Integrating Primary Care into
Your Behavioral Health Practice
Dave Cook, LICSW, Chief Executive Officer
Heather Geerts, LICSW, Clinical Director
Scott Gerdes, Chief Financial Officer
Casey Langworthy, RN, Primary Care Nurse, Care Coordinator
Community Resource for Behavioral Health
• Providing behavioral
health services to SE
Minnesota since 1966
– Therapy and
psychiatry
– Regional detox unit
– Residential/crisis
treatment facility
– Community support
programs
• 150 total employees
2
Community Resource for Behavioral Health
• Provide continuum of
behavioral services to
SE Minnesota and
state-wide
– Community mental
health center primarily
for Olmsted, Fillmore
county residents
3
Unique Patient Demographics
 Zumbro Valley Mental Health Center provides services
to 5,000 people annually
– 84% of these patients enrolled in publicly funded insurance
options
– Medicaid expansion in 2014 will add 4,700 new enrollees in
Olmsted County
 Many of these patients have significant behavioral and
medical conditions
– Over 70% of publicly funded patients diagnosed with serious
mental illness (SMI) or severe and persistent mental illness
(SPMI)
– 1 of 3 patients utilize multiple services
– More than 70% of patients seen in Psychiatry have a serious comorbid condition:
• Morbid obesity
• Hypertension
• Diabetes
• Asthma
• Chronic pain
• Heart disease
4
Challenges
• Mental health centers across state facing
variety of challenges
– Low reimbursement rates for expanding Medical
Assistance and Medicare populations
– Growing need for treatment of people with dual
diagnoses and co-morbid conditions
– Difficulty finding and retaining qualified
behavioral health professionals
– Transforming care to meet rapidly changing
demands of diverse populations
5
Services Prior to Integrated Care Model
Community
Support
Programs
•Case
management
•Adult Rehab
Mental
Health
Services
•Homeless
outreach
•Intensive
Community
Rehab
Services
Chemical
Health
Services
Outpatient
Therapy
•Youth
Behavioral
Health
•Child Adult
Relationship
Enrichment
•Psychiatric
services
•Psychiatry
•Medication
management
•Therapy individual
and group
•Intensive
Residential
Treatment
Services
•Crisis
services
Residential
Services
Children's
Services
6
•Detox
•Recovery
programs
•Choices
program
(adults and
adolescents)
Adding to the Continuum of Care
QoL meds
Apple Tree Dental
1000
250
800
200
600
150
400
100
200
50
0
0
April
May
June
July
August
April
Scripts
May
June
Patients
7
July
Visits
August
Pre-Primary Care Model
Intake
•Case
management
•Adult Rehab
Mental Health
Services
•Intensive
Community
Rehab Services
Community
Support
Programs
Children's
Services
•Youth Behavioral
Health
•Day treatment
•Psych services
•Detox
•Psychiatry
•Therapy individual and
group
Outpatient
Therapy
8
Residential
Services
•Intensive
residential
treatment
•Crisis services
•Detoxification
•Recovery
programs
•Choices program
(adults and
adolescents)
Chemical
Health Services
Co-morbidity is the Rule, Not the Exception
• Data-mining of Electronic
Medical Record revealed
74% of psychiatric patients
diagnosed with serious
medical condition
• Research shows that people
living with serious mental
illness die an average of 25
years earlier than the
general population1
Likelihood to Use Zumbro Valley
for Primary Care
16.4%
47.2%
21.5%
– Lack of access to primary
medical care
– Preventive health services
1
Colton, CW, Manderscheid, RW. “Congruencies in Increased
Mortality Rates, Years of Potential Life Lost and Causes of Death
among Public Mental Health Clients in Eight States.” Preventing
Chronic Disease, vol. 3, no. 2, 2006.
Very Likely
9
Likely
Somewhat Likely
Co-morbidity is the Rule, Not the Exception
• Integrated model of
care incorporates
mental health, chemical
health, case
management, housing,
dental and pharmacy
services with primary
care
• Goal is to significantly
improve clinical
outcomes for area’s
underserved
populations
10
Steps Toward Integration - Research
• Mental disorders and
medical co-morbidity
– The Synthesis Project.
Robert Wood Johnson
Foundation. 2011.
– Basis for project rationale
• Correlation between
childhood maltreatment
and later-life health and
well-being
– Adverse Child Experiences
(ACE) Study. Centers for
Disease Control and
Prevention. 2010.
