Transcript Investing in Integrated Care

INVESTING IN
INTEGRATED CARE
The Maine Health Access Foundation’s 12-year journey
(2005-2016) to improve patient-centered care in Maine
through the Integrated Care Initiative.
Table of Contents
The MeHAF Journey
Overview
MeHAF Activities 2005-2016
Expected Outcomes
Evaluation Results
Reach and Outcomes of Clinical Implementation Grants
Clinical Grantee Program Snapshots
DFD Russell Medical Centers
Downeast Health Services
Rosscare Nursing Home Network
Amistad Fi
Accomplishments and Lessons Learned
Systems Impact of Work
Lessons Learned
Policy Makers
Clinicians
Organizations
Payers
Grant Makers
Integrated Care Going Forward
The MeHAF Integrated
Care Initiative
People tell us that too often the health care system lacks organization, is difficult
to navigate, and is hard to understand. This is particularly an issue for those who
are uninsured or medically-underserved. MeHAF promotes more patientcentered and seamless care, particularly through the coordination and integration
of primary care, behavioral health, dental care, specialty care, and other services.
A centerpiece of our work is the Integrated Care Initiative, a twelve-year, over $14
million commitment to promote better patient-centered care by improving
coordination between behavioral health and primary care. This is an overview of
this initiative, the key components, and what has been learned during the journey.
Care Integration:
Comprehensive,
coordinated, and
continuous health
relationships that are
patient-centered, safe,
timely, efficient,
effective, equitable,
and accessible to
everyone in Maine.
Integrated care from
the patient’s perspective
“I have a team that covers
it all - rehab counselor, a case worker,
a psychiatrist. They coordinated everything.
They made sure I got dental, medical,
and blood work.”
Short- and long-term expected
outcomes of the initiative
Grantees
MeHAF
Short Term Outcomes
• Create models/culture of patient -centered
care and integration
• Identify and leverage trends, issues and
opportunities
• Stimulate systems change
• MeHAF is viewed as Partner
by grantees
• Increase understanding and level
of patient-centered care and integration
• Change delivery systems
• Improve patient outcomes
• Serve priority populations
• Patients and families become
advisors/advocates
• Data systems support integrated care
Long Term Outcomes
• Maine’s health system becomes more
integrated (including among non-grantee
providers)
• Increased percentage of Maine’s
population receives integrated care
• Non-grantee providers take up integrated
approach
• Sustainable integration created at
practice and systems levels
• Reduce barriers to systems change:
• Reimbursement
• Regulation
• Licensing
• Demonstrate value of integrated care
• Avoid unintended effects
Evaluation Results
Overview of clinical
implementation
grant evaluation
MeHAF awarded 42 grants across the state of Maine to develop integrated
behavioral health programs. This included 21 clinical implementation grantees
that were diverse in terms of types of organization - hospitals, primary care,
consumer advocacy; and in the patients they served - adults, children, and elderly.
The evaluation provided an opportunity to learn from diverse organizations and
approaches to integration that work in different contexts and for different
populations.
The evaluation used the framework of RE-AIM to analyze the Reach,
Effectiveness, Adoption, Implementation and Maintenance of the program.
The following infographic provides a snapshot of the data that describes the
reach of the programs, in terms of whom was served and the impact on access to
care and clinical outcomes for patients.
The full discussion of the findings of this evaluation can be found at: LINK
Evaluation Questions:
Did the services provided by
MeHAF’s Clinical
Implementation grantees’
become more integrated and
more patient-centered as a
result of the initiative?
What approaches/structures/
components of primary
care/behavioral health
integration and patientcentered care worked at the
patient, provider and
organizational levels?
What were the key factors
related to integration and
patient-centered care that
made them work or not work?
What were the considerations
for replication (e.g., what
circumstances –
populations/settings/
environments – optimize the
probability of successful
replication)?
Evaluation
Results
(info graphic)
Clinical Grantee
Program
Snapshots
A few grant projects and their results.
Selected grantee projects, key characteristics,
and results.
DFD Russell Medical Centers- Collaborative
care in an FQHC
Downeast Health Services- Integrated care
for at risk children and family support
Rosscare-Older adult integrated care services
Amistad- Support for healthy lifestyles for those
with severe and persistent mental illness
DFD Russell Medical Centers
FEDERALLY QUALIFIED HEALTH CENTER
MONMOUTH, AND TURNER, ME
LOCATED IN LEEDS,
DFD Russell has a long history of co-location of behavioral health providers. The purpose of
DFD Russell’s grant was to move beyond co-location to a more collaborative integrated
approach.
