MPCA Integrating Behavioral Health Project

National Association of Community Health Centers, Inc.

BH Integration:from the ordinary to the extraordinary

Beverly Hammerstrom

MPCA Conference

Traverse City, Michigan

September 17, 2007


Overview

History Define the problem today Why now? Exactly do we mean by integrated care? Examples of models Next steps


Let’s first look at insurance…….

Group health insurance first offered in 1910 by Montgomery Ward

Became readily available in the US in the late 1930’s Prior to this primarily offered on lives, houses, cars, etc. Covered only catastrophic losses

In-patient, emergency room Employer-sponsored health insurance became popular

in the 1950’s after the IRS ruled it was a tax-deductible business expense

1960 – Private Sector (75%); Public Sector (25%); but most private sector plans did not cover MH (carve outs)


Federal Health Insurance Policies By early 1960’s clamor began for federal

health insurance policies, primarily to aid poor and elderlyMedicareMedicaid

By end of 1960’s – federal share = 40%


How did physical and mental health become separated? 50 years ago – most people with mental illness were

living in asylums more than 20,000 people in Michigan were living in state

or county-operated facilities 1960’s – due to efforts of John Kennedy and

advances in medicine thinking began to change Michigan PA 258 of 1974 – “tipping point” from

institutional care to community-based system 1980-1990 – reduced by 50% number of people

living in tax-funded institutions Today only less than 2000 patients in state facilities


Promises Made; Promises Broken

Money was intended to follow consumers into the community programs

Employer-paid insurance had no reason to pick up the bill; most didn’t

Operating two systems – state & community; never enough money to fund both

Community-based mental health system has ALWAYS been under funded


Shift in state’s directions

Decreasing revenues have led to a shift in direction to maximize federal dollars and draw down more Medicaid match funds

Incentives put in place in 1995 to encourage CMH’s to become authorities; froze county match

Most treated in county-based systems today for mental illness are Medicaid Few general fund dollars available to treat other populations Guidelines specify they must treat the most severe first

American Association of State and Territorial Health Officials 2005

Just How Big is the Problem

Nearly 44 million Americans (26% of the population) experience a mental health problem annually

Only 5% of those suffering from a mental health problem receive treatment from a mental health professional

Community Mental Health Centers (CMHC) are not required to serve the uninsured population

National Association of Community Health Centers, Inc. (2004)

What does this mean for Primary Health Care Providers? More and more needing behavioral health services are

seeking it through primary care providers 95% seek treatment from a family physician – many for

physical complaints 92% of all elderly patients receive MH care from PCP 90% of most common complaints have no organic basis

70% of federally-funded health centers report on-site mental health treatment and counseling; 50% provide substance abuse treatment and counseling (2003)

The Journal of Family Practice (2001)

Prevalence of Psychiatric Disorders in Low-income PC Patients

Disorder Low-income General PC

At least one psych DX 51% 28%

Mood Disorder 33% 16%

Anxiety Disorder 36% 11%

Alcohol Abuse 17% 7%

Eating Disorder 10% 7%

Mental Health Weekly 1997 and Mountainview Consulting Group, Inc.

More facts………..

70-80% of all psychotropic medications are prescribed within primary care settings, sometimes inappropriately 67% of psychoactive agents prescribed by PCP 80% of antidepressants prescribed by PCP

About ½ the time, mental health problems go undetected in primary care settings

Even when diagnosed, these problems tend to be under-treated MH outcomes in primary care patients only slightly better than

spontaneous recovery


Compliance Issues

As few as 1 in 4 patients referred to specialty MH or CD make the first appointmentNationally = 45-75%“no shows” from 5-15% at first integrated

clinic in Washtenaw County 50-56% non-adherence to psychoactive

medications within first 4 weeks


Untreated/Under-treated Patients Over-utilize medical services

Visit physician twice as often as those receiving appropriate care

Seek treatment in emergency rooms when in crisis

People with persistent depression have annual adjusted medical costs 70% higher than those without depression


Why Patients Seek Mental Health Services in Primary Care Settings Limited access to specialty service providers Lack of adequate insurance coverage Cultural beliefs Eligibility requirements for public mental

health services Trust their own physician Stigma

Committee on the Future of Primary Care, Institute of Medicine, 1996

Primary Care Concurs

Committee on the Future of Primary CareThe committee recommends the reduction of

financial and organizational disincentives for the expanded role of primary care in the provision of mental health services. It further recommends the development and evaluation of collaborative care models that integrate primary care and mental health services more effectively. These models should involve both primary care clinicians and mental health professionals.


