Making the Affordable Care Act Affordable

1. Making the Affordable Care Act Affordable Presenters: Susan Blue, ACSW, Community Services Group Carmen Klingensmith, Community Services Group Claire Hornberger, LCSW, TrueNorth Wellness Services Mary McGrath, MSW, TrueNorth Wellness Services Barbara Terrill-Kettering, Psy.D., Community Services Group

2. Learning Objectives • Brief overview of “models” and toolkits that will help BH providers survive and thrive in this ACA environment. • Identify and apply strategies your organization may adopt and polish. • Understand the “packaging” your organization can maximize.

3. Introduction • Integrated care • TrueNorth Wellness Services – efforts in working with primary care providers • Community Services Group – efforts of wellness initiatives with employees

4. The Affordable Care Act (Patient Protection and Affordable Care Act) • “Obamacare” • Passed March 23, 2010 • Most significant regulatory change for the US healthcare system since Medicaid and Medicare • Goals: • Increasing quality and affordability of health insurance • Lowering the uninsured rate by expanding public and private insurance coverage • Reducing the costs of healthcare coverage for individuals and government

5. Affordable Care Act • Has forced a conversation about change, new service models, and controlling costs • Health Homes • Accountable Care Organizations • Patient Centered Medical Homes • Focused conversation on integration of behavioral health and general medicine • Small number of individuals account for largest percentage of costs • Behavioral health conditions – present in other high cost, chronic health conditions

6. Integration • Sea change for behavioral health providers • Craft a role with integration – value added • Consumer/Patient experience – behavior change • Financial bottom line – reduction of ED visits and hospital admissions and readmissions • Expand the reach of general healthcare beyond the doctor’s office and hospital into consumer/patient’s home and community

7. Expertise of Behavioral Health Providers • Behavioral Health Providers have expertise in approaches that are valuable and necessary to: • A partnership with general medicine in order to improve the health of our consumers/patients • Patient Centered Care and Patient Engagement • Community partnerships • Evidenced based care that changes behavior and reduces utilization of services while improving health outcomes: • Motivational interviewing • Trauma focused therapy • Cognitive behavioral therapy • Dialectical behavioral therapy

8. Goal of Integrated Care – Population Health • Helping people change their behavior is fundamental to achieving better and more cost effective outcomes • Jeffrey Brenner - MacArthur Genius and primary care physician explained that his model relied heavily on the work of behavioral health pioneers when he said, “Actually behavioral health is 30 years ahead of us. I hope primary care can learn from behavioral health. When psychiatric care was deinstitutionalized, behavioral health did heroic work to figure out how to deliver better care at lower cost and evolved some creative models.” • Clearly we have expertise to offer

9. Full Integration • We must focus on Mental as well as Physical Wellness to fully integrate healthcare • Our workshop will review several strategies for BH providers to include in their tool kit as they prepare to enter the world of integrated healthcare in whatever service model exists in their community. • TrueNorth Wellness Services – clinical services focus • IMPACT model • Lifestyle Management • Community Services Group – employee focus • Trauma Informed Care principles and therapy • Technology – My Strength

10. Trauma Informed Care • Research indicates early exposure to trauma can be correlated to behavioral health and substance abuse/addiction issues • Organizations that fail to understand the relevance of trauma on health issues are not likely to experience positive outcomes with individuals they serve and will have difficulty maintaining a healthy workforce • There are various options available to providers for addressing trauma with individuals in service and with a workforce

11. Integrated Health – Why Behavioral Health Fits into Primary Care • 10% of patients in primary care experience depression • People with depression have 50-100% higher health care costs • Only 50% of people with depression are treated • Many people prefer treatment by their PCP and PCPs prescribe the majority of antidepressants • Treating both physical and behavioral health achieves better results • Many physical symptoms that send patients to their PCP have behavioral health roots

12. IMPACT model – Improving Mood Promoting Access to Collaborative Treatment Stepped program • Assessment and education • Behavioral activation/pleasant events scheduling AND • Antidepressant medication OR problem-solving treatment • Maintenance and relapse prevention plan for patients in remission

13. IMPACT Model • Initial treatments are rarely sufficient • PHQ-9 used at every visit • Outreach to patients who do not attend • Can be adapted to and effective in a wide range of health care settings • Effective teamwork is essential • Behavioral health staff need the following skills • Strong engagement skills, solution focused, behavioral activation, ability to not engage in intensive therapy, motivational interviewing, problem solving • IMPACT implementation center • http://impact-uw.org/about/implementation.html

14. Collaboration is Not a Natural State! • Primary care, mental health, social services, community based services – we all operate in silos • Working under the same roof is not enough • Effective collaboration takes a lot of work • Successful integration requires: • Clinical, operational, and financial integration • A shared workflow and shared, measurable goals

15. Needed to Succeed: • A supportive PCP who “owns” the program and is able to “sell” it to the patient • A private workspace for behavioral health staff • Clearly defined workflows • Everyone in the clinic needs to know about the program and be able to sell it • Effective communication!

