behavioral health integration: a care management imperative€¦ · delayed diagnosis/treatment...

W W W . H E A L T H M A N A G E M E N T . C O M

Behavioral Health Integration: A Care Management Imperative

BEHAVIORAL HEALTH DISORDERS WERE THE LARGEST CAUSE OF DISEASE BURDEN IN THE UNITED STATES IN 2015

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3,355 3,131 3,065 2,419 2,357 1,827 1,463 1,050 642 624

Disability Adjusted Life Years (DALYs) Lost per 100,000 population

Source: Kamal R, Cox C, Rousseau D, et al. Costs and Outcomes of Mental Health and Substance Use Disorders in the US. JAMA 2017;318(5): 415.

MENTAL DISORDERS ARE THE MOST COSTLY CONDITIONS IN THE UNITED STATES IN 2013

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Source: Roehrig C, Mental Disorders Top The List Of The Most Costly Conditions In The United States: $201 Billion. Health Affairs 35, no. 6 (2016) 1130 – 1135.

$- $50 $100 $150 $200 $250

Mental disorders

Heart conditions

Trauma

Cancer

Pulmonary conditions

Annual Cost (Billions)

MENTAL HEALTH CONDITIONS INCREASE MEDICAL COSTS

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*Note: Does not include any BH spend

0% 20% 40% 60% 80% 100% 120% 140% 160% 180%

ArthtitisHypertensionChronic Pain

Diabetes MellitusAsthma

IHDCOPD

CancerCHF

Stroke

Percentage Increase in PMPM Medical* Spend when there is a Comorbid MH Condition

Anxiety Depression

Source: Melek S, Norris D. Chronic conditions and comorbid psychological disorders. Milliman Research Report. July, 2008.

5

Patrick Gordon

Tamara Hamlish

Virna Little

Joe Parks

Senior VP, Rocky Mountain Health

Plans/United

Executive Director, ECHO

Chicago

Senior VP, Institute for

Family Health

Medical Director, National Council

for Behavioral Health

TODAY’S PANEL

Thoughts From a ProviderBehavioral Health in Integrated

SettingsVirna Little, Psyd, LCSW, CCM, SAP

Transdisciplinary Team Care

• The advanced model of team care developed from collaboration and integration work

• What all current health home and care setting team members should aspire to

• Education and cross training are key • Shared accountability

IMPACT Team Care Model

TWO PROCESSESTWO NEW ‘TEAM MEMBERS’

Care Manager Consulting Psychiatrist

1. Systematic diagnosis and outcomes tracking

PHQ-9 to facilitate diagnosis and track depression outcomes

- Patient education / self management support

- Close follow-up to make sure pts don’t ‘fall through the cracks’

- Caseload consultation for care manager and PCP (population-based)

- Diagnostic consultation on difficult cases

2. Stepped Care

a) Change treatment according to evidence-based algorithm if patient is not improving

b) Relapse prevention once patient is improved

- Support anti-depressant Rx by PCP

- Brief counseling (behavioral activation, PST-PC, CBT, IPT)

- Facilitate treatment change / referral to mental health

- Relapse prevention

- Consultation focused on patients not improving as expected

- Recommendations for additional treatment / referral according to evidence-based guidelines

Shared Accountability

• Needs to be more than words• “ Baked “ into your system ( emr, evals)• Can rotate decision supports or areas of focus

Funding and Reimbursement

• Direct vs. Indirect• Productivity vs. Capacity • Transitions of Care• Collaborative care codes• Optimizing schedules and Coding for behavioral health

Questions and Thoughts

The mission of ECHO-Chicago is to establish a robust community-based knowledge

network that reduces the serious health disparities affecting children and adults in

underserved communities.

