Federally Qualified Health Federally Qualified Health Center Integration Efforts Center Integration Efforts

Michigan Institute for Prevention and Treatment EducationSeptember 16, 2013

Rebecca Cienki, Chief Operating Officer

Brittany Beard, Program Specialist

Michigan Primary Care Association

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Mission & VisionMission & VisionMPCA's mission is to promote,

support, and develop comprehensive, accessible, and

affordable community-based health care services to everyone

in Michigan.

MPCA vision is to build a healthy society in which all residents have convenient and affordable access to quality health care.

MPCA will be a leader in influencing health care policy, legislation, and regulation fostering comprehensive, community

governed, quality care that ensures excellent health and quality of life for all residents of

the United States.

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World Health OrganizationWorld Health Organization

Definition of Health:◦Health is a state of complete

physical, mental, and social well-being and not merely the absence of disease or infirmary

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Example Mission Example Mission StatementsStatements“…improves the health and

wellness of individuals by providing comprehensive primary and behavioral health care while encouraging access by those who are underserved”

“To improve the quality of life for our patients through the blending of primary care, behavioral health and prevention services.”

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Individuals w/ Substance Individuals w/ Substance Abuse Disorders have:Abuse Disorders have:

Nine times greater risk of congestive heart failure

Twelve times greater risk of liver cirrhosis

Twelve times the risk of developing pneumonia

54% of addiction treatment programs have 54% of addiction treatment programs have no physicianno physician

http://www.medscape.com/viewarticle/729401 5

Prevalence in Primary Prevalence in Primary CareCare20% of patients seen in family

practice have Substance Abuse Disorders

SUDs are currently ranked among the top 10 leading preventable risk factors for years of life lost to death and disability

2007, approx. 22.3 million adults were classified as having a substance dependence or abuse disorder

http://www.medscape.com/viewarticle/729401

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Outcomes from Outcomes from IntegrationIntegrationTwo or more primary care visits in a 6

month period has shown to improve abstinence during recovery from a SUD by 50%

Individuals with medical conditions related to substance abuse are three times more likely to achieve remission over 5 years

Regular health and addictions care for people with substance abuse disorders decreased hospitalizations by up to 30%

http://www.integration.samhsa.gov/clinical-practice/13_May_CIHS_Innovations.pdf 7

Mental Health & Substance Abuse Mental Health & Substance Abuse FTE in Michigan FQHCsFTE in Michigan FQHCs

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Mental Health & Substance Abuse Mental Health & Substance Abuse Visits per Provider Type in Michigan Visits per Provider Type in Michigan FQHCsFQHCs

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Number of Mental Health & Number of Mental Health & Substance Abuse Visits in Michigan Substance Abuse Visits in Michigan FQHCs*FQHCs*

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*2012 was the first year Health Centers were required to report for all diagnoses, not just primary. Dramatic increases more accurately reflect the population prevalence.

Number of Mental Health & Number of Mental Health & Substance Abuse Patients in Substance Abuse Patients in Michigan FQHCs*Michigan FQHCs*

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*2012 was the first year Health Centers were required to report for all diagnoses, not just primary. Dramatic increases more accurately reflect the population prevalence.

Prevalence of Behavioral Health Prevalence of Behavioral Health Conditions Among Medicaid Conditions Among Medicaid Expansion Population: Michigan, USExpansion Population: Michigan, US

Source: SAMHSA2008-2010 National Survey on Drug Use and Health2010 American Community Survey. 12

The National Institute of The National Institute of Mental Health Mental Health 2008

◦26.2% of Americans ages 18 and older suffer from a diagnosable mental disorder

◦57.7 million people½ of all lifetime cases begin by age

14¾ of all lifetime cases begin by age

2470% of primary care visits stem from

psychosocial issues

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Substance Abuse Disorders Substance Abuse Disorders (SAD)(SAD)20% of patients seen in family

practices have SADsRanked among the ten leading

preventable risk factors for years of life lost to death and disability

Diagnosed in only 9% of general and family practice visits and 8% of internal medicine visits

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John Hopkins HealthcareJohn Hopkins HealthcareDemonstrating a Return on Investment for

Integrated Substance Abuse Treatment and Medical Care Management

603 adult Medicaid enrollees, frequent use of medical services from past 12 month claims◦Received routine care

400 members placed in intervention group◦Management from substance abuse

coordinators◦Nurse care managers

http://www.chcs.org/publications3960/publications_show.htm?doc_id=633674

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John Hopkins HealthcareJohn Hopkins HealthcareResults

◦Within 12 months, savings of $122 per member per month

◦Decrease of 288 admissions per 1,000 members

◦Decrease in 92 days admitted per 1,000 members

◦Decrease by 45 days admitted per 1,000◦$3.65 return on investment for every $1

spent on interventionhttp://www.chcs.org/publications3960/publications_show.htm?doc_id=633674

