The Integration Train is Moving – Are You Onboard? If Not, Learn How to Get Your Ticket!

1. The Integration Train is Moving – Are You Onboard? If Not, Learn How to Get Your Ticket! • Presented by: • Mark A. Engelhardt, MS, MSW, ACSW • Rick Hankey, MA • Laureen Pagel, PhD, MS, CAP, CPP, CMHP • Rita Chamberlain, MBA • Kay Doughty, MA, CAP, CPP • Phillip Brooks, LMHC

2. Learning Objectives • Identify national, state and local models of behavioral healthcare and primary health integration • Identify and describe the continuum of healthcare integration models • Use the tools and tips provided to establish an integration action plan for beginning and/or enhancing integration efforts • Self-assess where their organization stands on the integration continuum model. • Leave with a list of contacts/resources pertaining to integration

3. Integrated Behavioral Health & Primary CareNational/State/Local Development FADAA/FCCMH Annual Pre-Conference Mark A. Engelhardt, MS, MSW, ACSW USF – FMHI – Dept. of Mental Health Law & Policy

4. The Case for Integrated Care • People with mental health and substance abuse disorders die 25 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

5. Organizational Support (2003-14) • 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

6. 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 for both behavioral and physical health ( SAMHSA – HRSA Grant focus)

7. 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 – More on Slide 13 with Hand out & Afternoon discussion

8. SAMHSA – HRSA Solutions • Target = People with Serious Mental Illnesses • 100 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 (EHR) with grantees • New PBHCI Grant applications to be awarded in 2015?

9. 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 (2009-14)

10. National Outcome Measures • Functioning – Wellness Healthy Overall • Functioning in Everyday Life • No Serious psychological distress - • Using Illegal Substances • Not binge drinking • Retained in the community • Housing Stability • Education and Employment • Criminal Justice Involvement • Perception of Care • Social Connectedness • Positive outcomes overall • Rand Evaluation

11. At Risk Criteria & Tracking TRAC • 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

12. Rand Research Questions • Process Evaluation – Is it possible to integrate Primary and Community-based Behavioral Health agencies? – Structural and clinical approaches • Outcomes – Does integration lead to improvement of in SAMH and health of a population of individuals with serious mental illnesses (& co-occurring) • Model Features – Which models or “features” of integration lead to better SAMH and Healthcare • National data (NOMS and TRAC) - Progress

13. Grantee Evaluation: Rand Corp. • 56 Grantees included in the National Evaluation • 67% Partnered with FQHC’s • Over 16,000 served since 10/1/09 -2012 • 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

14. 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 Programs; Wellness Recovery Action Plans; Screening – Brief Intervention- & Referral to Tx (SBRIT); Peer Specialists; Case management • Diverse Models – Clinic Based to Home visits

15. 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) • HAND OUT

16. 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

17. 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

18. 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

19. 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

20. Organization Readiness • Are you providing Primary Healthcare? If so, is it a Bi-directional On-site & Off-site Service? • Do you have signed contracts with FQHC’s, County Health Departments, Medicaid Managed Care Plans (I.E. Magellan, HMO’s) or Private Funding Panels • Are there shared staffing agreements? • Do you provide Wellness programs on-site or with a community partner? • To what degree are peer specialists employed? • Do you have Integration Strategic Plan?

21. Organizational Readiness • Have you conducted an “Integration Readiness Assessment” for the agency or pilot program? • What does your workforce look like? – Physicians, SAMH Professionals, Nurses, Psychiatry, etc. • Do you consider your agency as Co-occurring capable for SAMH? If so, how? Now, complexity capable? • Is your agency involved in a network or merger that will draw on the strengths of all organizations? • Do you know the mix of Indigent, Medicaid, Medicare, Dual Eligible or other local payer plans? (Counties)

22. 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

23. 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)

24. 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

25. 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

26. Primary and Behavioral Health Care Integration: Practical Approaches to ImplementationRick Hankey, Senior V. P. and Hospital Administrator LifeStream Behavioral Center, Inc.

27. “Mental health care cannot be divorced from primary care, and all attempts to do so are doomed to failure” (Frank Degruy)

28. What is Integrated Care? Our Definition • Integrated care is a service that combines medical and behavioral health services to more fully address the spectrum of problems that individuals have • It meets patients “where they are” in their experience of problems or pain • Integrated care is the structural realization of the biopsychosocial model • Reunification in practice of mind and body

29. Collaborative Care-Where Were We? LESS Courtesy report of involvement Referral call for information exchange Development of special referral relationship Meeting to discuss cases Meeting of providers with patient Working together regularly in delivering services (Blount, 1998) MORE

30. Reasons for Integration: Why We Did It • The burden of behavioral disorders is great. • Behavioral and physical health problems are interwoven. • The treatment gap for behavioral disorders is enormous. • Primary care settings for behavioral health services enhance access. • Delivering behavioral health services in integrated care settings reduces stigma and discrimination.

31. Reasons for Integration: Why We Did It • Treating common behavioral disorders in integrated care settings is cost-effective. • The majority of people with behavioral disorders treated in collaborative settings have good outcomes, particularly when linked to a network of services at a specialty care level and in the community. • Individuals with serious mental illness die on average 25 years sooner than the general population.

