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Integrating Behavioral & Physical Health: Building “Whole Person” Health

Presented by:Peter Currie, PH.D

Senior Director of Clinical Transformation & Integration

Inland Empire Health Plan

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IEHP Membership

2015

1,100,000

2009

400,000

2016

1,300,000(Projected)

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Carve Out Of Behavioral Health: Unintended Consequences

County Behavioral

Health

Drug Medi-Cal

Health Plan

Regional Center CCS

Why IEHP Integrated BH:

Physical Health and Behavioral Health (BH) care were Separate and Disconnected

Outpatient Mental Health Services Under Utilized & Substance Abuse Treatment was Nil

IEHP had no influence over the BH Network Coordination of Care – PCPs describe referring into the “Black

Hole” High Cost of BH Administrative Services:

50% of BH dollars reached the MBHO’s Providers (2009)Context – 95% of Tax Payer Dollars

paid to IEHP reach IEHP Medical Providers

The BH Integration Plan

Fully Integrated BH Program – “In House” Streamline the coordination of physical and mental

health benefitsRedirect MBHO Admin/Profit (50%)to fund Expanded

BH ServicesDirectly Contracted BH Network – Identify and

Support Best PracticesEliminate Reliance on Vendors (MBHOs) for all BH

Expertise including NCQA Compliance

BH Integration within the Health Plan: Results in the First Two Years

Increased access to BH services – Cost Neutral to Plan Medical Cost-Offsets for high-risk/high-cost populations Improve coordination of physical & behavioral healthcare

through Web: Access to Health Record for BH Providers & BH Treatment Reports through IEHP Portal for PCPs

IEHP’s Directly Contracted BH network - Private Sector, FQHCs, County Mental Health & CBOs

Met 100% of NCQA requirements for BH in 2012 & 2015

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BH Integration within the Health Plan: Foundation for Practice Transformation

PCP

PsychiatristCounty Mental Health

Intensive Outpatient Program

Member

Therapist

1-800 Number

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Identifying the Complex Target Population by Adding a BH Lens

Riverside County Specialty Mental Health Mortality Study (Jan 2007- May 2010)

RCDMH41.8 years

Natural Causes46.8 years

Unnatural/Unexpected38.8 years

US AverageLife Expectancy

77.7 years

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Lessons from Riverside County Co-Location Pilot

• Patients arrive to health care providers “fully integrated” with physical and BH needs intertwined

• Health care providers in the IE operate mostly in silos which limits their impact on overall health status

• Blaine Street County Mental Health and Rubidoux Public Health Clinic bi-directional Co-location pilot Learning People seek care where they are welcomed and

comfortable Rather than refer out to the “black hole” bring the

missing/needed care to where the population is getting care

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Chronic health condition + SMI condition = high costs

Medi-Cal FFS No SMI

Medi-Cal FFS SMI

Medi-Cal FFS Enrollees 1,413,654 166,786 11% SMI % of TotalMedi-Cal FFS Costs $3,790,393,322 $2,395,938,298 39% SMI % of TotalMedi-Cal FFS Cost/Enrollee $2,681 $14,365 5.4 SMI/Non-Ratio

Diabetes 3.2% 11.0% 3.5 SMI/Total-RatioIschemic Heart Disease 1.5% 6.0% 3.9Cerebrovascular Disease 0.8% 3.0% 3.9Chronic Respiratory Disease 4.1% 13.0% 3.2Arthritis 1.4% 7.0% 5.0Health Failure 0.8% 3.0% 3.9

Inpatient Episodes/1,000 77 293 3.8 SMI/Total-RatioER Visits/1,000 239 1,167 4.9Inpatient Acute Days/1,000 434 2,094 4.8Primary CareVisits/1,000 85 492 5.8Specialist Visits/1,000 639 6,058 9.5

California Fee for Service Medi-Cal Analysis - 2007

Metric

Data from JEN Associates, Cambridge, MA

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Health Care10%

Environment 19%

Human Bi-ology20%

Lifestyle51%

Traditional Health Care is NOT the Primary Determinate of Health Status

Schroeder, NEJM 357; 12

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Social Determinants: Drivers of Population Health and Patient Experience

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Pressure on Health Plans to Integrate Physical & Behavioral Health

• Download of BH Benefits into the Health Plans January 1, 2014 Medicaid Expansion of Mental Health April 1, 2014 Dual Eligible Pilot September 15, 2014 EPSDT Benefit for Autism

• State Direction & Lessons from IEHP’s recent CMS Audit Expectation that Health Plans have a Care Plan for members

that includes BH provider Treatment Plans Expectation that BH providers participate in Interdisciplinary