ECHO-Chicago Mission

Behavioral Health Integration Using ECHO2017 HMA ConferenceTamara Hamlish, PhD

ECHO: How it Works

Image courtesy of ECHO Institute

The Extension for Community Health Outcomes (ECHO) uses case-based, iterative, telehealth delivered via high-grade videoconference technology to bring advanced training and support to community-based primary care providers

ECHO: Benefits/ROI


• Patient care cost savings/ROI is systems level• Short term: patients have overall better health, fewer episodes of acute

illness, ER visits, hospital admissions • Long term: reduce complications and higher cost interventions from

delayed diagnosis/treatment (e.g., liver transplant for hep C)• Current unmet demand is met, at a lower cost than normally incurred• Advanced training across the care team: nurses, care coordinators, and

pharmacists take on expanded role, reducing annual cost per patient

• Provider training costs are comparable to or lower than conventional CME and significantly lower than comparable in-person practice coaching

ECHO ACT


The ECHO Act (December 14, 2016) requires the Department of Health and Human Services to report on technology-enabled collaborative learning and capacity building models which connect specialists to primary care providers through videoconferencing to facilitate case-based learning, dissemination of best practices, and evaluation of outcomes, and must include:

1. an analysis of the use, integration, and impact of such models;

2. a list of such models recently funded by HHS;

3. recommendations to reduce barriers to adoption of such models;

4. opportunities for adoption of such models into HHS programs; and recommendations regarding the role of such models in continuing medical education

U.S. ECHO Hubs and Superhubshttps://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/

Behavioral Health IntegrationCollaborative Care: Systems Change• Multi-disciplinary team play• Systems based quality

improvement strategies • Multi-institutional faculty team• Case presentation include

systems change, PDSA cycles• Capstone project

PCP Toolkit• Expand PCP skills and collaboration with behavioral health providers• Clinical guidelines/disease management • Patient case presentations

http://www.mhinnovation.net/innovations/collaborative-care-model

Contact InformationECHO-ChicagoThe University of Chicago Medicine5841 South Maryland Ave. MC 6082Chicago, IL 60637

Isa RodriguezOutreach CoordinatorMobile: (773) [email protected]

Daniel Johnson, MDDirector, ECHO-ChicagoPhone: [email protected]

Doriane Miller, MDBHI Facilitator and Subject Matter Expert [email protected]

Tamara Hamlish, PhDExecutive Director, ECHO-ChicagoPhone: [email protected]

Daniel Yohanna, MDBHI Facilitator and Subject Matter [email protected]

http://www.echo-chicago.org/

Care Management from the Behavioral Health Side

Behavioral Health Integration

• 2881 Members providing or supporting treatment for Mental Illnesses and Addiction

• Services– Mental Health First Aid – over 1 million trained– Center for Integrated Health Solutions (HHS)– CDC National Networks– Improving Business & Clinical Practices– Advocacy and Policy– Medical Director Institute

The National Council for Behavioral Health

People with SMI have Higher Rates of Chronic Medical Illness

59.4

33.930 28.6 28.4

22.8 21.7

16.5

11.5 11.16.3 5.9

0

20

40

60

80

% M

embe

rs

SMI (N=9224)

Non-SMI(N=7352)

Chart1

Skeletal- ConnectiveSkeletal- Connective

Gastro-IntestinalGastro-Intestinal

Obesity/DyslipidObesity/Dyslipid

COPDCOPD

Infectious DiseaseInfectious Disease

HypertensionHypertension

Dental DisordersDental Disorders

DiabetesDiabetes

CancerCancer

Heart DiseaseHeart Disease

Pneumonia/InfluenzaPneumonia/Influenza

Liver DiseaseLiver Disease

SMI (N=9224)

Non-SMI (N=7352)

% Members

59.4

44.3

33.9

19.7

30

20.4

28.6

15.2

28.4

17.9

22.8

17

21.7

11.5

16.5

10.1

11.5

9.9

11.1

7.9

6.3

3.9

5.9

1.9

Sheet1

Skeletal- ConnectiveGastro-IntestinalObesity/DyslipidCOPDInfectious DiseaseHypertensionDental DisordersDiabetesCancerHeart DiseasePneumonia/InfluenzaLiver Disease

SMI (N=9224)59.433.93028.628.422.821.716.511.511.16.35.9

Non-SMI (N=7352)44.319.720.415.217.91711.510.19.97.93.91.9

• Integration is a range of specific clinical work behaviors– Single point of accountability for overall care coordination

and management– Single treatment plan– Treatment team that is both medically and behavioral

health competent

• Integrated funding can be helpful but is neither necessary nor sufficient– Separate funding can be effectively blended– Integrated funding all too frequently ends up funding

separate care

Integrated Funding Versus Integrated Care

• Psychiatry Shortage– 40% of psychiatrists are in cash only practice– 70% of community mental health centers reported losing

money on psychiatric services– Hospitals have to subsidize part of the professional cost of

psychiatric care out of the hospital payment

• People Waiting in Emergency Rooms– Hospitals report losing money on inpatient psychiatric care– Community providers cannot get reimbursement for many of

the effective new practices

• Substantial portion persons with SMI are still uninsured

• Quality of treatment is very uneven - some is quite good and some not

No Integration without Real Parity

• Organizations limit provision of behavioral health care because they lose money or can make more money and other areas of healthcare

