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Health Reform, and Integration Challenges and Opportunities

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Title: Health Reform, and Integration Challenges and Opportunities


1
Health Reform, and Integration Challenges and
Opportunities
  • WVAADAC Conference
  • Center for Integrated Health Solutions
  • Oct. 4, 2011

2
Agenda
  • Health Reform/overview
  • What is Integration?
  • Why Do it?
  • Challenges
  • Opportunities

3
A Changing Healthcare Landscape Ensuring a Role
for Behavioral Health
  • Affordable Care Act
  • Substance Use/Mental Health Parity
  • Merged Block Grant Submissions

4
  • With new policy changes and more people with
    access to care, we will have to think creatively
    about how to increase capacity, reach out to
    underserved populations, and provide services in
    a way to meet new demands.
  • Accountability is the cornerstone of the new
    healthcare environment.
  • All of these initiatives will require investment
    in new technologies, especially technologies that
    interface with other systems and also measure
    outcomes.

5
A Population Health Approach
  • Need to think differently about health move from
    a focus on providing services to a single
    individual to measurably improving outcomes for
    the populations in our communities
  • Key strategies/elements
  • Prevention
  • Care management
  • Partnerships with primary care providers and
    others in the healthcare system
  • Data collection continuous quality improvement
  • Clinical accountability

6
  • Health Care Reform

7
Two Hypotheses
  • Sick Care/Health Care Federal, State and Local
    healthcare reform is in the process of
    dramatically changing the American healthcare
    system from a sick care system to a true health
    care system
  • Importance of Behavioral Health Prevalence and
    cost studies are showing that this cannot be
    accomplished without addressing the substance
    use and mental health needs of all Americans.

8
The Affordable Care Act Four Key Strategies
  • U.S. health care reform, with or without federal
    legislation, is moving forward to address key
    issues

8
9
Insurance Reform
  • Requires guaranteed issue and renewal
  • Prohibits annual and lifetime limits
  • Bans pre-existing condition exclusions
  • Create essential benefits package that provides
    comprehensive services including MH/SU at Parity
  • Requires plans to spend 80/85 of premiums on
    clinical services
  • Creates federal Health Insurance Rate Authority

10
Coverage Expansion
  • Requires most individuals to have coverage
  • Provides credits subsidies up to 400 Poverty
  • Employer coverage requirements (gt50 employees)
  • Small business tax credits
  • Creates State Health Insurance Exchanges
  • Expands Medicaid

11
(No Transcript)
12
Medicaid Expansions
13
Benefits for the Newly Eligible
  • Essential benefits include mental health and
    substance use treatment
  • MH and SUD must be offered at parity with
    medical/surgical benefits
  • This means
  • Most members of the safety net will have
    coverage, including mental health and substance
    use disorders
  • What is the health profile of the newly eligible?

14
Health Profile of the Newly Eligible
  • 16 million new Medicaid enrollees
  • This group on average is healthier relative to
    those who are currently enrolled in Medicaid (due
    to the fact that many of those with the worst
    health conditions already receive coverage
    through SSI or other disability pathways)
  • But
  • The newly eligible with the most serious health
    problems will likely be the first to enroll.

15
Payment Reform Service Delivery
DesignFollow the Money (Deep Throat quote
from Bob Woodwards account of Watergate)
  • Prevention Activities must be funded and widely
    deployed
  • Primary Care must become a desirable occupation
    and
  • Mental Health and Substance Use Disorder
    Assessment Treatment for all must become the
    Standard of Care
  • In order to Decrease Demand in the Specialty and
    Acute Care Systems

16
National Healthcare Reform Strategies and the
MH/SU Safety Net
  • In Treatment 2.3 million
  • Not in Treatment
  • Tens of millions (McClellan)
  • 21 (Willenbring)
  • How do we even begin to address these gaps
    asstates and health plansrealize they have to
    provide SU servicesat parity?

