SBIRT P t f P j t C I t tiSBIRT P t f P j t C I t tiSBIRT as Part of Project Care: Integrating SBIRT as Part of Project Care: Integrating Behavioral Healthcare Services in Kern Behavioral Healthcare Services in Kern

C t CAC t CACounty, CACounty, CA

Christopher Reilly, LCSWChristopher Reilly, LCSWBehavioral Health Director, Behavioral Health Director, ClinicaClinica Sierra VistaSierra Vista

LilyLily AlvarezAlvarezLily Lily AlvarezAlvarezBehavioral Health Behavioral Health System System Administrator, Kern County Mental Health DepartmentAdministrator, Kern County Mental Health Department

Darren Urada, Ph.D.Darren Urada, Ph.D.UCLA Integrated Substance Abuse ProgramsUCLA Integrated Substance Abuse ProgramsUCLA Integrated Substance Abuse ProgramsUCLA Integrated Substance Abuse Programs

June 25, 2014June 25, 2014Presented for the SAMHSA National SBIRT ATTC Presented for the SAMHSA National SBIRT ATTC

Kern and IntegrationKern and IntegrationKern and IntegrationKern and Integration

MHSA Prevention & Early InterventionMHSA Prevention & Early InterventionMHSA Prevention & Early Intervention MHSA Prevention & Early Intervention fundsfundsIn partnership with 8 FQHC clinics and 1In partnership with 8 FQHC clinics and 1In partnership with 8 FQHC clinics and 1 In partnership with 8 FQHC clinics and 1 county hospital outpatient cliniccounty hospital outpatient clinicB ildi C it i KB ildi C it i KBuilding Capacity in Kern Building Capacity in Kern

Features of IntegrationFeatures of IntegrationFeatures of IntegrationFeatures of Integration

ScreeningScreeningScreening Screening Warm handWarm hand--offsoffsI t tiI t tiInterventionsInterventions“huddles”“huddles”Psychiatric consultationsPsychiatric consultationsTreatment abilityTreatment abilityTreatment ability Treatment ability

OpportunitiesOpportunitiesOpportunitiesOpportunities

No barriers for allowable providersNo barriers for allowable providersNo barriers for allowable providers No barriers for allowable providers No requirements of face to face with No requirements of face to face with psychiatrypsychiatrypsychiatrypsychiatryTwo services in the same day allowedTwo services in the same day allowedFreedom to experimentFreedom to experiment

Still on the agendaStill on the agendaStill on the agendaStill on the agenda

When to refer to specialty carveWhen to refer to specialty carve--outsoutsWhen to refer to specialty carveWhen to refer to specialty carve outsoutsWhat information should be exchanged? What information should be exchanged? H h lth i t i ill h l tH h lth i t i ill h l tHow health registries will help to manage How health registries will help to manage the population(s) the population(s)

InfrastructureInfrastructureInfrastructure Infrastructure

Monthly provider meetings to create aMonthly provider meetings to create aMonthly provider meetings to create a Monthly provider meetings to create a learning environmentlearning environmentAssociation with UCLA for evaluation toAssociation with UCLA for evaluation toAssociation with UCLA for evaluation to Association with UCLA for evaluation to document and celebrate the workdocument and celebrate the workD t t i i ith CME’ tD t t i i ith CME’ tDoctor training with CME’s to encourage Doctor training with CME’s to encourage networkingnetworkingClinician training with CEU’s to build Clinician training with CEU’s to build knowledge and skills knowledge and skills

Mommies and BabiesMommies and BabiesMommies and BabiesMommies and Babies

Mental Health Plan orMental Health Plan orMental Health Plan or Mental Health Plan or Community Health CenterCommunity Health Center

Merging Two SystemsMerging Two SystemsMerging Two SystemsMerging Two Systems

What Doesn’t Kill You What Doesn’t Kill You SSMakes you StrongerMakes you Stronger