• Payment rates for behavioral healthcare must be sufficient to cover the actual cost of care

• Many components of the new effective care approaches are not directly reimbursable with the current payment methodologies and billing codes

• Some types of facilities and types of providers of the effective treatments are not reimbursable in general

Rates Are a Parity Issue

• Assess rate parity adequacy by comparison of the degree to which the managed care rates compare to the open market cash going rate -behavioral health vs general medical care

• Assess adequacy of the provider panel and access to care by secret shopper surveys

Enforce Parity Requirements

• SAMHSA-HRSA Primary and Behavioral Health Care Integration (PBHCI) Grantees

• 2703 Medicaid State Plan Amendments (SPA)– Allow for enhanced Medicaid funding (usually case rate) for Health Home for patients with SMI – May be located in a community mental health center, sometimes called a “behavioral health

home”

• Certified Community Behavioral Health Centers– Launched 2017

Whole person care management In the Behavioral Health Organizations

• Should be expanded beyond the current eight state demonstration and extended beyond the current two-year demonstration period

• The payment rates are set to be adequate to cover the actual cost of care (just like managed care rates)

• Payment rates can include financial incentive for high-quality care• Rates cover all components of new affective evidence-based

treatments • Required to provide treatment for addictions• Required to provide or coordinate with and support medical

treatment• Required to offer a wide range of new effective evidence-based

treatments• Required to offer extended hours and 24/7 crisis services• Required to publicly report treatment quality performance measures• Required to serve all patients regardless of ability to pay

Certified Community Behavioral Health Centers

• Higher Cost/Utilization Patients have more opportunities for improving and cost savings

• More Comfortable working outside of Clinic/in Community

• Ability to maintain engagement with people others don’t understand and can’t tolerate

• Actually know what Social Determinates of Health are and how to impact them

• Motivational Interviewing• Lower unit cost for personal interactions

BH Advantages

A1C Levels Over Time

About 7% had uncontrolled A1c levels

1 POINT DROP IN A1C

21% ↓ in diabetes related deaths

14% ↓ in heart attack

31% ↓ in microvascular complications

10.0

9.2 9.1

9.1

7.5

8

8.5

9

9.5

10

10.5

Baseline Year 1 Year 2 Year 3

PCHH

10.1

9.2

8.98.6

7.5

8

8.5

9

9.5

10

10.5


CMHC-HH

LDL Levels Over Time

About 45% had uncontrolled LDL levels

10% DROP IN LDL LEVEL

30% ↓ in cardiovascular disease

132

121 119116

100

110

120

130

140

150

160


PCHHs

132

115112

106

100

110

120

130

140

150

160


CMHC-HHs

Blood Pressure Changes Over Time

6 POINT DROP IN BLOOD PRESSURE

• 16% ↓ in CD

• 42% ↓ in stroke20-24% had uncontrolled BP levels

152.9

134.9 134.4 133.1

97.986 84.9 83.3

30

50

70

90

110

130

150

170


CMHC-HHs

Systolic

152.9144.1 143.3 141.4

96.989.7 89.1 87.4

30

50

70

90

110

130

150

170


PCHHs

Systolic

Diastolic

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

2012

-120

12-2

2012

-320

12-4

2012

-520

12-6

2012

-720

12-8

2012

-920

12-1

020

12-1

120

12-1

220

13-1

2013

-220

13-3

2013

-420

13-5

2013

-620

13-7

2013

-820

13-9

2013

-10

2013

-11

2013

-12

2014

-120

14-2

2014

-320

14-4

2014

-520

14-6

2014

-7

%Follow-Up

%MedicationReconciliation

Hospital Follow-up Jan 2012 through July 2014Follow-Up Within 72 Hours of Hospital Discharge

DIABETES

Adults continuously enrolled

N= 1,889 (at 3.5 years)

