Health IT plays an important role in efforts to integrate behavioral health and primary care as it helps support coordinated care and clinical decision-making in practices. The behavioral health community is generally supportive of sharing information with primary care and other health care providers. There are, however, many barriers to sharing information across settings since behavioral health IT systems often operate very differently than health IT in other health systems, and vary in type and scope of health IT used.
Jodi Daniel, J.D., M.P.H., Director of the Office of Policy and Planning, describes some of the activities the Office of the National Coordinator for Health IT (ONC) is working on in partnership with other Federal agencies to “help the adoption and use of health IT among behavioral health clinicians as well as support the care coordination among primary care and behavioral health clinicians.” The ONC is also taking steps to address the privacy considerations for the exchange of behavioral health information through research, policy implementation, and technical approaches.
In their recently published report called Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood, the Patient-Centered Primary Care Collaborative (PCPCC) supports primary care clinicians’ “efforts to adopt a population health approach that leverages health IT solutions.” The report offers insight on “health IT—enabled population health management that is built on a foundation of the patient-centered medical home (PCMH), and further extends into the medical neighborhood.” This medical neighborhood, which connects primary care practices to hospitals, home health agencies, mental health providers, and community wellness and safe living organizations, will only be successful if health IT is widely adopted. Indeed, David B. Nash, MD, MBA, Founding Dean of the Thomas Jefferson University, Jefferson School of Population Health and member of the reports review committee says “Health IT offers an essential infrastructure and solutions for population health management that can be adopted incrementally over time, and providers continue on a path of quality improvement and primary care transformation.”
Moreover, the report provides health IT tools incorporated in the five key attributes of PCMH and the medical neighborhood and a recommended top 10 list health IT-based population health management tools such as electronic health records, patient registries and health information exchange, to name a few. Also in the report are case studies of population health management from a variety of practices such as Twin City Pediatrics of Winston Salem, NC. These cases confirm “population health management technology is a prerequisite for primary care practices that want to identify health trends in their communities, exchange information across organizations, coordinate care as patients transition between providers, and deliver secure communications between providers and their patients,” according to Richard Hodach, MD, a member of the publication’s review committee and Chief Medical Officer of Phytel, a population health management company. This population health approach will also help accountable care organizations (ACOs) with managing financial risk, improving quality of care, and reducing costs.
Despite increased efforts to adopt health IT, there is still a lag in implementing this population health management approach. Outside the United States, “50 to 90 percent of doctors in developed countries routinely use advanced health IT tools, such as computerized alerts, reminder systems to notify patients about preventive or follow-up care, and prompts to provide patients with test results.” Conversely, in the United States, “only one in four [doctors has] such a system, and 40 percent or more [report] they have neither a manual nor electronic system for such tasks.” Indeed this report reveals barriers to using “innovative tools and technologies.” However, it also offers “a realistic assessment of the current state of population health management, and its implications for payment reform, workforce education and training, patient engagement, and the health IT industry” and states that there are plenty of opportunities for organizations to successfully manage population health.
Access the report: http://www.pcpcc.org/resource/managing-populations-maximizing-technology
Improving Medicaid Managed Care for Youth with Serious Behavioral Health Needs: A Quality Improvement Toolkit
The Center for Healthcare Strategies’ (CHCS) quality improvement toolkit titled “Improving Medicaid Managed Care for Youth with Serious Behavioral Health Needs” helps managed care organizations (MCOs), providers, and families enhance behavioral health care delivery for young people up to the age of 22. Current significant barriers to the receipt of quality behavioral health services for youth include: lack of implementation of evidence-based treatments into real-world clinic settings; delays in accurate diagnosis and therefore treatment in this population; and the stigma of behavioral health issues.
As a product of nine geographically diverse MCOs’ implemented initiatives, the outlined solutions and suggestions focus on consistent issues that arise for this population. Specifically, these MCOs aimed to reduce the use of out-of-home youth placements such as residential treatment and inpatient services; customize care management services; and provide primary care provider education to improve diagnostic accuracy for behavioral health disorders.
