TO INTEGRATE -- OR HOW?
A Decision Model for Practices
Charles Cooper, PhD
Director of Professional Affairs
North Carolina Psychological Association
APA State Leadership Conference
March 10, 2013
THE EXPECTED ENVIRONMENT:
2
THE MAUER MODEL
THE EXPECTED
ENVIRONMENT
Low Physical Health
Risk/Complexity
High Physical Health
Risk/Complexity
High Behavioral
Health
Risk/Complexity
QUADRANT II
QUADRANT IV
Clients served in
primary care and
specialty mental health
settings
Clients served in
primary care and
specialty mental health
settings
For treatment of: bipolar
disorder, chronic pain
Note: with MH stable, care
can be transitioned to PCP
For treatment of:
schizophrenia,
metabolic syndrome or
hepatitis C
QUADRANT I
QUADRANT III
Clients served in
primary care setting
Clients served in
primary care setting
For treatment of:
moderate alcohol
abuse, fibromyalgia
For treatment of:
moderate depression,
uncontrolled diabetes
Low Behavioral
Health
Risk/Complexity
3
Integrated Care – The Individual Model
A Two-Dimension Model for Decision Making
I. Top Margin: Level of Integration occurs along a
spectrum, from No Integration to Full Integration.
II. Side Margin: Actions would be based on the
clinician's inclination towards integration and
where the clinician is in his or her career.
4
The Individual Decision Model
Level of Integration
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Maintain
current practice
format
while keeping
watchful eye on
developments
Greatly improve
communication
with targeted
primary care
referral sources
Offering
contracted
services
to primary care,
medical homes,
or ACOs
“Co-Location”
maintaining
part or all of a
practice within
a primary care
setting
Assuming an
employed
position within
an integrated
setting
Clinician Practice
Qualities
Early Career
inclined toward integration
Early Career
disinclined toward integration
Mid Career
Inclined toward integration
Mid Career
disinclined toward integration
Late Career
inclined toward integration
Late Career
disinclined toward integration
5
Level of Integration
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Take
advantage of
learning
opportunities to
strengthen
skills that might
allow future
move closer to
integrated
systems
Identify target
primary care
practices;
build
relationships;
determine
what specific
kinds of
integration are
mutually
beneficial and
clinically
valuable; Then
build the
collaboration
Be on high
alert regarding
integrating
systems and
design ways to
serve patients
in medical
homes while
continuing
independent
practice. Build
your skills to
address unmet
needs of
integrating
systems
Acquire
specialty
training if
possible
targeting some
particular area
of health
psychology in
which you can
demonstrate
high levels of
skill
Survey primary
care provider
community
looking for colocation
possibilities
Acquire
specialty
training if
possible
targeting
some
particular area
of health
psychology in
which you can
demonstrate
high levels of
skill
Survey fully
integrated
systems and
their needs for
behavioral
health
Clinician Practice
Qualities
Early
Career
inclined
toward
integration
6
Level of Integration
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Develop a
niche that will
likely grow
regardless of
integration. Be
prepared to
change
strategy should
local system
developments
require it.
Identify one or
more niches
that hold
promise for
creating
practice
distinction.
Build on that
niche and be
aware of how
it could be
affected by
integration in
the larger
health system
Take
advantage of
medical homes
and integrated
systems and
their organized
care
management.
Seize
marketing
opportunities
with care
managers for
niche offerings
and
specialized
services not
offered in the
“home”
Take
advantage of
rapidly growing
awareness of
unmet
behavioral
needs of
primary care
patients. Seize
marketing
opportunities
by offering
niche services
especially
tailored to
those unmet
needs.
Take
advantage of
integrated
systems and
their
organized
care
management.
Seize
opportunities
with care
coordinators
for marketing
your niche
offerings and
specialized
services not
offered in the
“home”
Clinician Practice
Qualities
Early
Career
disinclined
toward
integration
7
Level of Integration
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Capitalize on
strengths of
your current
practice. Be
prepared to
change
strategy should
local
developments
require it.
