Safety Net or Death Trap? Improving Behavioral Health & Primary Care for the Most Vulnerable Wayne P. Law, MSW Administrator, Hawaii Dept. of Health - Adult Mental Health Division - Community Mental Health Center System Administration C. Kimo Alameda, PhD. Director, Hawaii Dept. of Health - Office of Health Equity & Multicultural Services

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Behavioral Health Safety-Net The Problem: The Stigma of Mental Illness Still Exists: Thus, some ethnic (or geographic) groups with mild-moderate mental illness prefer going through the “primary care door” rather than the “mental health door”, and by the time they get into the “mental health door”, they have SMPI.

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Behavioral Health Safety Net How will it be better addressed?: At the front -- catching mental illness at the onset (in primary care) with people who tend not to use mental health services so they can obtain treatment earlier. At the back – catching chronic disease earlier with the SMPI population so they can live longer.

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Behavioral Health Safety-Net The Problem…cont.: People with SMPI die on an average of 25 years earlier than those without SMPI. This high mortality is largely due to preventable conditions: Smoking Obesity, Diabetes and Metabolic Syndrome Alcohol and Substance Abuse Infectious Diseases (HIV, TB)

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Behavioral Health Safety Net The Idea: A Person-Centered Integrated Health Care Home where one’s behavioral health and primary care needs can be addressed earlier -- in a holistic, culturally appropriate, and non- stigmatizing way.

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Hawaii’s Safety-Net Health Care Home---Why Else? Financial Incentives via ACA A. “Medical Home” $9-$1 federal match for the first 2 years. State plan amendment available to all eligible providers state wide. Short Term

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Hawaii’s Safety-Net Health Care Home---Why Else? B. Continuum of care reduces health disparities for patients with multiple chronic diseases like diabetes, hypertension, and depression, which are aggressive drivers of costs$$$. 2. Already Happening: The majority of “behavioral health care” in the US is delivered in primary care settings -- 65% of all behavioral health medications are given through the primary health care system. Long Term

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Financially, how is it now? “It's carved-in for QUEST, carved-out for QExA (with members getting care through AMHD or CCS) and then other underinsured/uninsured served by AMHD.” Quest Expanded Access for the ABD--Aged, Blind, or Disabled Under Age 65 and not ABD--Aged, Blind, or Disabled

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Big Island Project …considering working with the FQHC’s, Participating PCPs, the Health Plans, and the Beacon Grant

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Who are the Partners? Dept. of Health-Behavioral Health Objectives: All mental health and behavioral health consumers will have a PCP (or will be incentivized to have a PCP) who participates in a health home. The “home” could be the nearest FQHC (or participating PCP health home) or the Mental Health Center / Family Guidance Center if primary care is brought in. Pharmacy and Dental will be connected.

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Who are the Partners? FQHCs and/or Participating PCPs Objectives: All patients with suspected severe mental illness will be screened for AMHD/CAMHD eligibility. FQHCs/PCPs will have Electronic Health Records. Health Plans will provide incentives to the FQHCs and PCPs to allow for such a move. Base payment per client per month for being a Health Home? Bonus payment for improved outcomes? A Care Coordinator / Patient Navigator

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Who are the Funders? Dept. of Human Services—Medicaid Objectives: The possibility of utilizing the $9-1 ACA federal match. Hawaii’s State Plan Amendment includes behavioral health services as part of the Health Home definition and in addition to FQHCs, may allow PCPs, and Mental Health Centers to qualify for this incentive. Other?

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Who are the Funders? Beacon Grant (Big Island) Objectives: Beacon will zero-in their efforts on the Medicaid population to ensure all have an Electronic Health Record (HER). Beacon will offer funding for the navigator role in the FQHC and for PCPs participating as a health home.

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Kalihi-Palama Project Oahu

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Using the ACA Incentive? A. “Medical Home” $9-$1 federal match for the first 2 years. Hawaii’s State Plan Amendment includes behavioral health services as part of the Health Home definition and in addition to FQHCs, may allow PCPs, and Mental Health Centers to qualify for this incentive.

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Kalihi Palama Community Mental Health Center is looking at…. Bi-Directional Integrated Health Care Approach By Partnering with Kalihi Community Health Center, a FQHC, and using the Medicaid Match

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health NCCBH Four Quadrant Model: A Conceptual Understanding Mental Health Needs HIGHHIGH QII: MH is Locus of Care Coordinate with PCP QIV: MH and/or PC is Locus of Care Combined Care LOWLOW QI: PC is Locus of Care Provide MH by PC? QIII: PC is Locus of Care Provide MH by PC LowHigh Physical Health Needs Note: We are targeting Quadrant II and Quadrant IV populations

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health What Are We Talking About? Consumer/Patient AMHD Health Center BH Staff PC Staff Services as Usual + Some Primary Care Services as Usual + Behavioral Health Package Funding Opportunities Adding Staff?  Integrated Team?  Coordination of Care via Patient Navigator?  Electronic Record?  Standardized Screening Tools / Assessment?  Cross-agency Forms and Procedures?  Cross Training?  MOA with other Partners Cross Assessment Cross Screening Funding Opportunities Adding Staff?

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Some Barriers & Potential Solutions We Are Working Through…. Barrier of not knowing Reimbursement Issues such as: What do we know about who pays for what?. What are the billing rules by payer (eg., billing primary care visit same day as behavioral health visit, number of visit limits, auth/preauthorization's, etc.? What do we know about the Medicaid requirements for billing?. Solution: Work with Medicaid and get involved with the SPA.

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Inability of the Mental Health Centers to be a provider for QUEST patients. Many of KP- CHC’s patients are QUEST insured and will need a higher level of behavioral health intervention. Solution: Revisit DOH’s current policy established by the previous administration toward restoring the CMHC’s contractual relationship with QUEST Health Plans. Some Barriers & Potential Solutions We Are Working Through….

9/12/11Wayne P. Law & C. Kimo Alameda -- Hawaii Department of Health Thank You Mahalo!! Hilo Bay Front