The Greater Houston Behavioral Health Affordable Care Act Initiative:

Leveraging Collective Impact to Advance Integrated Health Care Practice and Policy

Shannon Evans, MBA, LSSGB, Manager, Health System Strategy Operations, Harris Health System

Alejandra Posada, MEd, Director of Education and Training, Mental Health America of Greater Houston

Elizabeth Reed, LMSW, Program Manager, BHACA Initiative, Network of Behavioral Health Providers

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session A5bOctober 17, 2015

1

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

2

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Identify at least four ways in which a collaborative, such as the BHACA Initiative, can leverage collective impact to advance integrated health care policy and practice.

• Describe how the Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration can be utilized by a group of organizations to support the advancement of IHC within each organization and collectively.

• List three characteristics of the level of integrated health care across a large metropolitan area (greater Houston) and describe how survey results can inform collaborative action.

3

Bibliography / Reference

1. Brown Levey, S.M., Miller, B.F., and deGruy III, F.V. (2012). Behavioral health integration: an essential element of population-based healthcare redesign. Translational Behavioral Medicine. Published online July 26, 2012. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3717906/

2. Grantmakers for Effective Organizations and Research Center for Leadership in Action (NYU Wagner). (2012). Learn and Let Learn: Supporting Learning Communities for Innovation and Impact. Available at http://www.geofunders.org/resource-library/all/record/a066000000AhjF4AAJ

3. Heath, B., Wise Romero, P., and Reynolds, K. (2013). A Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. Available at http://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdfReference

4. Lopez, M. A. and Stevens-Manser, S. (2014). Texas 1115 Medicaid Demonstration Waiver: A Review of Behavioral Health Projects. Texas Institute for Excellence in Mental Health, School of Social Work, University of Texas at Austin. Available at http://sites.utexas.edu/mental-health-institute/files/2012/10/1115-Waiver-BH-Projects-Report-Final.pdf

5. SAMHSA-HRSA Center for Integrated Health Solutions. (2014). Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration. Available at http://www.integration.samhsa.gov/operations-administration/OATI_Overview_FINAL.pdf

4

The Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative

5

• Introduction to the BHACA Initiative• Integrated Health Care (IHC) Component of the

BHACA Initiative

The Greater Houston Behavioral Health Affordable Care Act Initiative

(BHACA)Collaboration of the Network of Behavioral Health Providers (NBHP) and Mental Health America of Greater Houston (MHA)

Goal: To assist greater Houston area mental health and substance use providers in responding to the Patient Protection and Affordable Care Act and other recent healthcare reforms across four domains:

(1) enhancing and increasing the delivery of integrated health care (IHC), (2) maximizing third party funding streams revenue, (3) adopting certified electronic health records (EHRs), and (4) developing outcome-based evaluations.

6

NBHP Member Agencies

NBHP was founded in 2004 to be a roundtable for the CEOs and Executive Directors of Greater Houston’s behavioral health providers. Currently there are 34 behavioral health provider agencies in NBHP. A list of NBHP’s members can be found online at www.nbhp.org/member-organizations.html. 7

NBHP Membership 2015 - 2016Baylor College of Medicine Teen Health Clinic Houston Galveston Institute

Career and Recovery Resources Houston Methodist

Catholic Charities of the Diocese of Galveston-Houston Houston Recovery Center

The Center for Success and Independence Interface-Samaritan Counseling Centers

The Council on Recovery IntraCare Behavioral Health

Covenant House Texas Jewish Family Service

DePelchin Children’s Center Legacy Community Health Services

El Centro de Corazon Memorial Hermann Behavioral Health Services

Family Services of Greater Houston The Menninger Clinic

Fort Bend Regional Council on Substance Abuse, Inc. Mental Health America of Greater Houston

The Harris Center for Mental Health and IDD The Montrose Center

Harris County Protective Services for Children and Adults Open Door Mission

Harris County Psychiatric Center Santa Maria Hostel, Inc.

Harris Health System SEARCH Homeless Services

Hays-Caldwell Council and Alcohol and Drug Abuse St. Joseph Medical Center

Healthcare for the Homeless-Houston Vecino Health Centers

Houston Area Community Services, Inc. The Women’s Home

8

IHC Component of BHACA

• Assessment of current status of community provider level of integration

9

IHC Component of BHACA

• Assessment • Provider education about what integrated

health care is

10

IHC Component of BHACA

• Assessment • Provider education • Engagement of potential primary

care/physical health partners invested in serving a similar population, such as federally qualified health centers (FQHCs) and charity clinics

11

IHC Component of BHACA

• Assessment • Provider education • Engagement of primary care• Engagement of key community partners in

outreaching to a diverse and large audience (Harris County Healthcare Alliance, the Southeast Texas Regional Healthcare Partnership (Medicaid 1115 Waiver) Learning Collaborative, and the Houston Recovery Initiative)