16. Lessons learned one year in: • We are guests in their house • We must learn their culture • We must speak their language • Allow for “local” leadership • PCP and support staff champions are critical • Behavioral health needs to establish TRUST with the PCP • BH personality is as important as credentials • Review the finances first!

17. Motivational Interviewing • The “magic ingredient” of helping patients make positive behavioral changes to support better health • There are 4 principles of MI: • Express empathy, avoid arguing • Develop discrepancy • Roll with resistance • Support self sufficiency • The basic process: • Look for signs of readiness for change • Strengthen commitment to change • Develop and negotiate a change plan • Proceed at the person or organization’s pace

18. Motivational Interviewing: Following the basic process • Motivational interviewing is NOT what you were already doing. • When you hear yourself or your staff reflecting “we already do that”. This is nothing new, be wary. • We are all CHANGE AVERSE!

19. Motivational Interviewing: • Use EARS as a clinical and administrative skill: Elaborate Affirm Reflect Summarize • Or, forge ahead as an organization! May involve recruiting new & different people who share your vision of change or starting a new “division” of your organization

20. Workplace Wellness • Health care costs continue to increase • Focusing on work place wellness with a trauma informed perspective supports health behavior change and impacts health care costs

21. CSG strategies for employees’ physical and behavioral health • In an attempt to improve health literacy and normalize accessing BH services, CSG has crafted an internal EAP program with an updated menu of services within a trauma informed focus • Trauma Informed education and certification is a focus for EAP clinicians • Non-therapists are being identified and trained in crisis management skills to provide emergency response • CSG has made the confidential online resource and screening tool “My Strength” available to all staff to use as needed • CSG provides Mental Health First Aid classes to educate non-clinician participants about managing crisis or someone’s developing behavioral health issue • Other strategies include tobacco cessation and a workplace wellness initiative to encourage healthful eating and increased physical activity

22. THRIVING IN THE ACA ENVIRONMENT “THE HOW TO’s”:Important Characteristics to Nurture: • Nimble staff and organization • Strengths focused • Flexible • Results oriented • Solution focused

23. Skills/Expertise • Engagement • System perspective • System and street “savvy” with non-compliant patients • Motivational interviewing • Navigating through obstacles • Trauma informed care

24. Must Do • Evidence based practices • Become indispensable to the physical health providers • Demonstrate cost structure advantage • Demonstrate positive patient outcomes • Solve their system issues/challenges • Focus on what works • Translate patient communications and behaviors to physical health providers • Join with physical health providers but differentiate ourselves • Embrace continuing education

25. Future Considerations • Population health management • Real outcomes that translate into healthier population at lower cost • Aging demographic and growing health care needs of aging populations • How to meet these demands without increased costs?

26. WRAP UPTo tie together the major points/learning from this presentation: • Susan emphasized that we can navigate the “sea change” that accompanies the ACA from a provider and employer perspective. • Carmen enlightened us about the power of adopting trauma informed care as a bedrock philosophy of all we do. • Barbara described CSG’s robust workplace wellness services and how they incorporate trauma informed care to improve employee health & reduce healthcare costs. • Claire shared the IMPACT model for depression care in a primary care setting as well as the “system savvy” BH providers must demonstrate to make these collaborations successful.

27. Wrap Up (cont.) • I highlighted Motivational interviewing as a key skill to master to create behavior change in the clinical work of integrated care and lifestyle management as well as a central component of the organizational redesign and rebranding BH providers must do to thrive in this ACA world. • Hopefully, we have met the learning objectives for this workshop and shared the philosophies, skill sets and adaptive characteristics each of our organizations must embrace to go beyond “surviving” to THRIVE in an ACA environment.

28. References & Resources • Adverse Childhood Experience (ACE Study/1995-1997 ) Collaborative effort between the Centers for Disease Control and Prevention and the Kaiser Permanente’s Health Appraisal Clinic, San Diego, California • Resources to acknowledge: • National Council’s learning communities • SAMHSA • SAMHSA-HRSA (Health Resources and Services Administration) • Center for Integrated Health Solutions (CIHS) • Sara Collins, PH.D, The Commonwealth Fund

29. THE END Thank you for this opportunity to tell our story today!