california institute for behavioral health solutions ......health network (nsrhn), the california...

North State Rural Primary Care - Mental Health Summit:

Collaborating for Care

FINAL REPORT

This Summit is made possible through the support of The California Endowment

The North State Rural Primary Care and Mental Health Summit: Collaborating for Care

Report 2002

We wish to express our appreciation to the more than 125 primary care county mental health staff, statewide policy representatives and consumer advocates who gave their time and creative energies to develop strategies to meet the mental health needs of California’s rural north state. Through generous funding from the California Endowment, The North State Rural Primary Care and Mental Health Summit was held April 26, 2002 in Chico, California. The groups met to discuss priority issues and to develop collaborative solutions. This report reflects the collective thinking of the summit participants. It is our hope that this report will not gather dust on a shelf—rather, that it becomes a stimulus for action in your local communities, as well as in regional and statewide policy venues, to make changes large and small, that will improve availability and access to mental health services in the North State. Speranza Avram, MPA, Northern Sierra Rural Health Network Sandra Naylor Goodwin, MSW, PhD, California Institute for Mental Health Patricia Ryan, MPA, California Mental Health Directors Association

THE NORTH STATE RURAL PRIMARY CARE AND MENTAL HEALTH SUMMIT: COLLABORATING FOR CARE

BACKGROUND Rural communities in Northern California face challenges similar to rural communities throughout the United States: distances are vast; population centers are small; and resources are limited, including health resources. In particular, health specialty services can be very difficult to access. Recognizing the need to improve access to mental health services, The Northern Sierra Rural Health Network (NSRHN), the California Mental Health Directors Association (CMHDA) and the California Institute for Mental Health (CIMH) worked together to both identify issues and develop solutions for improving access and availability of mental health services in rural Northern California. It is our shared vision to fill gaps in services in rural and frontier areas by identifying and prioritizing collaborative solutions without compromising existing services. Through surveys and focus groups, the following question was presented to individuals and representatives from mental health and primary care organizations throughout Northern California during the fall of 2001:

“The mental health system in California is challenged in many ways. What unique challenges do rural communities face in providing a comprehensive level of mental health services to their residents?”

Responses to this question were received from individuals and focus groups representing primary care providers, county mental health systems, and consumers. The responses were synthesized and categorized into “like groups” of answers. The twelve most common or most frequently mentioned problems were then listed and brought to a work group of interested mental health and primary care providers who volunteered to help distill them into the top three most pressing issues for rural northern California. The work group examined and discussed the top twelve issues at length and selected the following three issues as being the most important:

• Lack of mental health providers of all kinds in rural Northern California • Lack of resources to support mental health services, including reimbursement issues for

all parts of the mental health system • Lack of coordination along the full spectrum of mental health services, including stigma

of receiving services in small communities and the different models of care between primary care and county-based systems

More detail about these three issues, as well as a list of all the issues identified by the focus groups, is included as Appendix A of this report. Through funding received from The California Endowment, NSRHN, CIMH and CMHDA co-sponsored The North State Rural Primary Care and Mental Health Summit: Collaborating for Care on April 26, 2002. Over 125 primary care, county mental health staff, statewide policy

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representatives and consumer advocates met in Chico to review the issues identified and develop strategies to address them. This report summarizes the findings of the Summit for use by conference attendees and others interested in supporting mental health services in rural Northern California. OVERVIEW OF RURAL MENTAL HEALTH SUMMIT The Summit participants opened with a presentation by Keynote Speaker Assemblywoman Helen Thomson, Chair of the State Assembly Health Committee, who reminded the audience of the importance of caring for the most vulnerable members of our communities. The complexities associated with reimbursement for mental health services are challenging, yet through collaboration and persistence, small but lasting changes can be made. NSRHN Executive Director, Speranza Avram, provided an overview of relevant data that supported many of the findings identified through the Summit research process. A copy of this presentation is included as Appendix B of this report. Dr. Neal Adams, Medical Director for Adult Services, California Department of Mental Health discussed the development of the mental health system and how it interfaces with the health care delivery system. A copy of his presentation is included as Appendix C of this report. Mental Health Claims Data and Statistics as presented by Sandra Naylor Goodwin, Ph.D., Executive Director of CIMH, is included as Appendix D. A panel of mental health professionals from a variety of disciplines used a case based scenario to discuss how the different agencies would provide services to a fictional family with a variety of presenting problems. This discussion helped clarify roles and responsibilities across the range of services represented. The major activity of the Summit was discussion in small regional work groups to identify:

• Strategies to address each of the three top issues • Existing assets and resources that can be used to implement the strategies • Overarching policy issues that need to be addressed at regional, state, and national levels • Create a local area action plan

Each work group brought their work products back to the full Summit. Dr. Goodwin summarized major themes. A summary of the work group findings is presented below and details of each of the work group discussions is included as Appendix E of this report.

