Category Archives: behavioral health primary care integration

Challenges to Integrating Behavioral Health and Primary Care Services Revisited

One year ago a poll was published in the LinkedIn group, Behavioral Health Integration:

What is the greatest challenge for integrating behavioral health and primary care services?

The poll generated a tremendous amount of interest, both in voting on the poll and in comments. Much has happened in the healthcare industry in the past twelve months, changes that have an impact on the way behavioral health and primary care will be delivered in the future.

The greatest impact has come from the Patient Protection and Affordable Care Act (ACA) that was upheld by the Supreme Court of the United States on June 28, 2012. Though passed in 2010, the flurry of activity toward implementing began after the Supreme Court ruling. As states prepare for the 2014 implementation of the new health laws, more and more are agreeing to participation in the Medicaid Health Home plan.

Poll Results

As we near the end of the first quarter 2013, time is running out quickly for implementation. With integrated care playing a crucial role in health reform, the challenges for integrating healthcare services are more and more apparent. Revisiting the below results of the poll conducted one year ago, one has to wonder whether the perceived challenges remain the same among healthcare providers.

Poll results from LinkedIn group, Behavioral Health Integration 3/5/2012 - 3/5/2013

Poll results from LinkedIn group, Behavioral Health Integration
3/5/2012 – 3/5/2013

Finance and Billing

Poll responses indicated that sustainability issues related to finance and billing were the greatest challenge for integration efforts. While many providers have successfully overcome this barrier, it is no easy feat to develop a financially sustainable integrated services delivery system. Fortunately, the ACA created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with chronic conditions who receive Medicaid benefits. While only a handful signed on initially, there are currently 24 states and the District of Columbia who have elected to participate in the Medicaid Expansion. Fourteen states have elected not to participate; and 12 states remain undecided. (Click here for more information on where each state stands on ACA’s Medicaid expansion.)

States that are moving forward with Medicaid Health Homes are in the process of making adjustments to policies, billing, and service delivery to enable service providers to integrate behavioral health and primary care services, a requirement of Health Homes:

“Health Homes providers will integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person.” – Medicaid.gov

Partnership Issues

Regular visitors to this blog know that much has been published here about the partnership between behavioral health and primary care providers. This was ranked as second most challenging in the poll.

Why do so many people find partnership issues as challenging? It’s counterintuitive. Most providers approach the integration of behavioral health and primary care with a blind eye to the process of partnership development. It is assumed that the interpersonal aspects will fall into place. Unfortunately, it is far more likely that an integration effort will fail due to partnership issues than financial ones. They are not unlike other partnerships, requiring attention to building a strong foundation from the onset.

Here are additional resources:

Operations/Workflow Issues

All healthcare administrators acknowledge the importance of operations for successful service delivery. That’s why 15% of respondents to the poll indicated that this area is the greatest challenge. Once a smooth-running clinic takes on an entirely new service-line, a degree of disruption is inevitable. The workflow will likely be drastically different than the service providers and support staff have grown accustomed to. Of course, taking on a new service also means addressing the organization’s policies, regulatory requirements, physical space requirements, etc.

With a little careful planning and a LOT of patience, your new integrated clinic will be operating smoothly in no time. Click here for a useful integration planning checklist.

Workforce Issues

Seven percent of the respondents indicated that workforce is the greatest challenge. With the current shortage of primary care providers, nurses, and psychiatrists, it’s no wonder that this is of concern. Fortunately, programs for training about integrated care delivery are available, such as the University of Massachusetts Medical School’s Center for Integrated Primary Care, which offers three programs aimed at training healthcare providers for providing integrated services:

Health Information Technology Issues

Despite concerns over the dilemma of sharing health records for integrating behavioral health and primary care, health information technology garnered 5% of the responses. Fortunately vendors of electronic health records are working earnestly to develop products that allow for the seamless sharing of behavioral health and primary care records. (Click here for more information on the role of HIT in integrated healthcare.)

One Year Later

What are the greatest challenges to integrating behavioral health and primary care in 2013? What will be the challenges next year? Dare we suggest that in the near future there will no longer be challenges?

