Integrating Primary Care into Your Behavioral Health Practice

1. Integrating Primary Care into Your Behavioral Health Practice Dave Cook, LICSW, Chief Executive Officer Heather Geerts, LICSW, Clinical Director Scott Gerdes, Chief Financial Officer Casey Langworthy, RN, Primary Care Nurse, Care Coordinator

2. Community Resource for Behavioral Health • Providing behavioral health services to SE Minnesota since 1966 • Therapy and psychiatry • Regional detox unit • Residential/crisis treatment facility • Community support programs • 150 total employees

3. Community Resource for Behavioral Health • Provide continuum of behavioral services to SE Minnesota and state-wide • Community mental health center primarily for Olmsted, Fillmore county residents

4. Unique Patient Demographics • Morbid obesity • Hypertension • Diabetes • Asthma • Chronic pain • Heart disease • Zumbro Valley Mental Health Center provides services to 5,000 people annually • 84% of these patients enrolled in publicly funded insurance options • Medicaid expansion in 2014 will add 4,700 new enrollees in Olmsted County • Many of these patients have significant behavioral and medical conditions • Over 70% of publicly funded patients diagnosed with serious mental illness (SMI) or severe and persistent mental illness (SPMI) • 1 of 3 patients utilize multiple services • More than 70% of patients seen in Psychiatry have a serious co-morbid condition:

5. Challenges • Mental health centers across state facing variety of challenges • Low reimbursement rates for expanding Medical Assistance and Medicare populations • Growing need for treatment of people with dual diagnoses and co-morbid conditions • Difficulty finding and retaining qualified behavioral health professionals • Transforming care to meet rapidly changing demands of diverse populations

6. Services Prior to Integrated Care Model

7. Adding to the Continuum of Care

8. Pre-Primary Care Model Intake Pharmacy Electronic Medical Record Dental

9. Co-morbidity is the Rule, Not the Exception • Data-mining of Electronic Medical Record revealed 74% of psychiatric patients diagnosed with serious medical condition • Research shows that people living with serious mental illness die an average of 25 years earlier than the general population1 • Lack of access to primary medical care • Preventive health services 1 Colton, CW, Manderscheid, RW. “Congruencies in Increased Mortality Rates, Years of Potential Life Lost and Causes of Death among Public Mental Health Clients in Eight States.” Preventing Chronic Disease, vol. 3, no. 2, 2006.

10. Co-morbidity is the Rule, Not the Exception • Integrated model of care incorporates mental health, chemical health, case management, housing, dental and pharmacy services with primary care • Goal is to significantly improve clinical outcomes for area’s underserved populations

11. Steps Toward Integration - Research • Mental disorders and medical co-morbidity • The Synthesis Project. Robert Wood Johnson Foundation. 2011. • Basis for project rationale • Correlation between childhood maltreatment and later-life health and well-being • Adverse Child Experiences (ACE) Study. Centers for Disease Control and Prevention. 2010.

12. Steps Toward Integration – Pre-Planning (Phase 1) • A pre-planning group of community leaders, Zumbro Valley staff and board members was assembled to discuss the research and subsequent efforts to address the problem • Zumbro Valley conducted an internal patient survey and review of records that determined approximately 85% of psychiatric clients have a serious co-morbid medical condition

13. Steps Toward Integration – Pre-Planning (Phase 1) Conduct literature review on the service models for integrated care Evaluate how primary care services have successfully been integrated in community mental health centers within Minnesota and other parts of the country Determine the financial model required for operation Develop the space and specifications needed for on-site services Explore the need for other resources

14. Steps Toward Integration – Planning (Phase 2) • Developed on-going Community Advisory Committee to assist Zumbro Valley board and leadership team in the development and implementation of the Primary Care Clinic • Mayo Clinic ­ Olmsted Medical Center • Olmsted County ­ Rochester Area Foundation • MN Dept. of Health ­ Olmsted Public Health • United Way of ­ MN Dept. of HumanOlmsted County Services

15. Steps Toward Integration – Planning (Phase 2) • Committee agreed community required integrated care model and primary care services for area’s under-served populations • Hired consultant to develop business plan and assist with financial pro forma • Developed guiding principles, goals, performance outcomes, community benefits, etc. • Formalized clinical model of care, with clinical integration manager serving as hub

16. Steps Toward Integration – Planning (Phase 2) • Trust major issue for target population • People diagnosed with a serious mental illness significantly less likely to trust others • Lack of follow-through by these clients with community medical providers • Survey found clients view Zumbro Valley MHC as their primary care provider

