HEALTH CARE INTEGRATION:
BLESSINGS & BLOCKAGES
Focus on small, rural
programs and
communities
Twelfth Statewide Conference
Integrating Substance Use, Mental Health,
and Primary Care Services:
Integration from the Ground Up
Universal City, California
October 28-29, 2015
Tara Shepherd, MA, CADC-CAS
Deputy Director
Modoc County Health Services
Modoc County Behavioral Health
What is integrated health care?
“Integrated care is when
health professionals consider
all health conditions at the
same time.”
SAMHSA, Understanding Health Reform:
Integrated Care and Why You Should Care, 2012.
Why Integrate ?
o People w/ serious mental illness
die 25 years earlier than general population ...
2/3 of these deaths are from preventable, treatable
conditions – heart, lung, diabetes, infectious diseases
o Co-occurring MH/SU disorders worst
mortality gap ...
Both SMI & SU – average age of death = 45
SMI only – average age of death = 53
Mental
The client –
Health
and family/
Services
significant
others –
Client/
Substance
must have
Patient/
Use
central roles Services
Consumer Primary
in the
Healthcare
Services
partnership.
Some “blessings” of integration:
Treating the “whole person”
 Better, safer client outcomes
 Increased client satisfaction
Most effective approach for
people with multiple healthcare
needs
More “blessings” of integration:
Coordination of diagnoses &
treatments
Medication reconciliation
Interdisciplinary care teams
Continuity of care
Most effective use of resources
Some “blockages” to integration:
• Shortage of healthcare practitioners,
especially in isolated, rural areas (Medically
Underserved Areas);
• 42CFR as a potential barrier to information
sharing;
• Funding silos - “Carve outs,” managed care,
fee-for-service, Drug Medi-Cal, Speciality MH
Medi-Cal, private insurance, federal regs.
More potential
Blocks
• Different “cultures” – primary care, substance
use and mental health;
• Stigma – substance use and mental health
disorders.
MODOC COUNTY
Designated by legislation as a
“Frontier County”
Service delivery is hampered
by extremely low density of
residents
9,147 – total County population
< 3 people per square mile
Designation as a
Medically Underserved Area
Medically Underserved Areas (MUAs) are
determined by evaluation of criteria established
through federal regulation to identify geographic
areas based on demographic data.
Approximately 17% of Californians live
in a MUA, with MUAs in 33/58 counties.
“Medically Underserved Area”
designation requests
CRITERIA . . .
 Percentage of population at 100%
below poverty;
 Percentage of population > 65;
 Infant mortality rate; and
 Primary care physicians per 1,000 population
Impacts of healthcare provider shortages on
Integration Efforts – The Modoc County Experience
 Not enough medical providers, especially for a
high poverty/high risk population
 Overworked medical providers do not have the
time to take a proactive role in integration
 Medical providers are open (and sometimes
eager) to join integration/collaboration efforts
designed and led by Behavioral Health
MODOC COUNTY – FIRST FOCUSED ON
BEHAVIORAL HEALTH INTEGRATION
(MH & SU)
. . . THEN BEHAVIORAL HEALTH TOOK THE
LEAD ON COLLABORATION WITH PRIMARY
CARE
In
Modoc
County
Pre – 2011 – Modoc County Health Services
• Mental Health, Public Health, Alcohol and
Drug Services & Environmental Health
2011 – at the request of Health Services Modoc County
BOS approved combining MH and A&D Services into
Behavioral Health -- Reactions varied !!
Who Needs to Buy-in for BH
Integration to be Successful?
 Staff – Clinical, fiscal & support
 Consumers/Clients
 All management/supervisory levels
 Other community partners
Behavioral Health Integration
o Put together a Planning Team of MH/AOD
staff, management, clients/consumers, and
other stakeholders (e.g., Collaborative
Treatment Courts Coordinator,
Probation,Public Health);
o 2 Meetings a month for nearly a year.
The BH Integration Planning Team . . .
o Developed a Mission Statement
o Agreed on Goals and Objectives
o Designed a comprehensive Behavioral Health
system, addressing/integrating:
~ MH, SU and physical health
~ Client-centered, cultural competence,
wellness and recovery
So . . .
