David Johnson, MSW, ASW, Director of H ealth Services, Anthem, Inc.

1. Session # H2a October 16, 2015 Moving from Co-location to Integration: Collaboration Between a Health Plan (Managed Care Organization) and a Federally Qualified Health Center (FQHC) David Johnson, MSW, ASW, Director of Health Services, Anthem, Inc. Sean M. Benedict, Psy.D., LMFT, Clinical Supervisor, WellSpace Health Collaborative Family Healthcare Association 17thAnnual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Faculty Disclosure The presenters of this session • have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Define three components in building a collaboration between a payer and a provider. • Identify at least two strategies to move from co-located to integrated health services. • List three outcomes of a collaborative integrated health program

4. Bibliography / Reference Angstman, KB, Rohrer, JE, and Rasmussen, NH . PHQ-9 Response Curve: Rate of Improvement for Depression Treatment with Collaborative Care Management 2012 ;Journal of Primary Care & Community Health 2012; 3(3) 155-158 Kroenke, K and Spitzer, RL. The PHQ-9: A New Depression Diagnostic and Severity Measure Psychiatric Annals 2002;32(9) 1-7. Katon, WJ, et al. Collaborative Care for Patients with Depression and Chronic Illnesses. New England Journal of Medicine 2010; 363(27) 2611-2620. Pratt, LA and Brody, DJ. Depression in the U.S. Household population, 2009-2012, 2014 NCHS Data Brief, No. 172: National Center for Health Statistics. Waxmonsky, JA., et al Evaluating Depression Care Management in a Community Setting: Main Outcomes for a Medicaid HMO Population with Multiple Medical and Psychiatric Comorbidities. Depression Research and Treatment, 2012: Article ID 769298

5. Bibliography / Reference Nutting, PA., et al, Care Management for Depression in Primary Care Practice: Findings from the RESPECT-Depression Trial. Annals of Family Medicine, 2008; 6(1) 30-37. Whitebird, RR, et al Effective Implementation of Collaborative Care for Depression: What is Needed? The American Journal of Managed Care, 2014; 20(9) 699-708. Linde, K, et al, Effectiveness of Psychological Treatments for Depressive Disorders in Primary Care: Systematic Review and Meta-Analysis. Annals of Family Medicine, 2015;13(1) 56-68. Linde, K, et al. Efficacy and Acceptability of Pharmacological Treatments for Depressive Disorders in Primary Care: Systematic Review and Network Meta-Analysis. Annals of Family Medicine, 2015;13(1) 69-79. Coventry, P, et al. Integrated Primary Care for Patients with Mental and Physical Multimorbidity: Cluster Randomised Controlled Trial of Collaborative Care for Patients with Depression Comorbid with Diabetes or Cardiovascular Disease. British Medical Journal, 2015; h638.

6. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

7. WellSpace Health • Serving the Greater Sacramento Area since 1953 • Serving 35,000 unique patients a year in 13 health centers • Over 400 employees

8. WellSpace Health Services Include: • Medical, Dental, Women’s Health, Pediatrics • Behavioral Health includes: Psychiatry, IBH (PC Consults), Psychotherapy, Group Therapy, AOD Services, Case Management, ED Navigation, Transitional Housing, Suicide Prevention.

9. Anthem Inc. Fast Facts OUR MEMBERS Together, we aretransforming health care with trusted and caring solutions Purpose Statement 1 in 9 Americans 37 million total medical members 14 states 19 states 51,000 associates are employed by Anthem 68M $73B BC or BCBS plan Medicaid presence total operating revenue individuals served =1,000 $160million $5.6 million $45.9 million active dollars in local communities pledged associate giving (including Foundation match) in grants to local and national initiatives since 2000 9

10. Anthem, Inc. Government Business Division Anthem, Inc. affiliated health plans serve 8.1 million people in state and federal government health programs, including: • 5.2 million Medicaid members in 19 states • 580,000 Medicare members in 20 states • 204,000 MLTSS program members in eight states • Older adults and people with disabilities • Low income families • Other government-sponsored enrollees 10

11. Why Establish Integrated Behavioral Health? • “No health without mental health” • Quality of life • Morbidity • Impact on prognosis of other medical conditions (Prevalence 2 to 3 times higher for individuals with chronic pain, cancer, diabetes, heart disease, and other chronic health conditions) • Prevalent • Up to 26% of the US population suffers from a behavioral health disorder annually • The prevalence for any mood disorder is 9.5% • 6.7% Major Depressive Disorder; 1.5% Dysthymia; 2.6% Bipolar I and II • Demands on physician time

