Integration of Behavioral Health and Primary Care

1. Integration of Behavioral Health and Primary Care Butler Behavioral Health Services & Butler Community Health Consortium January 27, 2010 1 Insert AH 100 logoInsert AH 100 logo

2. QUIZ Cost Mortality Morbidity Utilization/Access 2

3. QUIZ Who has identified the following U.S. MH System Structural Problems? Access to care Financial barriers Evidence Based Practice adoption Workforce development Coordination of care Quality & Accountability 3

4. Health Care Reform Federal House/Senate bills Parity Regulations State Governor�s Ohio Health Care Coverage and Quality Council task forces: Patient Centered Medical Homes Informed and Activated Patients Health IT Payment Reform Benefits package/redefinition of SMD/SED 4

5. Opportunity More people with insurance More coverage of behavioral health services Recognition that attending to behavioral health is essential for health and cost HHS, HRSA, AHRQ, and SAMHSA have prioritized the expansion of primary care and behavioral health integration delivery models 5

6. What�s Happening in Ohio 6 Add background watermark of Ohio?Add background watermark of Ohio?

7. Integrating Primary Care and Behavioral Health Ohio Coordinating Center for Integrating Care Access Health 100 7

8. Recession Has Affected Health Safety Net Bad debt for area�s top hospitals was $301.5 million this year, up 10 percent from 2008 More than 234,000 people in Greater Cincinnati are without private or public health insurance Area providers report increased demand for services from the recently unemployed, rising uninsured Growth on the dependence on publicly funded and nonprofit organizations for services 8 The recession has added stress to an already fragile health care safety net in Greater Cincinnati. Bad debt for the area's top 25 hospitals was $301.5 million for the most recent year reported, up from $275.3 million in the previous year � a 10 percent increase. More than 234,000 people in the Cincinnati metropolitan area go without private or public health insurance Area providers, such as TriHealth's parish nursing program, St. Vincent DePaul's local charitable pharmacies, Freestore Foodbank and local health centers, are reporting increased demand for services. A disproportionate share of the uninsured are poor and minorities. 30.7 percent of Hispanic Americans are uninsured, as are 19.1 percent of African Americans. In 2008, 24.5 percent of people in households with annual incomes of less than $25,000 had no health insurance coverage. Uninsured rates decreased as income rose. This also holds true for children. Children in poverty are more likely to be uninsured than other groups. Among all children, the percentage uninsured is 9.9 percent; among children in poverty, it is 15.7 percent. Among 18 to 64 year old workers in 2008, the percentage with no health insurance coverage grew from 18.1 percent in 2007 to 18.7 percent in 2008. The number of uninsured workers increased to 27.8 million in 2008, from 26.8 million in 2007. The recession has added stress to an already fragile health care safety net in Greater Cincinnati. Bad debt for the area's top 25 hospitals was $301.5 million for the most recent year reported, up from $275.3 million in the previous year � a 10 percent increase. More than 234,000 people in the Cincinnati metropolitan area go without private or public health insurance Area providers, such as TriHealth's parish nursing program, St. Vincent DePaul's local charitable pharmacies, Freestore Foodbank and local health centers, are reporting increased demand for services. A disproportionate share of the uninsured are poor and minorities. 30.7 percent of Hispanic Americans are uninsured, as are 19.1 percent of African Americans. In 2008, 24.5 percent of people in households with annual incomes of less than $25,000 had no health insurance coverage. Uninsured rates decreased as income rose. This also holds true for children. Children in poverty are more likely to be uninsured than other groups. Among all children, the percentage uninsured is 9.9 percent; among children in poverty, it is 15.7 percent. Among 18 to 64 year old workers in 2008, the percentage with no health insurance coverage grew from 18.1 percent in 2007 to 18.7 percent in 2008. The number of uninsured workers increased to 27.8 million in 2008, from 26.8 million in 2007.

