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Nancy Paull MS LADC I. Summary of Talk 1. Overview of integrated care, SSTARs model of primary care –behavioral health integration 2. latest initiative.

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Presentation on theme: "Nancy Paull MS LADC I. Summary of Talk 1. Overview of integrated care, SSTARs model of primary care –behavioral health integration 2. latest initiative."— Presentation transcript:

1 Nancy Paull MS LADC I

2 Summary of Talk 1. Overview of integrated care, SSTARs model of primary care –behavioral health integration 2. latest initiative through the NIATx Accelerating Reform Initiative - 3. Billing, IT issues impacting integration-

3 Founded in 1977 as a private, not for profit organization. Original programs included: a 20 bed alcohol detoxification program, an outpatient alcohol treatment program, an education program for persons convicted of driving under the influence of alcohol

4 SSTARs programs have been developed by listening to and trying to meet the needs of the clients we serve.

5 From the very early days of operation, it was clear that our clients were medically compromised. High rates of diabetes, Asthma Liver disease Nutritional deficiences

6 Our community has consistently had a high rate of opioid addiction. The first cases of HIV/ AIDS came to SSTAR very early in the epidemic; and there were no infectious disease specialists in our community. SSTAR became the first provider in the state to have a counseling/testing site in their drug treatment facility

7 When the first wave of individuals tested positive, we had push-back from the local private physician community, who didnt want us integrating those patients into their private practices. SSTAR staff had to refer most patients to Providence and Boston.

8 SSTARs Medical Director Frank Lepreau said: These are our patients- they deserve to be treated well within their own community

9 SO….. 1.Dr Lepreau sought help from Brown University Infectious Disease Specialists 2.Simultaneously, we started looking at state regulations for clinics and licensing requirements

10 We became a licensed clinic; licensed by the Massachusetts Department of Public Health; hired staff; and utilized our medical director and volunteer Docs from Browns program. In the first year of operation, we lost a staggering; $250,000.

11 We then decided to apply for FQHC status to the Bureau of Primary Care. Our application was rejected.

12 We then went to our local community Health Center Assn for help. Initially they were not thrilled to see us. The state had recently started a free care pool for community health centers and they did not want drug treatment agencies stealing their money.

13 The ASSN suggested we first apply for a Look-a –Like Clinic and after much work we were awarded that status. We became eligible for the states free care pool and our rates for Medicaid/ Medicare increase significantly. We started working our way back to financial health.

14 We then applied with another health center in town to be an FQHC. Since only 1 would be funded, SSTAR agreed to be the sub-recipient in this agreement.

15 We won FQHC status. We now have a grant which assist us with basic infrastructure costs. Our Health center doctors are covered by Federal Malpractice Insurance. However, it does not cover any inpatient work in our detox; or other services that our not in our scope of practice.


17 Building relationships with the local medical community; preparing for Medical Homes An Approach other organizations could use to link with Primary Care

18 Prepare for medical home payment reform by increasing collaboration with community primary care providers. Mobilize the local medical community to identify, treat, and improve outcomes for addicted individuals and their families.

19 2. CHANGE /DO Build on relationships with community medical providers – Partner with St. Annes Hospital Convene meeting of S-A primary care providers – 3/31

20 3. Results/ Study Two primary care providers who attended the meeting engage in collaboration. Referral/release of information form developed and implemented Both practices institute drug and alcohol screening (CAGE-AID) for annual physicals and new admits.

21 Results –contd SSTAR Family Health Care Center begins tracking CAGE results in their EHR. Hotline cell phone established for instant referral access to SSTAR case manager by participating medical providers. One of the two participating providers links us to third medical practice that agrees to participate – meetings at SSTAR and at the practice, adoption of referral form. Three referrals made

22 4. Next Steps/ Act Establish baseline – CAGE results plus tracking of referral outcomes. Form a change team to improve referral outcomes. Introduce ARISE family interventions as strategy to increase treatment engagement? Document successes and use to market the value of screening and SSTAR referrals to other community providers

23 5. Impact New and strengthened partnerships with community medical providers; increased focus on addressing the problems associated with managing addicted patients in community medical settings.

24 Understand the customer: community medical providers want solution to problem of their drug-seeking patients. We have TA to provide as well as treatment resources. Understand the customer: their referred patients dont necessarily want treatment or believe they need it. Change team needs to devise interventions to increase success of referrals by recognizing where patient is in stages of change model.

25 Outcomes Three community medical provider practices engage in project Referral/Release of Information form developed to improve coordination of care for shared patients Meetings/conference calls Hotline cell phone set up for community providers to make direct contact with SSTAR case manager for referrals and warm handoffs Two practices initiate use of CAGE AID for initial and annual physicals Each of the three practices makes at least one referral to the hotline


27 Reimbursement and IT Issues M ASSACHUSETTS !


29 Provider Type A community health center provider type usually cant bill to a behavioral health MCO carve out. They arent part of the provider network. Primary care cant bill for a behavioral health diagnosis to a medical payor – theyll say that should be billed to the BH carve out

30 Performance Standards - Billing Under Mental Health Clinic licensure regulations and payor standards, full psychosocial assessment must be completed and billed for in order to be eligible for reimbursement for other BH services such as individual counseling, group counseling, etc. If counselor meets with patient for a crisis session or patient drops in on a group, service isnt billable because full intake/assessment hasnt been processed first.

31 Credentials and Reimbursement BH Billing in primary care setting limited to LICSW, PhD licensed psychologist, psychiatrist, NP Services provided through our mental health clinic – depending on payor, reimburses for addiction counselors, LMHC, unlicensed Masters, etc

32 Staffing Issues BH staff of the Health Center are shared with the BH clinic to maximize reimbursement 2 addictions counselors, 1 LMHC, 1 LICSW Part of their salary paid from HC budget. They are not on the salary+productivity pay system that BH clinic staff are on so they have more flexibility in their schedules to respond to situations. When they provide a reimburseable service, its billed through the BH Clinic;

33 Varying payor credentialing requirements can contribute to uncollectible claims. Example: Suboxone group led by an addictions counselor; client with UBH attends the group and that particular insurance wont reimburse for that level provider. Its not cost-effective to have separate group for people with that insurance.

34 Your memo raises concerns that FQHCs are experiencing difficulty in obtaining Medicaid payments for behavioral health services by clinical psychologists, clinical social workers and nurse practitioners. ….. Therefore as long as these Practitioners are practicing within their scope of practice under state law, the FQHCs payment should reflect the services provided to Medicaid eligible Beneficiaries by these types of practitioners. CMS MEMO Sept 23, 2003

35 Integrated Documentation For those BH services provided and billed through the Health Center, there will be notes in the primary care chart / electronic health record in Nextgen But most of the BH care – because of the reimbursement issues - happens through the BH clinic and is recorded in the BH electronic health record. This is a different software application because there are special needs not met by primary care applications. Barrier to integrated care

36 HIT- options for BH-PC Integration/Interoperability Find one application that meets the needs of BH and Primary Care Create a software bridge to share/dump certain fields into the other application: for example medication lists, progress notes Develop a data warehouse storing information from both systems that would allow sharing Intranet to access the clinical information from each application

37 SUMMARY: It is difficult and expensive to start an FQHC Billing for Behavioral Health in an FQHC is complex IT systems are not yet integrated in a way that is acceptable to each type of provider and probably not acceptable to payers and accreditation/licensing bodies.

38 BUT: Patients can get better, more complete care. We are excited to be working to transform systems of care for our patients. SSTAR believes with Medical Homes and Accountable Care Organizations coming we need to ready ourselves for the changes

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