Service characteristics
•
Standardized Screening
•
Co-located behavioral health LCSW, psychologist, professional counselor,
and two case managers
•
Follow up by case managers on PHQ-9 (depression screening), missed
appointments, and emergency room and hospital visits
•
Focus on medication adherence and side effects education by case managers
Results
•
Patients with major depression (133/167 with complete data) had a drop in
symptoms (average of 5.6 PHQ-9 points). The drop of PHQ-9 points indicates
a reduction from severe or moderate depression to mild or minimal
depression.
•
48% of patients achieved a 50% or more reduction in symptoms
or a score of 5 or less (remission)
Downeast Health Services
MULTI-SERVICE ORGANIZATION LOCATED WASHINGTON COUNTY, ME
Washington County has one of the highest rates of substance abuse in the state and in the
nation, with substantial impact on the health of young children and mothers. Given the limited
number of pediatricians in the county Downeast Health Services in collaboration with the
Community Caring Collaborative (CCC), a group of health, social, and other community service
organizations, developed a program to address the early intervention and developmental needs
of children in the county.
Service characteristics
•
Identify high risk children age 0-8 (due to drug or alcohol exposure, pre-term,
born of teen parents, trauma or violence exposure, or attachment disorder)
•
Co-locate in primary care a Family support specialist to provide developmental
assessment, shared treatment plans, parent skills education, referrals and
linkages to community services
•
Family Support Specialist worked with family to develop goals to address risks,
health and developmental needs of children
Results
•
Over one-third of patients/families attained all of their goals, and 75 percent
improved or attained at least one goal.
•
The types of issues addressed in the treatment plan included issues relating to
child behavior (21 percent), case/care management (29 percent), family
dynamics/home environment (16 percent), prenatal health or child birth (4
percent), or general mental or physical health issues (30 percent).
Rosscare Nursing Home Network
HOSPITAL AND NURSING HOME PARTNERSHIP WITH EASTERN MAINE
HEALTH SYSTEMS IN BANGOR, ME
One of the challenges faced by Eastern Maine Health Systems was that several elderly
patients with mental health and/or dementia diagnoses were staying in the hospital for
extended periods of time after their acute medical issues were resolved. Nursing homes
didn’t have the ability to appropriately care for patients with mental health issues. Further,
patients in the nursing home did not have adequate access to behavioral health services.
Service characteristics
•
Co-located licensed clinical social worker in hospital and nursing home settings
•
Licensed clinical social worker created plans for care transitions between
hospital and nursing home
•
Training of nursing home staff on management of difficult behaviors of
residents, and clinical staff on prescribing and use of anti-psychotics
•
Psychiatrist consultation on-site and via telehealth
(remote phone and video access)
Results
•
Reduced hospital length of stay from 45 days to 6 days
•
Reduced use of anti-psychotic medications on a routine basis in the nursing
homes. No anti-psychotic medications were used “ as needed” during
the period of January 2010 through June 2011.
•
Patients were depressed fewer days and had fewer depressive symptoms
Amistad
CONSUMER DRIVEN MENTAL HEALTH ORGANIZATION IN PORTLAND, ME
Amistad is a consumer-run organization (100 percent of its board members are consumers)
serving persons living with mental illness in Portland, Maine since 1982. Individuals with
severe mental illness often have significant and multiple chronic medical conditions and
poorer access to medical care, contributing to a 25-year shorter life span, on average, than
those without severe mental illness. The purpose of Amistad’s grant was to address this
discrepancy by assisting its members to access medical care services more effectively and by
encouraging and teaching wellness and self-management.
Service characteristics
•
Peer patient navigator attended medical visits with patients
•
Healthy Amistad program focused on healthy eating options, goal setting
for weight, and provided physical activity support and programs
Results
•
Over the course of six months, 50% of clients had a substantial weight change
in the preferred direction, either gaining more than 5 pounds (2 of 4 clients)
or losing more than 5 pounds (9 of 18 clients).
Accomplishments
and Lessons
Learned
Impact on systems of care
Policy, Clinical, Organizational, Payer, and Grant
Maker perspectives
Systems Impact of Work
Patient Centered
Medical Home
Integration becomes a
core principle of Maine’s
Patient Centered Medical
Home Model reaching
over 200 practices
including Health Homes
Payment
Health and Behavior
Codes improve the
ability for providers to
bill for integrated
services
Measurement
The Site SelfAssessment Tool is
developed to support
practices in assessing
and planning for
integrated services
and becomes
recognized and used
at a national level
Health
Information
Exchange
An implementation
toolkit supports
behavioral health
electronic health
records connection to
Health Information
Exchange (HIE) to
support integrated
services and
behavioral health
records being added
to the Health
Information Exchange
Workforce
Integrated care
workforce
development is
expanded through an
Integrated Care
Preparation program
at University of New
England, and a
practicum established
between Husson
College and
Penobscot
Community Health
Center
Development of the State Integrated
Care Policy Committee
A multi-stakeholder committee
convenes at a state level to develop
an agenda and workplan for policy
changes that support integrated
care.
