Mental Health/Primary Care Integration:Lessons from Five Counties

Annette Gardner, PhD, MPH

Study Director

Philip R. Lee Institute for Health Policy Studies

University of California, San Francisco

July 31, 2013

SF

University of California San Francisco

Objectives

“Integration” defined Key federal and state policies Mental health/primary care Integration

programs in 5 counties Implications for providers

“Integration” Defined

Systems approach to the provision of the right care, at the right time, in the right place: “Comprehensive, coordinated, culturally competent

consumer-centered care” Two or more entities establish linkages for the

purpose of improving outcomes Reduce fragmentation and duplication of services and

consequently costs Greater transparency and accountability

Six Levels of Collaboration/Integration (SAMHSA-HRSA)

CoordinatedKey Element:

Communication

Co-LocatedKey Element:

Physical Proximity

IntegratedKey Element:

Practice Change

Level 1Minimal

Collaboration

Level 2Basic

Collaboration at a Distance

Level 3Basic

Collaboration Onsite

Level 4Close

Collaboration with Some

System Integration

Level 5Close

Collaboration Approaching an Integrated

Practice

Level 6Full

Collaboration in a Merged Integrated Practice

Behavioral health, primary care and other health care providers provide care:

Separate systems;Communicate rarely;Have limited understanding of roles.

Separate systems;Communicate periodically;Appreciate each others roles.

Separate systems;Communicate regularly;Collaborate;Part of informal team.

Share some systems;Communicate in-person;Collaborate;Have basic understanding of roles/culture.

Seek system solutions;Communicate frequently in-person;Collaborate frequently;Have in-depth understanding of roles/culture.

Function as one integrated system;Communicate at system, team, individual levels;Collaborate driven by shared concept of team care;Blended roles/cultures.

Road to Coordinated Care

PPACA Provisions to Promote Integration

Medicaid health homes or State Option to Provide Health Homes for Enrollees with Chronic Conditions (S 2703) Comprehensive care plans; Quality, cost-effective, culturally appropriate, evidence-based

patient/family centered services Inclusion of prevention, health promotion, mental health,

substance abuse, LTC Continuing care strategies, e.g., care management, transitional

care Providers must ensure array of coordinated services; and Use of HIT

Cal MediConnect program (planned) Coordinate care for Medicare/Medi-Cal dual elgibles in 8 counties

State Medicaid expansion Between 279,000 – 373,200 newly eligible are estimated to have

mental health care needs Health Benefit Exchange – Covered California

Must include mental health and substance use disorder services

California Counties – Health Stewards, Health Innovators

UCSF Safety Net Integration Study, 2012

28 integration activities in 5 diverse California counties;Factors that affect local safety nets’ ability to develop integrated delivery systems; Best practices or integration initiatives underway; andLessons learned and recommendations for facilitating safety net integration and laying the foundation for health care reform.

UCSF Safety Net Integration Study - Five Study Counties

Safety Net System

Medi-Cal Model and Study Plan

Study Safety Net Hospital

Study Non-County Clinic, Consortium

HCCI Legacy

County?

Contra Costa

Public/private 2-Plan (Contra Costa Health Plan)

Contra Costa Regional Medical Center

La Clinica de La Raza; Community Clinic Consortium

Yes

Humboldt (CMSP)

Private FFS St. Joseph Health System

OpenDoor CHCs, North Coast Clinics Network

No

San Diego Private GMC UC San Diego Medical Center

La Maestra CHCs; Council of Community Clinics

Yes

San Joaquin

Public/private 2-Plan (Health Plan of San Joaquin)

San Joaquin General Hospital

Community Medical Centers, Inc.

No

San Mateo Public COHS (Health Plan of San Mateo)

San Mateo Medical Center

Ravenswood Family Health Center

Yes

Health Care Safety Net Gaps

Populations

Undocumented uninsured;

Homeless;

Some sub-populations, e.g., Pacific Islanders;

Seniors.

Diseases, Conditions

Mental health, substance abuse;

Chronic diseases;

Obesity.

Services

Primary Care;

Mental Health;

Specialty Care;

Dental health;

Access issues, e.g., same day appointments.

Skill Gaps

Some provider types, e.g., primary care and orthopedics;

HIT, e.g., roll-out;

Connecting services, HIT systems

Capacity Assessment by County

Contra Costa

Humboldt San Diego San Joaquin San Mateo

Agree to Strongly Agree

Agree to Strongly Agree

Strongly Disagree to Strongly Agree

Disagree to Agree

Agree to Strongly Agree

“Gearing up for this and are well positioned”

“Already doing it” and “Have the organizations, communication, networking capacity”

“Increase in uninsured.” And “There is high commitment and resources”

“Pitting health care against other county issues” and “Uneven provider capacity”

“Already doing it” and “Have the will and the ingredients”

“The county has the organizations and resources to coordinate health care services to meet the needs of the newly insured as well as remaining uninsured, e.g., undocumented immigrants.”

