Pre-application Webinar for Primary and Behavioral Health Care Integration (PBHCI)

2. Pre-application Webinar for Primary and Behavioral Health Care Integration (PBHCI) Trina Dutta, MPP, MPH Center for Mental Health Services

3. Logistics Info • Agenda • Importance of integrated care to SAMHSA • History of PBHCI • Overview of new funding opportunity • Frequently Asked Questions • Question and Answer

4. Importance of integrated care to SAMHSA

5. Importance of integrated care to SAMHSA Physical Health Conditions among Adults with Mental Illnesses—New SAMHSA Study* Combined 2008 and 2009 data indicate that adults aged 18 or older with any mental illness (AMI) or major depressive episode (MDE) in the past year were more likely than adults without these mental illnesses to have high blood pressure, asthma, diabetes, heart disease, and stroke Adults with serious mental illness (SMI) in the past year were more likely than adults without SMI to have high blood pressure, asthma, and stroke Those with AMI, SMI, or MDE were more likely than adults without these mental illnesses to use an emergency room and to be hospitalized *SAMHSA NSDUH Report, “Physical Health Conditions among Adults with Mental Illnesses,” 4/5/12

6. Importance of integrated care to SAMHSA Past Year Emergency Room Use and Past Year Hospitalization among Persons Aged 18 or Older with and without Serious Mental Illness in the Past Year: 2008 and 2009

7. Importance of integrated care to SAMHSA

8. Monthly expenditures for those with and without physical conditions SAMHSA. (2010). Mental health and substance abuse services in Medicaid, 2003: Charts and state tables. HHS Publication No. (SMA) 10-4608.

9. For those with serious behavioral health issues • 70% of Maine’s population with SMI has 1 chronic health condition, 45% have 2, and 30% have >3 (among the general population, 1/5 Americans have multiple chronic conditions) • MA Department of Mental Health (DMH): among persons 25 to 44, CVD mortality was 6.6x higher among DMH clients than the general population • CVD was the primary cause of death in persons with mental illness (MO, OK, RI, TX, UT, VA, 1996-2000) • Rates of smoking

10. Importance of integrated care to SAMHSA What does this mean? These results suggest a greater need for: screening for and treating these physical conditions among persons with mental illnesses; screening for and treating mental illnesses among persons with these physical conditions; and promoting programs that integrate mental health screening, intervention, and treatment with primary care or primary care into specialty mental health care.

11. Importance of integrated care to SAMHSA If it’s that obvious, what’s happening to address this? AHRQ Evidence Report: Integration of Mental Health/Substance Abuse and Primary Care • Identified 33 studies that integrated behavioral health services into primary care settings • Identified 3 studies that integrated primary care services into behavioral health settings • Even then, these were in large integrated systems, not free-standing community settings, which is where many individuals with mental health needs receive their long-term care) We need to know more!

12. History of PBHCI

13. History of PBHCI high Quadrant II Quadrant IV PBHCI Both specialty behavioral health settings and primary care (with a strong need for collaboration between the two) Specialty behavioral health programs with linkages to primary care PBHCI PBHCI Behavioral health risk/status Quadrant I Quadrant III Primary care or in the medical specialty system Physician with on-site behavioral health staff low high Physical health risk/status Milbank 2010--Adapted from Mauer 06

14. History of PBHCI • Purpose: to improve the physical health status of people with SMI and those with COD by supporting communities to coordinate and integrate primary care services into publicly funded community-based behavioral health settings • 64 grantees • 13—awarded 2009 • 43—awarded 2010 • 8—awarded 2011 • Grantees • Community behavioral health organizations • 63% partnering with an FQHC • 37% hiring PC capacity (mostly rural grantees) or partnering with a hospital • Majority are CMHCs, ~10% are community SA providers • Served over 19,600 adults with SMI and/or COD

