100 Strong: Integration Continues to Grow
Feature article: 100 Strong: Integration Continues to Grow
Grantee Spotlight: CODAC: Creating a Culture of Integrated Care
Quick Tips: 6 Keys to Integration Success
Featured resource: Children’s paper
Building Primary Care Capacity in Behavioral Health Settings
by Laura Galbreath, Director, CIHS
The SAMHSA Primary and Behavioral Health Care Integration (PBHCI) grant program has now awarded 100 grants to organizations across the U.S. working to integrate primary and behavioral healthcare services. These grants support specialty behavioral health centers and primary care clinics (78% of grantees partner with a primary care provider), as well as the community partners they work with. There are now more than 40,000 individuals enrolled in the integrated care service provided by PBHCI grantees. These individuals have access to team-based coordinated care, ultimately leading to enhanced health and wellness.
It is encouraging to see that 100 organizations are now more primed for the changes to the healthcare landscape ahead. However, much work is still needed to truly shift American healthcare delivery. There are thousands of behavioral health and primary care providers in the U.S. that are not currently implementing integrated care strategies.
In 2014, millions of Americans will become eligible for services under Medicaid. Not all new enrollees will seek or need integrated primary and behavioral health services, but providers must meet this need and recognize that it also brings increased challenges. For some clients, this may be the first time in years that they will receive care outside of a hospital setting. To learn more about enrollment, visit www.samhsa.gov/enrollment/states.aspx.
These 100 PBHCI grantees are early innovators, and their work shows that the process is not simple. Successful integration requires building a whole new system of care. Integrated organizations do not simply add to their suite of services; they learn to increase access to care, strengthen connections to other community agencies, and provide team-based care.
Because of these learned skills, many of the PBHCI grantees are ahead of the curve on community connectivity and in becoming Medicaid health homes.
As part of providing and promoting integrated care, grantees form relationships across their community, including building partnerships with hospitals, aligning with universities and research centers, engaging with accountable care organizations, and strengthening community partnerships in new ways. For example, The Kent Center, a grantee in Rhode Island, partnered with their local YMCA on a wellness program to encourage clients to exercise.
Connecticut Mental Health Center just received a three-year grant from the Patient-Centered Outcomes Research Institute (PCORI) to determine the impact of integrated care in their community, which will connect them with researchers at Yale University and other health and social services agencies across their area.
Grantees are also ahead of the curve in becoming health information exchange organizations (HIOs), which facilitate access to and retrieval of clinical data across multiple healthcare providers to provide safe, timely, efficient, effective, equitable, patient-centered care.
PBHCI grantees are well positioned to take advantage of Medicaid health homes and in becoming health home providers, especially grantees in states with Medicaid state plan amendments that focus on serious mental illness, including Maryland and Ohio. A recent study on patient-centered medical homes shows that these kinds of models improve overall client and staff satisfaction. Transitioning to a health home requires hard work and adequate training to ensure all staff and clients understand the role they play in a health home and their mutual responsibilities to work towards positive behavior changes.
For more information on implementing health homes, visit www.integration.samhsa.gov/integrated-care-models/health-homes
Change Takes Time
The PBHCI program isn’t just about giving grants to centers to add primary care or behavioral health services. Through grantees, we’re learning how to create an integrated system, which means changing the way to do business, learning how to come together for the best interest of the client, and redefining the role of teams.
Overall, integration plays an important role in raising the profile of mental health and substance use nationally, an effort outlined at www.MentalHealth.gov.
For decades, CODAC Behavioral Health Services has provided substance abuse, mental health, and primary care services to more than 12,000 people a year, and prevention services to another 10,000 members of the Tucson community.
In 2009, when the organization received a SAMHSA Primary and Behavioral Health Care Integration grant, they partnered with the El Rio Santa Cruz Neighborhood Health Center, a federally qualified health center. CODAC had referred clients, whether uninsured or on Medicaid or Medicare, to El Rio for services for years. “It made sense to refer them to the experts,” said Dona Rivera-Gulko, PBHCI Project Director at CODAC.
When they started the PBHCI grant project, they knew they needed a new structure and culture that combined the two organizations more formally.
During the first three months of the grant, they focused on developing a building structure and layout to accommodate the flow of services. Then, over the next six months, they developed an implementation plan to provide integrated services. From the beginning, they held monthly steering committee meetings, which Rivera-Gulko says, “forced us to think about sustainability from day one. If it’s not going to be sustainable, then there’s not a whole lot of purpose for it.”
“First, we needed to change the culture” continued Rivera-Gulko. They underwent conscious planning to underscore that everyone in their shared building space knew that they were all on the same team. Now, they have shared break rooms to get people talking and interacting with each other. They hold weekly team meetings, weekly full-staff meetings, and monthly case review meetings between the medical teams. They encourage daily huddles in which everyone involved in someone’s care meets to discuss the individual and his or her care.
“It’s all about avoiding the lengthy email chain between each provider and instead just talking together all at once,” said Rivera-Gulko. “Now, it is hard to remember who works for El Rio and who works for CODAC.”
