Behavioral Health Integration: A Key Step towards the Triple Aim

1. Session # C4a October 18, 2014 Behavioral Health Integration: A Key Step towards the Triple Aim Mara Laderman, MSPH Senior Research Associate Institute for Healthcare Improvement Benjamin Miller, PsyD Director of Health Policy University of Colorado - Denver Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • We 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: • Learn about the Triple Aim benefits of primary care-behavioral health integration. • Use analyses of health plan and outcomes data to make the case for integration at their organization. • Describe IHI's approach to behavioral health integration.

4. Bibliography / Reference IHI 90-Day R&D Project Final Summary Report: Integrating Behavioral Health and Primary Care. Cambridge, MA: Institute for Healthcare Improvement; March 2014. Laderman M, Mate K. Integrating Behavioral Health into Primary Care. Healthcare Executive. 2014 Mar/Apr;29(2):74-77. Academy for Integrating Behavioral Health and Primary Care, Agency for Healthcare Research and Quality (AHRQ). Lexicon for Behavioral Health and Primary Care Integration. Available at: http://integrationacademy.ahrq.gov/lexicon Mental Health, Substance Abuse and Health Behavior Services in Patient-Centered Medical Homes. Kessler, R., Miller, B.F., Kelly, M., Graham, D. Kennedy, A., Littenberg, B., Maclean, C., van Eeghen, Scholle, S., Tirodkar, M., Morton, S., & Pace, W. The Journal of the American Board of Family Medicine, 27(5), 637-644. The Working Party Group on Integrated Behavioral Healthcare, Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., Epperly, T., Green, L., Henley, D., Kessler, R., Korsen, N., McDaniel, S., Miller, B., Pugno, P, Roberts, R., Schirmer, J., Seymour, D., & deGruy, F. (2014). Joint Principles: Integration Behavioral Health Care into the Patient-Centered Medical Home. The Annals of Family Medicine, 12(2), 183-185.

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Today’s Agenda • Making the case: Integration and the Triple Aim • Overview of IHI • IHI’s research on behavioral health integration • Five-step sequence to integrate BH • Future directions for IHI’s work • Behavioral Health Integration Capacity Assessment (BHICA)

7. Today’s Agenda • Making the case: Integration and the Triple Aim • Overview of IHI • IHI’s research on behavioral health integration • Five-step sequence to integrate BH • Future directions for IHI’s work • Behavioral Health Integration Capacity Assessment (BHICA)

8. Definition The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization. Value of Integration: Physical/Behavioral Integration is good health policy and good for health. Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.

9. No such thing as a single disease

11. In service to • Improving outcomes • Decreasing cost • Enhancing the patient experience

12. Drucker’s Big Seven (for innovative opportunity) • The unexpected success, failure or outside event • The incongruity – between reality as it actually is and reality as it is assumed to be • Innovation based on process need • Changes in industry or market structure • Demographics • Changes in perception, mood and meaning • New knowledge – scientific and nonscientific

13. Those who say it can’t be done are usually interrupted by others doing it James Baldwin

14. Today’s Agenda • Making the case: Integration and the Triple Aim • Overview of IHI • IHI’s research on behavioral health integration • Five-step sequence to integrate BH • Future directions for IHI’s work • Behavioral Health Integration Capacity Assessment (BHICA)

15. Our Mission:To improve health and health care worldwide

16. IHI’s Work: Five Key Areas

17. Our Goal: Drive the Triple Aim, simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities. Triple Aim for Populations

18. Proven Methodology: Science of Improvement W. Edwards Deming 1900-1993 API’s Model for Improvement

19. Today’s Agenda • Making the case: Integration and the Triple Aim • Overview of IHI • IHI’s research on behavioral health integration • Five-step sequence to integrate BH • Future directions for IHI’s work • Behavioral Health Integration Capacity Assessment (BHICA)

20. What drives IHI’s interest in integration? • Poor outcomes and high costs for patients with medical + behavioral comorbidities. • Getting to the Triple Aim will require addressing behavioral health! • Changing incentives will facilitate this.

21. Research Project Aims • Understand the core principles underlying successful approaches to integration of behavioral health services into primary care. • Develop IHI’s approach to integration. • Identify how IHI can support organizations to integrate behavioral health and primary care.

22. Research Methods • Reviewed peer-reviewed and grey literature and materials from existing models.

23. Key Research Findings • Perception is that there are many different ways to implement integration; we found that the commonalities are much greater than the differences. • Collaborative care principles; strong evidence base. • Five-step sequence to integrate BH • Biggest challenges are business case and operationalizing components into workflows. • Improvement approach is currently lacking. • Lack of integration outside of clinic visit.

