Integrating Behavioral Health into the Patient Centered Medical Home: The Massachusetts Experience

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1 Integrating Behavioral Health into the Patient Centered Medical Home: The Massachusetts Experience Megan E. Burns, MPP Judith L. Steinberg, MD, MPH Michael H. Bailit, MBA F. Alexander Blount, EdD

2 Disclosures It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. The following individual(s) in a position to control content relevant to this activity have disclosed the following relevant financial relationships: Alexander Blount, EdD, Integrated Primary Care Inc. owner, consulting practice. Megan Burns, MPP, spouse is employed by a technology firm that creates robotic applications and software solutions for health care. Judith Steinberg, MD, MPH and Michael Bailit, MBA have no relevant financial relationships to disclose. 2

3 Objectives Describe at least three elements of behavioral health care integration. Describe at least three challenges to integrating behavioral health care into the primary care practice. Discuss one strategy for assessing the level of behavioral health integration within a Patient-Centered Medical Home. Describe three strategies for improving the level of behavioral health integration within a Patient-Centered Medical Home. 3

4 Agenda Behavioral Health Integration and the PCMH Primary Care Transformation in MA Supporting Behavioral Health Integration in the PCMH Addressing Barriers Lessons Learned 4

5 Behavioral Health Integration Goal: Optimized access and engagement in coordinated care to achieve improved health outcomes, reduced costs Behavioral health focus in primary care: Screening Behavioral health skills Care coordination and information sharing Care management Community resources 5

6 I. Access and Continuity Access during and after office hours Electronic access Continuity Patient/ Family Partnership Cultural/linguistic appropriate services Practice organization (team based care) II. Identify/Manage Patient Populations Electronic basic and clinical searchable data Behavioral Health Focus Comprehensive health assessment Use data for population management III. Plan and Manage Care Guidelines for important conditions Care management Medication management Electronic prescribing 2011 NCQA Standards Optimized Access and Engagement Behavioral Health Focus Care Management IV. Self Management Support Self care process Self-care plan & monitoring tools Behavioral Health Skills V. Track and Coordinate Care Test & referral tracking/follow-up Care transitions Referrals to community resources Care Coordination Community Resources VI. Performance Measurement & QI Performance measurement Prevention, chronic disease, overuse, utilization measures Stratified for vulnerable pops. Patient/Family feedback Quality improvement Patient/family involvement in QI Improvement in health disparities Electronic reporting of performance measures To consumers, health plans, public 6

7 Primary Care Transformation in MA SNMHI Safety Net Medical Home Initiative CHIPRA Creating Pediatric Medical Homes in MA Initiative MA PCMHI MA Patient-Centered Medical Home Initiative Early Childhood Medical Home MYCHILD, LAUNCH Initiatives Primary Care Payment Reform 7

8 MA Patient-Centered Medical Home Initiative Statewide multi-payer initiative Sponsor: MA Health and Human Services Partners: UMass Medical School, Bailit Health Purchasing 46 participating practices 3 year demonstration; start March, 2011 Vision: All MA primary care practices will be PCMHs by

9 Primary Care Payment Reform (PCPR) Scaling up: Eligible providers- all Medicaid Primary Care Clinician Plan providers Clinical Model: PCMH with behavioral health integration RFP to be released January,

10 Payment Reform MA PCMHI Fee for service Start-up infrastructure payments Prospective Payments Medical Home activities Clinical care management Shared savings Primary Care Payment Reform Initiative* Risk-adjusted capitation: Outpatient Primary care Outpatient behavioral health Three shared-savings / shared-risk tracks available Quality performance is part of payment *Details of payment model are not finalized as of

11 Practice Redesign: Core Competencies Patient/family centeredness Team based care Planned visits & follow-up care Registry use for population and patient management Care coordination Care management for high risk patients Self management support Patient and family education Shared decision making, patient action plans Evidence based care Integration of QI Enhanced access Integration of behavioral health and primary care 11

12 Supporting Behavioral Health Integration in the PCMH Learning Collaboratives Discounted access to select resources within UMass Center for Integrated Care Medical Home Facilitators Delineated elements of care integration and are providing strategies to achieve each element of integration

