CATEGORY I OR 2 PROJECT NARRATIVE Identifying Project and Provider Information
Title of Project: Integrate Primary and Behavioral Health Care Services Category / Project Area / Project Option: 2.15.1
RHP Project Identification Number: 133542405.2.1
Performing Provider Name: Austin Travis County Integral Care Performing Provider TPI: 1335424-05
Project Description
Overall Project Description - This project addresses the challenge to increase access and the capacity of specialty behavioral health services in Austin and Travis County by establishing a new behavioral health outpatient clinic for children and adults. A fundamental component of this clinic is the integration of primary care services for adults with serious mental illness (SMI), to be done in collaboration with local federally qualified health clinic, CommUnityCare. Throughout the past 10 years, ATCIC has gained considerable experience in providing integrated behavioral health services in primary care clinics with CommUnityCare. Integrated services are a best practice and effective service delivery model used to address the chronic healthcare needs of adults with SMI (http://www.integration.samhsa.gov, August 20, 2012). This new outpatient behavioral health clinic would be located in the Dove Springs neighborhood of Austin and be the first specialty behavioral health clinic in south-southeast Austin - facilitating access to the right care at the right time and setting.
Since 1966, Austin Travis County Integral Care (ATCIC) has served as the local mental health authority for Travis County. ATCIC is Joint Commission accredited and the only dedicated outpatient specialty behavioral health provider in Austin that serves adults with SMI and children with Serious Emotional Disturbance (SED). ATCIC contracts with the Texas Department of State Health Services to provide specialty behavioral health services to people 200 percent below the Federal Poverty Level (FPL).
Treatment and support needs for adults with SMI become increasingly complex in presence of co-morbid medical conditions. A recent study funded through the Robert Wood Johnson Foundation found the national prevalence rates of behavioral health and co-morbid medical conditions to be as high as 68 percent (Mental Health Disorders and Medical Comorbidity, The Synthesis Project No.21, Robert Wood Johnson Foundation, February 2011). The regional (RHP-7) Community Needs Assessment (CNA) revealed almost 59 percent of Travis County patients with a mental health diagnosis also experienced a co- occurring medical condition. To address the co-morbid conditions of adults with SMI at this new clinic, ATCIC will provide primary care services in three dedicated exam rooms to be used by the primary care team. Additionally, ATCIC will also provide and coordinate health promotion and wellness services to enhance and improve overall health outcomes for consumers.
In FY 2012, ATCIC served 7,500 unduplicated adults with SMI and 2,600 unduplicated children with SED in a third dedicated pediatric behavioral health clinic location. Of this total of 10,100 consumers,
approximately 1,700 adults and 570 children and their families reside in south-southeast Austin and must travel to a central or north Austin location to receive services from ATCIC. These capacity limitations delay access to an initial psychiatric evaluation and treatment for adults with SMI seeking services a range
of 90-120 days and 30 days or more for children with SED. Such obstacles to access treatment can result in delayed care or individuals to treatment at medical hospital emergency departments and/or ATCIC’s psychiatric emergency services, the most expensive points of service in our systems.
It is imperative to create additional capacity and access to specialty behavioral healthcare services for adults and children in Austin. The three existing ATCIC outpatient clinic sites are located in north and central Austin, leaving a significant gap for residents of south-southeast Austin who necessitate ready and convenient access to outpatient behavioral health services. This clinic will be located in the Dove Springs neighborhood where approximately 39,000 individuals reside. Eighteen percent of families are below the FPL and 53 percent speak a language other than English at home (Central Health, Board of Managers retreat presentation, April 30, 2011). Further, the Children’s Optimal Health collaborative conducted an analysis utilizing a Geographical Information System and found a high concentration of adults with SMI and SMI with co-morbid medical conditions residing in southeast Austin (Children’s Optimal Health, 2012). Increasing access to specialty community-based behavioral health services is facilitated by clinic locations close to the places that individuals and families live, work and attend school.
