An Environmental Scan of Behavioral Health Integration in Oregon PRESENTED BY JEN HALL, MPH Family Medicine, OHSU Proposal # / Session # D2b Collaborative Family Healthcare Association October 15-17, 2015 Portland, Oregon U.S.

FACULTY DISCLOSURE The presenters of this session have NOT had any relevant financial relationships during the past 12 months

LEARNING OBJECTIVES At the conclusion of this session, the participant will be able to: Describe the stages of behavioral health and primary care integration observed in Coordinated Care Organizations Identify contextual factors that shape behavioral health and primary care integration Identify and discuss key drivers and strategies for supporting behavioral health integration

REFERENCES 1. Cohen DJ, Davis MM, Hall JD, Gilchrist EC, Miller BF. A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration: Observations from Exemplary Sites. Rockville, MD: Agency for Healthcare Research and Quality; Cubic B, Mance J, Turgesen JN, Lamanna JD. Interprofessional education: preparing psychologists for success in integrated primary care. J Clin Psychol Med Settings 2012;19(1):84 ‐ Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative; McDaniel SH, Grus CL, Cubic BA, et al. Competencies for psychology practice in primary care. Am Psychol 2014;69(4):409 ‐ Rozensky R. Implications of the Affordable Care Act for education and training in professional psychology. Train Educ Prof Psychol 2014;8(2):83 ‐ 94.

LEARNING ASSESSMENT A learning assessment is required for CE credit A question and answer period will be conducted at the end of this presentation

BACKGROUND Coordinated Care Organizations (CCOS) are networks of health care providers and organizations (physical health care, addictions, mental health, oral health) who work together under one global budget, to delivery care to Medicaid beneficiaries First CCOs formed in CCOs in Oregon Operate under global budget

BACKGROUND: CCOs Accountable for patient health outcomes (17 metrics) Governance Governing Board Community Advisory Council Clinical Advisory Panel (optional)

BACKGROUND: CCOs Integration is a cornerstone of Oregon’s vision for CCOs A number of CCOs are piloting behavioral health integration in their practices 23 Transformation Fund projects focus on behavioral health integration

BEHAVIORAL HEALTH INTEGRATION Care that results from a practice team of primary care and behavioral health clinicians, working together to provide patient-centered care May address mental health, substance use, health behavior, life stressors and crises, stress related physical symptoms, and ineffective patterns of utilization

BEHAVIORAL HEALTH INTEGRATION A new model of care Not just PC + MH Requires a new kind of provider (or retrained provider) New infrastructure

“It’s a whole new language. It’s a whole new way of communicating and a whole different focus, which is very different and non traditional from when you truly think mental health therapy. I mean, it’s a different model. It’s short term. It’s solution focused.” -Behavioral Health Organization Leader BEHAVIORAL HEALTH INTEGRATION

THIS STUDY We conducted a survey of CCOs to better understand behavioral health integration efforts in Oregon

METHODS Sample: 5 of the 16 CCOs Membership size Geography Experience with integration 33 semi-structured interviews CCO leaders Behavioral health clinicians Primary care clinicians

METHODS Data analyzed by a multi-disciplinary team using crystallization-immersion approach Preliminary findings vetted with CCO- wide BH organization and refined Study protocol approved by the OHSU IRB

FINDINGS: HISTORY &EARLY ADOPTION Some practices and organizations in CCO network were integrating before CCO formation Early adoption also meant that partners often had experience and a history of working together

“Probably ten years ago, I sat in with a group called the mental health integration workgroup. […] We met with the Medical Director. We would talk about cases. We would talk about individual clients. And we weren’t the only ones involved. There was a number of people from our community.” FINDINGS: EARLY ADOPTION -BEHAVIORAL HEALTH CLINICIAN

FINDINGS CCOs in various stages of behavioral health integration implementation Major Implementation Pilot Plan

FINDINGS: PLANNING STAGE Site visits Learning from others Collecting data Surveying providers Determining interest

