2. Webinar Agenda Welcome & Introductions Todd Molfenter, Dep. Director, NIATx, University of WI-Madison Improving Collaboration Between PC & BH David Bingaman, Dep. Regional Administrator, HRSA Region V Integration Models Laura Galbreath, Dep. Director, SAMHSA/HRSA Center for Integrated Health Solutions, National Council for Community Behavioral Healthcare WI Case: Tri-County Partnerships Kristene Stacker, Exec. Dir., Fox Cities Community Health Center Project Invitation – Next Steps

3. Improving Collaboration between Primary Care and Behavioral Health Providers December 13, 2011 David Bingaman, LCSW DHHS, HRSA Office of Regional Operations

4. Improving Collaboration Cartesian Dichotomy Separation/Fragmentation Growing economic incentives for a more effective approach

5. Improving Collaboration Primary care foundation PCPs deliver half of BH care PCPs prescribe 70% of psychotropic drugs PCPs have limited BH training; widespread under diagnosis

6. Improving Collaboration Impact of Mental Illness: 26% suffer from a diagnosable mental disorder in a given year; half meet criteria for 2 or more Half of all cases begin by age 14 and ¾ have begun by age 24 Up to 70% of primary care visits stem from psychosocial issues

7. Improving Collaboration PCPs have limited time to treat psychosocial issues BH care inaccessible to PCPs Many referrals do not result in visits/services Limited capacity of BH system

8. Improving Collaboration MH consumers less likely to receive primary medical care SMI associated with increased morbidity and mortality

9. Improving Collaboration Drivers of Change: Berwick’s Triple Aim: Better care, better health, and reduced cost through quality improvement Patient Centered Medical Home (2011) State and Federal budget cuts

10. Improving Collaboration Drivers of Change, continued Affordable Care Act: Community Health Centers Medicaid Mental Health & Substance Abuse Services Accountable Care Organizations

11. Improving Collaboration NASMHP Director’s Report: “Good public policy will work to sustain, support and require integration of services between the two “safety net” systems of CHCs and MH providers with integration ranging from coordination of care to full integration of medical and behavioral service.”

12. HRSA’s Resources for B.H. Integration into Primary Care http://bphc.hrsa.gov/technicalassist ance/taresources/index.html

13. David Bingaman, LCSW Deputy Regional Administrator Health Resources & Services Administration (HRSA) U. S. Department of Health & Human Services 233 N. Michigan Ave., Suite 200 Chicago, IL 60601 312-353-8121 dbingaman@hrsa.gov

14. Models for Primary and Behavioral Health Integration Laura M Galbreath, MPP Deputy Director, CIHS laurag@thenationalcouncil.org

15. “…in essence integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served.” Connecting Body & Mind: A Resource Guide to Integrated Health Care in Texas and the U.S., Hogg Foundation for Mental Health

16. Primary Care Behavioral Health Behavioral Health Referrals Physical Health Status Collaborative Care

17. Individuals with Serious Mental Illness - The Statistics Persons with serious mental illness (SMI) are dying at the average age of 53 (comparable to Sub-Saharan Africa) While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006) OR state study found that those with co-occurring MH/SU disorders were at greatest risk (average age of death=45.1 years)

20. Top Ten Areas for Consideration in Developing and Supporting Patient Centered Health Care Homes State Level Leadership State Level Management Models/Strategies Culture Workforce Collaboration Confidentiality Finance Data Training

21. The Four Quadrant Clinical Integration Model (MH/SU)

22. Models of Bi-Directional Integration Behavioral Health –Disease Specific IMPACT RWJ MacArthur Foundation Diamond Project Hogg Foundation for Mental Health Primary Behavioral Healthcare Integration Grantees Behavioral Health - Systemic Approaches Cherokee Health System Washtenaw Community Health Organization American Association of Pediatrics - Toolkit Collaborative Health Care Association Health Navigator Training Physical Health TEAMcare Diabetes (American Diabetes Assoc) Heart Disease Integrated Behavioral Health Project – California – FQHCs Integration Maine Health Access Foundation – FQHC/CMHC Partnerships Virginia Healthcare Foundation – Pharmacy Management PCARE – Care Management Consumer Involvement HARP – Stanford Health and Wellness Screening – New Jersey (Peggy Swarbrick) Peer Support (Larry Fricks)

23. Primary and Behavioral Health Integration Works PC→BH P-CARE - NIMH-funded Trial  Medical case management for individuals with serious mental illnesses  Fewer medical ER visits, improved cardio risk factors, and more likely to have a usual source of PCP care PC→BH Diabetes Care Coordination - AHRQ Health Care Innovation  Nursing and mental health care coordination to educate and empower clients with SMI to manage their diabetes  The number of clients with ideal blood sugar levels increased from 32% to 43%. Mean health risk status improved significantly from baseline to program. 23 BH→PC RESPECT – MacArthur Initiative  Cluster randomized controlled trial  60% response to treatment and 37% remission at 6 months, compared to 47% and 27% in usual care practices BH→PC IMPACT Study  Randomized clinical trial of collaborative care intervention for elderly patients  Showed significant improvements in symptoms and functionality at 6 months, 12 months, and 2 years BH→PC DIAMOND Initiative  Adapted IMPACT program for general population setting and studied outcomes  64% response to treatment and 44% remission at 6 months; 72% response and 52% remission at 12 months