Identify target
primary care
practices;
build
relationships;
determine
what specific
kinds of
integration are
mutually
beneficial and
clinically
valuable; Then
build the
collaboration
Take
advantage of
your practice
reputation in
the community.
Watch for
compatible
primary care or
“medical
home”
organizations
– particularly
ones with likely
unmet needs
for behavioral
services for
which they
may need to
refer out.
Take
advantage of
your practice
reputation in
the community.
Survey primary
care provider
community
looking for
compatible colocation
possibilities.
Build
relationships
and explore
how to put a
“toe in the
water”
Capitalize and
build on skills
and interests
that may be
sought by fully
integrated
systems.
Acquire
additional
training in
areas that
may be in
demand
within those
systems. Get
to know the
developing
integrated
systems and
their needs.
Build
relationships.
Clinician Practice
Qualities
Mid
Career
inclined
toward
integration
8
Level of Integration
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Capitalize on
strengths of
your current
practice.
Monitor your
payer mix.
Exploit niche
opportunities.
Be prepared to
change
strategy should
local
developments
require it.
Identify target
primary care
practices;
build
relationships;
determine
what current
features of
your practice
(or reasonable
adjustments in
your
procedures)
might attract
referrals; Then
build the
collaboration.
Take
advantage of
medical homes
and integrated
systems and
their organized
care
management.
Seize
marketing
opportunities
with care
managers for
niche offerings
and
specialized
services not
offered in the
“home”
Take
advantage of
rapidly growing
awareness of
unmet
behavioral
needs of
primary care
patients. Seize
marketing
opportunities
by offering
niche services
especially
tailored to
those unmet
needs.
Take
advantage of
integrated
systems and
their
organized
care
management.
Seize
opportunities
with care
coordinators
for marketing
your niche
offerings and
specialized
services not
offered in the
“home”
Clinician Practice
Qualities
Mid
Career
disinclined
toward
integration
9
Level of Integration
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Take
advantage of
reputation,
“health
orientation”
and
relationships. If
necessary,
adjust practice
to respond to
new referral
patterns that
may emerge
with some
large
integrating
systems
Identify target
one or more
primary care
practices;
Take
advantage of
reputation,
“health
orientation”
and
relationships
to strengthen
collaboration,
communicatio
ns, and
coordination
of care with
mutual
patients
Take
advantage of
your practice
reputation in
the community.
Watch for
compatible
primary care or
“medical
home”
organizations
– particularly
ones with likely
unmet needs
for behavioral
services for
which they
may need to
refer out.
If feasible,
consider
locating
practice very
near primary
care setting or
find other ways
to reduce
barriers to
easy, “warm”
referrals.
Regular
consultation /
contact with
primary care
providers can
approximate
co-location
If skills,
interests,
financial
rewards and
other
compatibilities
make practice
“inside” a fully
integrated
setting
desirable,
explore part of
full time
affiliation with
such a
setting.
Assess your
readiness to
accept
significant
work culture
change.
Clinician Practice
Qualities
Late
Career
inclined
toward
integration
10
Level of Integration
No
Integration
Ultra light
Integration
Maintain
awareness of
changes that
may occur and
diversify
referral and
payer mixes.
Enhance niche
aspects of
practice.
Maintain
awareness of
changes that
may occur
and diversify
referral and
payer mixes.
Enhance
niche aspects
of practice. Be
open to
making
reasonable
adjustments to
foster referrals
from primary
care providers
Light
Integration
Moderate
Integration
Full
Integration
Clinician Practice
Qualities
Late
Career
disinclined
toward
integration
Maintain
Watch with
awareness. Do interest.
an occasional
assessment of
yourself and of
the
developments
in integrating
health systems
to ascertain if it
is worth
building
relationships
with, marketing
to, and
collaborating
with primary
health
providers. See
if what you
already do can
“sell” to them.
Watch with
interest.
11
Integrated Care – The Practice Model
A Two-Dimension Model for Decision Making
I. Top Margin – Level of Integration: occurs
along a spectrum, from No Integration to Full
Integration.
