Integrating Primary Care and Behavioral Health: The National Perspective and Local Direction

1. Integrating Primary Care and Behavioral Health: The National Perspective and Local Direction Presented by: Kathleen Reynolds, LMSW, ACSW Vice President for Health Integration and Wellness

2. Why Integrate BH and PC?

3. History of Funding for Mental Health and Substance Abuse Services

4. What Created the U Turn? • The Impact of Block Grants on Mental Health and Substance Abuse Funding • During Regan Administration funding went to block grants to the states • Good at the time • Little if any increase to mental health or substance abuse block grants since

5. Movement to Medicaid as a Source of Funding for Mental Health • Substance abuse not included • Created entitlement to services for some who are Medicaid eligible • Less funding for persons without Medicaid

6. ARRA and Health Care Act Funding • Bureau or Primary Health Care ARRA Funding = $2 Billion + • SAMHSA – Did not ask for any • Bureau of Primary Health Care Patient Protection and Affordable Health Act = $11 Billion + • SAMHSA - $50 Million

7. Patient Protection and Affordable Health Care Act • Medicaid Expansion • Parity • Accountable Care Organizations • Medicaid/Medicare Medical Home Pilots

8. Accountable Care Organizations An ACO would have at least one hospital, a minimum of 50 physicians (primary care and specialists), commit to be in business for at least 3-5 years, and serve at least 5,000 patients. If the ACO met pre-established quality goals, it would receive an incentive payment. Penalties would be assessed if care did not meet the established quality goals. Incentive payments and penalties would be split between the members of the ACO. The providers in the ACO would follow best practices, be patient-centered and contribute to the development of best clinical practices to build standards of evidenced-based medicine

9. Behavioral Health Role in an ACO • Opportunity to define the role of behavioral health in the system • Specialty mental health only • Specialty mental health + physical health • Mental health for all • Other? • Expand role of mental health substance abuse role in primary care • Reduce stigma and increase access

10. Behavioral Health Role in ACO • Challenge to determine who will be the ACO in your area • Challenge to establish your position in the system if not already there • Important role for advocacy in the process

11. Medicaid/Medicare Health Care Home Home Pilots • The Medicaid Medical Home pilots allow states to enroll Medicaid beneficiaries with chronic conditions in medical home pilot projects as early as January 2011. This includes individuals with serious and persistent mental illnesses. Up to $25 million is available for states to plan and implement these projects. • Beginning in January 2012 Medicare can establish a pilot program that includes community health teams to increase access to comprehensive, community-based, coordinated care.

12. Medical Home Definition • While definitions of medical homes vary, the most widely accepted definition, supported by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and the American Osteopathic Association, includes the following principles; • Personal physician • Physician directed medical practice (team care that collectively takes responsibility for the ongoing care of patients) • Whole person orientation • Care that is coordinated and/or integrated • Quality and safety (including evidence based care, use of information technology and performance measurement/quality improvement) • Enhanced access to care • Payment structure that reflects these characteristics beyond the current encounter-based reimbursement mechanisms (http://www.pcpcc.net/)

13. Medical Homes & Behavioral Health - Opportunities • Need to insure that “medical” home includes mental health and substance abuse services • Get services to more people, earlier • Reduce stigma • As part of health care, reduce “stepchild” phenomena • Improve access to primary care

14. Medical Homes & Behavioral Health - Challenges • Insure that psycho-social treatment, case management and other key services get integrated into the model • Insure that those with the most severe issues do not get lost in the system • Where will the volume of new eligibles go?

15. Integration as Part of the Strategy • Integration does not mean return to a medical model • Provides access to multiple services at one time and place • Improves the quality of all services • Creates space within the current public sector for more consumers • Ultimately reduce the early loss of life for those with a serious and persistent mental illness

17. Bi-Directional Integration • BH in PC • Do it yourself • Work with private partner • Work with FQHC • PC in BH • Do it yourself • Work with private partner • Work with FQHC

18. The Four Quadrant Model for Integration National Council 4 Quadrant Model

19. Quadrant I • Quadrant I: Low BH/Low PH • PCP (with standard screening tools and BH practice guidelines) • PCP- Based BH • Interventions • Screening for BH Issues (Annually) • Age Specific Prevention Activities • Psychiatric Consultation • Financing • Primary Care Visits • SBIRT Codes for Substance Abuse

20. Quadrant III • Quadrant III – Low BH/High PH • PCP with screening tools • Care/Disease Management • Specialty Med/Surg • PCP based- BH • ER • Interventions • BH Ancillary to Medical Diagnosis • Group Disease Management • Psychiatric Consultation In PC • MSW in Primary Care • BH Registries in PC (Depression, Bipolar) • Financing • 96000 Series of Health and Behavioral Assessment Codes • Two BH Visits a month are billable

21. Quadrant II • Quadrant II – High BH/Low PH • BH Case Manager w/responsibility for coordination w/PCP • PCP with tools • Specialty BH • Residential BH • Crisis/ER • Behavioral Health IP • Other Community Supports • BH Interventions in Primary Care • IMPACT Model for Depression • MacArthur Foundation Model • Behavioral Health Consultation Model • Case Manager in PC • Psychiatric Consultation • PC Interventions CMH • NASMHPD Measures • Wellness Programs • Nurse Practitioner, Physician’s Assistant, Physician in BH • Financing • Disease Management Pilot in Michigan • CMH Capitation • Two BH visits a month in primary care

22. Quadrant IV • Quadrant IV- High BH/High PH • PCP with screening tools • BH Case Manager with Coordination with Care Management and Disease Management • Specialty BH/PH • Interventions in Primary Care • Psychiatric Consultation • MSW in Primary Care • Case Management • Care Coordination • Interventions in BH • Registries for Major PC Issues (Diabetes, COPD, Cardiac Care) • NASMPD Disease Measures • NP, PA or Physician in BH • Financing • BH Capitation • Primary Care Visits

23. Local Initiatives • Detroit Wayne County Integrated Health Work Group • The workgroup’s shared vision creates a healthcare community that supports all residents of the Detroit Wayne County region with behavioral and physical health services integrated to meet the needs of their bodies and minds as they work toward recovery and true.

24. Workgroup Objectives • To identify and/or design practical models for providing medical care in a community mental health center setting and mental health care in a primary health care setting • To identify policy or procedural changes needed to make these models self-sustaining • To obtain commitments from Medicaid Health Plans, Substance Abuse Coordinating Agencies, state and county governments • To make the policy and procedural changes necessary to implement successful integrated care models across Wayne County. • To examine ways to utilize existing resources to expand integrated healthcare • To enhance relationships between mental health providers and community health clinics in order to bring behavioral health services into primary care settings AND to bring primary care services into behavioral health settings

25. Workgroup Outcomes • This Training! • Financial Worksheet for Michigan • Sample Contract for FQHCs and CBHO’s to use for partnerships • Three Year Strategic Plan • Environmental Scan Local Innovators

26. National Training and Technical Assistance Center for PCBHI • Awarded to the National Council for Community Behavioral HealthCare • Four years; $5.3 Million/year • Target Audience • SAMHSA Grantees • HRSA Grantees • General Public • Services • Training and Technical Assistance • Knowledge Development • Prevention and Wellness • Workforce Development • Health Reform Monitoring and Updates

27. Questions?