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SUMMARY OF WORK GROUP FINDINGS

Four main themes emerged from the Work Groups:

• The value of regionalization to share resources, overcome access barriers, and address system change

• The need for better communication, collaboration and cross-training along the full range of existing mental health services (state, county, primary care and community-based)

• Increased use of telepsychiatry to expand access to services • The importance of advocacy for increased funding for services and to address policy

issues, including reimbursement barriers, relating to a variety of provider issues Work Group participants identified the following ASSETS/RESOURCES in rural northern California that can be used to impact rural mental health:

• A range of community-based, safety net and county services typified by limited personnel, “wearing more than one hat,” and limited resources to commit to large service areas often with less than 7 people per square mile

• Advocacy, lobbying and coalition building • Networking/Networks/Consortiums • Telemedicine/connectivity • Commitment to collaboration

Common POLICY ISSUES mentioned by the Work Groups included:

• Allowing reimbursement for telepsychiatry services initiated by primary care providers • Overcoming barriers created by confidentiality (HIPAA) • Reimbursement rates inadequate to provide services/ Restrictive regulations that affect

reimbursement/mandates • Lack of genuine mental health parity • Simplifying billing codes • Maintaining and expanding mental health provider shortage designations • Implementation/enforcement of Knox-Keene • Allowing Licensed Marriage Family Therapists (LMFT) to be reimbursed by Medicare

and Medi-cal when providing services in hospitals and primary care practices. The STRATEGIES identified by the Work Groups to address each of the issues include: Lack of Providers:

The issue of lack of providers in rural northern California is profound. Focus group and mail-in respondents state a particular lack of bilingual providers, few to no specialty providers such as child or geriatric psychiatrists, provider licensing issues such as inability to use certain providers for Medicare and Medi-Cal in certain venues, problematic recruitment and retention from Masters level to Psychiatrists and providers who are geographically available,

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but may not provide services to those most in need (e.g. don’t take Medi-Cal, Healthy families, Medicare, etc., may not serve Developmentally Disabled, or treat certain diagnosis, such as dementia) as some of most troublesome aspects of this issue.

Strategies include:

• Access recent retirees for part time positions, draw upon large pool of skilled retirees – pay them to mentor students

• Increased use of Telepsychiatry and Telemedicine, use technology for supervision component of licensing, telepsychiatry, training, direct service provision and more

• Develop partnerships to “grow your own” personnel in rural communities, provide career ladder trainings

• Financial incentives (stipend bonus) to come to the area and local university stipends for training and non-economic incentives

• Paid internships • Advertise in recreational magazines for professionals who might enjoy rural life • Improved behavioral health training or availability of specialty consultation for

primary care providers • Collaborations and partnerships for Training and Telemedicine Services with

Foundations, Community Based Organizations and County Behavioral health Departments, Primary Care, Department of Mental Health, Public Education, lobbyists, elected officials, media, Faith-based providers, and Coordination with Medical Centers/Universities

• Residency Rotations • County-wide and/or regional (shared) recruitment • Grants and loan forgiveness programs • Better use of volunteers and peer counselors

Lack of Resources: The issue of lack of resources in rural Northern California includes inequities in the funding base for county behavioral health programs and the fact that the cost of providing the full range of services for a very few people is often greater than the reimbursement for those services. Insurance parity issues are prevalent, and when this is coupled with the serious and persistent nature of mental illness, creates an environment of serious unmet need. Issues for clinics include the need for behavioral health specialty consultation, inability to obtain reimbursement for the full range of behavioral health providers, difficulties with reimbursement for telepsychiatry visits and being unable to bill for more than one service in a single day. In addition, rural communities are vulnerable to the market economy because resources and quantity are so scarce and demand is so high. Strategies include:

• Regionalize behavioral health care • Grants or special legislation to fill holes and pilot projects to effect change

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• Increase the number and availability of crisis beds – children/adults (increased funding for liability, etc), and treatment facilities for children

• Website for centralized information • Increase human services and adequate housing for Children and adults in crisis • Collaborations and partnerships for Training, Telemedicine Services, and Residency

Rotations with Foundations, Community Based Organizations and County Behavioral health Departments, Primary Care, Department of Mental Health, Public Education, lobbyists, elected officials, media, Faith-based providers, and Coordination w/Medical Centers/Universities

Lack of Coordination:

Coordination is impacted by “small town” confidentiality issues and consumer denial of need, due to stigma. Conflicts between different service models, the lack of interdisciplinary training and funding for time spent in cooperative/coordinated efforts are also problematic. Coordination problems are encountered due to the inadequate emergency services access, follow-up, transportation, bed space, efficacy of emergency interventions, cost to county system of in-patient care, closures of psychiatric hospitals, and burdens on hospital emergency rooms. This issue also includes barriers to coordination and collaboration between primary care and specialty mental health systems created by differences in language (medical vs. mental health terminology) and separate service components and delivery systems. Focus group respondents state there is a general lack of understanding of the full range of services from one provider to the next. Strategies include:

• Improved behavioral health training for primary care providers/integration of mental

health and primary care services • Geriatric training for multidisciplinary services • Improve educational and cross training standards – opportunities • Anti-Stigma – satellite clinics located in the community and/or locating services in

primary care clinics where consumers could be seeking services for a variety of reasons

• Develop multi-agency release form to allow easy collaboration on high risk patients • Work with local pharmacies to track medical usage/compliance • Local multi-agency, multi-disciplinary task forces, which include schools and law

enforcement • Collaboratives for early intervention • Public-private partnerships • Use technology to make collaboration, shared trainings and conference meetings/calls

most cost effective/time efficient

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NEXT STEPS As a result of the Summit, a number of county mental health and primary care providers have committed to continue to work together to address specific strategies relevant to their community and county-wide situation. Additionally, NSRHN, CMHDA and/or CIMH have committed to:

• Distribute this report to Summit participants, as well as policy makers and funders who have an interest in rural mental health.