24. Relapse Prevention Patient Registry Screening/ Monitoring Consulting Psychiatrist Care Manager Primary Care Provider Stepped Care Approach Components of Collaborative Care Model

25. Collaborative care’s key ingredients Care management – Patient education & empowerment, ongoing monitoring, care/provider coordination Evidence-based treatments – Effective medication management, psychotherapy, disease management Expert consultation for patients who are not improving Systematic diagnosis and outcome tracking Stepped care Technology support – registries J. Unutzer, 2010, www.cimh.org/LinkClick.aspx?fileticket=84F6JQndwg8%3d&tabid=804www.cimh.org/LinkClick.aspx?fileticket=84F6JQndwg8%3d&tabid=804 S. Gilbody et al, Arch Intern Med. 2006;166:2314-2321

26. Lessons from Practice Transformation to a Patient-Centered Medical Home Six lessons from 36 family practice settings across the country that participated in a two-year practice transformation project 1.“ Becoming a patient-centered medical home (PCMH) requires transformation. 2.Technology needed for the PCMH is not plug-and- play. 3.Transformation to the PCMH requires personal transformation of physicians. 4.Change fatigue is a serious concern even within capable and highly motivated practices. 5.Transformation to a PCMH is a developmental process. 6.Transformation is a local process.” Resonates with the experience in implementing integrated care—this is also a process of transforming personal and organizational practice in the context of local relationships—ideally, the medical home and integration changes can be woven together

27. Services Available from CIHS Web-based Resources (http://www.integration.samhsa.gov) eSolutions Newsletter National Webinars Regional and State Based Learning Communities Health Home Consultation to States

28. Tri-County Partnerships Calumet, Outagamie and Winnebago Counties working together with Fox Cities Community Health Center.

29. Who am I?  Kristene Stacker, R.N. Executive Director Fox Cities Community Health Ctr. (FCCHC)

30. Fox Cities Community Health Center: FCCHC  Started in 1997 as free community clinic.  2005 became a FQHC (Federally Qualified Community Health Center).  Board of Directors comprised of 51% consumer/users of the Health Center.  2009 served 6,989 individual consumers with 22,000 encounters.

31. Service Area  Outagamie County: 176,695K; 9.8% growth since 2000. 11.9% over 65; 24.7% under 18. 91% white;.1% black; 1.7% American Indian; 3% Asian 3.6% Hispanic. 8.7% below poverty. (increase from 6.9 in 09) Health and Human Services agency. Regionalized Family Care County. County HHS Budget of 59.3 million. Median household income $55,100

32. Service Area  Winnebago County: 166,994 (2010 data) 12.8% 65 or older; 21.1% under 18 92.59% white, 1.8 %Black, 3.5% Hispanic,.6% Native American, 2.3 Asian. 11.9 % Below Poverty increase from 6.9 in 2009) Human Services Agency. Regionalized Family Care County. 58 Million County HS Budget. Median Household income $47,486

33. Service Area  Calumet County: 48,971K 20.5% growth since 2000. 3 rd fastest growing county is State. 94.3 % White,.5 %Black, 3.5% Hispanic,2.1@ Asian,.4% Native American. 26.9 under 18; 10.8 over 65. 5.5 % Below Poverty. Median Household income $65,600 Health and Human Services. Regionalized Family Care. 14.9 million County HS Budget (2011).

34. Outagamie/FCCHC MH Pilot  2009 began discussions.  4 main objectives Address increasing length of wait for outpatient MH services. Increase MH services available. Increase access for Medical Assistance patients. Begin integration of MH into primary care.

35. A Phased Approach to Expansion  Phase I began 4/09 with FCCHC IM physician providing care at crisis diversion facility.  Phase II increase FCCHC’s MH counselor to 70% productivity expectation and add 2 contracted MH therapists from County to FCCHC.

36. Phased Approach  Phase III 8/09 added contract psychiatrist 6 hours per week.  Additional 4 hours per month psychiatric care to Brewster Village (County Nursing Home).  Most recently, increased to 14 hours per week of psychiatry time.

37. Phased Approach-2011  Added 2 FTE Licensed Professional Counselors to clinic employment in 2011.  Calumet County added LPC for weekly contract hours for group treatment related to sex offender grant.  Added contract BH providers through county contracts and other community providers.

38. Project Outcomes  FCCHC saw improvement in both provider productivity and management of MH program.  FCCHC had 900 MH visits in first 6 months w/ average no show rate of 15% (reduced from 30-40%).  Increase in access to MH services within the region. FCCHC access to MH services 5 days/wk.

39. QUESTIONS/COMMENTS  Contact Kristene Stacker kristene.stacker@thedacare.org kristene.stacker@thedacare.org 920-750-6611

40. Next Steps Todd Molfenter, Dep. Director, NIATx, University of WI-Madison Invitation Five-month collaborative (Feb-July 2012), no fee to participate. Improve collaboration between FQHCs and behavioral health agencies offering substance abuse services. Application: http://www.niatx.net/WordDoc/WICollaboration/application_WI.docx Application deadline: Friday, January 6, 2012 Project Kickoff Workshop: Madison, February 16, 8:30am-3:30pm Questions? Call Carol Sherbeck, (608) 265-5997 or email carol.sherbeck@chess.wisc.edu