HEALTH CARE INTEGRATION: BLESSINGS & BLOCKAGES

Focus on small, rural programs and communities

Tara Shepherd, MA, CADC-CASDeputy DirectorModoc County Health ServicesModoc County Behavioral Health

Twelfth Statewide ConferenceIntegrating Substance Use, Mental Health, and Primary Care Services:

Integration from the Ground Up Universal City, California

October 28-29, 2015

What is integrated health care?“Integrated care is when health professionals consider all health conditions at the same time.”SAMHSA, Understanding Health Reform: Integrated Care and Why You Should Care, 2012.

Why Integrate ?o People w/ serious mental illness

die 25 years earlier than general population ...

2/3 of these deaths are from preventable, treatable conditions – heart, lung, diabetes, infectious diseases

o Co-occurring MH/SU disorders worst mortality gap ...

Both SMI & SU – average age of death = 45SMI only – average age of death = 53

Client/Patient/

Consumer

SubstanceUseServices

MentalHealthServices

PrimaryHealthcareServices

The client – and family/ significant others – must have central roles in the partnership.

Some “blessings” of integration:

Treating the “whole person” Better, safer client outcomes Increased client satisfactionMost effective approach for people with multiple healthcare needs

More “blessings” of integration:Coordination of diagnoses &

treatmentsMedication reconciliationInterdisciplinary care teamsContinuity of careMost effective use of resources

Some “blockages” to integration: • Shortage of healthcare practitioners,

especially in isolated, rural areas (Medically Underserved Areas);

• 42CFR as a potential barrier to information sharing;

• Funding silos - “Carve outs,” managed care, fee-for-service, Drug Medi-Cal, Speciality MH Medi-Cal, private insurance, federal regs.

More potential Blocks

• Different “cultures” – primary care, substance use and mental health;

• Stigma – substance use and mental health disorders.

MODOC COUNTY

Designated by legislation as a

“Frontier County”

Service delivery is hampered by extremely low density of residents

9,147 – total County population

< 3 people per square mile

Medically Underserved Areas (MUAs) are determined by evaluation of criteria established through federal regulation to identify geographic areas based on demographic data.

Approximately 17% of Californians live in a MUA, with MUAs in 33/58 counties.

Designation as a Medically Underserved Area

“Medically Underserved Area” designation requests

CRITERIA . . .

Percentage of population at 100% below poverty;

Percentage of population > 65; Infant mortality rate; and Primary care physicians per 1,000 population

Impacts of healthcare provider shortages on Integration Efforts – The Modoc County Experience Not enough medical providers, especially for a high poverty/high risk population Overworked medical providers do not have the time to take a proactive role in integration Medical providers are open (and sometimes eager) to join integration/collaboration efforts designed and led by Behavioral Health

MODOC COUNTY – FIRST FOCUSED ON BEHAVIORAL HEALTH INTEGRATION (MH & SU)

. . . THEN BEHAVIORAL HEALTH TOOK THE LEAD ON COLLABORATION WITH PRIMARY CARE

InModocCounty

Pre – 2011 – Modoc County Health Services• Mental Health, Public Health, Alcohol and

Drug Services & Environmental Health2011 – at the request of Health Services Modoc CountyBOS approved combining MH and A&D Services into Behavioral Health -- Reactions varied !!

? ? ? Buy – In ? ? ?

Who Needs to Buy-in for BH Integration to be Successful? Staff – Clinical, fiscal & support Consumers/Clients All management/supervisory levels Other community partners

Behavioral Health Integrationo Put together a Planning Team of MH/AOD

staff, management, clients/consumers, and other stakeholders (e.g., Collaborative Treatment Courts Coordinator, Probation,Public Health);

o 2 Meetings a month for nearly a year.

The BH Integration Planning Team . . .o Developed a Mission Statemento Agreed on Goals and Objectiveso Designed a comprehensive Behavioral Health

system, addressing/integrating:

~ MH, SU and physical health ~ Client-centered, cultural competence, wellness and recovery

So . . .How did we

handle 42 CFR for our BH

integration?