9. Environmental Context Key health indicators have not improved Poor and minorities suffer disproportionately Health care access point connections are needed Number and percentage of individuals without medical home is growing Number of uninsured is growing Growing shortages of key providers Government shortfalls contribute to concerns Safety net system is at risk 9 The data shared in this analysis show a system at risk. Despite many available resources attempting to reach out to the community, health care access has not improved over time. The number and percentage of individuals without a medical home is growing, as is the number of uninsured. Key health indicators have not improved; some have significantly worsened. None meet targets established by Healthy People 2010. Health disparities are clear - vulnerable populations - the poor and minorities - do not have the access available to all citizens of the area, and the disparity in health indicates reflects that lack of access. There are significant and growing shortages of key providers. Federal, state and local governments all have budget shortfalls, which have already caused reductions in services at a time when more services are needed. Multiple resources will be needed to address the issues identified. The data shared in this analysis show a system at risk. Despite many available resources attempting to reach out to the community, health care access has not improved over time. The number and percentage of individuals without a medical home is growing, as is the number of uninsured. Key health indicators have not improved; some have significantly worsened. None meet targets established by Healthy People 2010. Health disparities are clear - vulnerable populations - the poor and minorities - do not have the access available to all citizens of the area, and the disparity in health indicates reflects that lack of access. There are significant and growing shortages of key providers. Federal, state and local governments all have budget shortfalls, which have already caused reductions in services at a time when more services are needed. Multiple resources will be needed to address the issues identified.

10. Emergency Services Utilization 10 Hospitals in our area logged nearly one million emergency department visits in the past year. From16-21 percent of them were avoidable. Avoidable visits are scattered throughout the service area. Hospitals in our area logged nearly one million emergency department visits in the past year. From16-21 percent of them were avoidable. Avoidable visits are scattered throughout the service area.

11. Avoidable ED Visits 11 While avoidable visits come from all payor categories, individuals not covered by insurance and those covered by Medicaid account for a higher proportion of avoidable visits than those covered by commercial insurance The data suggest that individuals who lack health care coverage and who are not connected to timely care often use the emergency room as their primary care provider. The Greater Cincinnati Health Status Survey, conducted in 2005, bears this out. It showed that those living below 100 percent of the Federal Poverty Guidelines (FPG) and the uninsured were three times as likely to list an ER as their medical home. While avoidable visits come from all payor categories, individuals not covered by insurance and those covered by Medicaid account for a higher proportion of avoidable visits than those covered by commercial insurance The data suggest that individuals who lack health care coverage and who are not connected to timely care often use the emergency room as their primary care provider. The Greater Cincinnati Health Status Survey, conducted in 2005, bears this out. It showed that those living below 100 percent of the Federal Poverty Guidelines (FPG) and the uninsured were three times as likely to list an ER as their medical home.

12. 12 Introduced in 2006; with an aggressive pace of work. Our original goal was to create a long-term,multiphase effort to increase access to primary care Introduced in 2006; with an aggressive pace of work. Our original goal was to create a long-term,multiphase effort to increase access to primary care

13. 13 AH 100 � team work continues HCAN operations are put in placeAH 100 � team work continues HCAN operations are put in place

14. Access Health 100 Pilot Projects�Models That Work 14 The focus of funded projects; we will talk about where we have gained traction and commitmentsThe focus of funded projects; we will talk about where we have gained traction and commitments

