1. Integrating Behavioral Health Into Safety Net Primary Care Settings Regional Policy Council Mental Health American Meeting February 19, 2016 Alexander F. Ross, Sc.D. Senior Behavioral Health Advisor Office of Planning, Analysis and Evaluation Health Resources and Services Administration U.S. Department of Health and Human Services Aross@hrsa.gov

2. Overview of Presentation 1.HRSA’s Investments in Behavioral Health Integration 2.Technical Assistance To The Field 3.Discussion Questions

3. The Ryan White HIV/AIDS Program provides primary care, support services, and medications. Reaches 500,000 people living with HIV (more than half of all people living with diagnosed HIV infection in the United States). Mental Health Services were provided by almost 75% of Ryan White HIV/AIDS provider organizations /substance abuse services were provided by almost 34% of Ryan White HIV/AIDS provider organizations (CY 2014). Noteworthy Resources Integrating Mental Health and Substance Abuse Care into HIV Primary Care Toolkit (AETC National Resource Center). AIDS Education and Training Centers (AETCs) - Integrating Care through the Use of Screening and Brief Intervention in HIV Settings - Pacific AETC. HIV/AIDS Bureau

4. Maternal and Child Health Bureau The Maternal and Child Health Bureau (MCHB) provides leadership, with key stakeholders, to improve the physical and mental health, safety and well-being of women, infants, children, adolescents, and their families, including fathers and children with special health care needs. Key Programs HRSA Healthy Start- 100 Healthy Start sites provide Educational Activities for Women in Areas with High Infant Mortality and Shortages of Health Care Providers Community-Based Outreach/Case Management Behavioral Health Screening Maternal, Infant, and Early Childhood Home Visiting Program: Funds States, territories and tribal entities to provide evidence-based home visitation services to improve outcomes for children and families who reside in at-risk communities. Bright Futures Guidelines (Initiated by MCHB) https://brightfutures.aap.org/Pages/default.aspx https://brightfutures.aap.org/Pages/default.aspx Comprehensive Clinical Preventive Services covered by the Affordable Care Act. Preventive services include: Oral Health, Behavior Health, Social Determinates of Health.

5. Bureau of Primary Health Care 5 Over 1,200 health centers operate more than 9,000 service delivery sites that provide care to over 22.8 million patients in every state, DC, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin. Behavioral Health Service Delivery Almost 69% of health centers provide mental health treatment or counseling services on-site. In 2014, there were over 13 million mental health visits. 36% of health centers provide substance abuse counseling and treatment on-site. In 2014, there were over 4 million visits for substance abuse services. More than 7,200 behavioral health providers (physicians, psychologists, LCSW, counselors, etc.) work in health centers (2014). (Data Source: UDS 2014)

6. Bureau of Primary Health Care Behavioral Health Integration Awards (BHI) Purpose: BHI awards will improve/expand the delivery of behavioral health services through integrated primary care-behavioral health at existing Health Center Program grantee sites. Program Overview: Total awards: 436 awards; Maximum of $250,000 per award; Project period: August 1 st, 2014 – July 31 st, 2016. Grant Requirements: Increase in the number of patients screened via Screening, Brief Intervention, and Referral to Treatment (SBIRT); Hire 1.0 FTE licensed behavioral health provider; Propose and implement an integrated care model.

7. Bureau of Primary Health Care 7 FY 2016 Substance Abuse Expansion Grants Purpose: Improve and expand the delivery of substance abuse services in existing health centers, with a focus on Medication-assisted Treatment (MAT) in opioid use disorders Program Overview: Total awards: 310 expected awards Maximum of $325,000 per award Project period: March 1, 2016 - February 28, 2018 Application Review in progress Grant Requirements: Establish or enhance an integrated primary care/behavioral health model; Increase the number of patients screened for substance use disorders and connected to treatment via SBIRT and other evidence-based practices; Increase the number of patients with health center-funded access to MAT; Coordinate services necessary for patients to achieve and sustain recovery Provide training and educational resources.

8. Federal Office of Rural Health Policy Advises the Secretary of the U.S. Department of Health and Human Services on health care issues impacting rural communities. Helps increase access to care for underserved populations and build health care capacity through several programs. Rural Opioid Overdose Reversal Program 18 grantees ; $100,000 for one year to develop community-level partnerships comprised of EMS, schools, fire departments, police departments, and other private /public non- profit entities involved in the prevention and treatment of opioid overdoses. Rural Health Care Services Outreach Grant Program Supports innovative health care delivery systems in rural communities; requires grantees to form a consortium with at least two additional partners; 13 outreach grantees focused on mental health and/or substance abuse (FY 2015). Publications-Behavioral Health and Substance Use in Rural America www.ruralhealthresearch.org/ Rural and Frontier Mental and Behavioral Health Care: Barriers, Effective Policy Strategies, Best Practices; Integrating Primary Care and Mental Health: Current Practices in Rural Community Health Centers; Rural-Urban Chartbook - provides a rural-urban analysis on numerous health indicators and outcomes, including prevalence of mental illness, substance abuse treatment (2014 update).