Project Goals - The goal of this project is to increase access and capacity to provide specialty behavioral health services by establishing a new outpatient clinic in south-southeast Austin to provide the right care in the right setting. Additionally, the clinic will provide access to primary care services for adults with co- morbid chronic medical conditions. The goal during four years is to increase the number of new
consumers (adults/children) predominantly residing in southeast Austin and accessing behavioral health services by five percent in DSRIP year (DY) 4 and 10 percent in DY 5. The new clinic will also create additional capacity and access for the three existing outpatient clinics as these consumers transition their care, facilitate timely appointments, improve continuity of care, assist with averting crises and ultimately decrease use of costly alternatives such as hospital emergency departments.
Challenges or Issues Faced by the Performing Provider –
1. South and southeast Austin has never had an outpatient behavioral health services clinic. A challenge in establishing this new service site will be to inform the local community, other service providers and established consumers of services of the availability of this new clinic.
2. Timely recruitment of psychiatric providers is a second challenge in establishing this new clinic.
Availability of psychiatric providers interested in delivering specialty community-based outpatient services is a challenge for our community.
3. A third challenge for the new clinic will be recruiting bilingual employees who speak Spanish and understand the bi-cultural needs of the surrounding community.
4. The education and training of psychiatric and primary care medicine providers in integrated care is the fourth challenge for this new clinic. Traditional medical practices and training have approached the provision primary care medicine and psychiatric medicine as distinctly separate.
How the Project Addresses those Challenges –
1. A key factor for the success of this project includes providing community outreach to notify the community of the new clinic’s location, populations to be served, clinical services provided and how to access those services. Community education forums, brochures and engagement of key community partners will be utilized to achieve this. 2. ATCIC will address the provider recruitment challenge by partnering with an external provider to establish telepsychiatry services at the new clinic. This will help with access and flexibility in providing timely psychiatric assessments/consultations, particularly when a person presents with urgent needs. 3. ATCIC will recruit local members of the professional, medical and nursing programs in Austin, San Antonio and throughout Texas. In addition, every effort will be made to recruit individuals from south-southeast Austin neighborhoods who culturally, ethnically and linguistically represent the community. 4. ATCIC’s gained experience in working with FQHC partner,
CommUnityCare, will facilitate the education, training and the coordination of care and services. Vital to this effort is ensuring access to ATCIC’s health promotion and wellness initiatives to ensure adults with SMI utilize services such as tobacco cessation, exercise and dietary programs to improve health outcomes.
How the Project is Related to RHP Goals – The six counties that comprise RHP Region 7 in Texas have identified seven RHP goals, of which, the following five relate to this project:
1. Reduce health system costs by expanding opportunities for patients and families to access the most appropriate care in the most appropriate setting.
2. Improve the patient experience of care by investing in patient-centered, integrated, comprehensive care that is coordinated across systems.
3. Bolster individual and population health by improving chronic disease management.
4. Support prevention education and healthy lifestyles to improve population health.
5. Expand access to behavioral health services to ensure timely, effective treatment that minimizes the use of crisis services and promotes recovery
Starting Point/Baseline
Baseline Data - ATCIC currently operates two adult outpatient clinics and one dedicated child clinic that in FY 2012 respectively served approximately 7,500 adults and approximately 2,600 children. Of these 10,100 consumers, approximately 1,700 adults and 570 children reside in south-southeast Austin, where there are currently no outpatient specialty behavioral clinic services.
Time Period for Baseline – September 2011-August 2012 – source ATCIC’s EHR Rationale
Reason for Selection of Project Options and Components – The regional (RHP-7) CNA revealed that almost 59 percent of Travis County patients with a mental health diagnosis also experienced a co-occurring medical condition. An additional 20 percent had a substance abuse disorder, including 13 percent who had tri-morbid conditions (mental health, substance use disorder and medical condition). The experience of adults with SMI who are accessing and establishing a primary care medical home in traditional clinic systems may present a barrier to care. Navigating these services is daunting for both the patient and/or primary care provider due to complex clinical presentations, the neuroleptic medications regimen and functional/behavioral impairments. To ensure that these individuals receive the right care this integrated healthcare delivery strategy has been selected. Components of this project include:
a) Identify sites for integrated care projects, which would have the potential to benefit a significant a number of patients in the community. ATCIC will establish a new clinic site will be located in south-southeast Austin, a part of our community that has no specialty behavioral health outpatient behavioral health services readily available.
