1. Integrated Health Care Models and Practices
The Greater Houston Behavioral Health
Affordable Care Act (BHACA) Initiative
Behavioral Health Subgroup Meeting:
The Integration of Primary Care and Behavioral Health,
Region 3 Learning Collaborative
Alejandra Posada, M.Ed.
Director of Education and Training
Mental Health America of Greater Houston
Elizabeth Reed, LMSW
Assistant Project Manager – BHACA Initiative
Network of Behavioral Health Providers

2. Finding a Common IHC 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”
Source: Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: AHRQ Publication No. 13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality Available at

3. IHC Models: Theoretical Frameworks

4. Behavioral Health Care
Two Basic Models
Behavioral Health Care
Primary Care
bidirectional integration
BH may be MH or SA or both; integration of MH with SA is also critical – and also has not been the norm in traditional care.
BH into PC was original model of integration; therefore PC into BH has been called “reverse integration”; bidirectional integration is necessary to meet health needs of diverse population

5. The Four Quadrant Model
Quadrant II
BH PH 
Quadrant IV
BH PH 
Physical Health Risk/ Complexity
Quadrant I
BH PH 
Quadrant III
BH PH
Behavioral Health Risk/ Complexity
Source: SAMHSA-HRSA Center for Integrated Health Solutions

6. The Spectrum of Integrated Health Care:
Refer audience to handout in their packet
Source: Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. March 2013.
Available at

7. Variations & Considerations
One agency vs. a partnership between/among agencies
Behavioral health services – Mental health? Substance use? Both?
Psychiatry – On staff? Contracted? Tele-psychiatry? Consulting psychiatrist available to PCP?
Care manager or care coordinator who serves as the “glue” in connecting the team?
Additional integrated components based on particular needs/circumstances of clientele, e.g.:
Case management
Peer support services
Family support services
Social services
W/in substance abuse – SBIRT only? Or more in-depth SA services?
Care manager or care coordinator – Varying credentials and responsibilities; LCSW can provide both care management and clinical services (billable)

8. And now, an in depth look at the IMPACT Model…

9. IMPACT: Evidence-Based Depression Care
IMPACT has been shown in randomized controlled trials to double the effectiveness of usual care for depression while lowering long-term health care costs.
Five Key Components
Collaborative care is the cornerstone of the IMPACT model
Depression Care Manager
Designated Psychiatrist
Outcome measurement
Stepped care
Impact Study Sites:
University of Washington / Group Health Cooperative
Wayne Katon (PI), Elizabeth Lin (Co-PI), Paul Ciechanowski
Duke University
Linda Harpole (PI), Eugene Oddone (Co-PI), David Steffens
Kaiser Permanente, Southern CA (La Mesa, CA)
Richard Della Penna (Co-PI), Lydia Grypma (Co-PI), Mark Zweifach, MD,
Rita Haverkamp, RN, MSN, CNS
Indiana University
Christopher Callahan (PI), Kurt. Kroenke, Hugh. Hendrie (Co-PI)
UT Health Sciences Center at San Antonio
John Williams (PI), Polly Hitchcock-Noel (Co-PI), Jason Worchel
Kaiser Permanente, Northern CA
Enid Hunkeler (PI), Patricia Arean (Co-PI)
Desert Medical Group
Marc Hoffing (PI); Stuart Levine (Co-PI)
Source: impact-uw.org

