e-Solutions September 2014
Feature article: Lessons Learned from Integration Pioneers
Grantee Profile: Stories of Success from PBHCI Programs
Quick Tips: 8 Integration Insights from PBHCI Grantees
Featured resource: Population health management
Webinars: Archive of lessons learned webinar
Laura Galbreath, MPP, Director, SAMHSA-HRSA Center for Integrated Health Solutions
Grant cycles are akin to congressional elections: an opportunity every four years to stop and assess positive change and think about the issues that continue to demand attention. Last month, at a meeting of grantees involved in SAMHSA’s Primary and Behavioral Health Care Integration (PBHCI) program, I was struck by how profoundly different the tenor of conversation was compared to just four years ago.
To date, SAMHSA has awarded 100 PBHCI grants to organizations across the country. These grants support specialty behavioral health centers, as well as their community partners (78% of grantees partner with a primary care provider, including HRSA-supported safety net providers and other community health centers), to improve access to primary care services; improve prevention, early identification, and intervention to reduce the incidence of chronic illnesses; and to improve the overall health status of people living with mental illnesses and addictions.
More than 50,000 individuals have enrolled in the integrated care services of PBHCI programs since the program began in 2009. For many enrollees, this is the first time they have seen a primary care provider in years. Roughly a third self-reported that they attained improved functioning in everyday life and many show a clearly reduced risk for high cholesterol.
To reduce the overall cost of care, more than 15% of PBHCI programs partner with community hospital systems to help divert individuals with serious mental illnesses to less costly community resources.
Addressing the health disparities and early mortality of individuals with serious mental illnesses continues to be the guiding vision and mission of the SAMHSA PBHCI program, and the program continues to support a growing cadre of pioneers that change the way care is delivered. What has changed over these four years is the confidence and knowledge of providers in addressing the complex organizational, workforce, and cultural changes needed to successfully integrate primary care. These providers demonstrate comfort in communicating the value of integrated care to partnering providers, payers, hospitals, and policy makers, as well as sharing clinical improvement data with individuals and staff.
PBHCI grantees shared a few key strategies and “aha!” moments around their success:
- Don’t just collect data, use it! It is important to routinely collect health indicator data, and just as important to use it in a variety of ways. Inform the individuals you serve about their improved health and wellness. Use client-level data to support overall population health management (and associated continuous quality improvement efforts) that focus on measuring and achieving explicit health outcomes across all individuals served, and also between groups (e.g., ethnic and racial populations, various co-morbid chronic illness). Also use the data to build the case for integration and share it with organizational leadership, county officials, and payers.
- Involve peers. Engage peers in the design, selection, and implementation of all wellness programming. Peer wellness coaches have a key role in supporting implementation of evidence-based health and wellness interventions, working with individuals on health and wellness goals, and recruiting and engaging individuals in the program.
- Remember that implementing integrated care is a major culture change. Both primary and behavioral health care staff will experience a fundamental shift in the way they think about health care and reinterpreting their clinical role in an integrated care environment. Providers must address how to successfully blend different professional cultures in their service to customers, and support staff with iterative cross-training on integrated care.
Be clear with staff that it is everyone’s responsibility to address whole health. Share the principle that health is fundamental to a recovery-oriented system of care.
Recognize the importance of the team. A team puts the individual at the center to achieve quality outcomes. Implement mechanisms to support integrated team functioning, including hallway consults, daily/weekly team huddles, and integrated electronic health records.
Recognize that care managers are the "bridge" across systems. They support health care navigation, integrated care team functioning, and integrated treatment planning.
Cross train behavioral health and primary care staff on the particulars of behavioral health and primary care, including specific training on medication assisted treatments for substance use disorders.
Focus on long-term engagement. Many health conditions require longer-term behavioral intervention (e.g., weight loss and tobacco cessation), with studies showing improvements after 18 months or longer following an intervention.
Understand the value of technology in integrated health care. Bridge across distinct electronic data systems to share individual’s integrated behavioral health and primary care data.
- Recognize that integrating care is more than adding primary care services. Integrated primary care means more time to work on complexities and the ability to work with individuals outside the clinic, in their home and in the community. A focus on prevention means learning to screen for chronic health issues, including breast cancer, colon cancer, and hepatitis. Structure integrated care services, staffing, and quality measures to meet developing Medicaid health home criteria.
- Give attention to partnerships with health centers. Understand what your primary care partner may benefit from your working relationship - provide "incentives" for meaningful participation so the partnership can move from "on paper only" to "fully embraced."
Identify the cost benefits associated with integrated care. Analyze the data to determine the savings achieved through integrated care. This may include reduced emergency room use, reduced no-shows, or increased efficiency/reimbursable use of staff time.
- Identify and confront challenges. There may be challenges accessing data on hospitalization and emergency room use, or in facing state/local policies that can inhibit integrated care (e.g., requirements for having separate behavioral health and primary care staff break rooms, separate doors for primary care and behavioral health services). Address these challenges to try and find the root of the problem and confront it.
