Notes from the Field: Lessons Learned in Behavioral Health Integration

Barbara Wall, ADN, BSHA, JD Attune Healthcare Partners August 3, 2017

• An investment of Healthier Washington managed by the Washington State Department of Health

• Helps practices successfully move to whole-person, patient-centered care

The Healthier Washington Practice Transformation Support Hub

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• Three separate contracts, funded by DOH

• Qualis Health provides Practice Coaches and Regional Connectors programs

• Web Resource Portal offered through partnership with UW Department of Family Medicine Primary Care Innovation Lab

The Hub: A Four-year, State Innovation Model (SIM) Testing Grant

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• Connect practices to the best fit resources and TA

• Personalized practice assessments, education, and tools

• Support for bi-directional physical and behavioral health integration

• Finding and coordinating community-based linkages

• Education and training

The Hub: What Do You Need to Support Practice Transformation Efforts?

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Attune Healthcare Partners

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www.AttuneHealthcare.com

Integration at the Level of Managed Care Plan & Behavioral Health Agency

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• Value Based CCO Model

– CCOs have full risk contracts for • Physical, behavioral and oral health services • Coordination with community resources • 4% withhold to quality incentive pool

– CCOs benefit flexibility • Complements traditional Medicaid medical coverage • Facilitates community resource integration

– Clinical Model of Care • The Patient Centered Primary Care Home

– Shared medical & behavioral health care planning – Care coordination – Chronic & preventive registries, protocols, outreach – Clinical Quality Measure reporting

Oregon Model: Based on Coordinated Care Organizations (CCOs)

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• AllCare CCO – Independently owned and committed to its community

• Serves Josephine, Jackson & Curry Co. in SW Oregon

– IPA supports preservation of small rural practices

– Funds community resources • Public Health Dept. staff in Josephine Co. • Multi-million $ grant for housing for vulnerable

populations in Josephine Co.

– Supports a regional Health Information Exchange

– Participates in CMS Demonstration Project to meet patient needs related to Social Determinants of Health

CCO Super Stars: AllCare Health

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• 1981: Founded as a Community Mental Health Center – Provides psycho-social rehab services to patients with long term

mental illness • Holistic approach addresses housing, advocacy, community

integration, crisis intervention, therapy, co-occurring issues, education, work, and economic well-being

• 1990’s: Became AllCare Mental Health agency contractor

• 2013: Established Integrated Primary Care Program – First primary care practice in a Behavioral Health setting to

achieve highest level of medical home certification in Oregon

• 2016: Top performer in ER visit reduction in AllCare CCO Alternative Payment Model

• 2017: Expanded to substance use recovery services

CCO Super Stars: Options for Southern Oregon

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• Transitions of Care – Emergency Room

– AllCare Care Management Dept. began tracking and outreach to frequent low-intensity Emergency Room (ER) visitors soon after the start of the CCO

– Complexity of privacy rules for sharing information between medical, Mental Health and substance recovery organizations inhibited coordination efforts(1)

– The CCO started weekly face-to-face meetings between

case managers from all 3 organizations

Challenge to Integration for Managed Care Plan & Behavioral Health Agencies

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• Sharing processes – AllCare Care Management Dept. began by sharing

• AllCare ER visit tracking report • Utilization and cost reports for frequent ER visitors • ER visit follow up letters sent to patients • Experiences with patients

• Systemic revelations – Behavioral health organizations unaware of frequent ER visit

pattern in individual patients

• Shared care planning – As the 3 teams reviewed the ER report, they naturally began

collaborative follow up plans on individual patients

• Standard processes – Next, managers from the 3 organizations developed standard

formats for documentation and information sharing

Integration Begins with Emergency Room Follow Up

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• Sharing processes

– Sharing & problem solving got people engaged • Led to a new understanding of how roles and resources

differ between the 3 organizations

– Collaboration accelerated with a new understanding of operations across the entire system

• Building trust

– Those regular face-to-face meetings built relationships based on trust, and give and take

• Resources

– In-person meetings mobilized the teams to action at the start & laid the foundation for further collaboration

Lessons Learned

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• Works well in smaller insurance companies

– Joint meetings with behavioral health agencies started collaboration through problem solving

• Large insurance companies

– Investment in regular, in-person meetings may not match the corporate culture of some large companies

– Logistical challenges for large companies: staff may be located in other states

• Insurer & behavioral health organization wins

– ER savings provide quick wins for Medicaid risk contracts and Alternative Payment Models (APMs)

Application to Other Markets

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• Need identified: after hours crisis management

– The weekly ER visit meeting provided a forum to identify needs for integrated operations

• A patient crisis shortly before close of business required expertise from all 3 organizations

• That led to the development of an inter-organization protocol for after hours crisis management

• Process

– A roster of on-call leads for Case Management from each of the 3 organizations is maintained and shared

– The on-call lead who receives the issue initially determines the need for expertise in medical, mental health or substance use issues and contacts the other on-call leader(s)

Next Step in Integration

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• Why it works – The clinical and social service resources available to

the 3 organizations for crisis management and problem solving are complementary

– The relationships built through the regular ER meetings created an understanding and trust in the ability of the other team leaders to triage for them

– Better solutions are developed for the patient, better care results, wasted time and resources are avoided - everyone wins

After Hours Crisis Management

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Behavioral Health Integration at the Patient Care Delivery Level

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• Serious Mental Illness affects 4% of adults in the US – Includes

