Behavioral Health

Behavioral HealthIntegration

State ExamplesSusan Cahn, Dr.PH - Sr. Research Scientist, NORCDiane Liu, MD - Assistant Professor of PediatricsCo-Director, Utah Pediatric Partnership to Improve Healthcare Quality

Objectives

Introduce a consensus on the term ‘Integration’ as it pertains to behavioral healthReflect on essential elements to consider when pursuing integrationShare theoretical models to gain perspectiveHighlight examples from select states

Consensus

Bringing physical and behavioral health services together Varying degree of what is considered BH serviceIn management and finance (delivery and payment)To support the point-of-care delivery

There is no singular (or ideal) strategyMany states moving forward in stages

Key Elements

Multidisciplinary care teams accountable for coordinating the full range of medical, behavioral, and long-term supports and services as neededReal-time information sharing across systems to ensure that relevant information is available/accessible to all members of a care teamCompetent provider networks training workforce and issues with certificationAligned financial incentives across physical and behavioral health systemsMechanisms for assessing and rewarding high-quality care

Theoretical Models

Levels vs. Quadrants

Levels of Integrated Care

Levels of Integrated Care

Coordinated CareCo-Located CareIntegrated CareKey ElementCommunicationPhysical proximityPractice changeLevel of CollaborationProviders develop relationshipsRegular communication, sometimes in personFrequent, personal communicationSystemsPractices maintain separate systems and facilitiesPractices can share some systems, e.g. schedulingShared systems, such as an integrated medical recordMain GoalProviders view each other as resources and understand each other’s skillsPatients move easily between practices; providers build strong relationshipsPractices merge over time into a single, integrated system

Four Quadrant Clinical Integration Model

Population-based planning tool developed by the National Council for Behavioral Health in 2006, and updated in 2009Describes the subsets of the population that behavioral health/primary care integration must addressDescribes levels of integration in terms of primary care complexity and risk; mental health/substance use complexity and riskEach quadrant represents the major system components that would be used to meet the needs of individuals in that subset

Quadrant II: Behavioral health clinician/case manager w/ responsibility for coordination w/ PCPPCP (with standard screening tools and guidelines)Outstationed medical nurse practitioner/physician at behavioral health siteSpecialty behavioral healthResidential behavioral healthCrisis/EDBehavioral health inpatientOther community supportsQuadrant IV:PCP (with standard screening tools and guidelines)Outstationed medical nurse practitioner/physician at behavioral health siteNurse care manager at behavioral health siteBehavioral health clinician/case managerExternal care managerSpecialty medical/surgicalSpecialty behavioral healthResidential behavioral healthCrisis/EDBehavioral health and medical/surgical inpatientOther community supportsQuadrant I:PCP (with standard screening tools and behavioral health practice guidelines)PCP-based behavioral health consultant/care managerPsychiatric consultationQuadrant III:PCP (with standard screening tools and behavioral health practice guidelines)PCP-based behavioral health consultant/care manager (or in specific specialties)Specialty medical/surgicalPsychiatric consultationEDMedical/surgical inpatientNursing home/home based careOther community supports

Behavioral Health Risk/Complexity

Physical Health Risk/Complexity

Medicaid Health Homes

Lessons Learned

Medicaid Health Homes: Overview

ACA provision to strengthen care coordinationMedicaid Health Homes allows states to provide integrated care for beneficiaries with multiple chronic conditions as an optional state Medicaid plan service28 programs in 20 states as of March 2015Focus on high-cost, high-need populations Integration of physical and behavioral health care servicesCare management extends beyond medical services to include nonclinical supports, such as transportation and housing.Specialists, mental health providers, and home health can be “health home”

Medicaid Health Homes: Lessons Learned (based on 2015 evaluation of 13 programs in 11 states, inc. NY)

Three types emergedMedical home-like programsSpecialty provider-based programsCare management network programs (NY)Providers receive enhanced payment for delivering health home services to enrolled eligible persons

Lessons Learned (continued)

Administrative concerns

Slow implementation

Overburdening providers in direct service

Communication among provider teams, including nonclinical professionals takes time

