Behavioral HealthPhysical Health Integration Pilot

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Behavioral Health-Physical Health Integration
Pilot
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BH-PH Integration Pilot cont.

• Purpose
• Eliminate access to care barriers for ACCESS Plus
  enrollees who are active in both physical and
  behavioral health delivery systems

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BH-PH Integration Pilot cont.

• Mental health is central to overall health1
• and
• Physical health is central to mental health2

1Surgeon Generals Report to the Presidents New
Freedom Commission on Mental Health Achieving the
Promise -Transforming Mental Health Care in
America 2003 2National Association of State
Mental Health Program Directors (NASMHPD) Report
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BH-PH Integration Pilot cont.

• Importance of improved coordination of BH-PH
  services is well documented
• People with serious mental illness die, on
  average, 25 years earlier than general population
• 60 of premature deaths are due to medical
  conditions
• Cardiovascular disease
• Diabetes
• Pulmonary and infectious diseases

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BH-PH Integration Pilot cont.

• Goals
• Establish a formal mechanism to share guidelines
  and service expectations
• Identify commonalities across program approaches
• for enrollee support, outreach and follow up
• Improve care at BH-PH interface through
  information sharing, promotion of services and
  scripting
• Improve BH-PH follow up through
• telephonic support and field visits
• Reduce access to care barriers

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Shared Membership
Erie
McKean
Warren
Potter
Tioga
Bradford
Susquehanna
Crawford
Wayne
Wyoming
Forest
Sullivan
Lackawanna
Cameron
Elk
Venango
Pike
Lycoming
Mercer
Clinton
Clarion
Luzerne
Montour
Monroe
Jefferson
Lawrence
Clearfield
Columbia
Union
Butler
Carbon
Armstrong
Centre
Northumberland
Beaver
Northampton
Snyder
Schuylkill
Indiana
Mifflin
Lehigh
Cambria
Juniata
Allegheny
Blair
Berks
Bucks
Dauphin
Perry
Huntingdon
Westmoreland
Lebanon
Montgomery
Washington
Cumberland
Lancaster
Fulton
Chester
Bedford
Somerset
York
Fayette
Delaware
Greene
Philadelphia
Franklin
Adams
CBHNP Behavioral HealthChoices Counties
ACCESS Plus Counties

HealthChoices Counties(Non-ACCESS Plus)
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Shared Membership cont.

• Shared CBHNP and ACCESS Plus
• membership as of September 2008
• 48,000
• 7,160 in active BH treatment
• 723 inpatient hospitalization in
• past year
• 64 identified as high-risk for
• re-hospitalization

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Develop BH-PH Model

• Convened BH-PH work group to review current
  collaborative processes and identify coordination
  opportunities with
• CBHNP
• ACCESS Plus - Primary Care Case Management (PCCM)
  and Disease Management (DM)
• Department of Public Welfare Intensive Case
  Management Unit
• Office of Mental Health and Substance Abuse
  Services (OMHSAS)

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Protect Confidentiality

• Received input from DPW on HIPAA
• compliance issues
• Met the guidelines for nonconsensual
• release of information (DA records excluded)
• Signed revised confidentiality
• agreements between ACCESS Plus and CBHNP
• Included BH-PH coordination language in CBHNP and
  ACCESS Plus member newsletters and handbook

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Establish Process for Meaningful Data Exchange

• Determined how BH and PH data would be used by
  ACCESS Plus, DPW and CBHNP
• Defined criteria for BH high risk
• member
• Created bi-directional data exchange process
• Established platform for secure data exchange

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Finalize BH-PH data sharing

• BH Data Elements
• Members active in treatment
• Members designated as high risk
• Care manager contact information
• Inpatient discharge date
• Notes field
• Alternate phone numbers
• Warm transfer flag

• PH Data elements
• DM condition
• PCP and contact info.
• Pregnancy due date
• Alternate phone numbers
• Warm transfer flag
• Intensive Case Management
• High ED user
• Notes field
• Care manager contact information

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Prepare for BH-PH Pilot Launch

• Developed new BH transition language for ACCESS
  Plus Welcome Call and Needs Assessment scripts
• Trained telephonic and field based BH/PH staff on
  pilot objectives
• Established criteria to measure PH outcomes
• Telephonic and field outreach activities
• Medical homes established
• Preventive visits scheduled
• Contact barriers
• Contacts with High risk members
• Warm transfers for members lost to follow up

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Launched BH-PH Pilot -September 2008

• Implemented weekly data sharing
• Initiated PH outreach to high risk BH enrollees
• Utilized case notes to share demographic changes
  and coordinated care information
• Conducted warm transfers to PH or BH for
  enrollees lost to follow up or at risk
• Submitted initial outcomes report

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Next Steps

• Use outcomes measurements to refine
• BH-PH program goals and activities
• Replicate BH-PH program with BH MCOs across
  ACCESS Plus regions
• Coordinate efforts with the PA Serious Mental
  Illness Innovation Project funded by the Center
  for Health Care Strategies (CHCS)