Key accomplishments:
Collaboration with state initiatives: Maine
DHHS includes integrated care as
foundational component of its ACA Section
2703 Health Homes and Behavioral Health
Homes waivers and the State Innovation
Model initiative
National leader engagement: Maine hosts
CMS Region I Administrators on site visits to
integrated care practices to enhance
understanding and commitment to
integrated care.
“It was clear from the outset that in
addition to grant making, systemic
changes and policy enhancements
were needed to facilitate
sustainability of integrated care as
an important component of
patient-centered care.”
Participants
State government officials
National representation: Maine is
represented at the AHRQ Integrated Care
Academy by Neil Korsen, who lead the
effort to write and publish AHRQ
Integration Quality Measures Atlas
Payer engagement: Anthem piloted first in
Maine the use of Health and Behavioral
codes to financially support behavioral
health services in primary care settings.
This was then spread to other states.
Payers
Employers
MeHAF grantees
Patients
Statewide leaders in mental health
and primary care
MeHAF Staff
The lessons learned from the MeHAF initiative apply to many different stakeholders in the healthcare
community. Progressing towards a model of integrated care is a collaborative effort involving many!
Here we have summarized key lessons learned for the following audiences.
Lessons Learned
for Policy Makers
Health Information Exchange (HIE):
The issue of different standards for
treating mental health Information and
substance abuse information under State
and Federal law require complex
processes of separating mental health
from substance abuse information to
support HIE efforts. Through 2011, Maine
statutes related to consent for release of
medical records were a barrier to bringing
mental health records into HealthInfoNet,
Maine’s Health Information Exchange.
HealthInfoNet and other partners worked
as a coalition to change this law, and were
successful, such that patients can now
“opt in” to release their information.
Payment Reform: Payment for
behavioral health is complicated and
difficult for providers to navigate. Policy
can support convening forums for better
understanding how to use current
payment models to support integrated
care and design improved systems for the
future. MeHAF convened conversations
with payers and developed in-state
expertise on payment mechanisms for
integrated health that was then offered as
technical assistance to providers.
Alignment of State Programs: Engaging
and aligning work with the state health
and human services department
furthered the statewide impact. MeHAF
supported work on alignment of state
programs and services for the severely
mentally ill (SMI). The Maine Department
of Health and Human Services (DHHS)
worked to convene DHHS departments
and consumers and to inform a better
integrated care model for those with SMI.
This laid the groundwork
for future federal funding under the
Medicaid State Plans Amendment- Health
Homes program.
Lessons Learned
for Clinicians
Promoting adoption among primary
care providers(PCP). The transition to
integrated care requires PCPs to learn and
adapt to work with a new behavioral
health team member. Several tips to
engage physicians in the process include:
Building relationships between Primary
Care and Behavioral Health providers:
There are several strategies that
encourage the team building critical to
move from co-location of services to an
integrated care model.
• Include PCPs in planning process for
behavioral health integration
• Have behavioral health providers
(BHPs) “shadow” PCPs during visits.
BHPs and PCPs can then later discuss
how they could have teamed to
address patient needs and concerns
• Include PCPs in hiring of behavioral
health providers
• Engage other PCPs, either internally or
externally to talk about their
experience and benefits of integrated
care
• Schedule the BHP and PCP to work
during the same days so that “warm
hand offs” are possible
• If the BHP has an administrative desk,
locate it next to the PCP’s so informal
interactions are facilitated
Adapting behavioral health providers to
the integrated care setting: Behavioral
health providers adapt to providing care in
shorter visits from the traditional 60
minute to 15-30 minute appointment. The
following strategies help identify and
transition the behavioral health provider.
• Before recruiting, write BHP job
descriptions that clearly explain
practice’s approach to integrated
services and related expectations.
• Assess relationships between providers
by tracking referral patterns from each
PCP to the behavioral health provider
to assess differences among providers.
• Include BHP in PCP meetings and
huddles
Lessons Learned
for Organizations
Identify the value of integrated care for
the practice. Successful organizations
have clearly articulated what integrated
care will bring to the practice in way that
is meaningful to its staff and patients.
Some of the values articulated among
MeHAF grantees included:
Training: An asset to start-up and
sustainability of a program is training of
staff. The costs of training based on
internal budgets can be prohibitive so
organizations should look for outside
funding and prioritize training for both
primary care and behavioral health staff
at the outset of the program.
• Ability to provide holistic care
• Better manage care for complex
patients
• Supporting mental health will support
the overall health of our patients
• Teaming up with a behavioral health
provider frees up time of the medical
provider to focus on complex medical
needs
Measurement: The measurement of
outcomes of the integrated care program
assists staff in understanding and
measuring progress. Organizations should
not only collect data but share and
discuss data across peers.
