Paving the Way for Behavioral Health and Primary Care Integration

Angela Herman, MPA, CPHQMissouri Primary Care Association

April 10, 2012

Missouri Medicaid Reform Commission (1/05)

Acknowledged reform must take place in the

context of system transformationTwo state Associations hosted joint meeting of

CHCs and CMHCs to explore interest in primary care and behavioral health integration (6/06)

State Associations advocate for integration

funding (2007 Legislative Session)General Assembly appropriates Integration

funding (7/07)

Movement Towards Integration

Improving AccessTo primary care for people with serious mental illnessTo behavioral health services for people with

previously unrecognized and/or untreated mental health problems

To behavioral health supports for people who require assistance in effectively managing their chronic disease or improving health status

Improving Clinical CareSeeing mental health as essential to overall healthSeeing and treating the whole person

Improving Collaboration Between Systems of Care

Missouri’s Integration Initiative

Missouri Primary Care Health Home Initiative State Plan Amendment

• Section 2703 of the Affordable Care Act• Medicaid State Plan Amendment• Provide 6 defined Health Home Services for:• Serious and persistent mental illness• Two qualifying chronic conditions• One qualifying chronic condition and at risk for a second

qualifying chronic condition• State Defined Conditions

• 90% federal match for two years• Missouri has two approved: Mental Health

(Serious and Persistent Mental Illness) and Primary Care

Missouri Qualifying Conditions for Primary Care

• Combination of Two

• Diabetes (CMS approved to stand alone as

one chronic disease and risk for second)

• Heart Disease, including hypertension,

dyslipidemia, and CHF

• Asthma

• BMI above 25 (overweight and obesity)

• Tobacco Use

• Developmental Disabilities

Partners in Planning

• Department of Social Services (DSS)• Department of Mental Health (DMH)• MO Foundation for Health (MFH)• MO Primary Care Association (MPCA)• MO Coalition of Community Mental Health

Centers (CMHCs)• Consultants: Michael Bailit & Alicia Smith • Missouri Hospital Association (MHA)• Missouri School Board Association (MSBA)

Participating Primary Care Sites

• Provider Requirements

• At Least 25% Medicaid/Uninsured

• Using EMR for six months or longer

• Plans to apply for NCQA Patient Centered Medical

Home Recognition within 18 months• Organizations Selected to Participate

• 18 FQHCs operating 67 clinic sites• 6 Hospitals operating 22 clinic sites• One Independent Rural Health Clinic

Goals of the Primary Care Health Home Initiative

• Reduce inpatient hospitalization, readmissions and inappropriate Emergency Room visits

• Improve coordination and transitions of care• Implement and evaluate the Health Home model as a way

to achieve accessible, high quality primary health care and behavioral health care;

• Demonstrate cost-effectiveness in order to justify and support the sustainability and spread of the model; and

• Support primary care and behavioral care practice sites by increasing available resources and improving care coordination to result in improved quality of clinician work life and patient outcomes.

Performance Goals and Measures

• Improve primary health care • Improve behavioral health care • Improve patient empowerment and activation • Improve coordination of care • Improve preventive care • Improve diabetes care• Improve asthma care• Improve cardiovascular care

Six CMS-Defined Health Home Services

• Comprehensive care management • Care coordination • Health promotion • Comprehensive transitional care including follow-up

from inpatient and other settings • Patient and family support • Referral to community and support services

Health Home Team Members

• Health Home Director• Nurse Care Manager• Behavioral Health Consultant• Care Coordinator

Payment Method

• $58.47 per member per month (PMPM) for performing Health Home services and activities

• Providers required to pay a $3.47 PMPM for administrative costs associated with data management, training, technical and administrative support

• Future amendment to current state plan for provider incentive payments based on shared savings and distributed according to performance on quality and cost measures.