b) Develop provider agreements whereby co‐scheduling and information sharing between physical health and behavioral health providers could be facilitated. ATCIC’s primary care partner, CommUnityCare, have a long history of
providing integrated services. Formal provider agreements will not be required.
c) Establish protocols and processes for communication, data‐sharing, and referral between behavioral and physical health providers. Yes, protocols will be established to ensure that providers have mechanisms for sharing data, referrals and to ensure continuity of care.
d) Recruit a number of specialty providers (physical health, mental health, substance abuse, etc. to provide services in the specified locations. Yes, ACTIC will recruit behavioral health providers and staff for this new clinic location.
CommUnityCare will recruit, employ and train the primary care team and provider.
e) Train physical and behavioral health providers in protocols, effective communication and team approach. Build a shared culture of treatment to include specific protocols and methods of information sharing that include:
1) Regular consultative meetings between physical health and behavioral health practitioners Yes, all medical providers, nursing staff and medical assistants will participate in joint staffing meetings and be fully integrated into clinic functions, meetings and protocols.
2) Case conferences on an individualized as‐needed basis to discuss individuals served by both types of practitioners Yes, providers will share in “bullpen” type office that will facilitate interactions. Also, establishing the practice of “warm handoffs” will be an expectation from the outset.
3) Shared treatment plans co‐developed by both physical health and behavioral health practitioners. Currently the EHRs used by CommUnityCare and ATCIC are separate. Discussion has been underway to develop a portal through which providers will access records to ensure continuity of care.
Ultimately, the goal would be to develop a shared record.
f) Acquire data reporting, communication and collection tools (equipment) to be used in the integrated setting, which may include an integrated Electronic health record system or participation in a health information exchange – depending on the size and scope of the local project. Yes, developing a health information exchange is project being actively explored by our community. ATCIC is very interested in being an active participant in this effort as it develops. Although, an integrated health record is not available the use of patient registries to monitor care and ensure continuity of services between disciplines will be employed.
g) Explore the need for and develop any necessary legal agreements that may be needed in a collaborative practice. Yes, ATCIC and CommUnityCare have a long history and standing legal agreements between our two agencies.
h) Arrange for utilities and building services for these settings. Yes, a potential site has been identified and ATCIC has established building contractors manage the physical setting.
i) Develop and implement data collection and reporting mechanisms and standards to track the utilization of integrated services as well as the health care outcomes of individual treated in these integrated service settings. Yes, ATCIC and CommUnityCare have an established history of tracking and sharing individual patient outcomes, aggregate services data and contract performance measures to ensure the quality of services.
j) Conduct quality improvement for project using methods such as rapid cycle improvement.
Yes, CQI activities will focus on rapid cycle process improvements to ensure that clinical care, clinic processes and communication is optimized. Reports will be produced and consultations with all team members will be utilized to discuss outcomes, potential for improvement and successes.
Reason for Selection of Milestones & Metrics – Process milestone/metric P-5 and improvement milestone/metric I-8 were selected as they are consistent with the RHP-7 goals of: 1. Expanding access to behavioral health services to ensure timely, effective treatment that minimizes the use of crisis services and promotes recovery, and 2. Improve the patient experience of care by investing in patient-centered,
integrated, comprehensive care that is coordinated across systems.
Unique Community Need Identification Number – CN.2, CN.4, CN.6, CN.10, CN.15, CN.16 How the project represents a new initiative for the Performing Provider or significantly enhances an existing delivery system reform initiative – Although ATCIC has extensive experience in providing outpatient specialty behavioral health services this project will establish a new clinic site and embed primary care services into its service array.
