Jason Cheng, MD Marcia Titus-Prescott, RN Jeanie Tse, MD Institute for Community Living, Inc. NYS Clinic Technical Assistance Center Wednesday October 2, 2013
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Jason Cheng, MD Marcia Titus-Prescott, RN
Jeanie Tse, MD Institute for Community Living, Inc.
NYS Clinic Technical Assistance Center Wednesday October 2, 2013
Behavioral health medical homes: Integrating approaches to physical health, mental health and substance use
Collaborating for health: Disease management for individuals and families
Decision support tools: Optimizing health records for integrated care
Culture, spirituality and community factors: Reaching out to address health disparities
How does your clinic offer physical health care?
On-site primary care services
Formal partnership with medical clinic(s)
Nursing-supported liaison with outside medical providers
Referral to outside providers only
Why integrated care?
Self-management
Nursing-supported care management
Co-location: challenges and solutions
At the conclusion of this webinar, participants will be able to:
Describe the rationale for integrating treatment of
physical health, mental health, and substance use
Name components of a person-centered team-based
approach, including nursing-supported care
management
Strategize implementation or improvement of service
integration in their programs
NYC not-for-profit
>100 programs, 10,000 consumers, majority in
Brooklyn: housing, case management, ACT,
clinics, homeless shelters, health home, and
PROS
Founded Health Care Choices FQHC
In housing and case management: ◦ >70% schizophrenia / schizoaffective
Primarily paraprofessional workforce
People with serious mental illness (SMI) die an average of 25 years earlier than those in the general population
60% of excess mortality is due to treatable and preventable medical conditions (eg, heart disease, stroke, diabetes)
25% of deaths are attributable to alcohol, tobacco, and illicit drug use, which also increase the risk of physical health conditions
In 2009 in New York State, 58% of the behavioral
health Medicaid population accounted for 78.5%
of the total Medicaid expenditures
Those with behavioral issues account for more
total healthcare spending than those who do not,
and the majority of those expenditures are related
to physical health
Symptoms of mental illness such as avolition and low energy lead to reduced physical activity
Changes in appetite, medication side effects and income make it harder to maintain a healthy diet
Antipsychotics and other medications increase risk of dyslipidemia, diabetes and stroke
Substance use increases symptoms, worsens self care and has direct health effects
People with mental illness rarely receive needed health care interventions
The behavioral health workforce receives minimal training on physical health issues
Physical health problems are often misidentified as mental health symptoms or intoxication
Discrimination based upon mental illness, addictions, race and socioeconomic factors
Fragmentation of the health care system with poor information sharing
Financing and regulatory issues
Medical providers learning to work with people with
SMI and substance use disorders
Behavioral health providers learning to screen for
physical health problems and provide self-
management training
Inter-provider communication and collaboration to
provide integrated care
Regulatory restructuring and reimbursement by third
party payers
Self-Mgmt
Workbooks
Pthwys/
MedRisk
Mgmt
Care
Mgmt/
Co-Loc
Integrated
Electronic
Tx Plan
“The patient is the source of control” (IOM)
Goals and values determine how care is provided
Self-management Patient
Wellness education
Motivational interviewing to support change
Action steps to build momentum towards better
health
Tools facilitating conversations around health
Healthy Living / Diabetes Workbooks and disease-specific modules
Mini Cards
Quik Guides and trainings
Letters to PCPs and psychiatrists
All materials available on ICL intranet
PCP
Person
Psychiatrist
Peer health coach
Specialists
Nurse
Care
Manager
Entitlements
Care management programs apply systems, science, incentives, and information to improve medical practice and assist consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively.
The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.
Center for Health Care Strategies, Inc., 2007
Develop and maintain rapport with patient and provider
Educate the patient and the family
Monitor symptoms and communicate findings to provider
Develop and maintain a self-care action plan
Maximize adherence to the treatment plan through negotiation of solutions to treatment-emergent problems
Mauer 2009
Knowledge gap between provider and consumer
can be wide
Activated consumers can make providers
uncomfortable
Important for care manager to engage consumer
and members of the provider team
Connell 2013
Date of download:
8/18/2013
Copyright © American Psychiatric Association.
All rights reserved.
From: A Randomized Trial of Medical Care Management for Community Mental Health Settings:
The Primary Care Access, Referral, and Evaluation (PCARE) Study
Am J Psychiatry. 2009;167(2):151-159. doi:10.1176/appi.ajp.2009.09050691
Quality of Preventive Health Services in Mentally Ill Community Patients Randomly Assigned to Medical Care Management
Intervention or Usual Care
Figure Legend:
58.7%
21.8%
Communication and advocacy with medical
providers, health education, and support in
overcoming barriers to primary care
Treatment of cardiometabolic conditions:
34.9% vs. 27.7%
Primary care provider:
71.2% vs. 51.9%
Framingham Cardiovascular Risk Index
6.9% vs. 9.8%
Druss 2010
Medical risk screening at intake
Risk stratification and treatment planning in
collaboration with nurse care manager ◦ Acute risks
◦ Adherence issues
◦ Need for higher level of care
Registry to track risk and outcomes
Monthly multidisciplinary review
Liaison with medical providers
Direct individual and group intervention
with higher risk clients
Training of behavioral health workers in
disease management
Largely paraprofessional care managers
performing primary/ specialty care liaison role- few
nursing lines available
Regular screening and registry tracking/outcome measurement at psychiatric visits
Medical nurse practitioners/ primary care physicians located in behavioral health
A primary care supervising physician
An embedded nurse care manager
Evidence-based practices
Wellness programs
Preventive screening/health services
Acute primary care
Women and children’s health
Behavioral health
Management of chronic health conditions
End of life care
24/7 accountability
Enabling services, EHR, registries, access to lab, xray, specialty and hospital care
National Council 2009
Become a full-scope healthcare home, i.e. a
Federally Qualified Health Center (FQHC)
Partner with a full-scope healthcare home
Mauer 2009
Article 28/ FQHC Satellite: ◦ ICL shelters / Health Care Choices
◦ The Bridge / William F. Ryan Community Health Center
Hospital Article 28/ 31: ◦ Fountain House / St. Luke’s Roosevelt
◦ Maimonides Community Mental Health Center
Using Article 31 Part 599 reform
Highland Park Center
Rockaway Parkway Center
PCP, med tech, nurse care manager, peer health
coach
Therapist/ psychiatrist remain the “hub” of provider
team, delegating to “medical” staff
become the client’s PCP
vs.
