BHACA Initiative: Advancing Integrated Healthcare Practice and Policy

1. Session A5b October 17, 2015 The Greater Houston Behavioral Health Affordable Care Act Initiative: Leveraging Collective Impact to Advance Integrated Health Care Practice and Policy Shannon Evans, MBA, LSSGB, Manager, Health System Strategy Operations, Harris Health System Alejandra Posada, MEd, Director of Education and Training, Mental Health America of Greater Houston Elizabeth Reed, LMSW, Project Manager, BHACA Initiative, Network of Behavioral Health Providers Collaborative Family Healthcare Association 17thAnnual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Identify at least four ways in which a collaborative, such as the BHACA Initiative, can leverage collective impact to advance integrated health care policy and practice. • Describe how the Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration can be utilized by a group of organizations to support the advancement of IHC within each organization and collectively. • List three characteristics of the level of integrated health care across a large metropolitan area (greater Houston) and describe how survey results can inform collaborative action.

4. Bibliography / Reference Brown Levey, S.M., Miller, B.F., and deGruy III, F.V. (2012). Behavioral health integration: an essential element of population-based healthcare redesign. Translational Behavioral Medicine. Published online July 26, 2012. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3717906/ Grantmakers for Effective Organizations and Research Center for Leadership in Action (NYU Wagner). (2012). Learn and Let Learn: Supporting Learning Communities for Innovation and Impact. Available at http://www.geofunders.org/resource-library/all/record/a066000000AhjF4AAJ Heath, B., Wise Romero, P., and Reynolds, K. (2013). A Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. Available at http://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdfReference Lopez, M. A. and Stevens-Manser, S. (2014). Texas 1115 Medicaid Demonstration Waiver: A Review of Behavioral Health Projects. Texas Institute for Excellence in Mental Health, School of Social Work, University of Texas at Austin. Available at http://sites.utexas.edu/mental-health-institute/files/2012/10/1115-Waiver-BH-Projects-Report-Final.pdf SAMHSA-HRSA Center for Integrated Health Solutions. (2014). Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration. Available at http://www.integration.samhsa.gov/operations-administration/OATI_Overview_FINAL.pdf

5. The Greater Houston Behavioral Health Affordable Care Act Initiative (BHACA) Collaboration of the Network of Behavioral Health Providers (NBHP) and Mental Health America of Greater Houston (MHA) Goal: To assist greater Houston area mental health and substance use providers in responding to the Patient Protection and Affordable Care Act and other recent healthcare reforms across four domains: (1) enhancing and increasing the delivery of integrated health care (IHC), (2) maximizingthird party funding streams revenue, (3) adopting certified electronic health records (EHRs), and (4) developing outcome-based evaluations.

6. NBHP Member Agencies NBHP was founded in 2004 to be a roundtable for the CEOs and Executive Directors of Greater Houston’s behavioral health providers. Currently there are 34 behavioral health provider agencies in NBHP. A list of NBHP’s members can be found online at www.nbhp.org/member-organizations.html.

7. NBHP Membership 2015 - 2016

8. Integrated Health Care Component of BHACA • Assessment of current status of community provider level of integration

9. IHC Component of BHACA • Assessment • Provider education about what integrated health care is

10. IHC Component of BHACA • Assessment • Provider education • Engagement of potential primary care/physical health partners invested in serving a similar population, such as federally qualified health centers (FQHCs) and charity clinics

11. IHC Component of BHACA • Assessment • Provider education • Engagement of primary care • Engagement of key community partners in outreaching to a diverse and large audience (Harris County Healthcare Alliance, the Southeast Texas Regional Healthcare Partnership (Medicaid 1115 Waiver) Learning Collaborative, and the Houston Recovery Initiative)

12. IHC Component of BHACA • Assessment • Provider education • Engagement of primary care • Engagement of community partners • Community-wide education events about models of integration, financing of integrated health care, evaluation of integrated health care, and clinical cross-trainings (across substance use services, mental health, and physical health disciplines) that simultaneously promote provider networking

13. IHC Component of BHACA • Assessment • Provider education • Engagement of primary care • Engagement of community partners • Community education • Continued assessment of and support for developing projects toward integration and assessment of potential new avenues to build on (such as existing referral relationships)

14. Collaborator Engagement

15. Healthcare Transformation and Quality Improvement Program (Medicaid 1115 Waiver)

16. About Us • 23 Community Health Centers • 5 School Based Clinics, Dental Center, Dialysis Center, Mobile health units • 3 Hospitals • Affiliations with Baylor College of Medicine and University of Texas Health Science Center • Performing Provider • Anchor

