“Making Health Care Whole: Getting Integration Unstuck ” Beginning our Dialogue about the Future 11:00-12:00

1. “Making Health Care Whole: Getting Integration Unstuck”Beginning our Dialogue about the Future11:00-12:00 • Take the time to listen, travel, and learn from each other. • Current Values: Pay for Performance; Foster Trust, Hope & Ownership; Person-Centered; Triple Aim; Information Drives Practice & Mgmt; Transparent; Reduce Waste; Cooperate. • We need to find a way to not put aside our unfinished business. We need to look forward, while assessing opportunity & risk. • What is needed is the ongoing program evaluation that allows us to incorporate evidence-based practice in real-time based on our learning. • Need to create systems that focuses on Person Centered Care & Population Health. • Key Concept: Chaordic–made up word combining chaos and order. The leading edge of change is always chaotic. Behind is a set of order that keeps it alive. • During periods of change, we must keep our edge of chaos, supported by a structure that is modified as we continue to learn. • Integration “Home Runs”– occurring across the country (California, Washington, Colorado, Missouri…). • Some of the challenges that occur in Integration: policy barriers, performance metrics, shifts in the locus of power, need to have the right people at the table, need for medical education, split between primary care and recovery, needs to develop stronger electronic records system…

2. “Making Health Care Whole: Getting Integration Unstuck”Developing the Future/Following the Money1:30pm-3:15pm • We are in the process of inverting the Resource Allocation Triangle. • Financing & payment models are not keeping up with the rest of the transformation efforts related to integration. • New York’s Statewide Medicaid Program (Harvey Rosenthal); • Don’t need more money, need to move the money; • “Best friends” are the Budget Director and Director of Medicaid; • Medicaid being used to support housing, workforce, peer support in NY; • Relationship s are key. Start where people are. Person Centered Planning; • MRT (Medicaid Redesign Team) Plan included care management for everyone; • HARP (Healthy & Recovery Plans) work done through Home Health Teams, including rehabilitation, habilitation, crisis intervention, educational support, peer support, self directed services, employment & support services (outcomes attached); • Technical assistance made available. • Michigan (Tony Rothschild) • How do you position yourself for opportunity; • Answered question about what would happen if the carve-out went away; • First step was talking to everyone. Developed a core group of 4+providers to work together to maximize community Impact; • Spent time analyzing data. Engaged social investor, who help develop materials. Getting ready to launch.

3. “Making Health Care Whole: Getting Integration Unstuck”Developing the Future/Following the Money1:30pm-3:15pm • Orange County, CA (Mary Palafox, RN, Family Advocate) • Suggests that we expand and broaden the scope of what we are doing in integrated health; • Shared personal story; • Advocates for close medical supervision; • Emphasized the need for engagement early on; • “When you study the mind, don’t leave the body behind”; • Wants to emphasize compassion. • Open Comments • Suggested starting dialogue to get unstuck at local hospital (asking where their “pain point” is); • Need to broaden our toolkit; • Need to knock down the clinical and money silos; • Potential future sticking point, having too much disconnected care management. Need to coordinate service delivery and present to the client as a team. Bottom line, need one care team, one care plan , all connected electronically, driven by the person.

4. “Making Health Care Whole: Getting Integration Unstuck”Continuing our Dialogue/Managing Complex Populations in Primary Care & Specialty BH Settings8:45am-10:15 • Facilitator: Andy Sekel, PhD, CEO, Optum Specialty Networks • Panelists: Trudi Carter, MD, CMO, LA Care; Roger Kathol MD, CEO, Cartesian Health Solutions; Laura Galbreath, MPP, National Council; Ian Shaffer, MD, President, Behavioral Health Management Solutions • Levels of integration-how do we define? It can be from practice, to MCO, to funder levels to assure consistency of support. • Ian spoke about an attempt to integrate the range of people engaged with family, so much so it isn’t clear who works for which organization. Break down the barriers. • Trudi spoke about the transition that occurred w/LA Care. • Roger spoke about how we need to adapt because behavioral health will not be the same in 5 years. Need to incorporate value added services. • Laura talked about the need to focus on the vision for the future. Need to think about behavioral health as population-based health. • Andy talked about integration happening at Optum. • Discussion around integration as population management strategy vs. working with people with complex conditions. So far, money is focused on complex conditions. Encouraged to avoid “legacy thinking” when it comes to working with people w/complex conditions.

