Transcript Slide 1

Altarum Institute Policy
Roundtable
Integrating Primary and Behavioral Health
Services: A Community Health Center Paradigm
July 21, 2010
Washington, D.C.
Refining the Integration Paradigm:
A Challenge to Policy Makers
Dennis S. Freeman, Ph.D.
Chief Executive Officer
Cherokee Health Systems
© 2010 Cherokee Health Systems
All Rights Reserved
2
The Press for Integration -- Why the Future is Now
▲ Widespread acceptance of the “concept” of integration
▲ Tantalizing outcome studies are appearing
▲ Health status of persons with serious mental illness
▲ Increased appreciation of behavioral factors in chronic
disease management
▲ Emergence of the concept of the Healthcare Home
▲ Diminished scope of CMHC system
▲ Expansion of the FQHC system
© 2010 Cherokee Health Systems
All Rights Reserved
3
New Paradigms Emerging Across the Safety Net
Paradigm Shift at the Systems Level
▲ Primary Care-locus of most mental health intervention
▲ Increased mental health service capacity at FQHCs
▲ FQHC/CMHC collaborations
Paradigm Shift at the Clinical Level
▲ Primary Care Provider focus on behavioral factors
▲ Mental Health Provider focus on general health status
▲ New service role for Behaviorists in primary care
© 2010 Cherokee Health Systems
All Rights Reserved
4
5
A Few Nagging Questions About Integration
▲ What is it?
▲ How do we do it?
▲ Who can do it?
▲ How do we pay for it?
▲ What are the results?
© 2010 Cherokee Health Systems
All Rights Reserved
6
Integration: Beyond Co-Location
Integrated Care
Co-Located Mental Health
▲ Embedded member of
▲ Ancillary service provider
primary care team
▲ Patient contact via hand off
▲ Patient contact via referral
▲ Verbal communication
▲ Written communication
predominate
predominate
▲ Brief, aperiodic interventions
▲ Regular schedule of sessions
▲ Flexible schedule
▲ Fixed schedule
▲ Generalist orientation
▲ Specialty orientation
▲ Behavior medicine scope
▲ Psychiatric disorders scope
© 2010 Cherokee Health Systems
All Rights Reserved
7
Cherokee Health Systems:
Merging the Missions of
CMHCs and FQHCs
© 2010 Cherokee Health Systems
All Rights Reserved
8
Cherokee Health Systems
A Federally Qualified Health Center and
Community Mental Health Center
Corporate Profile
Founded: 1960
Services:
Primary Care - Community Mental Health - Dental - Corporate Health Strategies
Locations:
21 clinical locations in 14 Tennessee Counties
Behavioral health outreach at numerous other sites including primary care clinics, schools and Head Start Centers
Number of Clients: 58,561 unduplicated individuals served - 24,958 Medicaid (TennCare)
New Patients: 19,829
Patient Services: 442,626
Number of Employees: 538
Provider Staff:
Psychologists - 40
Primary Care Physicians - 31
NP/PA (Primary Care) - 17
Master’s level Clinicians - 59
Psychiatrists - 13
NP (Psych) - 7
Case Managers - 29
Pharmacists - 9
Dentists - 2
© 2010 Cherokee Health Systems
All Rights Reserved
9
Blending Behavioral Health
into Primary Care
Cherokee Health Systems’ Clinical Model
© 2010 Cherokee Health Systems
All Rights Reserved
10
Blending Behavioral Health into Primary Care
Cherokee Health Systems’ Clinical Model
Behaviorist on the Primary Team
The Behavioral Health Consultant (BHC) is an embedded, full-time member of the primary
care team. The BHC is a licensed Health Service Provider in Psychology. A Psychiatrist is
available, generally by telephone, for medication consults.
Service Description
The BHC provides brief, targeted, real-time interventions to address the psychosocial
aspects of primary care.
Typical Service Scenario
The Primary Care Provider (PCP) determines that psychosocial factors underlie the
patient’s presenting complaints or are adversely impacting the response to treatment.