Additional Resources:

Psychiatric News: Integrated-Care Models Increase Psychiatrists’ Impact

Integrated-Care Models Increase Psychiatrists’ Impact

As published in Psychiatric News by Mark Moran: 

If psychiatrists want to be more effective and help a much larger number of people, they need to work in a model of integrated care where they can collaborate closely with primary care physicians, said psychiatrist Jürgen Unützer, M.D., M.P.H., at APA’s 2012 Institute on Psychiatric Services in New York last month.

Click here to review the complete article in Psychiatric News

Mental Illness Awareness Week: Raising Awareness of the Need for Integrating Behavioral Health and Primary Care Services

Mental Illness Awareness Week, October 7 – 13, 2012

In the US the first week of October has been recognized as Mental Illness Awareness Week since 1990 when it was established by Congress in recognition of the National Alliance for Mental Illness’s efforts to increase public awareness about mental illness. Mental Illness Awareness Week also coincides with similar organizational campaigns:

There is no doubt that this campaign has been a successful one, raising awareness, encouraging people to screen for depression, and chipping away at the negativity surrounding mental illness. This theme is aligned with the philosophy of behavioral health integration. Therefore, perhaps a day can be designated for recognizing the importance of integrating behavioral health and primary care services. When physical health and behavioral health are addressed concurrently, people have better health outcomes and are better satisfied with their healthcare services. Integrated healthcare also offers improved access to services and reduces healthcare costs.

Integration has been referred to as the neck; a means of reconnecting the mind and body. In integrated healthcare, the mind and body are addressed as a whole, rather than compartmentalized. There is a focus on prevention and wellness that promotes improved health outcomes. Across the United States and around the world, behavioral health and primary care providers are transitioning service delivery to a more collaborative approach. The United States Department of Health and Human Services‘ Substance Abuse and Mental Health Services Administration has invested in nearly 100 initiatives in their Primary and Behavioral Healthcare Integration grants. This commitment demonstrates the importance placed on integrated healthcare by the United States.

Perhaps we can designate each Friday of Mental Illness Awareness Week as National Behavioral Health and Primary Care Integration Awareness Day.

What do you think?

Behavioral Health – Primary Care Integration: Focus on Wellness

Cardiometabolic syndrome (diabetes, hypertension, obesity, and dyslipidemia) is prevalent among people living with serious behavioral health conditions resulting in their dying decades prematurely. The integration of behavioral health and primary care holds great promise for improving health outcomes. Not only are comorbid conditions treated concurrently, the focus on wellness/prevention allows for learning healthy habits.

Focus on Wellness

The following video, Be One in a Million, was created by Intecovery Cobb CSB and the Peer Support Program at Cobb/Douglas CSB as part of the Million Hearts initiative. It provides a look at the prevalence of preventable health conditions and the contributing factors. This inspiring video features individuals who self-identify as living with behavioral health disorders and thought-leaders in healthcare integration. It provides suggestions of ways to adopt a healthier lifestyle.

Enjoy…after watching you may decide to take the pledge, too!

Integration of Behavioral Health and Primary Care: Preparing for Service Delivery

When your behavioral health and primary care integration partnership has worked through the preliminary groundwork for integrating services (click here for more information on planning), it’s time for preparing for the delivery of the services. The detailed outline created in earlier steps becomes your business plan. The plan serves as a map of the partnership’s goals and provides direction for delivering services.

Formalizing the partnership

When two organizations are collaborating for providing integrated services, it’s important to understand the legal and regulatory requirements. Working through this process should include consultation with an attorney. The following resources provide additional information for consideration:

Service Delivery

Once the legalities have been addressed, including the signing of a Memorandum of Understanding, Business Associates Agreement, etc., it’s (finally!) time to establish a start date and prepare for the delivery of the much needed services. The preliminary work, though tedious at times, was necessary to ensure the success of service delivery.

Careful planning is the hallmark of successful healthcare integration!

