2013-09-19 13.31 Integrating Behavioral Health in Primary Care Lessons from Health Centers

Transcript of Webinar:

2013-09-19 13.31 Integrating Behavioral Health in Primary Care_ Lessons from Health Centers

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BEGIN TRANSCRIPT:

LAURA GALBREATH: …Ary Care: Lessons Learned from Health Centers." My name is Laura Galbreath, and I will serve as the Moderator for today's webinar. [Pauses] Just a little bit about the Center for Integrated Health Solutions, if you're not already familiar with us, we are a national training and technical assistance center dedicated to supporting the bidirectional integration of primary and behavioral healthcare, and that really does mean both sides of integration – behavioral health into primary care as well as important primary care services embedded in the behavioral health setting. So thank you for joining us today for the Center for Integrated Health Solutions. We also want to thank our partner for today's webinar – the National Association of Community Health Centers, representing America's voice for community healthcare. Our partner in today's webinar is focused on the behavioral health learning community that the Center supported over this past year. [00:00:57]

What we'll be talking about today is we'll be getting some highlights of the learning community, so you can hear a little bit about what was achieved from the program. You'll hear from two health center participants, and then we'll have a question-and-answer and a discussion period so you can ask questions of any of our presenters to learn more about how they went about the process of integrating behavioral health into their primary care settings. A couple of housekeeping remarks before I turn it over to our presenters – just remember that today's webinar is being recorded, and that all of our participants are in a listen-only mode. You will be able to follow the call-in information on the webinar, on the right-hand side of the screen. At any time during the webinar, you can type in and submit your questions, and we'll get to those as soon as we can during the Q-and-A session and as time allows. And, again, I just want to remind you that today's webinar slides are available right now on the CIH's website. If you'd like to go to the website and pull those down and print those so that you could take notes, then that is an option that you can access. [00:02:04]

And so, with that, here is who we have today on the webinar. I've already introduced myself and Moderator. I'm going to introduce Roger Chaufournier, who is the principal at CSI Solutions and one of the lead faculty working with the National Association of Community Health Centers on this behavioral health learning community. So, Roger, I'm going to go ahead and turn it over to you to introduce our teams and get us started today.

ROGER CHAUFOURNIER: Great. Well, thank you so much, Laura. I am joined today by my colleague Laurel Simmons as well as Kathy McNamara from the National Association of Community Health Centers, and also with two community health centers on both sides of the United States, from Manet Community Health Center, Denise Mulcahy, who is the PCMH Project Manager, and Cynthia Sierra, who is Senior Director of Public Policy. In addition, I have at Tillamook over on the other Coast, in Oregon, Marlene Putman, who is the Administrator of the Tillamook County Health and Human Services, and Barbara Weathersby, who is a licensed social worker and a behavioral health provider. We are also joined by [Sherry Levitt, who – Lobocktu] (ph) is their patient representative. Next slide, please – [00:03:16]

So we'll be quickly talking about the context for this overall initiative. When we talk about behavioral health integration, there are certain design elements that we keep in mind, that would include: universal screening, degree of self-management support, and including the potential for brief interventions by behaviorists, the treatments that have identified that condition, that treatment by the care team, and then the appropriate referral necessary to psychologists or psychiatrists. So these are design elements, a part of the integration that we've been seeking. Next slide, please – [00:03:51]

As most of you know on the call, there is a spectrum of integration models. Part of this effort was to explore different models and see what models would fit best with local circumstances. So one of the end of spectrum are pure referral relationships, either informally or formal relationships, and at the other end of the spectrum is a fully integrated, multidisciplinary care team truly serving as a healthcare home for the population for behavioral health, other (ph) health, and other comorbidities, and co-services are integrated into a multidisciplinary care team environment. Next slide, please –

So the effort that we are talking about today is a learning community that was launched in support by the National Council as well as National Association of Community Health Centers, as well as SAMHSA, all working to explore what opportunities there are to accelerate integration within the federally qualified health center community environment. An audience of 11 health centers were recruited, and a curriculum was put together in a very rapid timeframe, that involved an initial face-to-face meeting and then a series of virtual webcasts and support, offline coaching, and helping the individual organizations with their efforts. You will hear from two of those centers today. Next slide, please – [00:05:12]

So through this journey, there were a series of participants. You'll see at the bottom half of the screen that they represented very diverse parts of the Country from Georgia to Montana, Indiana, Missouri, Michigan, Oregon, and Massachusetts, and so very diverse practice settings, both rural and urban; very different sizes of health center complexity; and very diverse populations. Next slide, please –

The meat of the work centered on several core areas of focus to explore the underlying integration opportunity. One of the key issues that every organization faces is the underlying business case – how do we pay for these services. [00:06:02]

