Integrated Health Care Models and Practices

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1 Integrated Health Care Models and Practices The Greater Houston Behav io r al Health Affordable Care Act Initiative S e c o n d C o m m u n i t y E d u c a t i o n E v e n t I n t e g r a t e d H e a l t h C a r e : F r o m C o n c e p t t o P r a c t i c e O c t o b e r 1 7, A l e j a n d r a P o s a d a, M. E d. D i r e c t o r o f E d u c a t i o n a n d T r a i n i n g M e n t a l H e a l t h A m e r i c a o f G r e a t e r H o u s t o n Definitions/Lexicon Primary Care The provision of services by clinicians who are accountable for addressing a large majority of personal health care needs.* Behavioral Health Care An umbrella term for care that addresses any behavioral problems bearing on health, including mental health and substance abuse conditions, stress-linked physical symptoms, patient activation, and health behaviors.* Physical/Medical Within the context of this presentation, these terms will be used to refer to care that is not behavioral health care (although behavioral health care also has physical/medical components). Patient/Client Within the context of this presentation, these terms will be used interchangeably to refer to the recipients of health care. *Definitions from Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: AHRQ Publication No. 13- IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality Available at 1

2 What IS integrated health care? The systematic coordination of physical and behavioral health care Connecting Body and Mind: A Resource Guide to Integrated Health Care in Texas and the United States. Hogg Foundation for Mental Health Available at The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: AHRQ Publication No. 13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality Available at Why Integrated Health Care? 2

3 Why Integrated Health Care? The majority of people seeking care for behavioral health issues seek it in primary care settings but these issues often go undetected and/or untreated in primary care. Although most individuals served in behavioral health settings have physical/medical conditions, over half of those conditions go undetected and/or untreated. Source: Connecting Body and Mind: A Resource Guide to Integrated Health Care in Texas and the United States. Hogg Foundation for Mental Health High Rates of Comorbidity Individuals with physical/medical conditions have higher rates of behavioral health conditions, and vice versa. For example, a study analyzing insurance claims over six years found that individuals with bipolar disorder were significantly more likely to have co-morbid physical health conditions up to three or more chronic conditions (41% vs. 12%).* For example, among individuals with chronic illness:** Heart Disease 20% rate of depression for outpatients with coronary heart disease; 33% for patients with congestive heart failure; 40 to 65% for patients with coronary heart disease and a history of myocardial infarction Diabetes 25% rate of depression Cancer 15 to 25% rate of depression for cancer patients; 50% of patients with terminal or advanced cancer suffer from a mental health issue Respiratory Diseases 20% prevalence rate of major depression and/or anxiety for individuals with asthma and chronic obstructive pulmonary disease General Population 6.7% rate of depression *Source: C.P. Carney et al., 2006, as cited in Partners in Health Interagency Toolkit. Integrated Behavioral Health Project. 2 nd edition, Available at **Source: Mental Health and Chronic Physical Illness: The Need for Continued and Integrated Care. World Federation of Mental Health Available at 3

4 Depression is the most common complication of almost all chronic or serious medical conditions. Source : Mental Health and Chronic Physical Illness: The Need for Continued and Integrated Care. World Federation of Mental Health Page 6. The Consequences For individuals with serious mental illness (SMI): Individuals with serious mental illness receiving services through the public mental health system die an average of 25 years earlier than the general population. In Texas, the discrepancy is even higher 28 to 29 years. Approximately 60% of premature deaths for individuals with SMI are due to physical health conditions. Schizophrenia, bipolar disorder, and major depressive disorder have all been shown to increase the likelihood of death due to a physical health condition by as much as 2 or 3 times as compared to the general population. Source: Mauer, B. Morbidity and mortality in people with serious mental illness. October Available at 4

5 The Consequences Effects of untreated behavioral health issues for individuals with chronic illness: Of course, a negative impact on the person s emotional health Decreased ability to cope with an illness, manage it, and take part in treatment and recovery Decreased energy to manage illness Poorer self-care Depression may contribute to behaviors that adversely affect health for example, smoking, excessive alcohol consumption, lack of exercise, poor diet, and lack of social support Poorer physical outcomes Increased medical costs Higher mortality rates a vicious cycle of worsening physical and emotional symptoms * Sources: Mental Health and Chronic Physical Illness: The Need for Continued and Integrated Care. World Federation of Mental Health (*p. 6) Connecting Body and Mind: A Resource Guide to Integrated Health Care in Texas and the United States. Hogg Foundation for Mental Health Integrated Health Care: A New Model of Care 5