12

IHC Component of BHACA

• Assessment • Provider education • Engagement of primary care• Engagement of community partners• Community-wide education events about models of

integration, financing of integrated health care, evaluation of integrated health care, and clinical cross-trainings (across substance use services, mental health, and physical health disciplines) that simultaneously promote provider networking

13

IHC Component of BHACA

• Assessment • Provider education • Engagement of primary care• Engagement of community partners• Community education • Continued assessment of and support for

developing projects toward integration and assessment of potential new avenues to build on (such as existing referral relationships)

14

15

Examples of BHACA Integrated Health Care Training Events

Brief Behavioral Interventions in Primary Care: Billing Considerations and Clinical

TrainingMay 8, 2015—Panelists: Emilie Becker, MD, Mental Health Medical Director for Texas Medicaid and CHIP; Katy Caldwell, CEO, Legacy Community Health Services; Rodney McDonald, RN, MSN, Nurse Consultant, CMS Medicare Fee for Service Branch Dallas Texas Regional Office; Heidi Schwarzwald, MD, MPH, CMO for Pediatrics, Texas Children’s Health Plan; Medical Director of Pediatrics, The Center for Children and Women; and Vice Chair and Section Head, Community Pediatrics with Baylor College of Medicine Department of Pediatrics. Breakout Session Leaders: Stephanie Chapman, PhD, Behavioral Health Clinical Team Lead, Texas Children’s Health Plan–The Center for Children and Women; Kavon Young, MD, Medical Director, El Centro de Corazón; Blanca Hernandez, PhD, Staff Psychologist, DePelchin Children’s Center; Rodolfo Orna, LMFT, Senior Manager of Behavioral Health Services, El Centro de Corazón; Stacy Ogbeide, PsyD, Behavioral Health Consultant, Healthcare for the Homeless–Houston.

Behavioral Health Screening in Primary Care Settings:

Integrated Health Care Models for Meeting Clients’ Real-Time,

Whole-Person NeedsSeptember 19, 2014

Presented by Stacy Ogbeide, PsyD, (at the time) Behavioral Health Consultant, Healthcare for the Homeless – Houston (an FQHC)

IHC: BHACA Initiative TrainingsIntegrated health care provider and administrator trainings focused on:• Clinical cross-training (for medical, mental health, and substance use

professionals)• Financing integrated health care• Building partnerships for the provision of integrated health care• Standardized frameworks for the assessment of integrated health care

Year 1 (July 1, 2013 – June 30, 2014): 7 IHC Events• 284 enrollments, 98 agencies (unduplicated)Year 2 (July 1, 2014 – June 30, 2015): 9 IHC Events• 380 enrollments, 128 agencies (unduplicated)Year 3 (July 1, 2015 – present/June 30, 2016): 1 IHC Event (to date)• 18 enrollments, 12 agencies (unduplicated, to date)

Total Count, Years 1 – 3 (July 1, 2013 to the present): 17 Events to date• 682 enrollments, 180 agencies (unduplicated, to date)

16

• University of Texas Medical Branch at Galveston (UTMB)

• Co-lead IHC learning collaborative cohort for DSRIP Medicaid 1115 Waiver

• Harris CountyHealthcare Alliance

• Houston Recovery Initiative (HRI)

Continuing Medical

Education (CMEs)

Large Provider Entities

Funded for IHC

Primary Care

Providers

Substance Use

Services

Collaborator Engagement

17

The Texas Medicaid 1115 Waiver

18

• Introduction to the Texas 1115 Waiver• Overview of Regional Healthcare Partnership 3• Behavioral Health and Integrated Care in RHP 3

What is the Texas 1115 Waiver?• In December 2011, the Texas Health and Human Services Commission (HHSC) received federal approval of

a five-year waiver that allows the state to expand Medicaid managed care while preserving hospital funding, provide incentive payments for health care improvements, and direct more funding to hospitals that serve large numbers of uninsured patients.

• Through the 1115 Healthcare Transformation waiver, supplemental payment funding, managed care savings, and negotiated funding goes into two statewide pools worth $29 billion (all funds) over five years. Funding from the pools is being distributed to hospitals and other providers to support the following objectives: (1) an uncompensated care (UC) pool to reimburse for uncompensated care costs as reported in the annual waiver application/UC cost report; and (2) a Delivery System Reform Incentive Payment (DSRIP) pool to incentivize hospitals and other providers to transform their service delivery practices to improve quality, health status, patient experience, coordination, and cost-effectiveness.

– Uncompensated Care Pool Payments are designed to help offset the costs of uncompensated care provided by the hospital or other providers.

– DSRIP Pool Payments are incentive payments to hospitals and other providers that develop programs or strategies to enhance access to health care, increase the quality of care, the cost-effectiveness of care provided and the health of the patients and families served.

