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
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.
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.
Agenda
• Behavioral Health Integration and the PCMH
• Primary Care Transformation in MA
• Supporting Behavioral Health Integration in the
PCMH
• Addressing Barriers
• Lessons Learned
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
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 CoordinationCare Management Behavioral Health Focus
Community Resources Behavioral Health Skills Optimized Access and Engagement
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
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
Primary Care Payment Reform (PCPR)
•
Scaling up
: Eligible providers- all Medicaid
Primary Care Clinician Plan providers
•
Clinical Model
: PCMH with behavioral health
integration
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
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
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
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
Integration
Elements
14Relationship &
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
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:
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
84% of respondents struggle to incorporate
smooth hand-offs into care
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
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%