TO INTEGRATE -- OR HOW? A Decision Model for Practices Charles Cooper, PhD Director of Professional Affairs North Carolina Psychological Association APA.

TO INTEGRATE -- OR HOW?A Decision Model for Practices

Charles Cooper, PhD Director of Professional Affairs

North Carolina Psychological Association

APA State Leadership Conference March 10, 2013

THE EXPECTED ENVIRONMENT:

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THE EXPECTED ENVIRONMENT

Low Physical Health Risk/Complexity

High Physical Health Risk/Complexity

High Behavioral Health Risk/Complexity

QUADRANT II

Clients served in primary care and specialty mental health settings

For treatment of: bipolar disorder, chronic pain

Note: with MH stable, care can be transitioned to PCP

QUADRANT IV

Clients served in primary care and specialty mental health settings

For treatment of: schizophrenia, metabolic syndrome or hepatitis C

Low Behavioral Health Risk/Complexity

QUADRANT I

Clients served in primary care setting

For treatment of: moderate alcohol abuse, fibromyalgia

QUADRANT III

Clients served in primary care setting

For treatment of: moderate depression, uncontrolled diabetes

THE MAUER MODEL

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Integrated Care – The Individual Model

A Two-Dimension Model for Decision Making

I. Top Margin: Level of Integration occurs along a spectrum, from No Integration to Full Integration.

II. Side Margin: Actions would be based on the clinician's inclination towards integration and where the clinician is in his or her career.

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The Individual Decision Model Level of Integration

Clinician Practice Qualities

No Integration

Maintain current practice format while keeping

watchful eye on developments

Ultra light IntegrationGreatly improve communication with targeted primary care

referral sources

Light Integration

Offering contracted services

to primary care, medical homes,

or ACOs

Moderate Integration“Co-Location”

maintaining part or all of a

practice within a primary care

setting

Full IntegrationAssuming an

employed position within an integrated setting

Early Career inclined toward integration

Early Career disinclined toward integration

Mid Career Inclined toward integration

Mid Career disinclined toward integration

Late Career inclined toward integration

Late Career disinclined toward integration

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Level of Integration


No Integration

Ultra light Integration

Light Integration

Moderate Integration

Full Integration

Early Career

inclined toward integration

Take advantage of learning opportunities to strengthen skills that might allow future move closer to integrated systems

Identify target primary care practices; build relationships; determine what specific kinds of integration are mutually beneficial and clinically valuable; Then build the collaboration

Be on high alert regarding integrating systems and design ways to serve patients in medical homes while continuing independent practice. Build your skills to address unmet needs of integrating systems

Acquire specialty training if possible targeting some particular area of health psychology in which you can demonstrate high levels of skillSurvey primary care provider community looking for co-location possibilities

Acquire specialty training if possible targeting some particular area of health psychology in which you can demonstrate high levels of skillSurvey fully integrated systems and their needs for behavioral health

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No Integration


Light Integration


Full Integration

Early Career

disinclined toward integration

Develop a niche that will likely grow regardless of integration. Be prepared to change strategy should local system developments require it.

Identify one or more niches that hold promise for creating practice distinction. Build on that niche and be aware of how it could be affected by integration in the larger health system

Take advantage of medical homes and integrated systems and their organized care management. Seize marketing opportunities with care managers for niche offerings and specialized services not offered in the “home”

Take advantage of rapidly growing awareness of unmet behavioral needs of primary care patients. Seize marketing opportunities by offering niche services especially tailored to those unmet needs.

Take advantage of integrated systems and their organized care management. Seize opportunities with care coordinators for marketing your niche offerings and specialized services not offered in the “home”

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No Integration


Light Integration


Full Integration

Mid Career


Capitalize on strengths of your current practice. Be prepared to change strategy should local developments require it.

Identify target primary care practices; build relationships; determine what specific kinds of integration are mutually beneficial and clinically valuable; Then build the collaboration

Take advantage of your practice reputation in the community. Watch for compatible primary care or “medical home” organizations – particularly ones with likely unmet needs for behavioral services for which they may need to refer out.

Take advantage of your practice reputation in the community. Survey primary care provider community looking for compatible co-location possibilities. Build relationships and explore how to put a “toe in the water”

Capitalize and build on skills and interests that may be sought by fully integrated systems. Acquire additional training in areas that may be in demand within those systems. Get to know the developing integrated systems and their needs. Build relationships.

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No Integration


Light Integration


Full Integration

Mid Career


Capitalize on strengths of your current practice. Monitor your payer mix. Exploit niche opportunities. Be prepared to change strategy should local developments require it.

Identify target primary care practices; build relationships; determine what current features of your practice (or reasonable adjustments in your procedures) might attract referrals; Then build the collaboration.

Take advantage of medical homes and integrated systems and their organized care management. Seize marketing opportunities with care managers for niche offerings and specialized services not offered in the “home”

Take advantage of rapidly growing awareness of unmet behavioral needs of primary care patients. Seize marketing opportunities by offering niche services especially tailored to those unmet needs.

