Federally Qualified Health Center Integration Efforts

1. Federally Qualified Health Center Integration Efforts Michigan Institute for Prevention and Treatment Education September 16, 2013 Rebecca Cienki, Chief Operating Officer Brittany Beard, Program Specialist Michigan Primary Care Association

2. Mission & Vision MPCA's mission is to promote, support, and develop comprehensive, accessible, and affordable community-based health care services to everyone in Michigan. MPCA vision is to build a healthy society in which all residents have convenient and affordable access to quality health care. MPCA will be a leader in influencing health care policy, legislation, and regulation fostering comprehensive, community governed, quality care that ensures excellent health and quality of life for all residents of the United States.

3. World Health Organization • Definition of Health: • Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmary

4. Example Mission Statements “…improves the health and wellness of individuals by providing comprehensive primary and behavioral health care while encouraging access by those who are underserved” “To improve the quality of life for our patients through the blending of primary care, behavioral health and prevention services.”

5. Individuals w/ Substance Abuse Disorders have: 54% of addiction treatment programs have no physician http://www.medscape.com/viewarticle/729401 Nine times greater risk of congestive heart failure Twelve times greater risk of liver cirrhosis Twelve times the risk of developing pneumonia

6. Prevalence in Primary Care http://www.medscape.com/viewarticle/729401 20% of patients seen in family practice have Substance Abuse Disorders SUDs are currently ranked among the top 10 leading preventable risk factors for years of life lost to death and disability 2007, approx. 22.3 million adults were classified as having a substance dependence or abuse disorder

7. Outcomes from Integration http://www.integration.samhsa.gov/clinical-practice/13_May_CIHS_Innovations.pdf • Two or more primary care visits in a 6 month period has shown to improve abstinence during recovery from a SUD by 50% • Individuals with medical conditions related to substance abuse are three times more likely to achieve remission over 5 years • Regular health and addictions care for people with substance abuse disorders decreased hospitalizations by up to 30%

8. Mental Health & Substance Abuse FTE in Michigan FQHCs

9. Mental Health & Substance Abuse Visits per Provider Type in Michigan FQHCs

10. Number of Mental Health & Substance Abuse Visits in Michigan FQHCs* *2012 was the first year Health Centers were required to report for all diagnoses, not just primary. Dramatic increases more accurately reflect the population prevalence.

11. Number of Mental Health & Substance Abuse Patients in Michigan FQHCs* *2012 was the first year Health Centers were required to report for all diagnoses, not just primary. Dramatic increases more accurately reflect the population prevalence.

12. Prevalence of Behavioral Health Conditions Among Medicaid Expansion Population: Michigan, US Source: SAMHSA 2008-2010 National Survey on Drug Use and Health 2010 American Community Survey.

13. The National Institute of Mental Health • 2008 • 26.2% of Americans ages 18 and older suffer from a diagnosable mental disorder • 57.7 million people • ½ of all lifetime cases begin by age 14 • ¾ of all lifetime cases begin by age 24 • 70% of primary care visits stem from psychosocial issues

14. Substance Abuse Disorders (SAD) 20% of patients seen in family practices have SADs Ranked among the ten leading preventable risk factors for years of life lost to death and disability Diagnosed in only 9% of general and family practice visits and 8% of internal medicine visits

15. John Hopkins Healthcare http://www.chcs.org/publications3960/publications_show.htm?doc_id=633674 • Demonstrating a Return on Investment for Integrated Substance Abuse Treatment and Medical Care Management • 603 adult Medicaid enrollees, frequent use of medical services from past 12 month claims • Received routine care • 400 members placed in intervention group • Management from substance abuse coordinators • Nurse care managers

16. John Hopkins Healthcare http://www.chcs.org/publications3960/publications_show.htm?doc_id=633674 • Results • Within 12 months, savings of $122 per member per month • Decrease of 288 admissions per 1,000 members • Decrease in 92 days admitted per 1,000 members • Decrease by 45 days admitted per 1,000 • $3.65 return on investment for every $1 spent on intervention