First Integration LessonsFirst Integration LessonsFirst Integration LessonsFirst Integration Lessons–– Brought MHP workers to CHCBrought MHP workers to CHC–– Space ProblemsSpace Problems–– Space ProblemsSpace Problems–– PartPart--TimeTime–– UnderutilizedUnderutilizedUnderutilized Underutilized –– Somebody else’s team Somebody else’s team and and somebody else’s somebody else’s

system.system.yy

Culture ClashCulture ClashCulture ClashCulture Clash

2424 –– 30 patients per provider/day30 patients per provider/day24 24 30 patients per provider/day30 patients per provider/day“Blind” or “Cold” Exams/Evaluations“Blind” or “Cold” Exams/EvaluationsL b f ti t iti lL b f ti t iti lLarge numbers of patients waiting long Large numbers of patients waiting long periods of time in bustling, crowded wait periods of time in bustling, crowded wait roomsrooms

And…And…BHP concerns about “germs”BHP concerns about “germs”

Clinica Sierra Vista VisionClinica Sierra Vista VisionClinica Sierra Vista VisionClinica Sierra Vista VisionWhat we knew of Integrated Behavioral Health models What we knew of Integrated Behavioral Health models

l d d d thi d t f dil d d d thi d t f diwe always depended upon third party funding.we always depended upon third party funding.

We wanted a business model that would sustain itself We wanted a business model that would sustain itself from community health center encounters alone. MHSA from community health center encounters alone. MHSA and the MHP gave us just the time and support to and the MHP gave us just the time and support to develop one.develop one.

Constructed to work “As if…” no MHP support:Constructed to work “As if…” no MHP support:–– LCSW, Psychologist and/or Psychiatrist ONLYLCSW, Psychologist and/or Psychiatrist ONLY–– No Same Day visitNo Same Day visit–– Contained within Four WallsContained within Four Walls–– Replicable Across preponderance of 29 CHC sites.Replicable Across preponderance of 29 CHC sites.

Clinica Sierra VistaClinica Sierra Vista –– Project CareProject CareClinica Sierra Vista Clinica Sierra Vista Project CareProject Care

Our own providersOur own providersOur own providersOur own providers

1 BHP Assigned Full Time at each CHC versus1 BHP Assigned Full Time at each CHC versus1 BHP Assigned Full Time at each CHC, versus 1 BHP Assigned Full Time at each CHC, versus a team rotating from one CHC to the nexta team rotating from one CHC to the next

BHP to be on the CHC TeamBHP to be on the CHC Team

Assimilating the BHP into the CHCAssimilating the BHP into the CHCAssimilating the BHP into the CHCAssimilating the BHP into the CHC

Abides the CHC Office ManagerAbides the CHC Office ManagerAbides the CHC Office ManagerAbides the CHC Office ManagerAttends CHC staff meetingsAttends CHC staff meetingsK CHC P ti t R dK CHC P ti t R dKeeps CHC Patient RecordsKeeps CHC Patient RecordsFollows CHC Meal Breaks, etc.Follows CHC Meal Breaks, etc.Understands The Joint Commission Understands The Joint Commission standards for Ambulatory Care as well as standards for Ambulatory Care as well as yyBehavioral Health Care.Behavioral Health Care.

First Rules of BHPFirst Rules of BHPFirst Rules of BHPFirst Rules of BHP

Make the Primary Care Providers HappyMake the Primary Care Providers HappyMake the Primary Care Providers HappyMake the Primary Care Providers HappyStay Busy!!Stay Busy!!

The First proved easier than the The First proved easier than the second. But we didn’t even appreciate second. But we didn’t even appreciate that. For a group of therapists, we still that. For a group of therapists, we still found PCP’s hard to read.found PCP’s hard to read.

Panic at the DiscoPanic at the DiscoPanic at the DiscoPanic at the Disco

OurOur providers were in the CHC providers were in the CHC –– Full Time Full Time ––and and stillstill seldom called upon.seldom called upon.pp

The promise of a busy schedule imagined byThe promise of a busy schedule imagined byThe promise of a busy schedule, imagined by The promise of a busy schedule, imagined by prior complaints of out of control patients; and prior complaints of out of control patients; and plenty of NIMH research about the prevalence of plenty of NIMH research about the prevalence of mental illness in underserved communities, was mental illness in underserved communities, was discouraged by about 5discouraged by about 5--6 client referrals 6 client referrals a week.a week.