17
  • Mental Health/ Substance Abuse Block Grant

18
  • In recent SAMHSA block grant application States
    were allowed to submit a combine MH/SA block
    grant application
  • Data was collected about state integration
    efforts

19
  • If ACA is implemented, changes to the block grant
    could be made, as Medicaid will become primary
    payer of services
  • Whether ACA is fully implemented or not
    Integration is on the minds of policy makers and
    payers

20
  • What does integration mean?

21
  • Substance Use Mental Health Disorders
  • Behavioral Health (SU MH) and Primary Care
  • Whole health approach for individuals with mental
    health and substance use problems
  • Considerations Clinical, operations, financing

22
Bi-Directional Integration
  • Placing mental health and substance abuse
    services in primary care
  • Placing primary care services in mental health
    and substance abuse settings
  • Health Homes assume integration

23
  • Why Integrate Behavioral Health and Primary Care?

24
Surgeon Generals 1999 Report
  • This hallmark report was the first major emphasis
    on Integrated Care
  • Dr. David Satcher, former US Surgeon General
    (1998 2002), declared
  • There is no Health without Mental Health.

25
  • 45 percent of Americans have one or more chronic
    conditions
  • Over half of these people receive their care from
    3 or more physicians
  • Treating these conditions accounts for 75 of
    direct medical care in the U.S.
  • In large part due to the fact that money doesnt
    start flowing in the U.S. healthcare system until
    after you become sick

26
Co-morbidities in the Adult Population
Source Druss Walker. Mental disorders and
medical comorbidity. The Robert Wood Johnson
Foundation Synthesis Project, February 2011.
27
Supporting Data
  • People with mental illness die, on average, at
    age 53 (Colton Manderscheid, 2006)
  • One in fourteen stays in U.S. community hospitals
    involved SU disorders (AHRQ, 2007)
  • 70 of primary care visits stem from psychosocial
    issues (Robinson Reiter, 2007)
  • Nearly 60 of individuals with bipolar disorder
    and 52 of persons with schizophrenia have a
    co-occurring SU disorder (Verduin et al, 2005)
  • Approximately 41 of individuals with an alcohol
    use disorder and 60 of individuals with a drug
    use disorder have a co-occurring mood disorder
    (Verduin et al, 2005)

28
Causes of Premature Death in the General
Population1
1. Schroeder S. New England Journal of Medicine
2007 Sep 20357(12)1221-8
29
  • Ideal for treatment of the whole person
  • Reducing health disparities of people who live
    with serious behavioral health conditions
  • Bi-directional integration allows for individual
    choice in determining the Healthcare Home
  • More efficient and effective use of healthcare
    dollars

30
Primary Care in SU Settings
  • Many individuals served in specialty SU have no
    PCP
  • Health evaluation and linkage to healthcare can
    improve SU status
  • On-site services are stronger than referral to
    services
  • Housing First settings can wrap-around MH, SU and
    primary care by mobile teams
  • Person-centered healthcare homes can be developed
    through partnerships between SU providers and
    primary care providers
  • Care management is a part of SU specialty
    treatment and the healthcare home

31
The Four Quadrant Clinical Integration Model (MH/SU)
32
Doherty, McDaniel Baird Integration Scale
33
(No Transcript)
34
What does it mean to provide primary care?
  • Its more than having a nurse on staff
  • Primary care is the provision of integrated,
    accessible health care services by clinicians who
    are accountable for addressing a range of
    personal health care needs, developing a
    sustained partnership with patients, and
    practicing in the context of family and
    community.
  • Partnerships with primary care providers/FQHCs

35
Connect with Other Providers
  • Do you use a collaborative care approach to
    clinical services?
  • Are you actively pursuing bi-directional
    involvement in your community as a
    person-centered healthcare home?
  • Can you electronically collect and share both
    demographic and clinical-level data with your
    partners in the healthcare community?

