Austin Travis County Integral Care (ATCIC) Title of Project: Unique RHP Project Identification Number: Performing Provider Name/TPI: Project Option:

Transcription

1 Austin Travis County Integral Care (ATCIC) Title of Project: Integrated School-Based Behavioral Health and Primary Care Services Unique RHP Project Identification Number: Performing Provider Name/TPI: Austin Travis County Integral Care/ Project Option: Design, implement, and evaluate projects that provide integrated primary and behavioral health care services. Brief Provider Description: Since 1966, Austin Travis County Integral Care (ATCIC) has served as the local mental health authority for Travis County. ATCIC is Joint Commission accredited and the only dedicated outpatient specialty behavioral health provider in Austin that serves children with a serious emotional disturbance (SED). ATCIC served over 2,600 children and their families in FY 2012 with behavioral health services. Description of the Intervention(s): The goal of this project is to increase access and capacity by establishing and providing Level 4 integrated outpatient primary care and behavioral health services on public school campuses to provide students with the right care at the right setting. Need for the project: The regional (RHP-7) CNA revealed that almost 71 percent of Travis County patients with a mental health diagnosis also experienced a co-occurring medical condition. An additional 20 percent had a substance abuse disorder, including 13 percent who had tri-morbid conditions (mental health, substance use disorder and medical condition). The experience of children who are accessing and establishing a primary care medical home in traditional clinic systems may present a barrier to care. Students in Del Valle Independent School District (DVISD), Manor Independent School District (MISD) and Pflugerville Independent School District (PISD) must often travel great distances to receive services. Since the majority does not have the ability to transport themselves, they must depend on their caregiver to transport them in an environment with poor public transportation infrastructures. Navigating these services is daunting for both the patient and/or primary care provider due to complex clinical presentations, the medications regimen and functional/behavioral impairments. To ensure that these children receive the right care, this integrated Level 4 healthcare delivery strategy has been selected. Target population: The target population for Level 4 integrated primary care and behavioral health services are children enrolled in Del Valle ISD, Manor ISD and Pflugerville ISD who have unmet behavioral health and primary care service needs that prevents them from achieving their full academic learning potential and maintaining a healthy lifestyle. ATCIC contracts with the Texas Department of State Health Services to provide specialty behavioral health services for children/youth with SED who are below 200 percent of the Federal Poverty Level. Currently, 92 percent of children served by ATCIC have Medicaid (80%), CHIP or are low income uninsured. This same percentage of Medicaid patients will apply to this project. All other individuals served and not covered by Medicaid, CHIP or private insurance, are funded by state general revenue funds received from the Texas Department of State Health Services. It is anticipated that during DY3, approximately 60 unduplicated child patients will be served, 250 during DY4 and 338 during DY5. 1

2 Category 1 or 2 (expected patient benefits and description of QPI metric): Process milestone/metric P-6/P-6.1 and P-10/P-10.1, and improvement milestone/metric 1-8/1-8.1 (QPI) were selected as they are consistent with RHP-7 s Strategic Plan goals of: 1. Transform health care delivery to create high quality, cost-effective, person-centered care for vulnerable people in Travis County, and 2. Improve the health of the Travis County population into the future by expanding the number of providers, increasing and improving health care facilities, implementing technology, and serving in a coordinating capacity for the transformation of regional health care delivery. These goals will be achieved through this project consistent with goals identified by Region 7 partners to include investing in patient-centered, integrated, comprehensive care that is coordinated across systems and reduces health care costs by expanding opportunities for patients and families to access the most appropriate care in the most appropriate setting. Since this project is establishing new integrated school-based service sites, baselines will have to be established for the milestones and metrics to measure the Quantifiable Patient Impact for this project option Number of unique individuals receiving integrated physical and behavioral health care services. It is anticipated that during DY3, approximately 60 unduplicated child patients will be served, 250 during DY4 and 338 during DY5. Description of the Category 3 measure(s) selected: This project includes a Category 3 improvement target consisting of one standalone measure for this project: OD-11 Behavioral Health/Substance Abuse Care, Behavioral Health Quality of Life, Activity of Daily Living, and Functional Status Assessments, (NEW) IT e - CANS Children and Adolescent Needs and Strengths Assessment (CANS-MH). The CANS-MH is an evidence-based reliable and valid multi-purpose assessment instrument developed to support care planning and level of care decision-making, to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services. CANS-MH is designed to be used either as a prospective assessment tool for decision support during the process of planning services or as a retrospective assessment tool based on the review of existing information for use in the design of high quality systems of services. This flexibility allows for a variety of innovative applications. The RHP-7 CNA reveals that 21% of school age children experience some form of mental illness and the percentage of overweight and obese students within this same population range from 19% to 48%. Goals of RHP-7 include: increasing the focus on healthy lifestyles and disease prevention for children and adolescents with health risk factors such as obesity, and the integration of primary care and behavioral health care to address children s mental health and medical co-morbidity. The CANS-MH captures primary care and behavioral health care data for assessing and measuring the physical and mental health status of children over time, especially with respect with the integrated interventions provided by caregivers. The CANS-MH will demonstrate measureable improvements with respect to the child s physical health and mental health condition while in services. 2

