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Care Model for Project 3ai:

Integration of Primary Care and Behavioral Health Services Webinar April 18, 2016

What is a care model?  “A standard set of roles, responsibilities, resources, and relationships for organizations within the PPS, designed to accomplish a specific project.”  Detailed implementation plans require an understanding of the local environment, and will be developed in conjunction with partners.  Our discussion today will focus on the care model for this project. We recognize that implementation is the fundamental work to achieve a successful initiative, and we welcome discussion with individual partners as we work on phasing implementation of this project across the OneCity Health PPS.

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Development of Care Models  October-December 2014 o Project-specific workgroup was created under leadership of subject matter experts to complete the NYS DOH DSRIP application. The application included description of the intervention that responded to the NYS DOH’s project requirements.

 January-June 2015 o Clinical expertise group with broad range of backgrounds met in February and in April 2015 to review application, submit updates required by the NYS DOH, and determine implementation steps for basic implementation planning.

 July-December 2015 o OneCity Health finalized details for the State Implementation Plan (SIP). o Behavioral Health Integration Care Model developed based on State requirements, national guidelines, literature review of evidence-based standards, and input from clinical expertise group and subject experts. o Behavioral Health Integration Care Model was completed and presented to the OneCity Health Care Models Committee on February 23, 2016. The Care Models Committee represents a range of partner types and professional backgrounds, and members were nominated through a formal application process. The care model was recommended by the Care Models Committee and subsequently approved by the OneCity Health Executive Committee.

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Presentation overview

Project description Target population Implementation strategy Questions/discussion

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Objective of behavioral health integration

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Provide coordinated, accessible behavioral health and primary care to patients with behavioral health issues Reduce hospital admissions and ED visits for patients with behavioral health issues RWJ Synthesis Project: Mental Disorders and Medical Comorbidity, B. Druss & E. Walker, Feb. 2011. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf69438/subassets/rwjf69438_1

State requirements for behavioral health integration

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 Model 1: Co-location of BH into Primary Care Setting  Model 2: Co-location of Primary Care into BH Setting (“reverse co-location”) For both co-location models: o Develop collaborative evidence-based standards of care including medication management and care engagement process. o Conduct preventive care screenings, including behavioral health screenings (e.g. PHQ-2 or 9 for those screening positive, SBIRT) implemented for all patients to identify unmet needs. o Shared EHR/ clinical record must be implemented; EHRs or other technical platforms will track all patients engaged in this project. o A quality process and outcome program will be implemented to ensure integration is efficient and appropriate outcomes metrics are met. o Regulatory requirements will be addressed.

 Model 3: IMPACT Model (“Improving Mood – Access to Collaborative Treatment”) o Utilize IMPACT Model (University of Washington) for screening and collaborative treatment of depression

State-defined Metrics for behavioral health integration Type of Metric Patient Engagement Commitment

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Measurement 3ai Patient Engagement Definitions: Model 1 Integration of BH into Primary Care Setting: “The total number of patients receiving appropriate preventive care screenings that include mental health/SA.” Model 2 Integration of Primary Care into BH Setting: “The total number of patients receiving primary care services at a participating mental health or substance abuse site.” Model 3 IMPACT Model: “The total number of patients screened using the PHQ-2 or 9/ SBIRT.” 3ai Patient Engagement Commitment (summed across Models): • Earliest commitment is DSRIP Year 1 (10,648 in last quarter, i.e. by 3/31/16) • Annual commitments: • 63,886 (DSRIP Year 2) • 106,477 (DSRIP Year 3) • 106,477 (DSRIP Year 4)