Take advantage of integrated systems and their organized care management. Seize opportunities with care coordinators for marketing your niche offerings and specialized services not offered in the “home”

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No Integration


Light Integration


Full Integration

LateCareer


Take advantage of reputation, “health orientation” and relationships. If necessary, adjust practice to respond to new referral patterns that may emerge with some large integrating systems

Identify target one or more primary care practices; Take advantage of reputation, “health orientation” and relationships to strengthen collaboration, communications, and coordination of care with mutual patients

Take advantage of your practice reputation in the community. Watch for compatible primary care or “medical home” organizations – particularly ones with likely unmet needs for behavioral services for which they may need to refer out.

If feasible, consider locating practice very near primary care setting or find other ways to reduce barriers to easy, “warm” referrals. Regular consultation / contact with primary care providers can approximate co-location

If skills, interests, financial rewards and other compatibilities make practice “inside” a fully integrated setting desirable, explore part of full time affiliation with such a setting. Assess your readiness to accept significant work culture change.

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No Integration


Light Integration


Full Integration

LateCareer


Maintain awareness of changes that may occur and diversify referral and payer mixes. Enhance niche aspects of practice.

Maintain awareness of changes that may occur and diversify referral and payer mixes. Enhance niche aspects of practice. Be open to making reasonable adjustments to foster referrals from primary care providers

Maintain awareness. Do an occasional assessment of yourself and of the developments in integrating health systems to ascertain if it is worth building relationships with, marketing to, and collaborating with primary health providers. See if what you already do can “sell” to them.

Watch with interest.

Watch with interest.

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Integrated Care – The Practice Model

A Two-Dimension Model for Decision Making

I. Top Margin – Level of Integration: occurs along a spectrum, from No Integration to Full Integration.

II. Side Margin – Economic/Business Factors: strategic choices and actions would be based factors of “supply” and “demand” and an analysis of strengths, weaknesses, opportunites and threats, (SWOT).

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Business Conditions for Decision Making

No Integration


Light Integration


Full Integration

Demand

•High and clear demand•Murky, ambiguous or unclear demand•Nil, low or mismatched demand

Supply

•Excellent•Uncertain, or Underdeveloped•Inadequate

Additional Factors

•SWOT•Wildcards

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Demand Conditions

No Integration


Light Integration


Full Integration

High and clear demandStrong demand with ready customers who have clear needsMurky, ambiguous or unclear demandDemand is Ambiguous, Still undeveloped but with significant potentialNil, low or mismatched demandDemand is non-existent or completely mismatched to your practice

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Integrated Care TablePractice Decision Model

None Collaboration FullIntegration Spectrum

Demand: High and Clear

Build relationships, Explore needs, Match resources to need, Make concrete proposals, Work out logistics, potential roles and workflow, Develop contracts, Coordinate and/or educate

Murky, Ambiguous, or Unclear Demand

Establish early communications with potential collaborators; Explore mutual interests; Engage in “Integration Education”; Conduct needs assessments

Low, Nil, or Completely Mismatched Demand

Engage the primary care community; Find ways to start communications; Work on joint projects; Participate in basic education in “Integration Awareness Building”

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Supply Conditions

No Integration


Light Integration


Full Integration

Excellent Supplyof well trained health psychologists who would be well matched and motivated to integrate

Uncertain or undeveloped supply of appropriate clinicians motivated to integrate

Inadequate Supply that is nil, ill-matched, or unmotivated to integrate

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None Collaboration FullIntegration Spectrum

Supply: Excellent, Well-matched, or well-motivated

Develop contracts; Build promising relationships; Introduce health psychologists to potential collaborators; Start joint ventures; Offer services that might lead to contractual integrations

Uncertain, or Underdeveloped Conduct self-assessments in your practice; Procure training in behavioral health and/or recruit health psychologists; Develop services linked to primary care that start a “track record” for your practice in integrated care

Nil, completely Unmotivated, or ill-matched

Look for hidden talent within the practice; Augment skills, retrain, or recruit behavioral health specialists

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LEVEL OF INTEGRATION

ADDITIONAL FACTORS

No Integration

Maintain current practice format while keeping

watchful eye on developments

Ultra light IntegrationGreatly improve communication with targeted primary care

referral sources

Light Integration

Offering contracted services

to primary care, medical homes, or

ACOs

Moderate Integration“Co-Location”

maintaining part or all of a practice within a primary

care setting

Full IntegrationAssuming an

employed position within an

integrated setting

STRENGTHSE.g., Management Capabilities are strong; reputation good and relationships excellent

WEAKNESSESE.g., Risk Tolerance is low; technology and IT is underdeveloped

OPPORTUNITIESE.g., To establish a strong referral network with primary care

THREATSE.g., Gradual loss of referrals as medical homes pick treat internally WILDCARDS Timing (Especially bad or good)Internal and external cultures

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None Collaboration Full Integration Spectrum

SWOT: Strengths Build upon and exploit strengths

Weaknesses Correct or “design around” weaknesses

Opportunities Orient toward opportunities

Threats Protect against threats

Wildcards: Internal Culture Time Considerations Competition

Prepare for the unexpected!!!