Alignment with organizational values:
Primary care organizations found
implementation more successfull if they
were able to align integrated care to the
organizational values.
Lessons Learned
for Payers
Providers need assistance in
understanding the appropriate billing
codes, and acceptable provider types to
bill for integrated services
Education on proper billing for behavioral
health is welcomed and desired by
practices. A major stumbling block is
location restrictions for billing. Consider
removing restrictions on where and who
can bill for integrated behavioral health
services, as this provides more flexibility
to ensure patients are receiving the
services in the location that best meets
their needs.
1 Maine
Accountable Care Organizations (ACOs)
will be the laboratories for developing
and testing quality metrics and
payment innovations related to
behavioral health and primary care
integration
In Maine, there has been a high level of
participation in the CMS funded ACO
Pioneer (three in Maine) and shared
savings (one in Maine) pilots. 1
Engage multiple stakeholders in
understanding the impact on total cost
of care
There is interest among provider systems,
and public entities to use claims data to
better understand the impact of
integrated services on total cost of care.
Under the Maine State Innovation Model
grant, partnerships are forming to analyze
these data.
Payment through per member per
month programs such as patient
centered medical home can support
integrated care by supporting care and
case management
Pioneer ACOs: Beacon LLC Shared Savings ACOs: MaineHealth, Maine Community Accountable Care, Central Maine
Lessons Learned
for Grant Makers
Supporting clinical and systems grants
Diversity in funding of grants at clinical
and systems levels supports building
relationships and connecting lessons
learned across the system
and at the practice level.
Consumer engagement
Encouraging and requiring patient
engagement as part of grant making can
ground the work and ensure it is
accountable to the community
it is intended to benefit.
Technical assistance on data
measurement
Data management assistance is needed
by grantees of all levels of sophistication,
and supporting and teaching
organizations how to use data can have a
lasting impact on their work.
Engage in supportive policy and system
changes
The simultaneous existence of a policy
committee is a forum for discussion of
strategy to address systems issues
identified at the practice and community
level that require policy change. When
key-decision makers are part of the
learning process , they become
champions for integrated care.
A learning community develops
sustainable relationships
Developing a learning community
supports education and creates a broad
base of support and relationship building
which forges relationships for continued
peer learning and support.
Identify and nurture your champions
Deliberately develop champions in many
stakeholder sectors and look for unlikely
partners such as in housing,
transportation, and business- individuals
who may have a professional or personal
reason to support integrated care. Let
champions and decision makers know
when they have made a difference.
Integrated Care
Going Forward
Growth
Sustainability
and Accelerating Integrated Care
Growth of Integrated Care Sites
New funding after MeHAF
Sustaining Integrated Care:
Factors that impact sustainability for an organization
A financial model that supports
an integrated approach
The following support organizational
financial stability:
1) Regulations match practice and
provide consistency across
settings
2) Clear guidelines on how to code
visits, particular those that use
existing codes
3) Mechanisms exist to provide
integrated care without
“penalties” or the requirement of
a specific diagnosis.
Clinical and staff support
The level of knowledge, buy-in and
engagement among clinicians is
critical, and in the words of one
organization “makes all the
difference.”
Data demonstrating benefits
and value
Positive outcome data or cost data
are needed to help make a
persuasive argument for sustaining
this approach and describing its
value to decision makers.
Organizational leadership, support
and commitment
Organizations that establish
integrated care as a agency-wide
priority are perceived as more likely
to maintain the program and
monitor its efforts.
Accelerating Integration
Desired outcome:
“People’s health, daily lives, and
functioning improve as a result of
engaging with a health care
system that treats them as whole
persons. The system integrates
behavioral health and primary
care and is cost effective.”
Additional Resources
Evaluation and Policy
Reports
Maine Health Access Foundation
Integrated Care Initiative: Cross Site
Evaluation of Clinical Implementation
Grantees- Final Report
Bridging the Digital Divide: Using
Health IT to Integrate Behavioral and
Physical Health Care in Maine
Integration Moving Forward Issue Brief
Maine Integrated Care Policy
Committee Strategic Work Plan and
Accomplishments: 2013-2015
Case Studies
Healthy Amistad
Northeast Integrated Geriatrics Care:
Supporting Primary Care in Long Term
Care Settings
Patient Engagement: Practical Strategies
to Engage Patients in Integrated Care
Working Toward Collaborative Care.
Borkowski, N and Deckard, G eds.
Organizational Behavior in Healthcare:
Case Studies. 2013. Jones and Bartlett
Publishers
Tips for
Implementation
Tips for Implementing Integrated Care:
Lessons Learned from MeHAF Clinical
Implementation Grantees