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Session # C4a October 18, 2014. Behavioral Health Integration: A Key Step towards the Triple Aim. Mara Laderman, MSPH Senior Research Associate Institute for Healthcare Improvement Benjamin Miller, PsyD Director of Health Policy University of Colorado - Denver. - PowerPoint PPT Presentation
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Behavioral Health Integration: A Key Step towards the Triple
AimMara Laderman, MSPH
Senior Research AssociateInstitute for Healthcare Improvement
Benjamin Miller, PsyDDirector of Health Policy
University of Colorado - Denver
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session # C4aOctober 18, 2014
Faculty Disclosure
• We have not had any relevant financial relationships during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Learn about the Triple Aim benefits of primary care-behavioral health integration.
• Use analyses of health plan and outcomes data to make the case for integration at their organization.
• Describe IHI's approach to behavioral health integration.
Bibliography / Reference1. IHI 90-Day R&D Project Final Summary Report: Integrating Behavioral Health and
Primary Care. Cambridge, MA: Institute for Healthcare Improvement; March 2014.
2. Laderman M, Mate K. Integrating Behavioral Health into Primary Care. Healthcare Executive. 2014 Mar/Apr;29(2):74-77.
3. Academy for Integrating Behavioral Health and Primary Care, Agency for Healthcare Research and Quality (AHRQ). Lexicon for Behavioral Health and Primary Care Integration. Available at: http://integrationacademy.ahrq.gov/lexicon
4. Mental Health, Substance Abuse and Health Behavior Services in Patient-Centered Medical Homes. Kessler, R., Miller, B.F., Kelly, M., Graham, D. Kennedy, A., Littenberg, B., Maclean, C., van Eeghen, Scholle, S., Tirodkar, M., Morton, S., & Pace, W. The Journal of the American Board of Family Medicine, 27(5), 637-644.
5. The Working Party Group on Integrated Behavioral Healthcare, Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., Epperly, T., Green, L., Henley, D., Kessler, R., Korsen, N., McDaniel, S., Miller, B., Pugno, P, Roberts, R., Schirmer, J., Seymour, D., & deGruy, F. (2014). Joint Principles: Integration Behavioral Health Care into the Patient-Centered Medical Home. The Annals of Family Medicine, 12(2), 183-185.
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
Today’s Agenda
Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)
Today’s Agenda
Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)
Definition 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. This care may
address mental health, substance abuse conditions, health
behaviors (including their contribution to chronic medical illnesses),
life stressors and crises, stress-related physical symptoms,
ineffective patterns of health care utilization.
Value of Integration:
Physical/Behavioral Integration is good health policy and good
for health.
Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.
No such thing as a single disease 9
In service to
Improving outcomes
Decreasing cost
Enhancing the patient experience
11
Drucker’s Big Seven (for innovative opportunity)
The unexpected success, failure or outside eventThe incongruity – between reality as it actually is and reality as it is assumed to beInnovation based on process needChanges in industry or market structure Demographics Changes in perception, mood and meaning New knowledge – scientific and nonscientific
Those who say it can’t be done are usually interrupted by others doing itJames Baldwin
Today’s Agenda
Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)
Our Mission:To improve health and health care worldwide
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IHI’s Work: Five Key Areas16
Triple Aim for Populations17
Our Goal:
Drive the Triple Aim, simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities.
Proven Methodology: Science of Improvement
W. Edwards Deming1900-1993
API’s Model for Improvement
Today’s Agenda
Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)
What drives IHI’s interest in integration?
Poor outcomes and high costs for patients with medical + behavioral comorbidities.
Getting to the Triple Aim will require addressing behavioral health!
Changing incentives will facilitate this.
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Research Project Aims
Understand the core principles underlying successful approaches to integration of behavioral health services into primary care.
Develop IHI’s approach to integration.
Identify how IHI can support organizations to integrate behavioral health and primary care.
21
Research MethodsReviewed peer-reviewed and grey literature and materials from existing models.
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Name Organization
Gary Belkin NYC HHC / NYU
Benjamin Miller University of Colorado – Denver
Mary Rainwater Integration Consultant, formerly with IBHP
Laurie Alexander Integration Consultant, formerly with AIMS Center
Alexander Blount UMass Medical Center, Center for Integrated Care
Parinda Khatri Cherokee Health Systems
Jurgen Unutzer IMPACT / AIMS Center, University of Washington
Brenda Reiss-Brennan Intermountain Health Care
Robin Henderson St. Charles Health System
Russell Phillips Harvard Medical School, Center for Primary Care
Ileana Welte Big White Wall
Brady Cole U.S. Department of Veteran’s Affairs
Key Research Findings
Perception is that there are many different ways to implement integration; we found that the commonalities are much greater than the differences.– Collaborative care principles; strong evidence base.
Five-step sequence to integrate BH
Biggest challenges are business case and operationalizing components into workflows.
Improvement approach is currently lacking.
Lack of integration outside of clinic visit.
