1. The Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative Behavioral Health Subgroup Meeting: The Integration of Primary Care and Behavioral Health, Region 3 Learning Collaborative Alejandra Posada, M.Ed. Director of Education and Training Mental Health America of Greater Houston Elizabeth Reed, LMSW Assistant Project Manager – BHACA Initiative Network of Behavioral Health Providers Integrated Health Care Models and Practices

2. Finding a Common IHC Definition “The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population” Source: Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: AHRQ Publication No. 13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013. Available at http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf.

3. IHC Models: Theoretical Frameworks

4. Two Basic Models Behavioral Health Care Primary Care Behavioral Health Care bidirectional integration

5. The Four Quadrant Model Behavioral Health Risk/ Complexity Physical Health Risk/ Complexity Quadrant I BH  PH  Quadrant II BH  PH  Quadrant III BH  PH  Quadrant IV BH  PH  Source: SAMHSA-HRSA Center for Integrated Health Solutions

6. Source: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013. Available at http://www.integration.samhsa.gov/integrated-care-models/CIHS_Framework_Final_charts.pdf.http://www.integration.samhsa.gov/integrated-care-models/CIHS_Framework_Final_charts.pdf The Spectrum of Integrated Health Care:

7. Variations & Considerations One agency vs. a partnership between/among agencies Behavioral health services – Mental health? Substance use? Both? Psychiatry – On staff? Contracted? Tele-psychiatry? Consulting psychiatrist available to PCP? Care manager or care coordinator who serves as the “glue” in connecting the team? Additional integrated components based on particular needs/circumstances of clientele, e.g.:  Case management  Peer support services  Family support services  Social services

8. And now, an in depth look at the IMPACT Model…

9. IMPACT: Evidence-Based Depression Care IMPACT has been shown in randomized controlled trials to double the effectiveness of usual care for depression while lowering long- term health care costs. Five Key Components 1.Collaborative care is the cornerstone of the IMPACT model 2.Depression Care Manager 3.Designated Psychiatrist 4.Outcome measurement 5.Stepped care Source: impact-uw.org

10. IMPACT Cost-savings Source: impact-uw.org

11. Patient Primary Care Provider (PCP) Chooses treatment in consultation with provider(s): -Antidepressants and/or brief psychotherapy Refers; prescribes antidepressant medications IMPACT – Key Component #1: Collaborative Care + Depression Care Manager + Consulting Psychiatrist Source: impact-uw.org

12. IMPACT – Key Component #2: Depression Care Manager Depression Care Manager - may be a nurse, psychologist, social worker or licensed counselor and may be supported by a medical assistant or other paraprofessional. Role of the care manager: Educates the patient about depression Supports antidepressant therapy prescribed by the patient's primary care provider if appropriate Coaches patients in behavioral activation and pleasant events scheduling Offer a brief (six-eight session) course of counseling, such as Problem-Solving Treatment in Primary Care Monitors depression symptoms for treatment response Completes a relapse prevention plan with each patient who has improved The typical caseload for a full-time care manager is 100-150 patients. Similar Roles: Embedded Behavioral Specialist, Embedded Behavioral Health Consultant Source: impact-uw.org

13. IMPACT – Key Components #3, #4, and #5: Consulting Psychiatrist, Outcome Measurement, Stepped Care Designated Psychiatrist (Key Component #3): Consults to the care manager and PCP on the care of patients who do not respond to treatments as expected Outcome Measurement (Key Component #4): IMPACT care managers measure depressive symptoms at the start of a patient's treatment and regularly thereafter. The PHQ-9 is recommended as a tool, but there are other effective tools. Stepped Care (Key Component #5): Treatment adjusted based on clinical outcomes and according to an evidence- based algorithm Aim for a 50 percent reduction in symptoms within 10-12 weeks If patient is not significantly improved at 10-12 weeks after the start of a treatment plan, change the plan.

