Health Information Technology and Healthcare Integration

July 9, 2012July 10, 2012 ch1 Comment

Health information technology (HIT) is important to healthcare providers for a variety of reasons, not the least of which is for complying with Medicare and Medicaid Electronic Health Records (EHR) Incentive Program requirements.

HIT is critical to the success of health homes and healthcare integration, allowing behavioral health and primary care providers to share information. This sharing enables healthcare providers to have access to all available healthcare information related to the individual being served. And this, of course, results in improved health outcomes. The SAMHSA-HRSA Center for Integrated Health Solutions has a wide array of HIT resources: click here for more information.

The Past

Not too many years ago, healthcare providers were handwriting or dictating their progress notes. When patients were seen outside the office, or if the notes were not yet filed in the chart, the limited amount of information available created a challenge to providing the best care. A patient who was unable to provide a thorough medical history was being treated blindly in some regards. And health implications aside, numerous medical procedures were repeated due to lack of access to the reports. Duplication of the procedures drove up healthcare costs.

In addition, the sharing of information between providers was the exception rather than the rule. Coordination of care between providers for patients referred to specialty care was not reimbursed and, as a result of limited resources, less than ideal. This brief history lesson on medical records serves to illustrate the value of electronic health records and health information technology.

Fast Forward to the Present

Though far from ideal, the healthcare industry is making great strides in health information technology, including health information exchanges (HIEs) designed to facilitate the sharing of data. Despite the rapid progress, sharing information continues to be a challenge for behavioral health and primary care organizations. These integration efforts create unique challenges, largely due to problems with sharing information between two systems. The electronic health records (EHRs) used by primary care providers are seldom compatible with EHRs used by behavioral health providers. While some partnerships have implemented means of addressing this (work arounds), such as a third system to link the two or “home grown” alternatives, there are currently no ideal options available.

These noble community providers persevere however. They are well accustomed to dealing with challenges in the quest for pursuing their mission. People with serious mental illness are dying prematurely; and has been inadvertently perpetuated by this lack of information sharing. In an attempt to be respectful and responsible with healthcare information, limitations (and misunderstandings) have impeded information sharing. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191 and Title 42: Public Health Part 2—Confidentiality of Alcohol and Drug Abuse Patient Records, also known as 42-CFR Part 2, are the most frequently cited reasons for not sharing information. These federal regulations cite guidelines for confidential health information. Though intended to provide clarity, healthcare organizations have interpreted the regulations very conservatively.

The Future

HIT has changed the face of healthcare and holds great promise for the future of behavioral health and primary care integration. Health information technology is not only providing cost-effective means of providing superior collaborative treatment, it is paving the way for reducing the health disparities for people with serious mental illness and other behavioral health conditions.

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.

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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 · health disparities · healthcare integration · mental health · primary care behavioral health integration

OUTCOMES: The Fourth Key Component of a Successful Behavioral Health and Primary Care Marriage

November 12, 2011November 17, 2011 chLeave a comment

With individuals who suffer from serious mental illnesses dying 25 years prematurely on average, behavioral health and primary care have been mandated to address this health disparity. More effective protocols are in order and must be initiated immediately. This is a matter of life and death.

The Behavioral Health and Primary Care Marriage is a viable solution.

Growing Old Together

To recap, for behavioral health and primary care marriages to be effective, there are four components that are necessary. Vision, Communication, and Compromise have been explored in previous posts. The final component, derived from the first three, is Outcomes. This element builds and maintains the mature partnership for growing old together.

The Whole is Greater Than the Sum of Its Parts

The Behavioral Health – Primary Care Marriage, at its best, is an entity so much more than just two collaborating organizations. The synergistic effect of the partnering of two organizations has the ability to surpass what either can accomplish alone. The community behavioral health organization has expertise in treating complex behavioral health disorders but does not address the primary care needs of individuals. The primary care organization excels at treating a myriad of health conditions including mild behavioral health disorders but does not have the expertise to address serious mental illness or substance use disorders.

The marriage of behavioral health and primary care serves as a means of connecting the head and the body; it may be thought of as the neck of healthcare. The neck allows the best of both worlds to work together in unison, becoming far greater than either can be alone.

Enhanced Outcomes through Blending of Resources

Measuring outcomes provides evidence of the value of the partnership. Through building on the expertise of each, the blended resources result in enhanced outcomes. For example, the University of Washington’s IMPACT Evidence-based Depression Care has impressive results in improved outcomes with significant cost reduction through collaborative care.