Through the careful planning of the behavioral health and primary care providers, they are ready to offer services in a more holistic manner. With co-morbid behavioral and physical health conditions more often the rule rather than the exception, the newly integrated services enable the team to provide much more comprehensive care coordination in this behavioral health and primary care marriage than either partner could have done independently. The whole is greater than the sum of its parts!

Celebrating Success

Once the equipment and supplies are in place, staff training is completed, and the start date has been announced to internal and external referral sources, it’s time to celebrate!

Celebrating important milestones is very important for ongoing success. It is an opportunity to strengthen relations among the healthcare integration team. Also, celebrating milestones is a valuable opportunity for leaders to re-energize their employees around the partnership’s Strategic Objectives by thanking the people who helped make the achievements happen.

Though things won’t always be harmonious, the partnership can persevere the difficult times through establishing a strong core to build upon. As discussed in The Partnership: Creating a Solid Foundation for Successful Healthcare Integration: “A partnership that has the solid and flexible foundation that is necessary for a lasting partnership” will weather the inevitable storms ahead.

If we are together nothing is impossible. If we are divided all will fail.
–Winston Churchill

Integrating Behavioral Health and Primary Care Services: Checklist for Developing the Plan

You have decided on the model that best meets the needs of your partnership and community (click here for Choosing the Right Model for Your Integrated Healthcare Services) and you’re ready to move forward to the next stage. The planning stage is preparation for implementing services and can be divided into three parts: clinical, financial, and operational.

This guide can serve as a checklist for partners to use in preparing for service delivery.

Clinical

The planning should include a detailed account of the service array to be provided, to include the following:

  • Identification of the targeted recipients of the services
  • Determine the specific services to be delivered and by whom
  • What clinical tools will be used?

Financial

Prepare a detailed account of the codes that are to be billed, including which partner will bill for each service. Other important topics include:

  • A determination of how labs and prescriptions will be processed. Typically, CHCs have access to better rates for each. Careful planning allows for maximizing billing opportunities.
  • Who will operate the patient assistance program? How will it be managed?

Operational

Entering into a partnership affects every aspect of the organization: clinical, support, administrative, IT, etc. Successfully navigating change cannot be accomplished without staff buy-in: they will be the ones primarily responsible for implementation. Therefore it is vital to involve employees from each of the organizations in the planning process.

Don’t forget that communication is a key element. Transparency is necessary from the onset. Identify champions from various levels within the organizations to assist with the detailed planning. Create implementation teams with staff from each organization for early face-to-face interaction.

Include the following in your planning:

  • The physical space: Careful thought must be put into this and MUST include both partners. It’s common for new projects to be housed in existing empty offices, frequently in out-of-the-way locations. This, however, is not the correct approach for healthcare integration. The physical space is extremely important and requires careful consideration in ensuring that the imbedded staff do not work in isolation but are able to interact with others frequently. Shared space allows the relationships to develop, fostering the sense of being a team. Frequent passing in the hallways allows for hallway consults, facilitation the collaborative approach.
  • Compliance: Regulatory requirements of JCAHO, CARF, etc. It is very important to understand and respect your partner’s requirements.
  • Liability insurance: Depending on the type of partnership, coverage will vary. It’s important to review requirements to ensure appropriate coverage.
  • Process mapping: This a vital component and must include input from clinical and administrative staff.
  • Workflow: Focusing on the experience of the patient/client is important for success.

Also, the following are very important to consider:

  • What clinical, financial, and operational outcomes are expected?
  • How will clinical, financial, and operational outcomes be tracked and measured?

It cannot be emphasized enough that this process cannot be successfully completed by a small group of executive staff. Successful change requires the involvement of all stakeholders.

The Partnership: Choosing the Right Model for Your Integrated Healthcare Services

Determining the Model

How do partnering Community Behavioral Health Centers (CBHC) and  Community Health Centers (CHC) determine the ideal model for their foray into integration? There are many factors to consider such as:

  • What are the needs of the individuals served by the partnering organizations?
  • What are the needs of the community?
  • What resources do the organizations bring to the partnership?

