Integration Of Physical and Behavioral Healthcare

1. Integration Of Physical and Behavioral Healthcare Timothy E. Stone, MD, DFAPA Medical Director, Alabama Department Of Mental Health

2. Definitions • Healthcare Systems are integrated • Healthcare Services are coordinated • Healthcare integration and Healthcare coordination aren’t interchangeable terms ADMH 1-21-14

3. Healthcare Integration: Important Questions • What degree of integration currently exists between Alabama’s behavioral and physical healthcare systems? • If current levels of integration are low, why is this the case? ADMH 1-21-14

4. A Standard Framework For Levels Of Integrated Care* *SAMHSA-HRSA Center For Integrated Health Solutions ADMH 1-21-14

5. Lack of Healthcare Integration: Why? • National pattern of parallel development of dual healthcare systems for individuals with and without serious behavioral health disorders due to institutional segregation of behaviorally disturbed populations • Concept of treating of individuals with serious behavioral health disorders in the community is relatively new ADMH 1-21-14

6. Behavioral and Physical Healthcare Integration In Alabama • Alabama’s public mental health system is: • Large - > 104,000 individuals served in 2013 by Outpatient MI-SA providers alone • Complex and highly evolved – shaped by legal, financial, and political factors • Quite effective in helping individuals with serious mental illnesses to live successfully in the community • Extremely vulnerable to disruption of vital services and potential disruption of current system of care for thousands of seriously mentally ill individuals who currently live in the community ADMH 1-21-14

7. Alabama Department Of Mental Health

8. ADMH – A Few Of Its Administrative and Funding Relationships ADMH 1-21-14

9. FY13 Appropriations ADMH 1-21-14

10. Medicaid 1115 Waiver • Federal government matches state funds used to provide “Medicaid-like services” to non-Medicaid eligible populations • In 2012 ADMH affiliated MI providers served104,278 individuals • 34,383 (33%) – Medicaid only • 21,490 (21%) – Medicaid + Other (Dual-Eligible) • 48,405 (46%) – Non-Medicaid (Indigent) • The majority of DSHP (designated state health program) funds identified by Alabama Medicaid for the 1115 waiver are State General Fund appropriations to the ADMH that will be used to treat Non-Medicaid (indigent) SMI patients ADMH 1-21-14

11. Why Worry About Healthcare Integration In Alabama? • Behavioral health integration is a dominant theme in the efforts to transform Medicaid in Alabama • The eventual success of Medicaid Transformation in Alabama is dependent, to a greater or lesser degree, on how successfully the State’s public behavioral and physical healthcare systems integrate ADMH 1-21-14

12. Healthcare Integration: What Are The Potential Benefits? • Improvement In Quality Of Care • Cost Containment ADMH 1-21-14

13. Healthcare Integration: What Are The Potential Benefits? • Improvement In Quality Of Care • Expansion of mental health services to individuals considered to be “too healthy” to receive services from the public mental health system by current standards • Improved Care Coordination for chronically medically and mentally ill “high utilizers” with resulting improved health outcomes • Expanded support forprimary-care and specialty medical providers by mental health providers • Shared expertise • Etc. ADMH 1-21-14

14. Cost ControlMedicaid Eligible SMI Patients • In 2013, over 970,000 individuals were eligible to receive Medicaid health services • 63,400 (6.5%) were diagnosed with a serious mental illness (either as a primary or secondary diagnosis) • 25,000 were diagnosed with a psychotic disorder • 45,297 were diagnosed with a mood disorder • Many were diagnosed with both mood and psychotic disorders, with a small percentage being diagnosed with severe anxiety, as well ADMH 1-21-14

15. Medicaid Eligible SMI Population • Those individuals in the SMI group accounted for $900 Million (21% of total) in payments to providers • 6.5% of the population accounted for 21% of the total amount paid to providers in 2013 ADMH 1-21-14

16. Targeting Costs ADMH 1-21-14

17. Targeting Costs ADMH 1-21-14

18. Behavioral Health Domains Of Care • Access • Care Coordination • Prevention • Health Monitoring/Management • Patient Satisfaction ADMH 1-21-14

19. Healthcare Quality Measures For Medicaid Eligible Adults • Medical Assistance With Smoking and Tobacco Use Cessation • Screening for Clinical Depression and Follow-Up Plan • Follow-Up After Hospitalization for Mental Illness • Antidepressant Medication Management • Adherence to Antipsychotics for Individuals with Schizophrenia • Annual Monitoring for Patients on Persistent Medications • Care Transition—Transition Record Transmitted to Health Care Professional • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment. • Federal Register /Vol. 77, No. 2 /Wednesday, January 4, 2012 /Notices ADMH 1-21-14

20. Health Home Core Quality Measures ADMH 1-21-14

21. National Outcome Measures (NOMS)* ADMH 1-21-14 SAMHSA

22. Care Coordination Accountability Measures For Primary Practice • Extracted from Care Coordination Measures Atlas • Applicability to primary care practice evaluation • Focus on general population (not disease-specific) • Broad coverage of activity domains from Care Coordination Measures Atlas framework • Focus on care coordination (some measures in the Atlas embed care coordination items within a broader assessment of care) • Feasibility • Evidence of reliability and validity ADMH 1-21-14

23. Other Important Measures • Patients who lose Medicaid eligibility due to incarceration or hospitalization • Length of time required to re-establish eligibility after discharge from state hospital or incarceration • Readmission to designated mental health facilities or state hospitals • Etc. ADMH 1-21-14

24. Integration Of Physical and Behavioral Healthcare Questions? Timothy E. Stone, MD, DFAPA Medical Director, Alabama Department Of Mental Health