During the visit the PCP “hands off” the patient to the BHC for assessment or intervention.
© 2010 Cherokee Health Systems
All Rights Reserved
11
The Behavioral Health Consultant (BHC)
in Primary Care
▲ Management of psychosocial aspects of chronic and acute
diseases
▲ Application of behavioral principles to address lifestyle and
health risk issues
▲ Emphasis on prevention and self-help approaches,
partnering with patients in a treatment approach that builds
resiliency and encourages personal responsibility for health
▲ Consultation and co-management in the treatment of mental
disorders and psychological issues
© 2010 Cherokee Health Systems
All Rights Reserved
12
Cherokee’s Patient-Centered Healthcare Home
▲ Embedded Behavioral Health Consultant on the Primary Care
Team
▲ Real time behavioral and psychiatric consultation available to
PCP
▲ Focused behavioral intervention in primary care
▲ Behavioral medicine scope of practice
▲ Encourage patient responsibility for healthful living
▲ A behaviorally enhanced Healthcare Home
© 2010 Cherokee Health Systems
All Rights Reserved
13
Outcomes of Cherokee’s Behaviorist Enriched
Healthcare Home
▲ Penetration rate
▲ Efficient management of utilization
▲ Improved health outcomes
▲ Focus on patient responsibility and behavioral change
▲ Provider and patient satisfaction
© 2010 Cherokee Health Systems
All Rights Reserved
14
117%
78%
63%
Cost
Hospital Care
32%
Specialty Care
58%
ER Visits
Primary Care Visits
% of Average Utilization
x utilization level for other regional providers
Figure 1: Comparison of CHS utilization with regional providers
© 2010 Cherokee Health Systems
All Rights Reserved
15
Payment Policy Disincentives for the Integration
Paradigm
▲ Mental health carve-outs
▲ Excessive documentation requirements
▲ Same day billing prohibition
▲ Encounter-based reimbursement
▲ Antiquated coding requirements
© 2010 Cherokee Health Systems
All Rights Reserved
16
Refining the Integration Paradigm: The Policy Dilemma
Obvious Questions, Challenging Answers, Controversial Solutions
▲ Since most mental health problems are treated only in primary care,
why do most behaviorists practice elsewhere?
▲ Is the academic health manpower pipeline generating the workforce
for tomorrow’s healthcare system?
▲ Since so much of primary care is behavioral in nature, why is
treatment primarily bio-chemical in response?
▲ Why do we have 2 separate, community-based safety net systems
when most patients of each system need the services of both?
▲ Since primary care/behavioral health integration enjoys such acclaim,
why is there so little of it in existence?
© 2010 Cherokee Health Systems
All Rights Reserved
17
Contact Information:
Dennis S. Freeman, Ph.D.
Chief Executive Officer
[email protected]
Cherokee Health Systems
2018 Western Avenue
Knoxville, Tennessee 37921
Phone: (865) 934-6711
Fax: (865) 934-6780
© 2010 Cherokee Health Systems
All Rights Reserved
18
The Patient-Centered Medical Home:
The Role of Behavioral Health
Alexander Blount, EdD
Professor of Family Medicine and Psychiatry
University of Massachusetts Medical School
Director of Behavioral Science
Department of Family Medicine and Community Health
19
The Patient Centered Medical Home “Defined”
ACP, AAFP, AAP, AOA
▲ Personal physician - each patient has an ongoing relationship with a personal physician
trained to provide first contact, continuous and comprehensive care.
▲ Physician directed medical practice – the personal physician leads a team of individuals at
the practice level who collectively take responsibility for the ongoing care of patients.
▲ Whole person orientation – the personal physician is responsible for providing for all the
patient’s health care needs or taking responsibility for appropriately arranging care with other
qualified professionals. This includes care for all stages of life; acute care; chronic care;
preventive services; and end of life care.
▲ Care is coordinated and/or integrated across all elements of the complex health care system
(e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s
community (e.g., family, public and private community-based services). Care is facilitated by
registries, information technology, health information exchange and other means to assure that
patients get the indicated care when and where they need and want it in a culturally and
linguistically appropriate manner
▲ http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home
20
How Much Does it Cost Us?