So often, this is held out as a problem that is preventing integration, preventing the ability to offer these services, so we wanted to explore where there are opportunities for a business case. So we know, on the business case side, there are costs of services that include the costs of screening, the cost of the actual intervention, but there is also costs for transition that include training, any time that staff are working on the initiative, and that needs to be built into the model. But there is also – those costs are, hopefully, offset by some degree of reimbursement. And, in some cases, there may be very little reimbursement, but one of the hidden aspects of the business case or the productivity gains for serving - addressing behavioral health issues in the primary care model. As we talk to our federally qualified health centers, we see an increasing number of the patient population as a comorbidity of depression, anxiety disorder, or behavioral health conditions, and that – those disorders often are taking up the bulk of the time in the clinical offices. Next slide, please – [00:07:06]

So when you look at day-to-day productivity in primary care, a lot of the productivity is hindered by having to address some of the behavioral health issues without the adequate resources, training, and support to do that. So we have the different centers participate in walking through a model. This tool will be available, and we'll [speak to that] (ph) a little bit later in the call, but an ability to customize a model to the local state reimbursement, so, again, the local salary and cost levels. In the top right-hand corner, you see estimates on looking at what could be done to actually save time. So we had the centers do time-and-motion studies where they actually went in and looked at their visits and made some estimates of how much time - when the time went over a standard 15-minute visit, how much of that time was taken up with behavioral health issues, and what opportunity costs did that represent. [00:08:00]

And by saving that time, that would then translate into potential new slots and potential new revenue for the center. So, with this tool, most of the centers came in assuming there was often not a business case or there was very poor reimbursement, and when they factored in the existing reimbursement, the productivity settings (ph), they often discovered that there were – actually was a business case. Next slide, please –

A second body of work was something that we focused on as part of, how do you build will across your organization. How do you get the medical component to want to integrate the behavioral health services? How do you get leadership brought in, the board, other stakeholders in the organization? And, often, these discussions are very abstract. So the next slides we borrowed from, actually, some work that had been done in the Hawaii Beacon community to take a – challenge each of the organizations to take a very complex patient that they have, who represent a high-cost, someone who is in the ER frequently, has many comorbidities including behavioral health, and follow that patient for a 90-day period to create an ideal pathway for what support and services does that individual need, and document the business case, and then use that information to educate your stakeholders. Next slide, please – [00:09:16]

And so we see that, from that, this is an example again. This is from the Bay Clinic in Hawaii, so shout out to the FQHC in that environment. They had a 69 year-old male who was – you see multiple chronic diseases that included renal failure, heart failure, hypertension, and you see polysubstance abuse as well as undetermined psychiatric issues. Next slide, please –

So they followed this patient, diligently working with their expanded medical neighborhood, and began to look at what were some of the interventions that needed to be made, and then began to systematically address those issues. Next slide, please – [00:09:56]

Through that process, they discovered there were a lot of challenges. You see from just mapping who in the care team and the expanded medical neighborhood that need to be involved in the care, it starts to get quite complicated, and needing to really map that as part of an integrated team. Next slide, please –

So each of our 11 centers were challenged to do this exercise and then use the information to be able to build will within the organization help explain why do we need to make these changes, what is the benefit for the organization and our patients, and how can we move forward. So this is an example of some of the work that had been done with this [particular patient] (ph). Next slide, please – and you'll hear a [valid story] (ph) from our colleagues in a second. Each of the groups were challenged to step back and to better understand who do they measure integration and how do they measure progress in terms of improving the health of their population. So we were able to aggregate the prevailing measures used in the industry, provide them with some better information, and work on the type of dashboards that they would want to see, that offer balanced measures to understand the integration of behavioral health working with their population. So each team chose a set of measures to assess their own progress and to use part of their long-term dashboard. Next slide, please – [00:11:14]

So with those measures are some examples of some of the standard measures that should be familiar to many of those on the phone, everything from patient satisfaction scores to [PHQ economic] (ph) scores, and even looking at things like the warm hand-offs and to what degree are we able to achieve those warm hand-offs between our primary care team and our behavioral health support team that is part of our integrated model. Next slide, please –

So, as we look at how these teams progressed, we see that there was a behavioral health integration assessment tool that we asked them to self-assess at their baseline and then downstream, at the end of the initiative. They completed, as you see, those two surveys – one in December and then in May – so this project transpired over a six- to seven-month period. [00:12:07]

We had - most of the participants were able to resolve their model of integration and have been able to make headway in at least two or more of the key elements of the integration of that screening or the types of relationships they'd set up, and most were able to achieve clarity on the business case and really understand the micro- and macroeconomics of behavioral health integration in their organization. Next slide, please –

So we'll see from voices from the field that they – this is very hard work. Integration is slow. Sometimes, it is starting off with a very base resource and evolving. Buy-in is something that does take some time, and, again, having that type of dolly case can help to facilitate that buy-in. But once through this transition and integration, the feedback from the care teams and the medical providers, and the behavioral health team is that life is so much easier having been able to move into the integration and really having a major impact on their work flows, on the impact on their patients, and on the quality of work life for all of those involved. Next slide, please – [00:13:14]