Health Care for the Homeless Training Hawaii Primary Care Association June 27, 2013 Brenda Goldstein, MPH

Integrated Collaborative Care A coordinated system combining medical and behavioral services Coordinated detection, treatment, and follow-up of both mental and physical conditions. Whole person care Consumer experience is that, for almost any problem, they’ve come to the right place Bidirectional Primary Care Behavioral Health

Access Many people will not go to a specialty mental health provider – but they will go to see their primary care provider Those receiving services in the specialty mental health system do not go for regular primary care With ACA there will be a huge increase in insured adults with mental health needs – integrated care increases access

Health Benefits People with serious mental illness are: dying on average 25 yrs. earlier than the general population 3.4 times more likely to die of heart disease 6.6 times more likely to die of pneumonia and influenza 5 times more likely to die of other respiratory ailments 60% of premature deaths in persons with schizophrenia are due to medical conditions 7 of 10 leading causes of death ( e.g. heart disease, stroke, respiratory disease, accidents, diabetes, suicide) have a psychological and/or behavioral component.

Cost Benefits Patients who receive care for depression in integrated primary care were 54% less likely to use emergency departments Adding integrated services in one study added $250 per patient to costs, but saved $500 in additional medical costs A review of 57 studies found an average of 27% cost savings with integrated care 21% decline in costs at 18 months for Medicaid high utilizers who received intensive psychosocial services compared to a 22% rise for those not receiving notreatment

Integration or Parallel Play?

Hallmarks of Integrated Care Multidisciplinary staffing Patient/Client driven goals Shared space Shared records Informal and formal communication Warm handoffs Hallway consults Case conference s Integrated care directly addresses the triple aim and patient centered health “homeness”

Staffing Considerations Who is on the team? Licensed? Non-licensed? Primary Care Providers Behavioral Health What is their training? Productivity expectations? Traditional mental health treatment vs. shorter term/behavioral change focused care? Interruptions?

Using Data and IT Can EHRs support collaborative care? HIPAA – is it really a barrier? Outcome driven care relies on collecting and using data from assessment tools Can existing data systems be tweaked to support team based care? Individual patient vs. population based management

Costs of Collaborative Care Productivity issues Same day visits? Group visits? Substance use services FQHC vs. Specialty Mental Health billing – can this be combined? Mental health diagnoses only or are behavioral interventions for chronic disease billable?

One of the best resources in the whole world for information on integrated primary care and behavioral health Integrated Behavioral Health Project