State-defined Metrics for behavioral health integration Type of Metric

Measurement

Behavioral Health Domain 3 Metrics

Utilization • Potentially Preventable Emergency Department Visits for persons with BH diagnosis • Total hospitalizations, ED visits, and readmissions (medical or BH) Care transitions • Follow-up after hospitalization for Mental Illness – within 7 days • Follow-up after hospitalization for Mental Illness – within 30 days Screening • Screening for Clinical Depression and follow-up Depression management • Antidepressant Medication Management – Effective Acute Phase Treatment • Antidepressant Medication Management – Effective Continuation Phase Treatment Care management/ integrated pathways for patients with schizophrenia or bipolar disease • Adherence to Antipsychotic Medications for People with Schizophrenia • Diabetes Monitoring for People with Diabetes and Schizophrenia • Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication • Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia Substance use disorder treatment • Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) • Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 days) ADHD treatment follow-up • Follow-up care for Children Prescribed ADHD Medications – Initiation Phase • Follow-up care for Children Prescribed ADHD Medications – Continuation Phase

While many of these metrics can be affected from the outpatient BH/ primary care environments, others will be influenced by • care transitions project, • ED Care Triage project, and • increased care management resources

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Integration of Primary Care and Behavioral Health Services

Project description Target population Implementation strategy Questions/discussion

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A spectrum of services to meet a spectrum of patient needs Patients with undiagnosed conditions including depression, alcohol abuse

Primary care screening for undiagnosed behavioral health conditions

Patients with mildmoderate behavioral health problems

Behavioral health managed by primary care clinicians

Collaborative Care (IMPACT) model; treatment modalities provided within primary care (e.g. CBT)

Patients with more complex behavioral health problems, but not requiring wraparound services

Behavioral health managed by BH specialists within primary care

Co-location into primary care site

Patients with complex behavioral health problems, +/- need for wraparound services, able to access routine primary care services

Behavioral health site manages BH issues, primary care provided separately

Enhanced care may result from ongoing relationship-building between sites as extension of collaborative or co-located services

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Behavioral health patients with difficulty navigating routine primary care services

Behavioral health site with co-located primary care

Co-location into behavioral health site

Considerations for referral

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From

To

Behavioral health site

Co-located primary care services • at the BH site • •

Primary care site

Considerations for referral

Primary care site with colocated BH specialist

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Stable psychiatric disease with follow-up needs limited to medication refills and monitoring

Collaborative care BH treatment led by primary care clinician (i.e. IMPACT)

• • •

Positive screening for target condition (depression, etc.) Target conditions expected to expand as program evolves (alcohol, anxiety) Collaborative care program offers services (such as cognitive behavioral therapy) that are evidence-based treatments for the target disorder

BH specialist co-located at primary care site

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More complex BH condition requiring visit to BH provider as consultant to primary care clinician, or for shorter term treatment

BH site (shared care without colocation)

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Stable primary care relationship but patient requires intensity of BH services not available at primary care site

Transfer of primary care to colocated provider at BH site

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Patient receives behavioral health services at a site with co-located or needs new BH outpatient referral Patient with poor ability to follow up with primary care in standard setting Poor medical outcomes (hospitalizations, ED visits) due to interface of BH and medical conditions, despite existing primary care efforts

• • Other referral sources (other outpatient services, hospital, ED, care management, etc.)

Significant barriers to successfully accessing primary care Ongoing intense BH treatment needs with frequent interactions at BH site History of multiple ER or hospital visits for medical complications

BH site/ co-located primary care Primary care site/ co-located BH

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Referrals may be directed according to considerations above

Integration of Primary Care and Behavioral Health Services

Project description Target population Implementation strategy Questions/discussion

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Implementation strategy overview  OneCity Health has committed to implementing all three models of behavioral health integration  Standard elements of implementation for both co-location models will include: o Co-location must be supported by processes that ensure communication, such as scheduled time for joint case reviews or regular huddles for collaborative planning. o Referrals will be “warm hand-offs” with staff introducing the patient to the program o Providers will have shared records, or mutual access to records if in separate systems o Screening protocols will be mutually agreed to for key interfaces between BH and primary care conditions (e.g. metabolic screening for patients on antipsychotics) o Clinical teams will have access to care management services

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Behavioral health sites: implementation strategy  Primary care services can be provided by any independently licensed provider (MD, DO, NP)  Primary care services will include functions including: o o o o

standard preventive care services screening and medical management issues specific to behavioral health population population health management for common chronic conditions collaboration with care management services

