1. Behavioral Health Integration: A Key Step towards the Triple Aim
Session # C4a
October 18, 2014
Behavioral Health Integration: A Key Step towards the Triple Aim
Mara Laderman, MSPH
Senior Research Associate
Institute for Healthcare Improvement
Benjamin Miller, PsyD
Director of Health Policy
University of Colorado - Denver
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Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, Washington, DC U.S.A.
Collaborative Family Healthcare Association 12th Annual Conference

2. Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
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Collaborative Family Healthcare Association 12th Annual Conference

3. Learning Objectives At the conclusion of this session, the participant will be able to:
Learn about the Triple Aim benefits of primary care-behavioral health integration.
Use analyses of health plan and outcomes data to make the case for integration at their organization.
Describe IHI's approach to behavioral health integration.
Include the behavioral learning objectives for this session
Collaborative Family Healthcare Association 12th Annual Conference

4. Bibliography / Reference
IHI 90-Day R&D Project Final Summary Report: Integrating Behavioral Health and Primary Care. Cambridge, MA: Institute for Healthcare Improvement; March 2014.
Laderman M, Mate K. Integrating Behavioral Health into Primary Care. Healthcare Executive Mar/Apr;29(2):74-77.
Academy for Integrating Behavioral Health and Primary Care, Agency for Healthcare Research and Quality (AHRQ). Lexicon for Behavioral Health and Primary Care Integration. Available at:
Mental Health, Substance Abuse and Health Behavior Services in Patient-Centered Medical Homes. Kessler, R., Miller, B.F., Kelly, M., Graham, D. Kennedy, A., Littenberg, B., Maclean, C., van Eeghen, Scholle, S., Tirodkar, M., Morton, S., & Pace, W. The Journal of the American Board of Family Medicine, 27(5),
The Working Party Group on Integrated Behavioral Healthcare, Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., Epperly, T., Green, L., Henley, D., Kessler, R., Korsen, N., McDaniel, S., Miller, B., Pugno, P, Roberts, R., Schirmer, J., Seymour, D., & deGruy, F. (2014). Joint Principles: Integration Behavioral Health Care into the Patient-Centered Medical Home. The Annals of Family Medicine, 12(2),
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Continuing education approval now requires that presenters include five references within the last 5 years.
Please list at least FIVE (5) references for this presentation that are no older than 5 years.
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Collaborative Family Healthcare Association 12th Annual Conference

5. Learning Assessment A learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
Please incorporate audience interaction through a brief Question & Answer period during or at the conclusion of your presentation.
This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy accreditation requirements.
Collaborative Family Healthcare Association 12th Annual Conference

6. Today’s Agenda Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)

7. Today’s Agenda Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)

8. Definition
The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization.
Value of Integration:
Physical/Behavioral Integration is good health policy and good for health.
For consistencies sake, here again is the DEFINITION we are using when we talk about integration. Interestingly enough, this definition also foreshadows our discussion today. You see, for integration to be successful and having the biggest bang for the buck, it has to be about allowing the providers, both behavioral health and primary care, to work together on a range of issues. Integration is about offering up comprehensive team based services to a community who often presents with multiple chronic conditions and not just a single disease.
But you already knew that.
Let’s drill down into how we got to where we are and set some context.
Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.

9. No such thing as a single disease

10. Confusion. You want confusion
Confusion? You want confusion? Try to figure out how to change policy with a movement that is so spread as collaborative care.

11. In service to Improving outcomes Decreasing cost
Enhancing the patient experience

12. Drucker’s Big Seven (for innovative opportunity)
The unexpected success, failure or outside event
The incongruity – between reality as it actually is and reality as it is assumed to be
Innovation based on process need
Changes in industry or market structure
Demographics
Changes in perception, mood and meaning
New knowledge – scientific and nonscientific

13. Those who say it can’t be done are usually interrupted by others doing it
James Baldwin

14. Today’s Agenda Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)

15. Our Mission: To improve health and health care worldwide
The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization.
We were founded just about 25 years ago with a mission to improve health and healthcare worldwide and since that time, we have grown to become a leading innovator in health and health care improvement.
People understood that the science of improvement was working in other industries, and our founders realized that this same science could be applied to health care.
We are headquartered in Cambridge, Massachusetts but work around the world on six continents. Though our organization is small with just over 120 people, we realize enormous leverage from our more than 200 talented faculty who are proven leaders in their fields, strategic partners responsible for remarkable transformations in their own systems and a connected and committed community of individuals and organizations who come together year after year at our trainings, seminars, conferences and other large meetings to exchange best practices, co-create new tools and soak in the best of health care improvement from around the world.

