Integrated Care Thought Leader Series: Dale Klatzker, PhD

January 22, 2014April 20, 2017 ch

The Times, They Are a-Changin’

When Bob Dylan wrote this iconic song, many felt that it captured the spirit of social and political upheaval of the 1960s, much in the same way that we view mental health as “a-changin’.” And these changes require mental/behavioral health providers to change the manner in which they deliver services.

Reports over the past decade have brought attention to the current mental health crisis:

In addition, over the past few years far too many catastrophic events have brought attention to this mental health crisis, resulting in a public outcry, demanding that changes are made to prevent future tragedies.

But change isn’t easy.

The relatively brief history of community mental health services has been a challenging one. Just a few months ago, as we celebrated the 50th anniversary of President John F. Kennedy’s signing the Community Mental Health Bill into law, the conversations quickly progressed to the subject that is on the minds of virtually all behavioral health providers—and an unusually large number of the general public and policy makers, given the historical lackluster interest in the topic—mental health is in dire need of change.

The economic downturn in the US in 2008 resulted in massive budget cuts in all but a few states. The March 2011 NAMI report, State Mental Health Cuts: A National Crisis, demonstrated the cumulative cut to mental health services in the U.S. during that time was nearly $1.6 billion. Community mental health services plummeted from being barely adequate to the critical point in many states. Safety-net providers were forced to close programs due to the slashed budgets. Many of those affected ended up on the streets or in jail.

The recent announcement on the anniversary of the Sandy Hook tragedy, of the planned infusion of dollars into help repair our broken mental health system, is encouraging. However, the entire mental health system is in dire need of an overhaul. One that looks at the broader healthcare picture and strategically plans for mental health and substance use disorder treatment to be included. A person-centered, whole health approach to treatment is necessary for improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care: the Triple Aim.

Dr. Dale Klatzker knows that, although it isn’t easy, change is vital for community behavioral health providers.

It’s exciting to be able to offer a look at integrated care from the perspective of a provider, particularly a provider who has demonstrated leadership excellence in integrating behavioral health and primary care services. Dr. Klatzker currently serves as the Chief Executive Officer of The Providence Center in Providence, Rhode Island. He has been a leader in behavioral healthcare for more than 35 years. Since becoming president/CEO of The Providence Center in 2004, Dr. Klatzker, a visionary, has transformed the system of care, quality of service delivery, and social policy decision making at The Providence Center and the state of Rhode Island. Click here for Dr. Dale Klatzker’s bio.

The Providence Center and the Providence Community Health Centers have created a successful partnership to meet the whole-health needs of the people they serve within their community; a need that is clearly outlined in the literature. According to the Robert Wood Foundation’s Mental Disorders and Medical Comorbidity authored by Dr. Benjamin Druss and Elizabeth Walker, comorbidity between medical and mental conditions is the rule rather than the exception:

In 2002, more than half of disabled Medicaid enrollees with psychiatric conditions also had claims for diabetes, cardiovascular disease (CVD), or pulmonary disease, substantially higher than rates of these illnesses among persons without psychiatric conditions. The authors conclude that the high prevalence of psychiatric diagnoses among people with chronic medical conditions should be an impetus for prioritizing the improved integration of behavioral and medical care.

What advice do you have for healthcare leaders?

Dr. Klatzker: Change is a good thing. Most CMHCs haven’t changed a lot. They haven’t prepared themselves to change a lot and have marginalized themselves and the people that they serve by not being more a part of the mainstream. We have sets of skills that are integral to wellness and to health across a wide spectrum. We need to be proud of what we do, but also to expand it and extend it because this is the perfect time for this. We have a lot of things to offer that others are trying to replicate.

Things don’t stay static. You have to look though the windshield but also through the rear-view mirror. You have to know where you are but you also have to know where you’re going.

As executive director/CEO of a behavioral health organization, you have the obligation to push yourself, and that will push your organization, to do what is necessary so that your mission is reinforced but also to serve the needs of the community. It’s hard to do that if you’re doing the same thing you did 20 years ago. We do our consumers a disservice if we do that.

