Health Reform, and Integration Challenges and Opportunities WVAADAC Conference Center for Integrated Health Solutions Oct. 4, 2011
Dec 25, 2015
Health Reform, and Integration Challenges and Opportunities
WVAADAC ConferenceCenter for Integrated Health Solutions
Oct. 4, 2011
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
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
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
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
– 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
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.
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
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
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
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
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 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: [email protected]