17. Steps Toward Integration – Planning (Phase 2) • Planning workgroup developed project goals to assess short- and long-term outcomes • Improve health outcomes by enhancing the diagnosis of chronic health conditions and providing treatment of these conditions • Improve quality of health by increasing focus on wellness and healthy lifestyles • Provide person-centered care and whole-person-centered care approaches • Contain health care costs • Improve care coordination between behavioral and primary care services • Improve the patient experience

18. Steps Toward Integration - Implementation Referral Source Call to Zumbro Valley Hunt Line Primary Care Clinic Pharmacy Dental Electronic Medical Record

19. Steps Toward Integration - Implementation • The Primary Care Clinic team consists of a primary care provider (nurse practitioner) and support staff (registered nurse) • Perform ancillary services – vital signs, measuring BMI, etc. • Process lab samples and send out for results • Provide medical exam and any ongoing care • Refer patients to community specialty care providers

20. Steps Toward Integration - Implementation Current Model • RN care coordinator performs both clinical and care coordination duties • Primary responsibilities: • Performs triage of new and ongoing patients to determine level of care needed • Coordinates care for clinic patients with internal and external providers • Provides regular follow-up contact to affirm adherence to treatment plan

21. Steps Toward Integration - Implementation Future Model • Primary care clinic also has an intake worker (BA level social worker) to assist with care coordination • Primary responsibilities: • Answer calls within 30 seconds • Triage level of care needed: crisis, urgent, routine • Arrange for logistics: transportation, community resources, insurance enrollment, etc. • Make appointment reminder calls

22. Steps Toward Integration - Implementation • Each new patient is assigned a clinical integration manager (nurse practitioner or clinical social worker) for the course of treatment • Primary responsibilities: • Conduct diagnostic assessment • Triage risk level: high, medium, low • Monitor and evaluate risk levels • Refer to appropriate behavioral/medical provider • Lead weekly clinical care conferences • Track patient outcomes

23. Steps Toward Integration - Benefits • Improved quality of life for clients • Increased medical and behavioral compliance • Wellness programs that compliment medical and behavioral services • Ability to share clinical information via EMR • Improved overall health and well-being

24. Steps Toward Integration - Benefits • Appropriate Level of Care = Reduced Costs • Reduced ER visits and inpatient hospital days • Decreased utilization of after-hours crisis/ambulance services • Visits can be routine (primary care) rather than acute (emergency department) • Fewer psychiatric visits due to medical stability

25. Steps Toward Integration - Benefits • Enhanced Access to Care = Improved Outcomes • Proper medical care contributes to overall housing stability • Improved medical health results in better overall health of clients • Ability to share clinical information with other health care providers via electronic medical record

26. Steps Toward Integration - Payment • Developing a strong financial pro forma key to successful plan • Where do we start? • What pieces are different than mental health? • What CPT codes do we need to include? • How is productivity different?

27. Steps Toward Integration - Payment • Developing a financial pro forma – where to start? • Examination of payer mix • Research Evaluation and Management (E/M) codes to identify appropriate types and levels • Review Medicare and Medicaid reimbursement rates for selected services • Determine billing rates for medical services

28. Steps Toward Integration - Payment • Developing a financial pro forma – start-up costs? • Building space • Supplies • Equipment • Furniture

29. Steps Toward Integration - Payment New Patient Codes

30. Steps Toward Integration - Payment Established Patient Codes

31. Steps Toward Integration - Payment

32. Steps Toward Integration - Payment

33. Steps Toward Integration - Payment • Developing a financial pro forma – other costs? • Services and coding • Fee matrixes for primary care • Lab service integration

34. Steps Toward Integration - Payment • Model for financing publically funded primary care clinic has many financial challenges • Low reimbursement rates from Medicare, Medicaid do not support expenses • Low reimbursement levels = requires higher volume of clients • Tax status change (MNCare)

35. Steps Toward Integration - Payment • Zumbro Valley utilized variety of sources to pay for clinic • Obtained funding from Minnesota State Legislature to pilot integrated care model • Applied for and received multiple grants from local, state and national sources to help offset operational expenses • Explored opportunities to obtain FQBHC, health home and behavioral health home status for higher reimbursement of services • Received equipment donations from community sources such as Mayo Clinic

