Health Homes for People with Behavioral Health Issues: Emerging Strategies and

Challenges

Trina Dutta, MPP, MPHNASHP's 24th Annual State Health Policy Conference

October 4, 2011

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SAMHSA’s Connections to Health Homes

• ACA Section 2703 (person centered health home)

• Integration Initiative– Primary and Behavioral Health Care

Integration (grant program)– SAMHSA/HRSA Center for Integrated Health

Solutions (training and technical assistance provider)

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ACA Section 2703

“State Option to Provide Health Homes for Enrollees with Chronic Conditions”*

Goal: enhanced integration and coordination of primary, acute, behavioral health (mental health and substance use), and long-term services and supports for persons across the lifespan with chronic illness

The health home provision provides an opportunity to build a person-centered system of care that achieves improved outcomes for beneficiaries and better services and value for State Medicaid programs

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Affordable Care Act, Section 2703

Population Served• Eligible individuals are those with chronic conditions, meaning an

individual who is eligible for medical assistance under the State plan or under a waiver of such plan and has at least– 2 chronic conditions; or– 1 chronic condition and is at risk of having a second chronic

condition; or– 1 serious and persistent mental health condition

• Chronic conditions must include:– A mental health condition– A substance use disorder– Asthma– Diabetes– Heart disease– Being overweight, as evidenced by having a BMI >25

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Required Services

• Comprehensive care management;• Care coordination and health promotion;• Comprehensive transitional care, including appropriate

follow-up, from inpatient to other settings;• Patient and family support (including authorized

representatives); and• Referral to community and social support services, if

relevant;

(Use of health information technology to link services, as feasible and appropriate.)

Affordable Care Act, Section 2703

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SAMHSA’s Connection to 2703

According to the November 16, 2010 “Dear State Medicaid Director” letter

• Section 1945(e) of the Act requires States to consult and coordinate with SAMHSA in addressing issues of prevention and treatment of mental illness and substance use disorders for individuals who are low-income and/or have one or more chronic illnesses who are at greater risk of developing mental health and substance use disorders

• As such, CMS is requiring States to consult with SAMHSA as they develop their approaches to health homes, prior to submitting their State plan amendments.

• SAMHSA will only respond to requests from the State Medicaid Agency (SMA)– All other formal requests from an individual

organization in a particular State will be directed to that State’s SMA

• We encourage SMAs to coordinate with their State behavioral health (mental health and substance abuse) authorities regarding 2703 planning– Requests for consultations should indicate how

the state’s relevant behavioral health authority(ies) will be involved in the process

SAMHSA 2703 Consultations with States

– What is/are the target chronic condition(s) of your health home proposal?

– How will individuals be identified and referred to health homes?  How will individuals not connected to either the primary care or behavioral health care system be informed and referred to your health home program?

– Describe the flow depicting how clients will move in, through, and out of your health home program.

– What measures will be used to screen and intervene for behavioral health disorders? • Alcohol abuse and/or dependence• Drug abuse/dependence • Tobacco use/dependence• Depression and suicide risk

– Do you anticipate policy and reimbursement barriers regarding the establishment of health homes for individuals with behavioral health conditions (e.g. same day billing issues)?

2703: Key areas of discussion

What are the key behavioral health questions, organized according to the Health Home

Service components involved in Section 2703, that States should be thinking about?

SAMHSA’s 2703 Guidance Document

• How will your health home providers outreach to, plan, and communicate with other primary and specialty care providers regarding a patient’s care?

• How will your health home providers develop an individualized treatment plan, informed by the patient, which integrates care across varied care systems (i.e. mental health, substance use, primary care, etc.)?

• How will your health home providers clarify and communicate the patient’s preferences to all involved providers while assuring timely delivery of services?

• Composition of Your Health Home Team– What credentials or core competencies are recommended and/or

required for health home team members serving individuals with a behavioral health condition? How are health care professionals identified as team members who can treat individuals with chronic illnesses (including MH/SA)? What are the functions of these team members?

– What are the behavioral health workforce needs of your health home?– Will individuals in recovery from MH/SA be a part of your

health home team approach?

Comprehensive Care Management

• What are the linkages established between primary and behavioral health care providers? How will you promote care coordination among your participating health home agencies and other providers within their network?

• How will information be shared with other agencies patients are referred to? How will records be transferred if a patient leaves the health home?

• Will your health home providers use an agreed upon shared continuity of care record or similar vehicle? Will this be part of their medical record system?

• What specific mechanisms has your health home team established with community (e.g., YMCA) and specialty care providers? Are there formal mechanisms, such as “Memoranda of Understanding” or network alliances that link those in a specific locale?

• Do you have a shared consent form among providers? How will you manage the exchange of consent information?