• HHSC established geographic boundaries for new Regional Healthcare Partnerships (RHP). Each RHP developed a plan that identifies the participating partners, community needs, proposed projects and funding distribution.

– The Houston-Metropolitan Service area is RHP 3 and includes the following counties: Austin, Calhoun, Chambers, Colorado, Fort Bend, Harris, Matagorda, Waller and Wharton.

Provider

• There are 26 providers with active DSRIP projects, including:

•Hospitals•Academic Health Science Centers

•Local Public Health Departments

•Local Mental Health Authorities

County

RHP 3 Quick Facts:•9 counties•8,580 square miles•4.8 million residents•51% Anglo/31% Hispanic

•16.8% live below poverty line

•8% average unemployment

•26% without health coverage

•$50,363 per capita income

Project Focus

• Providers selected project areas from a menu called the RHP Planning Protocol

• All proposed projects were reviewed and approved by HHSC and CMS.

• Incentives are paid for achieving approved milestones and metrics. Outcome

Measure

• 190 outcome measures were selected by RHP 3 providers.

• Baselines were set in DY3.

• DY4 incentives will be paid for reporting and performance.

• DY5 incentives will be paid for performance only.

Community Need

• Providers choose one or more community needs.

• RHP3 includes 25 community needs derived from over 40 community needs assessments throughout the Region

Regional Health Partnership 3 (RHP3)

177 Projects worth approximately $1.8 billion in

incentive payments

21

Local Mental Health Authorities (LMHAs)

• About Us– 3 Hospitals

• Affiliations with Baylor College of Medicine and University of Texas Health Science Center

• 18 community health centers, including the nation's first free-standing HIV/AIDS treatment center

• Two large multi-specialty clinics• Six same day clinics• Five school-based clinics• 10 homeless shelter clinics and five homeless eligibility service locations• One free-standing dental center• One geriatric assessment center• Immunization and medical outreach program with mobile health units

– Performing Provider • 22 Internal Projects

– RHP 3 Anchor

Liason

Technical Expertise

Anchor

Region 3 Cohorts and AccomplishmentsPatient Navigation EC Utilization Behavioral Health:

Continuity of CareIntegrated Care

Readmission Collaboration Best Practices

Start Date 2013 2014 2014 2014 2015

Goal/ Charter Develop two comprehensive web based tools:• Patient navigation

• Regional Continuing Education Tool for CHWs

• Decrease non-emergent EC visits

• Increase area clinics visits

• ID strategies to address all cause 30-day readmission rates

• Evaluate Primary Behavioral Health Care via the Organizational Assessment Toolkit (OATI)

• Engage providers to collaboratively impact regional readmission rates

• ID common best practices and process improvement/ implementation

Outcomes • Memorandum of Understanding with institutions to share data

• Development of

Navigation website

• Evaluation of navigation models

• Meetings with ECs to prevent inappropriate EC use

• Navigate patients to area clinics

• Analysis of regional hospital discharge data correlating patient characteristics with readmission

• OATI pilots

• Completed a survey to ID specific readmission focus areas

• Shared document with community partners discussing challenges to collaboration

Texas 1115 Waiver Behavioral Health Projects

1; 2%5; 12%

7; 17%

14; 34%

1; 2%

12; 29%

1; 2%

$186,649

$48,242,102

$90,024,439

$117,092,899

$7,093,560

$133,606,848

$661,274

1

4

5

4

1

8

1

Health Education

Care Transition

Crisis Stabilization

Expand Behavioral Health

Expand Inpatient Behavioral Health

Integrated Care

Juvenile Detention Diversion

Number of Providers

Value of Projects

Number, Percent of Projects

Project # Provider Description1 Harris County Hospital District

Ben Taub General HospitalIntegrate Behavioral Health and Primary Care Enhance service availability Behavioral Health Care - Adults - This project will to enhance service availability of appropriate levels of behavioral health care by expanding mental health services in the ambulatory care setting. Therapists and psychiatrists will be added ( 13.4 Psychiatry and Behavioral Health FTEs) to existing Harris Health System health centers across Harris County.

2 Bayshore Medical Center Integrate Behavioral Health and Emergency Care Implement telemedicine program to provide or expand specialist referral services in an area identified as needed to the region - HCA intends to expand its existing telemedicine program to include a 24/7 tele-psychiatry program in its Bayshore Emergency Department (ED), as well as implementing telemedicine capabilities in the EDs at its other local hospitals. Specifically, HCA will identify the necessary technology to establish the program, reach out to behavioral health providers to participate, train the ED staff at each hospital to effectively use the new capabilities, and will implement protocols for obtaining tele psychiatry consults and referrals to and from Bayshore.

4 City of Houston Department of Health and Human Services

Integrate Behavioral Health and Housing Assistance This new Homeless project will serve 200 individuals who are chronically homeless and offer comprehensive service integration intervention. This project will implement its comprehensive five step intervention for the homeless involving 1) permanent housing supportive model 2) program service linkages 3) physical and behavioral health needs 4) financial support 5) other services.