11
Steps Toward Integration – Pre-Planning (Phase 1)
• A pre-planning group of community leaders,
Zumbro Valley staff and board members was
assembled to discuss the research and
subsequent efforts to address the problem
• Zumbro Valley conducted an internal patient
survey and review of records that determined
approximately 85% of psychiatric clients have a
serious co-morbid medical condition
12
Steps Toward Integration – Pre-Planning (Phase 1)
• Conduct literature review on the service models for
integrated care
• Evaluate how primary care services have
successfully been integrated in community mental
health centers within Minnesota and other parts of
the country
• Determine the financial model required for
operation
• Develop the space and specifications needed for onsite services
• Explore the need for other resources
13
Steps Toward Integration – Planning (Phase 2)
• Developed on-going Community Advisory
Committee to assist Zumbro Valley board
and leadership team in the development and
implementation of the Primary Care Clinic
-
Mayo Clinic
Olmsted County
MN Dept. of Health
United Way of
Olmsted County
Olmsted Medical Center
Rochester Area Foundation
Olmsted Public Health
MN Dept. of Human
Services
14
Steps Toward Integration – Planning (Phase 2)
• Committee agreed community required
integrated care model and primary care
services for area’s under-served populations
- Hired consultant to develop business plan and
assist with financial pro forma
- Developed guiding principles, goals,
performance outcomes, community benefits, etc.
- Formalized clinical model of care, with clinical
integration manager serving as hub
15
Steps Toward Integration – Planning (Phase 2)
• Trust major issue for
target population
– People diagnosed with a
serious mental illness
significantly less likely to
trust others
– Lack of follow-through by
these clients with
community medical
providers
– Survey found clients view
Zumbro Valley MHC as
their primary care provider
16
Steps Toward Integration – Planning (Phase 2)
• Planning workgroup developed project goals to
assess short- and long-term outcomes
– Improve health outcomes by enhancing the diagnosis of chronic
health conditions and providing treatment of these conditions
– Improve quality of health by increasing focus on wellness and
healthy lifestyles
– Provide person-centered care and whole-person-centered care
approaches
– Contain health care costs
– Improve care coordination between behavioral and primary care
services
– Improve the patient experience
17
Steps Toward Integration - Implementation
Referral
Source
Call to Zumbro
Valley Hunt
Line
18
Steps Toward Integration - Implementation
• The Primary Care Clinic
team consists of a primary
care provider (nurse
practitioner) and support
staff (registered nurse)
- Perform ancillary services –
vital signs, measuring BMI,
etc.
- Process lab samples and
send out for results
- Provide medical exam and
any ongoing care
- Refer patients to community
specialty care providers
19
Steps Toward Integration - Implementation
Current Model
• RN care coordinator performs both clinical and
care coordination duties
• Primary responsibilities:
– Performs triage of new and ongoing patients to
determine level of care needed
– Coordinates care for clinic patients with internal and
external providers
– Provides regular follow-up contact to affirm
adherence to treatment plan
20
Steps Toward Integration - Implementation
Future Model
• Primary care clinic also has an intake worker
(BA level social worker) to assist with care
coordination
• Primary responsibilities:
– Answer calls within 30 seconds
– Triage level of care needed: crisis, urgent, routine
– Arrange for logistics: transportation, community
resources, insurance enrollment, etc.
– Make appointment reminder calls
21
Steps Toward Integration - Implementation
• Each new patient is assigned a clinical
integration manager (nurse practitioner or
clinical social worker) for the course of treatment
• Primary responsibilities:
–
–
–
–
–
–
Conduct diagnostic assessment
Triage risk level: high, medium, low
Monitor and evaluate risk levels
Refer to appropriate behavioral/medical provider
Lead weekly clinical care conferences
Track patient outcomes
22
Steps Toward Integration - Benefits
• Improved quality of life
for clients
– Increased medical and
behavioral compliance
– Wellness programs that
compliment medical and
behavioral services
– Ability to share clinical
information via EMR
– Improved overall health
and well-being
23
Steps Toward Integration - Benefits
• Appropriate Level of
Care = Reduced Costs
– Reduced ER visits and
inpatient hospital days
– Decreased utilization of
after-hours
crisis/ambulance services
– Visits can be routine
(primary care) rather than
acute (emergency
department)
– Fewer psychiatric visits
due to medical stability
24
Steps Toward Integration - Benefits
• Enhanced Access to Care = Improved Outcomes
- Proper medical care contributes to overall housing stability
- Improved medical health results in better overall health of
clients
- Ability to share clinical information with other health care
providers via electronic medical record
25
Steps Toward Integration - Payment
•
Developing a strong
financial pro forma
key to successful plan
-
-
-
Where do we start?
What pieces are
different than mental
health?
