Federally Qualified Health
Center Integration Efforts
Michigan Institute for Prevention and Treatment
Education
September 16, 2013
Rebecca Cienki, Chief Operating Officer
Brittany Beard, Program Specialist
Michigan Primary Care Association
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Mission & Vision
MPCA's mission is to promote,
support, and develop comprehensive,
accessible, and affordable communitybased health care services to
everyone in Michigan.
MPCA vision is to build a healthy society in which
all residents have convenient and affordable access
to quality health care. MPCA will be a leader in
influencing health care policy, legislation, and
regulation fostering comprehensive, community
governed, quality care that ensures excellent
health and quality of life for all residents of the
United States.
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World Health Organization

Definition of Health:
◦ Health is a state of complete physical, mental,
and social well-being and not merely the
absence of disease or infirmary
3
Example Mission Statements
“…improves the health and wellness of
individuals by providing comprehensive
primary and behavioral health care while
encouraging access by those who are
underserved”
 “To improve the quality of life for our
patients through the blending of primary
care, behavioral health and prevention
services.”

4
Individuals w/ Substance Abuse
Disorders have:
Nine times greater risk of congestive
heart failure
 Twelve times greater risk of liver cirrhosis
 Twelve times the risk of developing
pneumonia

54% of addiction treatment programs have no physician
http://www.medscape.com/viewarticle/729401
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Prevalence in Primary Care
20% of patients seen in family practice
have Substance Abuse Disorders
 SUDs are currently ranked among the top
10 leading preventable risk factors for
years of life lost to death and disability
 2007, approx. 22.3 million adults were
classified as having a substance
dependence or abuse disorder

http://www.medscape.com/viewarticle/729401
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Outcomes from Integration

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Two or more primary care visits in a 6
month period has shown to improve
abstinence during recovery from a SUD by
50%
Individuals with medical conditions related
to substance abuse are three times more
likely to achieve remission over 5 years
Regular health and addictions care for
people with substance abuse disorders
decreased hospitalizations by up to 30%
http://www.integration.samhsa.gov/clinical-practice/13_May_CIHS_Innovations.pdf
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Mental Health & Substance Abuse FTE in
Michigan FQHCs
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Mental Health & Substance Abuse Visits per
Provider Type in Michigan FQHCs
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Number of Mental Health & Substance
Abuse Visits in Michigan FQHCs*
*2012 was the first year Health Centers were required to report for all diagnoses, not just primary. Dramatic
increases more accurately reflect the population prevalence.
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Number of Mental Health & Substance
Abuse Patients in Michigan FQHCs*
*2012 was the first year Health Centers were required to report for all diagnoses, not just primary. Dramatic
increases more accurately reflect the population prevalence.
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Prevalence of Behavioral Health Conditions
Among Medicaid Expansion Population:
Michigan, US
Source: SAMHSA
2008-2010 National Survey on Drug Use and Health
2010 American Community Survey.
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The National Institute of Mental
Health

2008
◦ 26.2% of Americans ages 18 and older suffer
from a diagnosable mental disorder
◦ 57.7 million people
½ of all lifetime cases begin by age 14
 ¾ of all lifetime cases begin by age 24
 70% of primary care visits stem from
psychosocial issues

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Substance Abuse Disorders (SAD)
20% of patients seen in family practices
have SADs
 Ranked among the ten leading
preventable risk factors for years of life
lost to death and disability
 Diagnosed in only 9% of general and
family practice visits and 8% of internal
medicine visits

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John Hopkins Healthcare


Demonstrating a Return on Investment for
Integrated Substance Abuse Treatment and
Medical Care Management
603 adult Medicaid enrollees, frequent use of
medical services from past 12 month claims
◦ Received routine care

400 members placed in intervention group
◦ Management from substance abuse coordinators
◦ Nurse care managers
http://www.chcs.org/publications3960/publications_show.htm?doc_id=633674
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John Hopkins Healthcare

Results
◦ Within 12 months, savings of $122 per member per
month
◦ Decrease of 288 admissions per 1,000 members
◦ Decrease in 92 days admitted per 1,000 members
◦ Decrease by 45 days admitted per 1,000
◦ $3.65 return on investment for every $1 spent on
intervention
http://www.chcs.org/publications3960/publications_show.htm?doc_id=633674
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Definition