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Primary care sites: implementation strategy  Collaborative care (IMPACT) and co-location are two points in the spectrum of integration  Different sites will have different baseline states of behavioral health integration  Primary care sites may choose different target states based on their own resources and needs o Behavioral health integration survey will inform implementation planning across the PPS primary care network, including baseline states and resources gaps

 Collaborative care models will focus first on depression (IMPACT model) and may expand to additional common behavioral health issues (alcohol misuse/ SBIRT, anxiety). o For conditions targeted by collaborative care models, population-based screening will be implemented o For IMPACT model, we will be guided by the University of Washington model and build on existing experience with this program within OneCity Health primary care sites o Enhancement of on-site services (e.g. cognitive behavioral therapy) expands primary care capabilities, independent of co-location of prescribing provider

 For co-location in primary care setting: o Behavioral health provider can be any licensed independent behavioral health professional with access to prescribing professional for consultation and prescribing purposes o Behavioral health provider will have time set aside to facilitate consultation to primary care teams

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IMPACT Model for depression will be first-phase implementation strategy Key components

Component description

Collaborative depression care

Patient’s primary care physician works with a depression care manager (nurse or social worker) to develop and implement a treatment plan

Depression care manager

Licensed clinical professional (e.g. RN, SW, psychologist) educates patient, supports adherence, provides coaching and brief counseling, monitors symptoms for response, develops relapse prevention plan

Designated psychiatrist

Care manager and primary care provider consult with psychiatrist to change treatment plans if patients do not improve

Outcomes measurement

Monitor progression of symptoms using PHQ-9 or similar tool

Stepped care

Adjust treatment using evidence-based algorithm

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Enhancing behavioral health skills in primary care teams  Training strategy will focus on increasing skills base among primary care team members for management of behavioral health conditions  OneCity Health will consider trainings of different intensities, to match site-specific needs and capacities, as part of overall approach to capacity building for integration o Trainings may target entire team vs. ‘expert’ within the primary care team o Mini-fellowships may support ‘expert’ function for physicians and other clinically licensed professionals who wish to lead integration efforts within the primary care team o Skills-based training can enhance primary care team’s capacity to provide non-pharmacological treatment modalities for behavioral health conditions

 Assistive technologies such as web-based therapeutic interventions may be considered as additional ways to enhance access to non-pharmacologic interventions for primary care patients

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Anticipated challenges in implementation planning across all models

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Anticipated challenge

Potential strategies to address challenge

Identifying correct model/ degree of integration across many different primary care and behavioral health sites

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Behavioral health baseline survey for non-NYCHH primary care sites Partner outreach to understand existing capabilities and culture, and to identify regulatory and resource issues

Access and capacity limitations for behavioral health and primary care

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Ongoing access improvement work at clinical sites Centralizing information on new patient capacity

Staff shortages in behavioral health and in primary care

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Identification of existing resources; promotion of collaborative working environment Efficiencies in deployment of existing resources; hiring to increase capacity Support for key roles such as depression care manager, care management roles

Implementing and sustaining collaborative work in high-volume outpatient environments

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Identification of programmatic priorities and collaborative workflows

Challenges in developing shared EHRs/ sharing information between providers

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Support as feasible from OneCity Health IT team

Developing business plan for financial sustainability

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Technical support from PPS in defining business model and in optimizing financial sustainability based on current payment mechanisms Definition of resource gaps

• Need for integration of substance abuse treatment

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Support as needed for licensure requirements to integrate substance abuse treatment into behavioral health sites Mapping of substance abuse resources Primary care/ ED/ inpatient algorithms for referral to alcohol and drug abuse treatment

Improved integration of community-based organizations into delivery system

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Mapping PPS partner types and resources to support appropriate referrals and development of partnerships

Cultural competency needs

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Cultural competency training

Integration of Primary Care and Behavioral Health Services

Project description Target population Implementation strategy Questions/discussion

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