10. IMPACT Cost-savings Source: impact-uw.org
III. Addressing these psychosocial aspects often results in lower overall health costs.
■■ A meta-analysis of 91 studies found that with active behavioral health treatment, patients
diagnosed with a mental disorder had a reduced overall medical cost of 17%, while controls who
did not receive behavioral treatment increased an average of 12.3% (Chiles et al., 1999)
■■ Patients who receive care for depression in primary care clinics with routine mental health
integrated teams and care processes were 54% less likely to use high-order emergency
department services. (B. Reiss-Brennan et al., 2010)
■■ Adding integrated services in one study added $250 per patient to overall costs, but saved
approximately $500 in additional medical costs. (W. Katon et al., 1996)
■■ When family physicians worked collaboratively with mental health professionals to treat persons
on short-term mental health disability leave, their patients returned to work at higher rates than
those treated by physicians alone. The average cost savings to employers was $503 per patient.
(C. Dewa, 2009)
■■ An integrated primary care model for homeless individuals and injection-drug users in Santa
Clara County found that emergency and urgent care visit rates decreased from 3.8 visits in the
18 months prior to the clinic’s opening to 0.8 visits in the first 18 months of the clinic’s operation.
(Kwan et al., 2009)
Source: Partners in Health IHC Toolkit (2013)-
Source: impact-uw.org

11. Primary Care Provider (PCP)
IMPACT – Key Component #1: Collaborative Care
Patient
Primary Care Provider (PCP)
Chooses treatment in consultation with provider(s):
-Antidepressants and/or
brief psychotherapy
Refers; prescribes antidepressant medications
Collaborative care is the cornerstone of the IMPACT model and functions in two main ways
Patient’s PCP works with a care manager to develop and implement the treatment plan (medications and/or brief, evidence-based psychotherapy)
Care manager and primary care provider consult with psychiatrist to change treatment plans if patients do not improve
+ Depression Care Manager
+ Consulting Psychiatrist
Source: impact-uw.org

12. IMPACT – Key Component #2: Depression Care Manager
Depression Care Manager - may be a nurse, psychologist, social worker or licensed counselor and may be supported by a medical assistant or other paraprofessional.
Role of the care manager:
Educates the patient about depression
Supports antidepressant therapy prescribed by the patient's primary care provider if appropriate
Coaches patients in behavioral activation and pleasant events scheduling
Offer a brief (six-eight session) course of counseling, such as Problem-Solving Treatment in Primary Care
Monitors depression symptoms for treatment response
Completes a relapse prevention plan with each patient who has improved
The typical caseload for a full-time care manager is patients.
Similar Roles: Embedded Behavioral Specialist, Embedded Behavioral Health Consultant
Source: impact-uw.org

13. IMPACT – Key Components #3, #4, and #5: Consulting Psychiatrist, Outcome Measurement, Stepped Care
Designated Psychiatrist (Key Component #3): Consults to the care manager and PCP on the care of patients who do not respond to treatments as expected
Outcome Measurement (Key Component #4): IMPACT care managers measure depressive symptoms at the start of a patient's treatment and regularly thereafter. The PHQ-9 is recommended as a tool, but there are other effective tools.
Stepped Care (Key Component #5):
Treatment adjusted based on clinical outcomes and according to an evidence-based algorithm
Aim for a 50 percent reduction in symptoms within weeks
If patient is not significantly improved at weeks after the start of a treatment plan, change the plan.

14. Together the IMPACT Team…
Identifies and tracks depressed patients
a. Case finding (screening, referral) -> confirm diagnosis
b. Proactive follow-up & tracking (PHQ-9)
•Change treatment if patient not improving
•Relapse prevention plan for patients in remission
Enhances patient self-management
a. Education
b. Brief Therapy: Behavioral Activation / Problem Solving
Supports additional treatment
a. Primary Care (Antidepressant Medications)
b. Specialty Mental Health Care / Psychotherapy
Utilizes mental health consultation for difficult cases
a. Caseload supervision / consultation for care managers
b. Psychiatry consultation for treatment nonresponders
Source: impact-uw.org

15. The “Chocolate Cake Metaphor”

16. Key Elements – No Matter the Model
Team-based approach to care
Communication at all levels
Coordinated, collaborative care
Providers physically at the same location
Access to shared patient records
Understanding of each other’s roles and disciplinary cultures
Screening, evidence-based clinical practices
Patient experience of seamless care (“one stop shop”)

17. And now… we are proud to introduce
Andrea Richardson, Executive Director of Bluebonnet Trails Community Services,
a stellar example of how to go down the right road in integrated health care

18. Integration of Primary and Behavioral Health Services

20. So…Where are the Organizations as Partners?
Do the organizations have a common mission?
Do the organizations use the Triple Aim as a guiding framework?
improve the experience of care,
Improve the health of populations, and
reduce the cost of health care without compromising quality
Do the organizations have capacity to measure the health outcomes resulting from integration?

