eSolutions: Make it last: How to Sustain Integrated Care
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.
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.
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.
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.
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?
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.
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.
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.
- 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.
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.
Jenny Crawford, Deputy Director of CIHS, developed quick tips for you to consider when creating a sustainability plan for your integrated health program.
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.
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.
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.
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.
- 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.
- 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.”
Federal Healthcare Integration Innovations: A Round Robin
(Co-sponsored with the AHRQ Academy for Integrating Behavioral Health and Primary Care)
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.
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