17. Definition • Behavioral health integration (BHI) is defined as a partnership between primary care providers and mental health/substance abuse providers • This can be a partnership between organizations or a collaboration between providers within one organization

18. Collaboration Continuum

19. Type 1: Minimum Collaboration Primary care providers and behavioral health providers work in separate facilities, have separate systems, and communicate only sporadically

20. Type 2: Basic Collaboration at a Distance • Primary care and behavioral health providers have separate systems at separate sites, but engage in periodic communication about shared patients, generally by telephone, letter or email • Communication is driven largely by specific patient issues • Primary care and behavioral health providers view each other as resources, but do not share responsibility over patients

21. Type 3: Basic Collaboration On-Site • Behavioral health professionals and primary care providers have separate systems but share the same facility • Proximity allows for increased communication about shared patients, but each provider remains in his or her own professional culture • This model is primarily a referral-based process with providers working more closely and with improved communications

22. Type 4: Close Collaboration in a Partly Integrated System • Behavioral health professionals and primary care providers share the same facility and have some systems in common, such as scheduling appointments or medical records • Physical proximity between providers allows for regular face-to-face communication and even coordinated treatment plans for difficult cases • There is a sense of being part of a larger team, yet the pragmatics are sometimes difficult

23. Type 5: Close Collaboration approaching a Fully Integrated System • Behavioral health professionals and primary care providers share the same facility, the same vision, and the same systems to provide unified behavioral and physical health services • The patient experiences the behavioral health treatment as part of his or her regular primary care • Primary care and behavioral health staff interact regularly and typically have an integrated medical record and single treatment plan • All professionals are committed to the idea of a team-based approach and understand each other’s roles and functions

24. Type 6: Close Collaboration in a Fully Integrated System • The behavioral health provider and primary care provider are part of the same team and have overcome the barriers and limits to traditional care and funding structures • Patient care is provided through a team-based approach involving joint assessment and treatment plans, with shared responsibilities for outcomes • Providers and patients view the system as cohesive and holistic

25. Behavioral Health Mapping Project Goals Support from MPCA Support from other organizations Encourage organizational partnerships Encourage further development of integration projects Tool for policy advocacy

26. Michigan BHI Project

29. Benefits of Integrated Care • Patient’s health and well being becomes the focus of care • Team-based care is associated with higher patient satisfaction and better clinical outcomes • Greater opportunity for long-term management of chronic, complex illness • Higher likelihood of adherence to treatment plans • Greater opportunity for prevention and early intervention • Provides more holistic care • Increases access to care • Prevents duplication of services • Decreases stigma

30. Challenges Cited Developing relationships Increasing understanding Difficulty recruiting Communicating electronically and sharing health information Sustainability of funding Cross-training of staff

31. Common Barriers/Changes Made by Centers Integrating Services • Culture Change • Language • Mannerisms • Expectations about patient visit • Length of visit • One Mission/One Vision • Physical Layout of Center • Multidisciplinary Care Team Meetings • Address readiness to change • Reimbursement/SBIRT codes

32. Michigan Health Center Behavioral Health Survey • Winter 2000, MPCA commissioned a study, Addressing Patient’s Behavioral Health Needs in Michigan’s Community Health Centers • Results: • 1 of 2 patients have behavioral or emotional problems • 1 of 3 patients have depression as a primary or secondary diagnosis • 1 of 5 patients are currently receiving services from mental health professionals • Communication is poor between primary care and behavioral health professionals

33. Outcomes from Integrating Care http://archinte.jamanetwork.com/article.aspx?articleid=646882#WHYSUBOPTIMALLINKAGE? • On average 35% of patients receive physical healthcare at SUD clinics • Those that do, experience: • Greater Abstinence • Returning Twice as Often for Outpatient Visits • Lower Mortality Rate

34. FQHCs Licensed as Substance Abuse Providers • Baldwin Family Health Care • On-site counseling • State licensed substance abuse services • JCAHO accredited programs • On-site MSW’s • Certified addictions counselors on-site • Cherry Street Health Services • On-site Mental health and addiction counseling • Case Management • Outpatient counseling, residential treatment, transitional &re-entry services • Sterling Area Health Center • Psychiatry • Substance abuse treatment/counseling and prevention

