Transcript of Audio File:

2013 01 18 14.02 A (Health) Home Run

Operationalizing Behavioral Health Homes

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BEGIN TRANSCRIPT:

MODERATOR:Good afternoon everyone, and welcome to the SAMHSA-HRSACenter for Integrated Health Solutions webinar, “A (Health) Home Run:Operationalizing Behavioral Health Homes.” My name is Lara Ross and I will serve as your moderator today.Before we begin I would like to cover a few housekeeping notes.Today’s webinar is being recorded and all participants will be kept in a listen-only mode.You can find the call-in number for the webinar on the right-hand side of your screen.Questions may be submitted throughout the webinar by typing your question into the dialog box to the right of your screen and sending it to the organizer.We’ll answer as many of your questions as time allows.If at any point during the webinar you experience technical difficulties please call Citrix Tech Support at 888-259-8414.[1:00]

As you may know, the SAMHSA-HRSACenter for Integrated Health Solutions promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care settings.The Center for Integrated Health Solutions is pleased to be presenting this webinar in partnership with the National Association of State Mental Health Program Directors.Joining us today on the webinar is NASMHPD’s Executive Director Dr.Robert Glover.Dr. Glover has served as the Executive Director of the National Association of State Mental Health Program Directors since September of 1993.Founded in 1959, NASMHPD was organized to reflect and advocate for the collective interests of state mental health agency directors and staff at the national level, playing a vital role in the delivery, financing and evaluation of public mental health services within a rapidly evolving healthcare environment.[2:00]Prior to this position Dr. Glover served as Commissioner of the Department of Mental Health and Mental Retardation in Maine for three years, and has previous experience working in several states’ mental health departments, including Colorado, Idaho, Pennsylvania and Ohio.And with that I’m pleased to welcome Dr. Glover on our call.

DR. GLOVER:Thank you, Lara.NASMHPD’s proud to partner with SAMHSA and HRSA’s Center for Integrated Health Solutions and the National Council to co-sponsor today’s webinar.And a special thanks to Linda Rosenberg and her team for their leadership in this important area of health integration, especially assisting states and local communities in home and health home understanding, implementation and outcomes.In the past two years we’ve been proud to partner with the Center on several projects related to integration, including the development of a roadmap to assist state mental health authorities in obtaining Medicaid reimbursement for peer services.[3:00]We’re really excited about the fact that now 29 states bill Medicaid for these critical recovery services.And in addition to today’s webinar we will partnering again to co-sponsor a second webinar later this year on the financing of health homes.We hope to have information and details out to you very soon on this next webinar.As you all work to use health homes in the best manner to pitch your state’s and strengths we hope these two webinars will be really useful. I do want to remind all of you on the phone that making sure people in recovery—people in recovery—are part of every aspect of the development and implementation of integration in your states.[4:00] I want to thank you for all that you do to make recovery the expectation of all of our systems.Thank you very much.

MODERATOR:Great.Thank you so much, Dr. Glover.And as he mentioned, we are going to be hosting another webinar within the next few months around the financing of health homes, so please stay tuned for details on that.During today’s webinar you will hear an overview of the Medicaid health home option.We will then review the core clinical features of a behavioral health home as outlined in the paper developed by our first two presenters on behalf of the Center for Integrated Health Solutions.They will talk about options for structuring a behavioral health home and clear action steps for stakeholders.We will then hear Joe Parks present a case study example of how Missouri operationalized these core clinical features as they established health homes for people with serious mental illness.We will have time for questions at the end of both presentations.

I’d now like to introduce our first two speakers.[5:00]As the first Rosalynn Carter Chair in Mental Health at Emory University, Dr. Druss is working to build linkages between mental health, general medical health and public health.He works closely with the CarterCenter mental health program where he is a member of the mental health task force and journalism task force.He has been a member of two Institute of Medicine committees and has served as an expert consultant to the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, and the Assistant Secretary for Planning and Evaluation.Dr.Druss’ research focuses on improving physical health and healthcare among persons with serious mental disorders.

