Paving the Way for Behavioral Health and Primary Care Integration Angela Herman, MPA, CPHQ

1. Paving the Way for Behavioral Health and Primary Care Integration Angela Herman, MPA, CPHQ Missouri Primary Care Association April 10, 2012

2. Movement Towards Integration • Missouri Medicaid Reform Commission (1/05) • Acknowledged reform must take place in the context of system transformation • Two state Associations hosted joint meeting of CHCs and CMHCs to explore interest in primary care and behavioral health integration (6/06) • State Associations advocate for integration funding (2007 Legislative Session) • General Assembly appropriates Integration funding (7/07)

3. Missouri’s Integration Initiative • Improving Access • To primary care for people with serious mental illness • To behavioral health services for people with previously unrecognized and/or untreated mental health problems • To behavioral health supports for people who require assistance in effectively managing their chronic disease or improving health status • Improving Clinical Care • Seeing mental health as essential to overall health • Seeing and treating the whole person • Improving Collaboration Between Systems of Care

4. Missouri Primary Care Health Home Initiative State Plan Amendment • Section 2703 of the Affordable Care Act • Medicaid State Plan Amendment • Provide 6 defined Health Home Servicesfor: • Serious and persistent mental illness • Two qualifying chronic conditions • One qualifying chronic condition and at risk for a second qualifying chronic condition • State Defined Conditions • 90% federal match for two years • Missouri has two approved: Mental Health (Serious and Persistent Mental Illness) and Primary Care

5. Missouri Qualifying Conditions for Primary Care • Combination of Two • Diabetes (CMS approved to stand alone as one chronic disease and risk for second) • Heart Disease, including hypertension, dyslipidemia, and CHF • Asthma • BMI above 25 (overweight and obesity) • Tobacco Use • Developmental Disabilities

6. Partners in Planning • Department of Social Services (DSS) • Department of Mental Health (DMH) • MO Foundation for Health (MFH) • MO Primary Care Association (MPCA) • MO Coalition of Community Mental Health Centers (CMHCs) • Consultants: Michael Bailit & Alicia Smith • Missouri Hospital Association (MHA) • Missouri School Board Association (MSBA)

7. Participating Primary Care Sites • Provider Requirements • At Least 25% Medicaid/Uninsured • Using EMR for six months or longer • Plans to apply for NCQA Patient Centered Medical Home Recognition within 18 months • Organizations Selected to Participate • 18 FQHCs operating 67 clinic sites • 6 Hospitals operating 22 clinic sites • One Independent Rural Health Clinic

8. Goals of the Primary Care Health Home Initiative • Reduce inpatient hospitalization, readmissions and inappropriate Emergency Room visits • Improve coordination and transitions of care • Implement and evaluate the Health Home model as a way to achieve accessible, high quality primary health care and behavioral health care; • Demonstrate cost-effectiveness in order to justify and support the sustainability and spread of the model; and • Support primary care and behavioral care practice sites by increasing available resources and improving care coordination to result in improved quality of clinician work life and patient outcomes.

9. Performance Goals and Measures • Improve primary health care • Improve behavioral health care • Improve patient empowerment and activation • Improve coordination of care • Improve preventive care • Improve diabetes care • Improve asthma care • Improve cardiovascular care

10. Six CMS-Defined Health Home Services • Comprehensive care management • Care coordination • Health promotion • Comprehensive transitional care including follow-up from inpatient and other settings • Patient and family support • Referral to community and support services

11. Health Home Director Nurse Care Manager Behavioral Health Consultant Care Coordinator Health Home Team Members

12. Payment Method • $58.47 per member per month (PMPM) for performing Health Home services and activities • Providers required to pay a $3.47 PMPM for administrative costs associated with data management, training, technical and administrative support • Future amendment to current state plan for provider incentive payments based on shared savings and distributed according to performance on quality and cost measures. • NOT offset on FQHC cost report