Prevalence of Psychiatric Disorders in Low-income PC Patients

Psychiatric Disorder

Low-income Patients

General PC Population

At least One Psychiatric Dx

51% 28%

Mood Disorder 33% 16%

Anxiety Disorder 36% 11%

Alcohol Abuse 17% 7%

Eating Disorder 10% 7%


Low-income Patients with Psychiatric Dx 35% saw their PCP in the past 3 months 90% of low-income patients with

psychiatric Dx preferred integrated care

Morbidity and Mortality in People with Serious Mental Illness

Morbidity and Mortality Rates

People with serious mental illness are dying nearly three decades earlier (on average) than general population High prevalence of obesity, diabetes and

cardiovascular disease Newer medications for bipolar disorder and

schizophrenia can exacerbate metabolic risks BH Providers less likely to screen and monitor

regularly


Recommendations…….

Promote Coordinated and Integrated mental Health and Physical Health Care for Persons with SMIPromote integration of general health and

mental health recordsRevise laws and policies to support

communication between providers


And………

Adopt a Policy that Mental Health and Physical Healthcare should be Integrated

Implement Care Coordinated Models Assure financing methods for service

improvements. Include reimbursement for coordination activities, case management……..

Establish rates adequate to assure access to primary care by persons with SMI

President's New Freedom Commission Report (2000)

New Freedom Commission

Chapter on Integration in the Final Report as well as several Action Agenda activities related to integration

Recommended development of a comprehensive state plan across all mental health activities that should include a requirement to address primary care integration issues

President's New Freedom Commission on Mental Health, 2000

Why Now?

“Research demonstrates that mental health is key to overall physical health. Therefore, improving services for individuals with mental illness requires close attention to how mental health care and general medical care interact. While mental health and physical health are clearly connected, a chasm exists between the mental health and general health care systems in financing and practice.

President's New Freedom Commission on Mental Health, 2000

The Recommendation…….

“Commission suggests that collaborative care models should be widely implemented in primary health care settings and reimbursed by public and private insurance.”

New Freedom Commission Report (2000)

Goal #5:

The Commission recommends that Medicare, Medicaid, and the Department of Veterans Affairs, and other Federal and State-sponsored health insurance programs and private insurers identify and consider payment for core components of evidence-based collaborative care including: case management, disease management, supervision of case managers, consultations to primary care providers by qualified mental health specialists that do not involve face-to-face contact with clients


Changes at the Federal Level

Omnibus Budget Reconciliation Acts (OBRA) of 1987 and 1989 expanded Medicare and Medicaid reimbursements to include clinical psychologists and master’s level social workers practicing in rural areas

HRSA has provided grant funding to FQHC’s to increase behavioral health staff (no longer available)


And………..

PIN 2004-05 – Medicaid funding for BH in FQHC’s

All new FQHC applications must include HRSA is offering grant funds for

Developing Integrated Networks in rural areas and for developing networks

Michigan Mental Health Task Force Report to Governor, 20004

Michigan Task Force Concurs

Mental health and physical health should be more integrated……..

An ideal system is integrated; for consumers entering a confusing array of services, there is no wrong door.

Develop specific sustainable models of collaboration at the state and local levels maximizing resources earmarked for providing mental health services.

Michigan Mental Health Task Force Report to Governor, 2004

Goal #5

“Coordinate the delivery of mental health services by both federally qualified health clinics and community mental health programs.”

The writing’s on the wall, folks!

and it’s the right thing to do


NCCBH Goals for Integration

Every provider of public BH services assures assessment of health status as well as mental status and has specific protocols in place for medically monitoring all consumers receiving second generation antipsychotic medications. An integral part of their service for consumers is to assure that each person is connected to a primary care medical home and there are specific mechanisms between the BH and PCP for coordination of services.