How did we handle
42 CFR for our BH
integration?
Confidentiality . . .
 Rise to the higher level of
requirements
 Mental health and SU both
follow HIPPAA and 42-CFR
We posted a notice, and mailed the notice to
current clients . . .
o
o
o
Notification of our plans to integrate Mental
Health and Alcohol & Drug Services;
Informed current clients of new forms and
processes;
Current clients signed new forms at next
scheduled appointment.
New “Consent for Treatment/Admission Agreement”
o
Addressed all regulatory requirements for MH
and SU Services;
o
Notification of integration, including MH and SU
staff ability to access client records;
o
Reviewed and approved by Attorney Linda Garrett,
Risk Management Services.
MODOC COUNTY BEHAVIORAL HEALTH
CONSENT FOR TREATMENT/ADMISSION AGREEMENT
“It is understood that MCBH is an integrated
mental health and substance use treatment
program, which includes integrated recordkeeping, treatment planning, and treatment
provision. Staff providing substance use and/or
mental health services will have access to your
records to the extent it is required to effectively
do their jobs.”
• Integrated Electronic Health Record;
(Anasazi/Kingsview)
• Integrated scheduling;
• Integrated intake interview process
~ intro on integration, demographics, client
rights, data reporting elements, collection of
financial data, consent/admission agreement,
privacy practices and other informing materials.
. . . PROGRESS: Behavioral Health Integration
• Integrated Treatment Team meetings
o Monday am – Weekend crises calls review
o Tuesday – MHSA Full Service Partner
Reviews
o Thursday – QI/UR
• Integrated Behavioral Health Treatment Plans
MCBH Flow Chart of Client Services (Adults)
Mental Health Services
Intake Interview
Substance Use Services
Both
Medical Intake History & Vitals & PCP Release
Substance Use Assessment
w/ Psych Section ASI as screener
and/or
Mental Health Assessment
w/ SU Screener
Utilization Review
Primary + Treatment Team Members Assigned;
Referral Needs Assessed
Integrated BH Treatment Plan
Possible Tx Team Members
MH therapist, SU counselor,
case manager, BH nurse,
telepsychiatric provider,
rehab specialist,
peer support specialist
Possible Referrals: In-house
Full MH or SU assessment (per
screening), telepsych meds
assessment (MH &/or SU MAT),
meds mgmt w/ BH Nurse,
case mgmt or rehab services.
Possible Referrals: External
Consumer-operated non-profit Wellness
Center, medical, dental, vocational,
educational, legal, etc.
BH Initiatives for Collaborating w/
Primary Care in Modoc County
• Vigorously Seek ROI w/ Primary
Care Provider, & send copy to PCP;
• Medical Care Referral Form;
• Medical Care Visit Form;
• Medication Reconciliation with one primary
care clinic.
. . . On-going BH Efforts for Collaborating
with Primary Care in Modoc County
• To allow real-time sharing of information
between BH & PC:
o Through CIBHS Collaborative, tested two
registries;
o High hopes for current CIBHS initiative
with eBHS.
• Continue to pursue registry – high
hopes for eBHS (CIBHS);
• Respond to request from largest
clinic in County for medication
reconciliation efforts for “frequent
users” among shared clients – “by
hand” tabulation without registry.
. . . Where do we go from here?
• When new hospital/medical clinic is
built:
o Explore possibilities for co-locating BH
at new site . . .
~ Financial barriers to full colocation;
~ Options for partial co-location.
Resources
1. Croze, Colette, MSW, Healthcare Integration in the Era of the
Affordable Care Act, for the Association for Behavioral Health
and Wellness, 2015.
2. gis.oshpd.ca.gov/atlas/topics/shortage/mua.
3. Mauer, B. and Weisner, C., CIMH Webinar, The Case for
Integrated Care, 2010.
4. SAMHSA, Understanding Health Reform: Integrated Care and
Why You Should Care, 2012.
5. www.nasmhpd.org, Morbidity and Mortality in Persons with
Serious Mental Illness, 2006.
Thank
you!