• How will you educate patients on their consent options and implications of information sharing?

• How do you define health promotion in the context of your health home?

Care Coordination and Health Promotion

• What processes will be in place so all Medicaid provider hospitals identify and refer clients to a health home provider?

• How do you propose to ensure planning between levels of care (e.g., hospital to health home)? How will information be shared and updated between levels of care (e.g., how will discharge information be transferred from hospitals or nursing facilities to your health home providers)?

• How will you know how many individuals treated by your Health Home providers have been re-hospitalized within the last thirty days? How will you know how many have seen a primary or specialty care provider within thirty days of hospital discharge?

• Will there be mechanisms to involve health home providers with discharge planning from the hospital? Do your hospitals screen for MH/SA prior to discharge for those in or moving into health homes?

• How will your health home providers communicate and educate patients and caregivers about the transition process? What tools will health home providers use to engage patients in their care planning?

Comprehensive Transitional Care (including from inpatient

settings)

• How are you defining patient and family support?

• What is the role, if any, of peers and individuals in recovery in providing patient and family support?

 • How will your health home providers consider a patient-

directed approach in treatment planning?

Patient and Family Support

• How does the State ensure that health home providers make assessments and referral for community and recovery supports (e.g., housing, recovery support services, job training, employment placement, etc)?

• How will these referrals occur (e.g., electronically)? How will you track these referrals and the results? How will the receiving provider be notified about the referral?

Referral to Community and Social Services (if relevant)

• What outcome data do you have/need?• What information/data currently exist across the

systems?• What common information/data can be shared across

the systems?• What information/data would constitute evidence for a

successful intervention?• Does your EHR generate a bill and can it record a

payment?  If not, how do you do your billing currently?  How will you bill in the health home environment? 

• What medical records systems are currently in use by health home providers? How will they interoperate within the health home environment?

• Are your health home provider electronic medical records systems interoperable with other agencies?

Data and Health Information Technology to Link Services

To request a consultation with SAMHSA, SMAs should email to health.homes@SAMHSA.hhs.gov the following:

• The State contact person; • State timeframes and availability for obtaining the

consultation; and• Responses to “Key Areas of Discussion” (slide 9),

including a brief overview of the proposed design of the health home

Materials on screening tools, outcomes, models, research, and articles relevant to health homes and behavioral health are available at http://samhsa.gov/healthreform/healthhomes/.

Connect with Us

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SAMHSA’s Connections to Health Homes

• ACA Section 2703 (person centered health home)

• Integration Initiative– Primary and Behavioral Health Care

Integration, PBHCI (grant program)– SAMHSA/HRSA Center for Integrated Health

Solutions (training and technical assistance provider)

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What is PBHCI?

• Program purpose:– To improve the physical health status of people with

SMI and those with co-occurring substance use disorders by supporting communities to coordinate and integrate primary care services into publicly funded community-based behavioral health settings

• Expected outcome:– Grantees will enter into partnerships to develop or

expand their offering of primary healthcare services, resulting in improved health status

• Population of focus:– Those with SMI and co-occurring substance use

disorders served in the public behavioral health system

• Grantees: – Community behavioral health agencies, in

partnership with primary care providers

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PBHCI Services Delivery

• Facilitate screening and referral for primary care prevention and treatment needs

• Provide and/or ensure that primary care screening/assessment/ treatment and referral be provided in a community-based behavioral health agency

• Develop a registry/tracking system for all primary care needs and outcomes

• Build processes for referral and follow-up for needed treatments that are not appropriately provided in a primary care setting

• Offer prevention and wellness support services (>10% of grant funding)

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Where you can get support on 2703

SAMHSA/HRSA Center for Integrated Health Solutions (CIHS)

• Goal: To promote the planning and development of integrated primary and behavioral health care for those with SMI, addiction disorders and/or individuals with SMI and a co-occurring substance use disorder, whether seen in specialty mental health or primary care safety net provider settings across the country

• Purpose: – To serve as a national training and technical

assistance center on the bidirectional integration of primary and behavioral health care and related workforce development

www.centerforintegratedhealthsolutions.org

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SAMHSA/HRSA Center for Integrated Health Solutions (CIHS)

Award: National Council for Community Behavioral Healthcare

• CIHS Lead—Ms. Kathy Reynolds, MSW• Up to $5,350,000 (per year for up to four years)• $1.4M—SAMHSA, $350,000—HRSA, $3.6M—

Office of the Secretary’s Prevention Trust Fund

Email: integration@thenationalcouncil.orgWebsite: www.centerforintegratedhealthsolutions.orgPhone: 202-684-7457, ext 251

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Thank you!

Trina Dutta, MPP, MPHTrina.dutta@samhsa.hhs.gov240-276-1944