PRIMARY AND BEHAVIORAL HEALTH CARE INTEGRATION SEPTEMBER 30, 2014 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

ServicesService ProviderFunding Source Primary CareMidtown CHCSAMHSA Grant, patient fees Behavioral HealthMidtown CHCIntermountain Healthcare, St. Benedicts Foundation grant, patient fees Flow of Funds in Weber County Model Uninsured Clients Medicaid Clients ServicesService ProviderFunding Source Primary CareMidtown CHCMedicaid Reimbursement Behavioral HealthWeber Human ServicesMedicaid 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: 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 ,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

Challenges: Funding Long-term financial sustainability Midtown  Funding subsidizing care for uninsured clients expires September 30, 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 clients Evaluating 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