eSolutions: Primary Care Learning Communities
July 2013 eSolutions: Primary Care Learning Communities
Feature Article: Ready, Set, Integrate: Integrated Care Adventures in Community Health Centers
Grantee article: Corning Area Healthcare and Mid-South Health Systems
Featured resource: Sample Business case for Behavioral Health Integration
Quick tips: Create Your Own Dolly
An exclusive interview with Laurel Simmons and Roger Chaufornier, Behavioral Health Integration Learning Community facilitators
How can community health centers with little to no behavioral health capacity incorporate whole health services? Eleven health centers found out by participating with the Behavioral Health Integration Learning Community, an initiative of the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) carried out by the National Association of Community Health Centers (NACHC). The learning community health centers met regularly as a team with coaching from the project’s facilitators Laurel Simmons and Roger Chaufornier. Here are some of the core strategies they learned.
The nine-month learning community operated in a short timeframe — July 2012 through March 2013 —and the participating health centers knew they had to come into the initiative with a commitment to change.
“Readiness is key,” said Laurel Simmons. “This isn’t work that people should undertake if the senior leaders haven’t agreed it’s a priority for the organization.” Simmons notes that readiness has two forms: 1) organizational culture and 2) organizational infrastructure. If the organization doesn’t have a clear intention that integration is a priority or have the staffing or measurement system in place, the timing clearly isn’t right. Additionally, if you’re in the middle of restructuring or going through an audit, it can be challenging to begin an integration effort.
“Everybody — the docs, the nurses, everyone — needs to have a sense that this change is important, that it’s meaningful to clients, that it’s meaningful for me and my job. If that’s not true, then it’s much harder to make the change,” added Simmons.
Create a Measurable Aim
Health centers should ask themselves what they want to achieve in behavioral health integration. Responses can be used to form a structured aim statement – one that is specific and measurable. For example, “We will have screened 95 percent of all patients with a PHQ9 scale by December 2013.”
Centers should consider creating a set of measures – including process measures, business case measures, and client/staff satisfaction measures.
Determining what you want to assess is only one element of measurement. The other piece is building the infrastructure to collect the data. Part of this process is establishing relationships with IT folks or others who can help you access or analyze the data.
“It’s very tempting to let data sit in the computers and not look at it because we have all got lots of things to do,” said Roger Chaufornier.
Once an aim is established, it is important to share your goals and vision across the whole organization. Make sure your project leadership team includes physicians, nurses, behavioral health professionals, and IT staff. Integrated care requires strong relationships inside the organization to facilitate timely hand-offs between physicians, nurses, and behavioral health professionals and achievement of metrics.
Illustrate the Value of Integration
“Change is very hard. One potential response will be, ‘Yes, but we can’t afford it. We can’t get paid for it.’ And that’s a very effective barrier to prevent change,” added Simmons.
The business case for the integration of behavioral health varies from state to state. For centers in states that allow same day billing, teams were impressed at how much the benefits outweighed the costs. Centers can create their own business case by entering their costs and revenues into a simple Excel template developed by the learning community.
“Most primary care organizations underestimate the real impact behavioral health has on their bottom line in terms of clinical productivity,” said Chaufornier. For example, if a client comes in for an eight-minute visit and finds out he or she has diabetes, that appointment can easily become a 50 minute visit. Most of those extra 32 minutes are taken up with psychosocial concerns, which could be more effectively served by a behavioral health professional than an MD.
In many environments, even when there’s no reimbursement for behavioral health, if you can do warm hand-offs to an appropriate resource, the return on investment is realized quickly.
Go Beyond the Numbers – The Dolly Exercise
In addition to talking about numbers and showing graphs about how many people received a behavioral health intervention, the Learning Community found it powerful to use a real client’s story. They called her “Dolly.”
As an exercise, each learning community team mapped out on a piece of paper how Dolly, a client with complex needs, gets all of their care, from her perspective. How does she get to her appointments? How does she get food? How does she get prescriptions refilled? What are all the things that become barriers? The resulting picture is impactful because it shows the challenge behind navigating all the care and services Dolly needs, while also connecting providers to a very real, personal situation. Then, each team mapped out what Dolly’s experience might look like if she received integrated care.
