The Nitty Gritty of Behavioral Health and Primary Health Integration

January 10th, 2019 - State of Reform

Today’s Objectives

Understanding the different definitions and models of integrated care

Understanding

Understanding the need to integrate bi-directionally

Understanding

Understanding the advantages and challenges in integrating care

Understanding

Understanding the role of quadrant 4 and Wellfound Behavioral Health Hospital

Understanding

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Defining Integrated Health…

From: Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: AHRQ Publication No.13-IP001-EF. Rockville, MD: Agency

for Healthcare Research and Quality. 2013. Available at http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf

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Perspectives Shaping

Behavioral Health and

Primary Care Integration

Provider: Coordinated services, information sharing and patient care across professional systems boundaries.

Patient Advocate: Advocate for patients including addressing the social determinants of health

Policy Makers: Design “integration friendly” policies which address regulations an reimbursement, quality of care standards, evaluation, and incentivize payment structures.

Healthcare Leadership: Build and maintain a patient centered culture, develop integrated outcomes, and transparency

Regulators: Eliminate silos of care, monitor and evaluate

Payors: Align reimbursement to incentivize integration and de-incentivize silos.

Patients: greater activation and engagement, self advocacy and establishment of expectations

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The Goal of BH/PH Integration

Improve population health.Improve

Reduce per capita cost. Reduce

Improve patient experience of care. Improve

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The Four Quadrant Clinical

Integration Model (MH/SU)

It is important to look at

bi-directional integration.

Today we will explore

quadrant 4.

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

Ris

k/C

ompl

exity

Quadrant I

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 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

H

igh

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.

A Quadrant Four Model at Norfolk Community Services Board

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At the Norfolk Community Services Board, the Integrated Care Clinic

(I-Care) is an integrated psychiatric and primary care clinic that

provides comprehensive care within one community-based

setting. All services are provided by an interdisciplinary team of

licensed physicians, nurses, a care manager, and support staff.

Patients with serious mental illness are usually more

comfortable seeing a primary care physician where they feel the safest and most

comfortable, hence the value of quadrant four.

The I-CARE Program• Our four year enrollment target is 2230 patients.

• The I-CARE clinic serves adults 18 years or older who are diagnosed with a severe mental illness.

• We meet on an ongoing basis with the CSB’s Consumer Advisory Council to discuss the program and possibilities for peer involvement. This group was involved in the naming of the clinic (I-CARE) to mark the shift to integrated care.

• Patient artwork decorates the clinic’s waiting room and we have plans of using peers as liaisons in our waiting area, as well as incorporating peers into some of our planned wellness activities.

• The CSB has selected Unicare as its Electronic Health Record vendor and we have a “go-live” date of October 1, 2012.

• Wellness services are programmed in our Master Plan to begin in the 4th Quarter of the project roll-out (July-Sept 2012.)

Who We Are

• The team includes the following CSB employees:

• Five Board-Certified psychiatrists (MD’s)

• A full time, Board-Certified Internist (MD, MPH)

• Psychiatric Nurse Practitioner (open position)

• Nurse Coordinator (RN)

• Two Licensed Practical Nurses

• Two Registered Nurses

• Integrated Care Manager (BA, MBA)

• Practice Manager (BA, MBA)

• Three Administrative Support Staff

• Part-time Registered Pharmacist

The Challenges in Integrating

• Payment mechanisms and revenue cycle management have not fully kept pace with

integration.

• Payers use separate provider networks, billing and coding practices, accreditation metrics, and

record-keeping requirements.

• “Health care as a system has not evolved to align financial mechanisms, practice delivery,

training, and education, and even our community expectation, to support a model of

care that integrates behavioral health.”

—Benjamin Miller, Psy.D., director of the Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine

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Challenges (continued)

• Professional training that bifurcates physical and behavioral health care impedes collaboration.

• e.g. Therapist are not often trained at addressing the impact the behavioral health disorder has on the individual’s overall health.

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• Privacy regulations that prevent providers from sharing information about

mental health and substance abuse.

• There is also an enduring stigma inside the medical field attached to mental

health problems, which discourages some patients from seeking help and some

providers and other caregivers from getting involved.

• Integration requires both primary care and behavioral health providers to

change the way they work, creating cultural conflicts

More Challenges

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A New Day Is Dawning

While there are still significant barriers to integrating behavioral health and primary care, there are also several forces encouraging it, among them: new payment policies, including models that begin to hold providers accountable for controlling overall costs, and demonstration programs led by Medicaid and Medicare. 1/10/2019 State of Reform 14

* A Wellfound Vessel always hold what it

needs for a safe voyage home. Properly

provisioned, it can more easily navigate rough waters. Steered by its

own strength and propelled by its own

belief in self, Wellfound provides the sure footing

to a hopeful future.

Walk-ins and family/friends accompanied individuals

Self-Referred

Community Provider Or

Physician

Emergency

Departments.

EMS

Hotlines

LAW

ENFORCEMENT.

Emergency Services

A Single Point Of Access – 24/7

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Components of Wellfound Behavioral Health Hospital’s

Crisis Continuum of Care

Single Point of Access

No Wrong Door

Electronic Health Record

Triage

Crisis Intervention and Initial

Identification Crisis Stabilization

BH and PH evaluations

Care Coordination

Bridge/Transitional Services

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Easing Stress on the Emergency Departments (ED) & Community Health – Increasing Numbers of

Behavioral Health Care Patients

• Reduced psychiatric inpatient beds

• Decreased inpatient lengths of stay

• Lack of community resources to prevent crises

• Lack of or limited health insurance

• Lack of access to care

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Psychiatric Patients

Adding to ED Overcrowding

Patients waiting for a psychiatric bed wait three times longer than patients waiting for a medical bed in hospital EDs

• ED staff spend twice as long locating inpatient beds for psychiatric patients than other patients

• Psych patients boarding in an ED can cost that hospital more than $100 per hour in lost income alone *

• Presently 1 in 8 patients seen in EDs have a mental health or substance-abuse condition**

* Treatment Advocacy Center, 2012** Agency for Healthcare Research and Quality, 20071/10/2019 State of Reform 19

Goals of Wellfound Behavioral Health Hospital

• Exclude Medical Etiologies for Symptoms • Rapid Stabilization of Acute Crisis • Avoid Coercion • Least Restrictive Setting • Therapeutic Alliance • Appropriate Disposition and Transition of Care

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Well-found Behavioral Health Hospital’s Transitional Services

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JAMA Psychiatry on May 31, 2017 reported that the suicide rate of patients in the first three months after discharge was approximately 100 times the global suicide rate of 11.4 per 100,000 patients per year in 2012.

1

The time it takes to see a psychiatrist in private practice may take more than 90 days.

2

Wellfound Behavioral Health Hospital, knowing the vulnerability of patients during this waiting period, will follow patients on an outpatient basis until a warm hand off is executed with a community provider.

3

Outcomes for both quadrant 4 and

Wellfound Behavioral Health

Hospital

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• Longitudinally mortality rates decline and life expectancy increases for individuals with mental illness

• Related co-morbid medical costs decrease

• Hospital and ED readmission rates decrease

• Adherence to medications and illness management increase

• % of 1st appoints kept

• % of medications refilled after 30 and 180 days

State of Reform

Wrong Solution:

Treating at the Destination Instead of the Source!

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Questions

Thank you

Maureen Womack

CEO Wellfound Behavioral Health Hospital

maureen@wellfound.org

913-981-3575

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