Transcript Mind and Body Reunited: How Community Health Centers

America’s Voice for Community Health Care
The National Association of Community Health
Centers (NACHC) represents Community and
Migrant Health Centers, as well as Health Care for
the Homeless and Public Housing Primary Care
Programs and other community-based health
centers.
Founded in 1971, NACHC is a nonprofit advocacy
organization providing education, training and
technical assistance to health centers in support of
their mission to provide quality health care to
medically underserved populations.
The NACHC Mission
To promote the provision of high quality,
comprehensive and affordable health care that is
coordinated, culturally and linguistically competent,
and community directed for all medically
underserved populations.
For further information about NACHC and
America’s Health Centers
Visit us at www.nachc.com
Mind and Body Reunited: How
Community Health Centers Successfully
Integrate Primary Care and Behavioral
Health Services
Jaime Hirschfeld
Director, Health Center Growth and
Development
April 23, 2013
What is NACHC?
• National Association of Community Health
Centers is a membership-supported organization,
providing training, technical assistance, group
purchasing programs, leadership and professional
development, lobbying/advocacy, and group
purchasing programs.
• NACHC provides strong advocacy before
Congress and with federal administrative and
regulatory bodies on all major issues that affect
health centers and our mission.
What is a Community Health Center (CHC)?
• A non-profit, community-based provider of high quality,
affordable primary care and preventive services
• See patients regardless of insurance status or ability to pay
• Improve access to care in medically underserved
communities
• Often provide the following services on-site:
–Dental
–Pharmaceutical
–Behavioral health
Five Characteristics of a CHC
1. Must Serve a high needs area (designated Medically
Underserved Area or Population)
2. Comprehensive healthcare and related services based on
the needs of the community
3. Open to all regardless of insurance status or ability to pay
4. Governed by the community (51% of board members
MUST be patients)
5. Held to strict accountability and performance measures
for clinical, financial and administrative operations by
Health Resources and Services Administration(HRSA)
Difference Between a CHC and FQHC
• A CHC designation comes from Health Resource
Services Administration
• FQHC designation comes from CMS and is a
payment mechanism
• For the purpose of this conversation we will use
them interchangeably
Types of FQHCs
• Community Health Centers serve a variety of underserved
populations and areas (Section 330)
• Migrant Health Centers serve migrant and seasonal
agricultural workers (Section 330g)
• Healthcare for the Homeless Programs reach out to
homeless individuals and families and provide primary care
and substance abuse services (Section 330h)
• Public Housing Primary Care Programs serve residents of
public housing and are located in or adjacent to the
communities they serve (Section 330i)
Types of FQHCs
• FQHC Look-a-Like is similar to a CHC and meet all
requirements under Section 330. However they do not
receive:
–Federal grant money
–Federal Tort Claims Act (FTCA) coverage.
• Look-a-likes are designated by HRSA and certified by the
Centers for Medicare and Medicaid Services (CMS) as and
therefore can receive Prospective Payment System (PPS)
benefits.
Health Center Board Governance
• The Governing board has at least 9 but no more than 25
members, as appropriate for the organization.
• Minimum of 51% of the board must be patients of the health
center.
• The remaining non-consumer members of the board shall be
representative of the community in which the center's service
area is located.
• No more than half of the non-consumer board members may
derived no more than 10% of their income from the health
care industry.
Who are health center patients?
Collectively, health centers are the Health Care Home
for 24 Million Americans
• 1 of 7 Uninsured Persons, including
–1 of 5 Low-income Uninsured Persons
• 1 of 7 Medicaid Beneficiaries
• 1 of 3 Individuals Living in Poverty
–1 out of 4 Minority Individuals Living in Poverty
• 1 of 7 Rural Americans
• 923,400 Farmworkers
• 1.1 Million Homeless Persons
Source: NACHC, 2012. Includes
patients of federally-funded health
centers, non-federally funded health
centers, and expected patient growth for
2012.
Who are health center patients?
Over 200%
7%
151-200%
7%
101-150%
14%
Health Center Patients Are
Predominately Low
Income
Source: Federally-funded health centers only.
2010 Uniform Data System, Bureau of Primary
Health Care, HRSA, DHHS.