Person-centered approach to care

Dr. Klatzker: What we’ve embraced here – what’s part of the DNA of the organization at The Providence Center – we believe in a person-centered approach to care. No two people are exactly the same. The people that we work for deserve as much access to a wide array of both health and social supports as anyone. That’s how you have to guide yourself. When you’re thinking of those things, primary care integration, working much more toward the mainstream of traditional healthcare is imperative for us.(7:14)

What we’ve found is, if you can build those relationships and find the right connections, then others will embrace you and value you for what you bring to the table. In fact, we bring a lot. Partnership is always the first choice, the default.

We don’t chase dollars, we don’t create programs because it’s the idea du jour from some funder somewhere, we consciously look on our mission as our touchstone and build upon that to provide as much choice to the people we serve. We can be very person-centered because there aren’t many gaps in what we’re providing. (They provide a wider array of services than the average CMHC) We’ve consciously built out a wide array because we think it’s the right thing to do. Rather than to take a “no,” if we can’t partner, we build.

Example of a successful integrated care partnership

Dr. Klatzker: The Providence Center is closely connected to one the largest federally qualified health center in the state of Rhode Island, the Providence Community Health Center. We have become the largest community mental health center. Neither had a desire to replicate the services that the other provided. Over the years we’ve built this into a “no wrong door” integrated collaborative effort so that in the mental health center, the FQHC runs a full-service practice with 1100-1200 patients. In the FQHC, we are integrated in their physician practices building and we also have a separate section of their building where we provide longer term care and some other types of specialty care. We’ve integrated our records with each other. We meet frequently to process and to try to figure out how to make our care efficient and effective. We are working closely with them now on adopting our health home model to integrate a modified health home into the FQHC.

Yes, the times they are a-changin’. And so are healthcare providers. (At least the forward-thinking providers like The Providence Center.) They are heeding the findings from the numerous expert reports and research. They are thinking outside the box, adopting a person-centered approach that enables better outcomes for the many who place their trust in them—trusting them to take care of their whole-health needs.

John F. Kennedy’s Community Mental Health Act of 1963: 50th Anniversary

October 31, 2013April 17, 2017 ch3 Comments

Today marks the 50^th anniversary of the date that President John F. Kennedy signed the 1963 Community Mental Health Act into law. It was to be the last before his death on 11/22/63. The Act represents a monumental turning point in the treatment of psychiatric disorders. President Kennedy’s call to action in 1963 was based on a belief that all Americans – including those with mental illnesses, intellectual disabilities, and addictions – have a right to lead dignified lives and to share in the benefits of our society. Patrick Kennedy, nephew of President Kennedy and former U.S. Representative of Rhode Island, is steadfast in his efforts to continue this important work via the Kennedy Forum.

Act of October 31, 1963 “Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963”, Public Law 88-164, 77 STAT 282, “to provide assistance in combating mental retardation through grants for construction of research centers and grants for facilities for the mentally retarded and assistance in improving mental health through grants for construction of community mental health centers, and for other purposes.”, 10/31/1963 (Figure 1 below)

History of Psychiatric Treatment

Figure 1: Mental Retardation and Community Mental Health Centers Construction Act of 1963

Early attempts to treat mental illness are thought to date back to 5000 B.C. or earlier, based on the discovery of trephine skulls. A series of barbaric practices followed for millennia. It is suspected that the first asylums were established around the sixteenth century. These early facilities offered no real treatment despite their primitive attempts at cures, consisting of the use of leeches, purges, barbaric contraptions, and the use of chains and other restraints. Conditions gradually began to improve by the mid 1800s thanks to efforts led by humanitarians such as Dorothea Dix. Treatment reform in the asylums offered a more humane approach to the care of people with mental illness.

New treatment options followed in the early twentieth century, including psychoanalysis, introduced by Austrian neurologist, Sigmund Freud, and electroconvulsive therapy, introduced by Italian neuropsychiatrists, Ugo Cerletti and Lucio Bini. Psychopharmacology followed, arguably providing the single most significant change in treatment to date. A former colleague, psychiatrist, Dr. John Wolaver, remarked that when Thorazine was introduced in the psychiatric hospitals, the facilities were suddenly calm and quiet for the first time. It seemed to be a miracle cure. Psychopharmacology provided the next necessary step that led to deinstitutionalization.

The introduction of the Mental Retardation and Community Mental Health Centers Construction Act of 1963, Public Law 88-164, a bold new effort, forever changed the face of mental health treatment. Prior to this, it was not uncommon for individuals with behavioral health conditions to be hospitalized for many years; hundreds of thousands lived their lives in institutions and were buried on the grounds. Unfortunately, this deinstitutionalization effort fell short of its goal. The USA Today report, Kennedy’s Vision for Mental Health Never Realized, takes a candid look at this.