What CPT codes do we
need to include?
How is productivity
different?
26
Steps Toward Integration - Payment
• Developing a financial pro forma – where to
start?
– Examination of payer mix
– Research Evaluation and Management (E/M) codes to
identify appropriate types and levels
– Review Medicare and Medicaid reimbursement rates
for selected services
– Determine billing rates for medical services
27
Steps Toward Integration - Payment
• Developing a
financial pro forma –
start-up costs?
–
–
–
–
Building space
Supplies
Equipment
Furniture
28
Steps Toward Integration - Payment
New Patient Codes
E/M
Codes
ZVMHC
Coding
Distribution
Medicaid
Fee
Schedule
Volume
Year 1
(85%)
Year 2
(100%)
Year 3
(100%)
Year 4
(100%)
99201
0%
$49.25
0
$0
$0
$0
$0
99202
3%
$61.61
15
$2,379
$2,828
$2,870
$2,971
99203
29%
$88.28
145
$30,996
$37,644
$38,209
39,552
99204
64%
$134.43
320
$104,448
$126,594
$128,493
$133,009
99205
4%
$166.53
20
$8,075
$9,767
$9,934
$10,283
29
Steps Toward Integration - Payment
Established Patient Codes
E/M
Codes
ZVMHC
Coding
Distribution
Medicaid
Fee
Schedule
Volume
Year 1
(85%)
Year 2
(100%)
Year 3
(100%)
Year 4
(100%)
99211
0%
$29.25
0
$0
$0
$0
$0
99212
7%
$36.11
140
$12,257
$14,636
$14,856
$15,079
99213
32%
$59.62
640
$92,480
$110,432
$112,088
$113,770
99214
54%
$87.99
1,080
$228,582
$272,954
$277,048
$281,204
99215
7%
$117.80
140
$39,627
$47,319
$48,029
$48,750
30
Steps Toward Integration - Payment
Zumbro Valley MHC – Primary Care Financial Pro Forma (Revenue)
Year 1
Year 2
Year 3
Year 4
$518,844
$619,581
$628,875
$638,308
$0
$0
$0
$0
Gross Revenue
$518,844
$619,581
$628,875
$638,308
Collection Ratio
41.1%
41.1%
41.1%
41.1%
$213,036
$254,399
$258,315
$262,088
Primary Care Services
Lab Services
Net Revenues
31
Steps Toward Integration - Payment
Zumbro Valley MHC – Primary Care Financial Pro Forma (Expenses)
Year 1
Year 2
Year 3
Year 4
Salaries
$288,100
$296,743
$305,645
$314,815
Benefits
$87,150
$98,667
$110,796
$114,120
Locum Coverage
$30,000
$30,000
$30,000
$30,000
Supplies (1% gross revenue)
$5,188
$6,196
$6,289
$6,383
$0
$0
$0
$0
$5,166
$6,169
$6,262
$6,356
$800
$1,200
$1,200
$1,200
Interest
$10,139
$8,860
$7,511
$6,086
Depreciation
$11,000
$11,000
$11,000
$11,000
Admin
$55,414
$58,272
$60,795
$62,225
Total
$492,957
$517,107
$539,498
$552,184
Net Revenues
$213,036
$254,399
$258,215
$262,088
($279,921)
($262,708)
($281,283)
($290,096)
Other Lab Expense
MNCare Tax
Malpractice Ins
Net Profit/(Loss)
32
Steps Toward Integration - Payment
• Developing a financial pro forma – other costs?
– Services and coding
– Fee matrixes for primary care
– Lab service integration
33
Steps Toward Integration - Payment
• Model for financing
publically funded
primary care clinic has
many financial
challenges
- Low reimbursement
rates from Medicare,
Medicaid do not support
expenses
- Low reimbursement
levels = requires higher
volume of clients
- Tax status change
(MNCare)
34
Steps Toward Integration - Payment
• Zumbro Valley utilized variety of sources to pay
for clinic
– Obtained funding from Minnesota State Legislature
to pilot integrated care model
– Applied for and received multiple grants from local,
state and national sources to help offset operational
expenses
– Explored opportunities to obtain FQBHC, health
home and behavioral health home status for higher
reimbursement of services
– Received equipment donations from community
sources such as Mayo Clinic
35
Steps Toward Integration - Challenges
• Project – and Qualifacts system – are using a
variety of measurements to determine outcomes
–
–
–
–
–
–
Meaningful Use
Physician Quality Reporting System (PQRS)
E-Prescribing (DrFirst)
DSM-5/ICD-10 cm enhancements
Minnesota 10x10 Initiative (Minnesota MHIS)
Minnesota Depression Care and Diabetes
management
36
Steps Toward Integration - Challenges
• Other Challenges – Electronic Medical Record
– Configuring Carelogic to bill primary care services
required close working relationship with QSI
– Key tasks included
 Creating new EDI file to accommodate Minnesota
Administrative Uniformity Committee
 Setting up overlapping E/M codes for primary care services
 Organizing CPT codes and other activities
 Creating pricing structure based upon market data
 Modifying program history for admitting diagnosis
 Mapping new National Provider Identifier number to all
services
37
Steps Toward Integration - Challenges
• Other Challenges –
Laboratory services
– Identify lab provider (Quest
Labs) who can interface with
system
– Utilize web portal to transact
information on patient lab
results, submit orders, review
results, etc.
