The Pitfall and Promise of Integrating Care

1. The Pitfall and Promise of Integrating Care David Freedman, Lina Castellanos, Thomas Jardon, Cynthia Rodriguez, David Fuentes, Ketia Harris, Megan Hartman, & Angela Mooss

2. Integrated Care: Reconnecting the Head and Body

3. Cost of Co-occurring Conditions Milliman, 2014

4. Cost Milliman, 2014

5. Cost and Disparities Netsmart, 2013

6. Three-Legged Stool of Healthcare Integration

7. Integration, you say?

8. Integration Service Flow

9. The Four Quadrant Clinical Integration Model samhsa.integration.gov

12. Minority AIDS Initiative – Targeted Capacity Expansion SAMHSAMAI-TCE: Miami SITE

13. 4.2 M for 3 Years from SAMHSA

14. Project Flow Chart SAMHSA Florida Health Behavioral Science Research Institute South Florida Behavioral Health Network Citrus Health JTCHC

15. SAMHSA Funding

16. Siloed Funding

17. Main Players: Behind the Scenes Florida Health- Tallahassee and Miami Dade (DOH) • Required grantee due to HIV impact • Coordinated with ECHPP South Florida Behavioral Health Network (SFBHN) • Managing entity for behavioral health dollars via Department of Children and Families Behavioral Science Research Institute (BSRI) • Evaluation team • Crossover with Ryan White Program

18. Main Players: The Providers Citrus Health • 5 medical clinics and 24 schools • Hialeah area • 55% female • >80% Hispanic/ Latino • 52% best served in another language • 28% uninsured Jessie Trice (JTCHC) • 9 medical clinics and 23 schools • Liberty City area • 63% female • 67% Black/African-American • 13% best served in another language • 60% uninsured

19. MAI-TCE Miami took on three distinct phases MAI-TCE Project Phases

20. Phase One:Gearing up for Integration • Start Date • February 2012 • Logistics • Funding • Staffing • Implementation • Buy-in • Organizational level • Between partners

21. Challenges Successes • Fiscal tracking • Data burden • Training/EBI’s • Staffing • Collaboration/Team building • SFBHN/organizational level • Data sharing with Evaluation • Provider MAI-TCE teams • Capacity Building Logistics

22. Challenges Successes • Cultural differences • Medical vs Behavioral health • HIV and Ryan White services • Billing for services • The need is recognized and departments find relief • Integration is accepted at top-down level in theory • SFBHN assists with billing and loosening staffing regulations Buy-in

23. Lessons Learned • Make preparations • Present changes to other departments ahead of time • Collaboration is critical • Need a team of support • Planning and persistence • This takes time

24. Phase Two:Customizable Integration • Start Date • June 2012-May 2014 • Planned changes • Mandated by funders (TRAC vs. GAIN) • Necessary to meet EBI requirements • Unplanned changes • HIV testing • Staff turnover

25. Challenges Successes • EBPs/DEBIs changed • Client needs and outdated practices • Training overload • Staff turnover • Systems-level funding and documentation • Flexibility in training and EBI implementation • Peers implementing • Translation of tools as needed • Data and service documentation • Removal of GAIN-I • SFBHN consistent updates (delete orphans, etc) • Data became useful internally Planned Changes

26. Challenges Successes • 80% follow up rate goal • Does not fit BH clients • Reassessment and DC lists become unmanageable • Rapid Testing HIV mandate • New testing site IDs • Training • Duplicative data • Testing numbers cannot be shared • Advanced integration model for service delivery • Advocating at all levels • A true team approach • DOH was instrumental • Capacity building • Filling a huge need (especially at Citrus) Unplanned Changes

27. Lessons Learned • The need to truly customize cannot be understated • Peers are critical to successful models for client satisfaction • Integration is working • More clients are getting the services they need and large FQHCs have fewer silos internally

28. Phase 3:Wrap-up and Sustainability • Start Date • June 2014 to present • A focus on Medicaid billing and staff coverage • Focus on implementing EHR systems that are effective • Concentration on seeking out additional funding through grants/foundations

29. Challenges Successes • Non-Medicaid expansion • EMRs lack sophisticated technology and are expensive • SAMHSA and other billing systems are not set up for co-occurring clients • Grant funding is competitive • SFBHN advocacy for EMRs and data systems changes • EMRs responding • Funders are responding • Miami secured grant monies Funding

30. Challenges Successes • Staffing • Certifications for peers, behavioral health techs, non-client specific coordinators • Organizational structure • What has really changed? • Medical and behavioral are still separate, but… • Staffing has changed organizational practice • Use of peers, recognition for coordination across sites • Other departments believe in the value of behavioral health • Healthcare culture is changing Organizational Integration Culture

31. Lessons Learned • Change happens with persistence • Generating buy-in at the organizational level can speed things up • Collaboration is key to successful integration and sustained funding

32. If you don’t remember anything else… Remember this Take away points

33. Behavioral Health Primary Care Network Committee (BHPCNC) • A committee for health integration • Guided by principles: • Inclusion, Collaboration, CQI, Resource savings, Community-based, Resilience and Recovery • Vision/Mission • Oversee the expansion of culturally competent and effective behavioral health services • To monitor and enhance the linkages between and integration of behavioral health services in primary care • Less formal • A focus on training and capacity building across the systems of care

34. The Miami Model • Screening (SBIRT) • Use of peers • HIV testing • EBIs • Data driven • Co-location has been extremely helpful with piloting/forming the model

35. Project Outcomes • Reduction in days spent: • Homeless • Hospital MH unit, detox, jail, emergency room • Reduction in unprotected sex • Increase in risk perceptions • Decrease in mental health symptoms and social support • Increase in access to comprehensive health services • Decrease in substance use • But not in tobacco use

36. System-wide Implications • Expansion of integration to chronic disease management and other aspects of health • Providers are held to higher standards of care and care coordination • Focus on prevention and wellness

37. Go Forth and Integrate Questions/Comments David Freedman – Project Director dfreedman@sfbhn.org (305) 860-8235