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Innovation: Full Spectrum IntegrationLayer of Service Frequency of
InteractionWhere service is provided
Who provides service
1 – Acute Care Continuous (during hospitalization)
Hospital Physician Cost
2 –Clinic Care Quarterly Clinic PCP; behavioral health provider. Could include group visits
3 – Community Care Weekly; more than once a week initially
Home, workplace, community organization
Community health workers; mobile clinics. Could include group visits
4 – Family Engagement in Care
Daily Home Family members
5 – Self-care Daily Home Patients
6 - Policy and Financial Considerations
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Which states and why?Variability in financial environment between states to support behavioral health integration.
Some states may be more interested than others due to: Medicaid waivers, Medicaid BH carve out, Medicaid expansion / expected growth in Medicaid population, # of ACOs & pushes for global payments.
We compiled a list of states with favorable markets for integration.
Favorable States: AZ, AR, CA,CO, IL, KY, MD, MI, NV, NJ, NM, OH, OR, and VT.
25
Today’s Agenda
Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)
Five Step Sequence
1. Assess readiness for integration.
2. Develop reliable operations and processes to support integrated care.
3. Develop the business case for integration.
4. Re-design care delivery using collaborative care principles for integration.
5. Operationalize changes into clinical workflows.
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1. Assess readiness for integration
Assess readiness based on:– Patient needs– Clinic characteristics– Policy & financial environment– Existing data & measurement system
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1. Assess Readiness
2. Develop Reliable Operations and Processes to Support Integrated Care
Leadership and culture
Access and workflows– Technology considerations– Workforce: recruitment, hiring, onboarding,
and oversight of staff– Workflows– Seamless information sharing &
communication
Tracking patients and using data– Continuous quality improvement and
outcomes monitoring
Space and supplies to support BH care
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1. Assess Readiness
2. Processes to Support Integration
3. The Business Case for Integration
Fee-for-service workarounds
Negotiate case rates with payers
Consider global funding strategies and blended payment systems
Identify federal and state incentives to support integrated care
Train staff to optimize use of existing revenue sources to provide cost efficient, medically necessary care.
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1. Assess Readiness
2. Processes to Support Integration
3. Make the Business Case
4. Re-design Care Delivery Using Collaborative Care Principles
Develop interdisciplinary care team
Promote self-care support and family engagement
Treatment to target
Stepped care
Systematic caseload review, consultation & referral
Adoption of evidence-based guidelines
BH providers support healthy behavior change in addition to screening, diagnosis, and treatment for BH conditions
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1. Assess Readiness
2. Processes to Support Integration
3. Make the Business Case
4. Redesign Care Delivery
5. Operationalize Changes in Clinical Workflows
Fully implement operational infrastructure
Sample change ideas to operationalize collaborative care principles:– Interdisciplinary care team proactively
manages a panel and chronic health conditions and participates in care planning
– Coordinate care inside and outside of org. including tracking referrals
Technological solutions when BH providers are not available in person
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1. Assess Readiness
2. Processes to Support Integration
3. Make the Business Case
4. Redesign Care Delivery
5. Operationalize Changes in Workflows
Today’s Agenda
Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)
Where IHI can add value
Focus on how to make specific changes and on addressing operational and organizational issues that need to be in place to facilitate implementation of integrated care.
Bring improvement science to integration.
Sense-making across different models.
Focus on leaders and systems.
Measurement of system-level integration outcomes.
New Collaborative Program
Optimize Primary Care Teams to Meet Patients’ Medical AND Behavioral Needs– Partnering with the MacColl Center for Health Care
Innovation – Launches in February, 2015
http://www.ihi.org/Engage/collaboratives/OptimizePrimaryCareTeamstoMeetPatientsMedicalANDBehavioralNeeds/Pages/default.aspx
Areas for future innovation work
Integration in high-risk specialty clinics.
Scaling to communities, regions, states and solving related structural challenges.
Costs (and ROI) of integration, alternative payment methods, and financial models.
Behavioral health providers performing other functions on the care team, such as supporting behavior change for patients with chronic disease.
Building out other layers of full spectrum integration.
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Today’s Agenda
Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)
Behavioral Health Integration Capacity Assessment Tool (BHICA)
Resource for organizations to assess their readiness to integrate behavioral health and primary care.
Consider potential approaches to integration;Understand the current infrastructure to support greater integration;Assess the organization’s strengths and challenges in undertaking different approaches to integration; Set and prioritize goals for integration efforts.
https://www.resourcesforintegratedcare.com/tool/bhica
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Five Sections of BHICA
1. Understanding Your Population
2. Assessing Your Infrastructure
3. Identifying the Population and Matching Care
4. Assessing the Optimal Integration Approach for Your Organization
5. Financing Integration
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Evaluation Framework Linked to Organization Processes, Impact, and Resources
Questions?41
Session Evaluation
Please complete and return theevaluation form to the classroom
monitor before leaving this session.
Thank you!