36
Stepped Care
  • Is your clinical delivery process
    consumer-centered and supportive of stepped
    care?
  • The ability to rapidly step care up to a greater
    level of intensity when needed?
  • The ability to step care down so that a
    consumers MH/SU care is provided in primary
    care with appropriate supports?
  • The ability to offer back porch services for
    consumers who graduate from planned care?
  • All offered from a client-centered,
    recovery-oriented perspective?

37
Primary Care and SU Services
  • Diffusion of screening and brief intervention
    (SBI) is underway
  • Motivational interviewing with fidelity should be
    a consistent component of SBI
  • Repeated BI in primary care is a promising
    practice
  • Medication-assisted therapies in primary care can
    be expanded

38
  • Challenges to Integration

39
Integration Discussion Points at the Clinical
Level
  • Traditional separation of Substance abuse and
    Mental health issues from general medical issues
  • Lack of awareness of Substance Abuse/Mental
    Health screening tools in the primary care
    setting
  • Limited options for referrals and consultation
    with specialty Substance Abuse providers
    including psychiatrists, especially in rural
    settings

40
Integration Discussion Points at the
Administrative Level
  • There is an absolute need for trust between the
    organizations for any collaboration to be
    successful
  • Administrative
  • Operations
  • Clinical
  • The partners must deal with issues like
  • Fears of one org. entering the other org.s turf
  • One org. taking over the other org., or learning
    how to do so

41
Cultural Integration at the Policy Level
  • Separation of physical health and Mental
    Haelth funding streams
  • Restrictions on allowable activities and
    services for community health centers and
    community substance use providers
  • Limitations on the population eligible for
    public mental health services
  • Statutory or regulatory restrictions of public
    organizations

42
Integration Discussion Points at the Financial
Level
  • Provision of multiple services on the same day
  • Delivery of co-occurring services
  • Reimbursement of services which are currently not
    being reimbursed
  • Medication Administration (i.e. methadone)
  • Crisis Intervention
  • Peer Counseling
  • Medical visits that are distinct from the
    substance abuse service billed separately

43
  • Opportunities

44
  • Models of Integration?

45
Healthcare Models of the Future
  • Collaborative Care
  • Patient Centered Healthcare Homes
  • Accountable Care Organizations
  • Accountability and quality improvement are
    hallmarks of the new healthcare ecosystem

46
Collaborative Care Approaches to Co-occurring
Disorders
  • gt30 randomized controlled trials have found
    collaborative care approaches improve quality and
    outcomes
  • Key active ingredients care managers and
    stepped care
  • Collaborative care approaches are highly cost
    effective
  • Variety of models, including
  • Fully integrated
  • Partnership model
  • Facilitated referral model

47
Core Components of Collaborative Care
Two Processes Two New Team Members Two New Team Members
Two Processes Care Manager Consulting BH Expert
Systematic diagnosis and outcomes tracking (e.g. PHQ-9 to facilitate diagnosis and track depression outcomes) Patient education/self-management support Close follow-up to make sure pts dont fall through the cracks Caseload consultation for care manager and PCP (population-based) Diagnostic consultation on difficult cases
Stepped Care Change treatment according to evidence-based algorithm if patient is not improving Relapse prevention once patient is improved Support medication Rx by PCP Brief counseling (behavioral activation, PST-PC, CBT, IPT) Facilitate treatment change/referral to BH Relapse prevention Consultation focused on patients not improving as expected Recommendations for additional treatment/referral according to evidence-based guidelines
48
  • Person-Centered Healthcare Homes
  • A new paradigm

49
  • Picture a world where everyone has...
  • An Ongoing Relationship with a responsible
    healthcare provider
  • A Care Team that collectively takes
    responsibility for ongoing care
  • And where...
  • Quality and Safety are hallmarks
  • Enhanced Access to care is available
  • Payment appropriately recognizes the Added Value
  • What does this look like in practice?

