Transcript SSTAR: An Organization of Integrated Behavioral & Primary

Nancy Paull MS LADC I
Summary of Talk
Overview of integrated care, SSTAR’s model of
primary care –behavioral health integration
2. latest initiative through the NIATx Accelerating
Reform Initiative 3. Billing, IT issues impacting integration1.
 Founded in 1977 as a private, not for profit
organization. Original programs included:
 a 20 bed alcohol detoxification program,
 an outpatient alcohol treatment program,
 an education program for persons convicted of driving
under the influence of alcohol
SSTAR’s programs have been developed by listening
to and trying to meet the needs of the clients we
serve.
From the very early days of operation, it was
clear that our clients were medically
compromised.
• High rates of diabetes,
•Asthma
•Liver disease
•Nutritional deficiences
•Our community has consistently had a high rate
of opioid addiction.
•The first cases of HIV/ AIDS came to SSTAR very
early in the epidemic; and there were no
infectious disease specialists in our community.
•SSTAR became the first provider in the state to
have a counseling/testing site in their drug
treatment facility
When the first wave of individuals tested
positive, we had push-back from the local
private physician community, who didn’t want
us integrating “those” patients into their
private practices.
SSTAR staff had to refer most patients to
Providence and Boston.
SSTAR”s Medical Director Frank Lepreau
said:
“These are our patients- they deserve to be
treated well within their own community”
SO…..
1.
Dr Lepreau sought help from Brown
University Infectious Disease
Specialists
2.
Simultaneously, we started looking
at state regulations for clinics and
licensing requirements
We became a licensed clinic; licensed by the
Massachusetts Department of Public Health;
hired staff; and utilized our medical director
and volunteer Docs from Browns program.
In the first year of operation, we lost a
staggering;
$250,000.
We then decided to apply for FQHC status to
the Bureau of Primary Care.
Our application was rejected.
We then went to our local community
Health Center Assn for help.
Initially they were not thrilled to see us.
•The state had recently started a free care
pool for community health centers and
they did not want drug treatment
agencies stealing their money.
The ASSN suggested we first apply for a
Look-a –Like Clinic and after much work we
were awarded that status.
We became eligible for the state’s free care pool
and our rates for Medicaid/ Medicare increase
significantly. We started working our way back
to financial health.
We then applied with another health center
in town to be an FQHC.
Since only 1 would be funded, SSTAR agreed
to be the sub-recipient in this agreement.
We won FQHC status.
We now have a grant which assist us with basic
infrastructure costs.
Our Health center doctors are covered by
Federal Malpractice Insurance. However, it
does not cover any inpatient work in our detox;
or other services that our not in our scope of
practice.
Building relationships with the local
medical community; preparing for
Medical Homes
•An Approach other organizations could
use to link with Primary Care
Prepare for “medical home” payment reform by increasing
collaboration with community primary care providers.
Mobilize the local medical community to identify, treat,
and improve outcomes for addicted individuals and their
families.
2. CHANGE /DO
Build on relationships with community
medical providers – Partner with St. Anne’s
Hospital
 Convene meeting of S-A primary
care providers – 3/31
3. Results/ Study
 Two primary care providers who attended
the meeting engage in collaboration.
 Referral/release of information form
developed and implemented
 Both practices institute drug and alcohol
screening (CAGE-AID) for annual physicals
and new admits.
Results –cont’d
 SSTAR Family Health Care Center begins tracking
CAGE results in their EHR .
 Hotline cell phone established for instant referral
access to SSTAR case manager by participating
medical providers.
 One of the two participating providers links us to
third medical practice that agrees to participate –
meetings at SSTAR and at the practice, adoption of
referral form.
 Three referrals made
4. Next Steps/ Act


Establish baseline – CAGE results plus tracking of
referral outcomes.
Form a change team to improve referral outcomes.
Introduce ARISE family interventions as strategy to increase treatment
engagement?