15. History of PBHCI • 2010: Launched the SAMHSA/HRSA Center for Integrated Health Solutions (www.integration.samhsa.gov) In partnership with HHS/Health Resources and Services Administration (HRSA) • Goal: To promote the planning and development of integrated primary and behavioral health care for those with SMI, addiction disorders and/or individuals with SMI and a co-occurring substance use disorder, whether seen in specialty mental health or primary care safety net provider settings across the country • Purpose: To serve as a training and technical assistance center on the bidirectional integration of primary and behavioral health care and related workforce development

16. Overview of new funding opportunity

17. Overview of new funding opportunity • Purpose: to establish projects for the provision of coordinated and integrated services through the co-location of primary and specialty care services in community-based mental and behavioral health settings. • Goal: to improve the physical health status of adults with serious mental illnesses (SMI) who have or are at risk for co-occurring primary care conditions and chronic diseases • Objective: to support the triple aim of improving the health of those with SMI; enhancing the consumer’s experience of care (including quality, access, and reliability); and reducing/controlling the per capita cost of care.

18. Overview of new funding opportunity • Application due date: June 8, 2012 • Estimated number of awards: 32 • Estimated award amount: Up to $400,000 per year • Cost Sharing/Match Required: no • Length of Project Period: 4 years • Eligible applicants: Qualified community mental health programs, as defined under section 1913(b)(1) of the Public Health Service Act, as amended. • (b) Providers of services • A funding agreement for a grant under section 300x of this title for a State is that, with respect to the plan submitted under section 300x–1(a) of this title for the fiscal year involved— • (1) services under the plan will be provided only through appropriate, qualified community programs (which may include community mental health centers, child mental-health programs, psychosocial rehabilitation programs, mental health peer-support programs, and mental-health primary consumer-directed programs);

19. Overview of new funding opportunity • Core Requirements (more information on Page 10, RFA) • Provide, by qualified primary care professionals, on site primary care services and • Provide, by qualified specialty care professionals or other coordinators of care, medically necessary referrals • Applicants must serve as a client’s health home where grantees must provide the following categories of service (see Appendix L for sample definitions of these services): • Comprehensive care management • Care coordination and health promotion • Comprehensive transitional care from inpatient to other settings, including appropriate follow-up • Individual and family support, which includes authorized representatives • Referral to community and social support services, including appropriate follow-up

20. Overview of new funding opportunity • Other areas of emphasis: HIT • SAMHSA expects PBHCI grantees to achieve Meaningful Use Standards, as defined by CMS, by the end of the grant period; to that end, applicants must propose how they will develop and demonstrate the ability to: • Submit at least 40% of prescriptions electronically (as allowable given state-specific laws regarding the use of e-prescriptions for controlled substances); • Receive structured lab results electronically; • Share a standard continuity of care record between behavioral health providers and physical health providers; and • Participate in the regional extension center program.

21. Overview of new funding opportunity • Other areas of emphasis: Prevention & Health Promotion • A continuum of preventive and health promotion services should be offered to clients within the PBHCI health home program, where different services are offered to different categories of clients according to the severity of the condition/risk factors. • Wellness programs (e.g., tobacco cessation, nutrition consultation, health education and literacy, self-help/management programs) should be available as primary as well as secondary preventive interventions that involve preventive screening and assessment tools, incorporating recovery principles and peer leadership and support

22. Overview of new funding opportunity • Other areas of emphasis: Sustainability • Applicants are expected to serve as health homes for PBHCI clients beyond the four year grant period.  • Grantees must utilize 3rd party and other revenue realized from provision of PBHCI health home services to the extent possible and only use SAMHSA grant funds for services to individuals who are ineligible for public health insurance programs, individuals for whom coverage has been formally determined to be unaffordable, or for services that are not sufficiently covered by an individual’s health insurance plan (co-pay or other cost sharing requirements are an acceptable use of SAMHSA grant funds).  • Applicants are expected to facilitate the health insurance application and enrollment process for eligible uninsured clients.   • Grantees will be required to submit a comprehensive sustainability plan in the beginning of Year 2 of the grant