3 Title of Project: Integrated School-Based Behavioral Health and Primary Care Services Project Identification Number: Performing Provider Name/TPI: Austin Travis County Integral Care/ Project Option: Design, implements, and evaluates projects that provide integrated primary and behavioral health care services. Project Description: This project addresses the need to increase access and the capacity of integrated behavioral health and primary care services for school-aged children with unmet primary care and behavioral health needs, especially children with a co-morbid medical condition and a Serious Emotional Disturbance (SED) ( This will be done by establishing new Level 4 (Close Collaboration in a Partly Integrated System) integrated behavioral health and primary care services on school campuses. A fundamental component of this clinic is the integration of primary care services for children with an SED, to be done in close collaboration with a locally federally qualified clinic, Lone Star Circle of Care (LSCC). In collaboration with school officials the project will establish campus-based, integrated care services in three (3) non-urban, rural school districts in Travis County, i.e., Del Valle Independent School District (DVISD), Manor Independent School District (MISD), and Pflugerville Independent School District (PISD). These school systems have submitted partnership letters of collaboration to ATCIC on this project. Project Goals: This project will increase access to integrated outpatient primary care and behavioral health services on public school campuses. This will facilitate timely appointments, improved continuity of care, reduce crisis and ultimately decrease use of costly alternatives such as out of home placements, psychiatric emergency services, hospital emergency departments and the criminal (juvenile) justice system. Challenges or Issues Faced by the Performing Provider: 1. A challenge in establishing these services in the schools will be to educate school staff regarding cues for mental health challenges and symptomology. 2. Timely recruitment of psychiatric providers is a second. Availability of child psychiatric and primary care providers is a challenge in our community. 3. A third challenge will be recruiting bilingual staff fluent in Spanish and who understand the diverse cultural needs of the students and their families. 4. A final challenge is the school district having the infrastructure to accommodate integrated behavioral health and primary care services on the campus. How the Project Addresses those Challenges: 1. Training forums and educational opportunities will be developed for school staff, coordinated and provided with school personnel and the community to achieve the goal of having an informed and engaged campus staff. 2. ATCIC will address the provider recruitment challenge by partnering with an external provider to establish tele-psychiatric services. This will help with access and flexibility. 3