• NOT offset on FQHC cost report

• Must be Licensed Clinical Psychologist or Licensed Clinical Social Worker• Ratio of 1:750 Patients in the State Plan Amendment and

$7.78 of the PMPM supports the BHC• Integration with Primary Care

• Support to Primary Care physician/teams in identifying and

behaviorally intervening with patients who could benefit from

behavioral intervention.

• Part of front line interventions with first looking to manage

behavioral health needs within the primary care practice.

• Focus on managing a population of patients versus specialty

care

Behavioral Health Consultant

• screening/evaluation of individuals for mental health and substance abuse disorders• brief interventions for individuals with behavioral health

problems• behavioral supports to assist individuals in improving

health status and managing chronic illnesses• The behavioral health consultant both meets regularly

with the primary care team to plan care and discuss cases, and exchanges appropriate information with team members in an informal “curbside “ manner as part of the daily routine of the clinic

Behavioral Health ConsultantContinued

• Interventions

• Identification of the problem behavior, discuss impact, decide

what to change

• Specific and goal directed interventions

• Use monitoring forms• Use behavioral health “prescription”• Multiple interventions simultaneously

Behavioral Health ConsultantContinued

Integration of Substance Use Prevention Activities in Primary Care

• SAMHSA Grant awarded to the MO Department of Mental Health, Missouri Screening, Brief Intervention, Referral, and Treatment (MOSBIRT)• Grant is administered by Missouri Institute of Mental

Health on behalf of MO Department of Mental Health• Grant is designed to reduce risky alcohol and other drug

use to reduce medical costs by reducing problem substance use in primary care.• Organizations participating in the Missouri Primary Care

Health Home Initiative will receive $30,000 in one-time funding to cover the costs associated with start-up for the implementation of MOSBIRT.

Benefits of Participation in MOSBIRT

• Assists in meeting five of the required performance measures for the Primary Care Health Home Initiative

• Substance abuse screening utilizing a standardized tool

• Reduce proportion of adults reporting use of illicit drugs

• Reduce proportion of adults who drank excessively

• Tobacco use assessment and cessation

advice/treatment

• Depression screening utilizing a standardized tool

Benefits of Participation in MOSBIRT Continued

• $30,000 in additional funding to support substance

use prevention efforts in primary care

• Access to training and technical assistance for your

behavioral health consultant

• Opportunity to develop and/or enhance the

relationship with your local alcohol and drug

treatment providers• MIMH in collaboration with DMH Division of Alcohol

and Drug will be providing a model MOU to help facilitate referral relationships.

Training and Technical Assistance

• Contractors:–St. Louis Behavioral Medicine Institute

–Missouri Institute of Mental Health

• Format of Training and Technical Assistance–Centralized and regional Face to Face

–Webinars

–Site Visits

–Telephone consultation

–Statewide Learning Collaborative Learning Sessions

Tools and Resources

• MO HealthNet Division, Primary Care Health Home Informationhttp://dss.mo.gov/mhd/cs/health-homes/

• Missouri Health Home State Plan Amendment Informationhttp://dmh.mo.gov/about/chiefclinicalofficer/healthcarehome.htm

• National Committee for Quality Assurance: www.ncqa.org/tabid/631/Default.aspx

• Commonwealth Fund: Safety Net Medical Home Initiativewww.qhmedicalhome.org/safety-net/change-concepts.cfm

• Improving Chronic Illness Care: www.improvingchroniccare.org/index.php?p=Patient-Centered_Medical_Home&s=224

• The Joint Commission:

http://www.jointcommission.org/accreditation/pchi.aspx

• Patient-Centered Primary Care Collaborative: www.pcpcc.net/content/patient-centered-medical-home

• American College of Physicians: www.acponline.org/running_practice/pcmh/

Contact Information

• Angela Herman- aherman@mo-pca.org • Susan Wilson- swilson@mo-pca.org

Missouri Primary Care Association

3325 Emerald Lane

Jefferson City, MO 65109-6879

(573) 636-4222

www.mo-pca.org