Integrated Behavioral Health & Primary Care National/State/Local Development

1. Integrated Behavioral Health & Primary CareNational/State/Local Development FADAA/FCCMH Annual Conference Mark A. Engelhardt, MS, MSW, ACSW USF – FMHI – Dept. of Mental Health Law & Policy August 7, 2013 – Orlando, Fl.

2. The Case for Integrated Care • People with mental health and substance abuse disorders die years earlier that the average person, mostly from untreated and preventable chronic illnesses like hypertension, diabetes, obesity and cardiovascular disease. • Poor health habits, such as inadequate physical activity, nutrition, smoking and substance abuse • Barriers to primary healthcare & complex systems • Solution – Integrated behavioral (SAMH) and primary healthcare produces better outcomes for people with complex needs involved in multiple systems of care. • Quality of Integrated Care & Cost to Person/System

3. Organizational Support (2003-13) • World Health Organization • Substance Abuse and Mental Health Service Administration (SAMHSA) • Health Resources Services Administration (HRSA) • National Council for Behavioral Healthcare – Community Mental Health Centers and Integrated Substance Abuse Providers • Community Health Centers – Federally Qualified Health Centers (FQHC’s) • Health & Behavioral Healthcare Advocates

4. Four Quadrant Model • Population Based (NCCBH) • Population with low to moderate risk/complexity for both behavioral and physical health issues • High Behavioral health risk/complexity and low to moderate physical health risk/complexity • Low to moderate behavioral health risk/complexity and high physical health risk/complexity • High risk and complexity I for both behavioral and physical health ( SAMHSA – HRSA Grant focus)

5. Integration Models (A Few) • Primary Care in Behavioral Health Settings; Behavioral Health in Primary Care Settings or Bi-Directional • Patient-Centered Health Homes (Approach, Not a Physical setting) – Integrated Treatment Planning • Chronic Care – Disease Management Models • Improving Mood – Promoting Access to Collaborative Treatment – IMPACT – Early Evidenced-based • Cherokee Health Systems – Fully Integrated (Tenn.) • Range: Coordinated – Co-Located – Integrated

6. SAMHSA – HRSA Solutions • Target = People with Serious Mental Illnesses • 94 Current SAMHSA-HRSA Primary Behavioral Health Care Integration grants • Center for Integrated Health Solutions – National Technical Assistance • http://www.integration.samhsa.gov • Supplemental Health Information Technology (HIT) One Year Grants to supports the development of Electronic Health Records (HER) with grantees • New PBHCI Grant applications to be awarded in 2014?

7. Southeast Learning Community • Seven (7) Florida Grantees • Apalachee Center – Tallahassee • Coastal Behavioral Healthcare – Sarasota • Lakeside Behavioral Healthcare – Orlando • Lifestream Behavioral Healthcare – Leesburg • Henderson BH (V) • Miami Behavioral Health Center – Miami • Community Rehabilitation Center – Jacksonville • 7 Others in HHS Region • Georgia = 3 Community Service Boards • 4 = Kentucky (I); S.C. – State DMH; NC & TN (V) • Cohorts I – V (2009-12)

8. National Outcome Measures • Functioning – WellnessHealthy Overall • Functioning in Everyday Life • No Serious psychological distress - • Using Illegal Substances • Notbinge drinking • Retained in the community • Housing Stability • Education and Employment • Criminal Justice Involvement • Perception of Care • Social Connectedness • Approximately 16,000 people served (To date) • Positive outcomes overall

9. At Risk Criteria & Tracking • Blood Pressure (130/85) • Body Mass Index (Greater of equal to 25) • Waist Circumference (Male – 102cm; Female 88 cm) • Breath CO – ( Greater than or equal to 10) • Fasting Plasma Glucose ( Greater than 100) • Cholesterol (HDL less than 40; LDL, Greater than or equal to 130; Triglycerides, Greater than or equal to 150 • The big one = SMOKING

10. Grantee Evaluation: Rand Corp. • 56 Grantees included in the National Evaluation • 67% Partnered with FQHC’s • Over 16,000 served since 10/1/09 • Outcome (Data), Process and Model Evaluation • 78% of Grantees are urban programs in 26 states • Use of Evidenced-based practices • Challenges - Data, recruiting staff and consumers, licensing, info-sharing • 1% arrested in past 30 days; 63% in stable housing