17. What is the Texas 1115 Waiver? • In December 2011, the Texas Health and Human Services Commission (HHSC) received federal approval of a five-year waiver that allows the state to expand Medicaid managed care while preserving hospital funding, provide incentive payments for health care improvements, and direct more funding to hospitals that serve large numbers of uninsured patients. • HHSC established geographic boundaries for new Regional Healthcare Partnerships (RHP). Each RHP developed a plan that identifies the participating partners, community needs, proposed projects and funding distribution. • RHP 3 includes the following counties: Austin, Calhoun, Chambers, Colorado, Fort Bend, Harris Matagorda, Waller and Wharton. • Each region is “anchored” by a public hospital or other governmental entity. Harris Health System is the anchor for RHP 3. • Through the 1115 Healthcare Transformation waiver, supplemental payment funding, managed care savings, and negotiated funding goes into two statewide pools worth $29 billion (all funds) over five years.  Funding from the pools is being distributed to hospitals and other providers to support the following objectives:  (1) an uncompensated care (UC) pool to reimburse for uncompensated care costs as reported in the annual waiver application/UC cost report; and (2) a Delivery System Reform Incentive Payment (DSRIP) pool to incentivize hospitals and other providers to transform their service delivery practices to improve quality, health status, patient experience, coordination, and cost-effectiveness. • Uncompensated Care Pool Payments are designed to help offset the costs of uncompensated care provided by the hospital or other providers. • DSRIP Pool Payments are incentive payments to hospitals and other providers that develop programs or strategies to enhance access to health care, increase the quality of care, the cost-effectiveness of care provided and the health of the patients and families served.

18. Regional Health Partnership 3 (RHP3) • RHP 3 Quick Facts: • 9 counties • 8,580 square miles • 4.8 million residents • 51% Anglo/31% Hispanic • 16.8% live below poverty line • 8% average unemployment • 26% without health coverage • $50,363 per capita income • Providers selected project areas from a menu called the RHP Planning Protocol • All proposed projects were reviewed and approved by HHSC and CMS. • Incentives are paid for achieving approved milestones and metrics. • 190 outcome measures were selected by RHP 3 providers. • Baselines were set in DY3. • DY4 incentives will be paid for reporting and performance. • DY5 incentives will be paid for performance only. • There are 26 providers with active DSRIP projects, including: • Hospitals • Local Mental Health Authorities • Academic Health Science Centers • Local Public Health Departments • Providers choose one ore more community needs. • RHP3 includes 25 community needs derived from over 40 community needs assessments throughout the Region Project Focus Provider County Community Need Outcome Measure 177 Projects worth approximately $1.8 billion in incentive payments

19. RHP 3 Local Mental Health Authorities (LMHAs)

20. RHP 3 Anchor • Role • Liaise between HHSC and the Region • Coordinate • Quality Improvement • Learning Collaborative

22. Region 3 Cohorts and Accomplishments

23. Texas 1115 Waiver Behavioral Health Projects

24. Cohort – Integration of Primary and Behavioral Health • AIMS • Assess the current state of integration at a project and regional level • Establish baseline for care within the region • Assess the desired state of integration • Reach desired levels of integration of project and regional integration • Assess changes in project and regional integration as a result of DSRIP projects

25. IHC

26. Cohort Participants *Also a member of the Network of Behavioral Health Providers

27. Assessing Integration – The Challenge of Tool Selection • Group wanted a tool that could help them measure their level of integration • Looked at several tools and their pros/cons: • Behavioral Health Integration Capacity Assessment Tool (BHICA) • Maine Health Access Foundation Site Self-Assessment Evaluation Tool • Custom-made tool • Joint Commission standards • Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration (OATI)

28. Organizational Assessment Toolkit for Primary and Behavioral Health Care Integration (OATI) • Created by the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) in collaboration with ZiaPartners, Inc. (Dr. Ken Minkoff) and MTM Associates (David Lloyd) • Versatile – Can be used by different kinds of organizations, using different integrated care models, and at different stages of their integrated care journey • Four main assessment tools: • The Partnership Checklist • The Executive Walkthrough • The Administrative Readiness Tool (ART) • The COMPASS – Primary Health and Behavioral Health

30. The COMPASS – PH/BH Tool • “… a continuous quality improvement tool for clinics and treatment programs…to organize themselves to develop core integrated capability to meet the needs of service populations with physical health and behavioral health issues” (SAMHSA-HRSA CIHS, 2014). • Fifteen sections; statements within each section each receive a rating on a five-point Likert scale ranging from “Not at all” to “Completely”

