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
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
• We have not had any relevant financial relationships
during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Learn about the Triple Aim benefits of primary carebehavioral 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.
Bibliography / Reference
1. IHI 90-Day R&D Project Final Summary Report: Integrating Behavioral Health and
Primary Care. Cambridge, MA: Institute for Healthcare Improvement; March 2014.
2. Laderman M, Mate K. Integrating Behavioral Health into Primary Care. Healthcare
Executive. 2014 Mar/Apr;29(2):74-77.
3. 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
4. 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.
5. 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.
Learning Assessment
• A learning assessment is required for CE
credit.
• A question and answer period will be
conducted at the end of this presentation.
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.
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.
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No such thing as a single disease
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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
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IHI’s Work: Five Key Areas
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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.
Proven Methodology:
Science of Improvement
W. Edwards Deming
1900-1993
API’s Model for Improvement
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.
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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
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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.
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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
2 –Clinic Care
Quarterly
Clinic
3 – Community Care
Weekly; more than
once a week initially
Home, workplace,
community
organization
PCP; behavioral
health provider. Could
include group visits
Community health
workers; mobile
clinics. Could include
group visits
4 – Family
Engagement in Care
Daily
Home
Family members
5 – Self-care
Daily
Home
Patients
6 - Policy and Financial Considerations
Cost
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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)
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Five Step Sequence
1. Assess readiness for integration.
2. Develop reliable operations and processes to
support integrated care.
3. Develop the business case for integration.
4. Re-design care delivery using collaborative care
principles for integration.
5. Operationalize changes into clinical workflows.
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1. Assess readiness for integration
1. Assess
Readiness
Assess readiness based on:
– Patient needs
– Clinic characteristics
– Policy & financial environment
– Existing data & measurement system
2. Develop Reliable Operations and
Processes to Support Integrated Care
1. Assess
Readiness
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Leadership and culture
Access and workflows
– Technology considerations
2. Processes to
Support Integration
– 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
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3. The Business Case for Integration
1. Assess
Readiness
2. Processes to
Support Integration
3. Make the
Business Case
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.
4. Re-design Care Delivery Using
Collaborative Care Principles
1. Assess
Readiness
2. Processes to
Support Integration
3. Make the
Business Case
4. Redesign
Care Delivery
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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
5. Operationalize Changes in
Clinical Workflows
1. Assess
Readiness
2. Processes to
Support Integration
3. Make the
Business Case
4. Redesign
Care Delivery
5. Operationalize
Changes in Workflows
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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
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/OptimizePrimaryC
areTeamstoMeetPatientsMedicalANDBehavioralNeeds/Pa
ges/default.aspx
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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
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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
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Questions?
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!