5 Texas Children's Hospital Integrate Behavioral Health and Primary Care Improve access to specialty care: Expand Women’s Mental Health Care - This project will allow us to create access resources which will allow us to diagnosis women quicker and enhance their quality of life. Educating and training obstetricians and pediatricians to improve screening in post-partum depression, to understand the challenges of psychiatric medications during pregnancy and breastfeeding, and to understand the mental health needs of menopausal women.

6 The University of Texas Health Science Center - Houston

Integrate Behavioral Health and Primary Care Integrate Primary and Behavioral Health Care Services: C13 Integrated Adult Primary and Behavioral Health Care Services - UT Health will design, implement and evaluate a project that will integrate primary and behavioral healthcare services within UT Physicians' clinics to achieve a close collaboration in a partly integrated system of care (Level IV). A behavioral health provider will be placed in the primary care setting to provide patients with behavioral health services at their usual source of health care. This will facilitate care coordination between primary and behavioral healthcare.

7 Gulf Bend Integrate Behavioral Health and Primary Care Develop and implement a Person-Centered Behavioral Health Medical Home in Port Lavaca, TX. The center will target at risk populations with co-morbid diseases of mental illness and chronic disease who currently go untreated or under treated and who routinely access more intensive and costly services such as emergency departments or jails. The person-centered behavioral health medical home will offer the following services in the same location:o Behavioral Health Services, Primary care services, Health behavior education and training programs, Long and short term care for those with mental illness and co-occurring chronic disease, and Case Management services to help patient navigate the services provided in the community

8 The Harris Center for Mental Health and IDD

Integrate Behavioral Health and Services for Vision Impaired Lighthouse Specialty Care - MHMRA proposes to establish behavioral healthcare clinic within the Lighthouse facility in order to provide mental health treatment capacity for persons with visual impairment to include identification of behavioral health needs, interventions, case management, patient and family education and coordination with primary care. The team (to include a director, 2 therapists, 1 intake counselor, a part-time nurse and psychiatrist) will develop services to address the specialized needs of persons with visual impairment with a mental health disorder to support wellness and independent functioning in the community.

9 The Harris Center for Mental Health and IDD

Integrate Primary Care and Behavioral Health Integrate primary and behavioral health care services: collaborative primary medical and behavioral health care that will design, implement, and evaluate a care management program that integrates primary and behavioral health care services.

10 Spindletop Center Integrate Primary Care and Behavioral Health Integrate primary and behavioral healthcare services: Design, implement and evaluate projects that provide integrated primary and behavioral health care services - Spindletop will co-locate primary care clinics in its existing buildings to facilitate coordination of healthcare visits and communication of information among healthcare providers. In addition, a mobile clinic will be purchased and equipped to provide physical and behavioral health services for our clients in locations other than existing Spindletop clinics. The mobile clinic could also be used to provide physical and behavioral health services during disasters such as hurricanes. To supplement the benefits of integrating primary care with behavioral health services, Spindletop will implement Individualized Self Health Action Plan for Empowerment ("In SHAPE"), a wellness program for individuals with mental illness.

11 The Harris Center for Mental Health and IDD

Integrate Substance Abuse and Mental Health Services Provide an intervention for a targeted behavioral health population to prevent unnecessary use of services in a specified setting: integrating substance abuse treatment services into mental health services - Substance abuse treatment services will be integrated and embedded into existing MHMRA mental health treatment services (psychosocial rehabilitation).

12 City of Houston Department of Health and Human Services

Sobering Center The performing provider will conduct monitoring, screening, assessment, service plan development and linking participants to care (if willing) for a maximum of individuals (N=8000/year) and a minimum of N=6000/year, who frequently display a range of mental and physical symptoms that indicate alcohol or other substance abuse in DY4-5.

Learning Collaborative Cohort –Integration of Primary and Behavioral

Health • AIMS

• Assess the current state of integration at a project and regional level

• Establish baseline for care within the region• Assess the desired state of integration• Reach desired levels of integration of project and

regional integration• Assess changes in project and regional integration

as a result of DSRIP projects

The Greater Houston

Behavioral Health Affordable Care

Act Initiative (BHACA)

Healthcare Transformation

and Quality Improvement

Program (Medicaid 1115

Waiver)

IHC

29

Cohort Participants

30*Also a member of the Network of Behavioral Health Providers

Organization Name Brief Description

Beacon Health Options CHC’s behavioral health vendor

Community Health Choice (CHC) Health plan carrier

The Harris Center for Mental Health and IDD (formerly MHMRA of Harris County)*

County LMHA/CMHC

Harris Health System – Psychiatry* County hospital system

Houston Methodist* Hospital

Houston Recovery Center* Sobering center

The Lighthouse of Houston Offers educational programs, community services and outpatient rehabilitation for the blind and visually impaired

Mental Health America of Greater Houston* Mental health policy, education, and advocacy organization

Memorial Hermann* Hospital

Network of Behavioral Health Providers* Behavioral health CEO roundtable (34 members)

Texas Children’s Hospital Pavilion for Women OB/GYN, prenatal care, reproductive psychiatry, labor & delivery, etc.

