Transcript SAMHSA Powerpoint Template

Integration of Primary Care
and Behavioral Health
Tenly Pau Biggs, MSW
Center for Mental Health Services
Mental Health America Regional Meeting, Feb. 19, 2016
Integrated Care
• What is integrated care?
• “Integrated care is the systematic coordination of
general and behavioral health. Integrating mental health,
substance abuse and primary care services produces
the best outcomes and proves the most effective
approach to caring for people with multiple healthcare
needs.”
-SAMHSA-HRSA Center for Integrated Health Solutions,
www.integration.samhsa.gov
The Problem
What does the data tell us?
National Comorbidity Survey Replication, 2001-2003 as Reported in Druss and Walker, 2011
The Cost of Having Multiple Chronic
Conditions
$5,000
$4,717
$4,500
$4,032
$4,000
$3,500
$3,233
$3,000
$2,739 $2,627
$2,500
$2,000
$1,601
$1,500
$1,000
$500
$2,052
$1,999
$1,382
$751 $680
$212
$-
No Costly Physical
Conditions
Mental Health Service Users
One Costly Physical
Condition
Two Costly Physical
Conditions
Substance Abuse Service Users
Three or More Costly
Physical Conditions
All Other Medicaid Beneficiaries
SAMHSA. (2010). Mental
health and substance abuse services in Medicaid, 2003: Charts and state
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tables. HHS Publication No. (SMA) 10-4608.
Medicaid Population: Data
MEDICAID BENEFICIARIES WITH DISABILITIES:
•45% have 3+ chronic conditions
•50% have a psychiatric illness
•35% have a chronic mental health/substance use disorder
(MH/SUD)
•60% of those with MH/SUD also have other chronic
physical conditions & report fair or poor health
Key Concepts of RFA SM-15005
•Healthcare spending is 60-70% higher for beneficiaries with
MH/SUD and chronic physical conditions;
•4-5 x more likely to be hospitalized for the top 5 most common
chronic conditions (asthma/COPD, congestive heart failure,
coronary heart disease, diabetes & hypertension)
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HHS/CDC Million Hearts ® Campaign
•Million Hearts® initiative will focus, coordinate, and
enhance cardiovascular disease prevention activities
across the public and private sectors in an unprecedented
effort to prevent 1 million heart attacks and strokes by 2017
and demonstrate to the American people that improving the
health system can save lives.
Key Concepts of RFA SM-15005
•ABCS
•Aspirin for people at risk for heart attack
•Blood Pressure Control
•Cholesterol Management
•Smoking Cessation
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Co-Occurrence Between Mental
Illness & Chronic Health Conditions
Overview of SAMHSA’s PBHCI Grant
•Purpose: to establish projects for the provision of
coordinated and integrated services through the co-location
of primary and specialty care services in community-based
mental and behavioral health settings.
Key Concepts of RFA SM-15•Goal: to improve the physical health status of adults with
005
serious mental illnesses (SMI)
who have or are at risk for
co-occurring primary care conditions and chronic diseases.
•Objective: to support the triple aim of improving the health
of those with SMI; enhancing the consumer’s experience of
care (including quality, access, and reliability); and
reducing/controlling the per capita cost of care.
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PBHCI Grantee Expectations
• Establish projects for the provision of coordinated and
integrated services through the co-location of primary and
specialty care medical services in the community-based
behavioral health settings
•
Key Concepts of RFA SM-15005
Requirements:
• Provide, by qualified primary care professionals, on
site primary care services and
• Provide, by qualified specialty care professionals or
other coordinators of care, medically necessary
referrals and linkages to primary care services.