II. Side Margin – Economic/Business Factors:
strategic choices and actions would be based
factors of “supply” and “demand” and an
analysis of strengths, weaknesses,
opportunites and threats, (SWOT).
12
Level of Integration
No
Integration
Ultra light
Integration
Light
Moderate
Full
Integration Integration Integration
Business Conditions for
Decision Making
Demand
•High and clear demand
•Murky, ambiguous or
unclear demand
•Nil, low or mismatched
demand
Supply
•Excellent
•Uncertain, or
Underdeveloped
•Inadequate
Additional Factors
•SWOT
•Wildcards
13
Level of Integration
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Demand
Conditions
High and clear
demand
Strong demand with
ready customers who
have clear needs
Murky,
ambiguous or
unclear demand
Demand is Ambiguous,
Still undeveloped but
with significant potential
Nil, low or
mismatched
demand
Demand is non-existent
or completely
mismatched to your
practice
14
Integrated Care Table
Practice Decision Model
Demand: High and Clear
None  Collaboration  Full
Integration Spectrum
Build relationships, Explore needs, Match
resources to need, Make concrete
proposals, Work out logistics, potential
roles and workflow, Develop contracts,
Coordinate and/or educate
Murky, Ambiguous, or Unclear
Demand
Establish early communications with
potential collaborators; Explore mutual
interests; Engage in “Integration
Education”; Conduct needs assessments
Low, Nil, or Completely
Mismatched Demand
Engage the primary care community; Find
ways to start communications; Work on
joint projects; Participate in basic
education in “Integration Awareness
Building”
15
Level of Integration
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Supply
Conditions
Excellent Supply
of well trained health
psychologists who
would be well matched
and motivated to
integrate
Uncertain or
undeveloped
supply
of appropriate clinicians
motivated to integrate
Inadequate
Supply
that is nil, ill-matched,
or unmotivated to
integrate
16
Integrated Care Table
None  Collaboration  Full
Practice Decision Model
Integration Spectrum
Supply: Excellent, Well-matched, or Develop contracts; Build promising
well-motivated
relationships; Introduce health
psychologists to potential collaborators;
Start joint ventures; Offer services that
might lead to contractual integrations
Uncertain, or Underdeveloped
Conduct self-assessments in your practice;
Procure training in behavioral health
and/or recruit health psychologists;
Develop services linked to primary care
that start a “track record” for your practice
in integrated care
Nil, completely Unmotivated, or illmatched
Look for hidden talent within the practice;
Augment skills, retrain, or recruit
behavioral health specialists
17
LEVEL OF
INTEGRATION
No
Integration
Ultra light
Integration
Light
Integration
Moderate
Integration
Full
Integration
Maintain
current practice
format
while keeping
watchful eye on
developments
Greatly improve
communication
with targeted
primary care
referral sources
Offering
contracted
services
to primary care,
medical homes,
or ACOs
“Co-Location”
maintaining part
or all of a practice
within a primary
care setting
Assuming an
employed
position within
an integrated
setting
ADDITIONAL FACTORS
STRENGTHS
E.g., Management Capabilities
are strong; reputation good
and relationships excellent
WEAKNESSES
E.g., Risk Tolerance is low;
technology and IT is
underdeveloped
OPPORTUNITIES
E.g., To establish a strong
referral network with primary
care
THREATS
E.g., Gradual loss of referrals
as medical homes pick treat
internally
WILDCARDS
Timing (Especially bad or
good)
Internal and external cultures
18
Integrated Care Table
Practice Decision Model
SWOT:
None  Collaboration  Full
Integration Spectrum
Strengths
Build upon and exploit strengths
Weaknesses
Correct or “design around”
weaknesses
Opportunities
Orient toward opportunities
Threats
Protect against threats
Wildcards:
Internal Culture
Time Considerations
Competition
Prepare for the unexpected!!!