15. Community Health Centers 50 community health center (FQHC) practice sites in our area Area community health centers logged 674,747 visits in 2008 181,711 patients 10 percent were new patients 34 % of patients uninsured Cincinnati Health Department is major provider 61,793 visits from 21,588 patients in first six months of 2009 55 % uninsured Community health centers are economic contributors to the region 15 The region includes 50 Federally Qualified Health Center (FQHC) practice sites. FQHC is a federal designation from the Bureau of Primary Health Care (BPHC) and the Center for Medicare and Medicaid Services (CMS) that is assigned to private non-profit or public health care organizations that serve predominantly uninsured or medically underserved populations. FQHCs are located in or serving a federally designated Medically Underserved Area/Population (MUA or MUP). All FQHCs must operate under a consumer majority board of directors' governance structure, and provide comprehensive primary health, oral and mental health/substance abuse services to persons in all stages of the life cycle. FQHCs provide their services to all persons regardless of ability to pay, and charge for services on a board-approved sliding-fee scale that is based on patients� family income and size. The Cincinnati Health Department has received FQHC lookalike designation in 2009, which provides additional revenue to offset some of the City of Cincinnati budget cuts. In 2008, the community health centers in our region logged 674,747 visits from 181,711 patients. New patients represented a little less than 10 percent of this number, or 17,026 individuals. About 34 percent of these patients were uninsured. The city of Cincinnati continues to serve as a major provider of health care. In the first six months of 2009, the City of Cincinnati Health Department logged 61,793 patient visits from 21,588 patients. About 55 percent of the patients were uninsured. In the community health centers for which data is available for the first six months of 2009, the percentage of uninsured patients ranges from 2.6 percent at HealthSource to 54.5 percent at the Cincinnati Health Department. A recent study of the Indiana FQHCs calculate that it costs $1,529 per year per patient to see patients at community health centers (CHCs), compared with $2,924 at other types of outpatient care centers, saving the system a total of $473 million from 2006 to 2007, through more costly ED avoidance. In addition, another study found that CHCs save the health system about $3,679 per diabetic patient and $2,467 per asthma patient. Finally, community health centers' management of chronic conditions saves in averted ED and hospitalization costsThe region includes 50 Federally Qualified Health Center (FQHC) practice sites. FQHC is a federal designation from the Bureau of Primary Health Care (BPHC) and the Center for Medicare and Medicaid Services (CMS) that is assigned to private non-profit or public health care organizations that serve predominantly uninsured or medically underserved populations. FQHCs are located in or serving a federally designated Medically Underserved Area/Population (MUA or MUP). All FQHCs must operate under a consumer majority board of directors' governance structure, and provide comprehensive primary health, oral and mental health/substance abuse services to persons in all stages of the life cycle. FQHCs provide their services to all persons regardless of ability to pay, and charge for services on a board-approved sliding-fee scale that is based on patients� family income and size. The Cincinnati Health Department has received FQHC lookalike designation in 2009, which provides additional revenue to offset some of the City of Cincinnati budget cuts. In 2008, the community health centers in our region logged 674,747 visits from 181,711 patients. New patients represented a little less than 10 percent of this number, or 17,026 individuals. About 34 percent of these patients were uninsured. The city of Cincinnati continues to serve as a major provider of health care. In the first six months of 2009, the City of Cincinnati Health Department logged 61,793 patient visits from 21,588 patients. About 55 percent of the patients were uninsured. In the community health centers for which data is available for the first six months of 2009, the percentage of uninsured patients ranges from 2.6 percent at HealthSource to 54.5 percent at the Cincinnati Health Department. A recent study of the Indiana FQHCs calculate that it costs $1,529 per year per patient to see patients at community health centers (CHCs), compared with $2,924 at other types of outpatient care centers, saving the system a total of $473 million from 2006 to 2007, through more costly ED avoidance. In addition, another study found that CHCs save the health system about $3,679 per diabetic patient and $2,467 per asthma patient. Finally, community health centers' management of chronic conditions saves in averted ED and hospitalization costs

16. 16 HCAN�s role is introduced to manage the pathway service integration across multiple sites, providers and potential payors; along with data analysisHCAN�s role is introduced to manage the pathway service integration across multiple sites, providers and potential payors; along with data analysis

17. ED Avoidance/Medical Home Pilot Projects Creating alternative patient flows Analyzing ED utilization data & defining key metrics Designing the deal between providers and payors Engaging primary care providers Implementing process improvements Developing the ED Care Coordination Pathway 17