UT School of Public Health Academic faculty

Assessing Level/Extent of Integration

31

• Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration (OATI)

• BHACA Survey (Based on CIHS Six Level Framework)

Assessing Integration – The Challenge of Tool Selection

• Group wanted a tool that could help them measure their level of integration

• Looked at several tools and their pros/cons:– Behavioral Health Integration Capacity Assessment Tool (B

HICA)– Maine Health Access Foundation Site Self-Assessment Eval

uation Tool– Custom-made tool– Joint Commission standards– Organizational Assessment Toolkit for Primary and Behavio

ral Health Care Integration (OATI)32

Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration (OATI)

• Created by the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) in collaboration with ZiaPartners, Inc. (Dr. Ken Minkoff) and MTM Associates (David Lloyd)

• Versatile – Can be used by different kinds of organizations, using different integrated care models, and at different stages of their integrated care journey

• Four main assessment tools:– The Partnership Checklist– The Executive Walkthrough– The Administrative Readiness Tool (ART)– The COMPASS – Primary Health and Behavioral Health

33

34

The COMPASS – PH/BH Tool• “… a continuous quality improvement tool for clinics and treatment

programs…to organize themselves to develop core integrated capability to meet the needs of service populations with physical health and behavioral health issues” (SAMHSA-HRSA CIHS, 2014).

• Fifteen sections; statements within each section each receive a rating on a five-point Likert scale ranging from “Not at all” to “Completely”

1. Program Mission & Vision 6. Integrated Assessment 11. Medication Management

2. Program Administrative Policies

7. Integrated Person-centered Planning

12. Integrated Discharge/ Transition Planning

3. Quality Improvement & Data

8. Integrated Treatment/ Recovery Programming

13. Program/Organizational Collaboration & Partnership

4. Access 9. Integrated Treatment/ Recovery Relationships

14. General Staff Competencies & Training

5. Screening & Identification 10. Integrated & Welcoming Program Policies

15. Specific Staff Competencies

35

One Sample Question (of Sixty-Five): OATI. Tool 4—COMPASS Primary Health and

Behavioral HealthTM

From Section 4: Access (PCMH*)

10. Individuals and families receive welcoming access to appropriate care regardless of active issues in any area (e.g., infectious disease status, need for injections or oxygen, presence of physical disability, blood alcohol level, urine toxicology screen, length of sobriety, commitment to maintain sobriety, intellectual functioning, active mental health symptoms, type of psychiatric diagnosis, or type of prescribed psychiatric medications, such as antipsychotics, stimulants, benzodiazepines, or opiate maintenance).1 2 3 4 5Not at all Slightly Somewhat Mostly Completely 36

Our Experience with the COMPASS• Honing our use of the tool

– Misguided attempt to link it directly to the CIHS 6-level spectrum– Input from Dr. Ken Minkoff

• Enthusiasm regarding tool vs. time required to complete it– Four organizations have completed it to date– Others exposed to and have used parts of it (many exposed to it at

December 2014 Learning Collaborative)

• Time needed for planning and scheduling before actual completion of tool

• Role of a “champion” within an organization• Structuring the process for maximal involvement with limited

time/resources• Usefulness of tool

– In planning phase– After implementation

37

"The OATI caused us to take a 360 degree look at our service model. We are now screening for physical health issues in our clients. We had realized many of our super-utilizers have stage four cancer or cirrhosis of the liver. We are dealing with the chronic inebriate formerly incarcerated homeless population. The medications to manage pain are really expensive, and they are using the substances as a pain management strategy. Our Intake Staff now tracks physical health issues of our clients and management is incorporating physical health into our service model and intervention strategy. The OATI was easy to conduct at the agency level using a PowerPoint for staff to follow along. It was well worth our time.”

Suzanne JarvisProgram ManagerHouston Recovery Center

38

OATI Data – Unit of Analysis

• 3 of 4 organizations completing the COMPASS are large, multi-site organizations/ health systems

• In completing the compass, organizations looked specifically at their IHC DSRIP-funded projects, which involved multiple clinic sites but NOT the organization’s entire system

• 1 organization is a single-location “sobering center” working collaboratively with providers across the community

39

What does our OATI data indicate?Areas to celebrate! (areas of strength)

• Program Mission & Vision• The program welcomes individuals with active physical, mental, and substance use conditions, and

cognitive disabilities, without discrimination, in all admission areas and waiting areas. (Weighted average of 4.5 out of 5. Three organizations say they do this “completely (5),” and one says they do this “somewhat (3).”)

