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(1)

Integrating Behavioral Health into

the Patient Centered Medical Home:

The Massachusetts Experience

Megan E. Burns, MPP

Judith L. Steinberg, MD, MPH

Michael H. Bailit, MBA

(2)

Disclosures

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation.

Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their

participation were involved in this CME activity.

The following individual(s) in a position to control content relevant to this activity have disclosed the following relevant financial relationships:

Alexander Blount, EdD, Integrated Primary Care Inc. owner, consulting practice. Megan Burns, MPP, spouse is employed by a technology firm that creates robotic applications and software solutions for health care.

Judith Steinberg, MD, MPH and Michael Bailit, MBA have no relevant financial relationships to disclose.

(3)

Objectives

Describe at least three

elements of behavioral health care

integration

.

Describe at least three

challenges to integrating behavioral

health care

into the primary care practice.

Discuss one strategy for

assessing the level of behavioral health

integration

within a Patient-Centered Medical Home.

Describe three strategies for

improving the level of behavioral

health integration

within a Patient-Centered Medical Home.

(4)

Agenda

• Behavioral Health Integration and the PCMH

• Primary Care Transformation in MA

• Supporting Behavioral Health Integration in the

PCMH

• Addressing Barriers

• Lessons Learned

(5)

Behavioral Health Integration

Goal: Optimized access and engagement in coordinated care

to achieve improved health outcomes, reduced costs

Behavioral health focus in primary care:

Screening

Behavioral health skills

Care coordination and information sharing

Care management

Community resources

(6)

2011 NCQA Standards

I. Access and Continuity

Access during and after office hours

Electronic access

Continuity

Patient/ Family Partnership

Cultural/linguistic appropriate services

Practice organization (team based care)

II. Identify/Manage Patient Populations

Electronic basic and clinical searchable

data

Comprehensive health assessment

Use data for population management

III. Plan and Manage Care

Guidelines for important conditions

Care management

Medication management

Electronic prescribing

IV. Self Management Support

Self care process

Self-care plan & monitoring tools

V. Track and Coordinate Care

Test & referral tracking/follow-up

Care transitions

Referrals to community resources

VI. Performance Measurement & QI

Performance measurement

Prevention, chronic disease, overuse,

utilization measures

Stratified for vulnerable pops

.

Patient/Family feedback

Quality improvement

Patient/family involvement in QI

Improvement in health disparities

Electronic reporting of performance

measures

To consumers, health plans, public

6

Behavioral Health Focus Care Coordination

Care Management Behavioral Health Focus

Community Resources Behavioral Health Skills Optimized Access and Engagement

(7)

Primary Care Transformation in MA

SNMHI

Safety Net Medical Home

Initiative

MA PCMHI

MA Patient-Centered Medical

Home Initiative

CHIPRA

Creating Pediatric Medical

Homes in MA Initiative

Early Childhood Medical

Home

MYCHILD, LAUNCH Initiatives

(8)

MA Patient-Centered Medical Home

Initiative

• Statewide multi-payer initiative

Sponsor

: MA Health and Human Services

Partners

: UMass Medical School, Bailit Health

Purchasing

• 46 participating practices

• 3 year demonstration; start March, 2011

Vision: All MA primary care practices will be

PCMHs by 2015

(9)

Primary Care Payment Reform (PCPR)

Scaling up

: Eligible providers- all Medicaid

Primary Care Clinician Plan providers

Clinical Model

: PCMH with behavioral health

integration

(10)

Payment Reform

MA PCMHI

• Fee for service

• Start-up infrastructure

payments

• Prospective Payments

Medical Home activities

Clinical care management

• Shared savings

Primary Care Payment

Reform Initiative*

• Risk-adjusted capitation:

Outpatient Primary care

Outpatient behavioral health

• Three shared-savings /

shared-risk tracks

available

• Quality performance is part

of payment

*Details of payment model are not finalized as of 12-1-12

(11)

Practice Redesign: Core Competencies

Patient/family centeredness

Team based care

Planned visits & follow-up

care

Registry use for population

and patient management

Care coordination

Care management for high

risk patients

Self management support

Patient and family education

Shared decision making,

patient action plans

Evidence based care

Integration of QI

Enhanced access

Integration of behavioral

health and primary care

(12)

Supporting Behavioral

Health Integration in the PCMH

• Learning Collaboratives

• Discounted access to select resources within

UMass Center for Integrated Care

• Medical Home Facilitators

• Delineated elements of care integration and are

providing strategies to achieve each element of

integration

(13)

Behavioral Health Integration:

Approaches and

Elements

Non-Co-located

Co-located

Co-located

& Fully

Integrated

Relationship and

Communication Practices

Patient Care and

Population

Impact

Community

Care

Management

Clinic System

Integration

Approaches

(14)