“I See Dead People”“I See Dead People”I See Dead PeopleI See Dead People

Patients did not always complete the Behavioral Patients did not always complete the Behavioral Health screening. And front office people Health screening. And front office people g p pg p pweren’t sure what to do with the screenings weren’t sure what to do with the screenings when done, because providers by and large when done, because providers by and large didn’t want to see them.didn’t want to see them.Some patients “mocked” the screening, entering Some patients “mocked” the screening, entering

ll i ll i ill i ll i iall negative, or all positive, answers. all negative, or all positive, answers. We were handling crisis, but not much else.We were handling crisis, but not much else.

“They don’t want to tell me, and I don’t want to ask.” “They don’t want to tell me, and I don’t want to ask.” –– Community Health Center PCP explaining Community Health Center PCP explaining why he would not present or review referrals to our BHP.why he would not present or review referrals to our BHP.

Selecting a BHPSelecting a BHPSelecting a BHP Selecting a BHP

In an extraordinarily busy setting, you In an extraordinarily busy setting, you don’t want to be the person with nothing to don’t want to be the person with nothing to do. On the upside, nobody was calling the do. On the upside, nobody was calling the police anymore. police anymore.

Finding the RightFinding the RightFinding the Right Finding the Right Behavioral Health ProviderBehavioral Health Provider

S b d h i f l d iS b d h i f l d i b i d lb i d lSomebody who is resourceful and outgoing Somebody who is resourceful and outgoing –– because in our model because in our model the Therapist risks becoming a fish out of water.the Therapist risks becoming a fish out of water.ClearClear--headed, humble and disciplined. Frequent and continuous headed, humble and disciplined. Frequent and continuous disclosure with her clinical supervisor protects against the more disclosure with her clinical supervisor protects against the more p p gp p gnebulous boundaries and relationships in a CHC, as compared with nebulous boundaries and relationships in a CHC, as compared with a strictly mental health work environment.a strictly mental health work environment.SelfSelf--assured, insightful and grounded. Seeing patients without any assured, insightful and grounded. Seeing patients without any knowledge of their prior mental health history Sometimes with aknowledge of their prior mental health history Sometimes with aknowledge of their prior mental health history. Sometimes with a knowledge of their prior mental health history. Sometimes with a referral that says as little as “Room #3 referral that says as little as “Room #3 –– crying,” can test your crying,” can test your confidence. Being okay with not knowing quite what to do is the confidence. Being okay with not knowing quite what to do is the safer route to treatment planning.safer route to treatment planning.

BHP BonusBHP BonusBHP BonusBHP Bonus

As the saying goesAs the saying goesAs the saying goes…As the saying goes…Because of a lack of LCSW’s in the community when our Because of a lack of LCSW’s in the community when our yycollaboration on Project Care started, we hired collaboration on Project Care started, we hired unlicensed ASW/MFTunlicensed ASW/MFT--Interns to be our first BHP’s.Interns to be our first BHP’s.They are required to accumulate psychotherapyThey are required to accumulate psychotherapyThey are required to accumulate psychotherapy They are required to accumulate psychotherapy experience to be eligible to sit for their exams. So we experience to be eligible to sit for their exams. So we hadhad to offer true, full, real psychotherapy in the CHC. to offer true, full, real psychotherapy in the CHC. Any notion of providing only screening and referral; orAny notion of providing only screening and referral; orAny notion of providing only screening and referral; or Any notion of providing only screening and referral; or just brief psychojust brief psycho--education; even limiting service to education; even limiting service to SBIRT and motivational interviewing, would cause too SBIRT and motivational interviewing, would cause too much anxiety for our providersmuch anxiety for our providersmuch anxiety for our providers.much anxiety for our providers.For better or worse, ours would be a psychotherapyFor better or worse, ours would be a psychotherapy--based programbased program

As Word SpreadAs Word Spread

Some behavioral health concerns are made forSome behavioral health concerns are made for primary care integration:

– The discreet nature of primary care has encouraged higher ratios of domestic violence counseling.P i it t ll t d t l t d- Proximity to small towns reduce travel cost and increase access.