9. The Bureau of Health Workforce increases access by developing, distributing and retaining a diverse, culturally competent workforce; helping health professions training programs address some of the most pressing needs across the health workforce. Training Grants: Health Professions/Nursing Workforce; Behavioral Health Focus: Graduate Psychology Education Grant/Behavioral Health Workforce Education and Training Programs Internships/Field Placements to strengthen the clinical field competencies of social workers and psychologists who pursue clinical service with high need and high demand population Area Health Education Centers: enhance access to high quality, culturally competent health care through academic-community partnerships to improve the distribution, diversity, and supply of the primary care health professions workforce serving in rural and underserved health care delivery sites. National Center for Workforce Analysis: provides modeling, and data collection to project current and future workforce demands; newly funded Behavioral Health Workforce Analysis Center. Bureau of Health Workforce

10. The National Health Service Corps (NHSC) The NHSC recruits fully-trained professionals to provide culturally competent, interdisciplinary primary health and behavioral health care services to underserved populations. NHSC programs assist in the professionals' repayment of qualifying educational loans that are outstanding. 87% of NHSC clinicians continue to practice in underserved areas up to two years after they complete their service commitment. In fiscal year (FY) 2015, over one in three NHSC clinicians (3,371 out of nearly 9,683 as of September 2015) provided mental and behavioral health services. Psychiatrists, Psychiatric Physician Assistants, Psychiatric Nurse Practitioners, Health Service Psychologists, Licensed Clinical Social Workers, Licensed Professional Counselors, Marriage and Family Therapists, and Psychiatric Nurse Specialists.

11. How Best To Integrate Care? That Depends 11 Minimal collaboration. Providers work in separate facilities, have separate records systems, and communicate sporadically. Basic collaboration at a distance. Providers have separate systems at separate facilities, but engage in periodic communication about shared patients. Basic collaboration on-site. Providers from separate organizations have separate systems but are co-located/share a facility. Source: Standard Framework for Levels of Integrated Healthcare, SAMHSA/HRSA Center.

12. Key Concepts for Integration Integrated Care Models Workforce Financing Clinical Practice Operations & Administration Health & Wellness

13. Dedicated to promoting the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings.

15. SAMHSA/HRSA Center for Integrated Health Solutions Mission of the Center – To Build Bidirectional Integration  Technical Assistance and Training Center on Primary and Behavioral Health Integration.  Improving Access to Primary Care for Behavioral Health Patients.  Improving Access to Behavioral Health for Primary Care Patients.  Contractor - National Council on Community Behavioral Health Care and a large cadre of partners.

16. SAMHSA/HRSA Center for Integrated Health Solutions www.integration.samhsa.gov Target Populations SAMHSA Primary & Behavioral Health Care Integration (PBHCI) Grantees HRSA Grantees General Public Services Knowledge Development (including training curriculum) Prevention and Health Promotion/Wellness Workforce Development Direct Technical Assistance Training Curricula White Papers and Factsheets eSolutions Newsletter – sign up!

17. SAMHSA/HRSA Center for Integrated Health Solutions Use the Quick Start Guide to Behavioral Health Integration to walk you through some of the questions to consider when integrating primary care and behavioral health and find the resources your organization needs. www.integration.samhsa.gov/resource/quick-start-guide-to-behavioral-health- integration www.integration.samhsa.gov/resource/quick-start-guide-to-behavioral-health- integration Use the Standard Framework for Levels of Integrated Healthcare to understand where your organization is on the integration continuum. www.integration.samhsa.gov/resource/standard-framework-for-levels-of- integrated-healthcare www.integration.samhsa.gov/resource/standard-framework-for-levels-of- integrated-healthcare The Core Competencies for Integrated Behavioral Health and Primary Care provide a reference for the vision of an integrated workforce and the six categories of workforce development so you can have all the necessary providers around the table. www.integration.samhsa.gov/workforce/core- competencies-for-integrated-carewww.integration.samhsa.gov/workforce/core- competencies-for-integrated-care Advancing Behavioral Health Integration Within NCQA Recognized Patient- Centered Medical Homes. www.integration.samhsa.gov/search?query=pcmhwww.integration.samhsa.gov/search?query=pcmh

18. SAMHSA/HRSA Center for Integrated Health Solutions Telebehavioral Health Learning Collaborative Divided into six sessions, the training will provide you with the tools and resources necessary to identify and implement a telebehavioral health program. What Makes for an Effective Behavioral Health/Primary Care Team Reviews team development within effective integrated primary and behavioral healthcare teams. The full review identifies four essential elements for effective integrated behavioral health and primary care teams and provides a roadmap for organizations designing their own teams Billing/Coding Worksheets CIHS compiled these state billing worksheets to help clinic managers, integrated care project directors, and billing/coding staff bill for services related to integrated primary and behavioral health care. Return on Investment – Can I Afford Behavioral Health Staff? Addresses the business case for integration of behavioral health into primary care and provides guidance on how to evaluate this business case at an individual Community Health Center. [Find all resources at: www.integration.samhsa.gov/]

19. Discussion Questions What works in building effective referral arrangements – primary care to behavioral health settings and vice-versa? Do you know examples of effective community-wide planning for behavioral services? How does data play a role in any of those examples? From your perspective, what are some important TA needs regarding the integration of behavioral health and primary care? How are you maximizing existing workforce to meet the demand for integrated care?

20. Contact Information Alexander F. Ross, Sc.D. (301) 443-1512 Aross@hrsa.gov