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Expectations (Continued)
• Health Home Services
Categories
• Care coordination
• Health promotion
• Comprehensive transitional
care from inpatient to other
settings, including
appropriate follow-up
• Individual and family
support, which includes
authorized representatives
• Referral to community and
social support service,
including appropriate followup
• Health Information
Technology
• Submit at least 40% of
prescriptions electronically
• Receive structured lab
results electronically
• Share a standard continuity
of care record between BH
providers and physical
health providers; and
• Participate in the regional
extension center program
Key Concepts of RFA SM-15005
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PBHCI Data Collection
PBHCI grantees collect the following health indicators:
a. Blood pressure—semiyearly
b. Body Mass Index (BMI)—semiyearly
c. Waist circumference— semiyearly
d. Breath CO (carbon monoxide)— semiyearly
e. Plasma Glucose (fasting) and/or HgbA1c—annually
f. Lipid profile (HDL, LDL, triglycerides)—annually
Measuring blood pressure, cholesterol and BMI are indicators for
the risk of cardiovascular disease. Plasma glucose, Hemoglobin
A1c and the lipid profile are predictors of diabetes. The risk of
having respiratory disease is also determined by Breath CO.
PBHCI Data 2015
DATA
• This data reflects all cohorts. Out of over
52,000 individual people in the data set,
15,516 had three data points of NOMS (intake,
6-months, and 12-months)
Participants by Gender
0.2%
48.4%
51.4%
Male
Female
Transgender
Participants by Race and Ethnic Group
Black
8%
29%
Asian
6%
64%
Native Haw./Alaska
3%
White
American Indian
Participants by Age
4% 6%
21%
14%
18 - 25
26 - 34
21%
35%
35 - 44
45 - 54
55 - 64
64 >
Overall Health
70
60%
60
50.7%
47.8%
Percent at Risk
50
40
30
20
10
Baseline
Statistically significant, p < .001
6-Month
12-Month
Physical Health Outcomes:
Blood Pressure (Diastolic)
50
45
44%
42%
Percent At Risk
41%
40
35
30
25
Baseline
Statistically significant, p < .001
6-Month
12-Month
Physical Health Outcomes:
Blood Pressure (Systolic)
58
57
Percent at Risk
56.5%
55.8%
56
54.9%
55
54
53
Baseline
Statistically significant, p < .001
6-Month
12-Month
Physical Health Outcomes:
Total Cholesterol
40
37%
35
Percent At Risk
32%
30
25
20
Baseline
Statistically significant, p < .001
12-Month
Physical Health Outcomes:
High Risk HDL
30%
27%
Percent At Risk
25%
24%
20%
15%
10%
Baseline
Statistically significant, p < .001
12-Months
Physical Health Outcomes:
High Risk LDL
50%
Percent At Risk
40%
35%
35%
Baseline
12-Months
30%
20%
10%
Not statistically significant
Physical Health Outcomes:
Triglycerides
46
44.5%
44
Percent At Risk
42.7%
42
40
38
36
Baseline
Statistically significant in wrong direction, p < .001
12-Month
Physical Health Outcomes:
Breath CO
50
47.3%
47.3%
46.6%
Percent at Risk
45
40
35
30
Baseline
Not statistically significant
6-Month
12-Month
Physical Health Outcomes:
HgbA1c
35%
30%
Percent At Risk
30%
25%
22%
20%
15%
10%
Baseline
Statistically significant in wrong direction, p < .001
12-Month
Integration Works
Grantee Example
The Institute for Community Living (ICL) assists individuals and their families affected by
mental or developmental disabilities with services and supports to improve their quality of
life and participation in community living. ICL serves individuals with serious mental illness
(SMI) at over 100 programs throughout New York City.
The PBHCI grant focuses on three of ICL’s New York State (NYS)-licensed mental health
treatment programs:
• Highland Park Center (HPC), a clinic;
• Personal Recovery-Oriented Services (PROS), a mental health rehabilitation program;
• Rockaway Parkway Center (RPC), a clinic, all located in Brooklyn, New York.
The populations served at these programs are primarily Medicaid recipients
disproportionately affected by several characteristics that negatively impact health and
treatment, including poverty, ethnic minority status, and high degree of medical
comorbidity.