4 3. ATCIC and LSCC will recruit therapists, MDs, etc. first within RHP 7 and if need be throughout Texas. Every effort will be made to recruit individuals from Del Valle, Manor and Pflugerville who culturally and linguistically represent the students and their families. 4. ATCIC will enter into formal written agreements with the local school districts to facilitate adequate space, data sharing and related facility needs. 3-year Expected Outcome(s) for Performing Provider and Patients: Access to integrated mental health and primary care services on school campus will result in improved school attendance, reduced classroom removals, positive impact on student learning, reduced student referrals to juvenile probation system, and reduced student referrals to crisis services or hospitalization. How the Project is Related to RHP Goals: Consistent with RHP Region 7 s vision: Good health is achievable for all people in the Region 7, specifically, the project aligns, as follows: In response to Goal 2, this project creates and expands opportunities for children and their families to access integrated behavioral health and primary care in appropriate settings (e.g., schools) resulting in reduced health system costs. In response to Goal 6 this project offers children real-time access to integrated behavioral health and primary care, and ensures timely, effective, evidence-based interventions and treatment options. Starting Point/Baseline: Baseline Data - These integrated Level 4 services will be new services provided in the targeted schools within the school districts. The baseline for these school-based integrated primary care and behavioral health care services will be zero. Time Period for Baseline - The information collected to identify the Baseline Data will be from DY3. Quantifiable Patient Impact: Number of Unique Individuals receiving integrated physical and behavioral health care: DY3-60, unduplicated children and youth will be served, 80% Medicaid and 12% Low Income Uninsured; DY4-250 unduplicated children and youth will be served, 80% Medicaid and 12% Low Income Uninsured; and DY5-338 unduplicated children and youth will be served, 80% Medicaid and 12% Low Income Uninsured. Rationale: Reason for Selection of Project Option - This project addresses several community needs identified in RHP 7: CN.1, CN.4, CN.5, CN.6, CN.7, CN.15 and CN.16 The regional (RHP-7) CNA revealed that almost 71 percent of Travis County patients with a mental health diagnosis also experienced a co-occurring medical condition. An additional 20 percent had a substance abuse disorder, including 13 percent who had tri-morbid conditions (mental health, substance use disorder and medical condition). The experience of children who are attempting to access and establish a primary care medical home in traditional clinic systems may be presented with a barrier to integrated care. Navigating these services is daunting for both patient and/or primary care provider due to complex clinical presentations, the medications regimen and functional/behavioral impairments. To ensure that these children receive the right care, this integrated Level 4 healthcare delivery strategy has been selected. 4

5 Treatment and support needs for children with SEDs or unmet behavioral health needs become increasingly complex in the presence of co-morbid medical conditions and other co-morbid conditions such as mental health and substance use. According to a 2008 study featured by the National Institute of Health, at least half of children with anxiety disorders had a comorbid physical illness. In addition, a recent study ( 2010), found that 22.1 percent of youths aged 12 to 17 (379,000 youths) with substance dependence or abuse in the past year also had past year Major Depressive Episode (MDE). The prevalence of past year MDE among youths with past year substance dependence was 25.0 percent (211,000 youths). Also, youths aged 12 to 17 with MDE in the past year were more likely than those without MDE to have a substance use disorder in the past year (19.9 vs. 6.1 percent). The above circumstances result in missed school days, which correlates directly with poor academic outcomes and higher Body Mass Index (BMI) among children (Source: Attendance Reasons Study Presentation , 2013 E 3 Alliance analysis data). Students in PISD, DVISD and MISD must often travel great distances to receive services. Access limitations result in no shows and/or preventable delays for psychiatric evaluations, medical interventions and for treatment for children with an SED. Since the majority of these children do not have the ability to transport themselves, they must depend on their caregiver to transport them in an environment with poor public transportation infrastructures. Additionally, since most families cannot afford child care, most travel with the entire family to the appointment. These are all barriers to timely service delivery. Reason for Selection of Milestones & Metrics - Process milestone/metric P-6/P-6.1 and P- 10/P-10.1, and improvement milestone/metric 1-8/1-8.1 (QPI) were selected as they are consistent with RHP-7 s Strategic Plan goals of: 1. Transform health care delivery to create high quality, cost-effective, person-centered care for vulnerable people in Travis County, and 2. Improve the health of the Travis County population into the future by expanding the number of providers, increasing and improving health care facilities, implementing technology, and serving in a coordinating capacity for the transformation of regional health care delivery. These goals will be achieved through this project consistent with goals identified by Region 7 partners to include investing in patient-centered, integrated, comprehensive care that is coordinated across systems and reduces health care costs by expanding opportunities for patients and families to access the most appropriate care in the most appropriate setting. How the project represents a new initiative for the Performing Provider or significantly enhances an existing delivery system reform initiative - This proposed DSRIP project represents a new initiative for ATCIC as the Performing Provider. Although ATCIC delivers Behavioral Health care in schools and integrated Behavioral Health and Primary Care in clinic settings, it does not yet deliver integrated Behavioral Health and Primary Care in school settings. Related Activities Funded by U.S. Dept. of Health and Human Services (DHHS). Currently, none. Project Core Components: a) Identify sites for integrated care projects, which would have the potential to benefit a significant a number of patients in the community. ATCIC will establish new, school-based services in three (3) non-urban, rural school 5