• Schizophrenia

• Bipolar disorder

• Severe forms of major depression, PTSD, and obsessive-compulsive disorder

• Those with a Serious Mental Illness (SMI): – Have higher rates of chronic conditions

• Cardiac disease, hypertension, diabetes, & obesity

– Are two times more likely to die prematurely • In part because of barriers to accessing primary and preventive

medical care

Primary Care and Patients with Serious Mental Illness (SMI)

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• Serious Mental Illness and Substance Use Disorder – When these patients receive primary care from a practice

integrated into their community behavioral health center, the evidence shows reductions in measures of

• Hypertension • Dyslipidemia • Diabetes • Cardiovascular disease • Risk for metabolic syndrome(2)

• Depression and Anxiety Disorders – Robust evidence supports the effectiveness of integrating

behavioral health into primary care settings for adults with depression and anxiety disorders

Behavioral Health Integration Categorized by Target Populations

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• Financial – “Carve-ins”, shared risk pools or other incentives

• Structural

– Refers to integration in practice structure – including facility set up and organizational structure

• Clinical – Clinical integration is what is experienced by the patient in

relation to the providers – It is the goal

• But, it is difficult to sustain without aligned financial arrangements and the structure needed to support collaboration(3)

Attributes of Integration

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• Structure

– Their primary care practice serves patients with a Serious Mental Illness and their family members

– Primary care offices are located within an Options office with counselors, a psychiatrist, and a pharmacy on-site

– An independent ARNP is employed by the Community Mental Health Center and shares call after hours with a group of small independent primary care practices

– Different clinical documentation and billing systems are used for mental health and primary care services

– Primary care and mental health appointment scheduling is centralized

Options for Southern Oregon’s Integrated Primary Care Program

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• Clinical Model

– Primary care and behavioral health clinicians collaborate on treatment planning & management

– Patient Centered Primary Care Home model • Patient registries, chart scrubbing, & dashboard monitoring

to address care gaps during & between visits – Protocols for outcomes improvement emphasize hypertension,

diabetes, obesity, & cardiac disease: risk factors for SMI

– Patient outreach to close care gaps between visits • RN CM meets patients in the clinic, community or home

– An Assertive Community Treatment (ACT) Program • Resources include psychiatrists, counselors, social workers,

care managers, a pharmacy, and employment and housing assistance

Integrated Primary Care at Options for Southern Oregon

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• Revenue

– For primary care services • Medicaid primary care capitation from AllCare • CCO Primary Care APM incentives • Primary care FFS billed to other health plans

– To Options as a provider of Mental Health care • For psychiatry, counseling & other MH specialty care

– Fee For Service payments roll up to overall contract/budget

– To Options in its Mental Health agency role • Fees for administrative services roll up to an contractual

budget • AllCare Behavioral Health APM incentives

– Measures of quality, utilization, access & satisfaction

Financial Model for Primary Care & Other Revenue to Options

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• Biggest challenge: IT

– Primary care EHRs • Very different from mental health EHRs

– Use of an EHR vendor with good customer service record is key take away

– Invest resources to select correct location of reportable data in the primary care EHR

– Primary care Clinical Quality Measures • There is a steep learning curve for reporting • Many more than MH Clinical Quality Measures

– Primary care coding and billing • Primary care coding was a challenge • Consider an external billing service to start

Lessons Learned: Operations

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• Factors contributing to Options’ success

– Assertive Community Treatment (ACT) Program • Options’ ACT program provided a bridge to successful

integration

– Pharmacy co-location • The pharmacy dispensary contributed to:

– Patient recruiting for the practice – Medication education and compliance

• Pharmacists with expertise in psychiatric medications consult with the Primary Care Provider

• Challenges in other markets

– Patient recruitment in competitive primary care markets

Applicability of the Options for Southern Oregon Integration Model to Other Markets

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1. CCO integration of physical, behavioral & oral care – 4.25% quality pool withhold required in Medicaid contract

2. AllCare CCO APM to Behavioral Health Agencies

3. AllCare CCO APM to primary care providers

Key to Financial Success: APMs at Multiple Payment Levels

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1. National Academy for State Policy, “Sharing Information Across Physical and Behavioral Health: Debunking Myths, Developing Strategies”, August 6, 2015.

2. Scharf, Deborah M., Eberhart, Nicole K., Hackbarth, Nicole S., Horvitz-Lennon, Marcela, Beckman, Robin, Han, Bing, Lovejoy, Susan L., Pincus, Harold A. Burnam, & M. Audrey, “Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program, Final Report, the Rand Corporation, 2014.

3. Mauer, Barbara J. “Finance, Policy and Integration of Services”, Prepared for the National Council for Community Behavioral Healthcare, 2006.

Footnotes

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• Let us know how we can help you:

• Contact the Help Desk for resources, questions, and to be added to our mailing list

• Talk to us about assessing your practice

• Find out how you can enroll in on-site technical assistance

The Hub: Offering a Menu of Services to Support Practice Transformation Efforts

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For More Information Hub Help Desk: (206) 288-2540 or (800) 949-7536 ext. 2540 or by email HubHelpDesk@qualishealth.org.

Healthier Washington Practice Transformation Support Hub Web sites:

• Healthier Washington: www.hca.wa.gov/hw/

• Qualis Health: www.QualisHealth.org/hub

• Hub Resource Portal: www.waportal.org

The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

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Barbara Wall Senior Partner Attune Healthcare Partners (206) 629-4174 bwall@attunehealthcare.com

Questions & Discussion

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