• Invite the annual conference held by the National Association for Rural Mental Health to Northern California

• Pursue the development and distribution of a HIPAA compliant inter-agency release form to support case-based collaboration

• Support technical assistance and training for increased use of telepsychiatry in the region • Continued collaboration and advocacy to protect and expand existing resources for rural

northern California LIST OF ATTACHMENTS: Appendix A – Mental Health Issues Impacting Rural Northern California Appendix B – A Review of Relevant Data – Presentation by Speranza Avram, M.P.A Appendix C – “Bridging the Gap” – Presentation by Neal Adams, MD Appendix D – Mental Health Claims Data and Statistics – Presentation by Sandra Naylor Goodwin, PhD Appendix E – Details of Work Group Reports

APPENDIX A – LIST OF MENTAL HEALTH ISSUES

Below is more detail regarding each of the top three issues identified through the Summit process: Lack of providers: • Especially bilingual, Masters level to Psychiatrists, lack of range of providers. • Few specialty providers such as child or geriatric psychiatrists/providers. • Provider licensing issues such as use of LMFT along full continuum of care. • Problematic recruitment and retention. • Providers that are available may not provide services to those most in need (e.g. don’t take

Medi-Cal, Healthy Families, Medicare, etc, may not serve the Developmentally Disabled, may not treat certain diagnoses such as dementia).

Lack of resources: • Inequities in funding base for counties. • Cost of providing full range of services for very few people. • Lack of mental health providers in rural northern California. • Lack of resources to support the delivery of services at all levels of the mental health system. • Challenges to coordination along the full range of behavioral health care services, including

the stigma of providing services in small communities, and the different care models present in primary care and county-based systems.

• Billing issues for clinics including reimbursement for the full range of BH providers. • Able to bill for more than one visit in a day and telepsychiatric visits at primary care

clinics. • Cost of providing treatment is often higher than reimbursement, and insurance parity

issues. • Vulnerability to market economy, as resources and quantity are scarce and demand is high. • The serious and persistent nature of severe mental illness makes this a costly and priority

service population.

Challenges to coordination along the full range of behavioral health care services include: • Stigma and “small town” confidentiality issues. Consumer denial of need due to stigma. • Conflicts between different service models and the lack of interdisciplinary training and

lack of funding for time spent in cooperative/coordinated efforts. • Emergency services access, follow-up, transportation, bed space, and efficacy of

emergency interventions, cost to county system of in-patient care, closures of psychiatric hospitals, burdens on hospital emergency rooms.

• Language and fractionated (other words used to describe the systems were different, separate, wholly unrelated) services, medical vs. mental health language illustrates the disconnected models delivery system and creates a significant barrier to collaboration.

• General lack of understanding of the full range of services from one provider to the next. • Lack of transitioning to Client-Centered and Client-Directed care along the continuum.

APPENDIX A – LIST OF MENTAL HEALTH ISSUES

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The full list of eleven issues is:

1. High suicide rates in rural communities

2. Geography: driving distances, lack of public transportation, poor roads, weather and impact on treatment.

3. Lack of providers: especially bilingual. Few specialty providers such as child or

geriatric psychiatrists/providers. Provider licensing issues such as use of LMFT along full continuum of care. Problematic recruitment and retention.

4. Lack of resources: Inequities in funding base for counties, cost of providing full range

of services for very few people, billing issues for clinics include approved providers, more than one visit in a day and telepsychiatric visits, cost of providing treatment is often higher than reimbursement, and insurance parity issues.

5. Lack of infrastructure: Limited range of services, level and locale of services, lack of

emergency and transitional beds, lack of full-range of supportive community services such as domestic violence, drug and alcohol, Adult Day Health Care, housing, food banks, etc.

6. Stigma: “Small town” confidentiality, consumer denial of service need due to stigma.

7. Lack of coordination along the entire continuum of mental health care services.

8. Emergency services: Access, follow-up, transportation, bed space, efficacy of

emergency interventions, cost

9. Conflicts between different service models: Lack of interdisciplinary training and lack of funding for time spent in cooperative/coordinated efforts.

10. Vulnerability to market economy, as resources and quantity are scarce and demand is

high.

11. Transition to client directed care

North State Rural Mental Health Summit

REVIEW OF RELEVANT DATA

Speranza Avram, M.P.A.Northern Sierra Rural Health Network

April 26, 2002

Presentation Overview

Unique North State Challenges in Providing Mental Health Services

The Role of Community-based Providers

Conclusions

North State Mental Health Challenges

Suicide rates tend to be higher in North State (and other rural regions of California)Region has fewer behavioral health specialists per capitaCounty mental health systems have severe provider shortagesProviders are unevenly distributed in the North State

*

*

*

*

*

*

** *

*

** *

**

** *

*

**

**

***

*

0 - 9.59.6 - 14.2514.26 - 1919.01 - 23

Deaths Due to SuicideTwo-year Age Adjusted Rate 1999-2000

*Death rateunreliable, standarderror > 22%

Source: California Department of Health ServicesCounty Health Status Profile 2002

North State Rural Mental Health SummitApril 26, 2002Presented by Northern Sierra Rural Health Networkmapping created by Center for Economic Development

State wide average: 9.5

North State Rural Mental Health SummitApril 26, 2002Presented by Northern Sierra Rural Health Network

mapping created by Center for Economic Development

Number of Therapists2 - 1011 - 1819 - 3132 - 63

Total Licensed Behavioral Professionalsper 10,000 People

Source: Compiled by Edward E. Hall Ph.D. www.therapistexchange.com State of California Licensing Board Records & 2000 Census

CMHDA RegionsBay AreaCentralLos AngelesSouthernSuperior

California Mental Health Directors AssociationRegional Breakdown of Counties

Source: California Mental Health Planning Council

Nor th S tate Rural Mental Health SummitApri l 26, 2002Presented by Northern Sierra Rural Health Network

mapp ing creat ed by Center fo r Economic D eve lopment

Vacancy Rates for Board Certified Child Psychiatristsfor County Operated Programs*

100.0%

9.1%

27.3%

0.0%0%

20%

40%

60%

80%

100%

120%

Superior California Bay Area Central California Southern California

*Data not available for Los Angeles Area.