N= 4,526 (Dec 2015)

Data source: CMT

Chart1

Good Cholesterol(

HYPERTENSION & CARDIOVASCULAR DISEASE

Adults continuously enrolled

CVD N= 232 (at 3.5 years)

CVD N= 564(Dec 2015)

HTN N= 2,401(at 3.5 years)

HTN N= 6,111(Dec 2015)

Data source: CMT

Chart1

Good Cholesterol for Clients w/ CVD(

% OF CLIENTS WITH 1+ HOSPITALIZATION

10%

15%

20%

25%

30%

35%

40%

2008 2009 2010 2011 2012

First Year

9.1%

CMHC HCH Implementation January 1, 2012

Data source: MIMH

ER & HOSPITAL DAYS PER 1,000

CMHC HCH Implementation January 1, 2012

Data source: MIMH

Chart1

20092009

20102010

20112011

20122012

20132013

20142014

Pre 1 vs Post 3 34%

Pre 1 vs Post 3 38%

ER Visits Per 1000

Hospital Days Per 1000

ER Visits

Hospital Days

34.5

197.7

43.4

254.9

46.2

263.4

37.9

208.6

33.2

184.1

30.4

163.1

Sheet1

ER VisitsHospital DaysSeries 3

200934.5197.72

201043.4254.92

201146.2263.43

201237.9208.65

201333.2184.1

201430.4163.1

HOSPITAL ENCOUNTERS

N= 17,084 (2011)

N= 18,776 (2012)

N= 19,103 (2013)

N= 20,345 (2014)

Data source: CMT

Chart1

Pre 12011Pre 12011

Year 12012Year 12012



54%

46%

45%

47%

55%

53%

53%

47%

PsychiatricHospitalization

General MedicalHospitalization

6733

7771

5815

7037

5514

6340

5642

6336

Sheet1

PsychiatricHospitalizationGeneral MedicalHospitalizationSeries 3

Pre 12011673377712

Year 12012581570372

Year 22013551463403

Year 3201456426336

4.52.85

ER ENCOUNTERS

N= 17,084 (2011)

N= 18,776 (2012)

N= 19,103 (2013)

N= 20,345 (2014)

85% 86% 86% 86%

15% 14% 14% 14%

Data source: CMT

Chart1

Pre 12011Pre 12011




PsychiatricER Visit

General MedicalER Visit

6534

36320

5792

36924

5498

34540

5694

36336

Sheet1

PsychiatricER VisitGeneral MedicalER VisitSeries 3

Pre 120116534363202

Year 120125792369242

Year 220135498345403

Year 32014569436336

AVERAGE # OF ER & HOSPITAL ENCOUNTERS

N= 17,084 (2011)

N= 18,776 (2012)

N= 19,103 (2013)

N= 20,345 (2014)

Chart1

Pre 12011Pre 12011




Avg # HospitalizationsPer Enrollee Per Year

Avg # ER VisitsPer Enrollee Per Year

0.85

2.5

0.68

2.27

0.62

2.09

0.58

2.06

Sheet1

Avg # HospitalizationsPer Enrollee Per YearAvg # ER VisitsPer Enrollee Per YearSeries 3

Pre 120110.852.52

Year 120120.682.272

Year 220130.622.093

Year 320140.582.06

Health Homes have saved Missouri an estimated$36.3 millionSAVINGS = $60 PMPM

Community Mental Health Center Healthcare Homes have saved Missouri $31 millionSAVINGS = $98 PMPM

DM3700 subset saved $22.8 millionSAVINGS = $395 PMPM(4,800 lives)

Cost Savings Year 1 (2012)

About CIHS

Make integrated care the national standard of practice

Create and operate world-class technical assistance

Ensure the success of SAMHSA, HRSA funded programs

Disseminate practical tools, resources, and lessons learned

About the Center Since 2010 CIHS has served as a national training and technical assistance

center on the bidirectional integration of primary and behavioral health care

CIHS is jointed funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration (HRSA)

CIHS is run by the National Council for Behavioral Health

The Center’s primary goals are to:

Support relevant funded grants and cooperative agreements working to integrate primary and behavioral health care, providing training and technical assistance (TTA) to communities with cooperative agreements awarded by SAMHSA and HRSA

Develop materials about integrated care for a national audience meeting the needs of SAMHSA and HRSA through research, development and dissemination of critical information and documents, therein creating greater awareness of the importance of integrating primary and behavioral health care to the overall health of the nation.