32. Factors Increasing Health Risk Poverty Less Likely to be Screened Poor Access to Primary Care Self-Care Capacity/Resource Disconnectedness of “Physical” & “Mental” Health Care Systems Under Diagnosis & Under Treatment Cognitive, Affective and Behavioral Symptoms Weight Gain System Navigation Barriers Tobacco and Substance Abuse Medications

33. Reasons for Integration (Florida Council For Community Mental Health)

34. Barriers to Integration • Behavioral and physical health providers have long operated in their separate silos. • Sharing of information rarely occurs. • Confidentiality laws pertaining to substance abuse (federal and state) and mental health (state) are generally more restrictive than those pertaining to physical health. While HIPAA is often cited as a barrier to sharing information between primary care and mental health practitioners, this is not accurate: sharing information for the purposes of care coordination is a permitted activity under HIPAA, not requiring formal consents. • Payment and parity issues are prevalent.

35. Understand The Differences

36. Culture Differences

37. Integration Considerations

38. Readiness Assessment • Leadership and Relationship Building • High Performing Provider-Access and Outcomes • Person Centered Healthcare Home Participation • Business Infrastructure • Consumer Advocacy

39. Readiness Assessment-Leadership • How active are you pursuing relationship building with leaders in the healthcare community? • How successful have you been in communicating the importance of mental health and substance use treatment in improving quality in the healthcare system? • Are you involved in assessing community needs and designing a local health improvement plan? • How involved are you in planning and decision making at the state level? Do you local leaders understand and support integration? • What have you done to develop and implement healthcare reform education within your organization? At what level has the discussion been held and what depth? Do you know how integration will affect your organization and community? What is the organization commitment? • How educated is your community?

40. Readiness Assessment-High Performing Provider • Readiness and recovery deeply embedded into your culture? • How quickly can individuals get access to care? Two hours for emergent? 24 hours for urgent and no later than 7 days for routine care requests? • How much is evidence based practices and programs utilized in your organization? Does leadership prioritize and promote the use of EBP? • Does your organization use person centered care planning and consumer engagement? • Are care management models utilized in your agency? Does your agency know the difference between case and care management? • Are you familiar with “treat to target” approach? • Are you a high performing provider?

41. Readiness Assessment: Person Centered Healthcare Home • Have you worked closely with your community’s primary care partners to determine how involved to ensure that all consumers with mental health/substance abuse disorders have a person-centered healthcare home? • How capable are you of being a good neighbor to the Person Centered Health Home, including a) effective communication, coordination and integration with health homes; b) appropriate and timely consultations and referrals; c)efficient, appropriate and effective flow of patient/care information; d)providing guidance in determining responsibility in co-management situations; and e) supporting the health home as the leader of the care team

42. Readiness Assessment: Infrastructure • Where is your organization regarding information technology? Do you have a electronic record that is available and appropriate for all staff? Is your information technology able to support real-time clinical decision making, quality improvement and effective management? • Is quality improvement part of your organizational culture or just as a department? How quickly can you complete Rapid Cycle Improvement? • How effective is your revenue cycle management? • Are you familiar with new payment models? If not, are you willing to learn them? • How bullet proof is your compliance plan and does it address healthcare reform, fraud and abuse?

43. Readiness Assessment: Consumer Advocacy • Do you have a workforce expansion plan? • How well educated are you on federal parity implementation? Do you have linkages with federal and state organizations to support or educate your agency on the implementation of federal parity regulations for Medicaid, Health Exchanges and private health insurance? • Do you have an enrollment strategy that provides outreach, assistance with the enrollment process and advocacy for the removal of structural barriers? • Are you ready to meet the needs of the additional population?

44. The Wellness Integration Network (W.I.N.) Clinic

45. W.I.N. Clinic Philosophy CONSUMER CENTERED APPROACH HEALTH HOME

46. The W.I.N. Clinic Model Components • Integrated services • Screen/registry tracking and outcomes • Primary care staff located in behavioral health setting/no FQHC • Embedded Nurse Care Managers • Wellness/prevention programming Evidence Based Models • SBIRT • IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) Model • Motivational Enhancement Techniques (MET) • Eli Lilly Wellness Program

47. W.I.N. Clinic-Our Program • Integration Model: Co-locate primary care physicians in behavioral health facilities to provide routine primary care services and serve as a consultant to the psychiatric care team; all staff are employed by LifeStream. There is no FQHC involvement. • Service delivery: includes providing wellness programming and incorporating integrated services; psychiatric and primary care are offered during the same visit. The clinic serves as a “Medical Home”. Specialty care is provided through agreements with community partners. • Enrollment Target:1,000 during the four year grant period. • Populations Served: Adults with serious mental illness living in Lake County who do not have access to primary care services or a medical home.

48. W.I.N. Clinic-Our Program SERVICES PROVIDED: • Integrated Primary and Behavioral Health Care; both services provided during the same appointment (when applicable), along with appropriate follow up. Emphasis is on preventive care. • Home visits by LPN Care Managers to coordinate and monitor care and assess goals. • Referrals to specialists and enhanced care coordination. The clinic has had great success with coordinating free and/or reduced rates with the specialists in our community for our clients. • Transportation to appointments when needed.

49. W.I.N. Clinic-Our Program • Wellness Activities and workshops on topics such as exercise, diet and nutrition, weight management, and tobacco cessation. • Wellness activities include: wellness testing (fitness and medical tests), health risk appraisals, hypertension screening and education, disease management seminars, in home education with care managers, stress management activities, and time management workshops • Access to LifeStream’s full continuum of care, including behavioral health and substance abuse services.

50. Client identified as not having PCP and referred to the program Initial Visit with Care Manager: Client is screened for medical and behavioral health issues by Care Manager. Client is seen by medical staff for history and physical. SBIRT used to identify co-occurring issues Consultation with appropriate parties, including the client Treatment Plan Assess Treatment Response through Weekly Contact Insufficient Response Complete Response Maintenance -Relapse Plan -Follow Up W.I.N. Clinic Work Flow