Transcript Lisa Nichols, MSW - Governor`s Health Summit

The Governor’s Health Summit
P R I M A R Y A N D B E H A V I O R A L H E A LT H C A R E I N T E G R AT I O N
SEPTEMBER 30, 2014
The Problem: Behavioral Health Clients Have Poor Health Status
 Seriously Mentally Ill (SMI) clients die approximately 25 years
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earlier than the rest of the population
Preventable medical conditions are the leading cause of
premature death among the SMI population
Behavioral Health clients have higher rates of co-occurring
conditions including—hypertension, diabetes, obesity, and
asthma
Life style choices and medication side effects create a unique
set of medical problems
Behavioral Health clients are less likely to receive care that
meets clinical guidelines
The Problem: Behavioral Health Clients Have Poor Health Status
 In a study of clients served in Weber County
 Only 56% reported having a PCP, 73% of those with a PCP reported
that their PCP was their psychiatrist
 100% reported the need for a care for a primary health condition
 24% had chronic health conditions
 87% had not had recommended preventive screenings
 50% had visited the emergency department for care
 91% who visited the emergency department had gone for a physical
health concern
Care Settings
 There are multiple settings behavioral health clients
access care
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Hospitals and Emergency Departments (ED)
Community Physicians in private practice
Community Health Centers
Volunteer Medical Centers (i.e. “free clinics”)
Challenges: Care Settings
 There are multiple doors and many wrong doors for accessing
care
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Primary care physicians are not trained in medication management for serious
mental illness
Psychiatrists are not trained to manage family practice concerns
It is difficult for clients to access multiple doors (transportation, scheduling,
time)
Understanding the system is difficult for both providers and clients
It is difficult for clients and providers to understand the system
 Care between systems is often disjointed and uncoordinated
 The health care system does not always accommodate
behavioral health clients
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Staff and non-behavioral health clients are uncomfortable with the behavioral
health clients’ behavior
Paperwork can be cumbersome and lengthy
Creating One Door
Community Health Centers
 CHCs are private non-profit organizations that receive some
federal funding
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Services are provided on a sliding fee scale for uninsured clients
 CHCs serve medically underserved areas and populations in
both urban and rural areas
 Behavioral health services, are much like in private physician
practices, and typically include:
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Counseling
Family Practice prescriptions for anxiety and depression
Some psychiatric services
 CHCs and their community mental health providers are
beginning to partner to provide some co-located services
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Weber, Utah, Washington
The Goal: Primary and Behavioral Health Care Integration
 Developed by the Substance Abuse and Mental Health Services
Administration to offer primary care to adults with SMI in
community mental health centers
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Preventive screening
Treatment for primary care conditions
Registry systems
Care Management
Prevention and wellness services
Practice integration and improved communication across the
continuum of care
Integration of Primary Care into Specialty Behavioral Health Care
Weber Human Services and Midtown Community Health Center
operate a federally funded Primary and Behavioral Health Care
Integration site (PBHCI)
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The PBHCI site is currently funded by the Substance Abuse and Mental
Health Services Administration (SAMHSA), and administered by the Center
for Integrated Health Solutions through the National Council for
Community Behavioral Healthcare
Currently there are 106 grantees nationwide
Grant funds are used to provide primary care services for seriously and
persistently mentally ill adults
Grant requires that primary care services be integrated into publicallyfunded, community-based behavioral health care settings
Grant also requires that grantees track services outcomes
Integrated Behavioral Health Model
Function
Access
• Co-location with same entrance
• Shared reception and staff
• Shared Waiting Area
Services
• Case management and staffing of shared clients
• Comprehensive Primary Care
• Medication management for behavioral health concerns
• Behavioral health therapy
Funding
• Grant funding
• Medicaid reimbursement
• Patient Fees
Governance
• Consumer Advisory Board
Data
• Separate data systems with shared access
• Patient registries
Flow of Funds in Weber County Model
Uninsured Clients
Services
Service Provider
Funding Source
Primary Care
Midtown CHC
SAMHSA Grant, patient fees
Behavioral Health
Midtown CHC
Intermountain Healthcare,
St. Benedicts Foundation
grant, patient fees
Services
Service Provider
Funding Source
Primary Care
Midtown CHC
Medicaid Reimbursement
Behavioral Health
Weber Human Services
Medicaid Reimbursement
Medicaid Clients
Managing Clients Entering through the ED
 Behavioral health clients use the emergency department
for primary and behavioral health care.