“Right now we’re gathering that information and doing the foundation. We’re taking in formation from folks who currently have integration efforts around what’s working and what isn’t, so we can look at how we can generalize that to our provider panel.” FINDINGS: PLANNING STAGE -CCO LEADERSHIP

FINDINGS: PILOTING STAGE Integration efforts in one or more practices, but not part of a systematic CCO effort

FINDINGS: MAJOR IMPLEMENTATION Dedicated resources Major focus area, part of vision Integrated care available to most members

FINDINGS: SUPPORTING INTEGRATION ONGOING LEARNING & SUPPORT GOVERANANCE STRUCTURE TRAINING BUY-IN & ENGAGEMENT FINANCING & RESOURCES

FINDINGS: GOVERNANCE Behavioral health representation on: Governing board Finance committees Clinical advisory panel Behavioral health provider organizations have strong connection and relationship with CCO

FINDINGS: TRAINING Learning Summits, Conferences, & Workshops SBIRT Tobacco cessation OPAL K Consulting with integration leaders in other states CCO provided/coordinated training on integration Primary care practices Behavioral health clinicians Primary care providers

It’s such a culture shift from doing the traditional mental health kind of therapy, move from 50 minute treatment hours and tons of sessions to 20 to 30 minutes and two to three sessions. It’s an entirely different vocabulary, a different focus, and a different way of meeting the needs of the patient. So [the intensive integration training] was helpful, that week of intense adoption of a new lens. That made a difference.” FINDINGS: TRAINING -BEHAVIORAL HEALTH CLINICIAN

FINDINGS: ONGOING LEARNING & SUPPORT Ongoing support and training to new BHCs Learning collaboratives for BHCs to share and learn from each other Learning collaboratives for integrated practices

“[The coordinator] goes around and visits the clinics and provides onsite consultation, as well as leads a learning collaborative group that meets twice a month to talk about issues related to integrated care. […] I thought it was important for the [BHCs] to continue to discuss issues, identify what works, what doesn’t.” -CCO PARTNER, CAP MEMBER FINDINGS: ONGOING LEARNING & SUPPORT

FINDINGS: BUY-IN & ENGAGEMENT CCO leaders with expertise or hired consultant(s) met with practice leaders: Provided integration readiness assessment Discussed how to begin behavioral health services in their practices

FINDINGS: BUY-IN & ENGAGEMENT Started in practices that were interested and ready Started in practices with a high number (or proportion) of Medicaid beneficiaries

FINDINGS: BUY-IN & ENGAGEMENT Clinical Advisory Panels (CAPs) (clinician leaders) Create buy-in in practices and local communities Key resource for engagement Clinician “change champions” at in a PC clinic or MHC can stimulate change and push integration forward Clinician word-of-mouth

“We knew [they] were going to be interested because they had been talking for a long time about really liking to have more access [to behavioral health.] And then there is some word of mouth that happens in the medical community. As people are happy with what’s happening, they talk about it with other practitioners. And then they either call us or bring it up to us in meetings [to] see if [they] can get something going in [their]practice.” FINDINGS: BUY-IN & ENGAGEMENT -CCO LEADERSHIP

FINDINGS: PILOTING & EXPERIMENTING

FINDINGS: FINANCING& RESOURCES Allocated Transformation Fund dollars to behavioral health integration projects Invest CCO dollars in integration pilots and initiatives Developing alternative payment methodologies for primary care reimbursement

LIMITATIONS CCOs and state policies change quickly Sample Only included 5 CCOs Did not include substance use providers Did not include patients The extent to which these findings are generalizable to other states is unknown

CONCLUSION State leaders play a role in shifting the environment to support an integrated health care system Providing guidance on effective strategies and sharing knowledge from Coordinated Care Organizations and their practices that are integrating care may accelerate integration efforts

THANK YOU! Thank you to the CCO leaders and providers who participated in our study. We appreciate the contributions of our collaborators who participated in this work: Integrated Behavioral Health Alliance of Oregon Oregon Health Authority Transformation Center Deb Cohen, PhD Jason Kroening-Roche, MD Ruth Rowland, MA David Cameron

SESSION EVALUATION Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!