50
New Medicaid State Option for Healthcare Homes
  • State plan option allowing Medicaid beneficiaries
    with or at risk of two or more chronic conditions
    (including mental illness or substance abuse) to
    designate a health home
  • Community behavioral health organizations are
    included as eligible providers
  • Effective Jan. 2011
  • Additional guidance forthcoming from HHS

51
Eligibility Criteria
  • To be eligible, individuals must have
  • Two or more chronic conditions, OR
  • One condition and the risk of developing another,
    OR
  • At least one serious and persistent mental health
    condition
  • The chronic conditions listed in statute include
    a mental health condition, a substance abuse
    disorder, asthma, diabetes, heart disease, and
    obesity (as evidenced by a BMI of gt 25).
  • States may add other conditions subject to
    approval by CMS

52
What its not
  • A residential facility
  • Primary care provider as gatekeeper

53
Defining the Healthcare Home
  • Everyone has a health home practitioner and team
  • Patients can easily make appointments and select
    the day and time.
  • Waiting times are short.
  • Email and telephone consultations are offered.
  • Off-hour service is available.

54
Defining the Healthcare Home
  • Health Home team has a patient-centered, whole
    person orientation
  • Care is tailored to the needs of each patient
  • Patients are active participants, with the option
    of being informed and engaged partners in their
    care.
  • Practices provide information on treatment plans,
    preventive and follow-up care reminders, access
    to medical records, assistance with self-care,
    and counseling.

55
Defining the Healthcare Home
  • Systems support high-quality care, practice-based
    learning, and quality improvement.
  • Practices maintain patient registries monitor
    adherence to treatment have easy access to lab
    and test results and receive reminders, decision
    support, and information on recommended
    treatments.
  • There is continuous learning and practice
    improvement.

56
Defining the Healthcare Home
  • The health home team engages in care coordination
    management within the team
  • The team also coordinates with other healthcare
    providers/organizations in the community
  • Systems are in place to prevent errors that occur
    when multiple physicians are involved.
  • Follow-up and support is provided.

57
Defining the Healthcare Home
  • Integrated and coordinated team care depends on a
    free flow of communication among physicians,
    nurses, case managers and other health
    professionals (including BH specialists).
  • Duplication of tests and procedures is avoided.

58
Defining the Healthcare Home
  • Patients routinely provide feedback to doctors
    practices take advantage of low-cost,
    internet-based patient surveys to learn from
    patients and inform treatment plans.
  • Patients have accurate, standardized information
    on physicians to help them choose a practice that
    will meet their needs.

59
Additional Necessary Components
  • The health home is supported by a sustainable
    business model appropriately aligned incentives
  • The health home is accountable for achieving
    improved clinical, financial, and patient
    experience outcomes

60
Are you ready to be a healthcare home? Do you
  • Have a provider team with a range of expertise
    (including primary care)?
  • Coordinate consumers care with their health
    providers in other organizations?
  • Engage patients in shared decision-making?
  • Collect and use practice data?
  • Analyze and report on a broad range of outcomes?
  • Have a sustainable business model for these
    activities?

61
Health Homes Serving Individuals with SMI and
Substance Use Disorders
  1. Assure regular health status screening and
    registry tracking/outcome measurement
  2. Locate medical nurse practitioners/primary care
    physicians in MH/SU facilities
  3. Identify a primary care supervising physician
  4. Embed nurse care managers
  5. Use evidence-based practices developed to improve
    health status
  6. Create wellness programs

62
  • Accountable Care Organization

63
Accountable Care Organizations (ACOs) the
homes for medical homes
64
On Your Mark, Get Set, ACO
  • Accountable Care Organizations bring together
    healthcare homes, specialty care, and ancillary
    services