23. Overview of new funding opportunity Data Collection Grantees are expected to serve at minimum 200 clients in Year 1, 375 clients in Year 2, 475 clients in Year 3, and 600 clients in Year 4. ( If you are unable to meet these goals, you may provide a detailed explanation of why along with your proposed goals of clients served.) Blood pressure—quarterly Body Mass Index—quarterly Waist circumference—quarterly Breath CO—quarterly Plasma Glucose (fasting) and/or HgbA1c—annually Lipid profile (HDL, LDL, triglycerides)—annually National Outcome Measures—every 6 months Quarterly Performance Reports

24. Overview of new funding opportunity • Funding restrictions • No less than 10% of the total grant award may be used for developing preventive and health promotion services. • No more than 25% of the total grant award may be used for developing the infrastructure necessary for expansion of services. (No more than 15% of the total grant award may be may be used for facility modifications and health information technology necessary for expansion of services.) • No more than 20% of the total grant award may be used for data collection, performance measurement and performance assessment, including incentives for participating in the required data collection follow-up.

25. What are we trying to achieve? A person-centered system of care that achieves improved outcomes and better services and value

26. Frequently Asked Questions Q: How does SAMHSA define a serious mental illness? A: SAMHSA definition of SMI stipulated in PL 102-321 requires the person to have at least one 12-month DSM disorder, other than a substance use disorder, and to have "serious impairment." SAMHSA decided that "serious impairment" is defined as a Global Assessment of Functioning (GAF) score of less than 60).

27. Frequently Asked Questions Q: Is the required minimum clients served a duplicated or unduplicated count? A: Grantees are expected to serve at minimum 200 clients in Year 1, 375 clients in Year 2, 475 clients in Year 3, and 600 clients in Year 4.  These numbers are unduplicated (but SAMHSA encourages grantees to exceed these numbers when possible.)

28. Frequently Asked Questions Q: I am having trouble locating section 1913(b)(1) of the Public Health Service Act that defines “qualified community mental health programs.” Could you provide me with that definition or with a link to that section of the law? A: Section 1913 of the PHS Act which is codified at 42 U.S.C. §300x-2 link: http://www.law.cornell.edu/uscode/text/42/300x-2.  You will then need to scroll down to (b)(1) (see slide 20 for exact language)

29. Frequently Asked Questions Q: Could two separate independent  community mental health centers write a single grant application for funding for the identical program to be implemented at both organizations? A: The two separate independent community mental health centers must submit separate grant applications for funding.  The two separate centers cannot submit a single grant application to implement the same program. That said, there could be one main fiduciary CMHC that subcontracts with a second CMHC. 

30. Frequently Asked Questions Q: My question has to do with Section 3.2 Evidence of Experience and Credentials, bullet point 2 under the three requirements.  Do we have to have two years experience providing primary care services AND mental health services, or just two years providing services in general?  A: Per the RFA, “each mental health/primary care treatment provider organization must have at least 2 years experience (as of the due date of the application).”  This means that whomever will be providing the primary care services must have documents 2 years of experience. If you (the applicant) are planning on providing the primary care services, you would need 2 years of experience.  If you plan on contracting with a local community provider, they would need 2 years experience.

31. Frequently Asked Questions Q: I am unclear if there is a licensing or other form of designation that also must be met to confirm that we meet these requirements and are officially considered a community mental health program.   A: There is no federal level accreditation for CMHCs, so we hold you to whatever it is you receive from your state to provide services.  If you receive the award, SAMHSA reserves the right to request documentation of your state certification, etc.  Many states have legislated definitions of CMHCs which your organization meets, and SAMHSA will defer to that definition.

32. Frequently Asked Questions Q: Is it a requirement for the co-located service to be physically located in the behavioral healthcare facility rather than the physical healthcare facility? A: Yes, these services must be co-located WITHIN the mental health setting.

33. Frequently Asked Questions Q: Could you tell me when awards for this grant would occur.  When does the first year funding start? A: The awards would in all likelihood be awarded close to/before September 30, 2012, with funding starting October 1, 2012 (beginning of the federal fiscal year).