For more details on lessons learned, and challenges and strategies utilized in these respective projects, please refer to the toolkit at: http://www.innovations.ahrq.gov/disclaimer.aspx?redirect=http://www.chcs.org/usr_doc/Improving_Medicaid_Managed_Care_for_Youth_with_Serious_Behavioral_Health_Needs_Toolkit.pdf
Read the original brief at http://www.innovations.ahrq.gov/content.aspx?id=2785
Treating mental health conditions in primary care settings can drastically improve patient health, reduce the rate of physician burnout, and ultimately reduce costs of care. A 2-year grant will fund a new program to integrate behavioral health services into six primary care medical practices at the Academic Innovations Collaborative under the Harvard Medical School Center for Primary Care. The initiative will integrate a network of staff including social workers, counselors, and mental health specialists alongside primary care physicians to coordinate the diagnosis of psychosocial conditions in conjunction with physical health concerns. Russell Phillips, MD, Director of the Center for Primary Care, says,
“Traditionally, behavioral health has been sort of marginalized…but we know mental health issues present commonly in primary care and complicate the care of patients with other medical conditions. So trying to integrate those services into primary care practice makes sense.” He adds that, “Mental health disorders complicate the care of patients with any chronic medical condition.”
Addressing mental and physical health concerns at once can lead to better overall health outcomes. Physicians will now have the support of other medical staff, which will increase the resources and abilities of the practice, and ensure a higher quality level of care for patients.
Although this integrative initiative is funded for only 2 years, Dr. Phillips is confident that the program will be financially sustainable over time. It will reduce costs of care by reducing the number of emergency hospitalizations and complications in physical health issues due to mental health concerns, and lead to a positive return on investment for the practice.
The payment system in place will allow growth for a positive return on investment over time, where the money spent on treatments and care will ultimately be less than the savings accumulated by offering these integrative services. In the future, Dr. Phillips anticipates that payment systems will be put in place to ensure organizations and institutions can provide comprehensive treatment options to patients that simultaneously reduce costs of care, accrue savings for their practice, and allow integrated behavioral health services in primary care practices to function sustainably.
More information on this program can be found at:
As a leading expert in and activist for the collaborative care model, psychiatrist Lori Raney, M.D. explains how her fellow psychiatrists having nothing to fear when it comes to adapting one’s practice to the rising tide of health care reform. Raney encourages providers to think about how they can benefit from collaborative care, an increasingly more common model of care in which psychiatrists play a key role in on-site consultation with other providers and/or deliver direct patient care in primary care settings. To meet patients’ mental and physical health needs most effectively, Raney explains, “Just as psychiatrists have an opportunity to assist in the management of depressive and anxiety disorders among patients in primary care settings (and among those with multiple, chronic medical conditions), so the mental health sector needs to incorporate the skills and expertise of primary care to monitor, manage, and treat metabolic disease and other chronic medical conditions among the population with severe and persistent mental illness.” She adds that collaborative care work is only part of what most psychiatrists do, with many continuing to practice in more traditional models of care. Increased workforce demand and population-based care drive the need for reforms like the collaborative care movement and Raney suggests brief retraining will benefit providers by helping them find their place given individual provider preferences, circumstances, and level of interest.
Read the original article: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1729313
In the United States, 25% of the population is affected by mental illness. However, due to lack of access to specialized care, illness unawareness, and stigma, patients often delay getting the care they need. Moreover, 60% of those who do not receive treatment for mental illness look to primary care for services. Consequently, many primary care practices are looking to integrate behavioral health and primary care to improve health outcomes and reduce healthcare costs. One such practice is Twin City Pediatrics, a group of three pediatric practices in Winston-Salem, North Carolina. Using the medical home framework, Twin City is using care team strategies and eHealth to improve care for children with Attention Deficit Hyperactive Disorder (ADHD).
The Twin City Pediatric care team consists of a mental health professional who serves as a care coordinator working directly with children who have ADHD and other behavioral health conditions. This care coordinator, a former school counselor, also works with parents and caregivers to help with appointment scheduling, prescriptions, and medication plans; reviews and signs forms required by schools; and offers advice on therapy and other specialty visits. In addition, Twin City aligns ADHD patient care plans with important times in the school year calendar. For instance, patients meet with their care team three times annually for wellness visits: summer’s focus is on modifying and reviewing treatment for the upcoming school year; the fall visit occurs 4-6 weeks into the school year to check on progress and effectiveness; and the spring visit is a check-in before end-of-year testing. This care plan monitors the percent of patients newly diagnosed with ADHD and seen for follow-up within 1 month of starting medication, percent of patients with established diagnosis seen at least twice in 9 months, andpercent of patients with ADHD in maintenance phase.
