Health Reform, and Integration Challenges and Opportunities

WVAADAC ConferenceCenter for Integrated Health Solutions

Oct. 4, 2011

Agenda

Health Reform/overview

What is Integration?

Why Do it?

Challenges

Opportunities

A Changing Healthcare Landscape: Ensuring a Role for Behavioral Health

• Affordable Care Act• Substance Use/Mental Health Parity• Merged Block Grant Submissions

With new policy changes and more people with access to care, we will have to think creatively about how to increase capacity, reach out to underserved populations, and provide services in a way to meet new demands.

Accountability is the cornerstone of the new healthcare environment.

All of these initiatives will require investment in new technologies, especially technologies that interface with other systems and also measure outcomes.

A Population Health ApproachNeed to think differently about health: move from a focus

on providing services to a single individual… to measurably improving outcomes for the populations in our communities

Key strategies/elements:PreventionCare managementPartnerships with primary care providers and others in the

healthcare systemData collection & continuous quality improvementClinical accountability

Health Care Reform

Two HypothesesSick Care/Health Care: Federal, State and Local

healthcare reform is in the process of dramatically changing the American healthcare system from a sick care system to a true health care system

Importance of Behavioral Health: Prevalence and cost studies are showing that this cannot be accomplished without addressing the substance use and mental health needs of all Americans.

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The Affordable Care Act: Four Key Strategies

U.S. health care reform, with or without federal legislation, is moving forward to address key issues

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Insurance Reform

Requires guaranteed issue and renewalProhibits annual and lifetime limitsBans pre-existing condition exclusionsCreate essential benefits package that

provides comprehensive services including MH/SU at Parity

Requires plans to spend 80%/85% of premiums on clinical services

Creates federal Health Insurance Rate Authority

Coverage Expansion

Requires most individuals to have coverage

Provides credits & subsidies up to 400% Poverty

Employer coverage requirements (>50 employees)

Small business tax creditsCreates State Health Insurance

ExchangesExpands Medicaid

Medicaid Expansions

Benefits for the Newly Eligible

Essential benefits include mental health and substance use treatment

MH and SUD must be offered at parity with medical/surgical benefits

This means…

…Most members of the safety net will have coverage, including mental health and substance use disorders

What is the health profile of the newly eligible?

Health Profile of the Newly Eligible

16 million new Medicaid enrollees

This group on average is healthier relative to those who are currently enrolled in Medicaid (due to the fact that many of those with the worst health conditions already receive coverage through SSI or other disability pathways)

But…

The newly eligible with the most serious health problems will likely be the first to enroll.

Payment Reform & Service Delivery Design“Follow the Money” (Deep Throat quote from Bob Woodward’s account of Watergate)• Prevention Activities must be

funded and widely deployed• Primary Care must become a

desirable occupation and• Mental Health and Substance

Use Disorder Assessment & Treatment for all must become the Standard of Care

• In order to Decrease Demand in the Specialty and Acute Care Systems

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Prevention, Early Intervention,

Primary Care, and Behavioral Health

Inpatient & Institutional

Needed Resource Allocation

All things Inpatient and Institutional

Prevention, Primary Care, BH

Current Resource Allocation

National Healthcare Reform Strategies and the MH/SU Safety Net

In Treatment: 2.3 millionNot in Treatment:

Tens of millions (McClellan) 21% + (Willenbring)

How do we even begin to address these gaps asstates and health plansrealize they have to provide SU servicesat parity?

In Treatment ~2.3 million

“Abuse/Dependence” ~23 million

“Unhealthy Use” ?? million

Little/No Substance Use

Mental Health/ Substance Abuse Block Grant

o In recent SAMHSA block grant application States were allowed to submit a combine MH/SA block grant application

o Data was collected about state integration efforts

If ACA is implemented, changes to the block grant could be made, as Medicaid will become primary payer of services

Whether ACA is fully implemented or not Integration is on the minds of policy makers and payers

What does integration mean?

– Substance Use & Mental Health Disorders– Behavioral Health (SU & MH) and Primary Care

• Whole health approach for individuals with mental health and substance use problems– Considerations: Clinical, operations, financing

Bi-Directional Integration

Placing mental health and substance abuse services in primary care

Placing primary care services in mental health and substance abuse settings

Health Homes assume integration

WHY INTEGRATE WHY INTEGRATE BEHAVIORAL HEALTH AND BEHAVIORAL HEALTH AND

PRIMARY CARE?PRIMARY CARE?