14. a. Primary Care (Antidepressant Medications) b. Specialty Mental Health Care / Psychotherapy Together the IMPACT Team… a. Case finding (screening, referral) -> confirm diagnosis b. Proactive follow-up & tracking (PHQ-9) Change treatment if patient not improving Relapse prevention plan for patients in remission Identifies and tracks depressed patients a. Education b. Brief Therapy: Behavioral Activation / Problem Solving Enhances patient self-management a. Caseload supervision / consultation for care managers b. Psychiatry consultation for treatment nonresponders Supports additional treatment Utilizes mental health consultation for difficult cases Source: impact-uw.org

15. The “Chocolate Cake Metaphor”

16. Key Elements – No Matter the Model Team-based approach to care Communication at all levels Coordinated, collaborative care Providers physically at the same location Access to shared patient records Understanding of each other’s roles and disciplinary cultures Screening, evidence-based clinical practices Patient experience of seamless care (“one stop shop”)

17. And now… we are proud to introduce Andrea Richardson, Executive Director of Bluebonnet Trails Community Services, a stellar example of how to go down the right road in integrated health care

18. Integration of Primary and Behavioral Health Services

20. Do the organizations have a common mission? Do the organizations use the Triple Aim as a guiding framework? improve the experience of care, Improve the health of populations, and reduce the cost of health care without compromising quality Do the organizations have capacity to measure the health outcomes resulting from integration? So…Where are the Organizations as Partners?

22. …and Where Do You Want to Go? Do the organizations want a separation of staff? What shared costs can be realized? What strengths may be shared: Medications Expertise in Service Delivery Billing Opportunities Technology Facilities

24. …and How Will You Know When You Get There? A Patient-Centered Model of Care…from the Front Door Onward Transparency of the Combined Effort A Unified Treatment Plan Communication and Action Planning Strengthening the System of Care

25. That’s All it Takes!?

26. Not so fast…

27. Sustainability For Quality Care: Focus on Access to Services Excellent Outcomes Establishing Continuity of Care Individualized Recovery and Health Plans

28. Sustainability For Financial Stability: Establishing Rates for Services Educating Health Plans Use of Telemedicine

29. Sustainability As a Partnership: Electronic Health Record Education of Staff Common Language Respect for Disparate Work Cultures Celebrations A

30. Discussion and Questions

31. Theory In Practice – Additional Real Life IHC Examples

32. A Texas Example – El Buen Samaritano El Buen Samaritano Episcopal Mission, Austin, Texas: Private, non-profit health and social service organization serving primarily Hispanic clients Wallace Mallory Clinic at El Buen Samaritano  Has been primarily nurse-managed  Integrated behavioral health (IBH) program began in October 2010 Behavioral health within a primary care setting  Adaptation of the IMPACT model

33. El Buen Samaritano (Continued) Clients screened for mental health issues during primary care visit and enrolled in IBH program LCSW (“embedded behavioral health specialist”) follows up with clients enrolled in the program  Possible “warm transfer”/client meets LCSW during primary care visit  LCSW serves as “care manager” (NOT case manager) and provides short-term course of therapy Psychiatric medication may be prescribed by PCP; PCP consults with psychiatrist as needed Provider communication and coordination

34. “Takeaways” from El Buen’s Experience Nurses’ training and perspective as facilitator in integrating care “Care management” role Benefits of a “warm transfer” Importance of mutual respect among all providers as equal members of the care team Role of formal and informal communication mechanisms Cultural and linguistic considerations

35. A Texas Example – Lubbock, Texas Sunrise Canyon Behavioral Health Network (CMHC) & Texas Tech University Health Science Center School of Nursing (FQHC): Integrated health care clinic at CMHC facility Shared vision for improving quality of care Space built out to include 10 exam rooms, lab space, shared staff offices Staffed by both CMHC and FQHC employees; intentional focus on operating as one clinical team even though employed by two agencies Nurse-managed

36. Lubbock Partnership (Continued) Funding:  SAMHSA grant and some state funding (after two years of collaboratively seeking funding)  Each agency’s regular funding streams (e.g., Medicaid reimbursement, CMHC general revenue funds)  FQHC bills as usual for the services its employees provide, and pays rent to CMHC  New Access Point funding Patient Satisfaction & Outcomes

37. “Takeaways” from Lubbock’s Experience Importance of shared priorities Importance of cultivating relationships and teamwork Nurses’ training and perspective as facilitator in integrating care Collaborative approach to funding (“the community’s money”) Critical need for integrated health care for individuals with serious mental illness