They still work to ensure staff recognize that they are a part of a whole health team and not separate elements of someone’s care. Together, CODAC and El Rio employ 12 fulltime employees dedicated to their integrated and whole health services. This includes nurses, a clinical manager, medical assistants, a medical office specialist, and three wellness support specialists. When they began, El Rio staffed only one fulltime behavioral health professional, but they soon realized that they needed a combination of staff to best serve their most complex patients. “We wanted to be sure that there were choices for people,” said Rivera-Gulko. “Different people will click with different types of providers.”
For a person to enroll in the whole health program, they must be a member. They have approximately 1,200 program enrollees, with more than 700 continually active. Ideally, they’d like to see at least 1,000 people continually active in the whole health program to support the staff levels they currently have under the PBHCI grant. While 1,000 would be ideal, Rivera-Gulko notes that they have assessed that 750 individuals would be “comfortable and sustainable” for them.
To expand the whole health program’s reach, CODAC is considering expansion of their services to all of the 6,500 clients they serve. “Every one of those people needs good primary care,” noted Rivera Gulko. “If we don’t help the person with a substance use disorder, they can easily become a more complex case.” “I see [whole health] as a prevention strategy.”
Rivera-Gulko estimates that 75% of the people they serve have some form of insurance, but she notes that without easy access to primary care, they likely go without it.
For financial sustainability, each provider within the program must see 12 patients a day. They are hitting that mark, and Rivera-Gulko regularly monitors weekly reports to keep them at that benchmark. To sustain those numbers, CODAC instituted same-day scheduling. At El Rio, nearly 70% of their appointments are same day, and they’ve embraced that perspective within the whole health team.
Challenges they continue to address include:
- Licensing - both agencies are required to have respective licenses for their facility.
- Data mining and operability between systems.
- Education - here’s little history on the program and they must continue to ensure everyone understands the goals.
Fortunately for CODAC and El Rio, recent legislation in Arizona helped ease the implementation of their sustainability plan. The licensing has changed so it is now easier for them to maintain shared spaces, which helps foster the cultural change they try to support. The Arizona legislature also voted to expand Medicaid, a big barrier they faced in being able to serve those not previously covered. “The state is moving in the right direction,” said Rivera-Gulko.
To enhance their data, CODAC partnered with seven community hospitals to begin sharing data on ER visits for behavioral health concerns. They have seen a decrease in these visits at all seven hospitals since receiving the grant. In addition, they have also seen a decrease in rates of incarcerations and homelessness.
According to Rivera-Gulko, the most important elements to ensuring sustainability for their integrated services include:
- The right people - all staff, down to the front office, must understand the importance of integrated services and why the agency provides these services.
- The right training - provide staff the tools and knowledge to work within an integrated health program.
- The right culture - an agency-wide culture shift is necessary to make these changes. Business as usual will hamper integration.
Rivera-Gulko shared, “The people who are trying to implement this understand what they’re buying into — what we’re doing, where we’re going, and why. This has been the most powerful project in my professional life. It has helped hundreds of people so far. It is clinically sound, and it is the way treatment should be.”
What advice do SAMHSA’s Primary and Behavioral Healthcare Integration grantees have about the essential elements to a successful integration program? Cobb-Douglas Community Service Boards, GA; The Providence Center, RI; Asian Community Mental Health Services, CA; and Alaska Island Community Services offer their top tips for making integration work.
Hire Peers: Integrated programs need a peer workforce in both the whole health and the wellness sides of the clinic. There are a lot of reasons an individual might lose hope and not return for treatment. A peer can instill hope, empower clients, and form a connection that supports ongoing access to services.
Get Organizational Buy-in: Integrated care needs top-down buy-in, but it also needs to have bottom-up buy-in. If the front desk staff doesn’t know what integrated care is, and a client asks a question about it, there could be confusion. It’s important that everyone has a level of buy-in. Also, having a position that’s dedicated to overseeing and managing the integrated care process of your organization is critical.
Address Cultural and Linguistic Competency: Organizations need to meet clients where they are, whether that’s through being able to communicate with them in a language they understand or through recognizing how their culture impacts their values and actions.
Co-locate for Better Communication and Better Care: Embedding a health clinic within a behavioral health organization or having behavioral health staff work onsite at the health center offers clients a chance to walk in to the first appointment already feeling like they’re understood. Co-location helps staff feel supported in managing complicated cases that otherwise might have posed some issues. For instance, a primary care doctor who doesn’t know what psychiatric medication a client is on or what issues that might present can quickly consult with the appropriate behavioral health colleagues regarding the potential impact of those medications on the client’s health.
Implement Health Information Technology: Sharing data is absolutely critical for outcome management. Implementing shared health IT means updated release forms, behavioral health forms and electronic health records. Right away that allows both partners to use each other’s electronic health records to see anything they need about the client.