16. IHI’s Work: Five Key Areas
IHI along with our partners and community are focusing on five core areas of work:

17. Triple Aim for Populations
Our Goal: Drive the Triple Aim, simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities.
The Triple Aim for Populations which strives to simultaneously improve the health of the population, enhance the experience and outcomes for patients, and reduces the per capita cost of care for the benefit of communities.

18. Proven Methodology: Science of Improvement
W. Edwards Deming
API’s Model for Improvement
IHI works with organizations using the science of improvement.
Originally goes back to Deming who taught that with certain principles of management, “organizations can increase quality and simultaneously reduce costs (by reducing waste, rework, staff attrition, and litigation while increasing customer loyalty). The key is to practice continual improvement and think of manufacturing as a system, not as bits and pieces.“ –
In 2009, the Model for Improvement was created by Associates for Process Improvement (API) based on Deming’s work and as a tool for the front lines. The Model asks 3 questions and then uses PDSA cycles for small, rapid-cycle tests of change.

19. Today’s Agenda Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)

20. What drives IHI’s interest in integration?
Poor outcomes and high costs for patients with medical + behavioral comorbidities.
Getting to the Triple Aim will require addressing behavioral health!
Changing incentives will facilitate this.

21. Research Project Aims
Understand the core principles underlying successful approaches to integration of behavioral health services into primary care.
Develop IHI’s approach to integration.
Identify how IHI can support organizations to integrate behavioral health and primary care.

22. Research Methods
Reviewed peer-reviewed and grey literature and materials from existing models.
Name
Organization
Gary Belkin
NYC HHC / NYU
Benjamin Miller
University of Colorado – Denver
Mary Rainwater
Integration Consultant, formerly with IBHP
Laurie Alexander
Integration Consultant, formerly with AIMS Center
Alexander Blount
UMass Medical Center, Center for Integrated Care
Parinda Khatri
Cherokee Health Systems
Jurgen Unutzer
IMPACT / AIMS Center, University of Washington
Brenda Reiss-Brennan
Intermountain Health Care
Robin Henderson
St. Charles Health System
Russell Phillips
Harvard Medical School, Center for Primary Care
Ileana Welte
Big White Wall
Brady Cole
U.S. Department of Veteran’s Affairs 12

23. Key Research Findings
Perception is that there are many different ways to implement integration; we found that the commonalities are much greater than the differences.
Collaborative care principles; strong evidence base.
Five-step sequence to integrate BH
Biggest challenges are business case and operationalizing components into workflows.
Improvement approach is currently lacking.
Lack of integration outside of clinic visit.
Preview 5 steps

24. Innovation: Full Spectrum Integration
Layer of Service
Frequency of Interaction
Where service is provided
Who provides service
1 – Acute Care
Continuous (during hospitalization)
Hospital
Physician
Cost
2 –Clinic Care
Quarterly
Clinic
PCP; behavioral health provider. Could include group visits
3 – Community Care
Weekly; more than once a week initially
Home, workplace, community organization
Community health workers; mobile clinics. Could include group visits
4 – Family Engagement in Care
Daily
Home
Family members
5 – Self-care
Patients
6 - Policy and Financial Considerations

25. Which states and why?
Variability in financial environment between states to support behavioral health integration.
Some states may be more interested than others due to: Medicaid waivers, Medicaid BH carve out, Medicaid expansion / expected growth in Medicaid population, # of ACOs & pushes for global payments.
We compiled a list of states with favorable markets for integration.
Favorable States: AZ, AR, CA,CO, IL, KY, MD, MI, NV, NJ, NM, OH, OR, and VT.