Confidentiality . . .

Rise to the higher level of requirements

Mental health and SU both follow HIPPAA and 42-CFR

We posted a notice, and mailed the notice to current clients . . .o Notification of our plans to integrate Mental

Health and Alcohol & Drug Services;o Informed current clients of new forms and

processes;o Current clients signed new forms at next

scheduled appointment.

New “Consent for Treatment/Admission Agreement”o Addressed all regulatory requirements for MH

and SU Services;o Notification of integration, including MH and SU

staff ability to access client records;o Reviewed and approved by Attorney Linda Garrett,

Risk Management Services.

MODOC COUNTY BEHAVIORAL HEALTHCONSENT FOR TREATMENT/ADMISSION

AGREEMENT“It is understood that MCBH is an integrated mental health and substance use treatment program, which includes integrated record-keeping, treatment planning, and treatment provision. Staff providing substance use and/or mental health services will have access to your records to the extent it is required to effectively do their jobs.”

•Integrated Electronic Health Record; (Anasazi/Kingsview)

•Integrated scheduling;

• Integrated intake interview process

~ intro on integration, demographics, client rights, data reporting elements, collection of financial data, consent/admission agreement, privacy practices and other informing materials.

. . . PROGRESS: Behavioral Health Integration

• Integrated Treatment Team meetings

o Monday am – Weekend crises calls review

o Tuesday – MHSA Full Service Partner Reviews

o Thursday – QI/UR

• Integrated Behavioral Health Treatment Plans

MCBH Flow Chart of Client Services (Adults)

Mental Health Services Substance Use Services Both

Intake Interview Medical Intake History & Vitals & PCP Release

Substance Use Assessment and/or Mental Health Assessment w/ Psych Section ASI as screener w/ SU Screener

Utilization ReviewPrimary + Treatment Team Members Assigned;

Referral Needs Assessed

Integrated BH Treatment Plan

Possible Referrals: In-houseFull MH or SU assessment (per screening), telepsych

meds assessment (MH &/or SU MAT),

meds mgmt w/ BH Nurse, case mgmt or rehab services.

Possible Tx Team Members

MH therapist, SU counselor,

case manager, BH nurse, telepsychiatric provider,

rehab specialist, peer support specialistPossible Referrals: External

Consumer-operated non-profit Wellness Center, medical, dental, vocational,

educational, legal, etc.

BH Initiatives for Collaborating w/ Primary Care in Modoc County

• Vigorously Seek ROI w/ Primary Care Provider, & send copy to PCP;

• Medical Care Referral Form;• Medical Care Visit Form;• Medication Reconciliation with one primary

care clinic.

. . . On-going BH Efforts for Collaborating with Primary Care in Modoc County

• To allow real-time sharing of information between BH & PC:o Through CIBHS Collaborative,

tested two registries;o High hopes for current CIBHS

initiative with eBHS.

Where do we go from here?• Continue to pursue registry –

high hopes for eBHS (CIBHS);

• Respond to request from largest clinic in County for medication reconciliation efforts for “frequent users” among shared clients – “by hand” tabulation without registry.

. . . Where do we go from here?• When new hospital/medical clinic is

built:o Explore possibilities for co-locating

BH at new site . . .

~ Financial barriers to full co-location;

~ Options for partial co-location.

Resources

1.Croze, Colette, MSW, Healthcare Integration in the Era of the Affordable Care Act, for the Association for Behavioral Health and Wellness, 2015.

2.gis.oshpd.ca.gov/atlas/topics/shortage/mua.3.Mauer, B. and Weisner, C., CIMH Webinar, The Case

for Integrated Care, 2010.4.SAMHSA, Understanding Health Reform: Integrated

Care and Why You Should Care, 2012.5.www.nasmhpd.org, Morbidity and Mortality in

Persons with Serious Mental Illness, 2006.

Thank you!