NCCBH Goals continued……..

The safety net population in every community served by providers of public BH services and by CHC’s has seamless access to both BH and physical health care. There is a strong working partnership among these providers, with roles defined, referral protocols in place and cross-placement of clinical staff.

CareIntegra Behavioral Healthcare Solutions

What is Integrated Care?

Not simply placing a MH specialist inside a medical setting

Medically oriented; pace fits with the ecology of the medical setting

Covers problems not typically seen in specialty mental health care

Focuses on population management and on supporting and enhancing the PCP who leads the integrated care team


Integrated care………

Includes a treatment plan containing behavioral and medical elements rather than two separate treatment plans

Is a health care model in which physical health and mental health clinicians partner to manage the treatment of mental health disorders in the primary setting


Elements of BH Integration

Financial or structural integration does not assure clinical integration

Clinical integration helps focus on what consumers need

Public sector efforts focused on financial integration (carve-ins) have had limited success

Clinical integration requires financial and structural supports

Public sector financing is a major barrier to achieving clinical integration in most settings


Benefits of Integration

Improved detection of behavioral health disorders

Significant increase in patients receiving recommended care and positive clinical outcome

Higher levels of patient adherence to treatment Better clinical outcome than by treatment in

either sector alone


More benefits……..

Improved consumer and provider satisfaction

Improved PCP skills in medication prescription practices

Increased confidence in PCP in managing BH conditions


And it saves money……..

More cost effective treatment Can reduce overall cost and reduce over-

utilization of the medical system Between 20 and 40% of total medical care

cost savings Up to 70% saved in treating older

Americans

O'Donahue, Cummings and Laygo (2004)

Oahu Study………

126,000 patients 40% reduction of costs by a sample of

high utilizers Reduced medical utilization by 21%


McDonnell-Douglas Corp. 1989

Provided in-house counseling for substance abuse, depression, family problems for employees – 20,000/4 years

Lowered health care cost of not only employees but also dependants

34-44% reduction in absences 60-80% lower attrition rate Saved $4 in health, absences, and attrition for

every $1 spent

ANNALS OF FAMILY MEDICINE July/August 2004

PCP prefer integrated care: PRISM-E Study of Elderly Better communication between PCP and

MHP (93%) Less stigma for patients (93%) Better coordination of care (92%) Better care of depression (64%) Better care of anxiety (76%) Better care of alcohol problems (66%)


Hypothesis:

Better identification of behavioral health needs and better targeting and managing of treatment to those needs using collaboration will lead to more cost-effective treatment, higher compliance and better patient outcomes.

It should be a slam dunk……


Getting there is not a “walk in the park” Financial Barriers

Not reimbursed for collaborative work Revenue silos Billing requirements; record-keeping regulations

Firewalls in communication systems Legal landmines Stigma and discrimination associated with mental health problems Lack of resources

Human (providers; staff) Funding Time/Space Interest Proper tools

Language and Cultural Differences


The Great Cultural Divide……..

Primary Care Docs 10-15 minute blocks Deal one-on-one w/other

physicians Find it difficult to deal with

interdisciplinary team Medical records short,

concise summaries of the diagnosis, treatment and outcome

Language = patients

Psychiatrists Language = clients or

consumers 45-60 minute sessions

Time with consumers considered sacrosanct

Behavioral health records are long and complex

Contain goals and objectives

Variety of provided services; may be re-evaluated over time

Contain consumer input


Training…………

Most primary care physicians receive little training in psychiatry

Most psychiatric specialty training does not provide much training in primary care issues

Neither receives significant training in collaborative, integrated practices arrangements


Barriers Identified by Michigan FQHC’s Funds to employ staff Limited availability of behavioral health

providers Limited space and staff Staff resistance Ownership of medical records; HIPPA Sharing of revenue sources

Peek, C.J., Phd. "Collaborative Care Aids to Navigation - A CFHA Perspective

Three World View: Three Languages Clinical

“Achievement” of health goalsGoal of care = quality

FinancialBottom linePrice/value

Structural/OperationalProductivityEfficiency

National Council for Community Behavioral Health Care, July 2006

Minkoff’s View (Medical Director of Choate Integrated Behavioral Care, Woburn, MA)

Clinical integration Dually trained clinicians or interdisciplinary teams

Clinical practice integration Formal collaboration and consultation mechanisms,

required screening practices, collaboration practices built into service protocols

National Association of Community Health Centers, Inc., 2006

Balance clinical integration with….. Programmatic integration

Structural integration Behavioral and primary care services under a

common administrative authority which can create standards for collaboration and clinical integration

Physical integration Co-location of services in either direction

National Association of Community Health Centers, Inc. 2006

And………..

