Barbara Mauer, MSW, CMC MCPP Healthcare Consulting Inc. Seattle, Washington

1. Overview from the Field: Key Conceptual Models, Definition of Integrated Behavioral Health, CA IPI and CALMEND ProjectsDepartment of Health Care ServicesBehavioral Health Technical Workgroup 2-24-2010 Barbara Mauer, MSW, CMC MCPP Healthcare Consulting Inc. Seattle, Washington

2. Overview from the Field Part One (Meeting 2/24) Healthcare Environment Universal Coverage/Parity Service Delivery Redesign Importance of MH/SU conditions Patient-centered medical homes Care management The Care Model Integrated Primary Care/MH/SU Person-centered healthcare homes Definition of integrated healthcare Models for clinical care Four Quadrant model California Integrated Policy Initiative (IPI) report CalMEND Learning Collaborative Financing Paradigms SPD Plans Part Two Financing and the Waiver SPD Plans Paradigms and Cost Offsets Alignment with the Waiver Management Models Assumptions Examples Integration Pilots

3. Part One

4. Universal Coverage/Parity: Will Likely Improve MH/SU Access and Available Services • Mental Health and Substance Use Services must be provided at parity with general healthcare services (no discrimination) • Large Employers (Parity Act) • Medicaid (Parity Act & Reform Legislation) • Health Insurance Exchanges for Individual and Small Group Policies (Health Reform Legislation) • Medicare: on the way (Medicare Modernization Act of 2003) • But... the parity regulations may not be the most important component if health reform passes; keep your eye on the Benchmark Benefit Package that ‘s currently in the Senate bill • In Medicaid most/all enrollees may be guaranteed a benchmark benefit package that at least provides “essential health benefits” • Mental Health and Substance Use are included in the definition of “essential health benefits” 4

5. Service Delivery Redesign: MH/SU Conditions are Now on the Health Policy Community’s “Radar Screen” • 49% of Medicaid beneficiaries with disabilities have a psychiatric illness (this is new information; previous studies that excluded pharmacy claims calculated the rate at 29%) • Substance use conditions do not show up in this study at the expected levels because it’s based on an analysis of claims and pharmacy scripts The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic ConditionsCenter for Health Care Strategies, Inc., October 2009

6. Service Delivery Redesign: MH/SU Conditions are Now on the Health Policy Community’s “Radar Screen” Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying earlier than the general population (average age of death is 53) While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006) OR state study found that those with co-occurring MH/SU disorders were at greatest risk (45.1 years)

7. Service Delivery Redesign: Patient-Centered Medical Homes (PCMH) • 45 percent of Americans have one or more chronic conditions. • Over half of these people receive their care from 3 or more physicians. • Treating these conditions account for 75% of direct medical care in the U.S. • PCMH, with care management, is a key strategy

8. Service Delivery Redesign: PCMH Principles • Ongoing Relationship with a PCP • Care Team who collectively take responsibility for ongoing care • Provides all healthcare or makes Appropriate Referrals • Care is Coordinated and/or Integrated • Quality and Safety are hallmarks • Enhanced Access to care is available • Payment appropriately recognizes the Added Value See the www.pcpcc.net site for more information

9. Service Delivery Redesign: Care Management • Care management is a multidimensional activity with models ranging in level of intensity and breadth of scope (key components of care management include: patient identification; individual assessment of risks/needs; care planning with patient/family; teaching patient/family about management of disease(s); coaching patient/family; tracking over time; and revising care plan as needed). • Studies of care management in primary care show convincing evidence of improving quality; however it takes time to realize these quality outcomes (e.g., 12 months is probably not enough time). • Care management studies in primary care are mixed regarding reductions in hospital use and healthcare costs (two promising studies included emphasis on training of care manager team, care management panel sizes at reasonable levels, close relationships between care managers and PCPs, and interactions with patients in-clinic, at home and by telephone).