Vac

ancy

Per

cent

age

(%)

N o rt h S t a t e R ura l M e nt a l He a lt h S ummitA p ril 2 6 , 2 0 0 2P re s e nt e d b y N o rt he rn S ie rra R ura l He a lt h N e t w o rk

c re a t e d b y C e nt e r f o r Ec o no mic D e v e lo p me nt , C S U , C hic o

S o urc e : C a lif o rnia M e nt a l He a lt h P lanning C o unc ilS t a t e w id e S urv e y o n V a c a nc y R a t e s in M e nt a l He a lt h P o s it io nsJ a nura ry , 2 0 0 0

Vacancy Rates for Licensed Marriage, Family, and Child Counselors for County Operated Programs*

49.4%

12.4%8.6%

25.8%

0%

10%

20%

30%

40%

50%

60%


*Note: Data not available for Los Angeles Area.

Vaca

ncy

Perc

enta

ge (

%)


c re at e d b y C e nt e r f o r Ec o no mic D e v e lo p me nt , C S U , C hic o

S o urc e : C a lif o rnia M e nt a l He a lt h P la nning C o unc ilS t a t e w id e S urv e y o n V ac a nc y R a t e s in M e nt a l He a lt h P o s it io nsJ anura ry , 2 0 0 0

Vacancy Rates for Mental Health Rehabilitation and Recovery Specialists for County Operated

Programs*

35.3%

12.7%

5.6%

13.2%

0%

5%

10%

15%

20%

25%

30%

35%

40%


*Note: Data not available for Los Angeles Area.

Vaca

ncy

Perc

enta

ge (

%)

S o urc e : C a li f o rnia M e nt a l He a lt h P la nning C o unc ilS t a t e w id e S urv e y o n V a c a nc y R a t e s in M e nt a l He a lt h P o s it io nsJ a nura ry , 2 0 0 0

N o rt h S t a t e R ura l M e nt a l He a lt h S ummitA p ri l 2 6 , 2 0 0 2P re s e nt e d b y N o rt he rn S ie rra R ura l He a lt h N e t w o rk


Vacancy Rates for Licensed Clinical Social Workersfor County Operated Programs

25.3%

31.3%

14.5%

7.6%

34.5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

SuperiorCalifornia

Bay Area CentralCalifornia

Los AngelesArea

SouthernCalifornia

Vac

ancy

Per

cent

age

(%)

N o rt h S t a t e R ura l M e nt a l He a lt h S ummitA p ri l 2 6 , 2 0 0 2P re s e nt e d b y N o rt he rn S ie rra R ura l He a lt h N e t w o rk


S o urc e : C a lif o rnia M e nt a l He a lt h P la nning C o unc ilS t a t e w id e S urv e y o n V a c a nc y R a t e s in M e nt a l He a lt h P o s it io nsJ a nura ry , 2 0 0 0

Vacancy Rates for Licensed Psychologistsfor County Operated Programs

25.0%

9.7% 9.4%

44.1%

12.5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

SuperiorCalifornia


Los AngelesArea

SouthernCalifornia

Vac

ancy

Per

cent

age

(%)


c re a t e d b y C e nt e r f o r Ec o no mic D e ve lo p me nt , C S U ,

S o urc e : C a lif o rnia M e nt a l He a lt h P la nning C o unc ilS t a t e w id e S urve y o n V ac anc y R at e s in M e nt a l He a lt h P o s it io nsJ anurary , 2 0 0 0

Vacancy Rates for Certified Alcohol and Drug Abuse Counselors

30.6%

19.2%

81.3%

33.3%

56.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

SuperiorCalifornia


Los AngelesArea

SouthernCalifornia

Vaca

ncy

Perc

enta

ge (

%)

S o urc e : C a lif o rnia M e nt a l He a lt h P lanning C o unc ilS t a t e w id e S urv e y o n V ac a nc y R at e s in M e nt a l He a lt h P o s it io nsJ a nura ry , 2 0 0 0



Vacancy Rates for Registered Nursesfor County Operated Programs

9.9% 10.1%

24.1%19.9%

15.1%

0%

5%

10%

15%

20%

25%

30%

SuperiorCalifornia


Los AngelesArea

SouthernCalifornia

Vac

ancy

Per

cent

age

(%

)


c re a t e d b y C e nt e r f o r Ec o no mic D e ve lo p me nt , C S U , C hic o

S o urc e : C a lif o rnia M e nt a l He a lt h P lanning C o unc i lS t a t e w id e S urv e y o n V a c anc y R at e s in M e nt a l He a lt h P o s it io nsJ anurary , 2 0 0 0

