Integration Models in Action: An Overview

1. Integration Models in Action: An Overview Integration of Physical & Behavioral Health Education Summit September 26, 2007 Barbara Coulter Edwards, Principal

2. The Case for Integration • Co-morbidity • Cancer, heart and cardiovascular diseases, diabetes, HIV/AIDS • Cost • Health care costs for people with alcohol problems are twice those without alcohol problems; MI/SUD account for up to 70% of all primary care visits • Crisis • People with serious mental illness have a life expectancy 25 years shorter than the general population

3. Integration in the Field • RWJF: Integrating Publicly Funded Physical and Behavioral Health Services Feb ’07 • Goal - Identify current practice • Describes 13 sites/models of integration across the country • Report on-line at RWJF or www.healthmanagement.com/news_details.asp?nid=122

4. What We Found • Diversity: programs were designed to solve specific local or statewide issues • Commonality: successful efforts focused on communication, screening, case management, and patient level information sharing • Sustainability: clinical success not enough!

5. Diversity • FQHC/primary care clinic focus • Community Care of North Carolina (Medicaid PCCM ): BH providers located in primary care facilities; adults & adolescents; based on Wagner chronic care model and NCCBH 4 quadrant integration model. • Community Health Center, Inc. CN: 4 sites provide co-located PC and BH for seamless service delivery; interdisciplinary team meets daily to plan service delivery

6. Diversity • Pediatric practices • Cleveland Coalition for Pediatric MH:a web-based resource guide available to 400 pediatricians; pilot testing Child Health and Development Interaction System in 3 pediatric practices to improve access to MH care • NH Center for Adolescent Health: general adolescent clinic provides bio-psychosocial health services through multidisciplinary/collaborative approach; evidence-based SA treatment services

7. Diversity • Managed Care Organizations: • Kaiser Permanente S.CA Depression Care:IMPACT collaborative stepped care model (Unutzer/U Wash). Adults with chronic disease; depression care manager works with patient & PCP; psychiatric supervision by phone; trained Kaiser staff at 12 regional med centers; PHQ-9 scores to monitor • ColoradoAccess:screened Medicaid adults targeted for physical care CM for depression (PHQ-9); care management team works with members, providers to support guideline concordant depression t’mt within PCPs

8. Diversity • CMHC focus: • Vermont Medical Home Project: Medicaid-sponsored pilot; adults w/ SMI & diabetes; primary care RN on site at CMHC; trained clinic staff and worked with patients; worked with FQHC for referrals • Horizon Health Services, NY: state-certified SUD/MH provider added medical services onsite at several locations to facilitate integration • Massachusetts BH/PC Integration Projects: State-sponsored demonstration at 6 MaBH Partnership sites; CMHCs & FQHCs partnership; EBP and integration in both settings

9. Diversity • Community efforts: • Rebuilding Lives PACT Team Initiative OH: county-wide collaboration of BH, PC, housing and others focused on homeless adults with moderate to severe MI/SUD • Washtenaw Community Health Org: collaborative effort by UM Dept Psychiatry, Washtenaw County, county MH center & local private health clinics developed service organization to administer PC, MH, SA and DD services and create best practices in caredelivery for Medicaid, Medicare, indigent; has implemented 5 integrated clinics

11. What We Found • Goals also varied: increase referrals, create linkages, improve outcomes, use EBPs • Why the focus on treatment within primary care system? • - it’s where the people are! (unaddressed need) • - inadequate capacity within BH specialty system

12. What We Found • Most of the integration models were strongly influenced by formal clinical and organizational models for integration or chronic care management • All reported modifying or adding to formal models to address local needs/realities

13. What We Found • Collaboration models: • directly engage providers in both systems to work together regarding individual patients, as well as using tools of screening, case management, consumer self-management, etc. • Coordination models: • focus on case management to assure consumer access to full range of needed services; facilitate communication across PC and BH systems; and promote consumer engagement

14. What We Found • Common Elements: • Screening tools (all) • Case Management (most) • Co-location (most) • IT support (simple to complex!) • Integrated funding (some) • EBPs (a lot of interest, varied definition)

15. What We Learned • Integration works! • More than one approach found success in terms of outcomes • Simple as well as complex models had an impact • Success was seen in improved access, improved outcomes/reduced symptoms, and cost savings (especially for physical health care)

16. What We Learned • Primary care settings found previously undiagnosed mild/moderate and serious MI when screening • Mental health settings found people who were physically much sicker than clinic staff had understood

17. What We Learned • Co-location is useful, • - but not required (and likely not practical outside of clinic delivery models) • - and not enough! (commitment to communication at the patient level was required or even co-location did not improve outcomes!)

18. What We Learned • Barriers are varied: • separate funding streams, payment barriers • start up costs • system organization (who’s responsible for the “whole person”?) • cultural (in both systems, resistance to integration) • knowledge (training critically important!) • system capacity

19. What We Learned • Sustainability: • The integration model was sustainable IF the entity making “the investment” also realized “the benefit” in terms of savings!

20. Policy Implications • The Business Case for Integration • - needs to identify existing resources to support the effort (service revenues) or • - identify how the payer (new resources) achieves a return on the investment

21. Policy Implications • Planning should involve the payers up front • most sites needed start-up funds (grants most common source) • - new staff • - IT support (simple to complex) • - training, training, training • reimbursement for services, CM • evaluation funding

22. Policy Implications • Broader systems perspective may be useful • Who are the stakeholders and potential beneficiaries of improved integration? • (law enforcement, social services, employers, physicians, families, consumers, taxpayers) • Clarity – about populations, challenges to be addressed – don’t assume everyone views the problem from the same perspective

23. Integrated Service Opportunities – View #1 Total ODMH Consumers = 302,350 ODMH Non-Medicaid Consumers = 70,267 CFC = 112,054 Other = 78,666 ABD = 41,363 • Duals • Spend Down • Foster Care Rx = $225 Million (Bx) Rx = $256 Million (Other) ODMH Medicaid Consumers = 232,083 = Bx thru CMHC = Px/Bx/Rx thru MCO = Px/Bx/Rx thru FFS = Psych Rx thru ODMH = Px thru ???

24. Integrated Service Opportunities – View #2 ODMH Medicaid Consumers = 232,083 • Clinic • Physician • Psychologist Diagnosed/Treated for Bx through FFS Medicaid providers • Inpatient • ER Undiagnosed but treated due to injury/illness • Postpartum moms • General depression • Self-medicating Undiagnosed (Walked Worried) Total Ohio Medicaid Eligibles = 1.8 Million; 70% in managed care organizations

25. Policy Implications • Addressing barriers • Regulatory barriers? (licensure/cert) • Reimbursement barriers? (billing codes) • Confidentiality • Cultural • Organizational • Capacity • Remove them or at least acknowledge them so you can look for “work-arounds”

26. Your turn… • Questions? • Comments?