– Billing for laboratory services
– Determine how payers
reimburse for lab services
– Discuss use of new e-Labs
program with Qualifacts
38
Steps Toward Integration - Challenges
• Other Challenges –
Third party contracting
– Negotiate agreements
with payers to reimburse
for medical codes
 Medicaid
 Medicare
 Others – Blue Cross Blue
Shield, Optum, MMSI
(Mayo), UCare
Minnesota, South
Country
39
Steps Toward Integration - Challenges
• Other Challenges - Clinical
- Found there were numerous cultural differences
between medical and mental health settings
- Success of integrated model dependent upon
availability and willingness for cross-consultation
- Need for seamless connection with external specialty
care providers for complex care needs
40
Steps Toward Integration - Challenges
• Other Challenges – Staff and training
– Staffing
 Identify right number of people and appropriate positions
 Budget for productivity
 Determine type of clinicians/licenses to properly bill for
services
- Training
 Prepare appropriate documentation
 Have provider choose the right codes
 Conduct ongoing training and note review
41
Steps Toward Integration - Challenges
• Other Challenges – Care coordination and
patient registry
– Coordinate with area health care providers to
transition care back and forth
– Use of weekly clinical conference to discuss highestneed patients with all applicable personnel
42
Steps Toward Integration - Outcomes
• Clinic staff has seen
nearly 100 people
since opening in
December 2013
• Expanding services at
7th Street office
– RN to be available 8
hours per week
43
Steps Toward Integration - Outcomes
• Development of patient
registry critical element
to gauge success
- Track patients with
specific chronic
conditions
- Allow for appropriate
patient staffing
- Determine who, if
anyone, is “falling
through the cracks”
• “Jane’s Story”
44
Steps Toward Integration - Outcomes
• Measurement of clinic outcomes was core
principle from project initiation
– Contracted with third party – Wilder Research – to
measure outcomes
– Wilder staff will present results of 2-year study to
Minnesota Legislature in 2015
• Collaborative effort to gather data
- Minnesota Department of Human Services
- Wilder Research Team
- Rochester Epidemiology Project
45
Steps Toward Integration – Lessons
• Important lesson learned
throughout process has been
having the right partners
– Company with a vision
– Roadmap for the future
– Knowledgeable program
staff
– Supportive agency
environment
• Key to success of project has
been willingness of QSI and
its staff to provide assistance
• Be flexible about model and
funding
46
Steps Toward Integration - Milestones
• 2011
– January: added pharmacy and dental services
– July: began research of Robert Woods Johnson Synthesis
Project and Adverse Childhood Experience (ACE) studies
– September: implemented Community Advisory
Committee
• 2012
–
–
–
–
January: formalized internal integration activities
June: submitted grant request to SAMHSA
July: began meetings with state leaders
July: entered Phase 2 of project and hired consultant
47
Steps Toward Integration - Milestones
• 2012 (continued)
– October: received financial support from Community
Advisory Committee members
– January – December: presented to local and regional
organizations
• 2013
– January: completed business plan and Olmsted County
designated our project as a key initiative for legislative
session
– July: received appropriation from State of Minnesota
– August: combined internal integration activities
• 2014
– January - September: received grants from Mayo
Foundation, Merchants Bank, Schmidt Foundation, Medica
Foundation
48
Questions?
49
For More Information…
• David Cook, LICSW
Chief Executive Officer
507.535.5718 or davec@zumbromhc.org
• Heather Geerts, LICSW
Clinical Director
507.535.5745 or heatherg@zumbromhc.org
• Scott Gerdes
Chief Financial Officer
507.535.5717 or scottg@zumbromhc.org
• Casey Langworthy, RN
Primary Care Nurse/Care Coordinator
507.535.5616 or caseyl@zumbromhc.org
50