- A focus on the health benefits of reducing/quittingA focus on the health benefits of reducing/quitting AOD use resonates in a primary care center.

- More…

Making it Pencil OutMaking it Pencil OutMaking it Pencil OutMaking it Pencil Out

Viability AssumptionsViability AssumptionsViability AssumptionsViability Assumptions1.1. BHP (LCSW) + overhead = $105,000/per yr. BHP (LCSW) + overhead = $105,000/per yr. ( ) $ , p y( ) $ , p y

(2080 paid hours)(2080 paid hours)2.2. BHP hours worked = 1,840 (Assumes 240 BHP hours worked = 1,840 (Assumes 240

h PTO)h PTO)hours PTO)hours PTO)3.3. CHC Rate of $100/encounterCHC Rate of $100/encounter44 45% M diC l ti t R ti45% M diC l ti t R ti4.4. 45% MediCal patient Ratio45% MediCal patient Ratio______________________________________________________________________________

Requires a Minimum of 4 6Requires a Minimum of 4 6 PAIDPAIDRequires a Minimum of 4.6 Requires a Minimum of 4.6 PAIDPAIDencounters/dayencounters/day

Fiscal ChallengesFiscal ChallengesFiscal ChallengesFiscal Challenges

We didn’t want the provider tempted toWe didn’t want the provider tempted toWe didn t want the provider tempted to We didn t want the provider tempted to manipulate the paying (insured) versus manipulate the paying (insured) versus nonnon--paying session schedule.paying session schedule.p y gp y gAgreement with the MHP required Agreement with the MHP required universal screening of all CHC patients (universal screening of all CHC patients (a a g p (g p (nonnon--payment certaintypayment certainty.).)Only about 1 in 9 patients return for Only about 1 in 9 patients return for y py pongoing sessions after the initial BHP ongoing sessions after the initial BHP encounter.encounter.

Encounter BreakoutEncounter BreakoutEncounter BreakoutEncounter Breakout

DailyDailyDaily Daily –– Required Required –– Ten recurring, 20Ten recurring, 20--30 minute 30 minute

psychotherapy appointmentspsychotherapy appointments (45% paid/55%(45% paid/55%psychotherapy appointments psychotherapy appointments (45% paid/55% (45% paid/55% unpaid)unpaid)

S CS C–– Up to 12 combination Screenings; PCP HandUp to 12 combination Screenings; PCP Hand--offs and Consultations (to generate new offs and Consultations (to generate new recurring clients)recurring clients)recurring clients)recurring clients)

Encounters (cont )Encounters (cont )Encounters (cont.)Encounters (cont.)4.6 paying clients/day required for the program 4.6 paying clients/day required for the program p y g y q p gp y g y q p gto cover its cost.to cover its cost.Therapy modality and approach must match Therapy modality and approach must match d d f i ( B i f Th d l id d f i ( B i f Th d l idemand for service (e.g. Brief Therapy model in demand for service (e.g. Brief Therapy model in busy CHC’s)busy CHC’s)30 Minute sessions (scheduled 1 per hour)30 Minute sessions (scheduled 1 per hour)30 Minute sessions, (scheduled 1 per hour)30 Minute sessions, (scheduled 1 per hour)Screens/exam room consults available the other Screens/exam room consults available the other half of each hour. Keeps any wait for handhalf of each hour. Keeps any wait for hand--off off a o eac ou eeps a y a t o a da o eac ou eeps a y a t o a d oomanageable. Reduces occurrence of disrupted manageable. Reduces occurrence of disrupted psychotherapy sessions.psychotherapy sessions.

