behavioral health integration: a key step towards the triple aim

Behavioral Health Integration: A Key Step towards the Triple

AimMara Laderman, MSPH

Senior Research AssociateInstitute for Healthcare Improvement

Benjamin Miller, PsyDDirector of Health Policy

University of Colorado - Denver

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session # C4aOctober 18, 2014

Faculty Disclosure

• We have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Learn about the Triple Aim benefits of primary care-behavioral health integration.

• Use analyses of health plan and outcomes data to make the case for integration at their organization.

• Describe IHI's approach to behavioral health integration.

Bibliography / Reference1. IHI 90-Day R&D Project Final Summary Report: Integrating Behavioral Health and

Primary Care. Cambridge, MA: Institute for Healthcare Improvement; March 2014.

2. Laderman M, Mate K. Integrating Behavioral Health into Primary Care. Healthcare Executive. 2014 Mar/Apr;29(2):74-77.

3. Academy for Integrating Behavioral Health and Primary Care, Agency for Healthcare Research and Quality (AHRQ). Lexicon for Behavioral Health and Primary Care Integration. Available at: http://integrationacademy.ahrq.gov/lexicon

4. Mental Health, Substance Abuse and Health Behavior Services in Patient-Centered Medical Homes. Kessler, R., Miller, B.F., Kelly, M., Graham, D. Kennedy, A., Littenberg, B., Maclean, C., van Eeghen, Scholle, S., Tirodkar, M., Morton, S., & Pace, W. The Journal of the American Board of Family Medicine, 27(5), 637-644.

5. The Working Party Group on Integrated Behavioral Healthcare, Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., Epperly, T., Green, L., Henley, D., Kessler, R., Korsen, N., McDaniel, S., Miller, B., Pugno, P, Roberts, R., Schirmer, J., Seymour, D., & deGruy, F. (2014). Joint Principles: Integration Behavioral Health Care into the Patient-Centered Medical Home. The Annals of Family Medicine, 12(2), 183-185.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Today’s Agenda

Making the case: Integration and the Triple Aim

Overview of IHI

IHI’s research on behavioral health integration

Five-step sequence to integrate BH

Future directions for IHI’s work

Behavioral Health Integration Capacity Assessment (BHICA)

Today’s Agenda

Making the case: Integration and the Triple Aim

Overview of IHI

IHI’s research on behavioral health integration

Five-step sequence to integrate BH

Future directions for IHI’s work

Behavioral Health Integration Capacity Assessment (BHICA)

Definition 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 care may

address mental health, substance abuse conditions, health

behaviors (including their contribution to chronic medical illnesses),

life stressors and crises, stress-related physical symptoms,

ineffective patterns of health care utilization.

Value of Integration:

Physical/Behavioral Integration is good health policy and good

for health.

Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.

No such thing as a single disease 9

In service to

Improving outcomes

Decreasing cost

Enhancing the patient experience

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Drucker’s Big Seven (for innovative opportunity)

The unexpected success, failure or outside eventThe incongruity – between reality as it actually is and reality as it is assumed to beInnovation based on process needChanges in industry or market structure Demographics Changes in perception, mood and meaning New knowledge – scientific and nonscientific

Those who say it can’t be done are usually interrupted by others doing itJames Baldwin

Today’s Agenda

Making the case: Integration and the Triple Aim

Overview of IHI

IHI’s research on behavioral health integration

Five-step sequence to integrate BH

Future directions for IHI’s work

Behavioral Health Integration Capacity Assessment (BHICA)

Our Mission:To improve health and health care worldwide

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IHI’s Work: Five Key Areas16

Triple Aim for Populations17

Our Goal:

Drive the Triple Aim, simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities.

Proven Methodology: Science of Improvement

W. Edwards Deming1900-1993

API’s Model for Improvement

Today’s Agenda

Making the case: Integration and the Triple Aim

Overview of IHI

IHI’s research on behavioral health integration

Five-step sequence to integrate BH

Future directions for IHI’s work

Behavioral Health Integration Capacity Assessment (BHICA)

What drives IHI’s interest in integration?

Poor outcomes and high costs for patients with medical + behavioral comorbidities.

Getting to the Triple Aim will require addressing behavioral health!

Changing incentives will facilitate this.

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Research Project Aims

Understand the core principles underlying successful approaches to integration of behavioral health services into primary care.

Develop IHI’s approach to integration.

Identify how IHI can support organizations to integrate behavioral health and primary care.

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Research MethodsReviewed peer-reviewed and grey literature and materials from existing models.

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Name Organization

Gary Belkin NYC HHC / NYU

Benjamin Miller University of Colorado – Denver

Mary Rainwater Integration Consultant, formerly with IBHP

Laurie Alexander Integration Consultant, formerly with AIMS Center

Alexander Blount UMass Medical Center, Center for Integrated Care

Parinda Khatri Cherokee Health Systems

Jurgen Unutzer IMPACT / AIMS Center, University of Washington

Brenda Reiss-Brennan Intermountain Health Care

Robin Henderson St. Charles Health System

Russell Phillips Harvard Medical School, Center for Primary Care

Ileana Welte Big White Wall

Brady Cole U.S. Department of Veteran’s Affairs

Key Research Findings

Perception is that there are many different ways to implement integration; we found that the commonalities are much greater than the differences.– Collaborative care principles; strong evidence base.

Five-step sequence to integrate BH

Biggest challenges are business case and operationalizing components into workflows.

Improvement approach is currently lacking.

Lack of integration outside of clinic visit.