13 Behavioral Health Integration: Approaches and Elements Relationship and Communication Practices Patient Care and Population Impact Non-Colocated Co-located Co-located & Fully Integrated Clinic System Integration Community Integration Approaches Care Management 13

14 Integration Elements Relationship & Communication Practices Patient Care and Population Impact Community Integration Care Management Clinic System Integration Triaged access BH screening and referral Self help referral connections Coordination of integrated treatment plan Schedule accessibility Smooth hand-offs BH skills used by primary care team Specialty mental health & substance use referral Use of behavioral health skills Leaders & staff committed to integrated care Team membership Integrated clinical pathways Community resources connections Use of community resources Health information exchange Program leadership Health care team leader Process integration Sharing expertise Family focused care Same day access 14

15 Practice Self-Assessment Goals: Establish practice baseline and track progress of integration over time Highlight common gaps in integration to help drive curriculum and technical assistance Methodology: Administered through SurveyMonkey Ideally completed by the primary care team in conjunction with the behavioral health providers Results: 96% response rate

16 Relationship and Communication Domain Strengths: Sharing expertise 88% of respondents report that PCPs are comfortable requesting advice from behavioral health providers Areas for Improvement: Triaged access at emergent, urgent and routine times Smooth hand-offs Training activities Program leadership Team membership 16

17 Relationship and Communication Domain 84% of respondents struggle to incorporate smooth hand-offs into care 17

18 Patient Care and Population Impact Domain Strengths: Routine screening of pediatrics Care team members trained in BH techniques Supporting health behavior change Areas for Improvement: Routine screening for adults Use of evidence-based interventions 18

19 Patient Care and Population Impact Domain 70% of practices screen for depression and alcohol but most do not screen routinely 40% 35% 30% 25% 20% 15% 10% 5% 0% Patients are routinely screened prior to or during annual physical exams with a standardized tool for both depression and alcohol 16% 35% 35% Rarely/Never Sometimes Routinely 19

20 Strengths: Care Manager Domain Awareness of community resources: 90% of respondents report that clinical care managers are aware of BH focused community resources and refer to them at least sometimes Areas for Improvement: Coordination of integrated treatment plan Use of behavioral health skills 20

21 Care Manager Domain Most respondents do not have effectively coordinated integrated treatment plans 21

22 Community Integration Domain Strengths: Community group and resources connections Connections with BH specialists Areas for Improvement: Routine self-help referral connections Routine community group and resource connections Peer or patient participation within the practice Offering of group behavioral health education programs 22

23 60% 50% 40% 30% 20% 10% 0% Most respondents reported some self-help referrals 30% Community Integration Domain The practice has available and regularly uses referral information for self-help groups, and offers books, pamphlets and websites that foster patient self-help 54% 16% Rarely/Never Sometimes Routinely *Foundational 23

24 Clinic System Integration Domain Areas for Improvement: Schedule accessibility Program staffing Chart note integration Process integration Same-day access for BH Open or coordinated scheduling 24

25 60% 50% 40% 30% 20% 10% 0% Clinic System Integration Domain Most respondents reported not being able to schedule a BH visit at the time of a primary care visit *Foundational The practice can facilitate the scheduling of a BH visit for a patient at the time of a patient visit. 26% 49% 26% Rarely/Never Sometimes Routinely 25

26 Behavioral Health Action Toolkit 26

27 Addressing Barriers Barriers: Payment & Regulatory, Real & Perceived Multi-stakeholder review of regulatory barriers CHC/stakeholder summit Department of Public Health planned approach to waiving regulation Medicaid review of payment barriers Planned multi-stakeholder taskforce on barriers to behavioral health integration 27

28 Lessons Learned It s difficult to play catch-up when behavioral health is not included at the start of an initiative. Behavioral health integration is not a separate topic: Integration is meant to be seamless Engaged leadership is required for successful transformation Care management and care coordination are key elements of PCMH and integrated care Change is hard!

29 Bailit Health Purchasing, LLC Acknowledgements UMass Medical School, Center for Health Policy and Research Mountainview Consulting Dr. Alexander Blount Members of the MA PCMHI Behavioral Health Integration Workgroup Members of the MassHealth Primary Care Payment Reform Clinical Workgroup 29

30 Megan E. Burns, MPP Judith L. Steinberg, MD, MPH Michael H. Bailit, MBA F. Alexander Blount, EdD 30