1. Integrating Behavioral & Physical Health: Building “Whole Person” Health Presented by: Peter Currie, PH.D Senior Director of Clinical Transformation & Integration Inland Empire Health Plan 1

2. IEHP Membership 2 2015 1,100,000 2009 400,000 2016 1,300,000 (Projected)

3. Carve Out Of Behavioral Health: Unintended Consequences 3 County Behavioral Health Drug Medi-Cal Health Plan Regional Center CCS

4. Why IEHP Integrated BH:  Physical Health and Behavioral Health (BH) care were Separate and Disconnected  Outpatient Mental Health Services Under Utilized & Substance Abuse Treatment was Nil  IEHP had no influence over the BH Network  Coordination of Care – PCPs describe referring into the “Black Hole”  High Cost of BH Administrative Services:  50% of BH dollars reached the MBHO’s Providers (2009)  Context – 95% of Tax Payer Dollars paid to IEHP reach IEHP Medical Providers

5. The BH Integration Plan  Fully Integrated BH Program – “In House”  Streamline the coordination of physical and mental health benefits  Redirect MBHO Admin/Profit (50%)to fund Expanded BH Services  Directly Contracted BH Network – Identify and Support Best Practices  Eliminate Reliance on Vendors (MBHOs) for all BH Expertise including NCQA Compliance

6. BH Integration within the Health Plan: Results in the First Two Years  Increased access to BH services – Cost Neutral to Plan  Medical Cost-Offsets for high-risk/high-cost populations  Improve coordination of physical & behavioral healthcare through Web: Access to Health Record for BH Providers & BH Treatment Reports through IEHP Portal for PCPs  IEHP’s Directly Contracted BH network - Private Sector, FQHCs, County Mental Health & CBOs  Met 100% of NCQA requirements for BH in 2012 & 2015

7. BH Integration within the Health Plan: Foundation for Practice Transformation 7 PCP Psychiatrist County Mental Health Intensive Outpatient Program Member Therapist 1-800 Number

8. Identifying the Complex Target Population by Adding a BH Lens 8 Riverside County Specialty Mental Health Mortality Study (Jan 2007- May 2010) RCDMH 41.8 years Natural Causes 46.8 years Unnatural/ Unexpected 38.8 years US Average Life Expectancy 77.7 years

9. Lessons from Riverside County Co-Location Pilot Patients arrive to health care providers “fully integrated” with physical and BH needs intertwined Health care providers in the IE operate mostly in silos which limits their impact on overall health status Blaine Street County Mental Health and Rubidoux Public Health Clinic bi-directional Co-location pilot Learning People seek care where they are welcomed and comfortable Rather than refer out to the “black hole” bring the missing/needed care to where the population is getting care 9

10. Chronic health condition + SMI condition = high costs 10

11. Traditional Health Care is NOT the Primary Determinate of Health Status Schroeder, NEJM 357; 12 11

12. Social Determinants: Drivers of Population Health and Patient Experience 12

13. Pressure on Health Plans to Integrate Physical & Behavioral Health Download of BH Benefits into the Health Plans January 1, 2014 Medicaid Expansion of Mental Health April 1, 2014 Dual Eligible Pilot September 15, 2014 EPSDT Benefit for Autism State Direction & Lessons from IEHP’s recent CMS Audit Expectation that Health Plans have a Care Plan for members that includes BH provider Treatment Plans Expectation that BH providers participate in Interdisciplinary Care Teams 13

14. Strategy for Change Develop an array of Health Homes that are tailored to support practice transformation and: “ Integrated care” 14 Integrated care “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 and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.” (Safety Net Medical Home Initiative, 2014)

15. IEHP Strategy: BH Integration as Platform for Population Healthcare 15 Primary Care FQHCSUD Specialty Clinic Long Term Care Facility