Identified in multiple states that on average extreme uncoordinated care pts (<10%)
account for approximately:
30% of all medical costs,
45% of all drug costs and
32% of total plan costs and for older pts even more
At least 35% of costs for the uncoordinated care groups represent potential savings
Approx. 10% of total direct care costs can be saved if the most extreme uncoordinated
care patients are better coordinated via medical homes, health information exchange
of data , targeted interventions and other combined strategies
Slide from Owens, Focusing Care Coordination
http://www.pcpcc.net/content/care-coordination
21
Traditional Disease/Utilization/Care
Management Program Approaches
▲ Voluntary pt enrollment
▲ Target all pts with a major chronic disease-same interv.
▲ Assume all high cost and high utilizers are cost & quality impactable
▲ Focus resources on contacts with high cost and high utilizers
▲ Often rely on pt reported behavior instead of actual claims or medical
chart data
▲ Assume chronic and/or complex disease drives majority of all cost
Slide from Owens, Focusing Care Coordination http://www.pcpcc.net/content/care-coordination
22
The Complex “Medical-only” Patient is Rare
Among Complex Patients
▲ The more somatic illnesses a person has, the more they are
likely to have one or more psychiatric diagnoses
▲ Low income and “neuroticism” correlate with more somatic
diagnoses as well as more psychiatric diagnoses
Neeleman, J., Ormel, J. AND Bijl, R. V (2001). The distribution of psychiatric and somatic ill
health: associations with personality and socioeconomic status, Psychosomatic
Medicine 63:239–247
▲ Finding similar to large pilot done by Boeing Corporation
www.integratedprimarycare.com
23
The Story of “Joan”
Medical Diagnoses:
▲ 1. Chronic thrombocytopenia probably secondary to chronic
ITP
▲ 2. Coronary artery disease. Status post CABG in 1993
▲ 3. Chronic obstructive pulmonary disease. The patient is
intermittently oxygen dependent (and a smoker)
▲ 4. Insulin requiring diabetes associated with neuropathy
▲ 5. Osteoarthritis
▲ 6. Bipolar disorder
▲ 7. Recurrent urinary tract infections
24
The Story of “Joan”
Medications:
▲ Norvasc, famotidine, furosemide, metformin, Neurontin,
diazepam, fluconazole, insulin, and Mellaril.
Other Statistics:
▲ Rank in calls to on call line: #1
▲ Rank in ER utilization (out of 22,000 pts): #1
▲ Rank in eliciting frustrated comments from nurses and
residents: #1
25
“Joan” Gets a Case Manager
▲ Blue Cross, trying desperately to contain costs, assigns her a
telephone case manager
▲ She tells the case manager how verbally abusive her husband
is to her, initiating a referral for elder abuse. It is not
substantiated.
▲ The case manager stops calling
▲ ER use unchanged
26
When depression is an important factor in a
complex presentation, many care managers
are a poor fit
▲ “Nurses, practice assistants, and HCAs complain of the
psychological burden of providing mental health services in
depression care. To avoid exhaustion, they prefer to work parttime. Reports of HCAs working in innovative depression care
programs are still rare." Genschen, J, et al, Health Care Assistants in Primary
Care Depression Management: Role Perception, Burdening Factors, and Disease
Conception. Annals of Family Medicine, Vol 7, no.6. 2009.
27
Why Should Behavioral Health Be a Core
Service of PCMH?
▲ Access – At least 50% better access to MH care if offered in
primary care. (different from managing care across medical
specialties) (Bartels, Coakley, Zubritsky, et al. Am J Psych, 2004)
▲ Complex patients with chronic illnesses needing behavioral health
care are more likely to be designated for Medical Home level of
care.
▲ Care in medical setting is a better cultural fit for many patients.
▲ Behavioral Health Clinicians free up time for PCPs to spend with
other patients, while enhancing patient satisfaction and selfefficacy.