31. One Sample Question (of Sixty-Five): O.A.T.I. Tool 4—COMPASS Primary Health and Behavioral HealthTM From Section 4: Access (PCMH*) 10. Individuals and families receive welcoming access to appropriate care regardless of active issues in any area (e.g., infectious disease status, need for injections or oxygen, presence of physical disability, blood alcohol level, urine toxicology screen, length of sobriety, commitment to maintain sobriety, intellectual functioning, active mental health symptoms, type of psychiatric diagnosis, or type of prescribed psychiatric medications, such as antipsychotics, stimulants, benzodiazepines, or opiate maintenance). 1 2 3 4 5 Not at all Slightly Somewhat Mostly Completely

32. Our Experience with the COMPASS • Honing our use of the tool • Misguided attempt to link it directly to the CIHS 6-level spectrum • Input from Dr. Ken Minkoff • Enthusiasm regarding tool vs. time required to complete it • Four organizations have completed it to date • Others exposed to and have used parts of it (many exposed to it at December 2014 Learning Collaborative) • Time needed for planning and scheduling before actual completion of tool • Role of a “champion” within an organization • Structuring the process for maximal involvement with limited time/resources • Usefulness of tool • In planning phase • After implementation

33. OATI Data – Unit of Analysis • 3 of 4 organizations completing the COMPASS are large, multi-site organizations/ health systems • In completing the compass, organizations looked specifically at their IHC DSRIP-funded projects, which involved multiple clinic sitesbut NOT the organization’s entire system • 1 organization is a single-location “sobering center” working collaboratively with providers across the community

34. What does our OATI data indicate? Areas to celebrate! (areas of strength) • Program Mission & Vision • The program welcomes individuals with active physical, mental, and substance use conditions, and cognitive disabilities, without discrimination, in all admission areas and waiting areas. (Weighted average of 4.5 out of 5. Three organizations say they do this “completely (5),” and one says they do this “somewhat (3).”) • Program Administrative Policies • The program confidentiality or release of information policies and procedures are written topromote appropriate and routine sharing of necessary informationbetween collaborative mental health provider, substance abuse treatment providers, and medical providers. (Weighted average of 4.75 out of 5. Three organizations say they do this “completely (5),” and one says they do this “mostly (3).”) • Clinical record-keeping policies support integrated documentation(e.g., in assessments, treatment plans, and progress notes) of attention to mental health, physical health, cognitive disability, and substance use issues in a single medical/clinical record or chart. (Weighted average of 4.5 out of 5. Three organizations say they do this “completely (5),” and one says they do this “somewhat (3).”) • Screening & Identification • The program’s screening policy states that all individuals are to be screenedfor issues and immediate risk in a welcoming and respectful manner for mental health issues (including trauma), substance use issues, cognitive issues, physical health issues, and basic safety and social needs. (Weighted average of 4.5 out of 5. Two organizations say they do this “completely (5),” and two say they do this “mostly (4).”)

35. What does our OATI data indicate? Additional areas of strength Quality Improvement & Data: Using information systems to collect QI data that is used to advance IHC Weighted Avg.: “mostly” (3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5). Integrated Treatment/Recovery Programming: Providing patients/clients with education and assistance regarding decisions about prevention Weighted Avg.: “mostly” (3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5). Medication Management: • Providing access to medication assessment for any condition regardless of other conditions that may be present Weighted Avg.: “mostly” (4.25/5). One “somewhat” (3), one “mostly” (4), two “completely” (5). • Routinely monitoring common risks associated with all medications and their interactions Weighted Avg.: “mostly” (3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5). General Staff Competencies: Written plan for integrated competency development Weighted Avg.: “mostly” (3.5/5). Three “somewhat” (3), one “completely” (5). Specific Staff Competencies: • Cultural and linguistic competency Weighted Avg.: “mostly” (4.25/5). One “somewhat” (3), one “mostly” (4), two “completely” (5). • Competency in providing education to family members/caregivers Weighted Avg.: “mostly” (3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5). • Competency in providing age-appropriate services Weighted Avg.: “mostly” (3.75/5). One “not at all” (1), one “mostly” (4), two “completely” (5).

