1. Implementing, Measuring, Improving and Sustaining Behavioral Health Integration Neil Korsen MD, MS Medical Director, Behavioral Health Integration MaineHealth

2. Outline  Background: Why integration?  Nuts and bolts: MaineHealth’s Behavioral Health Integration Program  National resources: AHRQ Academy for the Integration of Behavioral Health and Primary Care

3. Why Integration?

4.  “A sensible vision of primary health care must have mental health care woven into its fabric.”  Frank deGruy, MD, IOM Report ‘Primary Care: America’s Health in a New Era.’ 1996  “Behavioral health is integral to overall health as mind and body are inseparable.”  Patient Centered Primary Care Collaborative  Revised PCMH Joint Principles

5. Mental Health Integration in Maine

6. Members Affiliates Maine Mental Health Partners Miles Memorial Hospital St. Andrews Hospital Home Health Visiting Nurses Maine PHO Mid-Coast Hospital MaineGeneral Medical Center Maine Medical Center Penobscot Bay Medical Center Stephens Memorial Hospital St. Mary’s Regional Medical Center Waldo County General Hospital Southern Maine Medical Center MaineHealth

7. Screening for common mental health conditions Primary Care Treatment Integrated mental health services Consultation services: Collaborative care CPAP Primary & Specialty Medical Health CareSpecialty Mental Health Care Specialty MH care by referral Health behavior change/ Stress-related symptoms

8. Implementation - Operations

9. Engaging Leadership  Organizational leaders  Culture  ‘Permission’  Operational leaders  Resources  Problem solving  Front line leade rs  Energy  Communication

10. Choosing a Behavioral Health Specialist

11. Administrative meeting: the “friendly forum” Behavioral health clinicians, medical provider, billers/coders, practice manager  Review data on show rates, productivity, access  Payment information: codes getting reimbursed/denied  Clinical practice issues: e.g. length of sessions, frequency and duration of treatment

12. Implementation - Clinical

13. If you build it, they won’t (necessarily) come – need for patient ID  Who might benefit from behavioral health integration? –People who screen positive for common behavioral health problems  Depression  Anxiety disorders  Substance use disorders –People who need support for health behavior change –People with common symptoms such as headache, fatigue, other pain syndromes

14. Relationship Building  Huddles  Informal interactions –Mental health clinician has to be around and available  Warm handoffs  Lunch and learns/informal training

15. Workforce Development  Monthly and as needed supervision by LCSW experienced in integrated care  Group case review with psychiatrist monthly  Quarterly training and team building for all integrated clinicians across the system

16. Implementation - Financial

18. Health & Behavior Codes  Patients with underlying physical illness or injury  Where biopsychosocial factor may be affecting medical treatment  Diagnosis must be medical diagnosis, not mental health  Current challenges in use of H and B codes

19. Quality Measures

20. Initial Process Measures  Access – 3 rd next available appointment  No show rate  Productivity – billings  Referrals by provider  Warm handoffs by provider  Depression screening

21. Outcome measures  Currently able to measure –Financial performance vs. budget –Depression outcomes  Desired, not yet feasible –HRQOL/ General function –Total health care costs –Patient, provider and staff satisfaction –Measure of team function

22. Funded under contract #HHSA290-2010-00002i by the Agency for Healthcare Research and Quality The AHRQ Academy for Integrating Behavioral Health and Primary Care

23. ACADEMY PORTAL HOMEPAGE http://integrationacademy.ahrq.gov/http://integrationacademy.ahrq.gov/

24. Literature repository

25. Goal of the Lexicon was to develop conceptual & definitional clarity Provides a basis for effective research and communication for all stakeholders The Lexicon serves as the foundation for much of the Academy’s work LEXICONhttp://integrationacademy.ahrq.gov/lexiconhttp://integrationacademy.ahrq.gov/lexicon

26. 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. Integrated behavioral health care is:

27. Mental health and substance abuse conditions, Health behaviors (including their contribution to chronic medical illnesses), Life stressors and crises, Stress-related physical symptoms, and Ineffective patterns of health care utilization Integrated behavioral health care may address:

28. A practice team tailored to the needs of each patient and situation With a shared population and mission Using a systematic clinical approach Supported by: – A community, population, or individuals expecting that behavioral health and primary care will be integrated as a standard of care – Practice operational systems and processes, leadership alignment, and business model, and – Continuous quality improvement and measurement of effectiveness How is integrated care delivered?

29. Funded under contract #HHSA290-2010-00002i by the Agency for Healthcare Research and Quality Atlas of Integrated Behavioral Health Quality Measures IBHC Measures Atlas

30. Landing Page

31. The Integration Framework

32. Overview of Measures

33. Measures of Integrated Behavioral Health Care

34. Find a Measure

35. Core Measure Page

36. PDF Example of Included Measure

37. http://integrationacademy.ahrq.gov/

38. Start where you are Use what you’ve got Do what you can Arthur Ashe

39. Additional Resources: Websites  www.uwaims.org - Advancing Integrated Mental Health Solutions – resources for implementation from University of Washington www.uwaims.org  www.integratedprimarycare.com – National clearinghouse site for information on integrated care out of University of Massachusetts. www.integratedprimarycare.com  www.integration.samhsa.gov - Website of the SAMHSA-HRSA Center for Integrated Health Solutions www.integration.samhsa.gov  www.ibhp.org - Integrated Behavioral Health Project. Good general information on integrated care site out of California. www.ibhp.org  http://pcmhlearning.ehs.state.ma.us - Massachusetts state site about Patient Centered Medical Homes that provides useful information about integration http://pcmhlearning.ehs.state.ma.us Books  Blount, A. ed.(1998). Integrated Primary Care: The Future of Medical and Mental Health Collaboration. New York: Norton Publications  Butler M, Kane RI, McAlpine D, Kathol, RG, Fu SS, Hagedorn H, Wilt TJ. Integration of Mental Health/Substance Abuse and Primary Care No. 173 (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-02-009.) AHRQ Publication No. 09-E003. Rockville, MD. Agency for Healthcare Research and Quality. October 2008.

40. Questions? Neil Korsen, MD, MS nkorsenme@gmail.com