Now that the partners have a solid foundation and clear vision for their collaboration, it is time for the careful planning that is necessary to make it a reality.  There are effective tools available to assist organizations in working through this very important process. (Please note that these suggestions and resources are not limited to community providers.) 

The MH/Primary Care Integration Options scale  is available on the SAMHSA-HRSA Center for Integrated Health Solution website. This is very helpful for leading the discussion among the members of the implementation team. The scale assists the partners not only in determining the current reality but also mutually deciding on the desired level of integration: Minimal Collaboration, Basic Collaboration from a Distance, Basic Collaboration On-Site, Close Collaboration/Partly Integrated, and Fully Integrated/Merged in each of these key functional areas:

  1. Access: How do individuals access services?
  2. Services: Are the services separate and distinct or are the primary care and behavioral health services seamless? Or perhaps somewhere in between.
  3. Funding: Do the partners share resources or are they separate?
  4. Governance: Are there separate boards of directors for each organization?
  5. Evidence-based Practices: Do the organizations administer the PHQ-9 or disease registries, for example, and share the results?
  6. Data: Do the partners share information? Do the providers have access to the partner’s EHR?

This assessment process is most effective when stakeholders from each organization are included. Ideally, representatives are included from clinical, management, and administrative departments, as well as a few individuals who use the services. It’s very helpful to have frontline staff and board members to take part as well.  Call center and reception staff offer a unique perspective that leadership frequently finds enlightening.

Other useful tools available include the National Council’s Success in the New Healthcare Ecosystem: Mental Health & Substance Use Provider Readiness Assessment prepared by Dale Jarvis.   This allows provider organization management teams to assess their organization’s readiness for engaging in the changing healthcare system.

Another tool to consider is the COMPASS-PH/BH  created by Zia Partners.  This self-assessment tool is used for primary care/behavioral health integration for implementation of a Comprehensive Continuous Integrated System of Care.

Making the Vision into a Reality

Once the ideal model of integration has been determined, the journey begins to make it a reality. Be sure to stop by for the next installment in the series.

What tools or methods have you found to be helpful when selecting a model for your healthcare integration endeavor?

I would love to hear from you! Please email your suggestions to me at behavioralhealthintegration@gmail.com for inclusion in a future post.

 

Yours, Mine, and Ours: Workforce and Healthcare Integration

A company’s greatest asset is its workforce. The employees are the lifeblood of an organization, as I’m sure most leaders would agree. Therefore, paying close attention to keeping your employees informed and engaged when entering into an integrated behavioral health and primary care partnership is crucial for success. And the sooner, the better.

Sibling Rivalry

Like blended families, the integration of two organizations brings up some fundamental concerns among the employees. Concerns over job security, roles, and change in general are paramount. Your employees will be working with the employees from the partner company and will not likely develop into a cohesive team immediately. Additional challenges are introduced with the unique role of the employees who are hired jointly by the partners. The uncertainty and anxiety are sure to result in sibling rivalry among employees. Sibling rivalry is characterized by a jealousy that develops between employees. This, of course, impedes teamwork, especially if some members of the team are granted a superior status. This  sometimes happens when the integration efforts are held out as being a special or top-priority project. While it’s not possible to eliminate all anxiety, it’s possible to avoid sibling rivalry among your, my, and our employees and to allow them to transition into a unified team.

Healthcare integration is in its infancy and trained workforce is sparse. However, it is not necessary to hire new employees for your enhanced services. Providing training for employees, ongoing thorough and consistent communication, coupled with reassurance on the front end will go a long way toward successful integration of the employees, and are key to success. The following guidelines will help to promote a close-knit and committed integrated team:

  • Communicate an overview of the vision of the partnership followed with frequent status updates. This also helps your team develop a sense of buy in to the mission.
  • Provide each team member with a clear understanding of his or her role and how it fits into the whole.
  • Provide ample training for all team members to ensure that they are prepared for healthcare integration.
  • Building trust among employees is vital for effective teamwork. Frequent opportunities for face-to-face interaction are important for developing a sense of camaraderie.
  • Champions within the organization play a large role in the success of projects. Recognize them (they are in all levels of the organization, just look for them) and allow them to take on leadership roles.
  • As with all new endeavors, solicit feedback from your team. By providing an environment that values candor, early missteps are quickly corrected and creative ideas are put to use for long-term success.
  • It’s important to recognize that some people belong on the bus but are just in the wrong seats. Keep an eye out for employees who are onboard with the mission but struggling with their current role(s). These employees are keepers and should be placed in roles that emphasize their strengths.
  • And vital to a successful team, it’s important to acknowledge when an employee is neither prepared nor motivated for the adjustment in the mission and must seek professional fulfillment elsewhere.

What would you add to this list?

For successful healthcare integration, focused attention to your workforce can quickly transition “yours, mine, and ours” to an effective integrated team.

For Better or for Worse: Honoring the Partnership in Behavioral Health and Primary Care Integration

“I now pronounce you…Integrated.”

The early days of the integrated healthcare relationship are typically idyllic, filled with smiles and hopes and dreams. Oh, if we could only maintain that blissful state forever…

Unfortunately relationships don’t maintain a static pattern but are interspersed with disruptions on occasion (or frequently). When these disturbances intervene, the blissful state is challenged.

These are the times that try administrators’ souls.

For a partnership to persevere the inevitable challenges, the basic foundation must be solid.  Just as skyscrapers are built with deep foundations that are not only solid but allow flexibility to prevent collapse when severe environmental or other hazardous conditions erupt, the integrated partnership requires a carefully developed, yet flexible foundation. With a firm core, the relationship has the elements in place to withstand challenges that are sure to occur. (Click here for more information on building a successful behavioral health – primary care partnership.)

Sustainability Planning

Sustainability plans are often synonymous with financial sustainability but will occasionally focus on health information technology in the planning as well. The partnership itself, however, is often overlooked in the sustainability plan. This is unfortunate because if the partnership fails, the plan is rendered moot. The actual partnership itself is taken for granted after the initial honeymoon phase. This is a grave mistake for true sustainability.

Consider this scenario:
Due to internal operational and fiscal needs, the behavioral health partner’s executive team has decided to reassign the integrated BH counselor who has been working in the primary care clinic for two years. The counselor will be replaced with another counselor who is more experienced and is credentialed in both mental health and substance use disorders. Seeing this rearrangement as a win-win, the behavioral health partner is shocked and confused when they hear that the primary care partner, in reaction to this news, is considering hiring their own counselor instead of accepting the replacement counselor. There are even rumors that they might pull out of the partnership.

What went wrong?

  1. The behavioral health partner failed to include the primary care partner in the discussion, thus failing to honor the relationship; the primary care partner felt disrespected.
  2. Rather than express concern to the behavioral health partner, the primary care partner took a reactionary approach instead.
  3. Unaware of behavioral health partner’s internal issues, the primary care partner assumed the worst.
  4. The behavioral health partner failed to understand the value of the individual to the team, not just for the service provided. Counselors are not interchangeable. The counselor was viewed as a valued member of the primary care team.
  5. The executive teams of the partners stopped communicating after the partnership was launched, resulting in a weakening of the committment by each partner.

The list could go on.

This partnership, though financially sound, has neglected to nurture the core relationship. As long as things were going smoothly, the partnership appeared to be successful. Unfortunately, a slight disruption to the routine has threatened the weak core of the partnership. In addition to the obvious lack of effective communication taking place in this dysfunctional relationship, there are other factors also present that are all too common in partnerships:

  • Lack of commitment
  • Lack of respect

Commitment and respect underscore the core requirements for longevity.

Commitment

All partners must be committed to ensuring that integration efforts have the necessary tools for success. This includes the committment of time, not just financial and other resources. When the commitment is present, there is no concern over “fair weather friends” syndrome.

  • Are you prepared to make sacrifices necessary for success?
  • When the going gets tough are you still committed?