The marriage thrives with ongoing feedback, allowing for calibration to ensure that services are effective and financially sustainable. To provide a comprehensive overview, it is recommended that individual health outcome indicators, service outcome indicators, and outcomes data for decision making are included in the repertoire of data collected for analysis and sharing. Implement a system of collecting the indicators at the onset of the partnership. The indicators must be meaningful to both partners. The National Association of State Mental Health Program Directors has a very useful report for guiding the process, Measurement of Health Status for People with Serious Mental Illness.

Accountability

Frequent, regular intervals of sharing results with the team establish a sense of accountability that builds the foundation for longevity. Both partners have responsibility to the partnership and to producing positive outcomes.

By following the Four Key Components for a Successful Behavioral Health and Primary Care Marriage, the partnership will live happily ever after.

COMMUNICATION: The Second Key Component of a Successful Behavioral Health – Primary Care Marriage

July 17, 2011July 17, 2011 ch8 Comments

The next key component of a successful Behavioral Health – Primary Care Marriage focuses on Communication.

Early Phase: THE HONEYMOON

In the early days of the partnership, the Honeymoon phase, there is a distinct tendency toward assuming that both partners are speaking the same language and are working toward the same goals. The excitement of the new endeavor and the synergy created initially helps to move things along at a rapid pace. When the behavioral health partner talks about workflow and scheduling appointments, there is little thought given to the fact that these two concepts have VERY different meanings for the primary care provider. It is important to have a thorough review of operations from both perspectives and to find a viable middle-ground that both partners find acceptable. Making open, frequent communication a priority from the onset will prevent problems later on. This should include a thorough overview of each organization’s regulatory, financial, and operational processes as well as overall mission. Don’t assume that the two partners really understand how each other’s organization functions.

Problems within the Partnership (AKA THE HONEYMOON IS OVER!)

If the partners neglect to develop an open culture of communication on the front end, it is likely that miscommunication will develop.

The Honeymoon phase is in jeopardy.

The entrepreneurial partner fails to understand the ongoing delays from the partner with the extensive bureaucratic approval process that prevents a quick turnaround of virtually everything. As misunderstandings develop into disappointments and resentments, the previous harmony is disrupted.

The Honeymoon is over.

Internal conflicts must be addressed immediately with candor. This is a good time to have an open conversation about all the aforementioned points and develop a plan for ongoing, frequent communication. Concerns about the great divide over productivity targets, outcome measures, and caseloads must be openly discussed, among other important points of contention.

By devoting the necessary focus on the importance of Communication, the partnership will successfully transition to the third key component for a successful behavioral health – primary care marriage, Compromise. The shared mission to reduce health disparities for the individuals served who suffer from comorbid behavioral health and medical conditions will persevere.

However, failure to make this transition may very well land this promising partnership into divorce court.

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Behavioral Health – Primary Care Integration: Choosing a Model

March 27, 2011April 12, 2011 chLeave a comment

Which Models Work Best?

There are several model programs for behavioral health and primary care integration in the United States that are currently demonstrating outstanding results, such as Cherokee Health Systems, Intermountain Healthcare, and Washtenaw Community Health Organization. However, to quote Dale Jarvis, of Dale Jarvis and Associates, a national consultant specializing in payment and reimbursement system redesign, financial modeling, and business systems design for healthcare purchasers and providers: “All healthcare is local.” Behavioral health – primary care partnerships can learn much from the model programs but will need modification to meet the unique needs of their communities. A model that is successful in a rural community may not be effective in an urban setting. State regulations greatly impact the success of various models as well, especially if the model relies heavily on funding sources that may have significant differences from state to state.

The promotion of behavioral health and primary care integration has been identified nationally as holding promise for improved health outcomes and increased efficiency in the use of healthcare dollars. The United States Department of Health and Human Services, (HHS) is funding 56 Primary and Behavioral Healthcare Integration (PBHCI) projects in an attempt to identify effective means of integrating healthcare. HHS, in collaboration with the Office of the Assistant Secretary for Planning and Evaluation (ASPE), seeks to answer three questions about the integration of primary and behavioral healthcare, as noted in this excerpt from the 10/21/10 SAMHSA webinar, Primary and Behavioral Healthcare Integration by Trina Dutta:

Outcome Evaluation: Does the integration of primary and behavioral health care lead to improvements in the behavioral and physical health of the population with serious mental illness (SMI) and/or substance use disorders served by the grantees’ integration models?

Process Evaluation: Is it possible to integrate the services provided by primary care providers and community-based behavioral health agencies (i.e., what are the different structural and clinical approaches to integration being implemented)?