10. Service Delivery Redesign: Care Management • Selecting the right patients for care management is associated with reducing costs and improving quality (e.g., individuals who need end-of-life care need different services). • Training of care managers is an important factor in the success or failure to reduce costs and improve quality. • Successful programs have care managers as part of multidisciplinary teams that involve physicians. • Presence of family caregivers improves success of care management, and use of coaching techniques is a viable approach. • The intensity of the care management needed for success in improving quality and reducing costs is unclear. Bodenheimer T, Berry-Millett R. Care management of patients with complex health care needs Robert Wood Johnson Foundation Research Synthesis Report No. 19. December 2009. www.policysynthesis.org

11. Service Delivery Redesign: Overall Model for Improving Primary Care (CALMEND version)

12. Integrated Care: Patient-Centered Medical Homes become Person-Centered Healthcare Homes Person-Centered Healthcare Home Not a clear articulation in the PCMH model of the role of MH/SU Change to Person Centered Healthcare Home signals that MH/SU is a central part of healthcare and that healthcare includes a focus on supporting goals for improved self management Use a bi-directional approach to address the integration of primary care services in MH/SU settings as well as the need for MH/SU services in primary care settings Build in the care manager/ behavioral health consultant and consulting prescriber functions that have proven effective in the IMPACT model and mirror this model to bring planned primary care into MH/SU settings PCMH Principles Ongoing Relationship with a PCP Care Team who collectively take responsibility for ongoing care Provides all healthcare or makes Appropriate Referrals Care is Coordinated and/or Integrated Quality and Safety are hallmarks Enhanced Access to care is available Payment appropriately recognizes the added value

13. Integrated Care: Recent Reports • World Health Organization • Integrating Mental Health Into Primary Care: A Global Perspective (Fall 2008) • http://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf • Agency for Healthcare Research and Quality • Integration of Mental Health/Substance Abuse and Primary Care (Fall 2008) • http://www.ahrq.gov/clinic/tp/mhsapctp.htm • Hogg Foundation for Mental Health   • Connecting Body and Mind: A Resource Guide to Integrated Health Care in Texas and the United States (Fall 2008) • http://www.hogg.utexas.edu/programs_RLS15.html

14. Integrated Care: A Definition • “It has been defined in many ways, but in essence integrated healthcare is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served… The question is not whether to integrate, but how. Neither primary care nor behavioral health providers are trained to address both issues.” Hogg Foundation for Mental Health

15. Integrated Care: The Models for Clinical Care • Co-location • House BH specialists and primary care providers in same facility, supporting “warm hand-off” • Does not ensure that providers collaborate in treatment; this may vary greatly across clinics • Research is somewhat limited—“simply placing a BH specialist in PC is unlikely to improve patients’ outcomes unless care is coordinated and based in evidence-based approaches” • Primary Care Behavioral Health Model • BH consultant serves as consultant to PCP, focusing on optimizing the PCP’s quality of BH care for patients • Targets behavioral issues related to medical diagnoses instead of traditional BH problems like depression and anxiety • Has not yet been systematically evaluated—”although likely beneficial, the effectiveness of the model is not yet known”

16. Integrated Care: The Models for Clinical Care • Collaborative Care • Adaptation of the chronic care model for psychiatric disorders, used stepped care to treat depression, anxiety disorders, bipolar disorder • Integration of BH care manager and consulting psychiatrist into PC setting, with registry to track and monitor response to treatment • Numerous studies of clinical and cost effectiveness, with adolescents, adults, and older adults, with and without co-morbid medical illnesses and from different ethnic groups—”significant research evidence demonstrates that collaborative care improves outcomes for a wide range of patients” • This is the model the Hogg Foundation has been implementing in a number of Texas PC clinics Hogg Foundation for Mental Health

17. The National Council’s Four Quadrant Clinical Integration Model (MH/SU)

18. Focus: Quadrants I and III

19. Primary Care and Depression Most PCPs do a good job of diagnosing and beginning treatment for depression (studied 1,131 patients in 45 primary care practices across 13 states) PCPs do less well following up with treatment over time Less than half of patients completed a minimal course of medications or psychotherapy Few patients who don’t respond to initial treatment get adequate changes in treatment or referrals to specialists Lowest quality of care among those with the most serious symptoms, including those with evidence of suicide or substance use “Our finding of low rates of referral to mental health specialists for complex patients is typically addressed in collaborative care interventions through stepped care (e.g. , IMPACT) that prioritizes mental health specialist referrals on the basis of need.” Hepner et al, Ann Int Med, 9/07

20. Bipolar Disorder in Clinical Populations Patients Treated for Depression in a Family Medicine Clinic Screened positive* for bipolar disorder 21% 649 outpatients receiving treatment for depression MDQ sensitivity = 58%, specificity = 93%; based on SCID for DSM-IV Bipolar prevalence among 649 depressed patients = 27.9% *Using the Mood Disorder Questionnaire (MDQ)Hirschfeld RM, et al. J Am Board Fam Pract. 2005;18:233-239.

