1. Collaborative Care Atlantic Behavioral Health Lori Ann Rizzuto, LCSW Director, Behavioral & Integrative Health Services

2. Some issues to consider * Psychiatrist provides supervision for clinician and PCP Cultural differences  Billing  Length of appointment  Language  Treatment approach CoordinatedCo-locatedIntegrated LocationSeparateSome HoursOn Site CommunicationElectronic Referral Warm Hand Off*

3. Integration – what is it and why do we need it? Patient Centered Team Care behavioral health clinician identified as member of treatment team Population Based Care tracking outcomes in aggregate Measurement Based Treatment to Target Personal Goals PHQ-9 and GAD-7 Evidenced Based Care Problem solving therapy, CBT, Motivational Interviewing Improved medical outcomes and cost-effective means of providing population based psychiatric care for chronic conditions  Depression  Metabolic Syndrome  Hypertension  Cardiac Disease 45% of Americans have more than one chronic condition 3

4. What have we done  Screened 955 patients June 2015 – February 2016  Enrolled 107 patients  43 active patients Results: Statistically significant reduction in symptoms of anxiety and depression as measured by the GAD7 and PHQ9 4

5. Strengthening partnerships to improve access to care We can’t do this alone… Community Providers Faith Based Organizations Schools Peers Information & Referral 5

6. Patient Centered Medical Home Integrating Primary & Behavioral Health Care A Grass Roots Approach

7. 2014 Seton Center Co-Morbidity Data We looked at 544 cases that actively use our behavioral health services 29% of youth (under 21 years of age) have been diagnosed with a chronic medical condition 38% of our youth are diagnosed with two or more chronic conditions 35% of adults in our care are diagnosed with a chronic medical condition 60% have been diagnosed with two or more chronic medical conditions

8. 2014 Seton Center Population moving beyond Primary Care

9. Five Principles of Integrating Care A Patient-Centered Orientation Comprehensive team based care Care is coordinated by a single entity Continuous access to care available A system based approach to quality management and data collection

10. Some of our considerations when in- sourcing or out-sourcing integrated care In-source Fit out the office space for exam rooms Data/communication lines installed Purchase and install office equipment Hire PA 15+ hour/wk position to schedule, coordinate, gather charts, registration, billing, record data Leverage existing case managers to monitor clinical outcomes Requires medical staff “ownership” of the process Secure a doctor and/or NP to act as the primary care practitioner Tap into in-house experts to do regular patient education on data driven topics Keep current with changing insurance carriers to remain in-network Develop a network of specialists needed to meet the needs of the population Control internal referrals to St. Mary’s Possibly better control over branding Out-source Select a group practice specializing in the population to be served Craft a performance based agreement and monitor adherence Fit out the space for exam rooms Data/communications installed Selected groups comes with their own practitioners, support staff and office equipment Selected group comes with a network of specialists Group staff does the data collection, monitoring and reporting of outcomes Establish effective means of bi-directional communications with PCP group. Develop appropriate confidentiality and consent protocols

11. Local vendor search Share our Vision and be Outcomes Driven. Integrated Primary Care, On-Site. Utilize Advanced Practice Nurses, MD’s, and Nutritionists to deliver care. Integrate/Partner with access to Ancillary Specialist Services like Cardiology, Urology, Women’s Health, Gastro, Pulmonary, Endocrinology, immunizations, etc. to deliver total care. Refer acute care cases to our inpatient settings. All Insurance (Medicaid, Medicare, Dual Eligible) accepted. Connected with specialty pharmacy and laboratory services. Accessible 24/7/365 to staff and clients.

12. Two years later… Primary care practice on-site Specialty pharmacy serving our consumers Laboratory services available on-site Same day communication between primary care, psychiatry and laboratory 200+ people seen Positive outcomes being generated Planning for expansion

13. Lessons learned Not all community based providers are created equal “Integration” has many definitions Key to success is building partnerships with entities that share the same values Have a C-level executive champion

14. The Integrated Health Home for the Seriously Mentally Ill NJAMHAA Life is better healthy.

15. 15Background In 2013 Monmouth Medical Center Southern Campus (MMCSC) and Monmouth Medical Center (MMC) began implementation of a demonstration program for the Integrated Health Home (IHH) for the Seriously Mentally Ill (SMI) as part of the NJ Delivery System Reform Incentive Payment program (DSRIP) Based on the 2014 Rutgers Center for State Health Policy Report examining the role of Behavioral Health conditions in avoidable hospital use and cost Among Medicaid beneficiaries, SMI was present in 44.4% of IP super utilizers Among all IP hospitalizations, SMI-related costs accounted for 24.0% of IP BH costs ($211.5 Million) while SMI-related ED costs accounted for 17.1% of ED BH costs ($12.5 Million)

16. 16 Program Objectives The mission of the IHH is to provide behavioral and physical health services to the low-income SMI population in a co-located setting Provide a seamless integration of care from Inpatient to Outpatient treatment in the community Develop partnerships with community resources –Doctors and Specialists –Mental Health Clinics –Social Service Organizations Remove the barriers to successful outpatient treatment for the SMI population Improve health outcomes

17. 17 Components of Integration  Development of an integrated clinical EMR for seamless information transfer between Inpatient and Outpatient setting  Collaboration between Inpatient/Community Referral Sources and IHH team for patient assessment  Integrated team approach to program intakes and treatment  Intakes include Physician/APNs, Social Workers, Pharmacists, Community Health Workers (CHWs)  Comprehensive follow-up in the community setting  Wellness Calls and appointment reminders  CHW intervention

18. Success –Patient Engagement in Treatment –Collaboration with community partners –Improved Outcomes Patients seen within 7 days of referral: 84.7% (2014 Avg. 23%) First Appointment Adherence: 94.1% (5.9% No-Show) Inpatient Utilization by IHH Patients: Avg. Reduction of 60% in 2015 Challenges –The program has proven success but finding sustainability beyond the DSRIP dollars is a key challenge. Lessons Learned –Building strong collaborative relationships and processes between teams, agencies, and community partners requires time and commitment –The impact of Social Determinants on patients ability to address their own wellness is an important factor to patient success –Providing Health Literacy education for the low-income population is beneficial Success and Challenges 18

19. CONTACT Stan Evanowski Director, Integrated Health Home RWJBarnabasHealth sevanowski@barnabashealth.orgContact 19