Integrating Behavioral Health in Primary Care: Challenges & Opportunities in Rhode Island

1. What’s integrated care got to do with it?Looking back and forward in primary care for Rhode Island Date: May 11, 2018 Nelly burdette, psyD LEAD, IBH Practice facilitator

2. Funding Partners

3. Overview • IBH Pilots in Primary Care • Quality and Cost Data • Lessons Learned • Challenges • Opportunities

4. What’s integration got to do with it?

5. Studies show mental health has a lot to do with it Source: Corso, Cost of treating chronic health condition without the mental health condition costs more Per Health and Human Services Data from 2002-2003

6. From humble beginnings First Successful Quasi-Experimental/Pretest-Posttest study (2017) implementing IBH in Primary Care with the aid of practice facilitation

7. Training the Next Generation • Funded by RIF, RIC for 3 practice facilitators to be trained specifically within IBH in Primary Care • 6 month training • Didactic and Experiential • 3 additional PCMH sites to receive practice facilitation through trainees over 1 year period • Includes psychology, social work and marriage and family therapy trainees Represents the first training of its’ kind in the country

8. IBH in Primary Care Pilot • 10 PCMHs selected to implement • Universal Screening of depression, anxiety and substance use in primary care for all patients > 18 across two years • Rescreening within 6 months if positive at baseline • Onsite IBH providers offer evidence-based treatment • Three PDSAs • Increase screening rates of depression (90%), anxiety (70%) , and substance use (70%) • High ED utilization with behavioral health • Population health focus within behavioral health

9. 10 Practicing Sites Cohort 1 (blue) February 2016 Cohort 2 (yellow) November 2016

10. PDSA: Universal ScreeningCohort 1

11. PDSA: Universal ScreeningCohort 2

12. PDSA: High-Risk ED Utilization & IBH How can behavioral health impact high-risk ED utilization? • NCM/IBH Co-visits led to reduction in ED visits from 2.7 prior to intervention to 0.7 post intervention. • 75% of patients in sample of 12 did not return to the ED after IBH intervention • Education about urgent care, same day sick visits • NCM and IBH connected for first time at many sites

13. Measurement year: Year 1 – 1/1/2016-12/31/2016 Year 2 – 4/1/2016-3/31/2017

14. Measurement year: Year 1 – 1/1/2016-12/31/2016 Year 2 – 4/1/2016-3/31/2017

15. PDSA: Population Health • How can behavioral health be better utilized within chronic disease management in primary care? • Diabetes and Depression Classes • Women’s Cardiovascular Health Classes • Chronic Pain and Mood Classes • Hypertension and Yoga Classes

16. Evaluation Results • Site self-assessment utilizing Maine Health Access Foundation Integration Initiative • 18 domains measured by self-report across three time periods (baseline, midpoint - 1 year, completion- 2 years) • 9 Patient and family centered dimensions • 9 Organizational dimensions

17. Funding sources showed greatest change

18. Patient/family involvement next largest change

19. Screening integration next largest change

20. Qualitative Evaluation • Engaged leadership & ownership across all organizational levels support IBH success • Practice facilitation makes a difference • EHRs can help or hinder but are critical • Communication in real-time between care teams by any means possible • Parity among IBH and Primary Care • Operational changes

21. Lessons Learned

22. Lessons Learned Standardize the Universal Screening process • Self-administered • Completed by patient on laminated sheets, on-line • Verbally administered by medical assistant , entered directly into EHR • Linked to a Preventative Services reminder in EHR • Support staff need to recognize during huddle or pre-visit planning • If screening is negative, no need to rescreen for one year *unless clinically determined by provider

23. Lessons Learned Train and Re-Train the Care Team • Emphasize the reasons why we screen for IBH conditions • Emphasize the medical assistant’s crucial role on team • Never miss an opportunity to screen for IBH conditions

24. Lessons Learned Anticipate the naysayers… “We shouldn’t screen because…” - too busy already or it’s a sick visit - Don’t want to open up a can of worms - I’ll have to deal with the consequences Proactively expect and address concerns before they takes root

25. Lessons Learned • Sustainability • Huddles/Interdisciplinary Care Conferences • Increased Productivity = encompassing Primary Care pace • Within 2 years, most sites financially sustainable • Change takes time • Governor has sponsored S2540/H7806 bills • Requires insurance companies to consider behavioral health counseling and medication visits as primary care services = copay would be same • BCBSRI will start implementation on 1/1/2019

26. Challenges

27. Challenges • Financial and Billing • Mostly occurs in specialty model of care • Only face-to-face codes based on time can consistently be used and reimbursed • Culture and Training • Medical Culture vs IBH Culture • NCM relationship to IBH • Specialty Behavioral Health Referrals • Psychiatry wait-lists • Communicating between Specialty MH and Primary Care

28. Opportunities • Psychiatry in Primary Care • Project ECHO • Adult-based version of Pedi PRN • Training IBH Practice Facilitators • Collaboration with local universities • Web-based and online expansion • Alternative Payment for IBH • SIM currently conducting a review for PMPM within IBH in primary care • Billing codes for IBH Care Coordination

29. Opportunities • Workforce • Trained IBH providers/providers interested in learning IBH • Bilingual providers • Evidence-based treatment guidelines • Post-screening for depression, anxiety and substance use • Implementation of evidence-based treatment guidelines

30. The dream vs the reality

31. Questions • Nelly Burdette, Psy.D • Lead, IBH Practice Facilitator, CTC-RI • Director of Integrated Behavioral Health, PCHC • nellyburdette@gmail.com • www.drnellyburdette.com