▲ Care management is more effective when done by professionals
with behavioral health skills. (Pincus, Pechura, Keyser, et al. Administration
& Policy in Mental Health. 33(1):2-15, 2006
28
A Change of Pattern for “Joan”
▲ Family systems models teach us that recurrent patterns can be
understood as circular
▲ If they seem unidirectional, look for the hidden influence going
the other direction
▲ Arthur was always taking care of Joan, with more or less
success
▲ How could it be seen as the other way around?
▲ Joan and Arthur engage in occasional couples visits. ER visits
down after meetings. Strategies for night call devised, though
not consistent across residents. Relapse after daughter killed
in MVA.
29
The need for Behavioral Health services in
the PCMH is becoming clearer all the time
▲ NCQA increases the expectation of behavioral health
services (mental health, substance abuse, health behavior
change) in each successive version of the accreditation
requirements for PCMH
▲ URAC has a larger role for behavioral health services than
NCQA in its accreditation requirements for PCMH
30
Options arise when we develop new
descriptions or stories of familiar events
▲ When the health system is stuck in recurrent unhelpful
patterns with a “complex” patient, we need to look for
another story
▲ The details that support a new story could be anywhere in
the interactions of the person in their social network, but
their family is usually the richest source
▲ PCMH care managers need access to skills in family
interviewing and systems thinking in addition to skills in
CBT, relaxation therapies and Motivational Interviewing
31
How can the necessary skills be broadly available?
▲ Behavioral Health Clinician in Primary Care practices
▲ Properly trained clinician (usually psychiatrist or health
psychologist) provides supervision for care manager who
has some behavioral health training (IMPACT model)
▲ Special training programs for mental health professionals to
become primary care behavioral health professionals. (e.g.,
Certificate Program in Primary Care Behavioral Health,
Univ. of Mass. Medical School)
32
Let’s talk some more:
[email protected]
www.IntegratedPrimaryCare.com
Certificate Program In Primary Care
Behavioral Health
www.umassmed.edu/FMCH/PCBH/welcome.aspx
33
Health Care Reform and Integration:
A Federal Perspective
Peggy Clark, MSW, MPA
Nancy Kirchner, MSW
Disabled and Elderly Health Programs Group
Center for Medicaid, CHIP, and Survey & Certification
Centers for Medicare & Medicaid Services
34
Medicaid Facts and Figures
▲ In 2009, over 65 million people were enrolled in Medicaid
– 5.8 million were enrolled on the basis of being age 65 or older
– 9.5 million were enrolled on the basis of being blind or disabled
– 31.3 million were enrolled as eligible children
▲ In 2008, Federal and State government gross Medicaid
outlays were $351.8 billion
35
CMCS and Behavioral Health
▲ Medicaid is the largest payer for mental health services in
the United States
▲ Comprehensive services available through Medicaid;
many are optional under Medicaid so State’s have
considerable flexibility in benefit design
▲ In 2007, Medicaid funding comprised 58% of State Mental
Health Agency revenues for community mental health
services
36
Medicaid MH/SA Service Users
Mental Health
Service Users
10.9%
Substance
Abuse Service
Users
0.7%
All Other
Medicaid
Beneficiaries
88.3%
Source: SAMHSA
37
Medicaid Expenditures for MH/SA Service Users
Mental
Health
Service
Users
29.9%
All Other
Medicaid
Beneficiaries
68.3%
Substance
Abuse
Service
Users
1.8%
Source: SAMHSA
38
Costly Physical Conditions – 22-64
25%
Mental Health Services Users Ages 22 through 64
21.4%
All Medicaid Beneficiaries Ages 22 through 64
20%
15%
14.3%
10%
5.3%
3.5%
5%
5.2%
5.0%
3.4%
3.3%
3.2%
2.0%
3.2%
2.0%
2.2% 1.9%
0%
Any Costly
Physical
Condition
Diabetes
Cardiovascular
Renal
Gastrointestinal
Pulmonary
Cancer
Source: Medicaid Analytic eXtract (MAX), 2003, 13 states
39
MH/SUD: DEHPG Goals
▲ Federal policy supports the offer of effective services and
supports
▲ Improved integration of physical and behavioral health
care
▲ Person-centered, consumer-directed care that supports
successful community integration
▲ Improved accountability and program integrity to assure
Medicaid is a reliable funding option
40
Key Points—Medicaid Mental Health
1986-2005