Need to develop cooperative relations

Emergency department notification

Payment

Enhanced PMPM covered services for health homes patients only

Inadequate funding for practice transformation and HIT

HIT systems inadequate to support health home functions

Cost burdens for EMR

User fees for HIE

State Examples

Highlights – Washington, New York, Colorado

Areas of interest

Costs / Payments (Financing)Manpower / Workforce training (Personnel)Clinical quality outcomes being measured or consideredConsumer/community satisfaction being measured or considered

WA example: Overview

SIM Model Test 1: Early-Adopter of Medicaid IntegrationThe state is redesigning and consolidating its service areas; the designated Accountable Community of Health will provide oversight.Move toward full integration by 2020Early adopting regions will test integrating financing for physical and behavioral health services to deliver whole-person careCounties within early adopter regions will receive 10% state savings

WA example: Southwest region starts next month

In April 2016, two managed care organizations will manage Medicaid beneficiaries’ physical health, mental health, and substance use disorder services in the Southwest Washington Region (120,000 Medicaid beneficiaries or ~7% of the state Medicaid population).Mental health and substance abuse currently managed by three systems (county-based Regional Support Network (RSN) contracts, HCA, and DSHS).MCO contracts with HCA and will operate under an “Allied System Coordination Plan” which outlines coordination between county-managed programs, criminal justice, LTSS, trial entities, etc.Medicaid beneficiaries will receive services when they need them, in the setting that best suits their needs.

WA example: Key activities

Procure managed care organizations providing fully integrated services and operationalize transition to full integration.Modify information systems to support fully-integrated managed care and new behavioral health services only benefits.Obtain federal/state regulatory approval (e.g. 1932(a) SPA, 1915(b) waiver)Develop and implement an early warning capacity to identify and resolve implementation issues rapidlyDevelop and implement a culturally appropriate outreach plan to Medicaid beneficiaries, to educate on upcoming Medicaid changesEducate fully integrated managed care plans on behavioral health system and new services in preparation for transition to full integrationProvide technical assistance to behavioral health and physical health providers to assist in transition to fully integrated managed careEnroll Medicaid clients in fully integrated managed care plansMedicaid beneficiaries with co-occurring disorders receive care coordination through a whole person system of careConduct outreach to expand fully integrated model to additional regional services areasImplement fully integrated managed care in mid-adopter regions.Source: Pgs. 57-61 of Washington State SIM Operational Plan, Round 2 Model Test Awardee – December 1, 2016

WA example: Performance measure set

The performance measure set was designed to be manageable in size and reflective of the state’s goals. It includes:Alcohol or Drug Treatment Retention Alcohol/Drug Treatment Penetration Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia Childhood Immunization Status Comprehensive Diabetes Care First Trimester Care Mental Health Treatment Penetration Plan All-Cause Readmission Rate Psychiatric Hospitalization Readmission Rate Well Child Visits Source: Slides 26 and 27 of a presentation titled “HCA Update: Health Systems Transformation in Washington State”, presented on September 21, 2015, available at: http://www.hca.wa.gov/hw/Documents/swwa_presentation092115.pdf

New York: Overview

The Delivery System Reform Incentive Payment (DSRIP) Program is mechanism for the state to implement the Medicaid Redesign Team (MRT) Waiver Amendment. Purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, Primary goal is reducing avoidable hospital use by 25% over 5 yearsMRT Waiver has a significant focus on behavioral health IntegrationSource: https://www.health.ny.gov/health_care/medicaid/redesign/docs/dsrip_mrt_waiver_admendment_update_webinar_slides_bh.pdf

New York: MRT BH Provisions

$645.9 Million for enhanced behavioral health services DSRIP funds flow to managed care plans who will be required to contract for home and community based services.State is sponsoring a pilot to provide and test a new system of assessment, network development and person-centered planning. New York’s Medicaid Managed Long Term Services and Supports (MLTSS) transition for individuals with SMI /SUD

New York: DSRIP Providers and Domains

Performing Provider Systems (PPS)LocalInclude hospitals, clinics & FQHCs, behavioral health providers, SNFs, health homes, and other stakeholdersCommunity health care needs assessment based on multi-stakeholder input and objective dataBuild and implement a DSRIP project aligned with identified needsDSRIP DomainsDomain 1 – Overall Project ProgressDomain 2 – System TransformationDomain 3 – Clinical ImprovementDomain 4 – Population-wide Strategy Implementation – The Prevention Agenda

New York: BH in the Domains

Domain 2: Requirements for Behavioral Health component in all DSRIP Integrated Delivery Systems ProjectsDomain 3: All applicants carry out a clinical improvement project focused on behavioral health project Domain 4: Financial Incentives: DSRIP High Performing Fund includes incentive payments specifically for reductions of behavioral health hospitalizations.