Respect

Basic respect is crucial. Your partner has many challenges and concerns that are unrelated to your partnership. Respecting that these are important to your partner whether or not you can fully recognize the impact goes a long way toward being a good partner. Taking the time to gain a better understanding is even better.

  • Do you have a thorough understanding of your partner’s business model?
  • Do you understand the challenges that your partner faces specific to the specialty such as regulatory, operational, clinical, etc.?

Why are these things important?

Understanding and honoring the things that are important to your partner organization strengthens the core of your relationship. Remember, the Golden Rule applies to behavioral health and primary care integration partnerships, too.

No Margin No Mission: Sustainability in Behavioral Health – Primary Care Integration

Of the many challenges in integrating behavioral health and primary care services, the one that garners the most apprehension and concern is sustainability. It is also the most frequent reason for hesitation in moving forward. Healthcare is not set up to address this. Primary care and behavioral health have different billing codes with no easily decipherable means of venturing outside the confines to include payment for integrated services. The mere thought of the process required to begin to tear down the barriers separating the two worlds strikes fear in the hearts of the most courageous administrators.

Healthcare administrators are presented with conflicting demands and are struggling to reconcile the next step. They can:

  1. Ignore the ever increasing focus on healthcare integration and hope it is just another passing fad; or
  2. Place even more burden on the ever-shrinking budgets and hope for the best.

Let’s take a closer look at the options:

Ignoring healthcare integration seems like the easiest solution. Administrators can align themselves with like-minded peers creating a support group who reinforces the notion that it will all just fade away if they merely wait it out. This group gets considerable pleasure in observing the early adopters from a distance, filled with certainty that they are all making huge mistakes. They pat themselves on the back encouragingly as they watch their naïve peers make the occasional fumble, while attributing any successes to sheer (unsustainable) luck.

Over-burdening the current budget seems to be irresponsible. Behavioral health administrators have been faced with budget cuts in unprecedented amounts over the past few years. While they have either become masters at doing more with less or have chosen to leave the field entirely, taking on a new business-line during the increasing uncertainty of their organizations’ financial states seems to be overly risky and counterintuitive.

Yet the pressure is on.

Nationally, more and more behavioral health conferences are featuring healthcare integration tracks. The same is becoming true of primary care conferences and conventions as well. With more and more research and reports being released that provide the necessary data to support the need for integration, it’s becoming more and more difficult to write it off as a passing fad. The recent report from the SAMHSA-sponsored, National Survey on Drug Use and Health, Physical Health Conditions among Adults with Mental Illnesses provides further evidence supporting earlier reports demonstrating the need for integration.

The current model of providing behavioral healthcare may be on its way to becoming obsolete. Now is the time for behavioral healthcare administrators to begin the discussion of how to address the whole-health needs of the people they serve. Whether through collaborative partnership agreements, bi-directional integration, or full integration, this issue can no longer be ignored. There are many changes that can be implemented right away (focusing on billing codes and maximizing billing opportunities) while others will require advocating changes at the state and federal level. (Click here for helpful billing tools created by the SAMHSA-HRSA Center for Integrated Health Solutions.) Daunting though this may seem, the climate is right for these discussions with your state Medicaid and behavioral health offices. They are faced with the task of making the necessary changes to move into the new era of healthcare integration. Strategically, it’s far better to be a part of discussions on creating this new structure than to have it imposed on your organizations. The Georgia Association of Community Services Boards has partnered with the Carter Center to create a forum for change in Georgia via their Integrative Healthcare Learning Collaborative. Not only have they included the public behavioral health providers and their primary care partners, they also have representation from the Georgia Primary Care Association and area medical schools.  They recognize that in order to develop sustainable programs everyone must be at the table.

What are your strategies for sustaining healthcare integration?
I’d love to hear from you. Please enter your comments/suggestions/ideas below or email: behavioralhealthintegration@gmail.com.

Let’s not lose sight of the goal: we must work together to make a difference in improving health outcomes of the people we serve. We CAN ensure that the margin is there to continue the mission. Be a part of the solution!