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Innovation: Full Spectrum IntegrationLayer of Service Frequency of

InteractionWhere service is provided

Who provides service

1 – Acute Care Continuous (during hospitalization)

Hospital Physician Cost

2 –Clinic Care Quarterly Clinic PCP; behavioral health provider. Could include group visits

3 – Community Care Weekly; more than once a week initially

Home, workplace, community organization

Community health workers; mobile clinics. Could include group visits

4 – Family Engagement in Care

Daily Home Family members

5 – Self-care Daily Home Patients

6 - Policy and Financial Considerations  

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Which states and why?Variability in financial environment between states to support behavioral health integration.

Some states may be more interested than others due to: Medicaid waivers, Medicaid BH carve out, Medicaid expansion / expected growth in Medicaid population, # of ACOs & pushes for global payments.

We compiled a list of states with favorable markets for integration.

Favorable States: AZ, AR, CA,CO, IL, KY, MD, MI, NV, NJ, NM, OH, OR, and VT.

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Today’s Agenda

Making the case: Integration and the Triple Aim

Overview of IHI

IHI’s research on behavioral health integration

Five-step sequence to integrate BH

Future directions for IHI’s work

Behavioral Health Integration Capacity Assessment (BHICA)

Five Step Sequence

1. Assess readiness for integration.

2. Develop reliable operations and processes to support integrated care.

3. Develop the business case for integration.

4. Re-design care delivery using collaborative care principles for integration.

5. Operationalize changes into clinical workflows.

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1. Assess readiness for integration

Assess readiness based on:– Patient needs– Clinic characteristics– Policy & financial environment– Existing data & measurement system

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1. Assess Readiness

2. Develop Reliable Operations and Processes to Support Integrated Care

Leadership and culture

Access and workflows– Technology considerations– Workforce: recruitment, hiring, onboarding,

and oversight of staff– Workflows– Seamless information sharing &

communication

Tracking patients and using data– Continuous quality improvement and

outcomes monitoring

Space and supplies to support BH care

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1. Assess Readiness

2. Processes to Support Integration

3. The Business Case for Integration

Fee-for-service workarounds

Negotiate case rates with payers

Consider global funding strategies and blended payment systems

Identify federal and state incentives to support integrated care

Train staff to optimize use of existing revenue sources to provide cost efficient, medically necessary care.

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1. Assess Readiness

2. Processes to Support Integration

3. Make the Business Case

4. Re-design Care Delivery Using Collaborative Care Principles

Develop interdisciplinary care team

Promote self-care support and family engagement

Treatment to target

Stepped care

Systematic caseload review, consultation & referral

Adoption of evidence-based guidelines

BH providers support healthy behavior change in addition to screening, diagnosis, and treatment for BH conditions

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1. Assess Readiness

2. Processes to Support Integration

3. Make the Business Case

4. Redesign Care Delivery

5. Operationalize Changes in Clinical Workflows

Fully implement operational infrastructure

Sample change ideas to operationalize collaborative care principles:– Interdisciplinary care team proactively

manages a panel and chronic health conditions and participates in care planning

– Coordinate care inside and outside of org. including tracking referrals

Technological solutions when BH providers are not available in person

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1. Assess Readiness

2. Processes to Support Integration

3. Make the Business Case

4. Redesign Care Delivery

5. Operationalize Changes in Workflows

Today’s Agenda

Making the case: Integration and the Triple Aim

Overview of IHI

IHI’s research on behavioral health integration

Five-step sequence to integrate BH

Future directions for IHI’s work

Behavioral Health Integration Capacity Assessment (BHICA)

Where IHI can add value

Focus on how to make specific changes and on addressing operational and organizational issues that need to be in place to facilitate implementation of integrated care.

Bring improvement science to integration.

Sense-making across different models.

Focus on leaders and systems.

Measurement of system-level integration outcomes.

New Collaborative Program

Optimize Primary Care Teams to Meet Patients’ Medical AND Behavioral Needs– Partnering with the MacColl Center for Health Care

Innovation – Launches in February, 2015

http://www.ihi.org/Engage/collaboratives/OptimizePrimaryCareTeamstoMeetPatientsMedicalANDBehavioralNeeds/Pages/default.aspx

Areas for future innovation work

Integration in high-risk specialty clinics.

Scaling to communities, regions, states and solving related structural challenges.

Costs (and ROI) of integration, alternative payment methods, and financial models.

Behavioral health providers performing other functions on the care team, such as supporting behavior change for patients with chronic disease.

Building out other layers of full spectrum integration.

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Today’s Agenda

Making the case: Integration and the Triple Aim

Overview of IHI

IHI’s research on behavioral health integration

Five-step sequence to integrate BH

Future directions for IHI’s work

Behavioral Health Integration Capacity Assessment (BHICA)

Behavioral Health Integration Capacity Assessment Tool (BHICA)

Resource for organizations to assess their readiness to integrate behavioral health and primary care.

Consider potential approaches to integration;Understand the current infrastructure to support greater integration;Assess the organization’s strengths and challenges in undertaking different approaches to integration; Set and prioritize goals for integration efforts.

https://www.resourcesforintegratedcare.com/tool/bhica

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Five Sections of BHICA

1. Understanding Your Population

2. Assessing Your Infrastructure

3. Identifying the Population and Matching Care

4. Assessing the Optimal Integration Approach for Your Organization

5. Financing Integration

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Evaluation Framework Linked to Organization Processes, Impact, and Resources

Questions?41

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!