Our Target Audiences

Primary and Behavioral Health Care Integration (PBHCI)

Minority AIDS Initiative Continuum of Care (MAI-CoC)

HRSA Behavioral Health Expansion Grantees and other safety-net providers

National Audience: Providers, Policy Makers, Stakeholders

SAMHSA PBHCI GranteesCommunity Behavioral Health Organizations• Majority are CMHCs, ~40+% are SA providers• 79% partner with an Federally Qualified Health

Center (FQHC)• 60,000+ adults with SMI served• 126 Grants

Grantee Cohorts:13 awarded 200943 awarded 2010

8 awarded 201130 awarded 2012

6 awarded 201326 awarded 201460 awarded 2015

Services Available from CIHS

• Group Learning Experiences: Regional and Online Learning Communities Cross-site TA Trainings and Peer Learning National Webinars

• Tools: Web-based Tools and Resources Issue Briefs Webinars Curated Content Monthly eSolutions Newsletter

• Individual Technical Assistance: Phone and video consultations, e-mail, site visits

Paying for Integration, Learning LessonsHMA Future of Medicaid| Chicago 9-11-17

Who, what, where

• Colorado based, UnitedHealthcare plan;

• 185,000 Medicaid, MMP & CHIP members;

• Heavily invested in scaling APM payment for comprehensive primary care;

• Enhanced, risk-adjusted, attribution-based capitation for primary care;

• Additional BH funding for integrated in higher performing practices;

• Shared data, oversight and savings with CMHCs.

BH Model

• Critical facet of comprehensive primary care — no different than investments in practice-based care management, measurement and other data use competencies, technology and practice transformation support.

• Payment based upon defined practice budgets for personnel, interventions and related infrastructure – to create team-based, whole-person care

• RMHP payer mix in practice is ~+30%

• BH providers are not trapped in a workflow designed to maximize volume-based payments, or pigeon holed into distinct “physical” and “mental health” coding categories.

• Primary care practices “own” their own behavioral health resources and are fully accountable for measured outcomes.

Measures

• Patient Activation

• Anxiety

• Depression

• Substance Abuse

• Chronic conditions management

• Productivity

In-flight status….

• High practice engagement, progressive CMHC leadership.

• Improved screening and diagnoses.

• TCOC 2-4% lower than non-transforming peers._________________________________________________________• CMHC referral and loop closure still opaque.

• Unclear ratio of BH resource to population need.

• BH role still unfolding.

• Culture, culture, culture....

Slide Number 1Behavioral health disorders were the Largest cause of disease burden in the united states in 2015Mental disorders are the most costly conditions in the united states in 2013Mental health conditions increase medical costs Slide Number 5Slide Number 6Thoughts From a Provider�Behavioral Health in Integrated SettingsTransdisciplinary Team CareIMPACT Team Care ModelShared AccountabilityFunding and ReimbursementQuestions and Thoughts Slide Number 13Slide Number 14ECHO: How it WorksECHO: Benefits/ROIECHO ACTSlide Number 18Contact InformationSlide Number 20Behavioral Health IntegrationThe National Council for Behavioral HealthPeople with SMI have Higher Rates of Chronic Medical IllnessIntegrated Funding Versus Integrated CareNo Integration without Real ParityRates Are a Parity IssueEnforce Parity RequirementsWhole person care management In the Behavioral Health OrganizationsCertified Community Behavioral Health CentersBH AdvantagesA1C Levels Over TimeLDL Levels Over TimeBlood Pressure �Changes Over TimeSlide Number 34Diabetes�Hypertension & Cardiovascular Disease% of Clients with 1+ HospitalizationER & Hospital Days per 1,000Hospital EncountersER EncountersAverage # of ER & Hospital EncountersSlide Number 42About CIHS�About the Center Our Target AudiencesSAMHSA PBHCI GranteesServices Available from CIHSSlide Number 48Paying for Integration, Learning Lessons�HMA Future of Medicaid| Chicago 9-11-17Who, what, whereBH ModelMeasuresIn-flight status….

behavioral health integration: a care management imperative€¦ · delayed diagnosis/treatment...

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