36. What does our OATI data indicate? Areas for Potential Quality Improvement Program Mission & Vision: Written program descriptions welcoming people with any health conditions Weighted Avg.: “somewhat” (2.75/5). Two “slightly” (2), one “somewhat” (3), one “mostly” (4). Integrated Assessment: • Strengths-focused: Identifying recent periods of strength or stability Weighted Avg.: “slightly” (2.25/5). Two “not at all” (1), one “somewhat” (3), one “mostly” (4). • Documenting stages of change Weighted Avg.: “slightly” (1.75/5). Three “not at all” (1), one “mostly” (4). Integrated Person-Centered Planning: Focusing on building whole health self-management skills and supports Weighted Avg.: “slightly” (2.25/5). Two “not at all” (1), one “somewhat” (3), one “mostly” (4). Integrated Treatment/Recovery Programming: Protocol to address psychological issues re: pain management Weighted Avg.: “slightly” (2/5). Two “not at all” (1), two “somewhat” (3). Medication Management: Procedures/materials to help patients/clients learn about medications and communicate with providers about them Weighted Avg.: “slightly” (1.75/5). Two “not at all” (1), one “slightly” (2), one “somewhat” (3). Program/Organizational Collaboration & Partnership: Providing and receiving consultation to/from collaborating organization(s) providing complementary services Weighted Avg.: “slightly” (2.25/5). Two “not at all” (1), one “somewhat” (3), one “mostly” (4). General Staff Competencies and Training: Integrated care competencies included in staff performance reviews Weighted Avg.: “somewhat” (2.5/5). Two “not at all” (1), one “somewhat” (3), one “completely” (5).

37. OATI as Starting Point for QI • Areas of strength – Learn from each other • Areas for potential improvement – Opportunities for collaborative QI • Example: Discrepancy b/n welcoming individuals with any health conditions (area of strength) vs. written program descriptions welcoming people with any health condition (area for improvement) Work on brochure creation/enhancement

38. Additional Data from BHACA Survey • Data collected February to March, 2015. • Twenty-five total “agency” respondents, representing these types of providers across the Greater Houston system: • Hospitals: 4 (Behavioral Health Freestanding Hospitals—2, Behavioral Health Hospital Departments/Embedded—2) • Primary Care & Mental Health Clinic: 2 • Federally Qualified Health Center: 2 • Mental Health Outpatient: 8 • Substance Use Service Provider: 6 (Multilevel, Licensed—3; Multilevel, Unlicensed—2; Outpatient, Licensed—1)

39. The Spectrum of Integrated Health Care: Source: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013. Available at http://www.integration.samhsa.gov/integrated-care-models/CIHS_Framework_Final_charts.pdf.

40. Adapted from: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

41. Adapted from: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

42. BHACA-Adapted Center for Integrated Health Solutions (CIHS) Levels of Collaboration/Integration Tool: Hospital (Freestanding & Departments/Embedded, Primary Care & Mental Health Clinics, FQHC)

43. BHACA-Adapted Center for Integrated Health Solutions (CIHS) Levels of Collaboration/Integration Tool: Mental Health Outpatient

44. BHACA-Adapted Center for Integrated Health Solutions (CIHS) Levels of Collaboration/Integration Tool: Substance Use Facilities

45. Reported Challenges to Implementing IHC (7) (6) (6) (5) (3) (3) (3) (2) (2) (2)

46. Reported Helpful Factors in Implementing IHC (11)

47. Lessons Learned • Celebrate successes—tool completion and strengths identified • Retell the story of the tool selection/group’s raison d'être • Adaption of tool to specific provider environment • Value of the process of tool completion (group participation) • Factors influencing tool completion • Surprising lack of understanding across system

48. IHC Tools/Frameworks Newly Introduced to Two Sets of Area Providers BHACA Initiative Participating Providers (2013-2016) 1115 Waiver Participating Providers (2011-2016) Midpoint Evaluation (Feb.-March 2015) Question #1: Prior to completing the Center for Integrated Health Solutions (CIHS) Levels of Collaboration/Integration that you just finished, were you aware of the framework?

49. Lessons Learned (Continued) • Policy challenges including funding streams • Value of a few committed community experts • Hard to be “match.com” for partnerships • Complex funding streams drive collaborations • Need collaborative partners to engage primary care • Value of site visits • Value of networking at live events

50. What’s Next? • Texas 1115 Waiver 2.0 • Certified Community Behavioral Health Clinics • Trainings informed by survey data • Clinical cross-training • Financing • Outcome-based evaluation • Electronic health record selection • Renewed engagement of primary care/FQHCs • MHA of Greater Houston systems-change initiative around financing IHC and preparing providers for IHC