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eSolutions: Make it last: How to Sustain Integrated Care

eSolutions: Sustainability 

Feature Article: Sustainability: Making Integrated Care Stick
Quick Tips: Keeping Integrated Care on the Table
Featured Resource: Sustainability Checklist
CIHS Webinars
Hot Topics


Sustainability: Making Integrated Care Stick

Kathy Reynolds, Senior Consultant, SAMHSA-HRSA Center for Integrated Health Solutions 

How do you ensure your organization’s integrated primary and behavioral healthcare services continue into the future? 

When people think of sustainability, they often confuse it with financing. While financing is critical, it is only one component of what makes integrated care stick. 

By nature, bidirectional integrated care is provided in a variety of settings, each with its own billing, workflow, and operation considerations. A solid sustainability plan includes both administrative and clinical components. 

  1. Leadership and Mission: To sustain your integrated services, your organization must embed integrated care delivery into its mission and vision and work to shift your organizational culture so staff sees health and wellness as part of their role. Sustainability requires buy-in from the CEO and board of directors of each organization involved. Embedding integrated care into your organization’s culture means that every employee understands the importance of these services and operates with the expectation that all consumers receive this care. Organizations invested in sustaining their integrated services will establish a powerful “change team” to influence integration in their clinic. Integrated care is part of orientation for all new, and all supervisors review physical health and behavioral health goals during team meetings. In addition, administrative policies, job descriptions, performance reviews, confidentiality agreements, and care coordination practices all support an integrated practice.
     
  2. Strategy: Sustainability won’t happen unless integrated care goals are prioritized in the organization’s strategic plan. Integrated care also requires a business plan to sustain and grow revenue. In states with Medicaid expansion plans, each organization will need to project that expansion in their integrated business plan for 2014 and determine how much funding is required to prepare to serve this new population. Your strategy must also include helping those you serve to understand that they are entitled to integrated care and that there are avenues where they can advocate for the sustainability of these care models.
     
  3. Technology: Sharing information between primary care and behavioral health providers is at the core of providing integrated care. Organizations need to operate using certified electronic health records (EHRs), generate health registries to monitor care for chronic illnesses, track healthcare industry-wide standards of care (i.e., HEDIS metrics) electronically, and monitor treatment outcomes by individual client, program, location, and organization. Ideally, all integrated care organizations will be able to generate and share a coordination of care document (CCD) that includes both primary health and behavioral health information. Check out the meaningful use standards for more information.
     
  4. Clinical Workflows: Clear and consistent clinical workflows are needed to support integrated care. Think about these questions: Is staff trained to coordinate healthcare and provide mental health or substance use services? Does clinical staff review annual lab work for all those served? Have you trained all staff in motivational interviewing, behavioral activation, and how to work with clients on their goals, including smoking reduction? Are blood pressure and BMI measured at each visit? Are you monitoring to ensure that your primary care and behavioral health staff create person-centered integrated care plans for each person served that includes all of the person’s behavioral health and primary health goals?
     
  5. Financing: Financing options for integrated care vary, depending on whether the model was developed in partnership with one or more organizations or within just one organization. Each state’s polices and Medicaid plans also determine financing. Organizations providing integrated care need to understand their state’s billing policies and should talk with state partners about barriers to financing integrated care. State-directed billing options that support integrated care include permitting both behavioral health and primary health services to be billed on the same day by the same organization, payment for care coordination, and payment for Health and Behavioral Intervention codes (HBAI). These codes allow behavioral health providers in primary care settings to address behaviors that impede health improvement. Providers must be able to bill for all primary care and behavioral health services provided.
     
  6. Billing: If billing through a partnership, each organization can bill through separate tax ID numbers for their own services in the integrated care model. It is imperative that partnering organizations understand each other’s billing rules and regulations. Together, the clinical and billing staff from both organizations benefit from walking through a workflow to understand which credentialed staff are allowed to bill for each step of the process. In addition, organizations need to set volume targets for sustainability. Primary care providers typically require a panel of 1,500 patients to cover their costs. Integrated care clinics that need additional volume may want to consider marketing their integrated services to the community for new clients to meet their business model targets.
     
