1. DHHS NORTH CAROLINA MEDICAID REFORM North Carolina National Alliance on Mental Illness October 17, 2014 Courtney Cantrell, Ph.D. Director, Division of Mental Health, Developmental Disability and Substance Abuse Services

2. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES …and How YOU Can Benefit Understanding Integrated Care Options…

3. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 3 “Every patient, every person, must have a comprehensive personal care plan, that addresses the whole person. That includes all of their problems and concerns and resources and fears and experiences, and essentially, incorporates into that those factors such that you've got a coherent plan for health…that makes use of all of that. So that if there are mental diagnoses, if there are chronic diseases, if there are acute problems, prevention needs, all of those are understood in the context of each other; a whole person plan of care.” These remarks by Frank DeGruy, MD, NIAC Chair, were part of the Mental Health Forum and Town Hall Meeting at the AHRQ 2011 Annual Conference. This Forum featured national experts on integrated healthcare, including several members of the National Integration Academy Council (NIAC) who discussed policy, research, and the state of the field related to integrating behavioral health and primary care. Frank DeGruy, MD, NIAC Chair,

4. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Integrated Care Integrated care model Treating medical/physical and behavioral (mental health/substance use) conditions in an integrated, coordinated fashion in primary care, with the PCP coordinator of the care team Collaborative Care An integrated approach to health care delivery in primary care, medical and behavioral health providers work together to address the patients medical and behavioral health needs.

5. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Care is… Integrated Team-based Behavioral health care - mental health - substance abuse Primary care - Prevention - Acute Care - Chronic Care Specialist care INTEGRATION and Changing Payment Models (ACOs) Other care Integrated Medical Team PC Physicians BH Specialists Specialists Other licensed health care providers Coordination Collaboration Communication System Integration and Transformation Needed 5 Usual Care Fragmented (siloed) Not coordinated Patient

6. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES TODAY’S CARE Integrated Primary Care My main problem for the day is what determines my care; BH problems may or may not be discussed All of my health needs are covered, including BH, stress, housing, job… factors necessary to plan care Care is determined by today’s problem and time available today Care is guided by patients goals Care varies by scheduled time and memory or skill of the doctor Care is standardized according to evidence-based guidelines I am responsible for coordinating my own care Along with a team of professionals, I help coordinate my care I assume I’m getting quality care because my doc is well-trained Quality of my care is measured, and continuously improved I have to tell the doc what happened to me The doc knows all about my other medical visits/tests/prescriptions I have to go to another provider for BH issues in another clinic A team works with me, at the top of their licenses to serve patients I always have to make an appointment or wait as walk-in; ED If I need care today, I can walk-in or get help without traveling to the clinic Modified Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma 6

7. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Severe Mental Health/ Substance Use Identification and Treatment of Mental Health and Substance Use Medical and Psychological Presentations Medical Presentations Which Need Behavioral Treatment Primary Care FunctionsManage pharmacology; coordinate w/ community providers; crisis management Identification; motivational interviewing; brief intervention; pharmacology, refer to mental health/substance abuse Identification; patient education, co- treatment w/ mental health, monitor activation and adherence (e.g. chronic medical disorders, non- adherence) Identification; education; referral for consultation and co- treatment (e.g., primary insomnia, Gastrointestinal, headache) Primary Care Behavioral Health Clinician Crisis intervention; communication w/ outside specialty care providers Treatment of depression/anxiety; co- treatment w/ PCP; evidence based treatment; medication monitoring Psychoeducation; motivational Interviewing; behavioral activation Health behavior change; psychoeducation; evidence based treatment Range of Need for Collaboration in the Patient Centered Medical Home (Kessler & Miller, 2009) Miller & Kessler, 2009 How the Team Works with Different Peoples’ Needs 7

8. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES What it Looks and Feels Like in Primary Care or a Beh Health Agency 8 You are at the center of your care You work with a team as a member of the healthcare team; brief interventions All of your needs are addressed …IF you have high blood pressure… …if you MIGHT drink a little too much… …IF you have schizophrenia… …IF you have I/DD… …IF you’re a caregiver…

9. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Six Reasons You Want Behavioral Health in Primary Care Reason 1: We all go to Primary Care (or we should), including those with BH needs Reason 2: Many people don’t get BH needs met Reason 3: High Cost of Unmet Behavioral Health Needs Reason 4: Better Health Outcomes Reason 5: Improved Satisfaction 9 Primary Care Behavioral Health -Improves Access -Reduces Costs -Improves Patient -Leads to Better Health

10. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 10 84% of the time, the 14 most common physical complaints have no identifiable cause 1 80% with a behavioral health disorder will visit primary care at least 1 time in a year 2 HALF of all behavioral health disorders are treated in primary care 3 Almost half of the appointments for all psychiatric medications are with a non-psychiatric primary care provider 4 Patient-Centered Medical Home Reason One: Most of Us Get Primary Care 1. Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266. 2. Narrow et al., Arch Gen Psychiatry. 1993;50:5-107. 3. Kessler et al., NEJM. 2006;353:2515-23. 4. Pincus et al., JAMA. 1998;279:526-531.

11. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 11 Patient-Centered Medical Home Reason Two: Unmet Behavioral Health Needs More than half of people with a behavioral health disorder do not get behavioral health treatment 1 30-50% of referrals from primary care to an outpatient behavioral health clinic don’t make first appt 2,3 Two-thirds of primary care physicians reported not being able to access outpatient behavioral health for their patients…due to shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage 1.Kessler et al., NEJM. 2005;352:515-23. 2. Fisher & Ransom, Arch Intern Med. 1997;6:324-333. 3. Hoge et al., JAMA. 2006;95:1023-1032. 4. Cunningham, Health Affairs. 2009; 3:w490-w501.

12. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 12 Unmet Needs: Reasons People Die 1.McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12. 2.Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

13. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Cost of Unmet Needs Continued Healthcare use/costs twice as high in diabetes and heart disease patients with depression 1 1. Original source data is the U.S. Dept of HHS the 2002 and 2003 MEPS. AHRQ as cited in Petterson et al. “Why there must be room for mental health in the medical home (Graham Center One-Pager) Approximately 217 million days of work are lost annually to related mental illness and substance use disorders (costing employers $17 billion/year) 2 Annual Cost – those without MH condition Annual Cost – those with MH condition Heart Condition$4,697$6,919 High Blood Pressure$3,481$5,492 Asthma$2,908$4,028 Diabetes$4,172$5,559 13

14. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 14 Patient-Centered Medical Home Reason Four: Better Outcomes Depression 1-4 Panic Disorder 1-2 Tobacco Alcohol Misuse Diabetes IBS GAD Chronic Pain Primary Insomnia Somatic Complaints 1. Butler et al., AHRQ Publication No. 09- E003. Rockville, MD. AHRQ. 2008. 2. Craven et al., Canadian Journal of Psychiatry. 2006;51:1S-72S. 3. Gilbody et al., British Journal of Psychiatry, 2006;189:484-493. 4. Williams et al., General Hospital Psychiatry, 2007; 29:91-116. 5. Hunter et al., Integrated Behavioral Health in Primary Care: American Psychological Association, 2009

15. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 15 Patient Centered Medical Home Reason Six: Improved Satisfaction Improved Patient Satisfaction 1-5 Improved Primary Care Provider Satisfaction 6,7 1.Chen et al., American Journal of Geriatric Psychiatry. 2006; 14:371-379. 2.Unutzer et al., JAMA. 2002; 288:2836-2845. 3.Katon et al., JAMA. 1995; 273:1026-1031. 4.Katon et al., Archives of General Psychiatry. 1999; 56:1109-1115. 5.Katon et al., Archives of General Psychiatry. 1996; 53:924-932. 6.Gallo et al., Annals of Family Medicine. 2004; 2:305-309. 7.Levine et al., General Hospital Psychiatry. 2005; 27:383-391.

16. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Sounds GREAT…How do I get it? 16 NOT Paid for in current fee for service system Some FQHCs and a few primary care practices funded by grants Some BH agencies offer primary care in their agencies as well

17. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES THE ANSWER: Medicaid Reform Accountable Care Organizations are integrated groups of health care providers who: Deliver coordinated care across health care settings Agree to be held accountable for achieving: –measured quality improvements and –reductions in the rate of spending growth. Keep and Improve the LME-MCO System

18. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES Sounds GREAT…How do I get it? 18 Talk to your general assembly members about what YOU want, because where the state system goes, others usually follow! www.nhmh.orgwww.nhmh.org: No Health without Mental Health; Consumer/Patient Guide to Integrated Care http://integrationacademy.ahrq.gov/ Federal site all about Integrating Behavioral Health and Primary Care

19. NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES THANK YOU! Courtney Cantrell Courtney.m.Cantrell@dhhs.nc.gov 919-733-7011