Care Teams

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Strategy for Change

Develop an array of Health Homes that are tailored to support practice transformation and:

“Integrated care” Integrated care “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 and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”(Safety Net Medical Home Initiative, 2014)

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IEHP Strategy: BH Integration as Platform for Population Healthcare

Primary Care

FQHCSUD

Specialty Clinic Long Term Care Facility

Whole health care that is person-centered, cost effective, and results in

improved health and wellness

BHI-I Themes: Patient/Provider

Experience Team Based Care Care CoordinationSelf-Management Population Health

Shared Areas of Improvement: Access to Care

Integration of Care Coordinated Care

Plan of Action Site Based Planning

CIN/PTI Themes: Electronic Health

Record ConversionPatient

Management Complex Care Management

Disease Management

BHI-I and CIN/PTI Shared Areas of Improvement

PROVIDE FUNDING FOR INFRASTRUCTURE DEVELOPMENT

IEHP invests $20,000,000 over 2 years in 13 health care orgs

a) Build individual health homes tailored to their target population AND ALSO

b) Work collectively to improve the Inland Empire local health care system

SUPPORT PRACTICE TRANSFORMATION WITH COACHING

JCC Coaching Team Practice Improvement Areasa) Improve

patient and provider team experience

b) Provide team-based care and treat-to-target

c) Coordinate care

d) Manage population health

e) Promote self-management

SUPPORT CULTURE CHANGE FROM VOLUME TO VALUE WITH QI FRAMEWORK

The Behavioral Health Integration Initiative (BHI-I) Approach

BHI-I Aim:

Improve the whole

health and

wellness of all

individuals in the Inland

Empire by creating an array

of population-based, integrated health homes

©2015 Jen Clancy Consulting Team. Copying and distribution permitted with citation to JCC Team

BHI-I Coaching Principles1. “Bottom-Up” Approach to Building Population-Specific

Health Homes2. Relationship Based and Accessible to Ensure

Accountability3. Promote Learning and Improvement4. Use of Qualitative and Quantitative Data5. Peer to Peer & Health System to Health System

Relationship Building

Inland Empire’s Thirteen (13) BHI-I Pilot Health Care Learning Organizations

1. Riverside University Health System2. Riverside County Department of Ambulatory

Care3. Riverside County Department of Behavioral

Health4. Borrego Community Health5. Desert Clinic Pain Institute6. My Family Inc. Recovery Center7. Arrowhead Regional Medical Center Family

Medicine Clinics8. San Bernardino County Public Health9. San Bernardino County Behavioral Health10.Social Action Community Health System

Clinic11.Orchid Court, Inc.12.San Bernardino Adult Day Healthcare Center13.Telecare Corporation

Key BHI-I Goals1. Improve access to primary care and behavioral health

providers for adults and pediatric patients, and meet NCQA practice standards.

2. Health and wellness is tracked (using appropriate clinical measurement tools and data) to continuously increase the effectiveness of the treatment team to improve the health status of the target population.

3. Increase whole health screening & systematic follow ups to positive screens

4. Increase the percentage of individuals with self-selected “Total Health and Wellness Goals” that are shared between key providers

5. Improve medication reconciliation6. Improve patients & provider team’s experience of care7. Reduce avoidable emergency room utilization8. Reduce inappropriate hospital admissions9. Reduce 30 day hospital readmissions rate

©2015 Jen Clancy Consulting Team. Copying and distribution permitted with citation to JCC Team)

Behavioral Health Integration:Platform for Population Healthcare

Build & Support Health Home Array with “BH Inside”Supporting Provider Partners who are already integrating

care to build out & refine what they have already begunLinking best integration practices to achieve shared care

plans that live and breath and reflect the whole person Support New Trans Disciplinary Treatment Models for

Complex Populations:E.g. Combining Pain Management, Mental Health and Substance Abuse (SUD) to create a new Pain/Narcotic Misuse Treatment Center

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Why Behavioral Health Homes ?

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All Healthcare is Local

Emerging Designs

Fully Integrated Systems of Care that Align Service

Delivery, Management Structures and Financing

for Medical Care and Behavioral Health

Services in Support of Full Clinical Integration

Historical Designs

Managed Care Organizations (MCOs)

for Health Care of TANF

Fee for Service Health Care Services for Aged,

Blind, Disabled

Mental Health Carve-Out

Fee for Service Drug & Alcohol

Emerging Designs

Managed Care Organizations (MCOs)

for all Health Care

Behavioral Health Carve-Out

Clinical Integration Activities

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Achieving the Triple Aim by Integrating the Social and Behavioral Determinants of Health into Health

Care Payment and Delivery Systems