Dr. Laurie Alexander is an independent consultant specializing in integrated healthcare and a senior study director with the national consulting firm Westat.She has extensive experience in mental health advocacy and healthcare integration.[6:00]She is a clinical assistant professor at the University of Washington’s Department of Psychiatry and Behavioral Sciences and serves as a member of the Advancing Integrated Mental Health (AIMH) Center Advisory Board.Dr.Alexander worked for the Hogg Foundation for Mental Health in Texas where she led the foundation’s integrated care initiative.And with that it is my pleasure to hand it over to Dr.Alexander and Dr. Druss.

DR. ALEXANDER:Great.Thank you very much, Lara.So as Lara mentioned, the presentation today is based on a paper that Ben and I wrote for the Center for Integrated Health Solutions.We were asked to focus specifically on the clinical work of a health home serving people with mental health and substance abuse conditions, and that’s what we’ll be talking about today.So that’s great that the next webinar is going to be on financing, we’ll look forward to that.That’ll be an excellent follow up on this presentation today.So if you could, the next slide, Lara.And the next one.

Slide:Context

So just some context.[7:00]I’m sure many of you are familiar with this, but the Affordable Care Act, the ACA, passed in 2010, created a new option for state Medicaid programs to provide health homes for enrollees with chronic conditions, including mental health and substance use conditions.This option became available to states in 2011, and so subject to CMS approval a state plan amendment could be submitted to start doing these health homes.The new option I think very importantly contains financial incentives for states, and I’m sure this will be addressed further in the next webinar.But some of these involve, for the first eight quarters of the state’s health home benefit the federal medical assistance percentage for health home-related payments will by 90 percent.States may also propose alternative payment models for health home services, for example doing bundled payments, and they may target certain populations, regions or diagnostic groups.And the ACA also authorized state planning grants that are funded at the Medicaid administrative federal matching rate of the requesting state.[8:00]Next slide please.

Slide:Required services

The CMS health home guidance lays out several service requirements that come from the ACA and also what they term “well established chronic care models.” The required services are also termed “provider standards” in the guidance.So just so you know, if you’re looking at that legislation that’s what that is.These required services include the following:

-Each patient must have a comprehensive care plan.

-Services must be quality-driven, cost effective, culturally appropriate, person- and family-centered, and evidence-based.

-Services must include prevention and health promotion healthcare, mental health and substance use disorder care, long-term care services, as well as linkages to community supports and resources.

Next slide.[9:00]

Slide:Required services (continued)

In addition, service delivery must involve continuing care strategies, including care management, care coordination, and transitional care from the hospital to the community.Health home providers importantly do not need to provide all the required services themselves, but they must ensure that the full array of services is available and coordinated.And finally, providers must be able to use health information technology to facilitate the work of the health home and establish quality improvement efforts.Next slide please.

Slide:Target population

In terms of target populations for this, individuals to be served by the health home must have a chronic condition, mainly a mental health or substance use condition, asthma, diabetes, heart disease, or be overweight.The guidance from CMS notes that this list may actually grow over time.While states may propose in their state plan amendment to address all of the eligible chronic conditions, at a minimum they must target the program to people who have either two or more chronic conditions, have one chronic condition and are at risk for another, or have one serious and persistent mental health condition.[10:00]

What is I think very striking to many of us as you look at this is that, regardless of which conditions are selected for focus, states are instructed to address mental health and substance use disorder services and are required to consult with SAMHSA about how they propose to provide mental health and substance use disorder prevention and treatment.So that’s regardless of what conditions they’re focusing on for this health home initiative.This new option offers the opportunity for mental health and substance use disorder treatment providers to become a health home for the people they serve, making real the concept of a behavioral health-based health home.The challenge for behavioral health agencies is how to create a behavioral health home that’s not just an administrative entity but possesses the capacity to actually improve outcomes for people with mental health and substance use conditions.And that’s really what we want to outline today, is some of the clinical pieces that need to be in place in order to ensure that.[11:00]So I’ll turn it over to you, Ben.

DR. DRUSS:Thank, Laurie.Next slide.

Slide:The opportunity

So I’ve always been outlining this as a real opportunity.It’s an opportunity for mental health consumers and an opportunity for mental health and substance use providers to become the health home for the people that they serve.And this would be a behavioral health-based health home, a health home that is situated in a behavioral Health Safety Net setting.Next slide.