Integration

Elements

14

Relationship &

Communication

Practices

Patient Care

and Population

Impact

Community

Integration

Care

Management

Clinic System

Integration

Triaged access BH screening and

referral Self help referral connections Coordination of integrated treatment plan

Schedule accessibility

Smooth

hand-offs BH skills used by primary care team Specialty mental health & substance use referral Use of behavioral

health skills Leaders & staff committed to integrated care

Team membership Integrated clinical

pathways Community resources connections

Use of community

resources Health information exchange

Program leadership Health care team

leader Process integration Sharing expertise Family focused

(15)

Practice Self-Assessment

• Goals:

Establish practice baseline

and

track progress

of

integration over time

– Highlight

common gaps

in integration to help drive

curriculum

and

technical assistance

• Methodology:

– Administered through “SurveyMonkey”

Ideally

completed by the primary care team in conjunction

with the behavioral health providers

• Results:

(16)

Relationship and Communication Domain

• Strengths:

– Sharing expertise

• 88% of respondents report that PCPs are comfortable

requesting advice from behavioral health providers

• Areas for Improvement:

– Triaged access at emergent, urgent and routine times

– Smooth hand-offs

– Training activities

– Program leadership

– Team membership

(17)

84% of respondents struggle to incorporate

smooth hand-offs into care

(18)

Patient Care and Population Impact Domain

• Strengths:

– Routine screening of pediatrics

– Care team members trained in BH techniques

– Supporting health behavior change

• Areas for Improvement

:

– Routine screening for adults

– Use of evidence-based interventions

(19)

70% of practices screen for depression and

alcohol but most do not screen routinely

16% 35% 35% 0% 5% 10% 15% 20% 25% 30% 35% 40%

Patients are routinely screened prior to or during annual

physical exams with a standardized tool for both

depression and alcohol

(20)

Care Manager Domain

• Strengths:

– Awareness of community resources:

• 90% of respondents report that clinical care managers

are aware of BH focused community resources and refer

to them at least sometimes

• Areas for Improvement:

– Coordination of integrated treatment plan

– Use of behavioral health skills

(21)

Most respondents do not have effectively

coordinated integrated treatment plans

(22)

Community Integration Domain

• Strengths:

– Community group and resources connections

– Connections with BH specialists

• Areas for Improvement:

– Routine self-help referral connections

– Routine community group and resource

connections

– Peer or patient participation within the practice

– Offering of group behavioral health education

programs

(23)

Most respondents reported

some self-help referrals

30%

54%

16%

0%

10%

20%

30%

40%

50%

60%

Rarely/Never

Sometimes

Routinely

The practice has available and regularly uses referral

information for self-help groups, and offers books,

pamphlets and websites that foster patient self-help

*Foundational

(24)

Clinic System Integration Domain

• Areas for Improvement:

– Schedule accessibility

– Program staffing

– Chart note integration

– Process integration

– Same-day access for BH

– Open or coordinated scheduling

(25)

Most respondents reported not being able to

schedule a BH visit at the time of a primary care

visit

26%

49%

26%

0%

10%

20%

30%

40%

50%

60%

Rarely/Never

Sometimes

Routinely

The practice can facilitate the scheduling of a BH visit for a

patient at the time of a patient visit.

*Foundational

(26)

Behavioral Health Action Toolkit

26

(27)

Addressing Barriers

Barriers: Payment & Regulatory,

Real & Perceived

• Multi-stakeholder review of regulatory barriers

• CHC/stakeholder summit

• Department of Public Health planned approach to

waiving regulation

• Medicaid review of payment barriers

• Planned multi-stakeholder taskforce on barriers to

behavioral health integration

(28)

Lessons Learned

• It’s difficult to

play “catch-up”

when behavioral

health is not included at the start of an initiative.

• Behavioral health integration is not a separate

topic:

Integration is meant to be seamless

Engaged leadership

is required for successful

transformation

Care management and care coordination

are

key elements of PCMH and integrated care

(29)

Acknowledgements

Bailit Health Purchasing, LLC

www.bailit-health.com

UMass Medical School, Center for Health Policy and Research

http://www.umassmed.edu/chpr/index.aspx

Mountainview Consulting

Dr. Alexander Blount

Members of the MA PCMHI Behavioral Health Integration Workgroup

Members of the MassHealth Primary Care Payment Reform Clinical

Workgroup

(30)

30

Megan E. Burns, MPP

mburns@bailit-health.com

Judith L. Steinberg, MD, MPH

Judith.steinberg@umassmed.edu

Michael H. Bailit, MBA

mbailit@bailit-health.com

F. Alexander Blount, EdD

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