Push for ClientsPush for ClientsPush for ClientsPush for ClientsBHP lobbying BHP lobbying y gy gOccasional overt patient with severe Occasional overt patient with severe presentation.presentation.MHP (specialty) patients it wished to step down MHP (specialty) patients it wished to step down to primary careto primary careA t f i iti l hi t i l tiA t f i iti l hi t i l tiAgreement for initial psychiatric evaluations on Agreement for initial psychiatric evaluations on behalf of PCP’s, in exchange for acceptance of behalf of PCP’s, in exchange for acceptance of stable/uncomplicated step down clients.stable/uncomplicated step down clients.stab e/u co p cated step do c e tsstab e/u co p cated step do c e tsOutreach to MHP Access and Assessment Outreach to MHP Access and Assessment Center for referral of “denied” clients.Center for referral of “denied” clients.

Push for ClientsPush for ClientsPush for ClientsPush for ClientsFurther defined threshold scores. BHP referral Further defined threshold scores. BHP referral based on responses to the PHQbased on responses to the PHQ--9, AUDIT C and 9, AUDIT C and GADGAD--7, as well as a protocol by which all 7, as well as a protocol by which all screenings were seenscreenings were seen firstfirst by the primary careby the primary carescreenings were seen screenings were seen firstfirst by the primary care by the primary care provider.provider.Change in BHP Productivity Standard fromChange in BHP Productivity Standard fromChange in BHP Productivity Standard from Change in BHP Productivity Standard from minutes of service per day, to number of minutes of service per day, to number of encounters per day encounters per day –– incentivizes rounds at the incentivizes rounds at the

t ti d f t i t tit ti d f t i t tinurses station and more frequent interaction nurses station and more frequent interaction with the PCP’s.with the PCP’s.

TodayTodayTodayToday

Aug. 1, 2013Aug. 1, 2013Aug. 1, 2013 Aug. 1, 2013 –– 4 BHP’s in 4 rural CHC’s are averaging 182 4 BHP’s in 4 rural CHC’s are averaging 182

encounters/month (previous 12 months). encounters/month (previous 12 months). –– Or 8.3/day. Or 8.3/day.

Just shy of the 10 encounters (4.6 paid) needed Just shy of the 10 encounters (4.6 paid) needed f f CSf f CSto pay for a full time LCSW.to pay for a full time LCSW.

Contingent upon passing the exams, our first Contingent upon passing the exams, our first LCSW ill t t i t b b d CHCLCSW ill t t i t b b d CHCLCSW will start service at an urban based CHC, LCSW will start service at an urban based CHC, independent from the MHSA Project Care in independent from the MHSA Project Care in JanuaryJanuaryJanuary.January.

Future ViabilityFuture ViabilityFuture ViabilityFuture ViabilityACA may improve the ratio of insured, reducing ACA may improve the ratio of insured, reducing y p , gy p , gby our formula the number of recurring by our formula the number of recurring encounters needed to reach the 4.6 paid daily encounters needed to reach the 4.6 paid daily minimumminimumminimum.minimum.Same Day “loss” may be absorbable in OP Same Day “loss” may be absorbable in OP psychotherapy model so long as sufficient paidpsychotherapy model so long as sufficient paidpsychotherapy model, so long as sufficient paid psychotherapy model, so long as sufficient paid encounters occur.encounters occur.Universal screening of Universal screening of new new patients, is patients, is manageable, and may further help identify comanageable, and may further help identify co--morbid needs of CHC patient population.morbid needs of CHC patient population.

Smoke ‘em if you got ‘em!Smoke ‘em if you got ‘em!Smoke em if you got em!Smoke em if you got em!

Many regions already have a Many regions already have a MediCal:Uninsured ratio that by ourMediCal:Uninsured ratio that by ourMediCal:Uninsured ratio that , by our MediCal:Uninsured ratio that , by our model, make them viable.model, make them viable.

MediCal expansion will provide the ratio MediCal expansion will provide the ratio needed for other regions in the future.needed for other regions in the future.