21. SU Conditions are Relevant for Primary Care SU conditions are prevalent in primary care Tens of millions (McClellan) 21% + (Willenbring) SU conditions add to overall healthcare costs, especially for Medicaid SU conditions can cause or exacerbate other chronic health conditions SU interventions can reduce healthcare utilization and cost

22. Primary Care and SU Services Diffusion of screening and brief intervention (SBI) is underway Motivational interviewing with fidelity should be a consistent component of SBI Repeated BI in primary care is a promising practice Medication-assisted therapies in primary care can be expanded

23. IMPACT Collaborative Care in Primary Care 23

24. IMPACT: Doubles the Effectiveness of Usual Care for Depression 50 % or greater improvement in depression at 12 months % Participating Organizations Unutzer et al., JAMA 2002; Psychiatr Clin N America 2005

25. Washington State GA-U Project(General Assistance Unemployable) DSHS | GA-U Clients: Challenges and OpportunitiesAugust 2006

26. GAU Goal: Collaborative Care 6 FQHC systems (26 clinic sites), 10 mental health agencies, the safety net health plan, the RSN and UW CMHC Level II Care PCP GA-U Client CSO (benefits) Consulting Psychiatrists Care Coordinator DVR (employment) Other clinic-based mental health providers* Substance Use Treatment Level I Care * Available in some clinics

27. Washington State GA-U Project (First Year Findings) Unutzer. University of Washington • Clients with follow up within 4 weeks of initial assessment • Level I: 42% (range across clinics: 32%-64%) • Clients with Psychiatrist Consultation • Level I: 31% (range across clinics: 20%-83%) • Level I outcomes 12 weeks after initial assessment • Clients with PHQ-9 score improved at least 50% over 12 weeks = 20% (range across clinics: 12%-28%) • Clients with GAD-7 score improved at least 50% over 12 weeks = 20% (range across clinics: 13%-26%) • Quality Improvement effort, with attention to core components/workflow • High rates of engagement (100%) and 4 week follow-up (93%) • Effective use of in-person and telephone contacts • Psychiatric Consultation at 60% • 63-72 % with substantial (>50 %) clinical improvement

28. Washington State GA-U Project Removing many of the barriers commonly identified (finance, regulation, sharing of information) did not remove the cultural differences, historic lack of trust, or the challenges of implementing evidence-based practices While all of the “usual suspect” barriers must be addressed, the most formidable is changing practice in the field There was significant variation in work processes across PC and MH clinics and in implementation of the care coordinator role across PC clinics This created variation in client follow up and use of psychiatric consultation This reduced ability to provide stepped care and lack of fidelity to the stepped care model, and negatively impacted outcomes However, client outcomes were positively impacted by greater fidelity to the model

29. The Person-Centered Healthcare Home: Q I and III • Incorporate the lessons of the IMPACT model, explicitly building into the medical home the care manager/ behavioral health consultant (MH and SU competent) and consulting prescriber functions that have proven effective in the IMPACT model • DIAMOND project in MN—monthly case rate payments for covering these components in primary care practices, all major payors participating • All healthcare is local—working out the details of who does what, for what levels of MH/SU services (Intermountain model), has to engage local partnerships—the California IPI Continuum is a guide for these dialogues http://www.cimh.org/Services/Special-Projects/Primary-Care/Initiative-Feedback.aspx 29

30. Focus: Quadrants II and IV

31. Massachusetts Study: Deaths from Heart Disease by Age Group/DMH Enrollees with SMI Compared to Massachusetts 1998-2000 2.2RR 4.9RR 1.5RR 3.5 RR

32. CATIE Study CATIE source for SMI data NHANESIII source for general population data Meyer et al., Presented at APA annual meeting, May 21-26, 2005. McEvoy JP et al. Schizophr Res. 2005;(August 29).