6 districts in Travis County: Del Valle ISD, Manor ISD and Pflugerville ISD, which have no specialty Level 4 integrated behavioral health and primary care outpatient services readily available. b) Develop provider agreements whereby co scheduling and information sharing between physical health and behavioral health providers could be facilitated. ATCIC and its primary care partner, Lone Star Circle of Care, have a long history of providing integrated services. Formal provider agreements will be developed. c) Establish protocols and processes for communication, data sharing, and referral between behavioral and physical health providers. Protocols will be established to ensure that providers have mechanisms for sharing data, referrals and to ensure seamless continuity of care. d) Recruit a number of specialty providers (physical health, mental health, substance abuse, etc.), to provide services in the specified locations. ACTIC will recruit behavioral health providers for these new school-based Level 4 integrated services. Lone Star Circle of Care will recruit, employ and train the primary care team. e) Train physical and behavioral health providers in protocols, effective communication and team approach. Build a shared culture of treatment to include specific protocols and methods of information sharing that include: 1) Regular consultative meetings between physical health and behavioral health practitioners. All behavioral health and medical providers, nursing staff and medical assistants will participate in joint staffing meetings and be fully integrated into school-based clinic functions, meetings and protocols. 2) Case conferences on an individualized as needed basis to discuss individuals served by both types of practitioners. Providers will share in bullpen type office that will facilitate interactions. Also, establishing the practice of warm handoffs will be an expectation from the outset. 3) Shared treatment plans co developed by both physical health and behavioral health practitioners. Work is underway to develop a portal through which providers will share appropriate EHR data to ensure continuity of care. f) Acquire data reporting, communication and collection tools (equipment) to be used in the integrated setting, which may include an integrated Electronic health record system or participation in a health information exchange depending on the size and scope of the local project. A health information exchange is being actively explored by our community. ATCIC is very interested in being an active participant in this effort as it develops. g) Explore the need for and develop any necessary legal agreements that may be needed in a collaborative practice. ATCIC, as the Local Mental Health Authority for Travis County and LSCC, a Federally Qualified Health Clinic (FQHC) are establishing legal agreements between our two agencies to provide medical services. In addition, ATCIC, Austin Child Guidance Center (ACGC) and the University of Texas, School of Educational Psychology (UT), are developing agreements for the provision of psychological services. h) Arrange for utilities and building services for these settings. Individual school campuses in each of the school districts have been identified as sites by school administrators where services will be provided. i) Develop and implement data collection and reporting mechanisms and standards to track the utilization of integrated services as well as the health care outcomes of individual treated in these integrated service settings. ATCIC and LSCC are working together to develop a system to track and share individual patient outcomes, to aggregate services data and to contract performance measures to ensure the quality of services. j) Conduct quality improvement for project using methods such as rapid cycle improvement. Continuous Quality Improvement (CQI), using Plan, Do, Study and Act (PDSA) activities will focus on rapid cycle process improvements to ensure quality clinical care and clinic processes. Customizable Process or Improvement Milestone: N/A 6