18. ED Avoidance/Medical Home Pilot Projects Results 1000+ ED patients connected to medical homes Reduction in ED visits � average of 2 visits/patient Patients now have consistent care, access to prescription services and dental care, pending availability of dentists 18

19. 9/26/2012 19 ER work is tough enough as it is. We all know it can be a burnout environment. But when I review the status reports of the patients we�ve seen through our EDCCP work, I see clues to what we might be accomplishing. And when I talk to the successful patients, it becomes clear. And it energizes me. Dr. Jeff Walker - EDCCP Physician Coordinator Providence St. Peter Hospital Emergency Dept.

20. 9/26/2012 20 Model That Works: EDCCPOlympia, WA Currently at 5 hospitals in 5 county region CHOICE involvement is a logical evolution of its outreach, enrollment and system navigation services for clients Is one of many inter-related strategies to increase the capacity and integration of the safety net Is one of the identified eight critical activities of community Collaboratives

21. 9/26/2012 21 Model That Works � Olympia, WAEDCCP Patient characteristics Frequently prescription pain medication addicted, �seeking� High incidence of rebound pain suspected Mental & behavioral health issues Somatization, anxiety, anger, depression, denial, psychoses Often co-occurring with chronic health issues Severely and persistently mentally ill die 20-25 years younger from their co-occurring chronic illnesses Some �frequent flyers� come to us looking more like business commuters Average of 18 visits to ED per year Multiple EDs in multiple counties �Playing� the EDs, PCPs, specialists, pain clinics, walk-in clinics Commerce is frequently evident

22. 9/26/2012 22 The patient we enrolled No PCP or poor relations ED is primary care source, multiple & frequent visits, mostly unnecessary & ineffective Narcotic pain meds � uncontrolled & excessive use, multiple sources, dangerous Chronic conditions are uncontrolled and severely threatening Emotionally volatile, feels vulnerable & abused by an uncaring and hostile health care system Denial of true core issues, in survival mode, consigned to misery Often hostile and /or manipulative

23. 9/26/2012 23 EDCCP: The person who succeeds In partnership with PCP Presents to ED appropriately and infrequently, if at all Narcotic medications no longer necessary or greatly reduced, managed and appropriate Chronic medical issues are self-managed, controlled, no longer the patient�s �life story� Emotionally stable, self-controlled, and system savvy Self aware, goal oriented, active in their own progress, and committed to increasingly better health A person with the right tools and knowledge, and a new history of success

24. 9/26/2012 24 �ER work is tough enough as it is. We all know it can be a burnout environment. But when I review the status reports of the patients we�ve seen through our EDCCP work, I see clues to what we might be accomplishing. And when I talk to the successful patients, it becomes clear. And it energizes me.� Dr. Jeff Walker - EDCCP Physician Coordinator Providence St. Peter Hospital Emergency Dept., a CHOICE hospital partner

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26. Integrating Primary Care and Behavioral Health Ohio Behavioral Health Providers are developing integrated care initiatives (from 8 to 48+) High healthcare cost of people with a serious mental illness and another physical health condition will drive integration Behavioral Health is becoming part of health care (operational/fiscally) 26

27. Ohio is Embracing the Medical Home Concept Governor�s Ohio Health Care Coverage and Quality Council task forces: Patient Centered Medical Homes Informed and Activated Patients Health IT Payment Reform Benefits package/redefinition of SMD/SED 27

28. What are Person-Centered Healthcare Homes? Medical Chronic Care Model Medical Home Renaming National Council's Continuum: PCHCHs 28 MH�.or PCMH�..or PCHCH�� An expression of integration A model of engaged tx being used in HC Reform (OHIO and Nationally) A model of COMPREHENSIVE PC that coordinates care�..facilitates partnerships among medical professionals�.pts. and families� creates an �activated� pt. that participates (due to opportunity- and education) in coordinated TXMH�.or PCMH�..or PCHCH�� An expression of integration A model of engaged tx being used in HC Reform (OHIO and Nationally) A model of COMPREHENSIVE PC that coordinates care�..facilitates partnerships among medical professionals�.pts. and families� creates an �activated� pt. that participates (due to opportunity- and education) in coordinated TX