▲ Medicaid funded a growing share of MH treatment—from
17% (1986) to 28% (2005)
▲ However, MH remained a small share of all Medicaid
spending (just 10% in 2005)
▲ Medicaid spending on MH prescription medications
increased rapidly—from 7% (1986) to 27% (2005) of all
Medicaid MH spending
▲ Hospital and LT MH treatment financed by Medicaid declined
as a share of Medicaid MH spending
41
Key Points—Medicaid Substance Abuse Spending
1986-2005
▲ Medicaid funded a rising share of SA treatment—from 12%
(1986) to 20% (2005)
▲ However, SA remained a very small and falling share of all
Medicaid spending (just 1% in 2005)
▲ Share of Medicaid SA spending for hospital care fell and the
share for SSACS and MSMHOs* rose from 1986 to 2005
▲ Medications currently played no significant role in SA
treatment
▲ Share of all Medicaid SA spending in outpatient settings
more than doubled; inpatient and residential settings share
fell from 1986 to 2006
* Center-based care in specialty substance abuse centers (SSACs) and multi-service mental health organizations (MSMHOs).
42
Medicaid State Plan Benefits
MANDATORY
- Physician services
- Laboratory & x-ray
- Inpatient hospital
- Outpatient hospital
- EPSDT
- Family planning
- Rural and federally-qualified
health centers
- Nurse-midwife services
- NF services for adults
- Home health
OPTIONAL
- Dental services
- Therapies –
PT/OT/Speech/Audiology
- Prosthetic devices, glasses
- Case management
- Clinic services
- Personal care, self-directed
personal care
- Hospice
- ICF/MR
- PRTF for <21
- Rehabilitative services
- Special services in waivers and
demonstrations
43
Some State Plan Options for Mental Health
Services
▲ Inpatient hospital services [other than those provided in an Institution for Mental
Diseases (IMD)]
▲ Outpatient Hospital Services
▲ Physicians’ Services
▲ Medical/Other remedial care furnished under State law, provided by other licensed
practitioners
▲ Home Health Services
▲ Clinic Services
▲ Rehabilitative Services
▲ Services for individuals 65+ in IMDs
▲ Intermediate Care Facility Services for the mentally
retarded /related conditions (ICFs/MR)
▲ Inpatient psychiatric facility services for individuals <22
▲ Case management services
▲ Section 1915(i)
44
Waiver and Demonstration Authorities
▲ Section 1915(a) – voluntary contract with organization
that agrees to provide care
▲ Section 1915(b) – managed care that restricts providers,
selective contracting, locality as central broker, additional
services generated through savings
▲ Section 1915(c) – home and community-based long term
services and supports
▲ 1115 demonstrations – managed care, expand eligibility,
impose cost-sharing, provide different benefits, budget
neutral
45
Managed Mental Health Care
Section 1915(b) waivers that cover mental health services:
▲ California
▲ Texas
▲ Colorado
▲ Utah
▲ Florida
▲ Washington
▲ Georgia
▲ Iowa
▲ Kansas
A federal team of reviewers including
▲ Michigan
representatives from SAMHSA, the Health
▲ Minnesota
Resources and Services Administration,
CMS, and OMB works together during the
▲ Nebraska
approval/renewal process
▲ New Jersey
▲ New Mexico
▲ North Carolina
46
States with 1915(c) Waivers Related to Mental Health
▲ Approved waivers that serve persons aged 18 and older:
– Colorado
– Montana
– Wisconsin
– Connecticut
▲ Approved waivers that serve children with serious emotional
disturbances:
– New York (2)
– Kansas
– Michigan
– Wyoming
– Wisconsin
– Texas
47
Health Reform and Medicaid Mental Health
▲ Health home, chronic conditions (1-1-2011)
– Enhanced FMAP
– Collaboration with SAMHSA
▲ Amendments to 1915 (i) – HCBS type services offered
under State Plan (10-1-2010)
– Allows waiver of comparability
– Prohibits waiver of statewideness
– Adds additional service options
– Increases income option
– Eliminates option to limit number of participants
48
Mental Health Parity
▲ Wellstone-Domenici Mental Health Parity and
Addiction Equity Act of 2008 was passed by Congress
in October 2008 as part of the Bush stimulus package
▲ 02/02/2010: Federal Departments of Treasury, Labor,
and HHS publish Interim Final Regulation in the
Federal Register
– 05/03/2010: Public comment period closed
– 07/01/2010: Regulation effective
▲ MHPAEA also applies to Medicaid managed care
plans (MCOs), CHIP State Plans, and benchmark
plans
– Further guidance from CMCS will be forthcoming
49
Where Are We Going?