An early evaluation of the PBHCI program (under contract to the RAND Corporation, supported by SAMHSA and the HHS/Office of the Assistant Secretary for Planning and Evaluation) offers additional lessons learned. The report shares:
“PBHCI programs were successful in several ways, such as building integrated, multidisciplinary teams that offer an array of integrated primary, [behavioral health], and wellness services... PBHCI programs also experienced several challenges, including lower-than-expected rates of consumer enrollment, financial sustainability, intra-team communication, and creating an integrated clinic culture…Future cohorts of grantees could consider several options to improve program implementation, such as maximizing data-driven, continuous quality improvement; monitoring implementation fidelity to evidence-based wellness programs; and investing in strategies that improve consumer access to integrated services, among others. Stakeholders in the field of integrated care could benefit from consensus around program performance expectations, and the establishment of national quality indicators for integrated care accountability and core performance monitoring requirements. Finally, technical assistance providers could consider continuing dissemination of emerging best care practices for adults with SMI and supporting grantees navigating concurrent health care reforms.”
As PBHCI grantees and the broader behavioral health field embrace integrated health, these lessons can help all providers improve the quality of care, reduce the overall cost of care, improve health outcomes, and support individuals to live a self-directed life.
What important lessons have you learned in the process of integrating primary care into behavioral health settings? Share your story with us, email integration@theNationalCouncil.org.
Since 2009, PBHCI programs have provided services to more than 50,000 people. Data and outcomes show whole health improvements in the people enrolled in these programs, but that only tells part of the story. As part of a national meeting of the PBHCI grantees, CIHS encouraged grantees to create videos to share how offering integrated primary care and wellness services supports people on their journey to whole health and wellness, to improve their physical health, and to reach their full potential. The more than 20 personal stories shared from 13 sites remind and inspire us of the importance of integration on supporting whole health, including:
- How Craig transitioned from homelessness to secure housing with support from Catholic Charities of Trenton, NJ. Watch Craig’s story
- Kiki, who hadn’t seen a primary care doctor in more than 5 years, addressed her whole health with the Bond-Apalachee Wellness Integration Center. Watch Kiki’s Story
- How Community Alliance-Crossroads to Health & Recovery in Omaha, Nebraska serves several members of their community. Watch their stories
- How Zelma appreciates getting all of her health needs addressed at ICL. Watch Zelma’s story
Watch even more success stories and access all the videos on our website.
Integration is no small task, and there are many ways to approach integrating primary care and behavioral health. PBHCI Grantees share a few of their most helpful hints and elements for success.
- Don’t lose momentum — continue regular team meetings with both behavioral health and primary care staff throughout your project’s duration.
- Start planning for sustainability in the first year.
- Secure top-level support—it is ‘a must’ for your success.
- Focus on your teams. Create partnerships within your organization and encourage ongoing collaboration by going to each other’s meetings.
- Embrace each other’s cultures — there is so much primary care and behavioral health can learn from each other.
- Celebrate each day with little victories, like when clients achieve short-term goals. Share successes to inspire others.
- Cultivate your results. “If it is worth asking, it is worth tracking,” – invest in your registry. Nothing changes minds faster than demonstrated outcomes.
- Take advantage of technical assistance. CIHS is here to help you shine — grantee or not, send your integration questions to integration@TheNationalCouncil.org (non-grantees can take advantage of one free hour of consultation with CIHS integration experts).
Looking for specific tips and lessons related to a certain aspect of integrated care? Check out our website for further resources, initiatives, and strategies on integrated care models, operations and administration, financing, workforce development, clinical practice, and health and wellness.
Population Management in Community Health Center-based Health Homes, a new resource from CIHS, explains the principles and steps integrated care providers can take to implement population health management (assessing, tracking, and addressing the health of an entire group or community). The paper includes a 10-step guide to implementing population health, also available in a PowerPoint for easy sharing.
A new report from the RAND Corporation describes three approaches to integrated care for adults with serious mental illness. The report characterizes, compares, and contrasts the three approaches to integrated care and provides recommendations for improving and evaluating the integration of primary medical and mental health services. Read the full report or the accompanying issue brief.
SAMHSA and the White House Office of National Drug Control Policy presented a webinar, Addressing Opioid Misuse and Abuse, on Tuesday, September 30, 2014 to review federal policy related to opioid misuse, abuse, and overdose; discuss the etiology of opioid abuse and clinician interventions that can reduce the risk of misuse; and overview SAMHSA’s Opioid Overdose Prevention Toolkit.
State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid Environment, a new report from the Commonwealth Fund, explores strategies states deploy to address or eliminate system-level barriers to integrated care for the Medicaid population.
Million Hearts® is looking for “hypertension control champions” — clinicians, practices, and health systems that provide continuing care and have achieved hypertension control rates greater than 70 percent. Submit your nomination or encourage high-performing small and large practices to enter the 2014 Million Hearts® Hypertension Control Challenge by October 10.
Did You Know? is a weekly CDC feature that offers three quick tips and resources that can inform your wellness activities. A recent issue shared information on awareness among adults who have prediabetes, and resources from the National Diabetes Prevention Program to promote healthy habits and lifestyle changes to prevent or delay type 2 diabetes.
In case you missed it, hear the Lessons Learned from PBHCI Grantees as these behavioral health organizations took on the task of integrating primary care into their services — and what outcomes they already achieved. Grantees shared concrete strategies for what works and what adjustments to expect along the way.