22. …and Where Do You Want to Go?
Do the organizations want a separation of staff?
What shared costs can be realized?
What strengths may be shared:
Medications
Expertise in Service Delivery
Billing Opportunities
Technology
Facilities

24. …and How Will You Know When You Get There?
A Patient-Centered Model of Care…from the Front Door Onward
Transparency of the Combined Effort
A Unified Treatment Plan
Communication and Action Planning Strengthening the System of Care

25. That’s All it Takes!?

26. Not so fast…

27. Sustainability For Quality Care: Focus on Access to Services
Excellent Outcomes
Establishing Continuity of Care
Individualized Recovery and Health Plans

28. Sustainability For Financial Stability:
Establishing Rates for Services
Educating Health Plans
Use of Telemedicine

29. Sustainability As a Partnership: Electronic Health Record
Education of Staff
Common Language
Respect for Disparate Work Cultures
Celebrations A

30. Discussion and Questions

31. Theory In Practice – Additional Real Life IHC Examples

32. A Texas Example – El Buen Samaritano
El Buen Samaritano Episcopal Mission, Austin, Texas:
Private, non-profit health and social service organization serving primarily Hispanic clients
Wallace Mallory Clinic at El Buen Samaritano
Has been primarily nurse-managed
Integrated behavioral health (IBH) program began in October 2010
Behavioral health within a primary care setting
Adaptation of the IMPACT model

33. El Buen Samaritano (Continued)
Clients screened for mental health issues during primary care visit and enrolled in IBH program
LCSW (“embedded behavioral health specialist”) follows up with clients enrolled in the program
Possible “warm transfer”/client meets LCSW during primary care visit
LCSW serves as “care manager” (NOT case manager) and provides short-term course of therapy
Psychiatric medication may be prescribed by PCP; PCP consults with psychiatrist as needed
Provider communication and coordination

34. “Takeaways” from El Buen’s Experience
Nurses’ training and perspective as facilitator in integrating care
“Care management” role
Benefits of a “warm transfer”
Importance of mutual respect among all providers as equal members of the care team
Role of formal and informal communication mechanisms
Cultural and linguistic considerations

35. A Texas Example – Lubbock, Texas
Sunrise Canyon Behavioral Health Network (CMHC) & Texas Tech University Health Science Center School of Nursing (FQHC):
Integrated health care clinic at CMHC facility
Shared vision for improving quality of care
Space built out to include 10 exam rooms, lab space, shared staff offices
Staffed by both CMHC and FQHC employees; intentional focus on operating as one clinical team even though employed by two agencies
Nurse-managed

36. Lubbock Partnership (Continued)
Funding:
SAMHSA grant and some state funding (after two years of collaboratively seeking funding)
Each agency’s regular funding streams (e.g., Medicaid reimbursement, CMHC general revenue funds)
FQHC bills as usual for the services its employees provide, and pays rent to CMHC
New Access Point funding
Patient Satisfaction & Outcomes

37. “Takeaways” from Lubbock’s Experience
Importance of shared priorities
Importance of cultivating relationships and teamwork
Nurses’ training and perspective as facilitator in integrating care
Collaborative approach to funding (“the community’s money”)
Critical need for integrated health care for individuals with serious mental illness

38. A Texas Example - LSCC Lone Star Circle of Care, Georgetown, Texas:
FQHC providing care in Central Texas
“Behaviorally enhanced health care home”
Behavioral health as an equal service line within the FQHC
Leadership – Behavioral Health Integration Council
Leveraging diverse collaborations in the community
Focus on financial sustainability
Bell, Williamson, and Travis Counties

