Why, What and How of Why, What and How of Contracting with Federally Contracting with Federally Qualified Health CentersQualified Health Centers

October 24, 2007October 24, 2007Marta McKenzie, R.D., M.P.H.Marta McKenzie, R.D., M.P.H.

Shasta County Health and Human Services Agency Shasta County Health and Human Services Agency DirectorDirector

Mark Montgomery, Psy.D.Mark Montgomery, Psy.D.

Shasta County Mental Health/Drug and Alcohol Shasta County Mental Health/Drug and Alcohol Services DirectorServices Director

Why Contract with Why Contract with FQHC’sFQHC’s

National landmark reports published in National landmark reports published in the last 10 years recommend the last 10 years recommend integrated/coordinated models of careintegrated/coordinated models of care

President’s New Freedom Commission, 2003President’s New Freedom Commission, 2003 IOM: Improving the Quality of Health Care IOM: Improving the Quality of Health Care

for Mental and Substance-Use Conditions, for Mental and Substance-Use Conditions, 20062006

The Surgeon General’s report on Mental The Surgeon General’s report on Mental Health, 1999Health, 1999

SAMSA: Transforming Mental Health Care in SAMSA: Transforming Mental Health Care in America, 2006America, 2006

The President’s New Freedom The President’s New Freedom Commission Report on Mental Commission Report on Mental

Health, 2003Health, 2003

Collaborative MH/Physical healthcare Collaborative MH/Physical healthcare helps bridge gaps in MH carehelps bridge gaps in MH care

Effective MH treatment strategies can Effective MH treatment strategies can be effectively delivered in primary care be effectively delivered in primary care settings settings

Embraces the fundamental Embraces the fundamental “understanding that mental health is “understanding that mental health is essential to overall health”essential to overall health”

Institute of Medicine: Institute of Medicine: Improving the Quality of Health Improving the Quality of Health Care for Mental and Substance-Care for Mental and Substance-

Use Conditions, 2006Use Conditions, 2006

Care Coordination is paramount for Care Coordination is paramount for better mental, substance abuse and better mental, substance abuse and general healthgeneral health

Entirety of Chapter 5 is devoted to Entirety of Chapter 5 is devoted to the subject of care integrationthe subject of care integration

Mental Health: A Report of Mental Health: A Report of the Surgeon General, 1999the Surgeon General, 1999

Integrated care facilitates entry into Integrated care facilitates entry into care and reduces fragmentationcare and reduces fragmentation

Emphasizes that mind and body are Emphasizes that mind and body are inseparableinseparable

Transforming Mental Health Care Transforming Mental Health Care in Americain America

Substance Abuse and Mental Health Substance Abuse and Mental Health

Services Administration, May 2006Services Administration, May 2006

Create Interlocking Systems of CareCreate Interlocking Systems of Care

Advance efforts to integrate mental Advance efforts to integrate mental health and primary care deliveryhealth and primary care delivery

The recently released report on mortality The recently released report on mortality demonstrated that mentally ill persons demonstrated that mentally ill persons have a 25 year shorter life span than the have a 25 year shorter life span than the general population – largely due to general population – largely due to untreated or poorly treated chronic untreated or poorly treated chronic diseasesdiseases

““People with serious mental illness treated by the public People with serious mental illness treated by the public mental health system die on the average 25 years earlier mental health system die on the average 25 years earlier than the general population. They live to 51, on average, than the general population. They live to 51, on average, compared with 76 for Americans overall.  According to compared with 76 for Americans overall.  According to the data, they are 3.4 times more likely to die of heart the data, they are 3.4 times more likely to die of heart disease; 6.6 times more likely to die of pneumonia and disease; 6.6 times more likely to die of pneumonia and influenza; and 5 times more likely to die of other influenza; and 5 times more likely to die of other respiratory ailments.”respiratory ailments.”

-C. Colton “Mortality: Health Status of the Served Population,-C. Colton “Mortality: Health Status of the Served Population, Sixteen State Pilot Study on Mental Health Performance Sixteen State Pilot Study on Mental Health Performance

Measures”,Measures”, based on 1997-2000 databased on 1997-2000 data

Other Why’sOther Why’s

FQHC’s mission is aligned with FQHC’s mission is aligned with providing services to uninsured and providing services to uninsured and underserved populationsunderserved populations

FQHC’s have an uncapped capacity to FQHC’s have an uncapped capacity to billbill Medi-cal on a cost based Medi-cal on a cost based reimbursement basis for behavioral reimbursement basis for behavioral health serviceshealth services

County Partnerships with FQHC’s have County Partnerships with FQHC’s have existed over time on a variety of issues existed over time on a variety of issues

FQHC’s often exist in hard to reach FQHC’s often exist in hard to reach and/or rural areas that are more difficult and/or rural areas that are more difficult for mental health departments to servefor mental health departments to serve

Reduces stigma as MH services are Reduces stigma as MH services are provided as part of routine medical careprovided as part of routine medical care

Reduces complexities of privacy and Reduces complexities of privacy and confidentiality as care is delivered as confidentiality as care is delivered as part of a “treatment team” within an part of a “treatment team” within an FQHCFQHC

Other Why’sOther Why’s

Opportunity to enhance services in Opportunity to enhance services in existing organizationsexisting organizations

Care coordination between behavioral Care coordination between behavioral health providers and primary care health providers and primary care providers can occur easier within the providers can occur easier within the same FQHC infrastructuresame FQHC infrastructure

Supports primary care physician skill Supports primary care physician skill development and comfort in treating MH development and comfort in treating MH conditions, and offers more tools to conditions, and offers more tools to confront issues complicating the delivery confront issues complicating the delivery or compliance with medical care or compliance with medical care

