The Pitfall and Promise of Integrating Care

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The Pitfall and Promise of Integrating Care

• David Freedman, Lina Castellanos, Thomas Jardon,
  Cynthia Rodriguez, David Fuentes, Ketia Harris,
  Megan Hartman, Angela Mooss

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Integrated Care Reconnecting the Head and Body
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Cost of Co-occurring Conditions
Milliman, 2014
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Cost
Milliman, 2014
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Cost and Disparities
Netsmart, 2013
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Three-Legged Stool of Healthcare Integration
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Integration, you say?
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Integration Service Flow
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The Four Quadrant Clinical Integration Model
samhsa.integration.gov
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Accountable Care-Change Of Focus Required Accountable Care-Change Of Focus Required Accountable Care-Change Of Focus Required
Element of Change Yesterday Today
Care focus Sick care "Healthcare" wellness and prevention, disease management
Care management Manage utilization and cost within a care setting Manage ongoing health
Delivery Model Fragmented/silos Care continuum and coordination
Care Setting In office/hospital In home, virtual
Quality measures Process-focused, individual Outcomes-focused, population-based
Payment Fee-for-service Value-based
Financial incentives Do more, make more Perform better on measures, make more
Financial performance Margin per service, procedure Margin per life
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SAMHSAMAI-TCE Miami SITE

• Minority AIDS Initiative Targeted Capacity
  Expansion

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4.2 M for 3 Years from SAMHSA
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Project Flow Chart
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SAMHSA Funding
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Siloed Funding
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Main Players Behind the Scenes

• Florida Health- Tallahassee and Miami Dade (DOH)
• Required grantee due to HIV impact
• Coordinated with ECHPP
• South Florida Behavioral Health Network (SFBHN)
• Managing entity for behavioral health dollars via
  Department of Children and Families
• Behavioral Science Research Institute (BSRI)
• Evaluation team
• Crossover with Ryan White Program

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Main Players The Providers

• Citrus Health
• 5 medical clinics and 24 schools
• Hialeah area
• 55 female
• gt80 Hispanic/ Latino
• 52 best served in another language
• 28 uninsured

• Jessie Trice (JTCHC)
• 9 medical clinics and 23 schools
• Liberty City area
• 63 female
• 67 Black/African-American
• 13 best served in another language
• 60 uninsured

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MAI-TCE Project Phases

• MAI-TCE Miami took on three distinct phases

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Phase OneGearing up for Integration

• Start Date
• February 2012
• Logistics
• Funding
• Staffing
• Implementation
• Buy-in
• Organizational level
• Between partners

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Logistics

• Challenges

• Successes

• Fiscal tracking
• Data burden
• Training/EBIs
• Staffing

• Collaboration/Team building
• SFBHN/organizational level
• Data sharing with Evaluation
• Provider MAI-TCE teams
• Capacity Building

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Buy-in

• Challenges

• Successes

• Cultural differences
• Medical vs Behavioral health
• HIV and Ryan White services
• Billing for services

• The need is recognized and departments find
  relief
• Integration is accepted at top-down level in
  theory
• SFBHN assists with billing and loosening staffing
  regulations

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Lessons Learned

• Make preparations
• Present changes to other departments ahead of
  time
• Collaboration is critical
• Need a team of support
• Planning and persistence
• This takes time

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Phase TwoCustomizable Integration

• Start Date
• June 2012-May 2014
• Planned changes
• Mandated by funders (TRAC vs. GAIN)
• Necessary to meet EBI requirements
• Unplanned changes
• HIV testing
• Staff turnover

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Planned Changes

• Challenges

• Successes

• EBPs/DEBIs changed
• Client needs and outdated practices
• Training overload
• Staff turnover
• Systems-level funding and documentation

• Flexibility in training and EBI implementation
• Peers implementing
• Translation of tools as needed
• Data and service documentation
• Removal of GAIN-I
• SFBHN consistent updates (delete orphans, etc)
• Data became useful internally

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Unplanned Changes

• Challenges

• Successes

• 80 follow up rate goal
• Does not fit BH clients
• Reassessment and DC lists become unmanageable
• Rapid Testing HIV mandate
• New testing site IDs
• Training
• Duplicative data
• Testing numbers cannot be shared

• Advanced integration model for service delivery
• Advocating at all levels
• A true team approach
• DOH was instrumental
• Capacity building
• Filling a huge need (especially at Citrus)

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Lessons Learned

• The need to truly customize cannot be understated
• Peers are critical to successful models for
  client satisfaction
• Integration is working
• More clients are getting the services they need
  and large FQHCs have fewer silos internally

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Phase 3Wrap-up and Sustainability

• Start Date
• June 2014 to present
• A focus on Medicaid billing and staff coverage
• Focus on implementing EHR systems that are
  effective
• Concentration on seeking out additional funding
  through grants/foundations

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Funding

• Challenges

• Successes

• Non-Medicaid expansion
• EMRs lack sophisticated technology and are
  expensive
• SAMHSA and other billing systems are not set up
  for co-occurring clients
• Grant funding is competitive

• SFBHN advocacy for EMRs and data systems changes
• EMRs responding
• Funders are responding
• Miami secured grant monies

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Organizational Integration Culture

• Challenges

• Successes

• Staffing
• Certifications for peers, behavioral health
  techs, non-client specific coordinators
• Organizational structure
• What has really changed?
• Medical and behavioral are still separate, but

• Staffing has changed organizational practice
• Use of peers, recognition for coordination across
  sites
• Other departments believe in the value of
  behavioral health
• Healthcare culture is changing

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Lessons Learned

• Change happens with persistence
• Generating buy-in at the organizational level can
  speed things up
• Collaboration is key to successful integration
  and sustained funding

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Take away points

• If you dont remember anything else Remember this

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Behavioral Health Primary Care Network Committee
(BHPCNC)

• A committee for health integration
• Guided by principles
• Inclusion, Collaboration, CQI, Resource savings,
  Community-based, Resilience and Recovery
• Vision/Mission
• Oversee the expansion of culturally competent and
  effective behavioral health services
• To monitor and enhance the linkages between and
  integration of behavioral health services in
  primary care
• Less formal
• A focus on training and capacity building across
  the systems of care

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The Miami Model

• Screening (SBIRT)
• Use of peers
• HIV testing
• EBIs
• Data driven
• Co-location has been extremely helpful with
  piloting/forming the model

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Project Outcomes

• Reduction in days spent
• Homeless
• Hospital MH unit, detox, jail, emergency room
• Reduction in unprotected sex
• Increase in risk perceptions
• Decrease in mental health symptoms and social
  support
• Increase in access to comprehensive health
  services
• Decrease in substance use
• But not in tobacco use

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System-wide Implications

• Expansion of integration to chronic disease
  management and other aspects of health
• Providers are held to higher standards of care
  and care coordination
• Focus on prevention and wellness

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Go Forth and Integrate

• Questions/Comments
• David Freedman Project Director
• dfreedman_at_sfbhn.org
• [phone]