HLQ – ER visits & hospital admissions
EMR-Based Healthy Living Questionnaire (HLQ)
This is an 18 item self-report that is not part of the PBHCI grant. However, ICL
administers this questionnaire to track ER visits, hospital admissions, missed medical
appointments and the desire to establish a physical health goal.
The individuals (n=72) reflected below are those who have both an initial NOMs and HLQ assessments and a
treatment plan with a 12 month period available for analysis.
ER visits and hospital admissions for physical health and mental health reasons over time, expressed as percentage of
entire cohort from initial to 12 month treatment plan^ (all=p<.05)
50%
ER/PH (n=70)*
40%
Hospital/PH (n=71)
30%
20%
20%
19%
14%
10%
18%
16%
8%
12%
0%
Initial/Baseline
5%
6 months
11%
11%
6%
4%
12 months
^Number of reports naturally vary over time points in conjunction with length of time in services
*statistically significant
ER/MH (n=72)*
Hospital/MH
(n=72)*
ER Visit for Physical Health Reasons
Percentage of participants with a ER visit for physical health reasons over a 3 month
period, over time:
50%
All_ER/PH(N=70)*
40%
30%
Blk/AA_ER/PH (n=47)*
19%
20%
10%
12%
14%
8%
0%
Initial/Baseline
*statistically significant
6 months
6%
4%
12 months
ER Visit for Mental Health Reasons
Percentage of participants with a ER visit for mental health reasons over a 3 month
period, by cohort over time:
50%
All_ER/MH(N=72)*
40%
30%
23%
21%
Blk/AA_ER/MH (n=48)*
17%
20%
20%
18%
10%
11%
0%
Initial/Baseline
*statistically significant
6 months
12 months
Hospital Admission for Mental Health
Reasons
Percentage of participants with a hospital admission for mental health reasons
over a 3 month period, by cohort over time:
50%
All_Hospital/MH(N=72)*
40%
30%
21%
18%
20%
Blk/AA_Hospital/MH (n=48)*
17%
19%
16%
10%
11%
0%
Initial/Baseline
*statistically significant
6 months
12 months
Evolution of PBHCI
2009
1st PBHCI FOA (aka RFA)
Awarded 13 grantees
SAMHSA and ASPE implement evaluation awarded to RAND
2010
ACA is passed
PBHCI – awarded 43 Grantees
Training and Technical Assistance Center FOA (Center for Integrated Health
Solutions) for SAMHSA and HRSA
2011
PBHCI - awarded 8 grantees
Health Information Technology Supplement grant – only for current grantees to
receive awards funds to expand EHR
Evolution of PBHCI
2012
2nd PBHCI FOA (aka RFA)
Awarded 30 grantees
CDC’s Million Hearts Campaign is launched
2013
PBHCI – awarded 7 grantees
RAND evaluation completed – initial findings
2014
PBHCI - awarded 26 grantees
2015
3rd PBHCI FOA (aka RFA)
Awarded 60 grantees
2nd PBHCI Evaluation awarded
Evolution of PBHCI
• 2009 – 1st FOA for PBHCI
– Broad definition of integration of primary care into mental health
– Data collection not as specific, for example smoking was not
collected
• 2012 – 2nd FOA for PBHCI
– Health homes services required
– Physical health data tied to CDC Million Hearts Initiative required
– Meeting Health Information Technology requirements
• 2015 – 3rd FOA for PBHCI
– Required to have substance abuse counselor and peer wellness
coach
– Must use a CDC blood pressure protocol
– Must use specific evidence based interventions
Lessons Learned
• Different models of integration
• Importance of having strong leadership and partnerships for
both mental health/behavioral health and primary care
• Having clear expectations of all the partners involved, especially
as it relates to sustainability of the program and services post
grant
• Having an EHR that reflects mental health and primary care,
using an integrated treatment plan
• Using data to demonstrate impact, especially the cost of having
multiple chronic conditions and the overuse of the ER/Eds
• Peers are KEY to successful program
SAMHSA’S Strategic Initiatives:
Leading Change 2.0, 2015 – 2018
1. Prevention
2. Health Care and Health Systems
Integration
3. Trauma and Justice
4. Recovery Support
5. Health Information Technology
6. Workforce
Slide 38
Strategic Initiative 2: Health Care and
Health Systems Integration
 Foster integration between behavioral health and health care, social
support, and prevention systems.