• Program Administrative Policies• The program confidentiality or release of information policies and procedures are written to

promote appropriate and routine sharing of necessary information between collaborative mental health provider, substance abuse treatment providers, and medical providers. (Weighted average of 4.75 out of 5. Three organizations say they do this “completely (5),” and one says they do this “mostly (3).”)

• Clinical record-keeping policies support integrated documentation (e.g., in assessments, treatment plans, and progress notes) of attention to mental health, physical health, cognitive disability, and substance use issues in a single medical/clinical record or chart. (Weighted average of 4.5 out of 5. Three organizations say they do this “completely (5),” and one says they do this “somewhat (3).”)

• Screening & Identification• The program’s screening policy states that all individuals are to be screened for issues and immediate

risk in a welcoming and respectful manner for mental health issues (including trauma), substance use issues, cognitive issues, physical health issues, and basic safety and social needs. (Weighted average of 4.5 out of 5. Two organizations say they do this “completely (5),” and two say they do this “mostly (4).”) 40

What does our OATI data indicate?Additional areas of strength

Quality Improvement & Data: Using information systems to collect QI data that is used to advance IHC Weighted Avg.: “mostly” (3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5).

Integrated Treatment/Recovery Programming: Providing patients/clients with education and assistance regarding decisions about prevention Weighted Avg.: “mostly” (3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5).

Medication Management:• Providing access to medication assessment for any condition regardless of other conditions

that may be present Weighted Avg.: “mostly” (4.25/5). One “somewhat” (3), one “mostly” (4), two “completely” (5).

• Routinely monitoring common risks associated with all medications and their interactions Weighted Avg.: “mostly” (3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5).

General Staff Competencies: Written plan for integrated competency development Weighted Avg.: “mostly” (3.5/5). Three “somewhat” (3), one “completely” (5).

Specific Staff Competencies:• Cultural and linguistic competency Weighted Avg.: “mostly” (4.25/5). One “somewhat” (3),

one “mostly” (4), two “completely” (5).• Competency in providing education to family members/caregivers Weighted Avg.: “mostly”

(3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5).• Competency in providing age-appropriate services Weighted Avg.: “mostly” (3.75/5). One

“not at all” (1), one “mostly” (4), two “completely” (5).41

What does our OATI data indicate?Areas for Potential Quality Improvement

Program Mission & Vision: Written program descriptions welcoming people with any health conditions Weighted Avg.: “somewhat” (2.75/5). Two “slightly” (2), one “somewhat” (3), one “mostly” (4).

Integrated Assessment:• Strengths-focused: Identifying recent periods of strength or stability Weighted Avg.: “slightly”

(2.25/5). Two “not at all” (1), one “somewhat” (3), one “mostly” (4).• Documenting stages of change Weighted Avg.: “slightly” (1.75/5). Three “not at all” (1), one

“mostly” (4).

Integrated Person-Centered Planning: Focusing on building whole health self-management skills and supports Weighted Avg.: “slightly” (2.25/5). Two “not at all” (1), one “somewhat” (3), one “mostly” (4).

Integrated Treatment/Recovery Programming: Protocol to address psychological issues re: pain management Weighted Avg.: “slightly” (2/5). Two “not at all” (1), two “somewhat” (3).

Medication Management: Procedures/materials to help patients/clients learn about medications and communicate with providers about them Weighted Avg.: “slightly” (1.75/5). Two “not at all” (1), one “slightly” (2), one “somewhat” (3).

Program/Organizational Collaboration & Partnership: Providing and receiving consultation to/from collaborating organization(s) providing complementary services Weighted Avg.: “slightly” (2.25/5). Two “not at all” (1), one “somewhat” (3), one “mostly” (4).

General Staff Competencies and Training: Integrated care competencies included in staff performance reviews Weighted Avg.: “somewhat” (2.5/5). Two “not at all” (1), one “somewhat” (3), one “completely” (5). 42

OATI as Starting Point for QI

• Areas of strength – Learn from each other

• Areas for potential improvement – Opportunities for collaborative QI

• Example: Discrepancy b/n welcoming individuals with any health conditions (area of strength) vs. written program descriptions welcoming people with any health condition (area for improvement)

Work on brochure creation/enhancement and honing of language describing IHC services

• Example: Staff competencies for integrated care Training and assessment resources

43

Additional Data from BHACA Survey• Data collected February to March, 2015.• Twenty-two total “agency” respondents,

representing these types of providers across the Greater Houston system:– Hospitals: 4 (Behavioral Health Freestanding Hospitals—2,

Behavioral Health Hospital Departments/Embedded—2) – Primary Care & Mental Health Clinics: 2 – Federally Qualified Health Centers: 2 – Mental Health Outpatient Providers: 8– Substance Use Service Providers: 6 (Multilevel, Licensed—

3; Multilevel, Unlicensed—2; Outpatient, Licensed—1)

44

Source: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013. Available at http://www.integration.samhsa.gov/integrated-care-models/CIHS_Framework_Final_charts.pdf.