16. Whole health care that is person- centered, cost effective, and results in improved health and wellness BHI-I Themes: Patient/Provider Experience Team Based Care Care Coordination Self-Management Population Health Shared Areas of Improvement: Access to Care Integration of Care Coordinated Care Plan of Action Site Based Planning CIN/PTI Themes: Electronic Health Record Conversion Patient Management Complex Care Management Disease Management BHI-I and CIN/PTI Shared Areas of Improvement

17. PROVIDE FUNDING FOR INFRASTRUCTURE DEVELOPMENT IEHP invests $20,000,000 over 2 years in 13 health care orgs a)Build individual health homes tailored to their target population AND ALSO b)Work collectively to improve the Inland Empire local health care system SUPPORT PRACTICE TRANSFORMATION WITH COACHING JCC Coaching Team Practice Improvement Areas a)Improve patient and provider team experience b)Provide team- based care and treat-to-target c)Coordinate care d)Manage population health e)Promote self- management SUPPORT CULTURE CHANGE FROM VOLUME TO VALUE WITH QI FRAMEWORK The Behavioral Health Integration Initiative (BHI-I) Approach BHI-I Aim: Improve the whole health and wellness of all individuals in the Inland Empire by creating an array of population- based, integrated health homes ©2015 Jen Clancy Consulting Team. Copying and distribution permitted with citation to JCC Team

18. BHI-I Coaching Principles 1. “Bottom-Up” Approach to Building Population-Specific Health Homes 2. Relationship Based and Accessible to Ensure Accountability 3. Promote Learning and Improvement 4. Use of Qualitative and Quantitative Data 5. Peer to Peer & Health System to Health System Relationship Building BHI-I Coaching Principles 1. “Bottom-Up” Approach to Building Population-Specific Health Homes 2. Relationship Based and Accessible to Ensure Accountability 3. Promote Learning and Improvement 4. Use of Qualitative and Quantitative Data 5. Peer to Peer & Health System to Health System Relationship Building

19. Inland Empire’s Thirteen (13) BHI-I Pilot Health Care Learning Organizations 1.Riverside University Health System 2.Riverside County Department of Ambulatory Care 3.Riverside County Department of Behavioral Health 4.Borrego Community Health 5.Desert Clinic Pain Institute 6.My Family Inc. Recovery Center 7.Arrowhead Regional Medical Center Family Medicine Clinics 8.San Bernardino County Public Health 9.San Bernardino County Behavioral Health 10.Social Action Community Health System Clinic 11.Orchid Court, Inc. 12.San Bernardino Adult Day Healthcare Center 13.Telecare Corporation

20. Key BHI-I Goals 1. Improve access to primary care and behavioral health providers for adults and pediatric patients, and meet NCQA practice standards. 2. Health and wellness is tracked (using appropriate clinical measurement tools and data) to continuously increase the effectiveness of the treatment team to improve the health status of the target population. 3. Increase whole health screening & systematic follow ups to positive screens 4. Increase the percentage of individuals with self-selected “Total Health and Wellness Goals” that are shared between key providers 5. Improve medication reconciliation 6. Improve patients & provider team’s experience of care 7. Reduce avoidable emergency room utilization 8. Reduce inappropriate hospital admissions 9. Reduce 30 day hospital readmissions rate ©2015 Jen Clancy Consulting Team. Copying and distribution permitted with citation to JCC Team)

21. Behavioral Health Integration: Platform for Population Healthcare  Build & Support Health Home Array with “BH Inside”  Supporting Provider Partners who are already integrating care to build out & refine what they have already begun  Linking best integration practices to achieve shared care plans that live and breath and reflect the whole person  Support New Trans Disciplinary Treatment Models for Complex Populations:  E.g. Combining Pain Management, Mental Health and Substance Abuse (SUD) to create a new Pain/Narcotic Misuse Treatment Center

22. Why Behavioral Health Homes ? 22

23. All Healthcare is Local 23

24. Achieving the Triple Aim by Integrating the Social and Behavioral Determinants of Health into Health Care Payment and Delivery Systems 24