Behavioral health integration (BHI) is
defined as a partnership between primary
care providers and mental
health/substance abuse providers

This can be a partnership between
organizations or a collaboration between
providers within one organization
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Collaboration Continuum
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Type 1: Minimum Collaboration

Primary care providers and behavioral
health providers work in separate
facilities, have separate systems, and
communicate only sporadically
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Type 2: Basic Collaboration at a
Distance



Primary care and behavioral health providers
have separate systems at separate sites, but
engage in periodic communication about
shared patients, generally by telephone,
letter or email
Communication is driven largely by specific
patient issues
Primary care and behavioral health providers
view each other as resources, but do not
share responsibility over patients
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Type 3: Basic Collaboration On-Site



Behavioral health professionals and primary
care providers have separate systems but
share the same facility
Proximity allows for increased
communication about shared patients, but
each provider remains in his or her own
professional culture
This model is primarily a referral-based
process with providers working more
closely and with improved communications
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Type 4: Close Collaboration in a
Partly Integrated System
Behavioral health professionals and primary
care providers share the same facility and
have some systems in common, such as
scheduling appointments or medical records
 Physical proximity between providers allows
for regular face-to-face communication and
even coordinated treatment plans for
difficult cases
 There is a sense of being part of a larger
team, yet the pragmatics are sometimes
difficult

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Type 5: Close Collaboration
approaching a Fully Integrated
System




Behavioral health professionals and primary care
providers share the same facility, the same vision,
and the same systems to provide unified
behavioral and physical health services
The patient experiences the behavioral health
treatment as part of his or her regular primary
care
Primary care and behavioral health staff interact
regularly and typically have an integrated medical
record and single treatment plan
All professionals are committed to the idea of a
team-based approach and understand each
other’s roles and functions
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Type 6: Close Collaboration in a
Fully Integrated System
The behavioral health provider and primary
care provider are part of the same team and
have overcome the barriers and limits to
traditional care and funding structures
 Patient care is provided through a teambased approach involving joint assessment
and treatment plans, with shared
responsibilities for outcomes
 Providers and patients view the system as
cohesive and holistic

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Behavioral Health Mapping Project
Goals
Support from MPCA
 Support from other organizations
 Encourage organizational partnerships
 Encourage further development of
integration projects
 Tool for policy advocacy

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Michigan BHI Project
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Benefits of Integrated Care

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Patient’s health and well being becomes the focus of
care
Team-based care is associated with higher patient
satisfaction and better clinical outcomes
Greater opportunity for long-term management of
chronic, complex illness
Higher likelihood of adherence to treatment plans
Greater opportunity for prevention and early
intervention
Provides more holistic care
Increases access to care
Prevents duplication of services
Decreases stigma
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Challenges Cited
Developing relationships
 Increasing understanding
 Difficulty recruiting
 Communicating electronically and sharing
health information
 Sustainability of funding
 Cross-training of staff

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Common Barriers/Changes Made
by Centers Integrating Services

Culture Change
◦
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Language
Mannerisms
Expectations about patient visit
Length of visit
One Mission/One Vision
Physical Layout of Center
Multidisciplinary Care Team Meetings
Address readiness to change
Reimbursement/SBIRT codes
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Michigan Health Center Behavioral
Health Survey
Winter 2000, MPCA commissioned a study, Addressing
Patient’s Behavioral Health Needs in Michigan’s
Community Health Centers
 Results:

◦ 1 of 2 patients have behavioral or emotional problems
◦ 1 of 3 patients have depression as a primary or
secondary diagnosis
◦ 1 of 5 patients are currently receiving services from
mental health professionals
◦ Communication is poor between primary care and
behavioral health professionals
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Outcomes from Integrating Care

On average 35% of patients receive
physical healthcare at SUD clinics

Those that do, experience:
◦ Greater Abstinence
◦ Returning Twice as Often for Outpatient Visits
◦ Lower Mortality Rate
http://archinte.jamanetwork.com/article.aspx?articleid=646882#WHYSUBOPTIMALLINKAGE?
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FQHCs Licensed as Substance
Abuse Providers

Baldwin Family Health Care
◦
◦
◦
◦
◦

On-site counseling
State licensed substance abuse services
JCAHO accredited programs
On-site MSW’s
Certified addictions counselors on-site
Cherry Street Health Services
◦ On-site Mental health and addiction counseling
◦ Case Management
◦ Outpatient counseling, residential treatment, transitional &reentry services