Level of Integration by County

Contra Costa

Humboldt San Diego San Joaquin

San Mateo

7.7(ranges from

6 to 9.5)

6.7(ranges from

5 to 9)

6.3(ranges from

5 to 8)

7.2(ranges from

6.5 to 8)

7.5 (ranges from

7 to 8)

“county-run; shared funding of positions”

“no shared funding; regular meetings, project-specific funding.

“project by project”

“Among county entities – 9; with outside entities – 6 to 7”

“depends on the area; separate budgets but will contribute to a joint project”

“Please rate the level of collaboration or integration that has been achieved by the organizations that work on initiatives to integrate the safety net on a scale of 1 – 10 where 1=information sharing and communication; 3=cooperation and coordination, e.g., do joint planning; 6=collaboration, e.g., sharing of funding/services; 8=consolidation, e.g., regular meetings of key players, cross-training of staff; 10=integration, e.g., shared funding of positions, joint budget development”

Findings – Activities Underway (Y) and Proposed (P), by County (N=28 activities)

Contra Costa

(25)

Humboldt (26)

San Diego (28)

San Joaquin

(25)

San Mateo (26)

System-level Activities

Participation in an ACO P P Y (ACC)

P Y (DSRIP)

Adoption of an integrated network of safety net providers (coordinate care across levels of care)

Y Y Y Y Y

Provider-level Activities

Adoption of panel management Y Y Y Y Y

Onsite mental health care at PC sites Y Y Y Y Y

Onsite dental health at PC sites Y Y Y Y Y

Expanded communications between primary care and specialty care

Y Y Y Y Y

Expanding provider scope of service Y Y Y Y Y

County contracts with comm. clinics Y Y Y Y Y

Adoption of PCMH Y Y Y Y Y

Addition of new health care services Y Y Y Y Y

Auto enrollment of Medi-Cal patients Y P Y Y Y

ER Diversion Programs Y Y Y Y Y

Activities Underway, Proposed, by County (cont.)Contra Costa

Humboldt San Diego

San Joaquin

San Mateo

Health Information Technology

Electronic eligibility and enrollment Y Y Y Y Y

Electronic prescribing Y Y Y Y Y

Electronic health information system (EMR) Y Y Y Y Y

Electronic Disease Registry Y Y Y Y Y

Electronic specialty care referral Y Y Y P Y

Electronic panel management system Y Y Y Y Y

Health Information Exchange P Y Y Y P

Patient-level Activities

After hours and/or same day scheduling Y Y Y Y Y

24/7 nurse advice line Y Y Y Y Y

E-Portals for patients to interact with systems

P Y Y P P

Case management services Y Y Y Y Y

Certified Application Assistors Y Y Y Y Y

Community Health Workers Y Y Y Y Y

Patient Navigators Y Y Y Y Y

Accessible telephone system Y Y Y Y Y

Language access Y Y Y Y Y

Areas of High Involvement by Most Providers

Provider-level Integration Adoption of Panel Management Mental Health/Primary Care Integration - Counties, Clinics,

Medi-Cal Health Plans Expanded Communications Between Primary Care and

Specialty Care Electronic Disease Registries

Patient-level Integration: After Hours/Same Day Scheduling Case Management Services Certified Application Assistors Community Health Workers Accessible Telephone Systems; and Language Access

Models of Integrated Care

Co-location/IntegratedContra Costa County Pilots, 2012

1) Location of a nurse practitioner at MH clinics to see people with some chronic conditions who are not comfortable going to a PC facility;

2) Wright psychology interns located in PC setting “hand off” patients to MH practitioner; and

3) Co-location model where one county primary care clinic is refitted to house a range of services, including PCMH.

Co-location/Integration of MH in PCSan Joaquin General Hospital

Launched in 2010 with support from Prop 63 (MHSA) Prevention and Early Intervention (PEI) funding ($779,000)

Expand patient access to behavioral services in a less stigmatized setting and expand the capacity of the county’s Family Practice Clinic to conduct mental health screenings, care coordination, and short-term mental health services.

Three clinicians were co-located at the Family Practice Clinic to provide short-term interventions to older adults as well as to provide staff and resident training.

An estimated 945 people were served directly and 5,000 indirectly through training and education.

