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 Please insert the assigned session number (letter and number), i.e., A2a Please insert the assigned DAY and DATE of your presentation, i.e., Friday, October 17, 2014 or Saturday, October 18, 2014 Please insert the TITLE of your presentation. List each PRESENTER who will attend the CFHA Conference to make this presentation. You may acknowledge other authors in subsequent slides. Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Collaborative Family Healthcare Association 12th Annual Conference

Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. CFHA requires that your presentation be FREE FROM COMMERCIAL BIAS. Educational materials that are a part of a continuing education activity such as slides, abstracts and handouts CANNOT contain any advertising or product‐group message. The content or format of a continuing education activity or its related materials must promote improvements or quality in health care and not a specific propriety business interest of a commercial interest. Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the educational material or content includes trade names, where available trade names for products of multiple commercial entities should be used, not just trade names from a single commercial entity. Faculty must be responsible for the scientific integrity of their presentations. Any information regarding commercial products/services must be based on scientific (evidence‐based) methods generally accepted by the medical community. Collaborative Family Healthcare Association 12th Annual Conference

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

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. 2014 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: http://integrationacademy.ahrq.gov/lexicon 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), 637-644. 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), 183-185. NEW! 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. Without these references, your session may NOT be approved for CE credit. Collaborative Family Healthcare Association 12th Annual Conference

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

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)

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)

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.

No such thing as a single disease

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.

In service to Improving outcomes Decreasing cost Enhancing the patient experience

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

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

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)

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.

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

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.

Proven Methodology: Science of Improvement W. Edwards Deming 1900-1993 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.

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)

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.

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.

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

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

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

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.

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)

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.

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

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

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

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

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

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)

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.

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 http://www.ihi.org/Engage/collaboratives/OptimizePrimaryCareTeamstoMeetPatientsMedicalANDBehavioralNeeds/Pages/default.aspx

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.

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)

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. https://www.resourcesforintegratedcare.com/tool/bhica

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

Evaluation Framework Linked to Organization Processes, Impact, and Resources

Questions?

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