In terms of eHealth, Twin City has a website with basic information (e.g., office hours, services), physician and staff bios, and office updates. Every 3-6 months, it adds new features like health literacy materials, educational podcasts, a physician’s blog, and information from the American Academy of Pediatrics. In addition, to make medical staff more accessible, Twin City offers online appointment scheduling, email alerts and an online patient portal where parents can access patient-provided medical information (e.g., questionnaires). Later, the online portal will also provide parents with access to their children’s clinical records and lab results.
Twin City uses a patient registry program designed to improve population health management for all patients. The registry, which is not linked to the practice’s electronic health records, is a supplementary tool used to record administrative data, clinical data and preventive care information. It also helps the care team recognize gaps in care, promote care improvements, and organize administrative duties. Twin City plans to expand the registry so it includes data like subspecialty referrals and more about mental health status.
Patients at Twin City are assigned complexity scores in a risk stratification system. To identify the level of care a patient should receive, they are separated into groups where group 1 is for patients who need routine care, group 2 is for patients with one common chronic disease (e.g., asthma, ADHD, obesity), group 3 is for patients with more than one common chronic disease, group 4 is for patients with one or more uncommon chronic disease (e.g., a seizure disorder, autism, Downs syndrome), and group 5 is for patients who depend on technology (e.g., a feeding tube, home ventilator) to live at home or have substantial home health care needs. About 70% of patients fall into group 1 while less than 1% fall in group 5. So that group 5 patients’ most complex needs are met, a nurse with pediatric intensive care experience serves as a care coordinator and spends half a day per week ordering home health care, working with families, and talking with specialist and hospitals if necessary.
Twin City Pediatrics believes that their expense on this care model and large staff is a long-term investment that yields high patient satisfaction. In time, they hope payment reform and more competencies in the medical home model with behavioral health will ameliorate their return on investment. Additional delivery innovations will certainly continue to strengthen Twin City and other patient-centered medical home practices.
Read the related brief (enter your email to download): http://www.pcpcc.org/download/4199/Case%20Study%20with%20Covers.pdf?redirect=node/6065
Also, visit the Twin City Pediatrics website: http://www.shotshurtless.com/index
The Center for Health Care Strategies’ Integrated Care Resource Center (ICRC) at the Center for Medicare and Medicaid Services (CMS) offers technical assistance tools that address key issues in contracts and RFPs for behavioral health and primary care coordination. For technical assistance in preparing your proposal, see:
Selected Provisions from Integrated Care RFPs and Contracts: Care Coordination
This technical assistance tool covers issues in the development of care coordination RFPs and contracts in the states of Arizona, Massachusetts, Minnesota, Tennessee, and Texas. It shows variation across the five states and offers examples of how their managed care experiences addressed care coordination requirements. Read more: http://www.chcs.org/usr_doc/ICRC_Care_Coordination_FINAL_7_29_13.pdf
For other ICRC-related resources about the integration of the behavioral health and primary care, visit: http://www.integratedcareresourcecenter.net/icmhealthintegration.aspx
Although the Affordable Care Act (ACA) offers new opportunities that are well-suited to the skills of mental health professionals, it also requires that they develop more capabilities and business literacy. For instance, integrated care systems such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs), outlined in the ACA, need professionals that “can provide team-based care in a primary care practice office or other medical settings.” Behavioral health clinicians can begin to help address the demands of the shifting health care environment by studying local ACOs that have formed, assessing their mental health needs, and filling those needs. With increased business literacy to overcome complex business structures, they can do so successfully. Furthermore, since both ACOs and PCMHs require the services of more than one clinician, savvy behavioral health providers can enhance the team, enabling it to improve the overall health of the population, and reduce health care costs.