The learning community found this exercise to be very effective in showing what individuals’ outcomes could be. It’s important to share inside the team so that the organization knows why you’re doing the work. The story complements the business case beautifully, and it explains to the staff why integration is important. (Check out the Quick Tips below on how to create your own Dolly story.)
“When you’re working in a short timeframe, the challenge is getting people mobilized,” noted Chaufornier. In order to get started, giving precise guidance, rather than providing a vague or general strategy, can help staff get oriented to providing integrated care.
“It worked beyond our expectations, and the key was having a concise prescriptive curriculum that focused on leadership, building the team, and the business case and measures. Giving teams specific to-dos worked very well in this context. Often, a learning collaborative is much more open-ended,” explained Simmons.
Don’t Go It Alone
One of the powers of a learning collaborative is the ability to learn from peers and to be able to share in a context and a timeframe that’s meaningful to your needs.
“My aspiration would be to make this scalable so that you can go from the initial learning community teams to several hundred,” said Chaufornier. His hope is that all health centers eventually have access to learning community support for integration, helping them transform care in a way that helps each individual organization.
For more information on NACHC’s behavioral health efforts, visit their website.
For more information on integrating behavioral health into primary care, visit CIHS’ website.
Grantee Feature: A Natural Partnership for the Natural State: Corning Area Healthcare and Mid-South Health Systems
Corning Area Healthcare, Inc., is a private non-profit community health center serving the comprehensive healthcare needs of northeast Arkansas. Corning participated in the CIHS-supported and NACHC-run Behavioral Health Integration Learning Community this past year.
Corning Area Healthcare works with Mid-South Health Systems, a community mental health center, to provide mental health services in three primary care clinics in three counties. The two organizations have worked together for over 15 years, providing a solid basis on which Corning built their integrated care models. Mid-South employs three behavioral health consultants from Corning.
What does integrating behavioral health into their center look like? Many of their efforts are focused around staff training and coordination. A physician and a behavioral health consultant work as a team, huddling in the morning to discuss the day’s schedule, which helps them conduct warm hand-offs as the day progresses. Corning trained its administrative staff to use Mid-South’s electronic medical record system, and the behavioral health consultants are trained to use Corning’s electronic medical records. Corning’s staff are now knowledgeable in the use of motivational interviewing and screening tools, including Patient Health Questionnaire-9 (PHQ9), Generalized Anxiety Disorder-7(GAD7), and the TCU drug and alcohol screen. They also use the Assess and Referral program model, which involves a brief assessment, a master treatment plan, up to six sessions with the behavioral health consultant, and then referral to an offsite specialist if further treatment is needed. They developed a formal communication structure, including a newsletter, a messaging system through the EMR, and monthly problem solving meetings among staff. Both Corning and Mid-South staff have learned how the other operates, and learned each other’s lingo and definitions. They jointly developed an Integrated Care Handbook, a script for warm hand-offs, and a standard approach to serving the same clients. Their goal is to provide an integrated care program to a minimum of 8 to 10 face-to-face billable contacts per day, including both scheduled and warm hand-offs.
When the Corning team was asked to develop their own Dolly story (see Quick Tips), they decided to use the real case of a family of three who all received treatment at their center. Originally, the son came in for care, and was experiencing serious health issues, including type 1 diabetes and bipolar disorder. Then, Corning began to care for his parents, all three independently had complex cases involving both physical and mental health challenges. Each of these challenges was compounded by the other’s health. None of the family members had received any mental health services prior to coming to the health clinic, all were living in poverty and unemployed due to their mental and physical health problems, and all saw worsening medical care concerns due to their financial situation.
After the integrated care program was implemented, this family was provided with a host of services that address their medical and mental health problems. These services have been life changing. “It would be hard to find a better example of where integrated care has truly worked for the benefit of, not only one person, but the whole family,” said an integrated health specialist at Corning Area Healthcare.