35. Screening, Brief Intervention, Referral, and Treatment • Non-confrontational, short health counseling technique • Not a quick fix treatment • Motivating an individual to do something about an existing substance abuse problem

36. Screening, Brief Intervention, Referral, and Treatment • Why SBIRT is a critical Prevention Strategy? • U.S. Preventive Services Task Force recommends screening and brief interventions • Similar to preventive screenings for chronic diseases • Covered by insurers with no deductible or co-pays

37. SBIRT Billing Codes Chart

38. MPCA’s Legislative Priority • Promote the Integration of Health Care Service with Commensurate Funding • Successful Integration: • Enhanced access to services • Improved quality of care • Lowered health care expenditures

39. Promoting Integration • Recommended Action for Michigan • Explore evidence-based integrated delivery care models • Create incentives for system change • Payment reform • Funding for shared efficiencies

40. Promoting Integration • Policies to Pursue • Medicaid payment for Patient-Centered Medical Home designation beyond the Michigan Primary Care Transformation Demonstration (MIPCT) • Medicaid participation in the Centers for Medicare and Medicaid Services (CMS) Health Home Initiative (Section 2703 of the Affordable Care Act) • Medicaid payment for non-traditional service providers including Certified Peer Support Specialists, Health Coaches, and Health Navigators • Medicaid reimbursement delivered in the form of bundled payment to facilitate the provision of team-based care, inclusive of care coordination and transition across different levels of the health care system

41. Recommended Actions • “Turn on” codes essential to integrating behavioral health services • 96110 – Developmental screening, with interpretation and report, per standardized instrument form • 96150 – Health Behavior Assessment; 15 minutes (initial assessment) • 96151 – Health Behavior Assessment; 15 minutes (reassessment) • 96152 – Health Behavior Assessment; 15 minutes (individual) • 96153 - Health Behavior Assessment; 15 minutes (2 or more patients) • 96154 – Health and Behavior Assessment; 15 minutes (family with patient) • 96155 – Health and Behavior Assessment; 15 minutes (family without patient) • 90839 – Psychotherapy for crisis, first 60 minutes • 90840 – Psychotherapy for crisis • 99406 – Smoking cessation • 99407 – Smoking cessation • 99238 – Hospital discharge day management; 30 minutes or less • 99239 – Hospital discharge day management; more than 30 minutes • 99408 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes • 99409 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes

42. Recommended Actions • Include additional mental health providers in the CHAMPS system; including licensed social workers and psychologists, recognizing their important role in an integrated health delivery system and providing a waiver of substance abuse certification/credentialing for all incensed behavioral health professionals. • This expanded workforce is necessary to meet the needs of the expanding Medicaid population

43. Recommended Actions Eliminate the limit of 20 behavioral health visits per year restriction, recognizing that chronic conditions, both behavioral and physical, require monitoring and consistent care and may not be treated properly within 20 visits.

44. Recommended Actions • Allow for reimbursable screening for mental health and substance abuse conditions in the primary care setting to identify patients getting care on in the primary care setting. • These screens are reimbursable through the codes (also listed above): • 96150 – Health Behavior Assessment; 15 minutes (initial assessment • 99408 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes • 99409 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes

45. Additional Resources • Michigan Primary Care Association Website – mpca.net • Clinical Services & Quality> Behavioral Health> Behavioral Health Integration Resources • Presentations from MPCA’s Statewide Conference • Operational Resources • Sample Behavioral Health Position Descriptions • Clinical Resources • Financial Resources • Archived Webinars • Tools and Templates

46. Questions? For further information, please contact: Brittany Beard Program Specialist Michigan Primary Care Association 517.827.0477 bbeard@mpca.net Rebecca Cienki, MPH Chief Operating Officer Michigan Primary Care Association 517.827.0474 rcienki@mpca.net