Figure 2 below illustrates the decrease in inpatient treatment between 1950 and 1995. As the psychiatric hospitals decreased in size, the homeless population grew. The jails and prisons began to fill with the individuals with behavioral health conditions. According to the 10/24/13 article, Why Are The Three Largest Mental Health Care Providers Jails? published by NewsOne: The three largest mental health providers in the nation are the following jails: Cook County in Illinois, Los Angeles County and Rikers Island in New York.

Integrated Care

Many thought-leaders believe that we have embarked upon another pivotal point in mental health (or more broadly, behavioral health) treatment. Mental Health: A Report of the Surgeon General published in 1999 called for the integration of behavioral health and primary care. And the 2006 NASMHPD report, Morbidity and Mortality in People with Serious Mental Illness has prompted the movement toward a whole health approach to treatment that integrates behavioral health and primary healthcare. This promising trend offers hope for improved access for individuals who live with mental health and/or substance use disorders, improved health outcomes, and controlling healthcare spending.

Let us work together to address health conditions wherever the individual presents for treatment. Healthcare must be redefined to include behavioral health. By removing the healthcare silos, providers will begin to recognize and treat the comorbid conditions in their patients. Mind-body integration improves patient outcomes and reduces costs.

Integrated care is necessary for improving the lives of of those who might have spent his or her life chained in a dungeon centuries ago. It is a key element in our efforts to achieve the Triple Aim.

behavioral health integration · behavioral health primary care integration · healthcare integration

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

August 21, 2012September 10, 2012 ch4 Comments

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

behavioral health primary care integration · healthcare integration

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

August 11, 2012September 2, 2012 ch3 Comments

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.

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · primary care behavioral health integration

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

July 30, 2012August 6, 2012 ch1 Comment

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:

Access: How do individuals access services?
Services: Are the services separate and distinct or are the primary care and behavioral health services seamless? Or perhaps somewhere in between.
Funding: Do the partners share resources or are they separate?
Governance: Are there separate boards of directors for each organization?
Evidence-based Practices: Do the organizations administer the PHQ-9 or disease registries, for example, and share the results?
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.

behavioral health integration · behavioral health primary care integration · healthcare integration

Yours, Mine, and Ours: Workforce and Healthcare Integration

June 25, 2012December 3, 2017 chLeave a comment

A company’s greatest asset is its workforce. The employees are the lifeblood of organizations, 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, much the same as it does among siblings. 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 well 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 on board 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.

behavioral health integration · behavioral health primary care integration

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

May 24, 2012July 10, 2012 ch3 Comments

“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?

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.
Rather than express concern to the behavioral health partner, the primary care partner took a reactionary approach instead.
Unaware of behavioral health partner’s internal issues, the primary care partner assumed the worst.
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.
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.

behavioral health integration · behavioral health primary care integration · primary care behavioral health integration

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

May 6, 2012May 11, 2012 ch2 Comments

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:

Ignore the ever increasing focus on healthcare integration and hope it is just another passing fad; or
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!

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · primary care behavioral health integration

UPDATE: The Greatest Challenges for Integrating Behavioral Health and Primary Care Services

April 1, 2012April 4, 2012 chLeave a comment

The recent poll conducted via the LinkedIn group, Behavioral Health Integration, continued to generate thought-provoking comments following the last post. (Click here to see the initial results.) Thought-leaders, behavioral health, and primary care professionals have offered their perspectives on the pressing question:

WHAT IS THE GREATEST CHALLENGE FOR INTEGRATING BEHAVIORAL HEALTH AND PRIMARY CARE SERVICES?*

Mark L: Community health records (CHR) that follows the patient and not the provider or payer source will create the sustainability –finance and billing that aid Partnerships to create better operations/workflow that in turn solve workforce issues.
I think the solution for integration of health care is an IT solution that allows for communication not in any “one” silo but in a cloud, it is the premise of the question about integration that it will be in a silo that leads to obsolescence or a least does not address systemic issues of communion about the actual needs of the patient first.