33. At CATIE baseline: 88% of subjects who had dyslipidemia 62.4% of subjects who had hypertension 30.2% of subjects who had diabetes WERE NOT RECEIVING TREATMENT FOR THESE CONDITIONS CATIE Study

34. Bi-directional Primary Care/MH/SU Services Many individuals served in specialty MH/SU have no PCP Health evaluation and linkage to healthcare can improve MH/SU status On-site services are stronger than referral to services Housing First settings can wrap-around MH, SU and primary care by mobile teams Person-centered healthcare homes can be developed through partnerships between MH/SU providers and primary care providers Care management is a part of MH/SU specialty treatment and the healthcare home

35. The Person-Centered Healthcare Home : Partnership Assure regular screening and registry tracking/outcome measurement for all MH /SU consumers Locate medical NPs/PCPs in MH/SU settings—provide routine primary care services in the MH/SU setting via staff out-stationed under the auspices of a full scope person-centered healthcare home MH/SU organization hiring a nurse practitioner directly, without the backup of a skilled PCP and a full scope healthcare home cannot be described as providing a healthcare home, and is not a recommended pathway Identify a primary care supervising physician within the full scope healthcare home to provide consultation on complex health issues Assign nurse care managers to support individuals with elevated levels of glucose, lipids, blood pressure, and/or chronic medical conditions Use evidence-based preventive care practices, adapting these practices for use in the MH/SU system (immunizations, cancer screening, etc.) Create wellness programs that use peer counselors

36. California: The Primary Care, Mental Health, and Substance Use Services Integration Policy Initiative (IPI) Vision:Overall health and wellness is embraced as a shared community responsibility To achieve individual and population health and wellness (physical, mental, social/emotional/ developmental and spiritual health), healthcare services for the whole person (physical, mental and substance use healthcare) must be: seamlessly integrated planned for and provided through collaboration at every level of the healthcare system, as well as coordinated with the supportive capacities within each community 36

37. California: IPI Principles (Additional Handout) Ten principles introduce the expectation that planning and implementation ensure that: Each individual has a person-centered healthcare home, which provides mental health (MH) and substance use (SU) services in the primary care setting or primary care services in the MH/SU setting. Each community has established a Collaborative Care Mental Health/Substance Use Continuum (the IPI Continuum). The IPI Continuum is a framework for service development that identifies population need across MH/SU levels of risk/complexity/acuity and assigns provider responsibilities within any given community for delivering those services. The community dialogue to establish the Continuum should result in mechanisms for stepped MH/SU healthcare back and forth across the Continuum, mechanisms to address the range of physical health risk/complexity/acuity needs of the population, and collaborative links between the integrated healthcare system and other systems, community services and resources. Measurement is aligned to support the IPI Continuum, Quality Improvement and fidelity implementation of proven models as well as evaluation of emerging models, with accountability, transparency and measures matched to the levels of the Continuum. 37

38. California: IPI Continuum 38

39. California: CalMEND—Joint Project of DHCS and DMH • State agencies working together to use the Care Model and use the IHI Breakthrough Series Learning Collaborative model to make major rapid changes that produce significant breakthrough results and sustained use of these changes • Pilot Collaborative will bring together mental health and primary care practitioners: Orange County, San Diego County, San Mateo County and Santa Clara County • CalMEND Primary Care and Mental Health Integration Change Package developed over the last year includes change concepts that operationalize the Care Model and integrated care • Health Care Organization • Delivery System Design • Decision Support • Clinical Information system • Community

40. California: CalMEND—Joint Project of DHCS and DMH

41. Financing: Paradigms • How will funds in other systems be integrated to support clinical integration? • We need a new paradigm—none of the old models (Carve-in or Carve-out) work for implementing bidirectional integrated care for the whole population • Lessons from the “field”: • Medical Home Pilots— case rate in addition to FFS, to cover prevention, care management of chronic medical conditions (why not build the BHC in PC role into the case rate?) • MN—financing the DIAMOND case rate (for BH in PC) out of the healthcare side (rather than the mental health side) believing that cost and quality improvements will be there • WA General Assistance project—explicit stepped care model that finances both Level 1 (primary care) and Level 2 (specialty) MH/SU benefits; dedicated financing for Levels 1 and 2; neither draw on dedicated mental health funding • Washtenaw Co, MI—global budget for Medicaid population; local consolidation of medical and behavioral health funding streams

42. Financing: Paradigms For example, the SPD plans should have a MH/SU benefit for primary care-based brief services Assuming that parity will be embedded as a requirement for most health plans in the final healthcare reform legislation and a broader behavioral health benefit will be available for most people with coverage, and … Drawing on the California Integration Policy Initiative framework of Mild, Moderate, Serious and Severe Levels of Care, and … 42