In addition, in keeping with the ACA’s emphasis on “health and wellness services as a cornerstone of improved health and cost outcomes,” mental health professionals like psychotherapists with strong foundations to build skills in health promotion and illness prevention can serve outside the traditional office or clinic. For example, worksite health and wellness services are an option. Employers who wish to move towards a holistic culture of health seek external consultants to help them do so. Since there are not enough Industrial and Organizational psychologists, opportunities are available for mental health clinicians to develop the skills for this type of work.
Psychotherapy, which has been proven particularly effective for many psychological disorders, can be leveraged to “solve other health problems and expand business opportunities for clinicians.” While more than psychotherapy is needed to treat health risks like obesity and tobacco use, clinicians have not yet figured out how to couple it effectively with health education, patient support, and nurse surveillance. Clinicians have also not been trained for each of the various types of service delivery modalities like telephonic and secure online sessions, as well as the more traditional face-to-face interactions. Health care expansion will require that mental health professionals receive additional training and develop effective new integrated models.
In the new world shaped by health reform, behavioral health teams can emphasize the economic impact of their work and prepare to offer ideas for integrating with the larger team to address depression and anxiety, especially in those patients with comorbid chronic medical problems. A Milliman publication, Chronic Conditions and Comorbid Psychological Disorders, co-authored by NIAC member, Steve Melek, reports that commercially insured members with chronic medical conditions and comorbid depression and anxiety cost $45 more per member per month than members with chronic medical conditions without depression or anxiety. With these increasing costs for people with chronic medical conditions and comorbid behavioral health conditions, mental health treatment is essential to the reduction of health care costs, to the success of ACOs and PCMHs, and to the improvement of the overall health status of the population.
The Behavioral Health Integration Advisory Committee, created by the Senate Bill 58 of the 83rd Texas Legislature (regular session), will be responsible for addressing planning and development needs for integrating Medicaid behavioral health services, including case management and mental health rehabilitative services, and physical health services by September 1, 2014. In efforts to receive input from the behavioral health community and formal recommendations on how to accomplish Integration within Medicaid Managed Care, the Texas Health and Human Services Commission (HHSC) committee is now accepting applications for membership in the Behavioral Health Integration Advisory Committee. It will consist of key stakeholders such as individuals with behavioral health conditions who are current or former Medicaid recipients of publicly funded behavioral health services, representatives of managed care organizations that are experts in offering behavioral health services, public and private providers of behavioral health services, and providers of behavioral health services who are also primary care providers for individuals who are dually eligible for Medicaid and Medicare. These members will meet at least quarterly in Austin and will work until September 1, 2017.
Read about the Behavioral Health Integration Advisory Committee on the HHSC website: http://www.hhsc.state.tx.us/about_hhsc/AdvisoryCommittees/bhiac.shtml
Sosunmolu Shoyinka, M.D., assistant professor of psychiatry at the University of Missouri and director of psychiatric outreach services discusses how the role of psychiatrists will change with the implementation of the Patient Protection and Affordable Care Act (ACA). As Dr. Shoyinka explains, the ACA emphasizes value-based care, prevention and health promotion, and specifically focuses on improving mental health and substance abuse treatment in medical care. Integrating mental health care into primary care is one service model that shows promise for accomplishing these goals. To foster integrated care, Title V of the ACA supports and expands the health care workforce especially through enhanced training of primary care and behavioral health providers. With the expanded implementation of integrated care and the likely increase in training programs for mental health care providers, Dr. Shoyinka makes a few predictions about the future of mental health services. First of all, he projects that there will be an initial shortage of psychiatrists to meet the needs of the new population of patients accessing mental health services in primary care. He says that psychiatrists will still play a critical role in providing direct clinical care and will also have the opportunity “to find expanded roles in planning and operationalizing mental health services, including prevention and wellness care, for entire clinic and insured populations.”
Dr. Shoyinka encouraged psychiatrists to maintain current clinical competencies while also embracing new ones such as monitoring and possibly treating non-psychiatric medical problems. He says “the ACA brings a sea change to all of medicine in this country. While we do not know how the details will play out, psychiatry as a profession will need to adapt and evolve to survive and thrive in this new world.”