Fly in the OintmentFly in the OintmentFly in the OintmentFly in the Ointment

Integration only works if you have eligibleIntegration only works if you have eligibleIntegration only works if you have eligible Integration only works if you have eligible providers (LCSW, Psychologist or providers (LCSW, Psychologist or Psychiatrist)Psychiatrist)y )y )Severe shortage of such willing providers Severe shortage of such willing providers in areas like the Central Valley, make the in areas like the Central Valley, make the yymodel costly and prohibitive.model costly and prohibitive.LMFT, LPCC and Certified Addiction LMFT, LPCC and Certified Addiction Counselors would expand the recruitment Counselors would expand the recruitment pool and make integration feasible.pool and make integration feasible.

Primary Care Providers Need and Enjoy the Support of BHP’sEnjoy the Support of BHP’s.

Staff PerceptionsStaff PerceptionsStaff PerceptionsStaff Perceptions

5.00

Primary Care Providers Value Services Provided by Behavioral Health Providers

Agree Strongly

4.00

3.00BaselineF ll

2.00

Followup

2.00

1.00BHP Respondents PCP RespondentsDisagree

Strongly

5.00

Primary Care Providers Value Behavioral Health Screening Information

Agree Strongly

4.00

3.00

2 002.00

1.00BHP Respondents PCP RespondentsDisagree

Strongly

5.00

Communication Between Medical and Behavioral Health Staff is Good

Agree Strongly

4.00

3.00 baselinef ll

2 00

followup

2.00

1.00BHP Respondents PCP RespondentsDisagree

Strongly

5.00

Recommend that Other Primary Care Providers Integrate Behavioral Health into their Facilities

Agree Strongly

4.00

3.00baselinef ll

2.00

followup

2.00

1.00BHP Respondents PCP RespondentsDisagree

Strongly

5.00

Appropriate balance between BH and non-BH patients in clinic

Agree Strongly

4 004.00

3.00

2.00

1.00BHP Respondents PCP RespondentsDisagree

Strongly

Overall Measure of IntegrationOverall Measure of IntegrationOverall Measure of IntegrationOverall Measure of Integration

Dual Diagnosis Capability in Health Care Settings Dual Diagnosis Capability in Health Care Settings

3.3Training

4 0

2.9

Continuity of Care

Staffing

2.8

4.0

Clinical Process: Treatment

Continuity of Care

2011

3.6Clinical Process: Assessment

2011

2.8Program Milieu

3.4

1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Program Structure

Dual Diagnosis Capability in Health Care Settings Dual Diagnosis Capability in Health Care Settings

4.33.3Training

3.5

4.0

2.9

Continuity of Care

Staffing

3 5

4.5

2.8Clinical Process: Treatment

Continuity of Care

2011

4.2

3.5

3.6Clinical Process: Assessment

2012

3.32.8Program Milieu

3.63.4

1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Program Structure

Screening DataScreening DataScreening DataScreening Data

500

Screenings per Month“Organization A”

400

450

500

350

400

250

300

150

200

50

100

0

50

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

PHQ-9 Scores Among Patients with an Initial Positive Screen and one Follow-up Screen*

“Organization A”

15 918

20Organization A

15.9

12.014

16

12.0

8

10

12

4

6

8

0

2

4

First PHQ-9 Second PHQ-9

* Only 35.6% had a second screen, making interpretation difficult.Average time between screens: 73 days

Planned Future/Ongoing WorkPlanned Future/Ongoing WorkPlanned Future/Ongoing WorkPlanned Future/Ongoing Work

More followMore follow--up surveys DDCHCsup surveys DDCHCsMore followMore follow up surveys, DDCHCsup surveys, DDCHCsRefinement and analysis of screening and Refinement and analysis of screening and service dataservice dataservice dataservice dataPatient perception focus groupsPatient perception focus groupsPatient outcome interviewsPatient outcome interviewsAdditional training & technical assistanceAdditional training & technical assistancegg

Thank you!Thank you!Thank you!Thank you!

Lily Alvarez LAlvarez@co.kern.ca.us

Christopher Reilly, LCSWChristopher.Reilly@clinicasierravista.orgChristopher.Reilly@clinicasierravista.org

Darren Urada, Ph.D.D d @ l dDurada@ucla.edu