Providers at all levels of care need to exchange information both horizontally and vertically, such as a transfer of care to another provider at a higher or lower level of care. Also community integration of available resources for discharges from one provider to the next or transitions to the public systems from private system or vice versa.

The public and private sectors need to work together to “speak the same IT Language” the health record should follow the person in any system.

Acute care and mental health care systems need the same ability to communicate, whether or not you call the person a client or patient. Mental health and acute care providers can then communicate and bill on a “continuity of care” coordinating treatment for a patient as a team and not in silos.
The export of data from one CHR to the next is where standardization needs to be the focus. I am excited to see future of blending of Regional Health Information Organizations (RHIOs), Health Information Exchange (HIE). RHIOs and HIE are changing the discussion from silos to clouds.

Leslie B: This may be one of my favorite topics. Yes, I agree that IT can play a part of it, but that is not the only part of the system that needs to change. Like one of the members of discussion, the providers and their ability to talk to each other is one. Program Development requires system and staff changes, changes in thinking, and the ability to assess each site. Each Primary care setting has its own challenges, so one can say provider insight at one location and Behavioral Health provider readiness at another location and yet another location might have the inability to see each other’s records or there may be a staffing problem. I think the biggest challenge can be who is going to pay for it, once everybody in the system figures out what it is anyway. It may require more behavioral health providers and more medical providers. Will there really be a return on that investment. The patient would probably get more holistic care, but it isn’t going to cost any less money.

Bob H: I believe that one of the greatest challenges is that we need to stop talking about behavioral health and primary care and begin focusing on the needs of the individuals receiving our services and how our systems can best serve their needs. We need to include clear measures of ‘behavioral economics’ and understand that we all act and react to rewards and benefits. We need to structure our systems and our interventions to incentivize overall health improvements, whether behavioral or medical.
We will only have truely intregrated care when we are patient centered and stop distinguishing between behavioral health and primary care. That does not mean that we will not have specialists; whether they be psychiatric, medical, communication, design, or information and technology. It is all about the focus on the patient’s needs and building workflows to address those needs appropriately to assist them in reaching productive and effective outcomes as a result of our services and interventions.

Nelson B: In short, the greatest challenge of healthcare integration is getting paid for effective services. Coleman Professional Services will look at the best outcome of our customer; their health, their ability to have stable living conditions, volunteering or employed and their ability to appropriate socialize in their community. Let’s look at the outcome for our customer and get paid for this outcome.

Michael J: Reading this thread shows that there is a great deal of thought being put into this topic. I think that some of this boils down to a chicken and an egg. And Nelson is right on target about the pay systems. We in our industry have not truly integrated mental healthcare and addictions treatment. Now I know there are pockets of good co-occurring treatment programs here and there, but as an industry they continue to be separate. And the biggest reason is following the money. The money for these services are not braided, and so they stay separate.
I’m currently working on a perinatal mental health integration project. We know what to do clinically (we are using the IMPACT model) and we have OBs who want to participate. We have Medicaid insured women we have identified as needing care. But since the Medicaid is carved-out, the physical health Medicaid plan will not pay for the service as they don’t pay for MH services, and the MH plan won’t pay because they don’t purchase physician services from non-psychiatrists unless they are credentialed as a part of a licensed agency with a MH contract. If the insurance companies and the government wanted to have integrated healthcare, they would have it. If there was a requirement that integrated care was insisted upon for reimbursement we would be all over it. In fact, we do all sorts of odd things now to respond to external requirements that have absolutely nothing to do with the delivery of care. So I have to believe that once the system starts demanding integration it will have it. The system gets what the market commands. The reason there are no solid IT solutions that can incorporate MH and PC is because the market doesn’t demand it. But vendors will respond when that’s required or they will be out of business, just like we would be if the demands were levied upon us and we didn’t respond.

Bob F: This has been a great discussion Cheryl – thanks for posting it. I read the responses from the other groups where you posted this question as well. It seems there isn’t necessarily an individual “biggest” challenge that organizations face versus as much as a varying number or group of issues that organizations face depending on a variety of factors: state environment, organizational structure, readiness to change, internal infrastructure, willing partners, etc. One of the keystones of integrated care is that our patients come to us fully assembled, and our treatment/wellness/prevention response to them has to be, in turn, as fully assembled in order to be effective. And efficient. Clearly the challenge we face in just about every region of the country is that the obstacles are likewise effectively assembled. At Cherokee Health Systems here in TN – even after running an integrated system for over 30 years new challenges surface all the time, chief among them payers who shift priorities from contract to contract, workforce (less primary care docs and psychiatrists all the time), finding time to be innovative in the development of such practices as telehealth, telepsychiatry and telepharmacy, etc. When we do our training academies we focus on all of these issues – administrative, operations, financing, workforce, PC-BH collaborations, model development – because we understand that it is almost never a single obstacle. Anyway – great to follow along and see the efforts being undertaken out there!