North State Licensed Behavioral Health Professionals

1203704

395

2302

0

500

1000

1500

2000

2500

Total MFCC LCSW PSY

Num

ber o

f Ser

vice

Pro

vide

rs

North State Rural Mental Health SummitApril 26, 2002Presented by Northern Sierra Rural Health Network

created by Center for Economic Development, CSU, Chico

Source: Compiled by Edward E. Hall, Ph.D.www.therapistexchange.comfrom State of California Licensing Board Records

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21 County Service Region# Licensed Behavioral Health Professionals

North State Concentration of Licensed Behavioral Health Professionals(LCSW, MFT, LCP)

Source: Compiled by Edward E. Hall, Ph.D. www.therapistexchange.com State of California Licensing Board Records

North State Rural Mental Health SummitApril 26, 2002Presented by Northern Sierra Rural Health Networkmapping created by Center for Economic Development

County Mental Health Services

Superior California region serves greater percentage of Medi-Cal population than other regionsSuperior California clients represent a larger percentage of the overall populationCounty mental health systems serve between 7.6% and 15.3% of Medi-Cal population and 1.4% and 2.1% of the overall population

County Mental Health Services

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County MH as% of Pop


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S o urc e : C a lif o rnia D e p art me nt o f M e nt a l He a lt h C lie nt and S e rv ic e Inf o rmat io n S y s t e m, 2 0 0 1

Community-based Mental Health Systems

Surgeon General Report estimates 1 in 4 persons (20% of population) suffers from mental illnessRecent National Mental Health Association report estimates twice as many people turn to their family doctor for a behavioral health problem than a psychiatristPrimary-level mental health services are part of scope of work for FQHC/RHC/ADHC providers AND are paid for outside of the county managed care system

21 County Service Region

North State Primary Care Mental Health Facilities

Source: Data from Office of Statewide Health Planning and DevelopmentNorth State Rural Mental Health SummitApril 26, 2002Presented by Northern Sierra Rural Health Networkcreated by Center for Economic Development, CSU, Chico

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DHS Medi-Cal Claim Data

10% sample of EDS claims paid by DHS for 2001 for all Medi-Cal providersICD9 codes analyzed for primary/secondary diagnosis:

Depression (311)Alzheimer’s Dementia (331)General Anxiety Disorder (300.02)Psychosis NOS (296)General Anxiety Disorder (300.02)Substance Abuse (303.9X)Schizophrenia (295)

Medi-Cal Data Findings

For the 21 North State counties analyzed, 51,000 claims for FFS mental health services were submitted by all provider types, representing 10% of all Medi-Cal FFS claimsMental health services represented 30% of all the payments made to FFS Medi-Cal providers, for a total of $16 million

Medi-Cal Data Findings –con’t

Primary care providers submitted 24,000 claims for mental health services, representing 48% of the total FFS mental health claimsPayments to primary care providers were only $2.3 million, representing 14% of the FFS mental health payments

Medi-Cal Claim DataAll Providers Mental Health Claims

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

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Mental Health Claims Mental Health Payments

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ent of M

/Cal C

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s

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S o u r c e : ED S C l a i m D a t a c o m p i l e d b y D HS Me d i c a l C a r e S t a t i s t i c s S e c t i o n10 % s a m p l e o f c l a i m s f o r 2 0 0 1 f o r s e c l e c t e d IC D - 9 c o d e s

Medi-Cal Claim DataPrimary Care Percentage of MH Claims

0.0%

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20.0%

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Primary Care MH Claims Primary Care MH Payments

Per

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/Cal

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Medi-Cal Claim Data –Conclusions

Services provided at long-term care facilities accounted for a majority of the payments for mental health services outside the county system, but not the claimsPrimary care facilities provide more lower-cost behavioral health services to more clientsSignificant service levels differences between providers in different counties due to prevalence of primary care facilities anddifferences in coding practices

Other Factors Impacting Rural Mental Health Services

Shortage of in-patient facilities and distance between service locationsStigma associated with receiving services, particularly in small towns (the Cheers affect –“where everybody knows your name”)Stoic self-reliance discourages seeking treatmentOverall lack of funding at the systems level impacts all aspects of service delivery

Conclusions

Limited options for new increased funding means leveraging existing resourcesRegulatory systems and categorical reimbursement streams place barriers in the way of collaborating for care at the community levelPatients do not separate their minds from their bodies – neither should we

Why is it so hard to link mental health and primary care

Neal Adams MDMedical DirectorCalifornia DMH

Or…

If salad is so good for me, why am I still eating fried chicken?

How it looks today…

Health MentalHealth

Addictions

How it could or should look…

Health

Mental Health

Addictions

Or perhaps…

HealthMentalHealth

Addictions

How did we get to where we are?

People who love law, sausages and health policy should watch neither being made.

What keeps us apart?

Disconnected models

Biomedicalbody as a machine

Psychoanalyticemotions and behavior only understood in psychological terms

Self Helpnon-professionalpeer-based

Stigma

Provider stigma and biasreluctance to make referrals

Confusion about providers and specialtiesMFT, MSW, PhD, MD

Patient resistance“I’m not crazy”economic burden

Benefit programs

MH is typically a carve-outpublicprivate

Parity legislation remains a struggleincluding Medicare and Medi-Cal

Access can be a problem

System issues and history

Mental Health--a public responsibilitystate hospitalcommunity MHsevere, persistent and disabling disorders

Medical Services--public and privateambulatory and outpatientacute and chronicindigent and benefited

County MH mandates

Assure basic health and safetyemergency psychiatric services

Target population / systems of careSDMISED

Medi-Cal eligiblesmanaged care

Disaster response

Realignment and State funding

Disincentives for state hospital utilizationStabilization of funding based upon vehicle licensing fees and sales tax

shifted responsibility for MH to countynot necessarily equitablefalling behind economic and population growth

