Download - The Pitfall and Promise of Integrating Care
The Pitfall and Promise of Integrating CareDavid Freedman, Lina Castellanos, Thomas Jardon, Cynthia Rodriguez, David Fuentes, Ketia Harris, Megan Hartman, & Angela Mooss
Integrated Care: Reconnecting the Head and Body
Milliman, 2014
Cost of Co-occurring Conditions
Milliman, 2014
Cost
Cost and Disparities
Netsmart, 2013
Three-Legged Stool of Healthcare Integration
INTEGRATION, YOU SAY?
Integration Service Flow
The Four Quadrant Clinical Integration Model
samhsa.integration.gov
Accountable Care-Change Of Focus Required
Element of Change Yesterday Today
Care focus Sick care"Healthcare" wellness
and prevention, disease management
Care managementManage utilization and
cost within a care setting
Manage ongoing health
Delivery Model Fragmented/silos Care continuum and coordination
Care Setting In office/hospital In home, virtual
Quality measures Process-focused, individual
Outcomes-focused, population-based
Payment Fee-for-service Value-based
Financial incentives Do more, make more Perform better on measures, make more
Financial performance Margin per service, procedure Margin per life
SAMHSAMAI-TCE: MIAMI SITEMinority AIDS Initiative – Targeted Capacity Expansion
4.2 M for 3 Years from SAMHSA
Project Flow Chart
SAMHSA
South Florida Behavioral Health Network
Behavioral Science Research Institute
Citrus Health
JTCHC
Florida Health
SAMHSA Funding
Siloed Funding
Main Players: Behind the ScenesFlorida Health- Tallahassee and Miami Dade (DOH)◦Required grantee due to HIV impact◦Coordinated with ECHPP
South Florida Behavioral Health Network (SFBHN)◦Managing entity for behavioral health dollars
via Department of Children and Families
Behavioral Science Research Institute (BSRI)◦Evaluation team◦Crossover with Ryan White Program
Main Players: The ProvidersCitrus Health5 medical clinics and
24 schools
Hialeah area
55% female
>80% Hispanic/ Latino
52% best served in another language
28% uninsured
Jessie Trice (JTCHC)9 medical clinics and
23 schools
Liberty City area
63% female
67% Black/African-American
13% best served in another language
60% uninsured
MAI-TCE PROJECT PHASES
MAI-TCE Miami took on three distinct phases
Phase One:Gearing up for IntegrationStart Date◦February 2012
Logistics ◦Funding ◦Staffing◦ Implementation
Buy-in ◦Organizational level ◦Between partners
Logistics
Challenges SuccessesFiscal tracking
Data burden
Training/EBI’s
Staffing
Collaboration/Team building◦ SFBHN/organizational
level◦ Data sharing with
Evaluation◦ Provider MAI-TCE
teams
Capacity Building
Buy-in
Challenges SuccessesCultural differences◦ Medical vs Behavioral
health◦ HIV and Ryan White
services
Billing for services
The need is recognized and departments find relief
Integration is accepted at top-down level in theory
SFBHN assists with billing and loosening staffing regulations
Lessons LearnedMake preparations ◦Present changes to other
departments ahead of time
Collaboration is critical◦Need a team of support
Planning and persistence◦This takes time
Phase Two:Customizable IntegrationStart Date◦June 2012-May 2014
Planned changes◦Mandated by funders (TRAC vs. GAIN)◦Necessary to meet EBI requirements
Unplanned changes◦HIV testing ◦Staff turnover
Planned Changes
Challenges SuccessesEBPs/DEBIs changed◦ Client needs and
outdated practices◦ Training overload◦ Staff turnover
Systems-level funding and documentation
Flexibility in training and EBI implementation◦ Peers implementing◦ Translation of tools as needed
Data and service documentation◦ Removal of GAIN-I◦ SFBHN consistent updates
(delete orphans, etc)◦ Data became useful internally
Unplanned Changes
Challenges Successes 80% follow up rate goal
◦ Does not fit BH clients◦ Reassessment and DC lists
become unmanageable
Rapid Testing HIV mandate◦ New testing site IDs◦ Training ◦ Duplicative data ◦ Testing numbers cannot be
shared
Advanced integration model for service delivery
Advocating at all levels ◦ A true team approach◦ DOH was instrumental◦ Capacity building◦ Filling a huge need
(especially at Citrus)
Lessons LearnedThe need to truly customize cannot
be understated
Peers are critical to successful models for client satisfaction
Integration is working◦More clients are getting the services
they need and large FQHCs have fewer silos internally
Phase 3:Wrap-up and SustainabilityStart Date◦ June 2014 to present
A focus on Medicaid billing and staff coverage
Focus on implementing EHR systems that are effective
Concentration on seeking out additional funding through grants/foundations
Funding
Challenges Successes Non-Medicaid expansion
EMRs lack sophisticated technology and are expensive
SAMHSA and other billing systems are not set up for co-occurring clients
Grant funding is competitive
SFBHN advocacy for EMRs and data systems changes
EMRs responding
Funders are responding
Miami secured grant monies
Organizational Integration Culture
Challenges SuccessesStaffing ◦ Certifications for peers,
behavioral health techs, non-client specific coordinators
Organizational structure◦ What has really changed?◦ Medical and behavioral are
still separate, but…
Staffing has changed organizational practice◦ Use of peers, recognition for
coordination across sites
Other departments believe in the value of behavioral health
Healthcare culture is changing
Lessons LearnedChange happens with persistence
Generating buy-in at the organizational level can speed things up
Collaboration is key to successful integration and sustained funding
TAKE AWAY POINTS
If you don’t remember anything else… Remember this
Behavioral Health Primary Care Network Committee (BHPCNC) A committee for health integration
Guided by principles:◦ Inclusion, Collaboration, CQI, Resource savings,
Community-based, Resilience and Recovery
Vision/Mission◦ Oversee the expansion of culturally competent and effective
behavioral health services◦ To monitor and enhance the linkages between and
integration of behavioral health services in primary care
Less formal◦ A focus on training and capacity building across the
systems of care
The Miami ModelScreening (SBIRT)
Use of peers
HIV testing
EBIs
Data driven
Co-location has been extremely helpful with piloting/forming the model
Project Outcomes Reduction in days spent:
◦ Homeless◦ Hospital MH unit, detox, jail, emergency room
Reduction in unprotected sex
Increase in risk perceptions
Decrease in mental health symptoms and social support
Increase in access to comprehensive health services
Decrease in substance use◦ But not in tobacco use
System-wide ImplicationsExpansion of integration to
chronic disease management and other aspects of health
Providers are held to higher standards of care and care coordination
Focus on prevention and wellness
Go Forth and Integrate
Questions/CommentsDavid Freedman – Project Director
[email protected](305) 860-8235