Note: Federal Poverty Level (FPL) for a family of
three in 2010 was $17,600. (See
http://aspe.hhs.gov/poverty/08poverty.shtml.)
Based on percent known. Percents may not total
100% due to rounding.
100% and
below
72%
Who are health center patients?
Most Health Center Patients
are Uninsured or Publicly
Insured
Other public may include non-Medicaid SCHIP and state-funded
insurance programs.
Source: Federally-funded health centers only. 2010 Uniform Data
System, Bureau of Primary Health Care, HRSA, DHHS.
Note: Percents may not total 100% due to rounding.
Where are health centers located?
There are more than 1,200 health center organizations
serving more than 24 million patients in over 8,000 rural
and urban communities.
>>Locate a Community Health Center<<
Services Provided by CHCs
•
•
•
•
All Services Provided to All Ages
• Basic Lab
Primary Health Care
• Emergency Care
Dental Care
• Radiological Services
Behavioral Health
• Transportation
Pharmacy
• Case Management
• After Hours Care
• Hospital/Specialty Care
*Please refer to Program
Requirements as this is not a
complete list of services.
Note: all services required on site or through established written arrangements/referrals
Effective Management of Chronic Illness
• Health Centers eliminate disparities in health outcomes
for poor, minority, and medically underserved
populations.
• The Institute of Medicine recognizes CHCs as models for
screening, diagnosing, and managing chronic conditions:
Diabetes
Depression
Cardiovascular Disease
Cancer
Asthma
HIV
• Record of Achievement: cited by Institute of Medicine,
Office of Management and Budget & General Accounting
Office for excellence in care, disparities reduction, costeffectiveness, and community benefit.
Community Health Centers are Cost Effective
• Health Centers saved an estimated $1,262 per patient in
20091
• Health Center efforts have led to improved health outcomes
for their patients, as well as lowered the cost of treating
patients with chronic disease2
• Health centers generated $20 billion in economic activity for
low income communities in 20093
1 Shi,
L et al. (2004). “America’s Health Centers: Reducing Racial and Ethnic Disparities in Prenatal and Birth Outcomes” Health Services Research, 39(6), Part I, 1881-1901.
Chin M. (2010) “Quality Improvement Implementation and Disparities: The Case of the Health Disparities Collaboratives.” Medical Care, 48(80):668-75
3 Community Health Centers: ROI Fact Sheet November 2010
2
Why support health centers?
Funding for CHCs
• Federal Grant – around $650,000 for basic grant but many
opportunities exist to increase funding thereafter (New Access
Points, Service Expansion, and Expanded Medical Capacity) All
federal $ to be used exclusively for the care of the uninsured.
• Medicaid – Prospective Payment System (PPS). A
reimbursement mechanism roughly based upon the cost of a
patient encounter. Rate is increased yearly by Medicare
Economic Index (MEI).
• Medicare – Prospective Payment System – similar to the
Medicaid system, cost report is filed yearly with CMS.
• Private Insurance – accepted just like private practices.
• Uninsured – Patients below 200% of the Federal Poverty Level
(FPL) pay on a sliding fee scale based upon ability to pay.
Health Centers’ Revenue Sources Do Not Resemble Those of
Private Physicians
10.0%
Self-Pay/Uninsured
11.6%
4.5%
9.9%
Private Insurance
64.0%
Other Public
Medicare
6.8%
Medicaid/SCHIP
64.0%
25.3%
15.5%
Health Center
Private Physicians
Source: Private Physician data: 2009
National Ambulatory Medical Care
Survey (visits). NACHC, 2012. Based
on Bureau of Primary Health Care,
HRSA, DHHS, 2010 Uniform Data
System. Note: Private Physicians does not
equal 100% due to reporting in NAMCS.
Income Sources for Health Centers
How do health centers…
INTEGRATE PRIMARY CARE
AND BEHAVIORAL HEALTH?
Health Centers & Behavioral Health
• 70% provide mental health counseling and
treatment
• 40% provide substance abuse counseling and
treatment
• 20% offer 24-hour crisis intervention services
• All provide referrals to substance abuse and
mental health services
Behavioral Health in a Health Center
• About 4,000 mental/behavioral health providers
work in health centers
• Account for approximately 5% of all patient visits
Why Integrate Behavioral Health & Primary
Care?