 Support federal, state, territorial, and tribal efforts to develop and
implement new provisions under Medicaid and Medicare.
 Support federal, state, territorial, and tribal efforts to influence and
support the efficient use of various financing models and mechanisms to
address behavioral health services and activities.
 Finalize and implement the parity provisions in the Mental Health Parity
and Addiction Equity Act (MHPAEA) and the Affordable Care Act, and
disseminate information about parity.
 Foster implementation of quality indicators to advance behavioral health
outcomes in the health care delivery
system.
Slide 39
Integration – Seeing Behavioral Health
As Any Other Public Health Condition
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 BH Fundamental to Individual/Community Health
•Community prevention and wellness
•Recovery support
•Treatment and health care (incorporated screening/brief
interventions, co-located services, care management models)
 BH’s Impact on Healthcare Costs and Outcomes
•Primary, specialty, emergency, rehabilitative care
 Implications for Workforce
•SAMHSA’s new Strategic Initiative re workforce FY 2015 -- 2018
•Preventionists, BH and other healthcare practitioners, community
services workers
Service Models, Payment Structures,
Demos to Achieve Better Care/Value
 State Innovation Models: Support for development and testing of state-based
models for multi-payer payment and health care delivery system transformation
 Health Homes (Section 2703): Whole person care for Medicaid recipients
w/specific characteristics or conditions (45 SAMHSA consultations with 25+ states)
 Accountable Care Organizations: Coordinating high quality care for Medicare
recipients, including behavioral health care
 Duals Demo: Ensuring Medicare-Medicaid enrollees have full access to seamless,
high quality health care that is cost effective
 Medicaid Emergency Psychiatric IMD Demo: Supporting higher quality care at a
lower total cost by reimbursing private psychiatric hospitals
 Medicaid Innovation Accelerator Program (to transform clinical care): Focusing
on payment and service delivery reforms to improve health and quality of care for
Medicaid beneficiaries; priority area – substance use disorders (SUDs)
Primary Care/Behavioral Health Integration:
Federal Initiatives
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 OASH: Co-morbidity working group
 SAMHSA’S Primary/BH Integration (PBHCI): Physical health of adults w/ SMI and
TA for bi-directional integration (Center for Integrated Health Solutions, w/ HRSA)
 Primary Care/Addiction Services Integration (PCASI): Proposed for FY 2015
 HRSA FQHCs: Integrating BH screening, brief intervention. and treatment into
primary care settings
 Million Hearts: Wrapping BH into efforts to address ABCS
 AHRQ Center for Integration Models: Developing models of integrated BH care in
primary care settings
 CMMI Innovative Financing Models for Integration: Grants to test models using
SAMHSA and AHRQ indicators and TA
 Medicare Accountable Care Organizations (ACOs): Payment for integrated care &
outcomes (ASPE tracking impacts for BH)
Specific SAMHSA/Medicaid Collaboration
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 Informational Bulletins: Medication Assisted Treatment (MAT);
coverage/service design of BH services for youth with serious
emotional disturbance (SED); trauma-focused services; prevention
and early identification of MH and SU conditions; and strengthening
management of psychotropic medications for vulnerable
populations – others in process . . .
 Ongoing Interactions: Payment rules; waiver consultation; state
plan amendments; regulation review; quality measures; same day
billing guidance; and parity
 Section 223 of the Protecting Access to Medicare Act of 2014:
SAMHSA developing criteria for Certified Community Behavioral
Health Clinics (CCBHCs) and managing state planning grants; CMS
developing prospective payment system; ASPE to
evaluate outcomes
Certified Community Behavioral Health Clinics
(CCBHC) Timeline
 Oct. 2015 – Planning Grants awarded to 24 states
 Oct. 2015-Oct. 2016 – Technical assistance provided to
24 states by SAMHSA, CMS, and ASPE.