provide education, support, monitoring
and referral
Need medical personnel well-versed in both
physical and behavioral health care
Active, assertive outreach skills
Match to the clinic population / culture
Flexible and willing to experiment
Part 599 allows article 31 clinics to bill for:
◦ health physical once a year
◦ health monitoring
Individual / group
smoking cessation counseling
alcohol or drug screens or interventions (SBIRT)
◦ complex care management
face-to-face or by phone within 5 days of f-f visit
Max 3 services/day; of those max 2 health svcs
Health monitoring rate (billed by MD, NP, PA, RN)
is half that of psychotherapy rate (billed by SW) for
same duration of service ◦ Poor sustainability
◦ Discourages becoming the primary PCP
Peer health coaching not reimbursable
Higher FQHC rates favor partnering rather than
use of part 599 at this time
These will change!- capitated care, HARPs
Treatment plans- incorporating physical health
services (OMH, OASAS)
Medical space and other specifications, e.g. flu
vaccine (DOH)
HARPs are specially designed plans for adults
with more serious, ongoing behavioral and
physical health needs
Financing for non-traditional Medicaid services like
peer support, employment and education, crisis
respite and self-directed care
Outcome measurement required
If separate organizations, bidirectional consent at
time of referral / intake
Face-to-face meetings
Video-conference, teleconference, email
Paper record vs. EHR
Most commonly, separate primary care and
behavioral health records used
Treatment and service plans ◦ streamlined physical health goal planning
◦ health outcomes assessment, including ER and
inpatient utilization
Psychiatry forms prompting for metabolic
measures and medical information
Regional Health Information Organizations
(RHIOs)
Future: integrated multi-provider treatment plans
Medical vs psychosocial models
Top-down vs. consensus decision-making
Physician vs. social service leadership
What’s the bridge?
◦ Self-management
◦Nurse care management
Supporting self-management is central to the
Behavioral Health Medical Home
Nursing-supported care management can
bridge a number of gaps between primary care
and behavioral health
Reimbursement, regulations and technology are
expected to shift in favor of integration- stay
tuned!
ICL’s Integrated Health Team:
Shivonne Blake, CDM
Carissa Caban-Aleman, MD
Jason Cheng, MD
Ruth Chiles, RD
Judy Chong
Elisa Chow, PhD
Elizabeth Cleek, PsyD
Eduard Levy, MD
Marc Manseau, MD
Rosemarie Sultana-Cordero, LMHC
Marcia Titus-Prescott, RN
Jeanie Tse, MD
Dana Tuqan, LMHC
and numerous program staff
Please feel free to contact us at [email protected]
Center for Health Care Strategies, Inc. Care Management Definition and Framework. http://www.chcs.org/usr_doc/Care_Management_Framework.pdf
Connell A. Developing an Integrated Care Management Program. http://www.umassmed.edu/uploadedFiles/fmch/CIPC/Training/CMN/CM%20Free%20intro%20webinar.pdf
Druss BG, von Esenwein SA, Compton MT, Rask KJ, Zhao L, Parker RM. A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study. Am J Psychiatry. 2010 Feb;167(2):151-9
Horvitz-Lennon M, Kilbourne AM, Pincus HA. From silos to bridges: meeting the general health care needs of adults with severe mental illnesses. Health Affairs, 25 (3): 659-669, 2006
Kathol RG, McAlpine D, Kishi Y, et al.. General medical and pharmacy claims expenditures in users of behavioral health services. J Gen Intern Med. 2005 Feb;20(2):160-7
Mauer B. Behavioral Health / Primary Care Integration and the Person-Centered Healthcare Home. National Council for Community Behavioral Healthcare. April 2009.
Mauer B. Morbidity and Mortality in People with Serious Mental Illness. http://www.nasmhpd.org/docs/publications/MDCdocs/Mortality%20and%20Morbidity%20Final%20Report%208.18.08.pdf
National Institute on Drug Abuse. Medical Consequences of Drug Abuse. http://www.drugabuse.gov/related-topics/medical-consequences-drug-abuse
New York State Department of Health. A Plan to Transform the Empire State’s Medicaid Program. http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf
Pollack DA, Raney L, Vanderlip ER. Integrated Care and Psychiatrists. Handbook of Community Psychiatry (McQuistion HL, Sowers WE, Ranz J, Feldman JM, Eds.). Springer, New York, NY 2012.
October 9, 2013 (12:30-1:30p): Collaborating for Health: Disease Management for Individuals and Families
October 16, 2013 (12:30-1:30p): Decision Support Tools: Optimizing Health Records for Integrated Care
October 23, 2013 (12:30-1:30p): Culture, Spirituality and Community: Reaching Out to address health disparities
For more information, please check the CTAC website at www.ctacny.com
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