Related Activities Funded by U.S. Dept. of Health and Human Services (DHHS) – None Related Category 3 Outcome Measure(s)
Category 3 Outcome Measures(s) Selected – Two Category 3 standalone improvement targets will be implemented for this project: 1) IT-1.18 - Follow-up after hospitalization for mental illness; and 2) IT-6.1 - Percent improvement over baseline of patient satisfaction scores, (1) patients are getting timely care, appointments, and information.
Reasons/Rationale for Selecting the Outcome Measure(s) – The CNA reveals that Travis
County experienced a 33 percent increase in inpatient psychiatric hospitalizations from 2008 to 2010. In Travis County, suicides are the eighth leading cause of death and the fourth leading preventable cause of death. Research indicates that the weeks after discharge represents a critical period for suicide risk. (Hunt et al. Psychological Medicine (2009). 39, 443-449) Establishing a new outpatient clinic location will assist people to receive timely psychiatric follow-up post psychiatric hospitalization. For people with co-morbid conditions, measuring the availability and timeliness of primary care and appointments that meet clients’
needs is essential. Measurement of this outcome underscores one of RHP-7 goals of improving the patient experience of care by investing in timely, patient-centered, integrated, comprehensive care that is coordinated across systems.
Relationship to Other RHP Projects
How Project Supports, Reinforces, Enables Other Projects TBD List of Related Category 1 & 2 Projects (RHP Project ID Number) TBD List of Related Category 4 Projects (RHP Project ID Number) N/A Relationship to Other Performing Providers’ Projects in the RHP
List of Other Providers in the RHP that are Proposing Similar Projects TBD Plan for Learning Collaborative
Plan for Participating in RHP-wide Learning Collaborative for Similar Projects – Region-wide, anchor-led meetings will be held at least annually and will offer an opportunity to share, listen, and learn what providers have encountered while implementing their DSRIP projects. Further, the region will continue to use its website (www.texasregion7rhp.net) to share information. Central Health, as RHP 7's anchor, will foster the development of topical learning collaboratives that will bring together all levels of stakeholders who are involved in DSRIP projects. This multi-pronged approach should allow for continuous improvement of regional projects and transform its healthcare delivery system.
Project Valuation
Approach and Rationale for Valuing Project – A cost-utility analysis was utilized to measure program cost in dollars and the health consequences in utility-weighted units called quality-adjusted life-years (QALYs). The QALY index incorporates costs averted when known (e.g., emergency room visits that are avoided). The proposed program’s value is based on a monetary value of $50,000 per QALY gained due to the intervention multiplied by number of participants. (Eichler, H. G., et al. (2004). "Use of cost-
effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge?" Value Health 7(5): 518-528; http://download.journals.elsevierhealth.com A description of the method used, titled ‘Valuing Transformation Projects,’ has been posted on the
performing provider website which will be linked to www.IntegralCare.org under the Medicaid 1115 Transformation Waiver tab. Complete write-up of the project will be available at performing provider site.
