Medicaid Matters Maryland Video Conference March 28, 2012 William J. Reidy, LCSW

2. Opportunities for Expanding Substance Use Treatment Services in Community Health Centers Medicaid Matters Maryland Video Conference March 28, 2012 William J. Reidy, LCSW Asst Director for Behavioral Health Integration Clinical Affairs Division National Association of Community Health Centers

3. Today’s Discussion • What are Federally Qualified Community Health Centers (FQHCs)? 2 . FQHC & Behavioral Health Services? 3. Practice Transformation: PCMH & Interdisciplinary Care Teams? 4. Preparing substance use treatment providers for new FQHC opportunities

4. America’s Voice for Community Health Care The NACHC Mission To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved people.

5. NACHC America’s Voice for Community Health Care The National Association of Community Health Centers (NACHC) represents Community and Migrant Health Centers, as well as Health Care for the Homeless and Public Housing Primary Care Programs and other community-based health centers. Founded in 1971, NACHC is a nonprofit advocacy organization providing education, training and technical assistance to health centers in support of their mission to provide quality health care to medically underserved populations.

6. NACHC PARTNER NACHC is a partner in the work of the HRSA/SAMHSA-HRSA Center for Integrated Health Solutions www.integration.samhsa.gov With a focus on working with FQHCs, Primary Care Association, Health Center Controlled Networks & other organizations to accelerate the spread and improvement of bi-directional integration of primary care and behavioral health services

7. 1. Federally Qualified Community HealthCenters Five Essential Elements of Community Health Centers • Located in high-need areas • Provide comprehensive health and related services (especially “enabling services”) • Open to all residents, regardless of ability to pay, with sliding scale fee charges based on income • Governed by community boards, ( 51% of board must be CHC users) to assure responsiveness to local needs • Follow performance and accountability requirements regarding their administrative, clinical, and financial operations as specified in Section 330 federal requirements

8. FQHCs Serve… • 1 in 7 Medicaid beneficiaries • 1 in 7 uninsured persons, including 1 in 5 low income uninsured • 1 in 3 individuals in poverty; 1 in 4 minority individuals in poverty • 1 in 7 rural Americans * Based on 2010 Uniform Data System (to which all federally funded health centers must report), estimates from survey data of non-federally funded health centers (health center “look alikes”), estimates for annual patient growth, and national data sources.

9. Health Center Patients By Insurance Status, 2010 Note: Other Public may include non-Medicaid SCHIP. Percents may not total 100% due to rounding. Source: Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System

10. FQHC Services Services: • Health Services related to: • Family Medicine • Internal Medicine • Pediatrics • Obstetrics • Mental Health • Substance Use Service • Diagnostic Laboratory and Radiologic Services • Dental Screenings • Pharmaceutical Services • Referrals to Other Providers • Patient Case Management and… • Enabling Services, Translations, Transportation, Outreach, and • Health Education

11. Case Management Environmental Health Risk Reduction Health Education Interpretation/Translation Services Outreach Child Care (during visits) Housing Assistance Transportation Home Visiting Parenting Education Employment referral & counseling Testing for Blood Lead Levels Food bank/meal delivery Enabling Services

12. Health Center Patient Visits by Type of Service, 2010 77 million encounters in 2010 * Encounters for enabling services only include visits to case managers and health educators. Source: Federally‐funded health centers only. 2010 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS.

13. 2. FQHC Primary Care & Behavioral Health Integration

14. 2. FQHCs & Behavioral Health: 71 % of CHCs provided behavioral health services 4,241 mental health services FTEs and 854 substance abuse FTEs provided over 5 million visits accounting for 8.2% of all health center visits Based on 2010 UDS data

15. 2010 UDS Dx Categories DiagnosTobacco Use Disorders                              110,031 Depression and Other Mood Disorders                              726,779 Anxiety Disorders Including PTSD                              397,541

16. Some Key Points • 70% of Health centers provide mental health services onsite, frequently with health center-employed staff • 20% of Health Centers provide substance abuse services on site. Uptake slow and strategies needed to accelerate spread of integrated SUD services • Access to community substance use treatment services is frequently a problem for FQHCs. Need for expanded relationships/ collaboration with community substance use and mental health providers • Funding and workforce issues need to be addressed • Major transformation underway: PCMH

18. Patient Centered Medical Home: Health Center Vision

19. What Are Key Design Features of a PCMH: (Commonwealth Fund Safety Net Medical Home Initiative) • Engaged Leadership • Quality Improvement Strategy • Empanelment (provider/team accountability for specific population of patients) • Enhanced access • Continuous, team based healing relationships with patients • Patient centered interactions (e.g. self-management support) • Organized evidenced base care • Care coordination

20. 4. Preparing for New Opportunities • In the context of PCMH, Behavioral Health is best understood as health team activities which address: • mental health conditions (e.g. anxiety or depression) • substance use disorders, & • health behaviors impacting the person’s overall health and well-being (e.g. tobacco cessation, substance use, healthy diet, exercise, self-care, healthy relationships, social support etc)* * PCPCC consensus definitions

21. Training for PC team on behavioral health assessment and treatment Training of BH providers on “non-traditional” treatment (short interventions) and physical health diagnosis Stigma reduction: all staff , providers and patients Organizational culture management Training (providers and patients) Shared space and record Identification of patients based on need (without limitations) Shared funding or other successful funding mechanism Multi-disciplinary team approach Shared record Co-location of behavioral health providers in primary care Appropriate space for behavioral interventions to take place, not separate • Improved patient outcomes through the integration of behavioral health into PCMH • Functional Status Primary care knowledge of screening tools Mechanism of escalation of high severity of patients Treat and refer back to PC model including the most severe patients Ability to be compensated for shorter behavioral health interventions Mechanism for funding BH specialists OUTCOME PRIMARY DRIVERS SECONDARY DRIVERS

22. FOR MORE INFORMATION CONTACT: William Reidy, LCSW Assistant Director for Behavioral Health Integration Clinical Affairs Division National Association of Community Health Centers 7200 Wisconsin Ave Suite 210 Bethesda, MD 20814 wreidy@nachc.com Additional resource materials: www.integration.samhsa.gov www.nachc.com/BehavioralHealth.cfm