1. AMHC Integrated Service Approach February 9, 2010

2. 2 AMHC Locations

3. February 9, 20103 AMHC & Integration: 36 Year History  Strategic priority for AMHC  Vision aligned with Four Quadrant, Strosahl and Care Model  Dedicated to improving health and wellness through a biopsychosocial approach  Implementing brief treatment and Stanford chronic disease lifestyle management model developed by  Guided by written, customized integration protocols for defined diseases and supported by expert training resources  Grounded in principles of providing immediate access to most appropriate, highest quality, affordable service  Informed by decades of experience working in Aroostook County, in Maine, nationally through MHCA, and internationally through IIMHL

4. February 9, 20104 IOM Influence  Grounded in the Institute of Medicine’s (IOM) Crossing the Quality Chasm aims: patient-centered safe timely efficient effective equitable

5. February 9, 20105 Service Models  Four Quadrant Clinical Integration Model  Chronic Care Model  Strosahl Primary Behavioral Health Care Model

6. February 9, 20106 Four Quadrant Clinical Integration Model Four Quadrant Clinical Integration Model Presentation by Service Population and Setting

7. February 9, 20107 Informed, Activated Patient ProductiveInteractions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design DecisionSupport Clinical Information Systems Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization / ICIC PHQ-9 Registry Self-Mgmt Tools Care Mgmt Psych consult Care Model

8. February 9, 20108 Strosahl Primary Behavioral Health Model  Goal is to increase effectiveness of primary care providers in addressing behavioral health needs of patients.  Focus on managing psychosocial aspects of disease by addressing lifestyle and health-risk issues through brief consultative interventions and temporary co-management of behavioral health conditions.

9. February 9, 20109 Self-Care Psychosocial and alternative therapeutic interventions Medical & drug interventions

10. February 9, 201010 Self-care Objectives  Patient at the center and in control of his health.  Uses a broad variety of techniques to attain and achieve optimal health.  This is a fundamental shift in the paradigm of health services currently focused on treating disease and expects practitioners to work with a patient to inform and support his ability to guide his own self-care.

11. February 9, 201011 Advantages  Improve access to behavioral and physical health services  Apply evidence based practices to improve client outcomes  Improve provider communication and coordination of care  Foster a multi-disciplinary team approach to treating substance abuse with a co-occurring chronic health issues (cancer, cardiovascular, COPD, depression, diabetes)

12. February 9, 201012 Advancing Approach to Practice  Embedding primary care family practice physician into AMHC’s service site to provide outpatient and medication management services  Primary goals: Encourage self-care Improve type and quality of services Meet unmet needs Increase cost efficiency Address workforce issues and offer professional advancement Improve primary care physician ability to treat patients with chronic mental illness

13. February 9, 201013 Key Activity Milestones  Administrators and clinical staff were oriented to the principles of the Four Quadrant Model and how it interfaces and complements the Planned (Chronic) Care Model.  Written, customized integration protocols for depression, anxiety, substance abuse, sexual assault, were developed  Assessment tools for depression, PQ-9, and substance abuse, the CAGE, were implemented and are used at the sites.  One blended record at the primary care site.  Periodic provider team meetings held to address care coordination and collaboration issues  Scheduling, staff credentialing and billing issues were improved Successfully secured DHHS reconsideration and approval for FQHC’s to bill MaineCare and be reimbursed for services provided by LMSW-cc credentialed clinicians.  Clinician assignments to support the integration efforts were maintained, with 90% of initial placements sustained throughout the life of the project.  Six Pines physicians have staffed AMHC’s opioid replacement therapy clinic since July 2006.  AMHC implemented an account management approach to working with the primary care practices to ensure immediate responsiveness to addressing clinical approach, staff availability, credentialing, scheduling, and billing issues.

14. February 9, 201014 Why integrate services?  International, national and state level movement to integration of services Federal Level Public Support  HRSA and SAMHSA and their counterparts in other countries through the International Initiative for Mental Health Leadership (IIMHL) Private National Organizations  Institute of Medicine (IOM)  National Council for Community Behavioral Healthcare (NCCBH)  Mental Health Corporations of America (MHCA) and its counterpart State Level Public support  Department of Health and Human Services (DHHS) Private Maine State Organizations  Maine Health Access Foundation (MeHAF)  Quality Counts (QC)  Primary Care Association (MePAC)  Association of Mental Health Services (MAMHS)  Association of Substance of Abuse Programs (MASAP)

15. February 9, 201015 Potential and Sought After Rewards  Improved Health Outcomes Healthier Patients Increased Patient Satisfaction  MeHAF focus groups found MH & SA patients reported having a higher degree of integrated care PH patients express a sense of loss when case management services offered by specialty providers were stopped and they returned to “regular care” Improved staff satisfaction  Working Conditions Perceived effectiveness in delivering quality services Coordination of services across multi-disciplinary professional

16. February 9, 201016 Potential and Sought After Rewards  Improved Organizational Performance Achieving Service Mission and Business Objectives  Service Effectiveness More comprehensive array of service responses aligned with true service needs  Service Efficiency Increased capacity and productivity achieved through appropriate utilization of multi-disciplinary staff resources  Improved Financial Performance Reduced cost of providing services when responses are aligned with true service needs Improved revenues generation resulting from increased productivity across multi-disciplinary staff.

17. February 9, 201017 How integrated are we?  5 Levels of Integration I. Minimal collaboration II. Basic collaboration from a distance III. Basic on site collaboration IV. Close collaboration that is partly integrated V. Fully integrated System

18. February 9, 201018 Project Mission  “To provide comprehensive, patient centered care that offers concurrent prevention and management of multiple physical and behavioral healthcare service needs of a patient in relationship to his or her family, life events, and environment.”

19. February 9, 201019 Project Activities  1. Confirm: Medical Director’s commitment to participate in and help guide the process. Behavioral and Physical Healthcare Provider willingness to  Improve integrated services  Participate in regularly scheduled multi-disciplinary staff meetings  2. Provide Refresher and Ongoing Education Integration Models and/or Evidence Based Practices Strategies to reduce barriers and advance integrated service practice  3.Commit to Including Patients in the Project to Help: Increase awareness, encourage participation, and reduce stigma.

20. February 9, 201020 Project Activities  4. Improve Delivery of Substance abuse and Co-occurring Disorder Services  5. Implement Care Coordination and Patient Self-management Services  6. Identify, Implement and Monitor Measurable Indicators to Support the Reporting of Achieved Outcomes.

21. February 9, 201021 Integration Barriers in Maine  Culture and Practice Patterns Selecting integration model(s) based on practice context 15 minute visit vs. 50 minute therapy session Education of providers is silo’d and there is no or limited understanding across disciplines.

22. February 9, 201022 Integration Barriers in Maine  Stigma and lack of awareness Stigma associated with some behavioral and physical health service needs is a barrier to seeking and providing service. Patient and provider lack awareness about integrated care and the advantages. Patients generally lack an understanding about how they may be able to self-manage care and advocate for integrated services.

23. February 9, 201023 Integration Barriers in Maine  Reimbursement: No reimbursement for integrative (e.g., collaborative care and team approaches), care coordination, and preventative services.

24. February 9, 201024 Next Steps