133542405.2.1 2.15 2.15.1
A-J INTEGRATE PRIMARY AND BEHAVIORAL HEALTHCARE SERVICES
Austin Travis County Integral Care 133542405
Related Category 3
Outcome Measure(s): 133542405.3.1
133542405.3.2 IT-1.18, IT-6.1 IT-1.18-Follow-up After Hospitalization for Mental Illness & IT-6.1 Percent Improvement over baseline for patient satisfaction scores
Year 2
(10/1/2012 – 9/30/2013) Year 3
(10/1/2013 – 9/30/2014) Year 4
(10/1/2014 – 9/30/2015) Year 5
(10/1/2015 – 9/30/2016) Milestone 1 P-5: Develop integrated
sites reflected in the number of locations and providers participating in the integration project
Metric 1 P-5.2: Number of primary care providers newly located in behavioral health settings
Baseline/Goal: 1 primary care provider
Data Source: Project Data Milestone 1 Estimated Incentive Payment: $4,674,285
Milestone 2 P-X: Establish baseline rates
Metric 1P-X.1: Establish baseline for the number of individuals receiving both physical and behavioral healthcare services at established location
Goal: Establish Baseline
Data Source: EHR & project data Milestone 2: Estimated Incentive Payment: $4,859,261
Milestone 3 I-8: Integrated Services
Metric 1 I-8.1: Percent of individuals receiving both physical and behavioral healthcare at the established location
Goal: Increase volume of new patients receiving integrated care services by 5%
over baseline Data Source: EHR
Milestone 3: Estimated Incentive Payment: $5,198,280
Milestone 4 I-8: Integrated Services
Metric 1 I-8.1: Percent of individuals receiving both physical and behavioral healthcare at the established location
Goal: Increase volume of new patients receiving integrated care services by 10% over baseline
Data Source: EHR
Milestone 4: Estimated Incentive Payment: $5,210,344
Year 2 Estimated Milestone Bundle
Amount: $4,674,285 Year 3 Estimated Milestone Bundle
Amount: $4,859,261 Year 4 Estimated Milestone Bundle
Amount: $5,198,280 Year 5 Estimated Milestone Bundle Amount: $5,210,344
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $19,942,170
CATEGORY 3 OUTCOME MEASURE NARRATIVE Identifying Project and Provider Information
Title of Outcome Measure (Improvement Target): Integrate Primary and Behavioral Health Care Services Unique RHP Outcome Identification Number: 133542405.3.1
Performing Provider Name: Austin Travis County Integral Care Performing Provider TPI: 133542405
Outcome Measure Description
Overall Outcome Measure Description
IT-1.18: Follow-up After Hospitalization for Mental Illness
IT-1.18: Rate 1 – Follow-up visit 30-days after discharge with a mental health practitioner;
Rate 2 – Follow-up visit 7-days after discharge with a mental health practitioner Process Milestones for Each Year
DY 2: P-1: Project Planning – Engage stakeholders, identify current capacity and needed resources, determine timelines and document implementations plans
Metric 2: Assessment/project report and implementation plan
DY 3: P-2: Establish Baseline Rates of Hospitalizations for Mental Illness for Members enrolled at this new clinic site and receiving a follow-up visit within 30-days and 7-days after discharge
Metric 1: Number members enrolled in services at this new outpatient clinic site who are hospitalized for mental illness between January 1 and December 31 of measurement year
DY 4: N/A DY 5: N/A
Outcome Improvement Targets for Each Year:
DY 2: N/A DY 3: N/A
DY 4: IT-1.18: Follow-up After Hospitalization for Mental Illness
Metric 1 IT-1.18: Rate 1 – 50% of members receive a follow-up outpatient visit 30-days after discharge;
Rate 2 – 70% of members receive a follow-up outpatient visit 7-days after discharge over baseline DY 5: IT- 1.18 Follow-up After Hospitalization for Mental Illness.
]Metric 1 IT-1.18: Rate 1 – 60% of members receive a follow-up outpatient visit 30-days after discharge;
Rate 2 – 80% of members receive a follow-up outpatient visit 7-days after discharge over baseline Related Category 1 and Category 2 Unique RHP Project Identifiers - 133542405.2.1
Rationale
Reasons for Selecting the Process Milestones and Outcome Improvement Targets
For DY2, process milestone P-1 was selected to ensure adequate time is invested in assessment, project planning and the finalization of the plan’s implementation. A focused, collaborative project planning process will provide opportunity for a deliberate and thoughtful planning process, with ample time to establish a new clinic, reach out to the local community, hire qualified personnel and develop collaborative processes with ATCIC’s FQHC partner, CommUnityCare. For DY3, process milestone P-2 was chosen to allow opportunity to establish baseline numbers and ensure appropriate planning in anticipation of achieving improvement targets during DY4 and DY5.
The CNA for RHP-7 reveals that Travis County experienced a 33 percent increase in inpatient
hospitalizations from 2008 to 2010. Further, Travis County, suicides are the eighth leading cause of death and the fourth leading preventable cause of death. Research indicates that the weeks after discharge represent a critical period for suicide risk (Hunt et al. Psychological Medicine (2009). 39, 443-449).