  7. Health Homes: States developing health homes may have the ultimate sustainability plan for health integration. Health home requirements and payments will support many components of integration currently in operation across the country. Care coordination is a foundational component to integrated care, and health home position descriptions and reimbursements will help sustain this often-unfunded function.
     
  8. Quality Improvement: Providers looking to sustain their current array of integrated services must be able to make data-driven decisions to determine which integrated care components actually improve care. For example, wellness programming funded only through a grant may be difficult to 1.       retain unless the activities can be identified — by data — as value-added. Presenting this data to payers (e.g., managed care providers, state, county providers) can create a sustainable funding stream for these services. Until contracts can be changed, key activities can be performed by volunteers, integrated into the job descriptions of existing staff, conducted by other community organizations (e.g., the YMCA, oral care providers), or sustained under other grant funding. Continuous quality improvement is a valuable way to make sure that your organization is meeting its integrated care goals of improving the overall health status of your clients. 

Featured Resource

There are many pieces to sustainability, and your organization must continually analyze and refine its strategy to keep integrated care working for your community. With the right planning and implementation, your organization can ensure that integrated care becomes the new standard.

To help you prioritize and begin the process of developing a sustainability plan, check out CIHS’ sustainability checklist.  


Quick Tips: Keeping Integrated Care on the Table

Jenny Crawford, Deputy Director of CIHS, developed quick tips for you to consider when creating a sustainability plan for your integrated health program.

  1. Create an integration leadership team with senior leaders and program directors from all your organization’s service areas. The leadership team will meet for regularly scheduled meetings and maintain responsibility for developing the organizational expectations, workflows, job descriptions, performance review language, and quality improvement benchmarks on integrated care.
     
  2. Provide regular updates to all governing boards about why integrated care is important and how your data demonstrates improved care. Involve a person who receives your integrated services to share the importance of integrated care on their overall wellbeing.
     
  3. Reach out to community stakeholders, elected officials, hospitals, and foundations to let them know how you are improving care and how your efforts might affect issues important to them. Remember that your audiences may remember some data, but they’ll always remember a powerful story.
     
  4. Make sure you know your costs for delivering integrated care and consider expanding access to other community members who do not have serious mental illnesses if you need additional volume to cover your costs.
     
  5. Build all employees’ whole health literacy. Provide in-service training for all behavioral health staff so that they are comfortable discussing BMI, cholesterol, and blood pressure numbers. Provide training to primary care providers to help them understand the behavioral health goals of the people they serve and the role of behavioral health staff in reaching those goals.
  6. Ask the integrated care clinic staff to present to the entire agency on both their work with adults with serious mental illness and health topics germane to agency staff. This helps set the tone of “integrated care is now our business as usual.” 

For more information, visit www.integration.samhsa.gov or contact CIHS at Integration@TheNationalCouncil.org


CIHS Webinars

Federal Healthcare Integration Innovations: A Round Robin
(Co-sponsored with the AHRQ Academy for Integrating Behavioral Health and Primary Care)
July TBD

Federal investment in healthcare redesign efforts is demonstrating the importance of education on behavioral health, screening for mental illnesses and addictions, and access to behavioral health treatment in communities across the country. Innovative programs across several federal agencies support the integration of primary and behavioral health services. During this webinar, each agency will share core features of their model or program, outcomes, and resources — valuable information that any provider can use to inform their integration efforts.

Visit the CIHS website regular to see upcoming webinars. Missed a past webinar? No problem. You can view and listen them at any time.


Hot Topics

White House Hosts National Conference on Mental Health
On June 3, President Obama and Vice President Biden hosted a National Conference on Mental Health at the White House as part of the administration’s effort to launch a national conversation to increase understanding and awareness about mental health.