Improved patient outcomes are not the only benefit of integration for Corning. Using the business case tool, they were able to show a benefit of an additional $23,000 per year due to increased availability of 177 appointment slots for primary care providers to see clients for medical treatment. If each behavioral health counselor completed four warm hand-offs, an estimate of $96,000 could be gained. While Corning was able to make their initial business case for the learning community, they caution that the partnership between a community health center and a community behavioral health center in providing integrated care can be complicated. Creating a mutually beneficial contract between partners needs to be informed by state billing requirements, the financial position of the partners, and the status of partner electronic medical records.
The team notes that you have to demonstrate the value of integration before you can convince payers to finance this level of care. They gauge this value in a variety of ways. Corning tracks the number of warm hand-offs completed, the number of hours the behavioral health counselor bills (their aim is for 100/month for sustainability), and the number of follow-up reports to the primary care provider from the behavioral health counselor. They also track quality measures, including client satisfaction and depression improvement (as measured by the PHQ9). The behavioral health counselors also keep track of clients referred for more intensive care.
The center is not currently compensated for the time spent between the behavioral health and primary care teams. These warm hand-offs work to decrease the number of no shows and increase overall productivity, but they are not billable. In Arkansas, Medicaid beneficiaries are allowed only 12 medical visits per year, so the primary care provider cannot afford to lose any visits for behavioral intervention. It is also hard to get referrals to help clients cope with the psychosocial aspect of their physical illness, which is often the reason for their non-compliance with medications or their providers’ suggestions.
In order to support behavioral health integration, the Corning team says that behavioral health and medical staff buy-in and leadership involvement have been key to helping providers remain vested in the success of behavioral health integration. Additionally, they found that enacting integration required intense collaboration and rethinking of multiple processes and services in order to ensure everything was a good fit for both agencies.
Need to make the case for behavioral healthcare integration to your finance or leadership team? Use this excel tool to build a sample business case for behavioral health integration.
Providing integrated healthcare services is about more than just the bottom line – it is also about improving the experience of healthcare and improving the overall health of the population you serve. Use these tips to illustrate how using integrated care at your center can impact your client’s experience.
- Think of a client with complex needs. Select someone your team has worked with who had behavioral health needs and other comorbidities, costlier care, and complex needs.
- Put yourself in their shoes. How do you get to your appointments? How do you get food? How do you refill prescriptions? What are all the things that go wrong?
- Map out on a piece of paper all of these considerations. Working with your team, create the full picture of how your “Dolly” gets the support she needs.
- Try to create the ideal pathway for support. In many cases, your Dolly map will look quite busy. How could you make this picture look better and more streamlined? Where can integrated behavioral and primary care make a difference?
- Document the business case. How would streamlining your care also help your center? Are there potential cost savings from an integrated approach? Or billable items you aren’t currently accounting for?
- Share with your team so that the organization – especially leadership – understands the potential value of an integrated care model. Turn your “Dolly” into a case study for communicating to your own stakeholders – making the case as a personal, quality improvement, and financial benefit.
CMS Releases Final Rule, Including Provisions on Eligibility
CMS’ new final rule finalizes Medicaid eligibility provisions; finalizes changes related to electronic Medicaid and the Children’s Health Insurance Program (CHIP) eligibility notices and delegation of appeals; modernizes and streamlines existing Medicaid eligibility rules; revises CHIP rules relating to the substitution of coverage to improve the coordination of CHIP coverage with other coverage; and amends requirements for benchmark and benchmark-equivalent benefit packages consistent with sections 1937 of the Social Security Act to ensure that these benefit packages include essential health benefits and meet certain other minimum standards.
Substance Use Disorder Professionals: Free Online Course on Primary Care
CIHS, in collaboration with the Addiction Technology Transfer Center (ATTC) Network and the Morehouse School of Medicine National Center for Primary Care, released a five-hour self-paced online course, Introduction to Primary Care for Substance Use Disorder Professionals, for addiction treatment professionals considering career opportunities in primary care. The course provides these professionals with resources and information to help them decide whether working in a primary care setting is right for them.