26. Today’s Agenda Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)

27. Five Step Sequence Assess readiness for integration.
Develop reliable operations and processes to support integrated care.
Develop the business case for integration.
Re-design care delivery using collaborative care principles for integration.
Operationalize changes into clinical workflows.

28. 1. Assess readiness for integration
Assess readiness based on:
Patient needs
Clinic characteristics
Policy & financial environment
Existing data & measurement system
1. Assess
Readiness

29. 2. Processes to Support Integration
2. Develop Reliable Operations and Processes to Support Integrated Care
Leadership and culture
Access and workflows
Technology considerations
Workforce: recruitment, hiring, onboarding, and oversight of staff
Workflows
Seamless information sharing & communication
Tracking patients and using data
Continuous quality improvement and outcomes monitoring
Space and supplies to support BH care
1. Assess
Readiness
2. Processes to Support Integration

30. 3. The Business Case for Integration
Fee-for-service workarounds
Negotiate case rates with payers
Consider global funding strategies and blended payment systems
Identify federal and state incentives to support integrated care
Train staff to optimize use of existing revenue sources to provide cost efficient, medically necessary care.
1. Assess
Readiness
2. Processes to Support Integration
3. Make the
Business Case

31. 4. Re-design Care Delivery Using Collaborative Care Principles
Develop interdisciplinary care team
Promote self-care support and family engagement
Treatment to target
Stepped care
Systematic caseload review, consultation & referral
Adoption of evidence-based guidelines
BH providers support healthy behavior change in addition to screening, diagnosis, and treatment for BH conditions
1. Assess
Readiness
2. Processes to Support Integration
3. Make the
Business Case
4. Redesign
Care Delivery

32. 5. Operationalize Changes in Clinical Workflows
Fully implement operational infrastructure
Sample change ideas to operationalize collaborative care principles:
Interdisciplinary care team proactively manages a panel and chronic health conditions and participates in care planning
Coordinate care inside and outside of org. including tracking referrals
Technological solutions when BH providers are not available in person
1. Assess
Readiness
2. Processes to Support Integration
3. Make the
Business Case
4. Redesign
Care Delivery
5. Operationalize Changes in Workflows

33. Today’s Agenda Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)

34. Where IHI can add value
Focus on how to make specific changes and on addressing operational and organizational issues that need to be in place to facilitate implementation of integrated care.
Bring improvement science to integration.
Sense-making across different models.
Focus on leaders and systems.
Measurement of system-level integration outcomes.

35. New Collaborative Program
Optimize Primary Care Teams to Meet Patients’ Medical AND Behavioral Needs
Partnering with the MacColl Center for Health Care Innovation
Launches in February, 2015

36. Areas for future innovation work
Integration in high-risk specialty clinics.
Scaling to communities, regions, states and solving related structural challenges.
Costs (and ROI) of integration, alternative payment methods, and financial models.
Behavioral health providers performing other functions on the care team, such as supporting behavior change for patients with chronic disease.
Building out other layers of full spectrum integration.

37. Today’s Agenda Making the case: Integration and the Triple Aim
Overview of IHI
IHI’s research on behavioral health integration
Five-step sequence to integrate BH
Future directions for IHI’s work
Behavioral Health Integration Capacity Assessment (BHICA)

38. Behavioral Health Integration Capacity Assessment Tool (BHICA)
Resource for organizations to assess their readiness to integrate behavioral health and primary care.
Consider potential approaches to integration;
Understand the current infrastructure to support greater integration;
Assess the organization’s strengths and challenges in undertaking different approaches to integration;
Set and prioritize goals for integration efforts.

39. Five Sections of BHICA 1. Understanding Your Population
2. Assessing Your Infrastructure
3. Identifying the Population and Matching Care
4. Assessing the Optimal Integration Approach for Your Organization
5. Financing Integration

40. Evaluation Framework Linked to Organization Processes, Impact, and Resources

41. Questions?

42. Session Evaluation
Please complete and return the evaluation form to the classroom monitor before leaving this session.
Thank you!
This should be the last slide of your presentation
Collaborative Family Healthcare Association 12th Annual Conference