39. Lone Star Circle of Care (Continued)
Active screening for behavioral health issues
Embedded behavioral health specialists
Provide “real time” consultation to medical staff
Conduct crisis intervention for patients in the clinic
Facilitate and expedite access to psychiatric services
Provide brief therapy/counseling services to patients
Coordinate care with the patient’s PCP
Assist with efficient patient flow
PCPs consult with child and adolescent psychiatrists
Tele-psychiatry
Provider communication and coordination
“Hallway” or “curbside” consults
Case conferences
Electronic Health Record

40. Lone Star Circle of Care (Continued)
Lone Star Circle of Care’s Belton Pediatric Clinic:
Primary Care Pediatric Clinic
Pediatricians
“Embedded” LCSW
EHR
LSCC “Intranet”
, cell phone
Meetings every other month
Psychiatrist at Another LSCC Location
Consults with LCSW and pediatrician
Provides direct patient services when needed

41. Lone Star Circle of Care – Partnerships
Partnerships with academic institutions:
Partnership with Texas A&M Health Science Center (TAMHSC)
LSCC operates a clinical “hub” at the TAMHSC College of Medicine facility in Round Rock, TX (Seton Family of Hospitals funded start-up costs for this clinical hub)
LSCC is an affiliate of the TAMHSC College of Medicine – LSCC doctors act as clinical faculty; medical students rotate through LSCC clinics
Similar partnerships with other academic institutions place students, interns, and residents at LSCC
Partnerships with area hospitals:
LSCC has partnered with area hospitals to coordinate care for uninsured patients
Area hospitals have awarded LSCC one-time grants to establish clinics
Increased access to primary care at a patient-centered medical home, complete with fully integrated behavioral health services, encourages more appropriate use of emergency services and thereby increases cost efficiency of care system wide
Due to this program’s success, area hospitals continue to partner with LSCC to open more clinics, sometimes co-branding clinics
After the initial grant to build and/or expand facilities, these LSCC clinics are fully sustainable and independently operated
Partnership benefits for LSCC, academic institutions, and students/residents:
Students/residents learn about practicing in an integrated setting
Students/residents learn about practicing in a community health center setting with underserved populations
Students/residents and their schools benefit from the expertise of LSCC staff
The opportunity to serve as clinical faculty is a selling point in the recruitment and retention of staff for LSCC
LSCC benefits from the services provided by students/residents and also from the creation of a “pipeline” of potential future staff

42. “Takeaways” from Lone Star’s Experience
Importance of leadership and organizational commitment
Integrated health care as part of the “culture” of an organization
Role of community collaborations
“Care management” role
Diverse mechanisms for communication; maximizing use of the EHR as a communication tool
Financial sustainability

43. The Greater Houston Behavioral Health Affordable Care Act (BHACA) Initiative
The Network of Behavioral Health Providers (NBHP) and Mental Health America of Greater Houston (MHA) have committed to work together to assist providers in Greater Houston/Harris County to adapt to health reform under the Patient Protection and Affordable Care Act (ACA).
Four BHACA Initiative Focus Areas:
Establishing integrated health care (IHC) partnerships
Maximizing third party funding streams revenue
Adopting a certified electronic health record
Developing outcome based evaluations

44. You’re Invited: Benefit from BHACA!
Find BHACA Resources housed at & Join our BHACA listserv! Go to the homepage to sign-up for bi-monthly resource s plus updates about upcoming training events. Open Call: Help us play matchmaker to leverage your medical staff to co-locate at interested behavioral health provider locations. Let us learn more about your resources and needs so we can support Houston area IHC partnerships. Community Events: Save the Date – Next IHC Open Discussion Meeting on April 23, from 2:00 to 3:30 PM. We are receptive to your requests for project-related trainings, so please be in touch!

45. What are your Questions?
For More Information:
Alejandra Posada, M.Ed.
Director of Education and Training
Mental Health America of Greater Houston
Elizabeth Reed, LMSW
Assistant Project Manager
The Greater Houston Behavioral Health
Affordable Care Act (BHACA) Initiative
Network of Behavioral Health Providers (NBHP)
What are your Questions?