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DefinitionDefinitionBehavioral health integration (BHI)

is defined as a partnership between primary care providers and mental health/substance abuse providers

This can be a partnership between organizations or a collaboration between providers within one organization

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Collaboration ContinuumCollaboration Continuum

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Type 1: Minimum Type 1: Minimum CollaborationCollaborationPrimary care providers and

behavioral health providers work in separate facilities, have separate systems, and communicate only sporadically

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Type 2: Basic Collaboration Type 2: Basic Collaboration at a Distanceat a DistancePrimary care and behavioral health

providers have separate systems at separate sites, but engage in periodic communication about shared patients, generally by telephone, letter or email

Communication is driven largely by specific patient issues

Primary care and behavioral health providers view each other as resources, but do not share responsibility over patients

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Type 3: Basic Collaboration Type 3: Basic Collaboration On-SiteOn-SiteBehavioral health professionals and

primary care providers have separate systems but share the same facility

Proximity allows for increased communication about shared patients, but each provider remains in his or her own professional culture

This model is primarily a referral-based process with providers working more closely and with improved communications

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Type 4: Close Collaboration Type 4: Close Collaboration in a Partly Integrated Systemin a Partly Integrated SystemBehavioral health professionals and

primary care providers share the same facility and have some systems in common, such as scheduling appointments or medical records

Physical proximity between providers allows for regular face-to-face communication and even coordinated treatment plans for difficult cases

There is a sense of being part of a larger team, yet the pragmatics are sometimes difficult

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Type 5: Close Collaboration Type 5: Close Collaboration approaching a Fully approaching a Fully Integrated SystemIntegrated SystemBehavioral health professionals and primary

care providers share the same facility, the same vision, and the same systems to provide unified behavioral and physical health services

The patient experiences the behavioral health treatment as part of his or her regular primary care

Primary care and behavioral health staff interact regularly and typically have an integrated medical record and single treatment plan

All professionals are committed to the idea of a team-based approach and understand each other’s roles and functions

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Type 6: Close Collaboration Type 6: Close Collaboration in a Fully Integrated Systemin a Fully Integrated SystemThe behavioral health provider and

primary care provider are part of the same team and have overcome the barriers and limits to traditional care and funding structures

Patient care is provided through a team-based approach involving joint assessment and treatment plans, with shared responsibilities for outcomes

Providers and patients view the system as cohesive and holistic

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Behavioral Health Mapping Behavioral Health Mapping Project GoalsProject GoalsSupport from MPCASupport from other organizationsEncourage organizational

partnershipsEncourage further development

of integration projectsTool for policy advocacy

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Michigan BHI ProjectMichigan BHI Project

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Benefits of Integrated Benefits of Integrated CareCarePatient’s health and well being becomes the

focus of careTeam-based care is associated with higher

patient satisfaction and better clinical outcomes

Greater opportunity for long-term management of chronic, complex illness

Higher likelihood of adherence to treatment plans

Greater opportunity for prevention and early intervention

Provides more holistic care Increases access to carePrevents duplication of servicesDecreases stigma

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Challenges CitedChallenges Cited

Developing relationshipsIncreasing understandingDifficulty recruitingCommunicating electronically

and sharing health informationSustainability of fundingCross-training of staff

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Common Barriers/Changes Common Barriers/Changes Made by Centers Integrating Made by Centers Integrating ServicesServicesCulture Change

◦Language◦Mannerisms◦Expectations about patient visit◦Length of visit

One Mission/One VisionPhysical Layout of CenterMultidisciplinary Care Team

MeetingsAddress readiness to changeReimbursement/SBIRT codes

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Michigan Health Center Michigan Health Center Behavioral Health SurveyBehavioral Health SurveyWinter 2000, MPCA commissioned a study,

Addressing Patient’s Behavioral Health Needs in Michigan’s Community Health Centers

Results:◦ 1 of 2 patients have behavioral or emotional

problems◦ 1 of 3 patients have depression as a primary or

secondary diagnosis◦ 1 of 5 patients are currently receiving services

from mental health professionals◦ Communication is poor between primary care

and behavioral health professionals32

Outcomes from Outcomes from Integrating CareIntegrating CareOn average 35% of patients

receive physical healthcare at SUD clinics

Those that do, experience:◦Greater Abstinence◦Returning Twice as Often for

Outpatient Visits◦Lower Mortality Rate

http://archinte.jamanetwork.com/article.aspx?articleid=646882#WHYSUBOPTIMALLINKAGE?