David R: New EMR processes are forcing medical case management accountability. Behavioral health case management processes are a generation behind medical and will require a sizable accountability shift for clinical participants.

*The question was also posted in these LinkedIn groups: Behavioral Healthcare Magazine Group, Mental Health Networking, The Friends of SAMHSA.

The poll results demonstrated a shift: with 44 total votes, Partnership has demonstrated a considerable increase, closing the gap on Sustainability.

POLL RESULTS:

Sustainability — finance and billing           38%

Partnership issues                                        31%

Workforce issues                                              7%

HIT issues                                                         5%

Operations/workflow issues                         18%

Without a doubt, each of the five factors is very important for successful integration. The next blog post will take a look at overcoming these challenges.

What do YOU think is the greatest challenge for integrating behavioral health and primary care services? Please send your comments to BehavioralHealthIntegration@gmail.com or visit Behavioral Health Integration

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · primary care behavioral health integration

The Greatest Challenges for Integrating Behavioral Health and Primary Care Services

March 10, 2012March 11, 2012 ch1 Comment

In a recent poll conducted via the LinkedIn group, Behavioral Health Integration, this question was posted*:

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

POLL RESULTS:

Sustainability — finance and billing         50%

Partnership issues                                        23%

Workforce issues                                           11%

HIT issues                                                          3%

Operations/workflow issues                        11%

The question produced a number of excellent comments that are listed below. Obviously there are differing opinions about the greatest challenge for integration. The most important factor is that the healthcare community is actively thinking about this very important topic! There is no easy solution. However, as long as we continue to move forward we will establish the path to success. It’s a challenge that is worthy of our efforts. We WILL make a difference.

Peggy H: Hmmmm. And possibly beneath it all is the issue that both systems are needing to care for an overwhelming number of people, with increasingly complex needs, in the first place. I have only recently joined, but am eager to learn more about how policy, the priorities it sets and the direction it gives to financing, is shaping critical features of integration efforts.

Joseph B: In my mind, until the silo mentality for benefit and payment is integrated, there can not be true clinical integration. In settings where integrated payment has been settled (VA, Kaiser, ACOs), all other issues solve themselves.

I believe that carved-in, risk sharing financial models are the solution to integration

Bob F: I think Dr. B is directly on target. Risk sharing models – capitated systems, shared savings models – can encourage better integration between modalities. Fee for service and carve outs fail to capture the true essence of integration – the vital “almost billable” services like warm handoffs, hallway consults, follow up phone calls, and the treatment team meeting; not to mention the varied allowable services among the states pertaining to same-day billing, discipline/credential requirements, etc. Trying to pound the traditional mental health square peg (with all of its burdensome documentation requirements) into the primary care round hole is not the answer – and just pounding harder with a bigger hammer is definitely not the answer.

Lena Z: I work for a pediatric health care system in Texas and we have only been able to deliver this type of service under grant funding…which was recently stripped away prematurely by the state of TX.

Bob F: It’s frustrating, isn’t it Lena? What we’ve found in TN is that it’s all about what you negotiate in your contract; the payers have latitude to “turn on” certain codes, allow for different funding arrangements/systems – but the provider has to be able to have the data and show the outcomes. The payer can also do some cost comparisons of your services versus your neighboring providers/competitors – that is the key. If you can get them to share their data in comparison with yours and can show those savings and improved outcomes – you have better leverage. We also learned that we were never going to be in a position to negotiate until we had a big enough member panel. It’s a battle well worth fighting – and one that is never truly won. Or lost.

Cheryl H: Each of the issues can and often does create barriers for behavioral health and primary care integration. Sustainability is the area in which most providers tend to focus for obvious reasons: No margin no mission. However, too often concern over sustainability becomes the primary focus, diverting attention from the other issues causing them to be neglected:

Partnership issues have brought about the demise of many promising partnerships. For long-term success, behavioral health and primary care partners must address establishing the mission for the partnership; identify a common language; maintaining pacing, flexibility, and capacity; develop shared solutions; determine expectations; delegate trust; create empowerment; and measure outcomes.