29. Overall Model for Improving Primary Care 29 Where did this medical home idea come from? (old idea- hx of FQHC/free clinics- early MC, etc�) To address quality/fragmentation�.Not what we are doing now��different systems/payment�.not team�not coordinated�not activated pt�� CCM model comes from Improving Chronic Illness care (ICIC)- with RWJ��. Informed by: IOM Crossing the quality chasm NCQA JACHO American Academy of Family Prac Am college of physicians WHO IMPROVING CHRONIC ILLNESS CARE � of all Americans have chronic conditions � of those that do have MULTIPLE Chronic Conditions In order to address: Rushed practioners Lack of coordination Lack of follow-up Pts. Inadequately trained to self-manage illness �innovative care for chronic conditions �..led to refinement/ creation of Medical Home model Where did this medical home idea come from? (old idea- hx of FQHC/free clinics- early MC, etc�) To address quality/fragmentation�.Not what we are doing now��different systems/payment�.not team�not coordinated�not activated pt�� CCM model comes from Improving Chronic Illness care (ICIC)- with RWJ��. Informed by: IOM Crossing the quality chasm NCQA JACHO American Academy of Family Prac Am college of physicians WHO IMPROVING CHRONIC ILLNESS CARE � of all Americans have chronic conditions � of those that do have MULTIPLE Chronic Conditions In order to address: Rushed practioners Lack of coordination Lack of follow-up Pts. Inadequately trained to self-manage illness �innovative care for chronic conditions �..led to refinement/ creation of Medical Home model

30. Implementing the Chronic Care Model Developing a Prepared, Proactive Practice Team For persons with SMI, this �team� will typically need to span multiple agencies: MH, SA, medical, and social services Need strategies for linking these services Developing an Informed, Activated Patient: Self-management : ability to understand and manage one�s health and medical problems Activation: ability to act effectively in managing one�s own healthcare Developing strategies for Reorganizing Healthcare: Need to work across multiple stakeholders and agencies 30 3 parts: ��coordinated team(clinical)�.activated pt. (psychoeduciaotnal)���organizational (and system) change3 parts: ��coordinated team(clinical)�.activated pt. (psychoeduciaotnal)���organizational (and system) change

31. Patient Centered Medical Homes Patient Centered Medical Homes are a mechanism for coordinating healthcare in order to: Improve health Increase patient satisfaction Enhance access Ensure the delivery of efficient and effective health care 31

32. The Patient-Centered Medical Home Principles of the Patient-Centered Medical Home Personal physician Physician/Nurse Practioner directed medical practice (team care that collectively takes responsibility for the ongoing care of patients) Whole person orientation The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association http://www.pcpcc.net/ 32 Patient Centered Primary Care Collaborative : American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association an approach to providing comprehensive primary care... that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient�s familyPatient Centered Primary Care Collaborative : American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association an approach to providing comprehensive primary care... that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient�s family

33. The Patient-Centered Medical Home Care that is coordinated and/or integrated Quality and safety (including evidence based care, use of information technology and performance measurement/quality improvement) Enhanced access to care Payment structure that reflects these characteristics beyond the current encounter-based reimbursement mechanisms The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association http://www.pcpcc.net/ 33