5. “Making Health Care Whole: Getting Integration Unstuck”Continuing our Dialogue/Managing Complex Populations in Primary Care & Specialty BH Settings8:45am-10:15 • Examples of value-added services: outpatient collaborative care (positive outcomes); inpatient proactive consultation (positive outcomes); peer support; behavioral health services that take place in medical settings; tele-health in rural communities. • The amount you save by adding clinical care to medical setting saves money in the long run. Behavioral health has to be part of medical benefits. • LA Care stratifies the risk into different levels, and everyone gets a risk assessment, not just those with complex conditions. • If we are truly going to have an integrated affordable system, we have to integrate behavioral health in primary care settings. Consolidation is going to have to happen. • Discussion about the need to have peer support on every behavioral health team. • Need to educate the workforce, including primary care doctors. Need to build capacity. • Need to have care management teams that include nurses, docs, social workers, peer supports… • Talked about the need to shift our thinking & focus to Wellness. • If we are going to integrate, we will each need to give up a little and will need to make room for each other. We tend to have varied approaches, so we need to be able to better define what we do.

6. “Making Health Care Whole: Getting Integration Unstuck”Practice Transformation as Litmus Test: Skills Development, Information and Infrastructure3:15-4:30 • Consideration of an Integration Interest Group including monthly calls, on-line consultation, webinars, Q&A. • Facilitator: Tomas Moran, CEO, Health Metrics Systems • Panelists: Trudi Carter, MD, CMC, LA Care; Danna Mauch, PhD, Senior Fellow AbtAssoicates; Gilbert Newman, PhD, Dean, Wright Institute, Berkeley, CA • Discussion about key characteristics of “transformation”: • Need to have a vision • Willingness to make changes to get there • Discussed “attitude” needed for change. At Wright Institute, changed the training program in order to respond to changing culture, did not make the changes through curriculum. • Need to decide which pieces of behavioral healthcare need to stay the same, and which need to change. • Leadership is critical, need people who can bring people together around a shared vision/mission. • Clinical systems and protocols needed for every piece of care. Practice management & financial systems that support this new structure. • Having practice-based QI that provide rapid feedback, so they can make adjustments as needed.

7. “Making Health Care Whole: Getting Integration Unstuck”Practice Transformation as Litmus Test: Skills Development, Information and Infrastructure3:15-4:30 • Talked about the need to give our staff more information about the context of their work, including financial information. Regular reports are needed to inform people how they are doing. • There has been a lack of data available. It is important that we are consistently collecting data and sharing it with staff. • Discussed sustainability. Some of the organizations that are doing integration well have worked hard to diversify their funding base. • The data collected is often process data, not outcome data. • Need for alignment of finances with outcome. • There may be waste in the system that could be opportunity for cost-saving. • It’s more difficult to show funders that they are going to save money when the individual has not “crashed and burned” yet. • As you begin to share information, you begin to change the nature of the conversation. As you see real data, it takes away the “us-them” dynamic. Data is not always easy to come by. • When we (behavioral & medical) are together, we are talking about the “total patient”, it becomes clear that people are better off at a lower cost. • Identified need to make sure preventative services are a key piece of the mix. LA Care has been considering primary care as a low-level behavioral health provider since people begin there. Primary care writes 80% of the prescriptions for behavior health.

8. “Making Health Care Whole: Getting Integration Unstuck”Practice Transformation as Litmus Test: Skills Development, Information and Infrastructure3:15-4:30 • Story shared where EMR’s and PC’s were introduced to primary care doctors, yet the majority are not using. Has come up against quite a bit of resistance. • Need to think about organizational shift and culture change. • Panelist challenged us to change our story to say, “we are masters at the storyline of savings”.