- Make Wellness Fun, Accessible and Social: Get clients involved around wellness. Create a wellness advisory board made up of clients or engage clients to advise program development based on their interests and health goals. By ensuring that wellness programs meet the clients where they are - and with regards to their health needs - individuals are more likely to stay engaged and involved in wellness activities. A recent study found that individuals with severe mental illnesses and obesity who exercised in groups and participated in a group nutrition class for an 18-month period were able to lose weight and keep it off.
Integrating Behavioral Health and Primary Care for Children and Youth: Concepts and Strategies, a new resource from the SAMHSA-HRSA Center for Integrated Health Solutions, provides information on: models of organizing service delivery for youth, five core competencies of integrated care systems for children with behavioral health problems, and financing mechanisms that support integrated care systems for children with behavioral health problems.
CIHS’ new infographic explores how integration of primary and behavioral healthcare can affect individuals and communities. Let others know about the important work you’re doing in integration by sharing the infographic via social media or on your website, in presentations, or print and post it to one of your center’s boards for all to see.
A newly revised consumer guide, Seeking Drug Abuse Treatment: Know What to Ask, is an evidence-based guide for people seeking addiction treatment for themselves or loved ones with questions they should ask potential treatment centers. The NIDA website also features videos of firsthand stories on recovery and from leaders in the recovery field.
CMS/Medicare outlines guidelines and resources on Same Day Billing for behavioral health and primary care providers in a new fact sheet. The overview is helpful for centers providing both mental health and substance abuse treatment.
PBHCI grantee Connecticut Mental Health Center was awarded a three-year research award from the Patient Centered Outcomes Research Institute (PCORI). Their project, Increasing Healthcare Choices and Improving Health Outcomes Among Persons with Serious Mental Illness, will compare the use and effectiveness of evidence-based practices to understand more about who chooses to use which integrated care services, with what short-term effects, and leading to what health outcomes. They will also identify barriers to and facilitators of access, service use, and improvements in person-centered outcomes. Connecticut Mental Health Center will collaborate with persons in recovery to develop and pilot a new peer-led, community-based intervention to enhance access and choice and improve person-centered health outcomes.
The report, A Window of Opportunity: Philanthropy's Role in Eliminating Health Disparities through Integrated Health Care, from Grantmakers In Health and the Hogg Foundation, presents recommendations on four key strategies - grantmaking, educating, convening, and advocating - that foundations can undertake as they work to improve the health status of the nation's most vulnerable populations.
Bring your health information technology (HIT) questions, comments, and issues to the new SAMHSA HIT Forum. The forum facilitates the exchange of ideas, suggestions, and personal experiences dealing with HIT for substance abuse treatment providers, mental health providers, software publishers, state agencies, consumers, families, and others involved in the field.
The North American Quitline Consortium promotes evidence based tobacco cessation programs and services across diverse communities in North America. Get more information about free quit line services available in your area by visiting their quitline map, including services offered, hours of operation, patient referrals, and more.
The Integrated Delivery Systems Toolkit captures ideas and expertise from states working to advance integration and payment reform. The toolkit was developed by the National Academy for State Health Policy, with the support of the Kaiser Permanente Community Benefit.
NIMH announced a funding opportunity for Improving Health and Reducing Premature Mortality in People with Severe Mental Illness to support research to test the effectiveness of services interventions that specifically target adults with serious mental illnesses and aim to reduce the prevalence and magnitude of common modifiable health risk factors that contribute to premature mortality. This opportunity is also intended to support research for children and youth with serious emotional disturbances (SED). The Letter of Intent is due by October 7, 2013 and the application is due by November 7, 2013.
AHRQ developed free Spanish-language resources (Toma las riendas: (Take the reins)) to help Latinos compare the benefits and risks of treatment options and prepare to discuss these options with their health care providers.
Ten peer-reviewed articles on reducing tobacco disparities among Asian American, Native Hawaiian, and Pacific Islander communities appear in a special supplement of the journal Heath Promotion Practice. The Society for Public Health Education (SOPHE) and Asian Pacific Partners for Empowerment, Advocacy and Leadership (APPEAL) compiled the articles, which cover tobacco research, culturally tailored interventions, policy, and the impact of the tobacco industry on tobacco use in these populations.
A new report from Columbia University’s School of Social Work discusses the importance of training both behavioral health and medical staff on the psychosocial and pharmacological interventions for substance use disorders.
Looking for information on integrated care in Health centers, trauma-informed care, and federal initiatives, but didn’t get the change to attend one of our recent webinars live? Access the recordings and browse our webinar history to see what you missed!
On September 19, two health centers, Tillamook in Oregon and Manet in Massachusetts, shared their lessons learned in establishing integrated care, including leadership, partnership development, business strategies, and program sustainability. Their approaches are applicable to a variety of safety-net providers trying to incorporate behavioral health services into their agency. View the recording.
Our August webinar on trauma-informed care featured the work of HRSA-funded safety-net providers in addressing trauma and working with clients who have experienced adverse life experiences. View the recording.