 The emergency department attracts a greater than
proportional number of uninsured clients with behavioral
health concerns.
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Behavioral Health Network – Intermountain Healthcare employs a
care coordinator to ensure access and timeliness of care
The RAND Study
 SAMHSA commissioned RAND to evaluate the program’s success.
56 sites were selected for a web-based survey and three sites
(including Weber County) were selected for intensive study
The RAND Study: Better Access to Care
The RAND Study: Better Access to Care
The RAND Study – Better Access to Care
The RAND Study: Surprising Results
 The use of shared information systems were associated
with decreased access to care
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Decreases face-to-face communication between staff
Interferes with the creation of a shared culture
Outcomes: Clients Served 2013
 1,170 clients served during 4,620 encounters
 Race and Ethnicity
77% Caucasian
 19% Hispanic
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Insurance Status
35% uninsured
 18% dually eligible for Medicaid and Medicare
 6% Medicare
 29% Medicaid
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Outcomes: Financial
 Overall health cost and financial outcomes are not tracked as
part of SAMHSAs PBHCI project
 Other research shows mixed findings for these factors
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ED use and hospital admissions decline for persons who have coverage who
have an effective ‘usual source of care,’ a probable source of health cost
savings
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However, the frequency of diagnosis and the likelihood of treatment of
behavioral health and other chronic conditions increase with improved
access to care, with the probable impact of increasing total cost, at least in
the short run.
Outcomes: Behavioral Health
National Outcome Measures (NOMs) Number of Consumers Positive at Baseline Positive at Second Interview Outcome Improved Percent Change
*Healthy overall (NOMs)
791
44.90%
62.70%
28.80%
39.70%
*Functioning in everyday life (NOMs)
802
38.50%
59.60%
63.00%
54.70%
*No serious psychological distress
(NOMs)
799
51.90%
74.80%
29.00%
44.10%
Experiencing serious psychological
distress (Past 30 days)
799
48.10%
25.20%
6.10%
-47.70%
*Were never using illegal substances
(NOMs)
799
81.70%
93.20%
15.30%
14.10%
Using illegal substances (Past 30 days)
799
18.30%
6.80%
3.80%
-63.00%
*Were not using tobacco products
(NOMs)
802
45.30%
47.50%
9.90%
5.00%
Challenges: Funding
 Long-term financial sustainability Midtown
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Funding subsidizing care for uninsured clients expires September 30, 2014.
It is not possible to maintain services when a high percentage of clients
remain uninsured
 Funding for new projects
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Financial viability without supplemental grant funding requires that all (or
nearly all) clients be covered by Medicaid or private insurance
Grant funding for uninsured clients has been available only on a very
limited basis
 Coverage
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Uninsured clients are not eligible for public assistance or subsidies under
the Marketplace
Clients are likely to be among the slowest to sign up for coverage and
maintain it. This has been true during the PCN enrollment and will likely
remain true under a Medicaid expansion
Challenges: The Model
 Creating a shared culture
 Primary care staff and behavioral staff are trained differently
 Primary care and behavioral health systems operate differently
 Recruiting and retaining qualified staff
 Shortage of providers trained in medication management and
primary care for seriously mentally ill clients
 Evaluating clinical and financial outcomes
 Financial data across the continuum of care is difficult to obtain or
understand
 Long-term health outcomes are difficult to measure
 Engaging and retaining clients