New 5-Hour Online Primary Care Course for Substance Use Professionals
CIHS, in collaboration with the Addiction Technology Transfer Center (ATTC) Network and the Morehouse School of Medicine National Center for Primary Care, has developed a 5-hour self-paced online course for addiction treatment professionals considering career opportunities in primary care. The free course provides resources and information to help these professionals decide whether working in a primary care setting is right for them. NAADAC, the Association for Addiction Professionals, and the National Board for Certified Counselors offer five continuing educations credits for this course for a fee ($25.00 to earn 5.00 NAADAC CEUs and 5.00 NBCC clock hours).

Smoke-Free Rules and Secondhand Smoke Exposure in Homes and Vehicles among US Adults
Four out of five U.S. adults do not allow smoking in their homes and three out of four ban the practice in in their vehicles, according to a study in Preventing Chronic Disease, a journal of the Centers for Disease Control and Prevention. Despite the high prevalence of voluntary smoke-free rules in homes and vehicles, the study found that almost 11 million non-smoking adults continue to be exposed to secondhand smoke at home, and almost 17 million non-smoking adults are exposed to secondhand smoke in vehicles.

Connection Between Smoking, Chronic Drinking, and Early Brain Aging
Researchers have found that among individuals with alcohol abuse issues, those who smoke have more problems with memory, problem solving, and quick thinking than those who do not smoke. The researchers advised that healthcare professionals should routinely offer smoking-cessation help to people seeking treatment for alcohol abuse.

Free Online Diabetes Workshop
The National Council on Aging is now offering a free online diabetes workshop. Better Choices, Better Health® — Diabetes is the online version of Stanford University's Chronic Disease Self-Management Program. Over six weeks, from the convenience of a computer, participants learn to manage their diabetes symptoms, eat well and exercise, communicate with their doctors, and live healthier. All participants also receive a free copy of the workbook, Living a Healthy Life with Chronic Conditions.

Components of an Integrated Delivery System: Managing Populations in a Safety Net Environment
Health Management Associates Accountable Care Institute developed a new document that overviews the essential areas that must be addressed when developing accountable care systems and provides guidance based on what they found works in real-world settings. 

Call Our Helpline: 202.684.7457

eSolutions: Sustainability 

Feature Article: Sustainability: Making Integrated Care Stick
Quick Tips: Keeping Integrated Care on the Table
Featured Resource: Sustainability Checklist
CIHS Webinars
Hot Topics


Sustainability: Making Integrated Care Stick

Kathy Reynolds, Senior Consultant, SAMHSA-HRSA Center for Integrated Health Solutions 

How do you ensure your organization’s integrated primary and behavioral healthcare services continue into the future? 

When people think of sustainability, they often confuse it with financing. While financing is critical, it is only one component of what makes integrated care stick. 

By nature, bidirectional integrated care is provided in a variety of settings, each with its own billing, workflow, and operation considerations. A solid sustainability plan includes both administrative and clinical components. 

  1. Leadership and Mission: To sustain your integrated services, your organization must embed integrated care delivery into its mission and vision and work to shift your organizational culture so staff sees health and wellness as part of their role. Sustainability requires buy-in from the CEO and board of directors of each organization involved. Embedding integrated care into your organization’s culture means that every employee understands the importance of these services and operates with the expectation that all consumers receive this care. Organizations invested in sustaining their integrated services will establish a powerful “change team” to influence integration in their clinic. Integrated care is part of orientation for all new, and all supervisors review physical health and behavioral health goals during team meetings. In addition, administrative policies, job descriptions, performance reviews, confidentiality agreements, and care coordination practices all support an integrated practice.
     
  2. Strategy: Sustainability won’t happen unless integrated care goals are prioritized in the organization’s strategic plan. Integrated care also requires a business plan to sustain and grow revenue. In states with Medicaid expansion plans, each organization will need to project that expansion in their integrated business plan for 2014 and determine how much funding is required to prepare to serve this new population. Your strategy must also include helping those you serve to understand that they are entitled to integrated care and that there are avenues where they can advocate for the sustainability of these care models.
     