In Case You Missed It: Integrating Physical and Behavioral Health – Illustrations from the Frontlines
This webinar showcased leaders and organizations that are at the forefront of redesigning care for individuals in need of both primary care and mental health services. Integrated care providers are more likely to help their clients connect the dots between body and mind, and improve underlying health problems in a more holistic way. Research has begun to demonstrate that this approach leads to improved chronic conditions and fewer trips to emergency rooms.
Check out the New Tobacco Cessation Resource from the Behavioral Health and Wellness Program
DIMENSIONS: Tobacco Free Toolkit for Healthcare Providers is designed for a broad continuum of healthcare providers and contains information and step-by-step instructions on tobacco use education, client engagement, methods for assessing people’s readiness to quit, and information and research on treatments. The toolkit also includes a supplement that addresses individuals with behavioral health conditions.
New Funding Opportunity to Improving Health and Reduce Premature Mortality in People with Severe Mental Illness
The National Institute of Mental Health has announced the availability of funding to support effective interventions to reduce common modifiable health risk factors for people with severe mental illness. This grant will support grants of up to five years for rigorous effectiveness testing of innovative services interventions designed to reduce the prevalence and magnitude of common modifiable health risk factors related to shortened lifespan in adults with mental illnesses, as well as in children and youth with serious emotional disturbances. Non-profit agencies are eligible to apply and letters of intent are due October 7, 2013.
New Report: Engage Substance Abuse Prevention Coalitions in Your Integration Work
To demonstrate the ways in which they can work with healthcare providers for the greatest effect, CADCA (Community Anti-Drug Coalitions of America) and CIHS developed Coalitions and Community Health: Integration of Behavioral Health and Primary Care. The report outlines how the nation’s 5,000+ community substance abuse prevention coalitions can help to reduce substance use in ways that complement healthcare providers’ whole health and integration efforts while ensuring that individuals needing coordinated services receive the care they need.
Smoking Rate Among Adults with Serious Psychological Distress Remains High
The SAMHSA Center for Behavioral Health Statistics and Quality reports that recent data from the National Survey on Drug Use and Health have shown that the U.S. smoking rate is much higher among persons with mental illness than among those who do not have mental illness. The data also show that serious psychological distress is associated with serious mental illness.
Free Continuing Education Credits for Tobacco Cessation Courses
The Smoking Cessation Leadership Center offers free continuing education credits for physicians and allied health professionals. You can choose any of the available online CME/CEU courses on the SCLC website, and can complete more than one course. Each online course is designated with 1.5 AMA PRA Category 1 CreditsTM. The free offer expires September 2013.
Health Habits Screening
Health Habits Screening is an online, anonymous, self-administered screening program, with audio and video prompts, that primarily screens individuals for potentially harmful drinking patterns, but includes additional questions on nutrition, smoking, and exercise behaviors and provides immediate, tailored feedback. Individuals can print out feedback, as well as a one-page “Provider Report,” which can be shared with a medical provider.
New Interactive Medical Home Map
The National Academy for State Health Policy (NASHP) recently launched a new interactive map tracking state efforts to advance medical homes for Medicaid and CHIP participants. In addition to analysis of medical home programs in each state, users can explore state medical home activity across five key domains: payments to medical homes, multi-payer initiatives, Affordable Care Act Section 2703 health homes, medical home qualification standards, and shared practice supports.
It’s Just Good Medicine: Trauma-Informed Primary Care
Tuesday, August 6, 2013, 1:00 pm -2:30 pm EDT
In the United States, 61% of men and 51% of women report exposure to at least one traumatic event in their lifetime, with many reporting more than one. For individuals with mental illnesses or substance use disorders, traumatic life events are the rule rather than the exception. These adverse life experiences have been found to be a risk factor for a variety of serious health conditions and are likely to contribute to an individual's avoidance of and discomfort with medical procedures in primary and specialty care. As HRSA-funded safety-net providers expand their behavioral health capacity to serve clients, trauma-informed care will increasingly become an integral part of good medicine. Register Today.