36. Steps Toward Integration - Challenges • Project – and Qualifacts system – are using a variety of measurements to determine outcomes • Meaningful Use • Physician Quality Reporting System (PQRS) • E-Prescribing (DrFirst) • DSM-5/ICD-10 cm enhancements • Minnesota 10x10 Initiative (Minnesota MHIS) • Minnesota Depression Care and Diabetes management

37. Steps Toward Integration - Challenges • Other Challenges – Electronic Medical Record • Configuring Carelogic to bill primary care services required close working relationship with QSI • Key tasks included • Creating new EDI file to accommodate Minnesota Administrative Uniformity Committee • Setting up overlapping E/M codes for primary care services • Organizing CPT codes and other activities • Creating pricing structure based upon market data • Modifying program history for admitting diagnosis • Mapping new National Provider Identifier number to all services

38. Steps Toward Integration - Challenges • Other Challenges – Laboratory services • Identify lab provider (Quest Labs) who can interface with system • Utilize web portal to transact information on patient lab results, submit orders, review results, etc. • Billing for laboratory services • Determine how payers reimburse for lab services • Discuss use of new e-Labs program with Qualifacts

39. Steps Toward Integration - Challenges • Other Challenges – Third party contracting • Negotiate agreements with payers to reimburse for medical codes • Medicaid • Medicare • Others – Blue Cross Blue Shield, Optum, MMSI (Mayo), UCare Minnesota, South Country

40. Steps Toward Integration - Challenges • Other Challenges - Clinical • Found there were numerous cultural differences between medical and mental health settings • Success of integrated model dependent upon availability and willingness for cross-consultation • Need for seamless connection with external specialty care providers for complex care needs

41. Steps Toward Integration - Challenges • Other Challenges – Staff and training • Staffing • Identify right number of people and appropriate positions • Budget for productivity • Determine type of clinicians/licenses to properly bill for services • Training • Prepare appropriate documentation • Have provider choose the right codes • Conduct ongoing training and note review

42. Steps Toward Integration - Challenges • Other Challenges – Care coordination and patient registry • Coordinate with area health care providers to transition care back and forth • Use of weekly clinical conference to discuss highest-need patients with all applicable personnel

43. Steps Toward Integration - Outcomes • Clinic staff has seen nearly 100 people since opening in December 2013 • Expanding services at 7th Street office • RN to be available 8 hours per week

44. Steps Toward Integration - Outcomes • Development of patient registry critical element to gauge success • Track patients with specific chronic conditions • Allow for appropriate patient staffing • Determine who, if anyone, is “falling through the cracks” • “Jane’s Story”

45. Steps Toward Integration - Outcomes • Measurement of clinic outcomes was core principle from project initiation • Contracted with third party – Wilder Research – to measure outcomes • Wilder staff will present results of 2-year study to Minnesota Legislature in 2015 • Collaborative effort to gather data • Minnesota Department of Human Services • Wilder Research Team • Rochester Epidemiology Project

46. Steps Toward Integration – Lessons • Important lesson learned throughout process has been having the right partners • Company with a vision • Roadmap for the future • Knowledgeable program staff • Supportive agency environment • Key to success of project has been willingness of QSI and its staff to provide assistance • Be flexible about model and funding

47. Steps Toward Integration - Milestones • 2011 • January: added pharmacy and dental services • July: began research of Robert Woods Johnson Synthesis Project and Adverse Childhood Experience (ACE) studies • September: implemented Community Advisory Committee • 2012 • January: formalized internal integration activities • June: submitted grant request to SAMHSA • July: began meetings with state leaders • July: entered Phase 2 of project and hired consultant

48. Steps Toward Integration - Milestones • 2012 (continued) • October: received financial support from Community Advisory Committee members • January – December: presented to local and regional organizations • 2013 • January: completed business plan and Olmsted County designated our project as a key initiative for legislative session • July: received appropriation from State of Minnesota • August: combined internal integration activities • 2014 • January - September: received grants from Mayo Foundation, Merchants Bank, Schmidt Foundation, Medica Foundation

49. Questions?

50. For More Information… David Cook, LICSWChief Executive Officer507.535.5718 or davec@zumbromhc.org Heather Geerts, LICSWClinical Director507.535.5745 or heatherg@zumbromhc.org Scott GerdesChief Financial Officer507.535.5717 or scottg@zumbromhc.org Casey Langworthy, RNPrimary Care Nurse/Care Coordinator507.535.5616 or caseyl@zumbromhc.org