FADAA/FCCMH Annual Conference
Mark A. Engelhardt, MS, MSW, ACSW
USF – FMHI – Dept. of Mental Health
Law & Policy
August 7, 2013 – Orlando, Fl.
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The Case for Integrated Care
 People with mental health and substance abuse disorders
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die years earlier that the average person, mostly from
untreated and preventable chronic illnesses like
hypertension, diabetes, obesity and cardiovascular disease.
Poor health habits, such as inadequate physical activity,
nutrition, smoking and substance abuse
Barriers to primary healthcare & complex systems
Solution – Integrated behavioral (SAMH) and primary
healthcare produces better outcomes for people with
complex needs involved in multiple systems of care.
Quality of Integrated Care & Cost to Person/System
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Organizational Support (2003-13)
 World Health Organization
 Substance Abuse and Mental Health Service
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Administration (SAMHSA)
Health Resources Services Administration (HRSA)
National Council for Behavioral Healthcare –
Community Mental Health Centers and Integrated
Substance Abuse Providers
Community Health Centers – Federally Qualified
Health Centers (FQHC’s)
Health & Behavioral Healthcare Advocates
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Four Quadrant Model
 Population Based (NCCBH)
Population with low to moderate risk/complexity for
both behavioral and physical health issues
2. High Behavioral health risk/complexity and low to
moderate physical health risk/complexity
3. Low to moderate behavioral health risk/complexity
and high physical health risk/complexity
4. High risk and complexity I for both behavioral and
physical health ( SAMHSA – HRSA Grant focus)
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Integration Models (A Few)
 Primary Care in Behavioral Health Settings; Behavioral
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Health in Primary Care Settings or Bi-Directional
Patient-Centered Health Homes (Approach, Not a
Physical setting) – Integrated Treatment Planning
Chronic Care – Disease Management Models
Improving Mood – Promoting Access to Collaborative
Treatment – IMPACT – Early Evidenced-based
Cherokee Health Systems – Fully Integrated (Tenn.)
Range: Coordinated – Co-Located – Integrated
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SAMHSA – HRSA Solutions
 Target = People with Serious Mental Illnesses
 94 Current SAMHSA-HRSA Primary Behavioral
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Health Care Integration grants
Center for Integrated Health Solutions – National
Technical Assistance
http://www.integration.samhsa.gov
Supplemental Health Information Technology (HIT)
One Year Grants to supports the development of
Electronic Health Records (HER) with grantees
New PBHCI Grant applications to be awarded in 2014?
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Southeast Learning Community
 Seven (7) Florida Grantees
 Miami Behavioral Health
 Apalachee Center –
Center – Miami
 Community Rehabilitation
Center – Jacksonville
 7 Others in HHS Region
 Georgia = 3 Community
Service Boards
 4 = Kentucky (I); S.C. –
State DMH; NC & TN (V)
 Cohorts I – V (2009-12)
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Tallahassee
Coastal Behavioral
Healthcare – Sarasota
Lakeside Behavioral
Healthcare – Orlando
Lifestream Behavioral
Healthcare – Leesburg
Henderson BH (V)
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National Outcome Measures
 Functioning – Wellness
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Healthy Overall
Functioning in Everyday
Life
No Serious psychological
distress Using Illegal Substances
Not binge drinking
Retained in the
community
 Housing Stability
 Education and
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Employment
Criminal Justice
Involvement
Perception of Care
Social Connectedness
Approximately 16,000
people served (To date)
Positive outcomes overall
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At Risk Criteria & Tracking
 Blood Pressure (130/85)
 Body Mass Index (Greater of equal to 25)
 Waist Circumference (Male – 102cm; Female 88 cm)
 Breath CO – ( Greater than or equal to 10)
 Fasting Plasma Glucose ( Greater than 100)
 Cholesterol (HDL less than 40; LDL, Greater than or
equal to 130; Triglycerides, Greater than or equal to 150
 The big one = SMOKING
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Grantee Evaluation: Rand Corp.