Model Evaluation: Which models and/or respective model features of integrated primary and behavioral health care lead to better mental and physical health outcomes?

(Contractor: RAND Corporation)

In a collaborative effort between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) a training and technical assistance center, the Center for Integrated Health Solutions, is available for PBHCI grantees and other organizations that are integrating behavioral health and primary care services. The Center for Integrated Health Solutions is a division of the National Council for Community Behavioral Healthcare.

behavioral health integration

Outcome Measures in the Behavioral Health – Primary Care Integration Partnership

March 18, 2011March 27, 2011 chLeave a comment

It is all well and good to say that the integration of behavioral health and primary care is beneficial, even vital, to the improvement of health outcomes for people who have a serious mental illness. However, unless we are able to provide evidence of such, it remains merely speculation. But how can we provide evidence?

Measuring Outcomes

Tracking outcomes allows for determining whether the healthcare interventions are effective. It is particularly important to screen for the following and routinely track as indicated:

Body-mass index (BMI)
Blood pressure
Hemoglobin A1c
Hyperglycemia
Hyperlipidemia
Family history of diabetes, hypertension, and cardiovascular disease
Tobacco use history
Depression
Substance use
Other areas as indicated

There are many screening tools and diagnostic labs that allow for screening many of the above. Ideally, these will be conducted on the initial visit to provide a baseline. Subsequent visits can focus on the areas that were identified a need and allows for tracking effectiveness of treatments.

These measurements provide an objective method of tracking response to treatment. This information is invaluable not only for treatment planning for the individual patient, but also provides data to demonstrate the effectiveness of the healthcare providers.

Demonstrating Treatment Efficacy

Electronic Health Records allow for the efficient gathering and reporting of outcomes. This data may be used as evidence of treatment efficacy, which is necessary for securing and maintaining funding (which is, of course, necessary for staying in business). This example is from a report from a behavioral health and primary care integration team that highlights the six month outcomes from 295 people served (click here for details): Behavioral Health – Primary Care Integration Outcomes.

In a similar collaborative effort between a community behavioral health organization and a private disease management initiative, the outcomes indicate a positive correlation between integrated efforts and follow up with health screenings (click here for details): Community Behavioral Health – Private Disease Management Collaboration Outcomes.

These two examples provide evidence of the effectiveness of behavioral health and primary care integration efforts to impact the health outcomes of people with serious behavioral health disorders.

Routine collection and reporting of data provides ongoing feedback to the team. The data allows for:

Reassurance of effectiveness of methods for team members
Evidence of efficacy for regulatory and funding organizations
Timely identification of areas requiring calibration for increased effectiveness
Potential and current patients/clients can make an informed decisions in choosing healthcare providers

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Behavioral Health – Primary Care Integration Partnerships: Measure Outcomes

February 26, 2011March 5, 2011 ch3 Comments

MEASURING OUTCOMES

The value of shared outcomes
It should be no surprise to either behavioral health nor primary care partner that measuring outcomes is important. Each organization has a number of metrics that are tracked routinely. Measuring outcomes of the integrated partnership are just as important. These outcomes should be jointly agreed upon early in the project. Periodic re-evaluation of the outcomes is beneficial to assuring that they remain relevant to each partner. Be prepared to modify as needed.

Identifying outcomes to be measured and faithfully tracking them provides the necessary data for the organizations’ decision makers. The data serves to demonstrate the effectiveness to others as well as for use in securing additional funding in the future. Outcome measures need not be expensive or overly complicated. The important thing is to be consistent.

Measuring the benefits of the partnership
The integrated behavioral – health primary care partnership is far greater than the sum of its parts. The synergistic effect of the partnership results in enhancing the lives of the individuals served to a degree that cannot be matched by either organization alone. Treating the hypertension of a person who also suffers from schizophrenia has a far greater impact that in treating either of the comorbid disorders separately. Measuring the outcomes clearly demonstrates the value of the partnership and the significant impact on the life of the individuals served. While most healthcare professionals are driven by the day to day intrinsic value of helping, successes identified in objective reports serve as further motivation to dedicated members of the team.

There is a clear benefit in having fewer services that must be duplicated when the behavioral health and the primary care is provided separately. When exams and diagnostic tests are done by one provider, there is considerable cost savings. Tracking these savings will demonstrate the added value of the partnership.

Quality of life and client satisfaction surveys are effective ways of determining the value that is provided through the collaborative approach to treatment.