  3. Technology: Sharing information between primary care and behavioral health providers is at the core of providing integrated care. Organizations need to operate using certified electronic health records (EHRs), generate health registries to monitor care for chronic illnesses, track healthcare industry-wide standards of care (i.e., HEDIS metrics) electronically, and monitor treatment outcomes by individual client, program, location, and organization. Ideally, all integrated care organizations will be able to generate and share a coordination of care document (CCD) that includes both primary health and behavioral health information. Check out the meaningful use standards for more information.
     
  4. Clinical Workflows: Clear and consistent clinical workflows are needed to support integrated care. Think about these questions: Is staff trained to coordinate healthcare and provide mental health or substance use services? Does clinical staff review annual lab work for all those served? Have you trained all staff in motivational interviewing, behavioral activation, and how to work with clients on their goals, including smoking reduction? Are blood pressure and BMI measured at each visit? Are you monitoring to ensure that your primary care and behavioral health staff create person-centered integrated care plans for each person served that includes all of the person’s behavioral health and primary health goals?
     
  5. Financing: Financing options for integrated care vary, depending on whether the model was developed in partnership with one or more organizations or within just one organization. Each state’s polices and Medicaid plans also determine financing. Organizations providing integrated care need to understand their state’s billing policies and should talk with state partners about barriers to financing integrated care. State-directed billing options that support integrated care include permitting both behavioral health and primary health services to be billed on the same day by the same organization, payment for care coordination, and payment for Health and Behavioral Intervention codes (HBAI). These codes allow behavioral health providers in primary care settings to address behaviors that impede health improvement. Providers must be able to bill for all primary care and behavioral health services provided.
     
  6. Billing: If billing through a partnership, each organization can bill through separate tax ID numbers for their own services in the integrated care model. It is imperative that partnering organizations understand each other’s billing rules and regulations. Together, the clinical and billing staff from both organizations benefit from walking through a workflow to understand which credentialed staff are allowed to bill for each step of the process. In addition, organizations need to set volume targets for sustainability. Primary care providers typically require a panel of 1,500 patients to cover their costs. Integrated care clinics that need additional volume may want to consider marketing their integrated services to the community for new clients to meet their business model targets.
     
  7. Health Homes: States developing health homes may have the ultimate sustainability plan for health integration. Health home requirements and payments will support many components of integration currently in operation across the country. Care coordination is a foundational component to integrated care, and health home position descriptions and reimbursements will help sustain this often-unfunded function.
     
  8. Quality Improvement: Providers looking to sustain their current array of integrated services must be able to make data-driven decisions to determine which integrated care components actually improve care. For example, wellness programming funded only through a grant may be difficult to 1.       retain unless the activities can be identified — by data — as value-added. Presenting this data to payers (e.g., managed care providers, state, county providers) can create a sustainable funding stream for these services. Until contracts can be changed, key activities can be performed by volunteers, integrated into the job descriptions of existing staff, conducted by other community organizations (e.g., the YMCA, oral care providers), or sustained under other grant funding. Continuous quality improvement is a valuable way to make sure that your organization is meeting its integrated care goals of improving the overall health status of your clients. 

Featured Resource

There are many pieces to sustainability, and your organization must continually analyze and refine its strategy to keep integrated care working for your community. With the right planning and implementation, your organization can ensure that integrated care becomes the new standard.

To help you prioritize and begin the process of developing a sustainability plan, check out CIHS’ sustainability checklist.  


Quick Tips: Keeping Integrated Care on the Table

Jenny Crawford, Deputy Director of CIHS, developed quick tips for you to consider when creating a sustainability plan for your integrated health program.

  1. Create an integration leadership team with senior leaders and program directors from all your organization’s service areas. The leadership team will meet for regularly scheduled meetings and maintain responsibility for developing the organizational expectations, workflows, job descriptions, performance review language, and quality improvement benchmarks on integrated care.
     
  2. Provide regular updates to all governing boards about why integrated care is important and how your data demonstrates improved care. Involve a person who receives your integrated services to share the importance of integrated care on their overall wellbeing.
     