 Oct. 2016 – Applications due to participate in
demonstration*
 January 2017 – Deadline to select eight states to
participate in two-year demonstration
*Must have a planning grant to be eligible for the demonstration program
Slide 44
Certified Community Behavioral Health Clinics
(CCBHC)
 Protecting Access to Medicare Act
(sec.223 – demonstration program–Excellence in Mental
Health Act)
 $25 M.- planning grants to develop applications to
participate in 2 yr. pilot
 Only 8 states selected
 90% Federal Medical Assistance Percentages
 Must develop Prospective Payment System for
Reimbursing CCBHC’s
Slide 45
SAMHSA Updates & Resources
UPDATES &
RESOURCES
Implementation of Agency
Priorities
Prevention
 Underage drinking Report to Congress on State Underage Drinking Prevention
Activities: scientific research on adolescent alcohol use.
Integration
 Health Care & Health Systems Integration Payment systems work in progress
Value-Based Purchasing (VBP) & Merit-Based Incentive Payment Systems
(MIPS) to align SAMHSA’s priorities in coordinated are with CMS CMMI’s
development of rules authorized by MACRA legislation. Goal to coordinate BH
services with future provider payment systems.
Trauma and Justice
 ACA Enrollment Available on CMS website: SAMHSA Criminal Justice
Enrollment Toolkit for special population enrollment
Recovery Support
 Homelessness Administration's commitment to providing permanent supportive
housing and support community integration for people with long-term services &
support needs through cost-effective, evidence- based solutions. With new
programs aimed at strengthening state-level collaboration between
health & housing agencies
Implementation of Agency Priorities
(cont.)
 Million Heart Campaign CDC’s Million Hearts Campaign focused on
cardiovascular diseases among individuals w/ BH disorders. Campaign centered
on smoking cessation
Health Information Technology
 42 CFR Part 2 Interested in area patient confidentiality and restrictions on
disclosure in the regulation apply to third party payers with regard to records
disclosed to them by federally assisted programs (2.12(d)(2))
Emerging Issues & Opportunities
 GAO Report on SAMHSA’s MH Grants Management (including CDP)
Handbook is completed and staff training is ongoing
 Clozapine guidelines & REMS new guidelines addressing safety concerns,
neutropenia, and REMS to reduce the administrative burden
 Workforce Development
National Child Trauma Stress Network
Learning Center’s New Product
Trauma & Intellectual Developmental Disabilities
Toolkit
“The Road to Recovery Supporting Children with
Intellectual Developmental Disabilities Who Have
Experienced Trauma”
http://nctsn.org/products/children-intellectual-and-developmentaldisabilities-who-have-experienced-trauma [Note: You will need to create
an account or log in to download the document]
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Updated in 2016
Opioid OD Prevention Toolkit
Download SAMHSA's updated Opioid
Overdose Prevention Toolkit, now including
information on the first nasal spray version of
naloxone hydrochloride approved by the FDA.
http://store.samhsa.gov/shin/content//SMA16-4742/SMA16-4742.pdf
Equips health care providers, communities and local governments with
material to develop practices and policies to help prevent opioid-related
overdoses and deaths. Addresses issues for health care providers, first
responders, treatment providers, and those recovering from opioid
overdose.
50
Conversion Therapy Report
51
Download New Resource
Apps
Launch of New SAMHSA+HRSA+ACF Center:
Infant and Early Childhood Mental Health Consultation
Senior Center Toolkit to
Promote Emotional Health and Prevent Suicide
SAMHSA Handbook
Recovery After a Suicide Attempt
Great New Free Apps!
Suicide Prevention for Providers
Prevent Bullying
Data & Health Information…
Treatments & Recovery…
Naltrexone and 223*
(*Certified Community Behavioral Health Clinics)
•