Transcript behavioral health care - State Health Policy Conference

Safety Net or Death Trap?
Improving Behavioral Health &
Primary Care for the
Most Vulnerable
Wayne P. Law, MSW
Administrator, Hawaii Dept. of Health - Adult Mental Health Division - Community
Mental Health Center System Administration
C. Kimo Alameda, PhD.
Director, Hawaii Dept. of Health - Office of Health Equity & Multicultural Services
Behavioral Health Safety-Net
The Problem:

The Stigma of Mental Illness Still Exists:
Thus, some ethnic (or geographic) groups
with mild-moderate mental illness
prefer going through the “primary care door”
rather than the “mental health door”, and by
the time they get into the “mental health
door”, they have SMPI.
9/12/11
Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Behavioral Health Safety Net
How will it be better addressed?:
At the front -- catching mental illness at the onset
(in primary care) with people who tend not to use
mental health services so they can obtain
treatment earlier.
At the back – catching chronic disease earlier with
the SMPI population so they can live longer.
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Behavioral Health Safety-Net
The Problem…cont.:

People with SMPI die on an average of 25
years earlier than those without SMPI. This
high mortality is largely due to preventable
conditions:




Smoking
Obesity, Diabetes and Metabolic Syndrome
Alcohol and Substance Abuse
Infectious Diseases (HIV, TB)
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Behavioral Health Safety Net
The Idea:
A Person-Centered Integrated Health Care
Home where one’s behavioral health and primary
care needs can be addressed earlier -- in a
holistic, culturally appropriate, and nonstigmatizing way.
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Hawaii’s Safety-Net
Health Care Home---Why Else?
Short
Term
Financial Incentives via ACA
A.
“Medical Home” $9-$1 federal match for
the first 2 years.

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State plan amendment available to all eligible
providers state wide.
Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Hawaii’s Safety-Net
Health Care Home---Why Else?
Long
Term
B. Continuum of care reduces health disparities
for patients with multiple chronic diseases like
diabetes, hypertension, and depression,
which are aggressive drivers of costs$$$.
2. Already Happening: The majority of “behavioral
health care” in the US is delivered in primary care
settings -- 65% of all behavioral health medications are
given through the primary health care system.
9/12/11
Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Financially, how is it now?
“It's carved-in for QUEST,
carved-out for QExA (with
members getting care through
AMHD or CCS) and then other
underinsured/uninsured
served by AMHD.”
Quest
Expanded
Access for the
ABD--Aged,
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Blind, or
Under Age 65 and
not ABD--Aged,
Blind, or Disabled
Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Big Island Project
…considering
working with the FQHC’s,
Participating PCPs, the Health Plans,
and the Beacon Grant
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Who are the Partners?
Dept. of Health-Behavioral Health
Objectives:
•
All mental health and behavioral health consumers
will have a PCP (or will be incentivized to have a
PCP) who participates in a health home.
•
•
The “home” could be the nearest FQHC (or
participating PCP health home) or the Mental Health
Center / Family Guidance Center if primary care is
brought in.
Pharmacy and Dental will be connected.
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Who are the Partners?
FQHCs and/or Participating PCPs
Objectives:
•
•
•
All patients with suspected severe mental illness
will be screened for AMHD/CAMHD eligibility.
FQHCs/PCPs will have Electronic Health Records.
Health Plans will provide incentives to the FQHCs
and PCPs to allow for such a move.
•
•
•
Base payment per client per month for being a Health
Home?
Bonus payment for improved outcomes?
A Care Coordinator / Patient Navigator
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Who are the Funders?
Dept. of Human Services—Medicaid
Objectives:
•
The possibility of utilizing the $9-1 ACA federal
match.
•
•
Hawaii’s State Plan Amendment includes behavioral
health services as part of the Health Home definition
and in addition to FQHCs, may allow PCPs, and Mental
Health Centers to qualify for this incentive.
Other?
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Who are the Funders?
Beacon Grant (Big Island)
Objectives:
•
Beacon will zero-in their efforts on the Medicaid
population to ensure all have an Electronic Health
Record (HER).
•
Beacon will offer funding for the navigator role in
the FQHC and for PCPs participating as a health
home.
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Kalihi-Palama Project
Oahu
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Using the ACA Incentive?
A.
“Medical Home” $9-$1 federal match for
the first 2 years.

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Hawaii’s State Plan Amendment includes
behavioral health services as part of the
Health Home definition and in addition to
FQHCs, may allow PCPs, and Mental Health
Centers to qualify for this incentive.
Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Kalihi Palama Community Mental
Health Center is looking at….
Bi-Directional Integrated
Health Care Approach
By Partnering with Kalihi Community
Health Center, a FQHC, and using
the Medicaid Match
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
NCCBH Four Quadrant Model:
A Conceptual Understanding
Mental H
I
Health G
H
Needs L
O
W
QII:
MH is Locus of Care
Coordinate with PCP
QIV:
MH and/or PC is Locus of
Care
Combined Care
QI:
PC is Locus of Care
Provide MH by PC?
QIII:
PC is Locus of Care
Provide MH by PC
Low
High
Physical Health Needs
Note: We are targeting Quadrant II and Quadrant IV populations
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
What Are We Talking About?
Cross Assessment
Cross Screening
Funding
Opportunities
Funding
Opportunities
Consumer/Patient
AMHD
BH
Staff
Adding
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Staff ?
Services
as Usual
+
Some
Primary
Care
Health
Integrated Team?
Coordination of Care Center
via Patient Navigator?
Electronic Record?
Standardized
Services
Screening Tools /
as Usual
Assessment?
Cross-agency Forms
+
and Procedures?
Behavioral
Cross Training?
Health
MOA
Wayne P. with
Law & C.other
Kimo Alameda -- Hawaii Package
Department of Health
Partners
PC
Staff
Adding
Staff ?
Some Barriers & Potential Solutions
We Are Working Through….

Barrier of not knowing Reimbursement Issues
such as:

What do we know about who pays for what?.

What are the billing rules by payer (eg., billing
primary care visit same day as behavioral health
visit, number of visit limits,
auth/preauthorization's, etc.?

What do we know about the Medicaid
requirements for billing?.
Solution: Work with Medicaid and get involved with
the SPA.
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Some Barriers & Potential Solutions
We Are Working Through….

Inability of the Mental Health Centers to be a
provider for QUEST patients. Many of KPCHC’s patients are QUEST insured and will
need a higher level of behavioral health
intervention.
Solution: Revisit DOH’s current policy
established by the previous administration
toward restoring the CMHC’s contractual
relationship with QUEST Health Plans.
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Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health
Thank You
Mahalo!!
Hilo Bay Front
9/12/11
Wayne P. Law & C. Kimo Alameda -- Hawaii
Department of Health