Fiscal integrationMental health and primary care services

under a common funding stream which can be utilized to promote any of the other’s activities


Doherty’s FIVE LEVELS OF COLLABORATIONBASIC BASIC AT

DISTANCEBASIC ON SITE CLOSE-PARTLY

INTEGRATEDCLOSE-FULLY INTEGRATED

TWO FRONT DOORS; SEPARATE FACILITIES

TWO FRONT DOORS; SEPARATE FACILITIES

SHARED FACILITY; MAY SHARE RECEPTION AREA

SHARED SITES ONE FRONT DOOR; SHARED SITE; ONE VISIT FOR ALL NEEDS

SEPARATE AND DISTINCT

TREATMENT PLAN AND SERVICES

OCCASIONAL PLAN SHARING; SEPARATE & DISTINCT SERVICES

TWO PHYSICIANS; TWO TREATMENT PLANS; SOME INTERACTION DUE TO PROXIMITY

COORDINATED TREATMENT PLAN;

REGULAR FACE-TO-FACE INTERACTION

SAME SYSTEMS; SEAMLESS; ONE TREATMENT PLAN; ON-GOING CONSULTATION

SEPARATE FUND-

ING SYSTEMS; NO RESOURCE SHARING

SEPARATE FUND-ING SYSTEMS

PRIMARY CARE PHYSICIAN WORKS WITH CLINICIAN ON SITE RATHER THAN PSYCHIATRIST

SEPARATE FUNDING WITH SHARED ON-SITE EXPENSES; SHARED STAFFING & INFRASTRUCTURE COSTS

INTEGRATED FUNDING WITH RE-SOURCES SHARED ACROSS NEEDS; MAXIMIZATION OF BILLING AND SUPPORT STAFF

SEPARATE DATA SYSTEMS; LIMITED SHARING

LINE STAFF WORK TOGETHER ON SOME CASES

NO SYSTEMIC APPROACH TO COLLABORATION

SOME DATA SHARING BUT SEPARATE DATA SETS

REGULAR COLLABORATIVE TEAM MEETINGS

LIMITED COMMUNICATION

LITTLE SHARED RESPONSIBILITY

APPRECIATION OF OTHERS’ ROLES

BASIC APPRECIA-TION OF OTHERS’ ROLE & CULLTURE

SHARED VISION

LITTLE UNDERSTAND-ING OF OTHERS’ CULTURE

NO COMMON LAN-GUAGE OR UNDER-STANDING OF OTHERS’ CULTURE

SHARED ALLEGIANCE TO BIOPSYCHOSOCIAL SYSTEMS PARADIGM

FULLY INTEGRATED ELECTRONIC HEALTH RECORD; NEED-TO-KNOW ACCESS FOR ALL PRACTITIONERS

Doherty’s Five Levels,


Bureau of Primary Health Care Model……….. Model I

Referral Relationship Model II

Co-location Teams working separately

Model III On-site; shared cases between BH and PCP

Model IV Integrated Care; BH specialist an active member of primary care

team


A very basic on-site integrated model Physicians remain in charge of patient’s

physical health Mental health professionals assess for

mental illnesses and link clients with appropriate services

Co-location provides “single point of entry”

Penny S. Bruckner and Cleveland G. Shields. FAMILIES, SYSTEMS & HEALTH (2003)

Collaboration – Contact & Communication Therapists read medical charts and notes Physicians read therapy notes Providers talk in the hallway Physicians join therapy sessions Therapists join medical sessions Conjoint family meetings Unified treatment team working to best assist

patient in physical and mental care

Mountainview Consulting Group, Inc.

