1. Evaluating a Global Payment Methodology in Integrated Primary Care Shandra M. Brown Levey, PhD, Department of Family Medicine, University of Colorado School of Medicine Emma Gilchrist, MPH, Eugene S. Farley, Jr. Health Policy Center, University of Colorado Denver; Kaile Ross, MA, Eugene S. Farley Health Policy Center, University of Colorado Denver; Benjamin F. Miller, PsyD,, Eugene S. Farley Jr. Health Policy Center, University of Colorado Denver; Polly Kurtz MBA, Collaborative Family Healthcare Association; Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # G5A October 17, 2015

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Discuss a global payment model for healthcare and its impact on clinical practice. Describe a mixed method evaluation used to determine if a global payment method can financially support and sustain behavioral health in primary care. Identify key components, measures, and lessons learned when working to implement, support, and evaluate innovative payment methodologies.

4. Bibliography / Reference 1. Kathol RG, deGruy F, Rollman, BL. Value-based financially sustainable behavioral health components in patient-centered medical homes. Annals of Family Medicine. 2014 Mar-Apr; 12(2) 172-5. 2. Kathol RG, Butler M, McAlpine DD, Kane RL. Barriers to physical and mental condition integrated service delivery. Psychosomatic Medicine. 2010; 72:511-518. 3. Katon W, Russo J, Lin EH, et al. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. Archives of general psychiatry. 2012;69(5):506-514. 4. Landon BE. Keeping score under a global payment system. New England Journal of Medicine. 2012; 366:393-395. 5. Lake TK, Rich EC, Valenzano CS, Maxfield MM. (2013) Paying more wisely: effects of payment reforms on evidence-based clinical decision- making. Journal of Comparative Effectiveness Research 2, 249-259.

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.

6. You can begin your slides here and REMOVE THIS SLIDE

7.  In this presentation, we will:  discuss a project intended to evaluate if a global payment method can financially support and sustain behavioral health in primary care,  describe how different payment models may affect clinical models of integration,  and present real world applications of a global payment methodology in primary care practices.  Through a description of our mixed methods evaluation approach, we will:  share how we worked to better understand clinical, claims, and interview data and how this is being used to help inform policy. Overview

8. Three Year Project with CFHA, DFM, and RMHP Project launched in July 2012 Year 1: Identified 3 control and 3 intervention practices 18 Month Study Period (Mixed method evaluation) 6 Months – Wrap-Up and Conclusions

10.  Data Collection - qualitative & quantitative data over 18 months.  Practice Information Forms (PIFs)  Integration workflows  CoACH Cost Tool  EHR system data  Monthly Calls  Site Visits (3 per site )  Baseline and Final Key Informant Interviews  Claims Data  Data Management  Field notes  Interviews were audio recorded and professionally transcribed  Practice information was collected via an paper-based survey  All data were deidentified.  Qualitative data were entered into Atlas.ti  Analysis  A multidisciplinary team with expertise in psychology, public health, integrated care, and primary care analyzed data using an inductive thematic content analysis. Methods

11.  Leadership  EMR  Roles  Turnover  Provider and Staff Experiences  Payment  Future Directions Findings

12.  Better understanding of team based care  New leadership roles within the practice  Commitment to the community with partnerships  “I think we have become more open and understand the value of team based Care. So I think at first, we maybe didn't quite understand. Ok, what is the Physician's role in the Team? Now we understand how much people outside of us, have to offer patients. So I think we have seen this sort of philosophical change away from the Physicians as the key element of the Practice. So really the Team is the key element of the Practice.” - MD Leadership

13.  Tracking through the EMR and outside the EMR when needed  Setting up structured data fields  For reports  For outreach  To track progress  To determine if efforts are worthwhile EMR

14.  Variety of clinical and administrative roles that interact with the BHP to support and facilitate patient connection to BH  Interaction with BHP and sense of personal responsibility for facilitating connection to BH seemed to increase from baseline to f/u  BHPs initiating QI projects to increase routine screening (i.e. depression and alcohol) in order to reach more patients in need  “My role is to find out how the patient is doing. Have everything prepared before the Provider comes in. I give them a PHQ. I ask those two questions about feeling down, or little interest. And if they are yes PHQ, go tell the Counselor, this patient is going to need your help. Or if you can talk to her…or sometimes in the morning, on our pre-visit planning, we have it ready and ‘BHP’, you are going to need to talk to this patient before the Provider goes in. Or you know what, Nancy? This patient is having a hard time coming to the Clinic. So can you go see what you can do? Things like that. Or doesn't have money for medication." – MA Roles

15.  Specialized skill set  Appropriate fit to position and organization culture  Leadership deficits  Trust is Key  Top down approaches don’t work  Power struggles lead to disenfranchisement  Rural Locations  Funding deficits Turnover

16.  PCP and staff felt more supported and able to provide good care with a BHP on board  PCPs appreciated BHP help when they had patients in crisis  Having BHP around gave PCPs more peace of mind and lessened workload  After experiencing integrated care, practices can’t imagine working without it  "So I've had several patients where after their or during their visits, that will have Integrated Care come in, right then and there. And it is so nice to have the patient education part going on. Because a lot of times our teams are busy providing the essential health care on my side. So when we call Integrated Care in, they will provide teaching and the patient then, all of a sudden, like I've seen like a light bulb go off..... And you may have told that patient the same exact thing, but somehow when Integrated Care presents it, they understand." Office Manager  Personal benefits to having BHP on site:  " To tell you the truth, I learned about it too. And I take advantage of it. I mean I take my daughters too. I mean things that I can't help them up, I've taken them to therapy and I have a 14 year old and a 9 year old, and it's helped me a lot. And because of my experience, I can let other people know and they don't feel judged or oh my gosh, you have the same issues I do." - MA Provider and Staff Experiences

17.  Payment is conceptually difficult to understand  Global payment strategy in a FFS world  Global payment methodology and relationship to clinical practice  Change in clinical practice/leadership/ shape benefits/ integrated care delivery  Not a fix all Payment Culture

18.  Now more than ever people are looking for real world payment reform solutions  This methodology can be scaled regardless of setting  Infrastructure and data management are essential  Multi-level change requires multi-level strategies  Don’t wait; move now So What?

19. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!