13. Behavioral Health Consultant • Must be Licensed Clinical Psychologist or Licensed Clinical Social Worker • Ratio of 1:750 Patients in the State Plan Amendment and $7.78 of the PMPM supports the BHC • Integration with Primary Care • Support to Primary Care physician/teams in identifying and behaviorally intervening with patients who could benefit from behavioral intervention. • Part of front line interventions with first looking to manage behavioral health needs within the primary care practice. • Focus on managing a population of patients versus specialty care

14. Behavioral Health ConsultantContinued • screening/evaluation of individuals for mental health and substance abuse disorders • brief interventions for individuals with behavioral health problems • behavioral supports to assist individuals in improving health status and managing chronic illnesses • The behavioral health consultant both meets regularly with the primary care team to plan care and discuss cases, and exchanges appropriate information with team members in an informal “curbside “ manner as part of the daily routine of the clinic

15. Behavioral Health ConsultantContinued • Interventions • Identification of the problem behavior, discuss impact, decide what to change • Specific and goal directed interventions • Use monitoring forms • Use behavioral health “prescription” • Multiple interventions simultaneously

16. Integration of Substance Use Prevention Activities in Primary Care • SAMHSA Grant awarded to the MO Department of Mental Health, Missouri Screening, Brief Intervention, Referral, and Treatment (MOSBIRT) • Grant is administered by Missouri Institute of Mental Health on behalf of MO Department of Mental Health • Grant is designed to reduce risky alcohol and other drug use to reduce medical costs by reducing problem substance use in primary care. • Organizations participating in the Missouri Primary Care Health Home Initiative will receive $30,000 in one-time funding to cover the costs associated with start-up for the implementation of MOSBIRT.

17. Benefits of Participation in MOSBIRT • Assists in meeting five of the required performance measures for the Primary Care Health Home Initiative • Substance abuse screening utilizing a standardized tool • Reduce proportion of adults reporting use of illicit drugs • Reduce proportion of adults who drank excessively • Tobacco use assessment and cessation advice/treatment • Depression screening utilizing a standardized tool

18. Benefits of Participation in MOSBIRT Continued • $30,000 in additional funding to support substance use prevention efforts in primary care • Access to training and technical assistance for your behavioral health consultant • Opportunity to develop and/or enhance the relationship with your local alcohol and drug treatment providers • MIMH in collaboration with DMH Division of Alcohol and Drug will be providing a model MOU to help facilitate referral relationships.

19. Training and Technical Assistance • Contractors: • St. Louis Behavioral Medicine Institute • Missouri Institute of Mental Health • Format of Training and Technical Assistance • Centralized and regional Face to Face • Webinars • Site Visits • Telephone consultation • Statewide Learning Collaborative Learning Sessions

20. Tools and Resources • MO HealthNet Division, Primary Care Health Home Information http://dss.mo.gov/mhd/cs/health-homes/ • Missouri Health Home State Plan Amendment Information http://dmh.mo.gov/about/chiefclinicalofficer/healthcarehome.htm • National Committee for Quality Assurance: www.ncqa.org/tabid/631/Default.aspx • Commonwealth Fund: Safety Net Medical Home Initiative www.qhmedicalhome.org/safety-net/change-concepts.cfm • Improving Chronic Illness Care: www.improvingchroniccare.org/index.php?p=Patient-Centered_Medical_Home&s=224 • The Joint Commission: http://www.jointcommission.org/accreditation/pchi.aspx • Patient-Centered Primary Care Collaborative: www.pcpcc.net/content/patient-centered-medical-home • American College of Physicians: www.acponline.org/running_practice/pcmh/

21. Contact Information • Angela Herman- aherman@mo-pca.org • Susan Wilson- swilson@mo-pca.org Missouri Primary Care Association 3325 Emerald Lane Jefferson City, MO 65109-6879 (573) 636-4222 www.mo-pca.org