Continuum of Integration

Model Desirability Attributes

Separate Location and Mission

-- Traditional BH Specialty Model

Referral Relationship + Preferred Provider

Some info exchange

Co-location ++ On-site BH Unit but Separate Team

Collaborative Care +++ On-site/shared cases

With BH specialist

Integrated Care +++++ BH specialists primary care team members

American Association of Community Psychiatrists

Components of an Integrated Model Behavioral Health Triage Comprehensive Behavioral Health Assessment On-site Behavioral Health Treatment Referral Consultation Care monitoring and chronic disease

management protocols


On-site Behavioral Health Treatment May include an array of services

Individual, group, family counselingPsychotherapyPsychopharmacological assessment and

treatment Limited by available behavioral health

staffing and budgetary capacity


Referrals

Internal referral back to PCP or other BH staff

External referral to specialty BH providers Other social service components

HousingEmployment


Care monitoring

Chronic psychiatric conditions that can be managed effectively in PC settingLess complicated cases of depression

Chronic health problems that are result of or complicated by co-morbid psychiatric conditionsDifficulty adjusting to diabetes or cancer


Cherokee Health Systems

Both a community health clinic and a community mental health provider in Tennessee

Opened its first co-located, integrated primary care and behavioral health clinic in 1984

Today Cherokee has 21 sites


Cherokee’s Patient Base

40,000 in 200144% sought primary health care56% sought behavioral health services57% of population is Medicaid reimbursed on

a capitation basis12% are covered by Medicare9% covered by federal and state grants


Core Objective = Integration

Entire staff is committed All staff (accounting, front-line, supporting) are

considered essential players in providing integrated care

Weekly case management meeting include the entire clinical staff Primary care providers are paid for time

required for collaboration

www.apa.org/monitor/janof/ppup.html

And………

Cherokee offers 12-month, 2000-hour internships to provide “an intensive and diverse clinical training experience within a community health setting”

BEHAVIORAL HEALTHCARE TOMORROW (April 2004)

According to Cherokee……..

……….placement of a behaviorist on each primary care team is crucial to their mission to help ensure that the patients will get the appropriate behavioral care prescribed and recommended.


Next steps……….

Determine where you are on the continuum of care and where you want to beMight require a stepped approachMight be different at each locationWill depend upon resources available

Staff, space, time, funding


Don’t reinvent the wheel….

Lots of model programs that have proven successful

Look at them, but then tweak them to meet the individual needs of your center


Washtenaw County WCHO

Delonis Homeless Shelter Small health clinic open 35 hrs. per week

Nurse Practitioner Clinic Services to consumers at CMH facility, including smoking

cessation classes Packard Community Clinic

Full-time MSW and 4 hrs. of psychiatric time per week Ypsilanti Family Practice

½ day per week adult and child psychiatrist on site for consultation and resident training

Corner Health Center Mental health staffing at center for persons 12-21 and children


National Models That Already Exist

MacArthur IMPACT RWJ Depression Disparities BPHC Health Disparities Program Washtenaw County Michigan Model Cherokee Health Systems - Tennessee


A rose by any other name….

If you’ve seen one integrated care program, you’ve seen one integrated care program

Each program should be designed to address the needs in the community and be consistent with the mission and objectives of primary care

Different models lead to different costs and outcomes


Look for ways to partner….

Shared staffing arrangements Shared services Don’t overlook opportunities through

telemedicine Opportunities to co-locate

Three Rivers Health St. Joseph CMH Dental practice


Look for funding opportunities

HRSA Grants Foundations

RWJF Hogg Foundation

Funding CMH Staff at Primary Care Clinics When the number of shared consumers is >40

(average case load size at CMH), and existing CMH professional and 5 hours of psychiatric time can be allocated to that clinic for the provision of on-site mental health services


Legislation may be needed….

Reimbursement codes Federal state

Insurance Laws Public/Mental Health Code Changes

Allow for partnerships/shared funding streams

Governance It’s not impossible…….


What’s on the Horizon………

National Learning Collaboratives National Learning Communities

National Council for Community Behavioral Healthcare

Statewide Learning Communities Statewide Pilot Projects Local Ideas


“There is no try; only do.” Yoda

Thank you.

Health & Medicine

MPCA Integrating Behavioral Health Project