COORDINATEDKEY ELEMENT:

COMMUNICATION

CO-LOCATEDKEY ELEMENT:

PROXIMITY

INTEGRATEDKEY ELEMENT:

PRACTICE CHANGE

LEVEL 1Minimal

Collaboration

LEVEL 2Basic

Collaboration at a Distance

LEVEL 3 Basic

Collaboration Onsite

LEVEL 4Close

Collaboration Onsite with

Some System Integration

LEVEL 5Close

Collaboration Approaching an Integrated

Practice

LEVEL 6Full

Collaboration in a

Transformed/Merged

Integrated Practice

The Spectrum of Integrated Health Care:

45

46

Coordinated Co-Located Integrated

Level 1Minimal Collaboration

Level 2Basic Collaboration at a

Distance

Level 3Basic Collaboration Onsite

Level 4Close Collaboration Onsite

with Some System Integration

Level 5Close Collaboration Approaching

an Integrated Practice

Level 6Full Collaboration in a

Transformed/Merged Integrated Practice

Behavioral health, primary care and other healthcare providers

Facilities < In separate facilities > In same facility not necessarily same space

In same space within the same facility

In same space within the same facility, with some shared practice space

In same space within the same facility, sharing all practice space

Communications Communicate about cases only rarely

Communicate periodically about shared patients

Communicate regularly about shared patients, by phone or e-mail

Communicate in person as needed

Communicate frequently in person

Communicate consistently at the system, team and individual levels

Collaboration Communicate, driven by provider need

Communicate, driven by specific patient issues

Collaborate, driven by need for each other’s services

Collaborate, driven by need for consultation and coordinated plans for difficult patients

Collaborate, driven by desire to be a member of the care team

Collaborate, driven by shared concept of team care

Meetings Provider team may never meet in person

Provider team may meet as part of larger community

Provider team meets occasionally to discuss cases due to close proximity

Provider team has regular face-to-face interactions about some patients

Provider team has regular team meetings to discuss overall patient care and specific patient issues

Provider team has formal and informal meetings to support integrated model of care

RolesInter-disciplinary providers have limited understanding of each other’s roles

Inter-disciplinary providers appreciate each other’s roles as resources

Inter-disciplinary providers feel part of a larger yet ill-defined team

Inter-disciplinary providers have a basic understanding of roles and culture

Inter-disciplinary providers have an in–depth understanding of roles and culture

Inter-disciplinary providers have roles and cultures that blur or blend

Resources No sharing of resources May share resources for single projects May share facility expenses

May share office expenses, staffing costs, or infrastructure

Variety of ways to structure the sharing of all expenses

Resources shared and allocated across whole practice

Adapted from: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

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Systems/Electronic Health Record (EHR)

Separate scheduling, charting, and (as applicable) EHR systems. Data may be communicated but this exchange across systems is rare

Separate scheduling, charting, and (as applicable) EHR systems. Periodic exchange of data about particular clients

Separate scheduling, charting, and EHR systems, yet separate systems have means of “talking to each other,” through a continuity of care document or a local health information exchange (i.e. Greater Houston Healthconnect)

Behavioral health and other healthcare providers share some systems in common, such as scheduling, charting, or (as applicable) EHRs, and separate systems have means of “talking to each other”

Behavioral health and other healthcare providers share all systems in common, including scheduling, charting, and EHRs; however, some inefficiencies in EHR design may make accessing all patient data cumbersome

Behavioral health and other healthcare providers share all systems in common, including scheduling, charting, and EHRs. All data is readily accessible to all providers

Treatment Plans Separate treatment plansSeparate treatment plans shared based on established relationships between specific providers

Separate treatment plans with some shared information

Collaborative treatment planning for specific patients

Collaborative treatment planning for all shared patients One treatment plan for all patients

Treatment Delivery Patient physical and behavioral health needs are treated as separate issues

Patient health needs are treated separately, but records are shared periodically

Patient health needs are treated separately at the same location

Patient health needs are treated separately at the same site, collaboration might include warm hand-offs

Patient needs are treated as a team for more complex patients but not for all patients

A team treats all health needs for all patients

Patient Experience Patient must negotiate separate practices and sites on their own

Patients may be referred, but a variety of barriers prevent many patients from accessing care

Close proximity allows referrals to be more successful and easier for patients

Patients are internally referred with better follow-up

Care is responsive to identified patient needs by a team of providers as needed, which feels like a one-stop shop

Patients experience a seamless response to all healthcare needs

Leadership Support No coordination or management of collaborative efforts

Some leadership in more systematic information sharing

Organization leaders supportive but often colocation is viewed as a project or program