SURGEON GENERAL’S SURGEON GENERAL’S 1999 REPORT 1999 REPORT This hallmark report was the first major emphasis on This hallmark report was the first major emphasis on

Integrated Care Integrated Care

Dr. David Satcher, former US Surgeon General (1998 Dr. David Satcher, former US Surgeon General (1998 – 2002), declared:– 2002), declared:

““There is no Health without There is no Health without Mental Health.Mental Health.””

• 45 percent of Americans have one or more chronic conditions

• Over half of these people receive their care from 3 or more physicians

• Treating these conditions accounts for 75% of direct medical care in the U.S.

• In large part due to the fact that money doesn’t start flowing in the U.S. healthcare system until after you become sick

Co-morbidities in the Adult Population

Source: Druss & Walker. “Mental disorders and medical comorbidity.” The Robert Wood Johnson Foundation Synthesis Project, February 2011.

Supporting Data• People with mental illness die, on average, at age 53 (Colton & Manderscheid,

2006)• One in fourteen stays in U.S. community hospitals involved SU disorders (AHRQ,

2007)• 70% of primary care visits stem from psychosocial issues (Robinson & Reiter,

2007)• Nearly 60% of individuals with bipolar disorder and 52% of persons with

schizophrenia have a co-occurring SU disorder (Verduin et al, 2005)• Approximately 41% of individuals with an alcohol use disorder and 60% of

individuals with a drug use disorder have a co-occurring mood disorder (Verduin et al, 2005)

1. Schroeder S. New England Journal of Medicine 2007 Sep 20;357(12):1221-8 1. Schroeder S. New England Journal of Medicine 2007 Sep 20;357(12):1221-8

• Ideal for treatment of the whole person

• Reducing health disparities of people who live with serious behavioral health conditions

• Bi-directional integration allows for individual choice in determining the Healthcare Home

• More efficient and effective use of healthcare dollars

•Many individuals served in specialty SU have no PCP•Health evaluation and linkage to healthcare can improve SU status•On-site services are stronger than referral to services•Housing First settings can wrap-around MH, SU and primary care by mobile teams •Person-centered healthcare homes can be developed through partnerships between SU providers and primary care providers•Care management is a part of SU specialty treatment and the healthcare home

Primary Care in SU Settings

The Four Quadrant Clinical Integration Model (MH/SU)

Quadrant II

MH/SU PH Outstationed medical nurse

practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP

MH/SU clinician/case manager w/ responsibility for coordination w/ PCP

Specialty outpatient MH/SU treatment including medication-assisted therapy

Residential MH/SU treatment Crisis/ED based MH/SU interventions Detox/sobering Wellness programming Other community supports

Quadrant IV

MH/SU PH Outstationed medical nurse

practitioner/physician at MH/SU site (with standard screening tools and guidelines) or community PCP

Nurse care manager at MH/SU site MH/SU clinician/case manager External care manager Specialty medical/surgical Specialty outpatient MH/SU treatment

including medication-assisted therapy Residential MH/SU treatment Crisis/ED based MH/SU interventions Detox/sobering Medical/surgical inpatient Nursing home/home based care Wellness programming Other community supports

MH

/SU R

isk

/Co

mp

lexit

y

Quadrant I

MH/SUPH PCP (with standard screening tools

and MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)

PCP-based BHC/care manager (competent in MH/SU)

Specialty prescribing consultation Wellness programming Crisis or ED based MH/SU

interventions Other community supports

Quadrant III

MH/SU PH PCP (with standard screening tools and

MH/SU practice guidelines for psychotropic medications and medication-assisted therapy)

PCP-based BHC/care manager (competent in MH/SU)

Specialty medical/surgical-based BHC/care manager

Specialty prescribing consultation Crisis or ED based MH/SU interventions Medical/surgical inpatient Nursing home/home based care Wellness programming Other community supports

Physical Health Risk/Complexity

Low High

Low

Hig

h

Persons with serious MH/SU conditions could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration.

Doherty, McDaniel & Baird Integration Scale

What does it mean to provide primary care?

It’s more than having a nurse on staff

Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a range of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Partnerships with primary care providers/FQHCs

Connect with Other Providers

Do you use a collaborative care approach to clinical services?

Are you actively pursuing bi-directional involvement in your community as a person-centered healthcare home?

Can you electronically collect and share both demographic and clinical-level data with your partners in the healthcare community?

Stepped Care

Is your clinical delivery process consumer-centered and supportive of “stepped care”?•The ability to rapidly step care up to a greater level of intensity when needed?•The ability to step care down so that a consumer’s MH/SU care is provided in primary care with appropriate supports?•The ability to offer “back porch” services for consumers who graduate from planned care?•All offered from a client-centered, recovery-oriented perspective?

