Primary-Behavioral Health
Integration: Successes, Barriers
and Solutions
Jerry Lowell LCSW
Senior Vice President
Behavioral Health and Community Services
Aunt Martha’s Youth Services
Increasing Access
to Vital Services
Providing BH in 10 of 17
clinics, Aunt Martha’s
remains true to its
founding vision to respond
to the needs of youth,
families and communities
by providing access to
integrated primarybehavioral health services.
Aunt Martha’s
Office &
Health Center
Locations
Depression diagnosis
rates at Aunt Martha’s
Health Centers
(2009-2010)
Access to Care
35,000
31,474
Growth Trend 2005 – 2009
30,000
25,000
26,120
21,517
20,000
15,000
10,000
5,000
3,878
4,757
5,520
0
07
Users
08
09*
Encounters
• 834% increase in users
509 users to 5.520 users
• 740% increase in encounters
3,107 encounters to 31,474
encounters
• 300% increase in Behavioral Health
service users as % of total users
at Aunt Martha’s: 2% to 8%
Cost Effective, Integrated Services
• We are one of the
largest provider of
behavioral health
services among Illinois’
FQHCs.
• We are also the lead
agency in the State’s
first telepsychiatry
network
Behavioral Health Costs as Percentage
of Total FQHC Costs
Year
AMYSC
ALL IL
FQHCs
National
2006
9%
4%
4%
2007
10%
4%
4%
2008
10%
4%
n/a
Our Behavioral Health Providers
• 11 Psychiatrists
– 2 Child & Adolescent only
– 2 Adult only
– 6 Child & Adolescent and Adult
• 5 Licensed Clinicians (LCSW, LCPC)
Our Support Staff
• Operations Manager
– Oversight of psych operations
– Coordination with health clinic
– Supervise Care Managers
– Handle patient complaints
– Interface with community
• 10 Care Managers
Aunt Martha’s-CMHC Collaborations
• Co-location of CMHC therapist
– Provides “warm hand-off” access
– Encourages cross referral
– Patients integrated into Primary Care
– Staffing and billing done separately
– Establishes relationship for further collaborations
Tele-psychiatry-CMHCs
• Grant from DMH supports connection to 6
downstate CMHCs
• Can now bill Medicaid at encounter rate
• Reimbursement rules require at least an MHP
to be with patient at local site during session
• One-time initial equipment cost, but
telecommunication line costs are high
Tele-psychiatry Network
Eliminating Barriers to Care
Business Model Basics
• Costs have to be considered as part of whole system
Service Specialty Reimbursement Rate:
• Psychiatric, Medical, OB/GYN$123.91
• Therapy (LCSW, LCPC)$49.60
• Psychiatry has to be productive, no administrative
time
Medical and Business Operations which includes:
3 Regional Administrators responsible for the fiscal and regional management of
clinics
Clinic Coordinators report to the Regional Administrator and are responsible for
administrative oversight all staff
Subspecialty Operations including OB, Behavioral Health and Dentalcomprised of 3 Operations Managers responsible for the fiscal compliance and
management of the care management model for all three service areas.
Social Services – all supplemental services that assist patients/clients.
Operational Supports including marketing, compliance assistance, data
management, medical records and training.
Business Model Basics
• Operations based on staffing ratio of 2 Care
Managers to 1 Psych provider
• Administrative overhead has to be lean
• Integration with primary and dental increases
Medicaid revenue
• Psychiatrists are high cost driver, so operations
and productivity have to lower the cost per
visit
Financial Integration: Costs and Benefits
• Costs and benefits to the system as a whole
are identified
• Productivity expectations are established
• Proportionate overhead costs are part of
Behavioral Health budget
Financial Integration: Costs and Benefits
• Cross referrals synergize both clinical and
economic outcomes
• Behavioral Health administration is part of
overall operations management
• Outreach and marketing can call attention to
the integrated services concept
Limitations
• Ideal continuum for FQHC BH is less seriously
mentally ill patients
• Who already access the FQHC for medical care
Even though
• We already see well over 100 with a diagnosis
of schizophrenia
Financial Limitations
• 330 Funding provides limited funding for
uninsured
• FQHCs cannot be the primary provider of BH
services to the Seriously Mentally Ill
Bi-Directional Integration
Great potential, but…
• Needs to be funded
• FQHCs need Change of Scope to provide
primary care in CMHC
• Practice has to recognize that regular
productivity is less
Summary
• FQHCs can be a model for the integration of
primary and behavioral healthcare
• Successful implementation requires effective
systems and management
• BH should be integrated into all areas of clinic
functioning
• FQHC-CMHC collaboration is promising but
should not be viewed as an alternative to
CMHCs for Seriously Mentally Ill