Establishing a new outpatient clinic location will assist people to receive timely psychiatric follow-up post psychiatric hospitalization.
If applicable, indicate that outcome improvement targets will be determined in DY 2 or 3.
The improvement targets will be determined in DY3.
Briefly describe how the related Category 1 and 2 projects will achieve this outcome measure.
This project addresses the challenge to increase access and the capacity of specialty behavioral health services in Austin and Travis County by establishing a new behavioral health outpatient clinic for children and adults. A fundamental component of this clinic is the integration of primary care services for adults with serious mental illness (SMI), to be done in collaboration with local federally qualified health clinic, CommUnityCare. Throughout the past 10 years, ATCIC has gained considerable experience in providing integrated behavioral health services in primary care clinics with CommUnityCare. Integrated services are a best practice and effective service delivery model used to address the chronic healthcare needs of adults with SMI (http://www.integration.samhsa.gov, August 20, 2012). This new outpatient behavioral health clinic would be located in the Dove Springs neighborhood of Austin and be the first specialty behavioral health clinic in south-southeast Austin - facilitating access to the right care at the right time and setting.
Outcome Measure Valuation
Approach and Rationale for Valuing Outcome Measure
This valuation used cost-utility analysis which measures program cost in dollars and the health consequences in utility-weighted units called quality-adjusted life-years (QALYs). The QALY index incorporates costs averted when known (e.g., emergency room visits that are avoided). The proposed program’s value is based on a monetary value of $50,000 per QALY gained due to the intervention multiplied by number of participants. (Eichler, H. G., et al. (2004). "Use of cost-effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge?" Value Health 7(5): 518-528; http://download.journals.elsevierhealth.com
A description of the method used, titled ‘Valuing Transformation Projects,’ has been posted on the performing provider website which will be linked to www.atcic.org under the Medicaid 1115
Transformation Waiver tab. Complete write-up of the project will be available at performing provider site.
133542405.3.1.18. 3.IT-1.18 1.18 Follow-up After Hospitalization for Mental Illness
Austin Travis County Integral Care 133542405
Related Category 1 or 2 Projects:: 133542405.2.1
Starting Point/Baseline: Baseline will be established in Year 3
Year 2
(10/1/2012 – 9/30/2013)
Year 3
(10/1/2013 – 9/30/2014)
Year 4
(10/1/2014 – 9/30/2015)
Year 5
(10/1/2015 – 9/30/2016) Process Milestone P-1: Project
Planning
Metric: Project report and implementation plan
Data Source: Project report and implementation plan
Process Milestone 1 Estimated Incentive Payment: $245,462
Process Milestone P-2: Establish Baseline Rates
Metric - Number enrolled in services, receiving f/u within specified time frames
Goal: Data Source: EHR & project data
Process Milestone 2 Estimated Incentive Payment: $421,688
Outcome Improvement Target 1 [IT-1.18]: Follow-up After
Hospitalization for Mental Illness Metric: IT-1.18: Rate 1 - Follow-up visit 30-days after discharge; Rate 2 – F/U 7-days after discharge Improvement Target: 5%
improvement over baseline Data Source: EHR & project data
Outcome Improvement Target 1 Estimated Incentive Payment:
$451,108
Outcome Improvement Target 2 [IT-1.18]: Follow-up After
Hospitalization for Mental Illness Metric: IT-1.18: Rate 1 - Follow-up visit 30-days after discharge; Rate 2 – F/U 7-days after discharge Improvement Target: 10%
improvement over baseline Data Source: EHR & project data
Outcome Improvement Target 2 Estimated Incentive Payment:
$930,294 Year 2 Estimated Outcome
Amount: $245,462 Year 3 Estimated Outcome
Amount: $421,688 Year 4 Estimated Outcome
Amount: $451,108 Year 5 Estimated Outcome Amount: $930,295
TOTAL ESTIMATED INCENTIVE PAYMENTS FOR 4-YEAR PERIOD: $2,048,553