Primary Care and SU Services

Diffusion of screening and brief intervention (SBI) is underway

Motivational interviewing with fidelity should be a consistent component of SBI

Repeated BI in primary care is a promising practice

Medication-assisted therapies in primary care can be expanded

Challenges to Integration

Integration Discussion Points at the Clinical Levelo Traditional separation of Substance abuse and Mental

health issues from general medical issues

o Lack of awareness of Substance Abuse/Mental Health

screening tools in the primary care setting

o Limited options for referrals and consultation with

specialty Substance Abuse providers including

psychiatrists, especially in rural settings

Integration Discussion Points at the Administrative LevelThere is an absolute need for trust between the

organizations for any collaboration to be successfulAdministrativeOperationsClinical

The partners must deal with issues like:Fears of one org. entering the other org.’s turfOne org. taking over the other org., or learning how

to do so

Cultural Integration at the Policy Level

• Separation of physical health and Mental Haelth funding streams

• Restrictions on allowable activities and services for community health centers and community substance use providers

• Limitations on the population eligible for public mental health services

• Statutory or regulatory restrictions of public organizations

Integration Discussion Points at the Financial LevelProvision of multiple services on the same day

Delivery of co-occurring services

Reimbursement of services which are currently not being reimbursedMedication Administration (i.e. methadone)Crisis InterventionPeer CounselingMedical visits that are distinct from the substance abuse

service billed separately

Opportunities

Models of Integration?

Healthcare Models of the Future

Collaborative CarePatient Centered Healthcare

HomesAccountable Care Organizations

Accountability and quality improvement are hallmarks of the new healthcare ecosystem

Collaborative Care Approaches to Co-occurring Disorders>30 randomized controlled trials have found collaborative

care approaches improve quality and outcomes

Key “active ingredients” = care managers and stepped care

Collaborative care approaches are highly cost effective

Variety of models, including:Fully integratedPartnership modelFacilitated referral model

Core Components of Collaborative Care

Two ProcessesTwo New Team Members

Care Manager Consulting BH Expert

Systematic diagnosis and outcomes tracking(e.g. PHQ-9 to facilitate diagnosis and track depression outcomes)

• Patient education/self-management support

• Close follow-up to make sure pts don’t fall through the cracks

• Caseload consultation for care manager and PCP (population-based)

• Diagnostic consultation on difficult cases

Stepped Care:a)Change treatment according to evidence-based algorithm if patient is not improvingb)Relapse prevention once patient is improved

• Support medication Rx by PCP

• Brief counseling (behavioral activation, PST-PC, CBT, IPT)

• Facilitate treatment change/referral to BH

• Relapse prevention

• Consultation focused on patients not improving as expected

• Recommendations for additional treatment/referral according to evidence-based guidelines

Person-Centered Healthcare Homes: A new paradigm

Picture a world where everyone has...An Ongoing Relationship with a responsible healthcare

providerA Care Team that collectively takes

responsibility for ongoing care

And where... Quality and Safety are hallmarksEnhanced Access to care is availablePayment appropriately recognizes the Added Value

What does this look like in practice?

New Medicaid State Option for Healthcare Homes

State plan option allowing Medicaid beneficiaries with or at risk of two or more chronic conditions (including mental illness or substance abuse) to designate a “health home”

Community behavioral health organizations are included as eligible providers

Effective Jan. 2011

Additional guidance forthcoming from HHS

Eligibility Criteria

To be eligible, individuals must have:Two or more chronic conditions, OROne condition and the risk of developing another, ORAt least one serious and persistent mental health

condition

The chronic conditions listed in statute include a mental health condition, a substance abuse disorder, asthma, diabetes, heart disease, and obesity (as evidenced by a BMI of > 25).

States may add other conditions subject to approval by CMS

What it’s not:

A residential facility

Primary care provider as gatekeeper

Defining the Healthcare Home

Everyone has a health home practitioner and team

Patients can easily make appointments and select the day and time.

Waiting times are short.

Email and telephone consultations are offered.

Off-hour service is available.

Defining the Healthcare Home

Health Home team has a patient-centered, whole person orientation

Care is tailored to the needs of each patient

Patients are active participants, with the option of being informed and engaged partners in their care.

Practices provide information on treatment plans, preventive and follow-up care reminders, access to medical records, assistance with self-care, and counseling.

Defining the Healthcare HomeSystems support high-quality care, practice-

based learning, and quality improvement.

Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments.

There is continuous learning and practice improvement.

Defining the Healthcare HomeThe health home team engages in care

coordination & management within the team

The team also coordinates with other healthcare providers/organizations in the community

Systems are in place to prevent errors that occur when multiple physicians are involved.

Follow-up and support is provided.

Defining the Healthcare Home

Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals (including BH specialists).