38. A Texas Example - LSCC Lone Star Circle of Care, Georgetown, Texas: FQHC providing care in Central Texas “Behaviorally enhanced health care home” Behavioral health as an equal service line within the FQHC Leadership – Behavioral Health Integration Council Leveraging diverse collaborations in the community Focus on financial sustainability

39. Lone Star Circle of Care (Continued) Active screening for behavioral health issues Embedded behavioral health specialists  Provide “real time” consultation to medical staff  Conduct crisis intervention for patients in the clinic  Facilitate and expedite access to psychiatric services  Provide brief therapy/counseling services to patients  Coordinate care with the patient’s PCP  Assist with efficient patient flow PCPs consult with child and adolescent psychiatrists Tele-psychiatry Provider communication and coordination  “Hallway” or “curbside” consults  Case conferences  Electronic Health Record

40. Lone Star Circle of Care (Continued) Lone Star Circle of Care’s Belton Pediatric Clinic: Primary Care Pediatric Clinic Pediatricians “Embedded” LCSW Psychiatrist at Another LSCC Location Consults with LCSW and pediatrician Provides direct patient services when needed EHR LSCC “Intranet” E-mail, cell phone Meetings every other month

41. Lone Star Circle of Care – Partnerships Partnerships with academic institutions: Partnership with Texas A&M Health Science Center (TAMHSC)  LSCC operates a clinical “hub” at the TAMHSC College of Medicine facility in Round Rock, TX (Seton Family of Hospitals funded start-up costs for this clinical hub)  LSCC is an affiliate of the TAMHSC College of Medicine – LSCC doctors act as clinical faculty; medical students rotate through LSCC clinics Similar partnerships with other academic institutions place students, interns, and residents at LSCC Partnerships with area hospitals: LSCC has partnered with area hospitals to coordinate care for uninsured patients Area hospitals have awarded LSCC one-time grants to establish clinics Increased access to primary care at a patient-centered medical home, complete with fully integrated behavioral health services, encourages more appropriate use of emergency services and thereby increases cost efficiency of care system wide Due to this program’s success, area hospitals continue to partner with LSCC to open more clinics, sometimes co-branding clinics After the initial grant to build and/or expand facilities, these LSCC clinics are fully sustainable and independently operated

42. “Takeaways” from Lone Star’s Experience Importance of leadership and organizational commitment Integrated health care as part of the “culture” of an organization Role of community collaborations “Care management” role Diverse mechanisms for communication; maximizing use of the EHR as a communication tool Financial sustainability

43. The Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative The Network of Behavioral Health Providers (NBHP) and Mental Health America of Greater Houston (MHA) have committed to work together to assist providers in Greater Houston/Harris County to adapt to health reform under the Patient Protection and Affordable Care Act (ACA). Four BHACA Initiative Focus Areas: 1) Establishing integrated health care (IHC) partnerships 2) Maximizing third party funding streams revenue 3) Adopting a certified electronic health record 4) Developing outcome based evaluations

44. You’re Invited: Benefit from BHACA! Find BHACA Resources housed at www.nbhp.org & www.mhahouston.org.www.nbhp.orgwww.mhahouston.org Join our BHACA listserv! Go to the www.nbhp.org homepage to sign-up for bi-monthly resource emails plus updates about upcoming training events.www.nbhp.org Open Call: Help us play matchmaker to leverage your medical staff to co-locate at interested behavioral health provider locations. Let us learn more about your resources and needs so we can support Houston area IHC partnerships. Community Events: Save the Date – Next IHC Open Discussion Meeting on April 23, from 2:00 to 3:30 PM. We are receptive to your requests for project-related trainings, so please be in touch!

45. What are your Questions? For More Information: Alejandra Posada, M.Ed. Director of Education and Training Mental Health America of Greater Houston 713-520-3473 aposada@mhahouston.org Elizabeth Reed, LMSW Assistant Project Manager The Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative Network of Behavioral Health Providers (NBHP) 713-520-3472 nbhp.bhaca@gmail.com