Workforce issues can create significant barriers to successful integration. Service provision in the integrated environment varies greatly from services provided in traditional behavioral health and primary care organizations. Training programs for current and future workforce is necessary for long-term success.

Health information technology issues create significant challenges for healthcare integration. Challenges created when partners have incompatible electronic records and other issues with record sharing inhibit successful integration.

Operational issues such as workflow can impact productivity, creating further challenges to sustainability.

With commitment among all stakeholders, successful integration of behavioral health and primary care can be accomplished. The resulting improvement of health outcomes for people with behavioral health disorders makes it worth all the effort.

Cindy M: As I think about this and read all your comments, I’m now thinking that the biggest challenge depends a lot on the people who are facing that challenge. I voted “workforce” because I’ve thusfar been able to find ways to deal with the silos in the back office so that they are transparent — or CAN be, at least — to the clients and possibly even the service delivery staff.

The biggest problems I’ve had are in teaching my fiscal dept. staff to think “integration” on the front line while complying with the silo mandates in the back office. Then there are the issues with some — not all, by any means — clinical and service staff who either are flummoxed a bit by the concepts and practices they have to integrate OR are stuck in “we don’t do that” gear.

The finance structure and silos are what I lose my religion over, but (apart from the unlucky fiscal staff) don’t need to interfere with anyone else. In dealing with THAT, I still find the main determinant to success or frustration being the persons I have to deal with at the governmental offices with whom we’re contracting. Some are very creative in helping create ways to make it work and others just AREN’T. Those ones do not help me find ways to create an “integration effect” without having an actual integration on the finance side. Which, again, is a work force issue.

Long story short: in my experience, integration has been as good as the people in charge of making it happen.

Stephen W: Great question. From an information system perspective, the greatest challenge is finding a software vendor that handles both BH and PC effectively. CCHIT has certification standards that address both BH and Ambulatory Care. These standards are more stringent than MU certification. I would start there and only look at those vendors that are certified in both.

Joseph P: I see a legacy of “carving out” behavioral health from medical benefits as segregating the two. Now that the value of treating diseases with high levels of psychological cormobidity is well established there will be a need to embed behavioral health with primary care much in the manner demonstrated by bariatric and transplant programs. Behavioral health specialists will need to provide brief cogent consults to PCPs and brief strategic interventions to patients focusing on patient education, compliance and stress/pain management in addition to more traditional psychological care. Insurance reimbursement can target shared risk/rewards for health care homes that provide this multidisciplinary approach.

Bill H: I don’t see it as a greatest single challenge as much as a multitude of challenges that require coordination, planning and leadership. I generally recommend starting small and building on successes. Once you effectively implement integration in one area, you will create a demand for similar services in other areas. Finding the right location to pilot a program that has a clinical need and a physician champion provides a great place to start an integration program. Would be happy to discuss integration in more detail.

I am currently working on developing a behavioral health model for accountable care organizations. Thoughts on that topic??

Karen M: The largest challenge I had dealing with both was a very direct problem but I do not think their is a simple and straightforward way to handle it. I found when working with Behavioral Health and also co-morbid medical cases I had a lack of communication between providers. This communication was the single item that told me whether a case would be successful or not. The willingness of providers to communicate is paramount to success and I know that isa complicated issue due to the fact physicians
and other professionals do not get paid for consultation but that leads me to believe some changes need to be made.

Joseph P: I am currently director of a multi-facility, multi-state program that offers integrated outpatient medical and behavioral health care to members of a Medicare Advantage program. We provide urgent ED level and ongoing complex care in conjunction with hospitalist service. This allows members a continuum of care that augments that provided by their PCP. PCPs have their HEDIS metrics improved (with higher level of reimbursement), patients receive excellent care that reduces inappropriate ED and hospital admissions and the insurance company reduces unnecessary costs. Behavioral medicine in these advanced care center focus on compliance and psychological factors that affect physical conditions. This type of program is likely to become a model of how care will be provided in the future as the carriers invest more dollars in better integrated healthcare as a wy of controlling inappropriate costs related to inappropriate higher level of care

Jim H: Possibly not the greatest challenge, but still a significant one is to provide an environment that is safe for patients who may have self-harm or suicidal tendencies. According to studies by the American Psychiatric Association we were averaging 1,500 inpatient suicides per year in 2003 and that number has increased to 1,800 by 2008. That averages just under 5 inpatient suicides per day. The typical med/surg hospital unit provides many opportunities for suicide and access to items that may be used by patients to harm themselves or others.