  3. Reach out to community stakeholders, elected officials, hospitals, and foundations to let them know how you are improving care and how your efforts might affect issues important to them. Remember that your audiences may remember some data, but they’ll always remember a powerful story.
     
  4. Make sure you know your costs for delivering integrated care and consider expanding access to other community members who do not have serious mental illnesses if you need additional volume to cover your costs.
     
  5. Build all employees’ whole health literacy. Provide in-service training for all behavioral health staff so that they are comfortable discussing BMI, cholesterol, and blood pressure numbers. Provide training to primary care providers to help them understand the behavioral health goals of the people they serve and the role of behavioral health staff in reaching those goals.
  6. Ask the integrated care clinic staff to present to the entire agency on both their work with adults with serious mental illness and health topics germane to agency staff. This helps set the tone of “integrated care is now our business as usual.” 

For more information, visit www.integration.samhsa.gov or contact CIHS at Integration@TheNationalCouncil.org


CIHS Webinars

Federal Healthcare Integration Innovations: A Round Robin
(Co-sponsored with the AHRQ Academy for Integrating Behavioral Health and Primary Care)
July TBD

Federal investment in healthcare redesign efforts is demonstrating the importance of education on behavioral health, screening for mental illnesses and addictions, and access to behavioral health treatment in communities across the country. Innovative programs across several federal agencies support the integration of primary and behavioral health services. During this webinar, each agency will share core features of their model or program, outcomes, and resources — valuable information that any provider can use to inform their integration efforts.

Visit the CIHS website regular to see upcoming webinars. Missed a past webinar? No problem. You can view and listen them at any time.


Hot Topics

White House Hosts National Conference on Mental Health
On June 3, President Obama and Vice President Biden hosted a National Conference on Mental Health at the White House as part of the administration’s effort to launch a national conversation to increase understanding and awareness about mental health.

New 5-Hour Online Primary Care Course for Substance Use Professionals
CIHS, in collaboration with the Addiction Technology Transfer Center (ATTC) Network and the Morehouse School of Medicine National Center for Primary Care, has developed a 5-hour self-paced online course for addiction treatment professionals considering career opportunities in primary care. The free course provides resources and information to help these professionals decide whether working in a primary care setting is right for them. NAADAC, the Association for Addiction Professionals, and the National Board for Certified Counselors offer five continuing educations credits for this course for a fee ($25.00 to earn 5.00 NAADAC CEUs and 5.00 NBCC clock hours).

Smoke-Free Rules and Secondhand Smoke Exposure in Homes and Vehicles among US Adults
Four out of five U.S. adults do not allow smoking in their homes and three out of four ban the practice in in their vehicles, according to a study in Preventing Chronic Disease, a journal of the Centers for Disease Control and Prevention. Despite the high prevalence of voluntary smoke-free rules in homes and vehicles, the study found that almost 11 million non-smoking adults continue to be exposed to secondhand smoke at home, and almost 17 million non-smoking adults are exposed to secondhand smoke in vehicles.

Connection Between Smoking, Chronic Drinking, and Early Brain Aging
Researchers have found that among individuals with alcohol abuse issues, those who smoke have more problems with memory, problem solving, and quick thinking than those who do not smoke. The researchers advised that healthcare professionals should routinely offer smoking-cessation help to people seeking treatment for alcohol abuse.

Free Online Diabetes Workshop
The National Council on Aging is now offering a free online diabetes workshop. Better Choices, Better Health® — Diabetes is the online version of Stanford University's Chronic Disease Self-Management Program. Over six weeks, from the convenience of a computer, participants learn to manage their diabetes symptoms, eat well and exercise, communicate with their doctors, and live healthier. All participants also receive a free copy of the workbook, Living a Healthy Life with Chronic Conditions.

Components of an Integrated Delivery System: Managing Populations in a Safety Net Environment
Health Management Associates Accountable Care Institute developed a new document that overviews the essential areas that must be addressed when developing accountable care systems and provides guidance based on what they found works in real-world settings. 

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Email: integration@thenationalcouncil.org

Phone: 202-684-7457