34. NCQA Certification Standards: Patient Centered Medical Home 34

35. Person-Centered Healthcare Home Access Heath 100 35

36. Person-Centered Healthcare Home Continuum of Behavioral Health Provider as part of Medical Home 36

37. 37 What is integrated Healthcare? TX the whole person Clinically Coordinated/collaborative approach Linked wellness/empowerment/activation Supports Initial Question: When talking about �integration��.at the most basic level- this is about coordinated care between PC/BH��so Operationally � One question that needs to be answered is WHERE is the �best locus of TX?���the answer of course is that we need to identify not just where- but where AND FOR WHOM?......this model helps one think about the location of servg=ices for general groupings of BH populationsWhat is integrated Healthcare? TX the whole person Clinically Coordinated/collaborative approach Linked wellness/empowerment/activation Supports Initial Question: When talking about �integration��.at the most basic level- this is about coordinated care between PC/BH��so Operationally � One question that needs to be answered is WHERE is the �best locus of TX?���the answer of course is that we need to identify not just where- but where AND FOR WHOM?......this model helps one think about the location of servg=ices for general groupings of BH populations

38. Person-Centered Healthcare Home Point 1- Coordination/Collaboration: Behavioral Health Provider as specialty care and linkage 38

39. 39 Identified PCP Clear communication/coordination mechanisms Regular screening A registry tracking/outcome system Education, provision and linking with prevention and wellness PCHCH for People with SMI: Coordination Identified PCP Clear communication/coordination mechanisms and expectations Assure regular screening at the time of psychiatric visits for all BH consumers receiving psychotropic medications A registry tracking/outcome system�for PH Education and Linking Identified PCP Clear communication/coordination mechanisms and expectations Assure regular screening at the time of psychiatric visits for all BH consumers receiving psychotropic medications A registry tracking/outcome system�for PH Education and Linking

40. 40 Ohio Examples Multiple �sub-population� examples ACT Teams Care Coordinator/Pt. Navigator Role(s) Barriers: Data/IT Infrastructure Payers Multiple Primary Care providers PCHCH for People with SMI: Coordination Identified PCP Clear communication/coordination mechanisms and expectations Assure regular screening at the time of psychiatric visits for all BH consumers receiving psychotropic medications A registry tracking/outcome system�for PH Education and Linking Identified PCP Clear communication/coordination mechanisms and expectations Assure regular screening at the time of psychiatric visits for all BH consumers receiving psychotropic medications A registry tracking/outcome system�for PH Education and Linking

41. Person-Centered Healthcare Home Point 2- Partnership �When BH Provider is medical home 41

42. 42 A PC Physician/Nurse Practitioner within the full scope healthcare home in BH clinics Nurse care managers to support/coordinate/collaborate Regular screening and a registry Use of evidence based practices Education, provision and linking with prevention and wellness PCHCH for People with SMI: Partnership FOR PH�.. Regular screening and registry tracking/outcome measurement at the time of psychiatric visits Locate medical nurse practitioners/PCPs in BH clinics�provide routine primary care services in the BH setting via staff out-stationed under the auspices of a full scope person-centered healthcare home A PC Physician/Nurse Practitioner within the full scope healthcare home to provide consultation on complex health issues Nurse care managers to support individuals with elevated levels of glucose, lipids, blood pressure, and/or weight/BMI Use evidence based practices to improve the health status, adapting these practices for use in the BH system Wellness programs for activation and empowerment; self- management FOR PH�.. Regular screening and registry tracking/outcome measurement at the time of psychiatric visits Locate medical nurse practitioners/PCPs in BH clinics�provide routine primary care services in the BH setting via staff out-stationed under the auspices of a full scope person-centered healthcare home A PC Physician/Nurse Practitioner within the full scope healthcare home to provide consultation on complex health issues Nurse care managers to support individuals with elevated levels of glucose, lipids, blood pressure, and/or weight/BMI Use evidence based practices to improve the health status, adapting these practices for use in the BH system Wellness programs for activation and empowerment; self- management

