spending and institute

reforms• Closely tied to New York’s implementation of the ACA

Multi-year action plan–still being implemented

Solution:New York State initiated revolutionary changes in health care in 2011

Key Components of MRT Reforms

Fiscal discipline, transparency

and accountability

Care management

Patient- centered

medical homes and Health

Homes

Targeting the social

determinants of health

$7B Designated for Delivery System Reform Incentive Payment Program (DSRIP) to:

Transform the State’s Health Care System

Bend the Medicaid Cost Curve

Assure Access to Quality Care for all Medicaid Members

Create a financially sustainable Safety Net infrastructure

• From fragmented and overly focused on inpatient care towards integrated and community focused

• From a re-active, provider-focused system to a pro-active, patient-focused system

• Allow providers to invest in changing their business models

DSRIP – Transforming the Delivery System

Patient-Centered

Transparent

Collaborative

Accountable

Value Driven

Transformation of the delivery system can only become and remain successful when the payment system is transformed as well

Solution: Managed Care and Value-Based Payment is the future of Medicaid and HIV Organizations

Many of NYS system’s problems are rooted in payment modelsFee For Service pays for inputs rather than outcome; an avoidable readmission is rewarded more than a successful transition to integrated care

Current payment systems do not adequately incentivize prevention, coordination or integration

•Care management (Health Home) program for multiple comorbidities• Chronic health conditions• Severe behavioral health challenges

•Coordinates services: primary care, specialists, social support, housing and benefit applications, etc.• Acts as Client’s advocate navigating bureaucracy

•Reduces ED visits, in-patient care and re-hospitalizations

Solution: Care Management puts health care reform into action

• Brightpoint Merger with Community Health Action of Staten Island (CHASI)• Brightpoint gets: New services and service area • CHASI gets: Financial and infrastructure support,

and scale from a larger organization

• How it happened and why it worked• Merger was based on shared vision, culture,

strategy and commitment to quality.• CHASI leadership integrated with Brightpoint. CEO

key addition to our team

Solution: Growth through affiliations and mergers

Brightpoint Health assumed management of NY Presbyterian/Queen’s AIDS center

• Brightpoint is known for excellence coordinating HIV care • World class hospital system care standards maintained

throughout transition• Comprehensive case management • Communication between the care coordination team and

NYP/Q• Care management staff on-site in the hospital is the first

step towards avoiding costly inpatient stays• Results: Strong quality metrics

– Lower viral loads– Retention in care

Solution: Hospital system partnerships

H

Our nursing home was our legacy.

Not our future.

Solution: Making tough decisions

In 2015, we made the very tough decision

to sell our nursing home license to a proprietary group

Heartbreaking but necessary for our long term success and

ability to serve more patients, including those

living with HIV.

New care models and Value Based

Payments discouraged inpatient Care.

Patients were getting the same services and the

same quality care on an outpatient basis.

Better Care• Over 85% of our primary care patients are

satisfied with their care, provider access and engagement. Almost all would recommend Brightpoint Health to a friend.

These Solutions Allow Us to Meet Our Overriding Objective: The Triple Aim

Bette

r Car

e Better HealthLower Costs

Lower Costs• Identify high risk/high cost patients.• Provide more intensive care

management and intervention toward reducing costly Emergency Department visits and inpatient care.

Better Health • Our clinical results meet or

exceed national and state benchmarks despite patients representing a less stable population than Medicaid recipients overall.

Result: Internal growth and adjusting to change

From four locations to

sixteen

From 300 employees to almost 800

From 90,000 health care

visits to over 130,000

Since 2012, Brightpoint Health has gone

We maintain our ten Core Values

Result: Internal growth and adjusting to change

Result: Internal growth and adjusting to change

How?•Invested in quality•Invested in culture•Continuity in executive leadership•Brand ownership