Slide:Current Status of Medicaid State Health Home Amendments

Currently eight states have received federal approval for their programs under Section 2703 of the Affordable Care Act.Six more states currently have amendments under review.We’re going to be hearing about one in depth later today, Missouri.[12:00]But all of the approved states include people with serious mental illness as at least one target population and use per-member-per-month payments to health home providers to support the sorts of clinical features that we’ll be talking about today.Next slide.

Slide:The challenge

But the challenge for behavioral health agencies is to create a behavioral health home that isn’t just an administrative entity but possesses the capacity to improve outcomes for people with mental health and substance use conditions.And really what we’re going to be focusing on for the remainder of our talk is what those features are.Next slide.

Slide:Redesigning care to serve as health home

To function as a behavioral health home requires a major shift in roles, processes and care provided in behavioral health settings.And to achieve the shift behavioral health home reorganizes care delivery in several key areas, which have been described in the Chronic Care Model.[13:00]These include self-management support, delivery system design, decision support, clinical information systems, and community linkages.These are the core elements that have been described as being important for care of chronic conditions in general and mental disorders in particular, and which serves as an overarching framework for the behavioral health home.Next slide.

Slide:Self-management support

So to start with, self-management support.Self-management support is critical when you think about how little time people with a chronic condition such as diabetes spend in a provider’s office compared to the time that they spend on their own making decisions about diet, exercise, medication adherence that have such an important impact on their outcomes.[14:00]I’ve heard one primary care doctor refer to this issue as “free range humans.” People are out living their lives outside of doctors’ offices most of the time.So supporting consumer self-management involves both assessing level of activation—so figuring out how engaged a patient already is in managing their own illness and working effectively within the health system—and then addressing deficits through supporting self-management.And this includes both education but also coaching to help people move along and become more activated.Next slide.Laurie?

Slide:Delivery system design

DR. ALEXANDER:Yeah.So the next component that we look at is the delivery system design.And in order to be effective as a behavioral health home the actual delivery of care needs to be redesigned in a couple of key ways.[15:00]Two of those include the formation of multi-disciplinary practice teams and the provision of care management.So a behavioral health home requires providers to work together as part of a multi-disciplinary team sharing responsibility for addressing consumers’ comprehensive care needs.This team can work in a bunch of different ways.So they may be housed under one room, or really just function virtually with members stationed in different settings.Regardless of where they’re located it is essential that the members are able to function as a single unit, and of course this is not a simple thing.This means having clear roles, a shared care plan, effective communication, and really solid mechanisms for coordinating care between team members.

In addition, care management, which I’m sure you all have heard lots about over the last four or five years, this is another really critical piece of the delivery system redesign.It’s a key strategy in ensuring that consumers do not fall through the cracks.[16:00]Consumers likely to benefit from this more intensive kind of work would include mental health and substance use disorder clients who have a higher utilization of services, as well as those with numerous comorbid conditions.Care management focuses on client activation and education, care coordination and, when working with the treating provider, monitoring the consumer’s participation in and response to treatment.Next slide.

Slide:Decision support

The next key element is decision support.That involves strategies for ensuring that clinical care is provided in line with best practices, and as we all know that’s no simple thing.If we think about the primary care-based health home, that practice team is largely comprised of generalists.And when we think about a behavioral health home instead—so one that is located in a behavioral health setting—that team is going to be primarily composed of behavioral health experts.So regardless of setting, the practice team has a responsibility for providing or coordinating comprehensive evidence-based care for the patients.[17:00]

Now, that’s very hard to do when all you have is a generalist, or most of what you have is just behavioral health experts.So what the team needs is to find ways to supplement their skills and knowledge with the expertise of specialists and by embedding evidence-based guidelines in the routine provision of care.Making medical specialists available to behavioral health home practice team can be one effective way to support clinical decision making.Medical specialists may include primary care providers and/or specialists such as endocrinologists.Primary care providers delivering services will be the most common medical specialists in a behavioral health home.These providers may be physicians, or so-called mid-level providers such as nurse practitioners.If sufficient resources are available the behavioral health home can contract with or even hire a specialist to be onsite full-time or a day or two a week.This allows for informal training of the clinician and more continuous contact with the same consumer, which is truly optimal as I’m sure you’d understand.[18:00]If that is not feasible however, there are some very good models out there for how to use even a small amount of specialist time to very good effect.