Primary-Behavioral Health Integration: Successes, Barriers and Solutions

1. Primary-Behavioral Health Integration: Successes, Barriers and Solutions Jerry Lowell LCSW Senior Vice President Behavioral Health and Community Services Aunt Martha’s Youth Services

2. Increasing Access to Vital Services Providing BH in 10 of 17 clinics, Aunt Martha’s remains true to its founding vision to respond to the needs of youth, families and communities by providing access to integrated primary-behavioral health services.

3. Aunt Martha’s Office & Health Center Locations

4. Depression diagnosis rates at Aunt Martha’s Health Centers (2009-2010)

5. Access to Care • Growth Trend 2005 – 2009 • 834% increase in users • 509 users to 5.520 users • 740% increase in encounters • 3,107 encounters to 31,474 encounters • 300% increase in Behavioral Health • service users as % of total users • at Aunt Martha’s: 2% to 8%

7. Cost Effective, Integrated Services • We are one of the largest provider of behavioral health services among Illinois’ FQHCs. • We are also the lead agency in the State’s first telepsychiatry network

8. Our Behavioral Health Providers • 11 Psychiatrists • 2 Child & Adolescent only • 2 Adult only • 6 Child & Adolescent and Adult • 5 Licensed Clinicians (LCSW, LCPC)

9. Our Support Staff • Operations Manager • Oversight of psych operations • Coordination with health clinic • Supervise Care Managers • Handle patient complaints • Interface with community • 10 Care Managers

10. Aunt Martha’s-CMHC Collaborations • Co-location of CMHC therapist • Provides “warm hand-off” access • Encourages cross referral • Patients integrated into Primary Care • Staffing and billing done separately • Establishes relationship for further collaborations

11. Tele-psychiatry-CMHCs • Grant from DMH supports connection to 6 downstate CMHCs • Can now bill Medicaid at encounter rate • Reimbursement rules require at least an MHP to be with patient at local site during session • One-time initial equipment cost, but telecommunication line costs are high

12. Tele-psychiatry NetworkEliminating Barriers to Care

13. Business Model Basics • Costs have to be considered as part of whole system Service Specialty Reimbursement Rate: • Psychiatric, Medical, OB/GYN$123.91 • Therapy (LCSW, LCPC)$49.60 • Psychiatry has to be productive, no administrative time

14. Medical and Business Operations which includes: 3 Regional Administrators responsible for the fiscal and regional management of clinics Clinic Coordinators report to the Regional Administrator and are responsible for administrative oversight all staff Subspecialty Operations including OB, Behavioral Health and Dental- comprised of 3 Operations Managers responsible for the fiscal compliance and management of the care management model for all three service areas. Social Services – all supplemental services that assist patients/clients. Operational Supports including marketing, compliance assistance, data management, medical records and training.

16. Source: National Association of Community Health Center, June 2010

17. Business Model Basics • Operations based on staffing ratio of 2 Care Managers to 1 Psych provider • Administrative overhead has to be lean • Integration with primary and dental increases Medicaid revenue • Psychiatrists are high cost driver, so operations and productivity have to lower the cost per visit

18. Financial Integration: Costs and Benefits • Costs and benefits to the system as a whole are identified • Productivity expectations are established • Proportionate overhead costs are part of Behavioral Health budget

19. Financial Integration: Costs and Benefits • Cross referrals synergize both clinical and economic outcomes • Behavioral Health administration is part of overall operations management • Outreach and marketing can call attention to the integrated services concept

20. Limitations • Ideal continuum for FQHC BH is less seriously mentally ill patients • Who already access the FQHC for medical care Even though • We already see well over 100 with a diagnosis of schizophrenia

21. Financial Limitations • 330 Funding provides limited funding for uninsured • FQHCs cannot be the primary provider of BH services to the Seriously Mentally Ill

22. Bi-Directional Integration Great potential, but… • Needs to be funded • FQHCs need Change of Scope to provide primary care in CMHC • Practice has to recognize that regular productivity is less

23. Summary • FQHCs can be a model for the integration of primary and behavioral healthcare • Successful implementation requires effective systems and management • BH should be integrated into all areas of clinic functioning • FQHC-CMHC collaboration is promising but should not be viewed as an alternative to CMHCs for Seriously Mentally Ill