7 Related Category 3 Outcome Measure(s): Category 3 Outcome Measures(s) Selected - This project includes a Category 3 improvement target consisting of one standalone measure for this project: OD-11 Behavioral Health/Substance Abuse Care, Behavioral Health Quality of Life, Activity of Daily Living, and Functional Status Assessments, (NEW) IT e - CANS Children and Adolescent Needs and Strengths Assessment (CANS-MH) 1. Reasons/Rationale for Selecting the Outcome Measure(s) - The CANS-MH is an evidencebased multi-purpose assessment instrument developed to support care planning and level of care decision-making, to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services. CANS-MH is designed to be used either as a prospective assessment tool for decision support during the process of planning services or as a retrospective assessment tool based on the review of existing information for use in the design of high quality systems of services. RHP- 7 CNA reveals that 21% of school age children experience some form of mental illness and the percentage of overweight and obese students within this same population range from 19% to 48%. Goals of RHP-7 include: increasing the focus on healthy lifestyles and disease prevention for children and adolescents with health risk factors such as obesity, and the integration of primary care and behavioral health care to address children s mental health and medical co-morbidity. The CANS-MH captures primary care and behavioral health care data for assessing and measuring the physical and mental health status of children over time, especially with respect with the integrated interventions provided by caregivers. The CANS-MH will demonstrate measureable improvements with respect to the child s physical health and mental health condition. Relationship to Other RHP Projects (including Other Performing Providers Projects in the RHP): How Project Supports, Reinforces, Enables Other Projects - ATCIC is providing Integrated Primary and Behavioral Health Care Services (RHP Project ID Number ), increasing access and capacity to specialty behavioral health services by establishing a new outpatient clinic in south-southeast Austin (Dove Springs), located in proximity to several targeted DVISD schools targeted for this proposed project. Students residing in the DVISD will have access to this clinic s more expansive array of services and resources not available through the integrated project. Through another waiver project, ATCIC has also implemented its Mobile Crisis Outreach Team (MCOT) Expansion (RHP Project ID Number ); at key intercept points, including schools in all three (3) school districts proposed on this project, to provide specialty behavioral health crisis intervention services, in collaboration with the DVISD School Resource Officers (SROs). This project will respond to psychiatric crises involving students at the school campus and will support the coordinated work of this proposed integrated school project. List of Other Category 2 Providers in RHP 7 with Similar Projects: Two other similar projects in RHP 7, Youth Counseling for Fayette and Lee Counties (RHP Project ID No.: ), and School Campus Counseling (RHP Project ID No.: ) provide behavioral health services in schools but these services do not a primary care component. We will coordinate with these two school projects on lessons learned and collaboration opportunities. 1 Substance Abuse and Mental Health Services Administration. (2011). Identifying mental health and substance use problems of children and adolescents: A guide for child-serving organizations (HHS Publication No. SMA ). Rockville, MD: Author. 7

8 List of Related Category 1 & 2 Projects: (RHP Project ID Number) Integrated Primary and Behavioral Health Care Services; and Mobile Crisis Outreach Team Expansion. Plan for Learning Collaborative: Plan for Participating in RHP-wide Learning Collaborative for Similar Projects -Region-wide, anchor-led meetings will be held at least two times annually and will offer an opportunity to share, listen, and learn what providers have encountered while implementing their DSRIP projects. Central Health, as RHP 7 s anchor, will foster the development of topical learning communities that will bring together all levels of stakeholders who are involved in DSRIP projects. This multipronged approach will facilitate continuous improvement of regional projects and transform the healthcare delivery system. Currently, RHP 7 learning collaborative work will be focused around the single regional goal to increase patient engagement. Aims will provide specific guidance on the population to be served, the desired improvement, and the time frame in which this improvement is anticipated. Project Valuation: Approach and Rationale for Valuing Project -The approach to valuing this Waiver project considered three primary factors: factors related to an improved patient experience, the benefit to our community, and costs reduction to healthcare system. In considering the incentive portion of the valuation three principles and their subsequent impacts were considered. These the principles included: investments required to initiate the project, value associated with the services delivered for a period of time until outcomes/benefits could be demonstrated before receiving reimbursement, and incentives to the performing provider to accelerate transformation of the delivery system. Calculating the value of interventions for this project for a specialty behavioral health population used an economic evaluation model and extensive review of the literature conducted by H. Shelton Brown, Ph.D. at the University of Texas Houston School of Public Health and Thomas Bohman, Ph.D. at the University of Texas Austin Center for Social Work Research. This model employs a costs-utility analysis to measure program cost in dollars and the health consequences in utilityweighted units called quality-adjusted life-years (QALYs). The QALY index incorporates costs averted when known (e.g., emergency room visits that are avoided, cost per depression-free days, suicides prevented). The proposed program s value is based on a monetary value gained due to the intervention multiplied by number of participants. (Eichler, H. G., et al. (2004). "Use of costeffectiveness analysis in health-care resource allocation decision-making: how is cost-effectiveness thresholds expected to emerge?" Value Health 7(5): ; The QALY value results in significant and meaningful values related to behavioral health interventions. Children with a Serious Emotional Disturbance are often intensive users of the healthcare system and frequently present with a number of functional impairments for effective social functioning. Incremental improvements in their behavioral and physical health status have significant impact on the improvement of the person s experience, benefit to the community, and the reduction of costs to the healthcare delivery system. 8