“A sustainable, person-driven long-term
support system, in which people with
disabilities and chronic conditions have
choice, control and access to a full array of
quality services that assure optimal
outcomes, such as independence, health
and quality of life.” – DEHPG Vision Statement
50
Treating the Whole Person
While Reducing Costs:
Practical Lessons from the California
Integrated Behavioral Health Project
Mary Rainwater, L.C.S.W
Project Director
Integrated Behavioral Health Project
51
Outline
▲ Brief Overview of Our Initiative
▲ Key Findings
▲ The “Business Case” – Quality and Cost Improvements
▲ The Challenges in Moving from Business Case to Policy
and Financing Reforms
52
In Support of the Field: IBHP Background and
Goals
Launched in 2006 by the Tides Center and The California
Endowment to accelerate the integration of behavioral health
services at primary care community clinics throughout California
Goals:
▲ Improve behavioral health treatment access
▲ Reduce stigma of seeking mental health services
▲ Improve patient outcomes
▲ Strengthen collaboration between mental health and
primary care providers
53
Building and Supporting Connections Across the
Field
▲ Grants
▲ Build and Support a Learning Community
▲ Policy and Advocacy Work
▲ Training and Technical Assistance
▲ Partnerships and Collaborations
54
Lessons Learned:
▲ Clinical:
– Higher Quality
– Improved Access
▲ Operational:
– Requires Customization
– Not One-Size-Fits-All
▲ Financial:
– Lower Health Care Costs
55
1115 Medicaid Waiver Behavioral Health Group’s
Menu
▲ Five Core Elements
– Care Management
– Data Management and Information Exchange
– Consumer Engagement
– Clear Designation of Person-Centered Health Care Home
– Performance Measures
▲ Five Domains to Track Best Practices
– Clinical
– Operational/Administrative
– Financial
– Oversight
– Population-Specific Considerations
56
Integrated Care’s Bottom Line:
Lower Overall Health Costs
57
6-Step Integration Game Plan:
▲ Design Clinical Model
▲ Identify and Address Funding Barriers
▲ Craft Integration Budget
▲ Revise Business Processes and Obtain Necessary
Approvals
▲ Design Implementation Plan
▲ Monitor and Adjust
58
Identify and Address Funding Barriers
59
Alignment of Current Funding
60
Health Care Reform
Three Components of Health Care Reform:
▲ Universal Coverage
▲ Delivery System Redesign
▲ Payment Reform
61
The “Big Fix”
62
California’s Puzzle
63
Health Care Reform and Parity Changes
Everything…
…How services are organized
…How mental illness/substance abuse are addressed
…How mental health/substance abuse treatment are
funded
64
Thank you
Please visit www.ibhp.org for more information, tools and
trainings.
Contact information:
Mary Rainwater: [email protected]
References:
“The Business Case for Integrated Care; Mental Health, Substance Use and
Primary Care Services”, June 2010; Barb Mauer and Dale Jarvis, MCPP
Healthcare Consulting
“Paying for Integrated Services: FQHC, Medi-Cal and Other Funding Strategies”,
June 24, 2010; Dale Jarvis, CPA, MCPP Healthcare Consulting
65