34. Frequently Asked Questions Q: We would like to apply to provide the primary care for SMI patients and contract with a behavioral health provider agency to provide these services at our primary care clinic sites.  Is this within the scope of services that SAMHSA is interested in?  Or do you require the primary care services be provided in a mental/behavioral healthcare setting? A: The explicit focus of the project is  the co-location of primary and specialty care medical services in community-based mental and behavioral health settings, so embedding mental health services into an FQHC would fall outside the scope of the project.

35. Frequently Asked Questions Q: On Page 21 of the RFA, it notes supporting information on Attachment 1-4, but then also mentions Attachment 5. Is this an error? A: Yes, this is an error. This section should read: Attachments 1 through 4 [change, if necessary] – Use only the attachments listed below. If your application includes any attachments not required in this document, they will be disregarded. Do not use more than a total of 30 pages for Attachments 1, 3 and 4 combined. There are no page limitations for Attachment 2.

36. Frequently Asked Questions Q: We are the administrative unit that contracts for all community mental health programs in the County. Are we as the County office eligible to apply? A: County operated community mental health centers are certainly eligible to apply.  The county, itself, could not apply for its centers, though, and I would suggest the contracted community mental health programs in your County serve as the primary applicant. 

37. Frequently Asked Questions Q: In terms of the specialty care services for uninsured people, how far is the grantee expected to go in paying for services?  For example, if we make a referral to a cardiologist who does a procedure costing thousands, does the grant pay for that?  Should the budget include funds to pay for prescription drugs? A: The requirement is for provision of PC services and referral to specialty care.  The budget can include payment for medicines, but again, in the name of sustainability you will have to discuss how this will be carried forward beyond the grant.  Per the RFA (pp. 46), SAMHSA grant funds must be used for purposes supported by the program and may not be used to: Pay for pharmacologies for HIV antiretroviral therapy, sexually transmitted diseases (STD)/sexually transmitted illnesses (STI), TB, and hepatitis B and C, or for psychotropic drugs.

38. Frequently Asked Questions Q: As a CMHC, if we partnered with a private practitioner with 2 yrs experience in primary care, but they were not a non-profit, in other words they were in private practice is that acceptable under the provisions of the grant? A: A grantee or grant applicant cannot contract or partner with a for-profit primary care organization for the programmatic health work.  They could contract with individual doctors in a for-profit practice, but not with the practice itself.  No HHS funds may be paid as profit (fees) per C45CFR Parts 74.81 and 92.22(2).

39. Frequently Asked Questions Q: Page 9 also includes a requirement that grantees participate in the Regional Extension Center program.  However, this program is specifically targeted to primary care providers that practice in groups of 10 or fewer providers.  Further, in some states, enrollment in the REC has been closed for some time.   Can you clarify what is meant by this requirement? A: While RECs receive federal dollars to support primary care, many will allow CMHCs to join for a small fee, and you can use your HIT dollars towards that (current PBHCI grantees are doing this with success).  For RECs with “closed enrollment,” SAMHSA will work with the Office of the National Coordinator.

40. Frequently Asked Questions Q: Do  the required number of individuals served need to be uninsured individuals?  A: You can serve whatever client mix of insured/uninsured exists in your community, but you can ONLY use SAMHSA grant dollars to cover services that aren’t billable via another vehicle (this goes for uninsured and insured folks). 

41. Frequently Asked Questions Q: We are in a rural area and are considering proposing that a mobile unit be purchased/leased.  The unit would be staffed with medical staff that can travel to our facilities where we provided behavioral  health services  in more rural areas as well as to assisted living facilities where we provide services. Can a mobile van/unit can be funded with grant dollars (for example out of the facility modifications allocation)? A: You may use the grant funds to purchase/lease the van mobile.  However, in order to determine what is more cost efficient, you should do a purchase/lease cost analysis and state it in the detailed budget justification.

42. Questions?

43. Future Questions AGENCY CONTACTS For questions about program issues contact: Trina Dutta Public Health Analyst, Center for Mental Health Services Trina.dutta@samhsa.hhs.gov (preferred) 240-276-1944 For questions on grants management and budget issues contact: Gwendolyn SimpsonOffice of Financial Resources, Division of Grants Managementgwendolyn.simpson@samhsa.hhs.gov (240) 276-1408