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A Case Study in North Carolina

A Case Study – The Demand Side

• The Business Environmento The Research Triangle Area of NC (3 major cities)o Large University-Based Health Systemso Large Independent Practice Association (IPA)o History of care integration in primary care settings (Medicaid)o Interest in care integration by commercial carrier (Private Sector)

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A Case Study – The Supply Side

• HRC Behavioral Health & Psychiatry, PAChapel Hill and Raleigh, NC

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A Case Study – Early Days

• Founded 1967

• 25 to 30 clinicians in two cities

• Multidisciplinary approach

• EAP Experience / Contract Experience

• General reputation in community

• Two experienced health psychologists

• High motivation to integrate (co-locate +)

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A Case Study – The Supply Side

• The Practice Group• Long history in the community

• Multi-specialty group practice o Psychologists ………………………………………………………..14

Health Psychologists ………………………………………….2o Psychiatrists …………………………………………………………. .6

Mid-level providers (Physician’s Assistants)…………………. .2o Social Workers………………………………………………………....2o Licensed Professional Counselor (substance abuse specialist)….1

• Total ……………………..…………………………….27

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The HRC Integration Story: Phase I

• Pre-Integration Days

o Referral Promotion: Internal discussion and monitoring the local landscape to promote referrals

o Relationship Building: with a nearby primary/urgent care practice, “The Family Doctor”

o My Job as Director of Professional Affairs >> SLC attendance >> awareness of need to develop practice as business

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The HRC Integration Story: Phase II

• Early Integration• Conversations with medical director of biggest

commercial carrier in area Discovered carrier’s strong interest in integration

• Invited conversations with nearby urgent care practice, “The Family Doctor” o How could we be more responsive? o How can we communicate most effectively? o How could we be better “integrated”?

• Discovery of a “Go Between”o Lawyer with interest in integrated care, provider

group contracting, and compliance with referral and kick-back issues under federal and state law

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The HRC Integration Story: Phase III

• Integration Matureso HRC contracts with Family Doctor practice to be their

behavioral resource for “Medical Home” statuso The “go-between” Steve Shaber (Poyner & Spruill Raleigh)

identifies prospective primary care practice o HRC identifies a clinician from our group who wants to co-

locate. o Discussions begin with Family Medical Associates of Raleigh

(Key IPA)o Contracting begins re: space, support services, coordination

of health records, money flows, etc.o Consultant/representative sent to the commercial carrier

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The HRC Integration Story: Phase IV

• Current Challenges: o Entering primary care cultureo Clarifying expectationso Refining contracts

Rent Services

o Fixing logistics, documentation, and information flows

o Dealing with insurance incompatibilities (panels and managed care problems)

o Dealing with payer + CPT code constrictions Eg, Health and Behavior Code 96150 – limit to 3

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The HRC Integration Story: Phase IV

• Current Challenges, cont’d: o Dealing with time demands for unpaid services

Hallway consults Uninsured patients and network incompatibility

o How to demonstrate value to primary care patientso Implementation Science Initiativeo How to reconfigure the “mother practice” to accommodate co-location

Less need for space in original psychology practice Challenges to cohesion and connection to original group

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Q&A

• What are the implications for other kinds of practices?

• What are implications for independent practice?

• How can our state, provincial, and territorial associations help practitioners?

• How can APA help?

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Resources• Collins, C et.al. Evolving Models of Behavioral Health Integration in

Primary Care, Milbank Memorial Fund, May 2010. http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf

• Community Care of North Carolina (CCNC). https://www.communitycarenc.org/population-management/behavioral-health-page/

• Mauer, B. 2006. Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-Based Practices. Rockville, MD: National Council for Community Behavioral Healthcare.

• Mechanic, David. Seizing Opportunities Under The Affordable Care Act For Transforming The Mental And Behavioral Health System. Health Affairs, 31, no.2 (2012): 376-382

• Trend Watch; Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes. American Hospital Association. January 2012

• Multiple articles on integrated care at APA’s Practice Central http://www.apapracticecentral.org/ (Search terms: “Integrated Care”)

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http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf

http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf

https://www.communitycarenc.org/population-management/behavioral-health-page/

http://www.apapracticecentral.org/

TO INTEGRATE -- OR HOW? A Decision Model for Practices Charles Cooper, PhD Director of Professional Affairs North Carolina Psychological Association APA.

Documents

integration early career

integration late career

acos moderate integration

specific kinds of integration

primary care setting

integrated care

target primary care

integrated systems