Required County contributionMedicaid rehab option

Medicaid Waivers

National trend toward managed care1915(b)

freedom of choicemultiple models for general health

capitation / pmpmcounty MH designated as sole source provider of mental health services

allocationbased on historical utilizationconsistent with national trends

End result for counties

Improved MH programming and services at local level

funding has increased compared to early 1990sNew responsibilities for non-SDMI populationOverall system still severely under-funded and many SDMI go unserved

shortages of fiscal and human resourcesIncentives to “push”acute MH to primary care

Changes / trends in primary care

Increased interest and training in psychiatric disorders

improved diagnosisrecognition of somatization as MH problem

70-80 % of psychotropic meds prescribed in primary careEmerging models of integrated care

collaborationco-location

Santa Cruz model

Build a clinical bridgecreate a functional linkagebring clinical language and practice to the required administrative MOUestablish boundariesclarify expectations and responsibilitiesfoster collaborationcreate a mechanism for dispute resolutionprovide training to primary care practioners

Vision and values

Patients should experience a continuum of quality, culturally competent and comprehensive care which is, as much as possible, focused, coordinated, and managed in the primary care setting.

The chief role of the mental health system is to support the primary care practitioner in providing appropriate psychological/psychiatric services. Additionally, the mental health professional is available to provide specialty mental health services when indicated.

Principles

1. The majority of patients initially present their distress in primary care settings.

2. Their problems are not either biological or psychological—they are both, presenting in an undifferentiated form.

3. For problems that are clearly psychological or psychiatric, (e.g. depression and anxiety) primary medical settings are the predominant locus of treatment.

Principles continued

4. There is a greater likelihood of adherence to treatment regimes and better outcomes when treatment is provided in the primary care setting.

5. When specific patient needs are identified which exceed the scope and practice of primary care, the mental health system is available to provide specialty mental health services.

Principles continued

6. It is critically important that relevant clinical information is readily accessible to both the primary care and mental health providers consistent with the standards of medical record confidentiality and the protection of patient privacy.

7. Children and adolescents may have special needs and require different approaches to the provision and coordination of services.

Levels of MH care

1. Telephone psychiatric consultation2. Face-to-face psychiatric consultation3. Ongoing psychiatric treatment / management4. Non-physician mental health services5. Acute inpatient6. System of care

24 hour carerange of outpatient services

PRN: Physician Response Now

On demand telephone consultationcould be televideo

Attempt to provide consultation and support while the patient is in the primary care office

reduce need for call backs and visitsmay clarify need for face-to-face consultation

Consultation issues

Consultations are most effective when the referring provider can specify their concerns

uncertain diagnosisnon-response to treatmentmedication side-effectsstrategies for on-going managementpossible need for additional specialty mental health services

On-going psychiatric management

Treatment with multiple psychoactive medications (i.e. combined therapy) is neededTreatment with an antipsychotic or other medication with which the primary care provider is unfamiliar is neededNo adequate therapeutic benefit despite multiple treatment attempts and initial psychiatric consultationChronically unstable and has treatment needs which exceed the skill / resources of the primary care provider

Non-physician MH services

PCP or self referralTypically time-limited focused brief goal oriented therapy

may include group and family therapyMust meet medical necessity criteria

includes / excludes specific diagnosisappropriate and efficacious

Assist in maintaining highest level of independent functioning

APPENDIX E – WORK GROUP DETAILS Below is the complete listing of the ideas generated by the Work Groups. The Resources/Assets Section, as well as the Policy Section, combines the responses from all of the groups. Strategies are identified for each of the six Work Groups, as well as Area Action Plans for each issue. RESOURCES/ASSETS – Work Groups identified the following resources and assets in the North State that can be used to improve mental health services:

• Community clinics-primary care providers- School based RHC/FQHC • Substance abuse – Community Based Organizations and county • County Behavioral Health Departments • Policy information and technical assistance for county mental health from the State of

California/DMH • Insight into indigent health coverage • Wellness and prevention services • Lobbying and coalition building • Contract monitoring • Networking/Networks/Consortiums • Telemedicine/Telepsychiatry • Intercommunity (individual) Advocacy and Activism • Grassroots Community Development/ Community people working together • Integration Projects/Plans • Hospital Services – ER – inpatient- psychiatric hospitals • Integrating resources • Resource Acquisition • Spiritual – Creative – Visionary - Enthusiasm • Financing, including CMSP • Tenacity “bulldog” • Staff, personnel and Human resources • Group homes • Advocacy • Outreach • Rural Health Departments, Community Health, Social service, Adult and Child

Protective Services, etc. • Non-profit Adult Day Health Care • Foundations/funders/Philanthropy • Urban rural perspective • NAM 1 • Children & Family 1st Commission • Elected policy makers • Prescription data

1

• Case management Services • Home based services/ Home Mental Health Care (including home detox) • Associations/Lobbyists • Consultants/Instructors • Caregiver Resource Centers • Commitment to collaboration • Attention to and help for dementia • Money to make a “bigger pie” • Naiveté (Ability to do the impossible simply because you don’t know you can’t) • Creativity from working in frontier and rural areas • Represent unique needs of Native American (and other ethnic) populations • Wide Experience • Interagency cooperation • Youth services

POLICY ISSUES Participants were asked to list anything that was “beyond your control” or things that were clearly regulatory or governmental in nature under “policy issues.” By listing policy issues separately, facilitators hoped to encourage unlimited brainstorming, but to also freely identify any barriers and possible future areas for change as well.