 56 Grantees included in the National Evaluation
 67% Partnered with FQHC’s
 Over 16,000 served since 10/1/09
 Outcome (Data), Process and Model Evaluation
 78% of Grantees are urban programs in 26 states
 Use of Evidenced-based practices
 Challenges - Data, recruiting staff and consumers,
licensing, info-sharing
 1% arrested in past 30 days; 63% in stable housing
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Rand Corporation Report
 Early Programs – SAMH in Health Care Settings
 Now Primary Care in SAMH Settings
 Common Features:
 Embedded Nurse, On-site Physician, Health
Screenings, Illness Management & Recovery (18
Programs; Wellness Recovery Action Plans (19);
Screening – Brief Intervention- & Referral to Tx
(SBRIT); Peer Specialists (18); Case management
 Diverse Models – Clinic Based to Home visits
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Levels of Integrated Healthcare
 Coordinated = Key element = Communication: usually
minimal to basic coordination
 Co-located = Key = Physical Proximity: usually basic to
close collaboration on-site
 Integrated = Key = Practices Change: usually close
collaboration to a fully transformed/merged integrated
practices – Clients experience a seamless response to
all of their health and behavioral healthcare needs
 Heath, Wise & Reynolds March 2013 (CIHS)
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Workforce Issues
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Peer Support Specialists
Shared Decision Making – Person Driven
Nursing – Physicians Assistants
Access to Psychiatry; Outpatient SAMH Treatment
Training – On-line, Certificate Programs (UMASS);
Numerous Webinars; Cross-training among disciplines,
attitudinal changes; case and care management models;
Recovery-oriented care
 Recruitment and retention (Future Medicaid Expansion
and Affordable Care Act)
 Cultural proficiency
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Clinical Considerations
 Screening Tools ( I.E. SBIRT – Screening, Brief
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Intervention & Referral to Treatment)
Health Indicators ( Substance use, tobacco, blood
pressure, cholesterol, weight, nutrition, etc.)
Motivational Interviewing
Medication Assisted Treatment – Pharmacology
Pain Management (Agency Policies)
Trauma Informed Care
Targeted Populations
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PBHCI Programs
 Million Heart Campaign – National HHS campaign to
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prevent 1 Million heart attacks & strokes in 5 years
Wellness programs = Strategies – Education, healthy
eating, physical activity, stress management, recovery
processes, peer support, diabetes management, etc.
Tobacco cessation (I.E., Univ. of Colorado)
Substance abuse prevention/relapse
Targeted populations = homeless, drop-in centers,
“housing is healthcare”, in-vivo.
Interns , students, volunteers, existing programs
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Administration & Operations
 Memorandum of Understanding with partners (I.E.
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FQHC’s) – Array of services ; who will provide what?
Contracts and formal agreements: Partners
Clarify Billing Opportunities and Revenue Sources –
Grants, Medicaid, Medicare, Physical Health &
Behavioral Healthcare – Now & Future (Affordable
Healthcare Act – Prospective)
Health Information Technology – Electronic Health
Records – Confidentiality & Integration
Meaningful Use & Data Analysis
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COMPASS PH/BH (Cline, Minkoff)
 Self-assessment Tool
 Integrated Treatment
 Program Philosophy
 Administrative Policies
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Data
 Access to Care
 Screening &
Identification
 Integrated Assessment
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Program & Relationships
Welcoming Policies
Medication Management
Integrated Discharge &
Transition Planning
Program Collaboration &
Partnerships
Staff Competencies
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Pilot Tool Kit: MTM & Zia Partners
 Executive Walk through
 Structured Prioritization
from a consumer
perspective
 Admin. Readiness
 Self-assessment Program Organizational
Level PBHCI Capability
 Strategic Partnership
Inventory
Template
 Guidance on design
Performance Plans with
Indicators
 Project Planning and
Organizational
Templates
 References for Specific
Materials (I.E. Tools)
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Homeless Integrated Care Examples
 SAMHSA - PBHCI Grantee – Seattle, WA. – Downtown
Emergency Services Center (DESC)
 Housing First Model Development – Pathways to
Housing – PA – Primary Care Partnership with
Thomas Jefferson University Dept. of Family &
Community Medicine – Philadelphia Dept. of
Behavioral Health & Office of Supportive Housing
 U.S. Dept. of Veterans Affairs – Homeless Veterans
Patient Aligned Care Teams (H-PACT) – Homeless
Medical Home – 23 Pilots: 37 sites funded in 2012/13
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Contact Information
 mengelhardt@usf.edu
 813-974-0769 (Direct Line)
 USF – Florida Mental Health Institute (FMHI) –
Department of Mental Health, Law & Policy
 http://mhlp.fmhi.usf.edu
 www.floridatac.org
Thank You
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