The American Society for Healthcare Engineering (ASHE) published a monograph last year that addresses this issue titled “Converting Medical/Surgical Units for Safe Use by Psychiatric Patients”. This is available for purchase on their website at http://www.ashe.org.

Also the National Association of Psychiatric Health Systems (NAPHS) publishes the “Design Guide for the Built Environment of Behavioral Health Facilities” that is available free of charge at either their website (www.naphs.org) or mine (www.bhfcllc.com). I am the co-author of both publications and I also offer free 30 minute phone consultations on patient and staff safety in behavioral health facilities.

Jay O: I’ve built several counseling centers and consulted for a lot of physicians. From my perspective, there are a number of issues that make it difficult, but could be overcome. Therapists in general are used to working in isolation. They typically do not communicate well with physicians and many are frankly afraid to do so. This can be overcome through training therapists how to adapt to a faster paced primary care setting.

I’ve embedded counselors in several primary care offices with some success. Patients feel less stigmatized going to a primary care office. There still needs to be strong referral patterns developed internally. Even with a therapist present, physicians still need to develop the habit of having a referral conversation with their patients and make a referral for an assessment. Alerts could be set up in EHR to remind the physician to do this when they prescribe psychotropic medications.

On the business side, a lot needs to be worked out to integrate with a practice. Medical space is often more expensive than a therapist can afford. The ROI on this space may be very low for the therapist, but high for the physician. If the space is unused, then it can be subleased at a reduced rate, otherwise it would not make financial sense for either party.

In general, therapists are not as good at creating business relationships and resolving operation issues that would need to be worked out to integrate with physician offices. These trends can be overcome with some training and coaching of the counselors.

Denise S: My position as a Behavioral Health Specialist was created to do just that to work as a link between Behavioral Health and the Medical Case Management Teams.

Bill H: A resource on the topic is: Understanding the Behavioral Healthcare Crisis: The Promise of Integrated Care and Diagnostic Reform. The book was edited by Cummings and O’ Donohue and published in 2011.

Scott W: A major challenge is the same challenge that exists in integrating primary health with any specialty area. Healthcare providers are largely oriented to focusing on the problem at hand, and do not necessarily feel able or equipped to take the time to understand the relationship between the various health problems a patient may have, including behavioral health. I believe to successfully integrate a patient’s different healthcare needs, there may need to be a professional (nurse) or paraprofessional (trained technician) who can serve as a care manager. Obviously, adding this expense would need to have some criteria and parameters to be cost effective.

Anyone who has an older family member or friend who has multiple health problems and a variety of medications knows that there can often be medical and/or psychiatric complications from the interactions of those medications. To me, and perhaps using an overly simple definition and context, integration means care management.

Ally L: The medical field has not experienced peer/family/youth/young adult involvement to the same extent that mental health has. They don’t yet understand the value or that we as peers and family members can understand the complexity of integration. We have made great strides in this area within mental health (always more work to be done) but it feels like we’re starting at square one with medical professionals in the development of statewide integration, Coordinated Care Organizations and Health Homes that is occurring here in Oregon.

The other challenge is the medical model. Mental health has operated under the medical model for many years as far as billing (Medicaid and private insurance); however, there are other elements of the medical model that do not translate well when it comes to practice. For example, the measuring of outcomes. Recovery is more easily measured when we are looking at physical illness or injury. Recovery in mental health and/or addiction is more subjective. The person in recovery determines what recovery looks like for them, not whether the rash is gone or the broken bone has healed. A mental health professional or family member’s definition of recovery for their “patient” or loved one may be very different than for the person working toward their self-defined recovery.

Cindy L: Reimbursement? I will be graduating in a year with my Psych Nurse Practitioner finding my place will be challenging

*The question was also posted in these groups: Behavioral Healthcare Magazine Group, Mental Health Networking, The Friends of SAMHSA. Several of the comments came from these groups.