• Reimbursement rates inadequate to provide services/ Restrictive regulations that affect reimbursement

• Lack of genuine mental health parity • Control of mental health delivery by HMOs, Medi-Cal, etc. (payment source gate

keeping despite eligibility, physician recommendation and covered services. May include red tape and billing nightmares to discourage providers)

• Restricted and limited criteria for eligibility for county mental health consumers • Cost shifting • Implementation enforcement of Knox-Keene • County Medical Services Program (CMSP) patients seen in primary care clinics • More covered mental health services for CMSP • Policy/ billing/funding strategy of fee for service may need to make a return • Allow MFT’s to practice in all Medicare/Medi-cal settings • Invest in mental health support • Hospitals involved in consultative services • Hospitals need to invest/commit in psychiatry as a specialty • No more local control – centralization of services • Local sensitivity – anti-stigma regulations • Legislation for inpatient psychiatry services/ Facility issues • Children’s policy council

APPENDIX E – WORK GROUP DETAILS 2

• Geographical isolation/allow for transportation and creative solutions for rural distances. Consider the effects of isolation and the population(s) who may seek it out. Effects of geography on access

• Limitations on realignment • Mandates without funding • Bureaucracy overload “one size fits all” (learning curve/community problems for new

state. Administrator) • Liabilities related to using volunteers • Healthy Families benefits are not being utilized • HIPAA re information sharing • ICD9 vs. DSMIV • Number of approved visits for behavioral health • Narrow definition of scope of responsibility • Share of cost • Reimbursement for telemedicine in primary care settings • Too much paperwork • Conflicting agency policy • Barriers created by confidentiality • Paid consumer peer support


1. LACK OF PROVIDERS: group 4 representing Butte, Tehama, and Glenn Counties. Facilitator: Pam Tupper, Executive Director, Shasta Consortium of Community Health Centers and group 6 representing “friends of the North State” with a number of participants from Modesto, with Mary Jane Alumbaugh, Ph.D. CIMH facilitating.

STRATEGIES Methods for improving the problem include:

• Access recent retirees for part time positions/ Draw upon large pool of skilled retirees – pay them to mentor students

• Education in middle schools/elementary schools for career opportunities in mental health (K-12)

• Job fairs • Use technology for supervision component of licensing • Develop partnerships to “grow your own” personnel in rural communities • Financial incentives (stipend bonus) • “Better” Coordination between departments and other providers • Collaborative “friendly” policies • Parity between county & Community Based Organizations • Develop infrastructure of Community Based Organizations • Form collaboratives with university and training facilities • Transport patients to providers • Mental health shortage designation • Regionalize behavioral health care • Educate around disciplines and requirements (MFT, LCSW, etc). • ROP for high schoolers in mental health • Develop “Community Mental Health” curriculum • Integrate dementia treatment/care into multidisciplinary trainings • Ask Department of Mental Health to look at training County Behavioral Health

Departments and Community Based Organizations in issues of licensing requirements for billing purposes

• Educate layman volunteers • Professionals need to be trained to graciously allow outsiders into their busy systems • Improve educational standards – and cross training - opportunity • Develop more educational opportunities

COLLABORATIONS & PARTNERSHIPS

Key providers ripe for possible collaborations and/or partnerships to improve the access to all/any providers in rural northern California were identified as primary care, county behavioral health and community based organizations seeking staff and:

• Tertiary care centers • CEU sponsorships • Chamber and recreations organizations


• Advocacy groups • Associations • Universities • Foundations • Private corporations

AREA ACTION PLAN

Work group participants created Area Action Plans that included:

• Increased use of telepsychiatry • Increased utilization of Family Nurse Practitioner/Physician’s Assistants • Develop conferences/trainings to take place in rural areas • Advertise in recreational magazines • Hiring partnerships such as Local hospitals and clinics recruiting together • Communication w/universities • Develop support for stipend program funding for rural training • Bring together a national mental health conference on rural services • CIMH offer scholarships to residents • How do we impact training of practitioner groups who might be partners? • National Alliance for Mentally Ill (CAMI), NASW, CSWE, CAMFT, Assoc of Ad.

Boards, National MH Assoc, Board Behavioral Science, Superior California MH Directors, CIMH – Cathy Wright and squeaky wheels- let them know that lack of providers is an issue we are serious about solving and seek their active assistance

• University job fairs • School (8th grade and other) job fairs • Health fairs • Mentoring programs in high school • Licensed providers by Education. Grants/loans/$ incentives for commitment to rural

practice • More collaboration in creative use of provider resources • Increased volunteer use • Certification of mental health workers/MHRS • Non-economic incentives and active provider outreach • Cross training of staff


2) LACK OF RESOURCES: Group 1 representing Sacramento, Yolo, El Dorado and Placer Counties. Facilitator: Jack Tanenbaum LCSW, Department of Mental Health, and Group 3, from Nevada, Plumas and Sierra counties with Sharon Avery Rural Health Center facilitating.