6 Traditional Model of Care Silos of Care : Primary Care Psychiatry Clinical Social Work, Psychology, Therapy Substance Abuse Services Social Services Models of Integrated Health Care Primary Care bidirectional integration Behavioral Health Care 6

7 Spectrum of Integrated Health Care: Source: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March Available at A Few Variations/Considerations One agency vs. a partnership between/among agencies Behavioral health services Mental health? Substance abuse? Both? Psychiatry On staff? Contracted? Tele-psychiatry? Consulting psychiatrist available to PCP? Care manager or care coordinator who serves as the glue in connecting the team? Additional integrated components based on particular needs/circumstances of clientele, e.g.: Case management Peer support services Family support services Social services 7

8 The Chocolate Cake Metaphor Key Elements No Matter the Model Team-based approach to care Communication at all levels Coordinated, collaborative care Providers physically at the same location Access to shared patient records Understanding of each other s roles and disciplinary cultures Screening, evidence-based clinical practices Patient experience of seamless care ( one stop shop ) 8

9 Making It Happen: Planning and Implementing IHC Barriers to Integrated Health Care Clinical Barriers Organizational Barriers Policy Barriers Financial Barriers Workforce Issues Workforce Shortages Training 9

10 Facilitators for Successful IHC Leaders, champions, and point persons (e.g., care manager) Buy-in and participation from staff across the organizations Organizational culture; IHC as part of the culture of the organizations Shared mission and culture of partnering agencies Community perspective (including philosophy about funding) Intentional planning Relationship-building Communication and coordination among providers Workforce development/appropriate training Shared electronic health records (EHRs) Technology (e.g., EHR, telemedicine, patient portals) Continual learning Evaluation feedback loop, shared learning IHC and the Affordable Care Act The ACA emphasizes and incentivizes integrated health care. Health homes States can establish a Medicaid plan option for individuals with chronic conditions to receive care in a health home (defined in Section 2703 of ACA) Medicare and Medicaid Innovation Center Responsible for testing and expanding models such as health homes Accountable Care Organizations (ACOs) Large groups of providers collaborating to improve care and reduce costs; ACA establishes voluntary program for ACOs to be piloted through Medicare Co-location of primary and behavioral health services Funding for co-location of physical health care in behavioral health settings Community-based Collaborative Care Network Program Supports consortia of providers in integrating care for uninsured/underinsured populations Workforce development Support for relevant training programs 10

11 Medical Homes vs. Health Homes Serve all populations Medical Homes Typically defined as physician-led primary care practices, but also mid-level practitioners and health centers In existence for multiple payers (e.g., Medicaid, commercial insurance) Focus on the delivery of traditional medical care (referral and lab tracking, guideline adherence, electronic prescribing, provider-patient communication) Use of IT for traditional care delivery Health Homes* Serve individuals with approved chronic conditions May include primary care practices, community mental health centers, federally qualified health centers, health home agencies, etc. Medicaid-only construct Strong focus on whole health (including substance abuse, mental health, and primary care), social support, other services (nutrition, home health, coordinating activities) Use of IT for coordination across continuum of care, including in-home (e.g., wireless monitoring) *As defined in Section 2703 of the Affordable Care Act Source: What is a Health Home? SAMHSA-HRSA Center for Integrated Health Solutions. Available at Recap - Benefits of Integrated Health Care Increased access to care Higher quality, comprehensive care Better health outcomes physical and behavioral Greater patient satisfaction Decrease in stigma associated with behavioral health care Cost savings More efficient, cost-effective care Societal cost savings due to increased productivity 11

12 Final Thoughts Integrated health care MAKES SENSE. Although CHALLENGES do exist, with COMMITMENT and DEDICATION, it presents exciting OPPORTUNITIES to BENEFIT people and communities. Questions? For More Information: Alejandra Posada, M.Ed. Director of Education and Training Mental Health America of Greater Houston