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FQHCs Licensed as FQHCs Licensed as Substance Abuse ProvidersSubstance Abuse Providers Baldwin Family Health Care

◦ On-site counseling◦ State licensed substance abuse services◦ JCAHO accredited programs◦ On-site MSW’s◦ Certified addictions counselors on-site

Cherry Street Health Services◦ On-site Mental health and addiction counseling◦ Case Management◦ Outpatient counseling, residential treatment,

transitional &re-entry services Sterling Area Health Center

◦ Psychiatry◦ Substance abuse treatment/counseling and

prevention

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Screening, Brief Intervention, Screening, Brief Intervention, Referral, and TreatmentReferral, and TreatmentNon-confrontational, short health

counseling technique

Not a quick fix treatment

Motivating an individual to do something about an existing substance abuse problem

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Screening, Brief Intervention, Screening, Brief Intervention, Referral, and TreatmentReferral, and TreatmentWhy SBIRT is a critical Prevention

Strategy?

◦U.S. Preventive Services Task Force recommends screening and brief interventions

◦Similar to preventive screenings for chronic diseases

◦Covered by insurers with no deductible or co-pays

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SBIRT Billing Codes ChartSBIRT Billing Codes Chart

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MPCA’s Legislative PriorityMPCA’s Legislative PriorityPromote the Integration of Health

Care Service with Commensurate Funding◦Successful Integration:

Enhanced access to services Improved quality of care Lowered health care expenditures

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Promoting IntegrationPromoting IntegrationRecommended Action for

Michigan◦Explore evidence-based integrated

delivery care models◦Create incentives for system change

Payment reform Funding for shared efficiencies

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Promoting IntegrationPromoting Integration Policies to Pursue◦ Medicaid payment for Patient-Centered Medical Home

designation beyond the Michigan Primary Care Transformation Demonstration (MIPCT)

◦ Medicaid participation in the Centers for Medicare and Medicaid Services (CMS) Health Home Initiative (Section 2703 of the Affordable Care Act)

◦ Medicaid payment for non-traditional service providers including Certified Peer Support Specialists, Health Coaches, and Health Navigators

◦ Medicaid reimbursement delivered in the form of bundled payment to facilitate the provision of team-based care, inclusive of care coordination and transition across different levels of the health care system

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Recommended ActionsRecommended Actions “Turn on” codes essential to integrating behavioral

health services◦ 96110 – Developmental screening, with interpretation and report, per

standardized instrument form◦ 96150 – Health Behavior Assessment; 15 minutes (initial assessment)◦ 96151 – Health Behavior Assessment; 15 minutes (reassessment)◦ 96152 – Health Behavior Assessment; 15 minutes (individual)◦ 96153 - Health Behavior Assessment; 15 minutes (2 or more patients)◦ 96154 – Health and Behavior Assessment; 15 minutes (family with patient)◦ 96155 – Health and Behavior Assessment; 15 minutes (family without patient)◦ 90839 – Psychotherapy for crisis, first 60 minutes◦ 90840 – Psychotherapy for crisis◦ 99406 – Smoking cessation◦ 99407 – Smoking cessation◦ 99238 – Hospital discharge day management; 30 minutes or less◦ 99239 – Hospital discharge day management; more than 30 minutes◦ 99408 – Alcohol and/or substance (other than tobacco) abuse structured

screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

◦ 99409 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes

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Recommended ActionsRecommended ActionsInclude additional mental health

providers in the CHAMPS system; including licensed social workers and psychologists, recognizing their important role in an integrated health delivery system and providing a waiver of substance abuse certification/credentialing for all incensed behavioral health professionals.

This expanded workforce is necessary to meet the needs of the expanding Medicaid population

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Recommended ActionsRecommended ActionsEliminate the limit of 20

behavioral health visits per year restriction, recognizing that chronic conditions, both behavioral and physical, require monitoring and consistent care and may not be treated properly within 20 visits.

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Recommended ActionsRecommended ActionsAllow for reimbursable screening for mental

health and substance abuse conditions in the primary care setting to identify patients getting care on in the primary care setting.

These screens are reimbursable through the codes (also listed above):◦ 96150 – Health Behavior Assessment; 15 minutes (initial assessment

◦ 99408 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes

◦ 99409 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes

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Additional ResourcesAdditional ResourcesMichigan Primary Care Association

Website – mpca.net ◦Clinical Services & Quality> Behavioral

Health> Behavioral Health Integration Resources Presentations from MPCA’s Statewide Conference Operational Resources Sample Behavioral Health Position Descriptions Clinical Resources Financial Resources Archived Webinars Tools and Templates

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Questions?Questions?For further information, please contact:

Brittany BeardProgram SpecialistMichigan Primary Care Association517.827.0477bbeard@mpca.net

Rebecca Cienki, MPHChief Operating OfficerMichigan Primary Care Association517.827.0474rcienki@mpca.net

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