Other Why’sOther Why’s

ChallengesChallenges

Primary care clinics are typically Primary care clinics are typically ‘medical model’ oriented‘medical model’ oriented

Behavioral health care may be ‘out of Behavioral health care may be ‘out of comfort zone’ for many comfort zone’ for many medical/primary care practitionersmedical/primary care practitioners

Support of psychiatrists is necessary Support of psychiatrists is necessary either through telemedicine, direct either through telemedicine, direct employment or consultative capacity employment or consultative capacity to primary care physiciansto primary care physicians

Model of Care – Model of Care – Shasta County MH/FQHCShasta County MH/FQHC

Contracting for: Contracting for:

Full Service Partnerships Care Full Service Partnerships Care

Rural Outreach and AccessRural Outreach and Access

Why this model?Why this model?

Improved client access to care Improved client access to care Recognizes the client’s identified ‘Medical Recognizes the client’s identified ‘Medical

Home’Home’ Mental Health Services ActMental Health Services Act

Introduced more flexible fundingIntroduced more flexible funding Philosophy of TreatmentPhilosophy of Treatment

‘‘Whatever it takes’ Whatever it takes’ ‘‘No Wrong Door’ No Wrong Door’ Integrated ServicesIntegrated Services

Menu of Services (Geographically Friendly)Menu of Services (Geographically Friendly)

Contracting Group – Contracting Group – Clinic Associations or Clinic Associations or

Individual ClinicsIndividual Clinics

Current agreement is with a single Current agreement is with a single FQHC clinicFQHC clinic

Hill Country Community ClinicHill Country Community Clinic

Working on agreements with other Working on agreements with other FQHC partners FQHC partners

Discussing the potential for a Clinic Discussing the potential for a Clinic Association agreementAssociation agreement

Which Clinics Were Chosen Which Clinics Were Chosen and Why?and Why?

MHSA plan identified unmet needs in the rural MHSA plan identified unmet needs in the rural areas of the County areas of the County

FQHC partners cover most of the unmet need FQHC partners cover most of the unmet need areasareas

One FQHC serves both urban and rural areas so One FQHC serves both urban and rural areas so we have amended our CSS plan to more broadly we have amended our CSS plan to more broadly reflect FQHC partnerships throughout the Countyreflect FQHC partnerships throughout the County

Capacity to deliver ‘whatever it takes’ FSP servicesCapacity to deliver ‘whatever it takes’ FSP services

Capacity to measure outcomesCapacity to measure outcomes

How long did it take to get How long did it take to get from vision to signed from vision to signed

agreements? agreements?

MHSA CSS plan approval 7/1/06 MHSA CSS plan approval 7/1/06 with Rural expansion componentwith Rural expansion component

Plan anticipated out stationed case Plan anticipated out stationed case manager staff and psychiatric manager staff and psychiatric support through telemedicine support through telemedicine

Challenges during Year One Challenges during Year One

MHSA implementation MHSA implementation County lost psychiatrists and County lost psychiatrists and

many/most of the FQHC’s had many/most of the FQHC’s had existing telemedicine relationships existing telemedicine relationships that they could continue that they could continue

Out stationed County case managers Out stationed County case managers had a difficult balancing act between had a difficult balancing act between significantly different delivery significantly different delivery systems and expectationssystems and expectations

Once we understood that the FQHC’s Once we understood that the FQHC’s were willing/interested in the direct were willing/interested in the direct employment of MH full service staff, employment of MH full service staff, it was a matter of figuring out a basis it was a matter of figuring out a basis to pay, and ensuring that we had to pay, and ensuring that we had state DMH/DHS conceptual approvalsstate DMH/DHS conceptual approvals

FQHC Cost Report DevelopmentFQHC Cost Report Development

Output Expectations for MH staff in an FQHC Output Expectations for MH staff in an FQHC environment environment

Legal Review – CPCA attorney and County Legal Review – CPCA attorney and County CounselCounsel

BOS Approval 6/26/07BOS Approval 6/26/07

From agreements to From agreements to actual actual

provision of servicesprovision of services

Work in progressWork in progress

How does the agreement How does the agreement work? work?

FQHC developed a cost report for FQHC developed a cost report for the new servicesthe new services

Cost Report nets anticipated Cost Report nets anticipated revenues from third party payersrevenues from third party payers

County pays the differenceCounty pays the difference Includes outreach and engagement Includes outreach and engagement

for under- or unserved personsfor under- or unserved persons Includes FSP’sIncludes FSP’s

Who’s responsible for Who’s responsible for what?what?

Primary CarePrimary Care Delivering “what ever it takes” Services Delivering “what ever it takes” Services Demonstrating Outcomes & Collecting Demonstrating Outcomes & Collecting

Data on FSP’sData on FSP’s County Mental HealthCounty Mental Health

Monitoring ContractsMonitoring Contracts Measuring Outcomes & Reporting Data Measuring Outcomes & Reporting Data

on FSP’son FSP’s

Thank you for your Thank you for your questions and comments questions and comments

Marta McKenzie, R.D., M.P.H.Marta McKenzie, R.D., M.P.H.Shasta County Health and Human Services Agency Shasta County Health and Human Services Agency

DirectorDirectormmckenzie@co.shasta.ca.usmmckenzie@co.shasta.ca.us

Mark Montgomery, Psy.D.Mark Montgomery, Psy.D.Shasta County Mental Health/Drug and Alcohol Shasta County Mental Health/Drug and Alcohol

Services DirectorServices Directormmontgomery@co.shasta.ca.usmmontgomery@co.shasta.ca.us