1999:
Surgeon
General’s
Report on
Mental Health
2003:
President’s New
Freedom
Commission on
Mental Health
promoted
integration
2004 – 2005:
Secretary’s
National
Advisory
Committee on
Rural Health
and Human
Services and
Institute of
Medicine call
for integration
2010: The
Affordable Care
Act includes
provisions that
provide for
states and
health care
providers to
adopt the
practice of the
integration of
primary care
and behavioral
health care
services
Why is it important for health centers to
integrate care?
• Depression is the third most common reason for a
visit to a health center after diabetes and
hypertension
• Primary care visits last an average of 13 minutes
and include an average of six patient problems
–A visit to a psychiatric professional typically lasts at
least 30 minutes and is focused on a clearly
defined issue.
Why is it important for health centers to
integrate care?
• 87.5% of family physicians said it was their
responsibility to treat depression
–35% were very confident and 48% were mostly
confident about their overall ability to manage
depression
• 80% of patients with depression present initially with
physical symptoms such as pain or fatigue or
worsening symptoms of a chronic medical illness.
–These patients are not likely to seek care through the
mental health system.
Visit Types
• The majority of health centers that offer behavioral
health services provide a same-day visit for
primary care and behavioral health if needed
–Warm Hand-off
–Traditional Therapy
–Behavioral Health Coaching
Warm Hand-Off
• Physician invites the behaviorist into the exam
room to make the introduction OR
• Walks the patient down the hall to the
behaviorist’s office and makes the introduction
–Behaviorist then spends 15 minutes with the
patient
–OR schedules a visit for another time
Warm Hand-Offs
• 40% show rate when PCP makes referral to
behavioral health without a warm hand-off
• 76% show rate when PCP makes the introduction!
(UMASS Certificate program in Primary Care)
Integration)
Traditional Therapy & Treatment
• 30, 45, 50 – minute counseling sessions
• Cognitive behavioral therapy
• Supporting client in trying new perceptions and
behaviors that will assist them in achieving their
goals
Behavioral Health Coaching
• 15 minute sessions in the primary care service
area or pod
• Offered by licensed clinician or unlicensed health
educator
• Empathy and motivational interviewing techniques
to help clients:
–
–
–
–
Modify behaviors
Solve problems
Schedule pleasant events
Reach other behavioral or physical health goals
EXAMPLES: Integrated Treatment Team
Meetings/ Training
• Daily team huddles
including a PCP & BH
provider
• Weekly provider meeting
including psychiatrists &
PCP
• Weekly or monthly case
management meetings
• Bi-monthly meetings on
integrated care
• Training PCPs on
psychotropic medications
attended by mental health
& medical providers
• Monthly medication therapy
management meetings
• Quality assurance sessions
consisting of a PCP and a
licensed psychologist at a
minimim
Screening Practices – Adults
• Many CHCs offer universal screening for:
–Depression
–Anxiety
–Other behavioral health conditions
• Other that are screened include:
– Diabetics
–Those with hypertension and/or obesity
–Individuals with HIV
–New patients
–Patients over 60
Screening Practices for Children
• Some health centers screen all children (about
25%)
• Children with certain diseases/ conditions such as
diabetes and obesity
• All children in the perinatal substance abuse
treatment program
• Prenatal teens
• Patients ages 16 and 17 who:
– Complain of depression or anxiety
–Are pregnant
–Are diabetic
How CHCs Eliminate Stigma With Accessing
Mental Health Services
• Do not treat behavioral health like a separate
program
• Minimal distinction in terms of signage and clinic
names
–“Integrated Care Office”
–“Collaborate Care Office”
Challenges of Integrated Care
• Shortage of behavioral health providers
• Limitations of reimbursement for health centers on
same day visits
• Reimbursement
–Managed Care
–Medicaid
–Medicare
–Dual Eligibles
• Relationship with public mental health agencies
vary across the county
Common Barriers and Myths
(to get over….quickly)
• Our patients do not want to address depression or
mental health.
• It is “understandable” that our patients are
depressed or mentally unhealthy.
• It will cost too much.
• Our patients need help with social and economic
issues, not mental health or depression.
