Best Practices in Integration: Where the Rubber Meets the Road

Helping Families. Supporting Communities. Empowering Individuals.


Best Practices in Integration: Where the Rubber Meets the Road

Kathleen Reynolds, LMSW, ACSW;

 kathyr@thenationalcouncil.org


Agenda

  • Core components of integrated care to improve health outcomes
  • Examples of different models of integration, examples of typical services that are provided and successfully billed in each model, and key elements of each
  • The top strategies for providers to implement to prepare for integrated partnerships
  • Integration models that work for MCOs- how do you monitor and hold them accountable?

Core Principles of Integration

  1. The behaviorists role is to identify, target treatment, triage and manage consumers with medical and/or behavioral health problems using a behavioral approach.
  2. The integrated care program is grounded in population-based care philosophy consistent with the primary care model.
  3. The healthcare services are based on and consistent with a primary-behavioral health model
  4. The behaviorist promotes a smooth interface between, medicine, psychiatry, specialty mental health and other behavioral health services.


Core Components of Effectiveness

  • Gilbody (2009) -
  • Consulting Psychiatrist
  • Care Coordination
  • Primary Care Prescriber - One Prescriber
  • PBHCI Grantee Program
  • Peer Support
  • Wellness that includes education, exercise and nutrition

What do we know works?

  • Consulting psychiatrist
  • One prescriber (with consultation) whenever possible
  • Care coordination - whole health(Gilbody, 2009)
  • Consumer engagement/peer involvement
  • Wellness programming
  • Addressing core physical health issues sequentially
  • Data, Data, Data (CIHS - PBHCI Grantees)


NASMHPD - Integrated Health Measures

Health Indicators

  1. Personal History of Diabetes, HTN, CV disease 6. Lipid Profile
  2. Family History of Diabetes, HTN, CV disease 7. Tobacco Use/History
  3. Weight/Height, Body Mass Index 8. Substance Abuse
  4. Blood Pressure 9. Medication: History and Current
  5. Blood C=Glucose or HbA1c 10. Social Supports
  6. Lipid Profile
  7. Tobacco Use/History
  8. Substance Abuse
  9. Medication: History and
  10. Social Supports

Process Indicators

  1. Screen/Monitor Risk and Health Conditions in MH
  2. Access to and utilization of Primary Care Services

Models of Integration

  • Levels of Collaboration/Integration
  • Evidence Based and Promising Practices

THE CONSUMER and STAFF PERSPECTIVE/EXPERIENCE

Function

Minimal

Collaboration

Basic

Collaboration from a Distance

Basic

Collaboration

On-Site

Close Collaboration/ Partly Integrated  Fully Integrated/Merged
Access Two front doors; consumers go to separate sites and organizations for services Two front doors; cross system conversations on individual cases with signed releases of information Separate reception, but accessible at same site; easier collaboration at time of service Same reception; some joint service provided with two providers with some overlap One reception area where appointments are scheduled; usually one health record, one visit to address all needs; integrated provider model
Services  Separate and distinct services and treatment plans; two physicians prescribing Separate and distinct services with occasional sharing of treatment plans for Q4 consumers Two physicians prescribing with consultation; two treatment plans but routine sharing on individual plans, probably in all quadrants; Q1 and Q3 one physician prescribing, with consultation; Q2 & 4 two physicians prescribing some treatment plan integration, but not consistently with all consumers One treatment plan with all consumers, one site for all services; ongoing consultation and involvement in services; one physician prescribing for Q1, 2, 3, and some 4; two physicians for some Q4: one set of lab work
Funding Separate systems and funding sources, no sharing of resources Separate funding systems; both may contribute to one project Separate funding, but sharing of some on-site expenses  Separate funding with shared on-site expenses, shared staffing costs and infrastructure  Integrated funding, with resources shared across needs; maximization of billing and support staff; potential new flexibility
 Governance Separate systems with little of no collaboration; consumer is left to navigate the chasm  Two governing Boards; line staff work together on individual cases Two governing Boards with Executive Director collaboration on services for groups of consumers, probably Q4 Two governing Boards that meet together periodically to discuss mutual issues One Board with equal representation from each partner
EBP Individual EBP's implemented in each system;  Two providers, some sharing of information but responsibility for care cited in one clinic or the other Some sharing of EBP's around high utilizers (Q4) ; some sharing of knowledge across disciplines Sharing of EBP's across systems; joint monitoring of health conditions for more quadrants  EBP's like PHQ9; IDDT, diabetes management; cardiac care provider across populations in all quadrants
Data Separate systems, often paper based, little if any sharing of data Separate data sets, some discussion with each other of what data shares Separate data sets; some collaboration on individual cases  Separate data sets, some collaboration around some individual cases; maybe some aggregate data sharing on population groups Fully integrated, (electronic) health record with information available to all practitioners on need to know basis; data collection from one source


Models/Strategies for Integration


Behavioral Health -Disease Specific

  • IMPACT
  • RWJ
  • MacArthur Foundation
  • Diamond Project
  • Hogg Foundation for Mental Health
  • Primary Behavioral Healthcare Integration Grantees

Behavioral Health - Systemic Approaches

  • Cherokee Health System
  • Washtenaw Community Health Organization
  • American Association of Pediatrics - Toolkit
  • Collaborative Health Care Association
  • Health Navigator Training

Physical Health

  • TEAMcare
  • Diabetes (American Diabetes Assoc)
  • Heart Disease
  • Integrated Behavioral Health Project - California - FQHCs Integration
  • Maine Health Access Foundation - FQHC/CMHC Partnerships
  • Virginia Healthcare Foundation - Pharmacy Management
  • PCARE - Care Management

Consumer Involvement

  • HARP - Stanford
  • Health and Wellness Screening - New Jersey (Peggy Swarbrick)
  • Peer Support (Larry Fricks)

The Four Quadrant Clinical Integration Model 

Quadrant 1 - Low BH/Low PH

  • PCP (with standard screening tools and BH practice guidelines)
  • PCP- Based BH *

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

Quadrant III: Low BH/High PH

  • PCP with screening tools
  • Care/Disease Management
  • Specialty medical/surgical
  • PCP based- BH
  • ER
  • Medical Surgical IP
  • SNF/home based care
  • Other community supports

Quadrant IV: High BH/High PH

  • PCP with screening tools
  • BH Case Manager with Coordination with Care Management and Disease Management
  • Care/Disease Management
  • Specialty medical/surgical
  • Specialty BH
  • Residential BH
  • Crisis/ER
  • BH and medical/surgical IP
  • Other community supports

Stable SPMII would be served in either setting. Plan for and deliver services based upon the needs of the individual, consumer choice and the specifics of the community and collaboration.

Quadrant 1 - 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

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


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

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


Working with MCOs

MCOs can plan a leadership role in convening groups and facilitating integration through:

  • Policies
  • Financing
  • Partnering and supporting integration with
    • Utilization Review
    • Data
    • Infrastructure

www.samhsa.integration.gov


Kathy Reynolds

Vice President, Health Integration and Wellness Promotion

kathyr@thenationalcouncil.org

734.476.9879