12. Core Program Components • Universal Screening or targeted screening • Identification/assessment of persons screening in clinical range • Interventions—collaboration between BHC and PCP • Health Coaching • Short-term, solution focused counseling • Medication • Referral to specialty MH • Consistent measurement and monitoring (registry) • Psychiatric Consultation

13. Getting Started • Health Plan • Collaboration • How many members by Provider • Staffing—”who owns the staff” • Training • Agreement—Contract, MOU • Finance Issues • Documentation and expected outcomes • Health Center • Administrative Support • Introduce program concept to staff • Review agreement • Physician champion • Logistics—space, phones, EHR forms • Hiring process

14. Roles and Responsibilities

15. Implementation Challenges

16. Program Launch The path to implementation is not likely to be straight All staff awareness Process in place for screening—if paper and pencil forms printed, know who will administer and what to do when patient scores in clinical range Ability to track agreed upon process and outcome measure

17. Implementation Challenges Health Center Health Plan Who supports implementation Moving beyond “cost offset” Role of Health Plan case managers Billing issues Training and orientation for health plan clinical services and provider relations If single payer, resolve that program will flow over to other payer’s members • Trust • More work for everyone • EMR/EHR modifications • Not the way we practice • Patient flow and process • Location of BHC • If single payer initiative how does program impact flows with other patients • Lack of staff experience

18. Addressing Challenges • Training—the model is an Evidence Based Treatment physicians can grasp • Meet • Frequent meetings early on • Reduce to monthly meetings to review program operations and data • Maintain flexibility and adaptability to reflect the health center culture

19. Member/Patient Engagement • Response to screening • Engaging members when in the clinical range • Diamond project noted an engagement rate of 15%. Whitebird, et al 2014 • Respect project reported 68.5% engagement Waxmonsky, et al 2013 • Organizational support (screener: “do you want to speak to BHC?”) • Physician support • Strong BHC

20. Moving from Co-location to Integration Health Center Health Plan Philosophy, a provider collaborative approach Financial model—value-based purchasing Consultation—technical and clinical expertise Data sharing & care coordination Quality management and outcomes • Philosophy, a team approach • Parsimony—screening and assessment • Evidence-based • Staffing • Team huddles • Documentation, EHR • Flexibility and adaptability • Outcomes and benefits

21. Outcomes • Improved detection and identification of depression • Improved health services—reduced wait time for specialty MH services • Decreased patient severity of depressive symptoms • Improved care coordination

22. Screening Program Initiation to June 15, 2015

23. Severity of Depressive Symptoms

24. Severity by Program Site Overall, a total of 1,260 members (30%) met our criteria for scoring in the clinical range with depressive symptoms. A multi-site program serving Medicaid members in Colorado screened 1,758 individuals, 36.9% scored a 10 or higher.

25. Member Prior Diagnosis and Treatment of Depression

26. Depression and SUD

27. Clinical OutcomesChanges in PHQ-9 ScoresIndex Visit to most recent

28. Sample Response Curve PC-INSITE

29. Sample Response Curve PC-INSITE

30. Non-Response or Treatment Resistant Depression • What about members who get significantly worse? • WellSpace review of 26 members in which symptom severity increased by 5 points or more • 17 Females; 9 males • Two-thirds did not engage, but continued to return for medical reasons • 22 of 26 meet criteria for SMI • 5 chronic pain; 2 presenting for controlled substances only • 3 of the 26 have reflected some improvement since these data were reported

31. Sustainability • Value-base as best practice • Improves the person’s experience as an active participant in addressing health issues • Clinical outcomes—improvement in health and well-being • Financial outcomes—physicians in clinic greater efficiencies; service utilization of emergency department and inpatient admissions decrease

32. Summary • Depression and SUD are significant factors impacting a person’s health and their health services utilization • PC-INSITE provides services in primary care settings to specifically address these conditions • Over 4,215 members have been screened since the launch of PC-INSITE in four states • 30% screened positive for depression • 9% screened positive for SUD • 60% of those members in the clinical range have had at least one follow-up contact and completed a second PHQ-9 • 59% Experienced at least some reduction in symptom severity at follow-up

33. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you! PEC-ALL-1661-15