It is not enough to feel that you are doing a good job when it comes to demonstrating success. Through measuring the value of services provided in an integrated behavioral health – primary care partnership, the value of the partnership can be indicated in undisputable terms.

This is the last in the series of steps for a successful behavioral health – primary care partnership. These eight steps have been adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June1998. Vol. 18 . No. 3:

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Behavioral Health – Primary Care Integration Partnerships: Delegate Trust

February 10, 2011February 21, 2011 ch3 Comments

The delicate subject of trust is the focus of this installment in the series devoted to creating a healthy integrated partnership between behavioral health and primary care. This has been adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June 1998. Vol. 18 . No. 3.

DELEGATING TRUST

Trust is necessary to overcome expected conflict

When team members of the behavioral health and the primary care organizations come together for an integrated partnership, typically everyone is on their best behavior. It is easy to have a harmonious relationship at this stage. However, when conflict first intrudes, particularly regarding shared goals and outcomes, the amount of trust between partners can make or break the partnership. Create the forums at the onset to maintain a system of checks and balances. Face-to-face time creates a forum for maintaining checks and balances to ensure fidelity to the mission. Constantly solicit feedback from partners at all levels. The transparency also breeds trust.

Focus on building trust at all levels

It takes a significant amount of trust for a person to commit to any partnership; the behavioral health primary care integrated partnership is no different. Often the partnership is created when two leaders, most likely chief executive officers of the organizations, decide to bring together their collective expertise. The two CEOs build upon their mutual shared experiences of serving on committees, community boards, etc. together. They travel in similar circles and have developed reciprocal trust and respect. Unfortunately, a frequently overlooked aspect of this process is the fact that the managers and frontline staff who must join together to make the collaborative partnership a reality have NOT had the opportunity to develop that same level of trust. The wise leader recognizes the importance of building the trust necessary for a solid foundation between partners. Trust does not automatically filter down. Devoting considerable face time during the planning stage aids in establishing a firm foundation of trust. Dedicated time for regular interaction (weekly/monthly meetings, conference calls, etc.) helps to maintain the connection. Maintaining the flow of communication helps everyone to stay current with expectations and reduces the chance of surprises, which can quickly erode trust. Bringing together staff with their counterparts allows for those relationships to develop separately in addition to the collective partnership/relationship. It also allows issues and solutions to be addressed at the appropriate level. Medical Directors must communicate with Medical Directors; nurses communicate with nurses. When the CEOs communicate with each other in their decision-making process, they will benefit from the solidarity among the matched pairs in gathering input. Making informed decisions prevents leaders from forcing issues and promotes the trust that is so vital to success relationships.

“The glue that holds all relationships together – including the relationship between the leader and the led is trust, and trust is based on integrity.” –Brian Tracy

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Behavioral Health – Primary Care Integration Partnerships: Determining Expectations

January 20, 2011January 20, 2011 ch2 Comments

The majority of integrated partnership failures occur due to irreconcilable differences. This step focuses on the sensitive issue of the compromise on expectations.

This fifth installment of vital steps for creating a successful behavioral health – primary care partnership, has been adapted from “Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, MD, Behavioral Health Management May/June1998. Vol. 18 . No. 3.

DETERMINE EXPECTATIONS

This step addresses the issue of the expected outcomes for the partnership, building upon the shared mission:

What results do you expect from the partnership?

Do your expectations coalesce with those of your partner?

Compromise is in order at this juncture. Chances are good that each partner will agree on some things, but not on all things. The most successful of partnerships will devote adequate time and energy at this point to identify mutually agreed upon expectations and how results will be measured. The partnership creates enhanced outcome opportunities. Open communication on an ongoing basis helps to keep everyone on track. Internal conflicts are inevitable and should be discussed openly. The partners must address differences of opinions on an ongoing basis to prevent resentments from building.

Partnerships create an opportunity for enhanced outcomes through blending of resources to maximize the capacity of each organization. The result is a synergy far greater than the individual components. The integrated behavioral health – primary care partnership is far more effective and powerful than the single behavioral health or primary care clinic. Addressing all healthcare needs of the individual yields benefits that far exceed treatment focused only on behavioral health or primary care concerns.

Once the data elements are identified, collect a baseline before starting. The project should first be piloted to allow for evaluation and for adjusting expectations to further clarify the outcomes to be measured. Re-evaluate and respond. Time devoted to this process at the beginning will save considerable time, energy, and frustration further along in the project. With a solid framework of data elements, baseline, and data collection processes in place, outcome measurement will be easy to accomplish. Outcomes that are meaningful to the mission of the partnership will provide the guidance necessary for ongoing success.