New York: DSRIP Sample Domain Projects

Domain 2 – System Transformation2a: Create IDS: Health Home At Risk Intervention Program–Proactive management of higher risk patients not currently eligible for Health Homes through access to high quality primary care and support services.2b: Care Coordination/Transitions: ED care triage for at-risk populationsImplementation of observational programs in hospitals2c: Connecting Care: Expand usage of telemedicine in underserved areas to provide access to otherwise scarce servicesDomain 3 – Clinical Improvement: Behavioral Health, CVD, Diabetes, Asthma, HIV, Perinatal, Palliative, and Renal Domain 4 – Population-wide Strategy Implementation4A. Promote Mental Health and Prevent Substance Abuse 4a-iii: Strengthen Mental Health and SubstanceAbuse Infrastructure across Systems

New York: Clinical Improvement Behavioral Health Projects (Domain 3)

Project

#

Description

3a-i

Integration of primary care services and behavioral health

3a-ii

Behavioral health community crisis stabilization services

3a-iiiImplementation of evidence based medication adherence program (MAP) in community based sites for behavioral health medication compliance.3a-ivDevelopment of withdrawal management (ambulatory detoxification) capabilities within communities.3a-vBehavioral Interventions Paradigm in Nursing Homes (BIPNH).

New York: DSRIP Performance and Behavioral and Population Health Measures

Metrics are chosen from nationally recognized, validated measures. Avoidable Hospitalizations (D2)Potentially Preventable Emergency Room Visits (PPVs).Prevention Quality Indicators-Adult (PQIs).System Transformation (D2)% Alternate payment strategies in MedicaidCare transitions measures

Domain 3A MeasuresAntidepressant Medication Management.Follow-up after hospitalization for Mental Illness (NCQA).Cardiovascular monitoring for People with CVD and Schizophrenia.Domain 4: Pop Hlth-NY Prevention AgendaMortality disparitiesPercentage of premature death (before age 65)•Ratio of Black non-Hispanics to White non-Hispanics•Ratio of Hispanics to White non-Hispanics

Colorado

State Healthcare Innovation Plan ‘The Colorado Framework’

AIM By 2019, 80% of Coloradans have access to Integrated Care

Payment Reform

Practice Trans-formation

Population Health

Health Information Technology

Consumer Engagement Policy Workforce Evaluation

Image adapted from SIM Operational Plan Jan 2016

Implementation

Based on 5 key principles for success resulting from prior effortsAlign the level of integration with patient needs and practice capacityInnovate and adapt both the workforce and the workplaceCreate new funding models that support integrationRecognize that patient numbers impact integration potentialLead creatively and learn constantlyCommunity-driven; not top-down / no state mandate

Costs / Payment

Payment ReformObservation PhaseIdentify current & future spending benchmarksIdentify outcome / quality baselinesCare Coordination & SavingsIncrease coordination through additional paymentsShared Risk & SavingsIncreased provider responsibilityExtra payment built into the cost of carePayments & Budgeting for Comprehensive Primary CarePayment based on total cost of care & coordination

Workforce Development & Training

Create a Provider Directory, designed to increase Colorado’s base of Workforce DataDevelop a plan for change management roll-out that will engage providers, administrators, and educators before, during, and after the innovationPartner with educational institutions to identify appropriate measures for defining workforce competencies and offer training that allows personnel to achieve high performance in an integrated care setting

Workforce Development & Training (cont.)

Enumerate, align, and define competencies for Colorado’s unlicensed workforceInfluence policies to address pipeline and workforce shortage issuesAddress other workforce-related issues as needed

Outcomes

18 quality of care measuresPatient experience measuresNot CAHPS12 population health measuresCosts of care / utilizationPer capita total health care spendingStay Tuned – actual data shared at Spring 2016 webinar

Questions & Comments

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