Sterling Area Health Center
◦ Psychiatry
◦ Substance abuse treatment/counseling and prevention
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Screening, Brief Intervention,
Referral, and Treatment

Non-confrontational, short health
counseling technique

Not a quick fix treatment

Motivating an individual to do something
about an existing substance abuse
problem
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Screening, Brief Intervention,
Referral, and Treatment

Why SBIRT is a critical Prevention Strategy?
◦ U.S. Preventive Services Task Force recommends
screening and brief interventions
◦ Similar to preventive screenings for chronic
diseases
◦ Covered by insurers with no deductible or copays
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SBIRT Billing Codes Chart
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MPCA’s Legislative Priority

Promote the Integration of Health Care
Service with Commensurate Funding
◦ Successful Integration:
 Enhanced access to services
 Improved quality of care
 Lowered health care expenditures
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Promoting Integration

Recommended Action for Michigan
◦ Explore evidence-based integrated delivery
care models
◦ Create incentives for system change
 Payment reform
 Funding for shared efficiencies
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Promoting Integration

Policies to Pursue
◦ Medicaid payment for Patient-Centered Medical Home
designation beyond the Michigan Primary Care Transformation
Demonstration (MIPCT)
◦ Medicaid participation in the Centers for Medicare and Medicaid
Services (CMS) Health Home Initiative (Section 2703 of the
Affordable Care Act)
◦ Medicaid payment for non-traditional service providers including
Certified Peer Support Specialists, Health Coaches, and Health
Navigators
◦ Medicaid reimbursement delivered in the form of bundled
payment to facilitate the provision of team-based care, inclusive
of care coordination and transition across different levels of the
health care system
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Recommended Actions

“Turn on” codes essential to integrating behavioral health services
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96110 – Developmental screening, with interpretation and report, per standardized instrument
form
96150 – Health Behavior Assessment; 15 minutes (initial assessment)
96151 – Health Behavior Assessment; 15 minutes (reassessment)
96152 – Health Behavior Assessment; 15 minutes (individual)
96153 - Health Behavior Assessment; 15 minutes (2 or more patients)
96154 – Health and Behavior Assessment; 15 minutes (family with patient)
96155 – Health and Behavior Assessment; 15 minutes (family without patient)
90839 – Psychotherapy for crisis, first 60 minutes
90840 – Psychotherapy for crisis
99406 – Smoking cessation
99407 – Smoking cessation
99238 – Hospital discharge day management; 30 minutes or less
99239 – Hospital discharge day management; more than 30 minutes
99408 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT,
DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT,
DAST), and brief intervention (SBI) services; greater than 30 minutes
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Recommended Actions
Include additional mental health providers in
the CHAMPS system; including licensed
social workers and psychologists, recognizing
their important role in an integrated health
delivery system and providing a waiver of
substance abuse certification/credentialing
for all incensed behavioral health
professionals.
 This expanded workforce is necessary to
meet the needs of the expanding Medicaid
population

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Recommended Actions

Eliminate the limit of 20 behavioral health
visits per year restriction, recognizing that
chronic conditions, both behavioral and
physical, require monitoring and
consistent care and may not be treated
properly within 20 visits.
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Recommended Actions

Allow for reimbursable screening for mental health
and substance abuse conditions in the primary care
setting to identify patients getting care on in the
primary care setting.

These screens are reimbursable through the codes
(also listed above):
◦ 96150 – Health Behavior Assessment; 15 minutes (initial assessment
◦ 99408 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg,
AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
◦ 99409 – Alcohol and/or substance (other than tobacco) abuse structured screening (eg,
AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
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Additional Resources

Michigan Primary Care Association Website
– mpca.net
◦ Clinical Services & Quality> Behavioral Health>
Behavioral Health Integration Resources
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Presentations from MPCA’s Statewide Conference
Operational Resources
Sample Behavioral Health Position Descriptions
Clinical Resources
Financial Resources
Archived Webinars
Tools and Templates
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Questions?
For further information, please contact:
Brittany Beard
Program Specialist
Michigan Primary Care Association
517.827.0477
bbeard@mpca.net
Rebecca Cienki, MPH
Chief Operating Officer
Michigan Primary Care Association
517.827.0474
rcienki@mpca.net
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