43. 43 Ohio Examples Primary Care in Behavioral Health Behavioral Health in Primary Care Barriers: Partnering Operations Data Sharing PCHCH for People with SMI: Partnership FOR PH�.. Regular screening and registry tracking/outcome measurement at the time of psychiatric visits Locate medical nurse practitioners/PCPs in BH clinics�provide routine primary care services in the BH setting via staff out-stationed under the auspices of a full scope person-centered healthcare home A PC Physician/Nurse Practitioner within the full scope healthcare home to provide consultation on complex health issues Nurse care managers to support individuals with elevated levels of glucose, lipids, blood pressure, and/or weight/BMI Use evidence based practices to improve the health status, adapting these practices for use in the BH system Wellness programs for activation and empowerment; self- management FOR PH�.. Regular screening and registry tracking/outcome measurement at the time of psychiatric visits Locate medical nurse practitioners/PCPs in BH clinics�provide routine primary care services in the BH setting via staff out-stationed under the auspices of a full scope person-centered healthcare home A PC Physician/Nurse Practitioner within the full scope healthcare home to provide consultation on complex health issues Nurse care managers to support individuals with elevated levels of glucose, lipids, blood pressure, and/or weight/BMI Use evidence based practices to improve the health status, adapting these practices for use in the BH system Wellness programs for activation and empowerment; self- management

44. Person-Centered Healthcare Home Point 3- �Single Provider� Integration Behavioral Health Provider as medical home 44

45. 45 Full range of Primary Care services Strong Links with Specialty Care Identified as PCHCH Prevention and wellness programs The Person-Centered Healthcare Home for People with SMI: Single Provider Examples��Cherokee/InterMountain�..Kaiser�. Full range of BOTH BH and PC �None of these in OHIO�some working on it��. Examples��Cherokee/InterMountain�..Kaiser�. Full range of BOTH BH and PC �None of these in OHIO�some working on it��.

46. 46 Ohio Examples Primary Care Clinics SAMHSA grantees Barriers: Physical Plant Billing expertise Internal alignment The Person-Centered Healthcare Home for People with SMI: Single Provider Examples��Cherokee/InterMountain�..Kaiser�. Full range of BOTH BH and PC �None of these in OHIO�some working on it��. Examples��Cherokee/InterMountain�..Kaiser�. Full range of BOTH BH and PC �None of these in OHIO�some working on it��.

47. Core Elements of Medical Homes Full scope of primary care and behavioral healthcare Healthcare is coordinated across providers and specialties Care management services are essential to ensure maximum benefit from clinical services Access to prevention and wellness services 47

48. Conclusions There are a growing number of approaches to improving health and health care in mental health consumers There is no �one size fits all� approach to improving health and health care for persons with SMI; appropriate models will depend on patient needs, onsite capacity, the funding environment, and community resources Everyone an do something! 48

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50. Future directions for the Behavioral Healthcare system 50

51. Top 10 Healthcare Reform Issues for Behavioral Health Communities Healthcare Reform will result in service delivery redesign and payment reform Behavioral Health is now on Policy Committee�s radar Parity will likely improve access and available services Most members of safety net will have coverage with a BH benefit There is no guarantee that BH revenue will be spent on Community BHO Services 51

52. Top 10 Healthcare Reform Issues for Behavioral Health Communities High healthcare costs of persons with SMI/SU will drive models, that are still evolving Payment reforms will be linked to clinical outcomes and cost management Current Behavioral Health payer structures may be disrupted as Medicaid authorities and plans seek to �bend the curve�. Health Insurance reforms will shift �Risk for Total Cost of Care� Health Insurance reform may unfold rapidly 52

53. Considerations for Behavioral Health System and Provider levels Develop capacity to describe your clients Clinically Process Fiscal Develop local infrastructure/leadership groups Start local initiatives Access Health 100 ED/CHC Care Coordination Pathway Continuum of PCHC Inpatient Follow-up(NEO) BCHC/BBH partnership 53

54. Thank You ! Jonas Thom 513-458-6733 jthom@healthfoundation.org Judith Warren, MPH Executive Director Health Care Access Now 513-707-5696 jwarren@healthcareaccessnow.org 54