43. Financing: SPD Plans • Ensure that the MH/SU community and consumers know about the consumer protections proposed in the California Healthcare Foundation 2005 report: Performance Standards for Medi-Cal Managed Care Organizations Serving People with Disabilities and Chronic Conditions http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSPDs.aspx • Consider overall recommendations for SPD Plans • Capitation rates that cover adequate (e.g., Medicare) reimbursement rates for primary care FFS • Capitation rates that include funding for a PMPM case rate payment to medical homes for care management activities • Capitation rates that include funding for a PMPM case rate for brief MH/SU services provided in primary care (e.g., behavioral health consultant/care manager and consulting psychiatrist )

44. Part Two

45. Financing: SPD Plans Ensure that the MH/SU community and consumers know about the consumer protections proposed in the California Healthcare Foundation 2005 report: Performance Standards for Medi-Cal Managed Care Organizations Serving People with Disabilities and Chronic Conditions http://www.dhcs.ca.gov/provgovpart/Pages/TechnicalWorkgroupSPDs.aspx Consider overall recommendations for SPD Plans Capitation rates that cover adequate (e.g., Medicare) reimbursement rates for primary care FFS Capitation rates that include funding for a PMPM case rate payment to medical homes for care management activities Capitation rates that include funding for a PMPM case rate for brief MH/SU services provided in primary care (e.g., behavioral health consultant/care manager and consulting psychiatrist )

46. Financing: Paradigms For example, the SPD plans should have a MH/SU benefit for primary care-based brief services Assuming that parity will be embedded as a requirement for most health plans in the final healthcare reform legislation and a broader behavioral health benefit will be available for most people with coverage, and … Drawing on the California Integration Policy Initiative framework of Mild, Moderate, Serious and Severe Levels of Care, and … 46

47. IMPACT Lowers Total Health Care Costs $ / year Grypma, et al; General Hospital Psychiatry, 2006

48. Washington State Studies of SU and Healthcare Costs • Medicaid medical expenses prior to specialty SU treatment and over a five-year follow up were compared to Medicaid expenses for the untreated population. • For the Supplemental Security Income (SSI) population, Washington studied the Medicaid cost differences for those who received treatment and those who did not. • Average monthly medical costs were $414 per month higher for those not receiving treatment, and with the cost of the treatment added in, there was still a net cost offset of $252 per month or $3,024 per year. • The net cost offset rose to $363 per month for those who completed treatment. • Providing treatment for stimulant (methamphetamine) addiction resulted in higher net cost savings ($296 per month) than treatment for other substances. For SSI recipients with opiate-addiction, cost offsets rose to $899 per month for those who remain in methadone treatment for at least one year. • In the SSI population, average monthly Emergency Department (ED) costs were lower for those treated—the number of visits per year was 19% lower and the average cost per visit was 29% lower, almost offsetting the average monthly cost of treatment. • For frequent ED users (12 or more visits/year) there was a 17% reduction in average visits for those who entered, but didn’t complete SU treatment and a 48% reduction for those who did complete treatment.

49. Kaiser Permanente Northern California Studies • The setting was an internally operated outpatient and day treatment SU program in which primary care was added • Kaiser tracked a subgroup of patients with Substance Abuse-Related Medical Conditions (SAMCs) which included: depression, injury and poisonings/overdoses, anxiety and nervous disorders, hypertension, asthma, psychoses, acid-peptic disorders, ischemic heart disease, pneumonia, chronic obstructive pulmonary disease, cirrhosis, hepatitis C, disease of the pancreas, alcoholic gastritis, toxic effects of alcohol, alcoholic neuropathy, alcoholic cardiomyopathy, excess blood alcohol level, and prenatal alcohol and drug dependence • Many of these are among the most costly conditions to the health plan • Focusing on the SAMC subgroup, they found that SAMC integrated care patients had significantly higher abstinence rates than SAMC independent care patients • SAMC integrated care patients demonstrated a significant decrease in inpatient rates while average medical costs (excluding addiction treatment) decreased from $470.39 PMPM to $226.86 PMPM.

50. Align with 1115 Concept Paper Population Focus Key Objectives Bring the majority of Duals and ABD(SPD) now in FFS into Managed Care Bring the CCS Youth into Managed Care Bring the Rest of TANF into Managed Care Expand the Medi-Cal “box” by bringing more Indigent/ Uninsured into Managed Care Note: Most of the costs are in the FFS Dual & FFS ABD boxes 50