STRATEGIES Suggestions for ways to improve the issue of lack of resources in rural northern California include:

• Paid internships (cross-issue impact with lack of providers) • Improved behavioral health training for primary care providers • Increased use of Telepsychiatry and Telemedicine • Linkages w/Universities/Medical Schools • More equitable/equal cost reimbursement • Collaboration – primary care and mental health providers • Outreach – public education regarding mental health inadequate resources • Education about severe mental illness to sources of funds. “Feedback for Sanity” • Grants to fill holes and pilot projects to effect change • Reduce paperwork requirements • Integrated system changes in service delivery system • Simplifying billing codes • Accurate documentation of service costs • Increase the number and availability of Crisis Beds – Children/Adults (increased funding

for liability, etc)/ Children treatment facilities • Increase human services and adequate housing for Children and adults in crisis • More $ • Geriatric training for multidisciplinary services • Coordinated treatment models • Regionalize services • Collocated case manager/Collocated services • Volunteers/paraprofessionals/interns • School outreach • Repeal Prop. 13 • Cross-training

COLLABORATIONS & PARTNERSHIPS

Suggested collaborations and partnerships that might improve the lack of resources in Northern California include:

• Foundations – Community Based Organizations and Counties • Primary care, Department of Mental Health, and Community Based Organizations • Coordination w/Medical Centers/Universities

o Training o Telemedicine Services o Residency Rotations


• State-County-Community Partnerships • Public education – Through all of the above partnerships • Lobbyists • Elected Officials • Media • Faith-Based Providers

AREA ACTION PLAN

The area action plans for these two groups included:

• Mental Health benefit reform • Investigate barriers to services and work to actively solve access issues • Lobbying task force • Collaboratives: public/private partnerships to fill gaps • Educate potential referrers • Define variables and standardize data collection • Utilize Rural Health Centers and Federally Qualified Health Centers for behavioral health

needs • Strategies for dementia • Identify new $ • Placement of mental providers in primary care clinics/ Primary Behavioral Health Care • Get a demonstration project funded (to maintain and enhance services for the indigent

population) • Lobby for stronger enforcement of Knox Keene (access) • Explore regional approaches to increase access to services


3) CHALLENGES TO COORDINATION ALONG THE FULL RANGE OF BEHAVIORAL HEALTH CARE SERVICES. Group2 covering Shasta County was facilitated by Liz Mantle, LMFT NSRHN Network Coordinator and Group 5 representing Siskiyou, Modoc, Trinity, Del Norte, Lassen, Humbolt and Mendocino Counties with Susan Ferrier, NSRHN Telemedicine Coordinator facilitating.

STRATEGIES

Solutions to improve coordination along the full range of services included:

• Move out of county department of mental health and go where the client is • Anti-Stigma – satellite clinic located in the community • Locating services in primary care clinics where consumer could be seeking services for a

variety of reasons • Psychiatrists in Federally Qualified Health Centers/ Psychologists in Federally Qualified

Health Centers. Coordinated effort to employ mental health and medical providers in one organization, such as LCSW & LMFT at primary care clinic

• Improved community-wide cross or inter-communication • Full list of phone numbers and services for all community, county, primary care non-

profit etc. services. And have the list available on-site at all those services • Resources list also available on website • Clinician to clinician exchange • Change in billing strategies • Cross training • Collaboration – partnerships. Revive collaboration group in our local area • Sharing of information • Develop multi-agency release form to allow easy collaboration on hi-risk patients • Work with local pharmacies to track medical usage/compliance • County mental health staff sees patients at primary care clinic site • Increased communication between P/C providers and county mental health • Decentralization of mental health services due to geography/distance • Funding puts barriers to expanded care – change funding structure to allow flexibility and

exceptions • Use grant funding to help fill gaps

COLLABORATIONS & PARTNERSHIPS Possible links to improve coordination of services include:

• Work with community partnerships through Emergency Rooms (as they may still be locally owned, and most hospitals are not any longer)

• Community coalition to increase county inpatient psychiatric beds and provide pediatric and youth beds

• For-profit private sector may be a significant partner • General community involvement • Expose students to model of interdisciplinary collaboration



• Regional effort to create release of information w/in HIPAA • Regular meeting of primary care, mental health, substance abuse • Have local psychiatric expertise present information to primary care providers • Have a county liaison w/psychiatrist to reduce calls from providers • Representation of mental health at primary care provider meetings and vice versa

AREA ACTION PLAN

• “Call Barbara Walters and Diane Sawyer” (community/state/national ed) • Patient sharing/networking/collaboration • Web page of resources and referrals that can be self-updated via passwords for providers • “Healthcare for the Homeless” – intergenerational planning group • Broaden our partnerships – legal, social services, mental health, primary care, community

non-profits, for profits, service organizations, individuals, etc. • Offer to collaborate with school outreach and education (e.g. arts and local history

diversity program to teach tolerance and appreciation of ethnic cultural contributions as non-intrusive way to improve mental health and decrease racial violence)

• Community involvement in school life skills/stress management/substance abuse prevention

• Countywide recruitment and coordinated scheme to improve responses to all three top mental health / primary care issues

• Provider responsibility to achieve outreach with key community collaborators i.e.: county behavioral health should know about primary care mental health services and telemedicine services and local primary care providers would like to know more about how county behavioral health works

• Provide cross county behavioral health department and primary care clinic/provider trainings (such as NSRHN is doing)

• Develop HIPAA friendly consent to reduce barriers to wrap-around services • Commitment to formal and informal meetings to discuss and surpass conflicting

regulations policy and practices • Continued countywide and region wide meetings of County mental health and primary

care providers • Remove barriers to reimbursement for services through legislative efforts

california institute for behavioral health solutions ......health network (nsrhn), the california...

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