Document successes and use to market the value of
screening and SSTAR referrals to other community
providers
5. Impact
New and strengthened partnerships with
community medical providers;
increased focus on addressing the problems
associated with managing addicted patients
in community medical settings.
•Understand the customer: community medical providers
want solution to problem of their “drug-seeking” patients. We
have TA to provide as well as treatment resources.
•Understand the customer: their referred patients don’t
necessarily want treatment or believe they need it. Change
team needs to devise interventions to increase success of
referrals by recognizing where patient is in stages of change
model.
Outcomes
 Three community medical provider practices engage in project
 Referral/Release of Information form developed to improve
coordination of care for shared patients
 Meetings/conference calls
 “Hotline” cell phone set up for community providers to make direct
contact with SSTAR case manager for referrals and “warm handoffs”
 Two practices initiate use of CAGE AID for initial and annual physicals
 Each of the three practices makes at least one referral to the “hotline”
Reimbursement and IT Issues
 M ASSACHUSETTS !
SSTAR of MA Sources of Funding - FY2009
Grants & Contracts
29%
Other Income
4%
Medicaid & M-based
MCOs
30%
Medicare
3%
Client Fees
2%
Commercial
Insurance
21%
Provider Type
 A community health center “provider type” usually
can’t bill to a behavioral health MCO “carve out”. They
aren’t part of the provider network.
 Primary care can’t bill for a behavioral health diagnosis
to a medical payor – they’ll say “that should be billed
to the BH carve out”
Performance Standards - Billing
Under Mental Health Clinic licensure regulations and
payor standards, full psychosocial assessment must be
completed and billed for in order to be eligible for
reimbursement for other BH services such as
individual counseling, group counseling, etc.
If counselor meets with patient for a crisis session or
patient drops in on a group, service isn’t billable
because full intake/assessment hasn’t been processed
first.
Credentials and
Reimbursement
BH Billing in primary care setting limited to LICSW,
PhD licensed psychologist, psychiatrist, NP
Services provided through our mental health clinic –
depending on payor, reimburses for addiction
counselors, LMHC, unlicensed Master’s, etc
Staffing Issues
 BH staff of the Health Center are shared with the BH
clinic to maximize reimbursement
 2 addictions counselors, 1 LMHC, 1 LICSW
 Part of their salary paid from HC budget. They are
not on the salary+productivity pay system that BH
clinic staff are on so they have more flexibility in their
schedules to respond to situations.
 When they provide a reimburseable service, it’s billed
through the BH Clinic;
 Varying payor credentialing requirements can
contribute to “uncollectible” claims.
 Example: Suboxone group led by an addictions
counselor; client with UBH attends the group and that
particular insurance won’t reimburse for that level
provider. It’s not cost-effective to have separate group
for people with that insurance.
“Your memo raises concerns that FQHCs are experiencing difficulty in obtaining
Medicaid payments for behavioral health services by clinical psychologists,
clinical social workers and nurse practitioners. ….. Therefore as long as these
Practitioners are practicing within their scope of practice under state law, the
FQHCs payment should reflect the services provided to Medicaid eligible
Beneficiaries by these types of practitioners.”
CMS MEMO Sept 23, 2003
Integrated Documentation
 For those BH services provided and billed through the
Health Center, there will be notes in the primary care
chart / electronic health record in Nextgen
 But most of the BH care – because of the
reimbursement issues - happens through the BH clinic
and is recorded in the BH electronic health record.
This is a different software application because there
are special needs not met by primary care applications.
 Barrier to integrated care
HIT- options for BH-PC
Integration/Interoperability
 Find one application that meets the needs of BH and
Primary Care
 Create a software bridge to share/dump certain fields into
the other application: for example medication lists,
progress notes
 Develop a data warehouse storing information from both
systems that would allow sharing
 Intranet to access the clinical information from each
application
SUMMARY:
 It is difficult and expensive to start an FQHC
 Billing for Behavioral Health in an FQHC is complex
 IT systems are not yet integrated in a way that is
acceptable to each type of provider and probably not
acceptable to payers and accreditation/licensing
bodies.
BUT:
 Patients can get better, more complete care.
 We are excited to be working to transform systems of
care for our patients.
 SSTAR believes with Medical Homes and Accountable
Care Organizations coming we need to ready ourselves
for the changes