P R I M A R Y A N D B E H AV I O R A L H E A LT H C A R E I N T E G R AT I O N S E P T E M B E R 3 0 , 2 0 1 4

The Governor’s Health Summit

The Problem: Behavioral Health Clients Have Poor Health Status

Seriously Mentally Ill (SMI) clients die approximately 25 years earlier than the rest of the population

Preventable medical conditions are the leading cause of premature death among the SMI population

Behavioral Health clients have higher rates of co-occurring conditions including—hypertension, diabetes, obesity, and asthma

Life style choices and medication side effects create a unique set of medical problems

Behavioral Health clients are less likely to receive care that meets clinical guidelines

The Problem: Behavioral Health Clients Have Poor Health Status

In a study of clients served in Weber County Only 56% reported having a PCP, 73% of those with a PCP reported

that their PCP was their psychiatrist 100% reported the need for a care for a primary health condition 24% had chronic health conditions 87% had not had recommended preventive screenings 50% had visited the emergency department for care 91% who visited the emergency department had gone for a physical

health concern

Care Settings

There are multiple settings behavioral health clients access care Hospitals and Emergency Departments (ED) Community Physicians in private practice Community Health Centers Volunteer Medical Centers (i.e. “free clinics”)

Challenges: Care Settings

There are multiple doors and many wrong doors for accessing care Primary care physicians are not trained in medication management for serious

mental illness Psychiatrists are not trained to manage family practice concerns It is difficult for clients to access multiple doors (transportation, scheduling, time) Understanding the system is difficult for both providers and clients It is difficult for clients and providers to understand the system

Care between systems is often disjointed and uncoordinated The health care system does not always accommodate behavioral

health clients Staff and non-behavioral health clients are uncomfortable with the behavioral

health clients’ behavior Paperwork can be cumbersome and lengthy

Creating One Door

Community Health Centers

CHCs are private non-profit organizations that receive some federal funding Services are provided on a sliding fee scale for uninsured clients

CHCs serve medically underserved areas and populations in both urban and rural areas

Behavioral health services, are much like in private physician practices, and typically include: Counseling Family Practice prescriptions for anxiety and depression Some psychiatric services

CHCs and their community mental health providers are beginning to partner to provide some co-located services Weber, Utah, Washington

The Goal: Primary and Behavioral Health Care Integration

Developed by the Substance Abuse and Mental Health Services Administration to offer primary care to adults with SMI in community mental health centers Preventive screening Treatment for primary care conditions Registry systems Care Management Prevention and wellness services Practice integration and improved communication across the

continuum of care

Integration of Primary Care into Specialty Behavioral Health Care

Weber Human Services and Midtown Community Health Center operate a federally funded Primary and Behavioral Health Care Integration site (PBHCI)

The PBHCI site is currently funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), and administered by the Center for Integrated Health Solutions through the National Council for Community Behavioral Healthcare

Currently there are 106 grantees nationwide Grant funds are used to provide primary care services for seriously and

persistently mentally ill adults Grant requires that primary care services be integrated into publically-funded,

community-based behavioral health care settings Grant also requires that grantees track services outcomes

Integrated Behavioral Health Model

Function

Access • Co-location with same entrance• Shared reception and staff• Shared Waiting Area

Services • Case management and staffing of shared clients• Comprehensive Primary Care• Medication management for behavioral health concerns• Behavioral health therapy

Funding • Grant funding• Medicaid reimbursement• Patient Fees

Governance • Consumer Advisory Board

Data • Separate data systems with shared access• Patient registries

Services Service Provider Funding Source

Primary Care Midtown CHC SAMHSA Grant, patient fees

Behavioral Health Midtown CHC Intermountain Healthcare, St. Benedicts Foundation grant, patient fees

Flow of Funds in Weber County Model

Uninsured Clients

Medicaid ClientsServices Service Provider Funding Source

Primary Care Midtown CHC Medicaid Reimbursement

Behavioral Health Weber Human Services Medicaid Reimbursement

Managing Clients Entering through the ED

Behavioral health clients use the emergency department for primary and behavioral health care.

The emergency department attracts a greater than proportional number of uninsured clients with behavioral health concerns. Behavioral Health Network – Intermountain Healthcare employs a

care coordinator to ensure access and timeliness of care

The RAND Study

SAMHSA commissioned RAND to evaluate the program’s success. 56 sites were selected for a web-based survey and three sites (including Weber County) were selected for intensive study

The RAND Study: Better Access to Care

The RAND Study: Better Access to Care

The RAND Study – Better Access to Care

The RAND Study: Surprising Results

The use of shared information systems were associated with decreased access to care Decreases face-to-face communication between staff Interferes with the creation of a shared culture

Outcomes: Clients Served 2013

1,170 clients served during 4,620 encounters Race and Ethnicity

77% Caucasian 19% Hispanic

Insurance Status 35% uninsured 18% dually eligible for Medicaid and Medicare 6% Medicare 29% Medicaid

Outcomes: Financial

Overall health cost and financial outcomes are not tracked as part of SAMHSAs PBHCI project

Other research shows mixed findings for these factors ED use and hospital admissions decline for persons who have coverage who

have an effective ‘usual source of care,’ a probable source of health cost savings

However, the frequency of diagnosis and the likelihood of treatment of behavioral health and other chronic conditions increase with improved access to care, with the probable impact of increasing total cost, at least in the short run.

Outcomes: Behavioral Health

National Outcome Measures (NOMs) Number of Consumers Positive at Baseline Positive at Second Interview Outcome Improved Percent Change*Healthy overall (NOMs) 791 44.90% 62.70% 28.80% 39.70%*Functioning in everyday life (NOMs) 802 38.50% 59.60% 63.00% 54.70%*No serious psychological distress (NOMs) 799 51.90% 74.80% 29.00% 44.10%Experiencing serious psychological distress (Past 30 days) 799 48.10% 25.20% 6.10% -47.70%*Were never using illegal substances (NOMs) 799 81.70% 93.20% 15.30% 14.10%Using illegal substances (Past 30 days) 799 18.30% 6.80% 3.80% -63.00%*Were not using tobacco products (NOMs) 802 45.30% 47.50% 9.90% 5.00%

Challenges: Funding

Long-term financial sustainability Midtown Funding subsidizing care for uninsured clients expires September 30, 2014. It is

not possible to maintain services when a high percentage of clients remain uninsured

Funding for new projects Financial viability without supplemental grant funding requires that all (or nearly

all) clients be covered by Medicaid or private insurance Grant funding for uninsured clients has been available only on a very limited basis

Coverage Uninsured clients are not eligible for public assistance or subsidies under the

Marketplace Clients are likely to be among the slowest to sign up for coverage and maintain it.

This has been true during the PCN enrollment and will likely remain true under a Medicaid expansion

Challenges: The Model

Creating a shared culture Primary care staff and behavioral staff are trained differently Primary care and behavioral health systems operate differently

Recruiting and retaining qualified staff Shortage of providers trained in medication management and

primary care for seriously mentally ill clientsEvaluating clinical and financial outcomes

Financial data across the continuum of care is difficult to obtain or understand

Long-term health outcomes are difficult to measure Engaging and retaining clients