24. Innovation: Full Spectrum Integration

25. Which states and why? • Variability in financial environment between states to support behavioral health integration. • Some states may be more interested than others due to: Medicaid waivers, Medicaid BH carve out, Medicaid expansion / expected growth in Medicaid population, # of ACOs & pushes for global payments. • We compiled a list of states with favorable markets for integration. • Favorable States: AZ, AR, CA,CO, IL, KY, MD, MI, NV, NJ, NM, OH, OR, and VT.

26. Today’s Agenda • Making the case: Integration and the Triple Aim • Overview of IHI • IHI’s research on behavioral health integration • Five-step sequence to integrate BH • Future directions for IHI’s work • Behavioral Health Integration Capacity Assessment (BHICA)

27. Five Step Sequence • Assess readiness for integration. • Develop reliable operations and processes to support integrated care. • Develop the business case for integration. • Re-design care delivery using collaborative care principles for integration. • Operationalize changes into clinical workflows.

28. 1. Assess readiness for integration • Assess readiness based on: • Patient needs • Clinic characteristics • Policy & financial environment • Existing data & measurement system 1. Assess Readiness

29. 2. Develop Reliable Operations and Processes to Support Integrated Care • Leadership and culture • Access and workflows • Technology considerations • Workforce: recruitment, hiring, onboarding, and oversight of staff • Workflows • Seamless information sharing & communication • Tracking patients and using data • Continuous quality improvement and outcomes monitoring • Space and supplies to support BH care 1. Assess Readiness 2. Processes to Support Integration

30. 3. The Business Case for Integration • Fee-for-service workarounds • Negotiate case rates with payers • Consider global funding strategies and blended payment systems • Identify federal and state incentives to support integrated care • Train staff to optimize use of existing revenue sources to provide cost efficient, medically necessary care. 1. Assess Readiness 2. Processes to Support Integration 3. Make the Business Case

31. 4. Re-design Care Delivery Using Collaborative Care Principles • Develop interdisciplinary care team • Promote self-care support and family engagement • Treatment to target • Stepped care • Systematic caseload review, consultation & referral • Adoption of evidence-based guidelines • BH providers support healthy behavior change in addition to screening, diagnosis, and treatment for BH conditions 1. Assess Readiness 2. Processes to Support Integration 3. Make the Business Case 4. Redesign Care Delivery

32. 5. Operationalize Changes in Clinical Workflows • Fully implement operational infrastructure • Sample change ideas to operationalize collaborative care principles: • Interdisciplinary care team proactively manages a panel and chronic health conditions and participates in care planning • Coordinate care inside and outside of org. including tracking referrals • Technological solutions when BH providers are not available in person 1. Assess Readiness 2. Processes to Support Integration 3. Make the Business Case 4. Redesign Care Delivery 5. Operationalize Changes in Workflows

33. Today’s Agenda • Making the case: Integration and the Triple Aim • Overview of IHI • IHI’s research on behavioral health integration • Five-step sequence to integrate BH • Future directions for IHI’s work • Behavioral Health Integration Capacity Assessment (BHICA)

34. Where IHI can add value • Focus on how to make specific changesand on addressing operational and organizational issues that need to be in place to facilitate implementation of integrated care. • Bring improvement science to integration. • Sense-making across different models. • Focus on leaders and systems. • Measurement of system-level integration outcomes.

35. New Collaborative Program • Optimize Primary Care Teams to Meet Patients’ Medical AND Behavioral Needs • Partnering with the MacColl Center for Health Care Innovation • Launches in February, 2015 http://www.ihi.org/Engage/collaboratives/OptimizePrimaryCareTeamstoMeetPatientsMedicalANDBehavioralNeeds/Pages/default.aspx

36. Areas for future innovation work • Integration in high-risk specialty clinics. • Scaling to communities, regions, states and solving related structural challenges. • Costs (and ROI) of integration, alternative payment methods, and financial models. • Behavioral health providers performing other functions on the care team, such as supporting behavior change for patients with chronic disease. • Building out other layers of full spectrum integration.

37. Today’s Agenda • Making the case: Integration and the Triple Aim • Overview of IHI • IHI’s research on behavioral health integration • Five-step sequence to integrate BH • Future directions for IHI’s work • Behavioral Health Integration Capacity Assessment (BHICA)

38. Behavioral Health Integration Capacity Assessment Tool (BHICA) • Resource for organizations to assess their readiness to integrate behavioral health and primary care. • Consider potential approaches to integration; • Understand the current infrastructure to support greater integration; • Assess the organization’s strengths and challenges in undertaking different approaches to integration; • Set and prioritize goals for integration efforts. • https://www.resourcesforintegratedcare.com/tool/bhica

39. Five Sections of BHICA 1. Understanding Your Population 2. Assessing Your Infrastructure 3. Identifying the Population and Matching Care 4. Assessing the Optimal Integration Approach for Your Organization 5. Financing Integration

40. Evaluation Framework Linked to Organization Processes, Impact, and Resources

41. Questions?

42. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!