Organization leaders support integration through mutual problem-solving of some system barriers

Organization leaders support integration, if funding allows, and efforts placed in solving as many system issues as possible, without changing fundamentally how disciplines are practiced

Organization leaders strongly support integration as practice model with expected change in service delivery, and resources provided for development

Provider Buy-in

Little provider buy-in to integration or even collaboration, up to individual providers to initiate

Some provider buy-in to collaboration and value placed on having needed information

Provider buy-in to making referrals work and appreciation of onsite availability

More buy-in to concept of integration but not consistent across providers

Nearly all providers engaged in integrated model. Buy-in may not include change in practice strategy for individual providers

Integrated care and all components embraced by all providers and active involvement in practice change

Adapted from: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

BHACA-Adapted Center for Integrated Health Solutions (CIHS) Levels of Collaboration/Integration Tool: Hospitals (Freestanding & Departments/Embedded),

Primary Care & Mental Health Clinics, FQHCs

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BHACA-Adapted Center for Integrated Health Solutions (CIHS) Levels of Collaboration/Integration Tool: Mental Health Outpatient

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BHACA-Adapted Center for Integrated Health Solutions (CIHS) Levels of Collaboration/Integration Tool: Substance Use Facilities

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Reported Challenges to Implementing IHC

Lack of shared EHRs

Inadequate funding

Insufficient provider comm.

Lack of buy-in from staff

Policy barriers

Inadequate clinical IHC training

Organizational culture not conducive

Lack of shared space

Insufficient relationship-building

Lack of shared mission and culture

-10% 0% 10% 20% 30% 40% 50% 60%

Percentage of Respondents (total number = 14)

51

(7)

(6)

(6)

(5)

(3)

(3)

(3)

(2)

(2)

(2)

Reported Helpful Factors in Implementing IHC

Communication among providers

Relationship-building

Shared mission and culture

Buy-in from staff

Shared EHRs

Organizational culture

Continual learning

Workforce development/training

Technology (e.g., EHR, telemed., pt. portals)

0% 10% 20% 30% 40% 50% 60% 70% 80%

Percentage of Respondents (total number = 14)

(10)

(10)

(10)

(7)

(5)

(4)

(3)

(2)52

(11)

Lessons Learned & Next Steps

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IHC Tools/Frameworks Newly Introduced to Two Sets of Area Providers

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Midpoint Evaluation (Feb.-March 2015)Question #1: Prior to completing the Center for Integrated Health Solutions (CIHS) Levels of Collaboration/Integration that you just finished, were you aware of the framework?

Tools/Frameworks

•SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) Six Levels•Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration (OATI)

Introduction•1115 Waiver BH Cohort Presentation on March 21, 2014, “Integrated Health Care Models and Practices”•Ongoing cohort meetings

Impact •13 organizations at 3.21.14 training; 10 organizations in ongoing cohort; 12 1115 Waiver IHC projects with a value of $133 million

1115 Waiver Participating Providers (2011-2016)

BHACA Initiative Participating Providers (2013-2016)

Lessons Learned

• Celebrate successes—tool completion and strengths identified

• Retell the story of the tool selection/group’s raison d'être

• Adaption of tool to specific provider environment• Value of the process of tool completion (group

participation)• Factors influencing tool completion• Surprising lack of understanding across system

and corresponding benefit of introducing frameworks

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Lessons Learned (Continued)

• Policy challenges including funding streams• Value of a few committed community experts • Hard to be “match.com” for partnerships• Complex funding streams drive collaborations• Need collaborative partners to engage

primary care• Value of site visits • Value of networking at live events

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What’s Next?• Texas 1115 Waiver 2.0• Certified Community Behavioral Health Clinics• Trainings informed by survey data

– Clinical cross-training– Financing – Outcome-based evaluation– Electronic health record selection

• Renewed engagement of primary care/FQHCs• MHA of Greater Houston systems-change initiative

around financing IHC and preparing providers for IHC

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Q&A / Discussion• How have collaborative efforts in your

community impacted integrated care practice and policy?

• How could the OATI (or other tools/ strategies/ processes discussed) be beneficial in your community?

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Contact Information

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Shannon Evans, MBA, LSSGBManager, Health System Strategy OperationsHarris Health Systemshannon.evans@harrishealth.orgHarris Health System: https://www.harrishealth.org/en/pages/home.aspxRHP 3: http://www.setexasrhp.com/go/doc/6182/2056886

Alejandra Posada, MEdDirector of Education and TrainingMental Health America of Greater Houstonaposada@mhahouston.orgMental Health America of Greater Houston: http://www.mhahouston.org

Elizabeth Reed, LMSWProgram Manager, BHACA InitiativeNetwork of Behavioral Health Providersnbhp.elizabeth@gmail.comNetwork of Behavioral Health Providers: http://www.nbhp.org

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!

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