Bi-directional Co-locationSan Mateo County Health System

Total Wellness Initiative launched in 2010 with support from a SAMHSA grant ($490,000 each year for four years)

The location of two NPs in 4 outpatient behavioral health sites to provide accessible primary care to patients with Serious Mental Illness (SMI)

Wellness groups run by peers and staff that target smoking cessation, physical activity, and nutrition, among other issues, provide support in targeting physical health issues not traditionally dealt with in behavioral health settings

County also provides mental health consultative support in county and non-county primary care settings to address routine behavioral health issues like depression and anxiety, and to coordinate medication

Adopting, Leveraging Information Technology

CommunicationsHumboldt County

• Established communications system—relationships and paper system—to ensure that patients get appropriate care in the right setting. Stabilizing psychiatric staff and steering patients to the same psychiatrist.

• Also have a psychiatric NP who uses telemedicine.

Telehealth—Open Door Community Health Centers, Humboldt County

Open Door has its own internal virtual private network and all sites have telehealth connections.

In 2006, it opened the Telehealth and Visiting Specialist Center in Eureka, CA.

It has four full exam rooms and two office exam rooms equipped with video conferencing equipment, on-site specialty care providers, and has links to 22 clinics as well as providers at UCSF and UCD.

By 2009, Open Door was conducting nearly 1,000 telehealth visits annually, and currently averages nearly 1,200 visits.

The field is moving very quickly and the next quantum leap is with TH going to phones and iPads. For example, the clinic can now arrange consults and visits between patients/providers in multiple sites

Co-location of PC in MH settingsCouncil of Community Clinics, San Diego

Launched in 2009 and funded by SAMHSA ($500,000) Provide primary care to individuals with Serious Mental Illness

(SMI) at behavioral health services organizations Two Federally Qualified Health Centers (FQHCs) paired with

two county-contracted specialty mental health programs in two different areas of the county (North/South). A nurse care manager (RN) from the FQHC is placed in the

specialty mental health setting and does basic health screenings.

One of the FQHCs has also out-stationed a part-time nurse practitioner at a mental health program

The other FQHC has created specific appointment slots for the individuals referred from the mental health program.

Primary care and mental health goals are shared to help persons with SMI improve their health status as well as improve provider decision-making.

Co-location of MH in PC settingsCouncil of Community Clinics, San Diego

Funded under MHSA in 2009. Nine clinics participateCouncil contracted with the County of San Diego's Behavioral Health Administration to implement the Mental Health and Primary Care Integration Project (MH&PCIP)Two treatment models:

Specialty Pool Services (SPS) for individuals with Serious Emotional Disability or with Serious Mental Illness (SED/SMI)

IMPACT (Improving Mood Promoting Access to Collaborative Care Treatment) to treat individuals who are suffering primarily from depression. Senior Peer Promotoras conduct outreach and work to maintain clinic patients in treatment.

Provider Collaboration

Medically Trained Cultural Liaison (MTCL) ModelLa Maestra Family Clinic, San Diego County

Implemented by La Maestra Family Clinic over 20 years ago. The clinic currently has 25 full-time MTCLs at its main site.Expands the Promotoras function to include medical training. The clinic has over twenty languages at their seven sites and it hired and trained people from these populations to ensure cultural competency. MTCLs are a conduit between patients and staff and providers on culturally specific issues that can inform their treatment and ensure compliance with preventive screening and treatment instructions. The MTCLs also serve as peers and advocates in the mental health world.

Mental Health/Primary Care Integration Best Practices

Funding: ACA MHSA funding Federal Substance Abuse and Mental Health Services

Administration (SAMHSA) grants Billing for encounters

Facilitating factors: Finding the middle ground having shared, motivated leadership Ownership by mental health and primary care stakeholders Integration philosophy and cultural change

Challenges: Resource intensive, e.g., lack of space, support staff and $ Finding middle ground

Observations Interprofessional collaboration and working as a team is key,

e.g., huddles, shared care plan, curb-side consults,

Integration requires tailored approach – provide patients with the care they need in the setting that works for them.

Organizational partnerships and collaboratives are key, e.g., between county and clinics, mental health and primary care

Leveraging/aligning with other safety net integration activities, e.g., patient care coordination, LIHP

Facilitating role of “nimble” organizations, e.g., clinic consortia, Medi-Cal health plans, e.g.,

Dedicate staff to develop relationships and attend meetings

Provide TA and develop tailored programs

Thank you!

For more information:

Annette L. Gardner, PhD, MPH

Assistant Professor

Philip R. Lee Institute for Health Policy Studies, UCSF

(415) 514-1543

Annette.gardner@ucsf.edu

http://healthpolicy.ucsf.edu/article/healthcare_safety_net