65
Core Principles of an ACO
  • Directed by a coordinated set of providers
  • Provides a full continuum of care to patients and
    populations
  • Healthcare homes, specialty care, hospital, case
    management, care coordination, transitions
    between levels of careand more
  • Financial incentives aligned with clinical goals
  • Cost containment
  • Enhancement of care quality and the patient
    experience
  • Improvement of overall health status

66
ACOs and the Safety Net
  • Coverage expansions The massive expansion of
    coverage in 2014 will require new models to
    assure access and control costs particularly
    for serving Medicaid patients, who will make up
    14 million of the newly insured
  • Care management Individuals served by the safety
    net experience higher rates of serious mental
    illness, substance use disorders, and poorly
    controlled multiple chronic conditions
  • Community behavioral health organizations have
    expertise and experience in caring for these
    populations, making them valuable partners in an
    ACO

67
Providers Need to Rethink their Service Approaches
  • Infrastructure development and process
    improvement are necessary
  • Continuing care should link the continuum of
    services together and support the individuals
    change process
  • Recovery Oriented Systems of Care support
    recovery as a process
  • Motivational Enhancement Therapy or the
    Transtheoretical Model are effective, but must be
    delivered with fidelity
  • Other approaches, including medication-assisted
    therapy are also effective
  • Communities must work together to create a
    continuum of services and agreements about
    seamless access, stepped care and other
    transitions

67
68
Designated Provider Types/Functions
  • Provider organizations may work alone or as part
    of a team
  • Functions include (but are not limited to)
  • Providing quality-driven, cost-effective,
    culturally appropriate, and person-centered care
  • Coordinating and providing access to high-quality
    services informed by evidence-based guidelines
  • Coordinating and providing access to mental
    health and substance abuse services
  • Coordinating and providing access to long-term
    care supports and services.

69
Dedicated to promoting the development of
integrated primary and behavioral health services
to better address the needs of individuals with
mental health and substance use conditions,
whether seen in specialty behavioral health or
primary care provider settings.
70
  • The SAMHSA/HRSA Center for Integrated Health
    Solutions (CIHS)
  • Purpose
  • To serve as a national training and technical
    assistance center on the bidirectional
    integration of primary and behavioral health care
    and related workforce development (including
    healthcare homes)
  • To provide technical assistance to 64 PBHCI
    grantees and FQHCs funded through HRSA to address
    the health care needs of individuals with mental
    illnesses, substance use and co-occurring
    disorders

www.CenterforIntegratedHealthSolutions.org
71
Resources
  • Behavioral Health/Primary Care Integration and
    The Person-Centered Healthcare Home, April 2009,
    The National Council.
  • Substance Use Disorders and the Person-Centered
    Healthcare Home, March 2010, The National
    Council.
  • http//www.thenationalcouncil.org/cs/resources_se
    rvices/resource_center_for_healthcare_collaboratio
    n/clinical/personcentered_healthcare_homes
  • California Primary Care, Mental Health, and
    Substance Use Services Integration Policy
    Initiative. Vols. I, II, and III. September 14,
    2009.
  • The Business Case for Bidirectional Integrated
    Care Mental Health and Substance Use Services
    in Primary Care Settings and Primary Care
    Services in Specialty Mental Health and Substance
    Use Settings. June 30, 2010. http//www.cimh.org/I
    nitiatives/Primary-Care-BH-Integration.aspx
  • Oregon Standards and Measures for Patient
    Centered Primary Care Homes. February 2010.
    Office for Oregon Health Policy and Research.
    http//courts.oregon.gov/OHPPR/HEALTHREFORM/PCPCH/
    docs/FinalReport_PCPCH.pdf

72
  • SAMHSA/HRSA Center for
  • Integrated Health Solutions
  • The resources and information needed to
    successfully Integrate primary and behavioral
    health care
  • For information, resources and technical
    assistance contact the CIHS team at
  • Online CenterforIntegratedHealthSolutions.org
  • Phone 202-684-7457
  • Email Integration_at_thenationalcouncil.org
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