11. Rand Corporation Report • Early Programs – SAMH in Health Care Settings • Now Primary Care in SAMH Settings • Common Features: • Embedded Nurse, On-site Physician, Health Screenings, Illness Management & Recovery (18 Programs; Wellness Recovery Action Plans (19); Screening – Brief Intervention- & Referral to Tx (SBRIT); Peer Specialists (18); Case management • Diverse Models – Clinic Based to Home visits

12. Levels of Integrated Healthcare • Coordinated = Key element = Communication: usually minimal to basic coordination • Co-located = Key = Physical Proximity: usually basic to close collaboration on-site • Integrated = Key = Practices Change: usually close collaboration to a fully transformed/merged integrated practices – Clients experience a seamless response to all of their health and behavioral healthcare needs • Heath, Wise & Reynolds March 2013 (CIHS)

13. Workforce Issues • Peer Support Specialists • Shared Decision Making – Person Driven • Nursing – Physicians Assistants • Access to Psychiatry; Outpatient SAMH Treatment • Training – On-line, Certificate Programs (UMASS); Numerous Webinars; Cross-training among disciplines, attitudinal changes; case and care management models; Recovery-oriented care • Recruitment and retention (Future Medicaid Expansion and Affordable Care Act) • Cultural proficiency

14. Clinical Considerations • Screening Tools ( I.E. SBIRT – Screening, Brief Intervention & Referral to Treatment) • Health Indicators ( Substance use, tobacco, blood pressure, cholesterol, weight, nutrition, etc.) • Motivational Interviewing • Medication Assisted Treatment – Pharmacology • Pain Management (Agency Policies) • Trauma Informed Care • Targeted Populations

15. PBHCI Programs • Million Heart Campaign – National HHS campaign to prevent 1 Million heart attacks & strokes in 5 years • Wellness programs = Strategies – Education, healthy eating, physical activity, stress management, recovery processes, peer support, diabetes management, etc. • Tobacco cessation (I.E., Univ. of Colorado) • Substance abuse prevention/relapse • Targeted populations = homeless, drop-in centers, “housing is healthcare”, in-vivo. • Interns , students, volunteers, existing programs

16. Administration & Operations • Memorandum of Understanding with partners (I.E. FQHC’s) – Array of services ; who will provide what? • Contracts and formal agreements: Partners • Clarify Billing Opportunities and Revenue Sources – Grants, Medicaid, Medicare, Physical Health & Behavioral Healthcare – Now & Future (Affordable Healthcare Act – Prospective) • Health Information Technology – Electronic Health Records – Confidentiality & Integration • Meaningful Use & Data Analysis

17. COMPASS PH/BH (Cline, Minkoff) • Self-assessment Tool • Program Philosophy • Administrative Policies • Quality Improvement & Data • Access to Care • Screening & Identification • Integrated Assessment • Integrated Treatment Program & Relationships • Welcoming Policies • Medication Management • Integrated Discharge & Transition Planning • Program Collaboration & Partnerships • Staff Competencies

18. Pilot Tool Kit: MTM & Zia Partners • Executive Walk through from a consumer perspective • Admin. Readiness • Self-assessment -Program Organizational Level PBHCI Capability • Strategic Partnership Inventory • Structured Prioritization Template • Guidance on design Performance Plans with Indicators • Project Planning and Organizational Templates • References for Specific Materials (I.E. Tools)

19. Homeless Integrated Care Examples • SAMHSA - PBHCI Grantee – Seattle, WA. – Downtown Emergency Services Center (DESC) • Housing First Model Development – Pathways to Housing – PA – Primary Care Partnership with Thomas Jefferson University Dept. of Family & Community Medicine – Philadelphia Dept. of Behavioral Health & Office of Supportive Housing • U.S. Dept. of Veterans Affairs – Homeless Veterans Patient Aligned Care Teams (H-PACT) – Homeless Medical Home – 23 Pilots: 37 sites funded in 2012/13

20. Contact Information • mengelhardt@usf.edu • 813-974-0769 (Direct Line) • USF – Florida Mental Health Institute (FMHI) – Department of Mental Health, Law & Policy • http://mhlp.fmhi.usf.edu • www.floridatac.org Thank You