What does integration of behavioral health and primary care look
like at a
HEALTH CENTER
Cherokee Health System
Knoxville, TN
• Community health center & community mental
health center founded in 1960
• 47 clinical sites in 13 Tennessee counties
• Services:
–Primary Care
–Community Mental Health
–Dental
–School Based Health
Cherokee Health System
Knoxville, TN
• Serve 63,800 unduplicated individuals
• 600+ employees
–Psychologists – 43
–Master’s level Clinicians - 64
–Case Managers - 34
–Primary Care Physicians – 25
–Psychiatrists - 10
–Pharmacists - 9
–NP/PA (Primary Care) - 25
–NP (Psych) - 12
–Dentists - 2
Cherokee Health System
Knoxville, TN
• Embedded Behavioral Health Consultant on the
Primary Care Team
• Real time behavioral and psychiatric consultation
available to PCP
• Focused behavioral intervention in primary care
• Behavioral medicine scope of practice
• Encourage patient responsibility for healthful living
• A behaviorally enhanced Healthcare Home
Cherokee Health System
Knoxville, TN
• Placing a VALUE on Integrated Care
–Reduced ER Utilization
–Reduced Inpatient Admissions
–Reduced Specialty Referrals
–Increased Patient Satisfaction
–Increased Primary Care Utilization
–Improved Outcomes
Cherokee Health System
Knoxville, TN
http://www.cherokeetraining.com/popup.asp
2018 Western Ave
Knoxville, TN 37921
Phone: (865)934-6734
LifeLong Medical Care
Berkeley, CA
• Community Health Center (FQHC) serving
Oakland, Berkeley, and Richmond, California
•
•
•
•
•
Ten primary care clinics
Two adult day health centers
Two Dental clinics
Supportive housing program
Frequent Users of Health Services program
• Services:
–Primary health and dental care
–Pediatric, adult and geriatric care
–Chronic disease and HIV/AIDs treatment
–Integrated behavioral health and primary care
• Serve over 22,000 unduplicated patients
LifeLong: A Model Rooted in Integrated Care
• Gray Panthers founded – medical and social service to
elderly to maintain independence.
• Historical focus on serving the disabled and homeless,
mental health and social problems with complex medical
problems
• Recent focus on managing chronic disease including
behavioral interventions – diabetes, hypertension, asthma
are all conditions that are most effectively managed
through behavioral changes.
• Traditional mental health model is now transitioning to a
mixture of traditional services, health psychology and
short term interventions as well as support groups.
LifeLong’s Primary Care Model
• MDs, Mid-levels, Psychiatrist and LCSWs/
Psychologists on staff at every primary care site
• Prescribe and provide access to psychiatric
medications
• Psychiatrists provide consults to PCPs –
supports expanded access to psychiatric
services
• Coordinate with County/City Mental Health
programs when person qualifies for services
A Spectrum of Care
• Provide traditional mental health services –
psychiatry, psychotherapy, long term treatment
• Provide:
–Short term interventions (1 – 3 sessions)
–½ hour visits
–Includes case management
–Focus on working with people with chronic
physical health conditions (e.g. diabetes,
hypertension)
Community Collaborations
• Partnerships with Mental Health Non-Profits and Public
Mental Health Agencies
• Collaboration with City of Berkeley and Berkeley Mental
Health to serve chronically homeless
• Planning co-location of primary care provider at a large
County operated out-patient mental health center
Non-Licensed Staff:
Essential Team Members
• Medical Assistants (MAs):
–Screening, facilitating warm hand offs
• Case Managers:
–Intensive services for the highest risk/highest need clients
–Outreach and assessment, education
• Clinical Care Assistants:
–Panel management, referrals, education and support, triage
• Health Educators:
–Provide group and individual interventions (behavior change
and chronic disease)
• Students (psychology and social work):
–Extend capacity and provide services that aren’t billable
These are just two examples…
GOAL =
Patient Centered
Medical Home (PCMH)
Contact Information
Jaime Hirschfeld
[email protected]
(301) 347-0400 ext 2091
Additional Resources
• Bureau of Primary Health Care http://bphc.hrsa.gov/
• HRSA
www.HRSA.gov
• NACHC
www.nachc.com
Questions?