Duplication of tests and procedures is avoided.

Defining the Healthcare Home

Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to learn from patients and inform treatment plans.

Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.

Additional Necessary Components

The health home is supported by a sustainable business model & appropriately aligned incentives

The health home is accountable for achieving improved clinical, financial, and patient experience outcomes

Are you ready to be a healthcare home? Do you…

Have a provider team with a range of expertise (including primary care)?

Coordinate consumers’ care with their health providers in other organizations?

Engage patients in shared decision-making?

Collect and use practice data?

Analyze and report on a broad range of outcomes?

Have a sustainable business model for these activities?

Health Homes Serving Individuals with SMI and Substance Use Disorders1. Assure regular health status screening and registry

tracking/outcome measurement

2. Locate medical nurse practitioners/primary care physicians in MH/SU facilities

3. Identify a primary care supervising physician

4. Embed nurse care managers

5. Use evidence-based practices developed to improve health status

6. Create wellness programs

Accountable Care Organization

Accountable Care Organizations (ACOs): the homes for medical homes

Medical Homes

Hospitals

Medical Homes

Food Mart

Specialty Clinics

Food Mart

Specialty Clinics

Medical Homes

Hospitals

Clinic

Clinic

Accountable Care Organization

Health Plan

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On Your Mark, Get Set, ACO…

Accountable Care Organizations bring together healthcare homes, specialty care, and ancillary services

Core Principles of an ACO• Directed by a coordinated set of providers

• Provides a full continuum of care to patients and populationsHealthcare homes, specialty care, hospital, case management,

care coordination, transitions between levels of care…and more

• Financial incentives aligned with clinical goals

• Cost containment

• Enhancement of care quality and the patient experience

• Improvement of overall health status

ACOs and the Safety NetCoverage expansions: The massive expansion of coverage

in 2014 will require new models to assure access and control costs – particularly for serving Medicaid patients, who will make up 14 million of the newly insured

Care management: Individuals served by the safety net experience higher rates of serious mental illness, substance use disorders, and poorly controlled multiple chronic conditions

Community behavioral health organizations have expertise and experience in caring for these populations, making them valuable partners in an ACO

Providers Need to Rethink their Service Approaches

• Infrastructure development and process improvement are necessary

• Continuing care should link the continuum of services together and support the individual’s change process

• Recovery Oriented Systems of Care support recovery as a process• Motivational Enhancement Therapy or the Transtheoretical Model

are effective, but must be delivered with fidelity• Other approaches, including medication-assisted therapy are also

effective• Communities must work together to create a continuum of services

and agreements about seamless access, stepped care and other transitions

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Designated Provider Types/Functions

Provider organizations may work alone or as part of a team

Functions include (but are not limited to):Providing quality-driven, cost-effective, culturally

appropriate, and person-centered care;Coordinating and providing access to high-quality services

informed by evidence-based guidelines;Coordinating and providing access to mental health and

substance abuse services;Coordinating and providing access to long-term care

supports and services.

Dedicated to promoting the development of integrated primary and behavioral health services to better address the needs of

individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care

provider settings.

The SAMHSA/HRSA Center for Integrated Health Solutions (CIHS)

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 (including healthcare homes)

To provide technical assistance to 64 PBHCI grantees and FQHCs funded through HRSA to address the health care needs of individuals with mental illnesses, substance use and co-occurring disorders

www.CenterforIntegratedHealthSolutions.org

ResourcesBehavioral Health/Primary Care Integration and The Person-Centered Healthcare

Home, April 2009, The National Council.

Substance Use Disorders and the Person-Centered Healthcare Home , March 2010, The National Council.

http://www.thenationalcouncil.org/cs/resources_services/resource_center_for_healthcare_collaboration/clinical/personcentered_healthcare_homes

California Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative. Vols. I, II, and III. September 14, 2009.

The Business Case for Bidirectional Integrated Care: Mental Health and Substance Use Services in Primary Care Settings and Primary Care Services in Specialty Mental Health and Substance Use Settings. June 30, 2010. http://www.cimh.org/Initiatives/Primary-Care-BH-Integration.aspx

Oregon Standards and Measures for Patient Centered Primary Care Homes. February 2010. Office for Oregon Health Policy and Research. http://courts.oregon.gov/OHPPR/HEALTHREFORM/PCPCH/docs/FinalReport_PCPCH.pdf

SAMHSA/HRSA Center for

Integrated Health SolutionsThe resources and information needed to successfully

Integrate primary and behavioral health care

For information, resources and technical assistance contact the CIHS team at:

Online: CenterforIntegratedHealthSolutions.orgPhone: 202-684-7457Email: Integration@thenationalcouncil.org