19
A Case Study in North Carolina
A Case Study – The Demand Side
• The Business Environment
o
o
o
o
o
The Research Triangle Area of NC (3 major cities)
Large University-Based Health Systems
Large Independent Practice Association (IPA)
History of care integration in primary care settings (Medicaid)
Interest in care integration by commercial carrier (Private Sector)
21
A Case Study – The Supply Side
• HRC Behavioral Health & Psychiatry, PA
Chapel Hill and Raleigh, NC
22
A Case Study – Early Days
•
•
•
•
•
•
•
Founded 1967
25 to 30 clinicians in two cities
Multidisciplinary approach
EAP Experience / Contract Experience
General reputation in community
Two experienced health psychologists
High motivation to integrate (co-locate +)
23
A Case Study – The Supply Side
• The Practice Group
•
•
•
Long history in the community
Multi-specialty group practice
o Psychologists ………………………………………………………..14
 Health Psychologists ………………………………………….2
o Psychiatrists …………………………………………………………. .6
 Mid-level providers (Physician’s Assistants)…………………. .2
o Social Workers………………………………………………………....2
o Licensed Professional Counselor (substance abuse specialist)….1
Total ……………………..…………………………….27
24
The HRC Integration Story: Phase I
•
Pre-Integration Days
o Referral Promotion: Internal discussion and
monitoring the local landscape to promote referrals
o Relationship Building: with a nearby primary/urgent
care practice, “The Family Doctor”
o My Job as Director of Professional Affairs >> SLC
attendance >> awareness of need to develop
practice as business
25
•
The HRC Integration Story: Phase II
Early Integration
•
•
•
Conversations with medical director of biggest
commercial carrier in area
 Discovered carrier’s strong interest in integration
Invited conversations with nearby urgent care
practice, “The Family Doctor”
o How could we be more responsive?
o How can we communicate most effectively?
o How could we be better “integrated”?
Discovery of a “Go Between”
o Lawyer with interest in integrated care, provider
group contracting, and compliance with referral
and kick-back issues under federal and state law
26
•
The HRC Integration Story: Phase III
Integration Matures
o
o
o
o
o
o
HRC contracts with Family Doctor practice to be their
behavioral resource for “Medical Home” status
The “go-between” Steve Shaber (Poyner & Spruill Raleigh)
identifies prospective primary care practice
HRC identifies a clinician from our group who wants to colocate.
Discussions begin with Family Medical Associates of Raleigh
(Key IPA)
Contracting begins re: space, support services, coordination
of health records, money flows, etc.
Consultant/representative sent to the commercial carrier
27
The HRC Integration Story: Phase IV
•
Current Challenges:
o Entering primary care culture
o Clarifying expectations
o Refining contracts
 Rent
 Services
o Fixing logistics, documentation, and information
flows
o Dealing with insurance incompatibilities (panels and
managed care problems)
o Dealing with payer + CPT code constrictions
 Eg, Health and Behavior Code 96150 – limit to 3
28
The HRC Integration Story: Phase IV
• Current Challenges, cont’d:
o Dealing with time demands for unpaid services
 Hallway consults
 Uninsured patients and network incompatibility
o How to demonstrate value to primary care patients
o Implementation Science Initiative
o How to reconfigure the “mother practice” to
accommodate co-location
 Less need for space in original psychology practice
 Challenges to cohesion and connection to original
group
29
Q&A
• What are the implications for other kinds of
•
•
•
practices?
What are implications for independent
practice?
How can our state, provincial, and territorial
associations help practitioners?
How can APA help?
30
Resources
•
•
•
•
•
•
Collins, C et.al. Evolving Models of Behavioral Health Integration in
Primary Care, Milbank Memorial Fund, May 2010.
http://www.milbank.org/reports/10430EvolvingCare/EvolvingCare.pdf
Community Care of North Carolina (CCNC).
https://www.communitycarenc.org/population-management/behavioral-health-page/
Mauer, B. 2006. Behavioral Health/Primary Care Integration: The
Four Quadrant Model and Evidence-Based Practices. Rockville,
MD: National Council for Community Behavioral Healthcare.
Mechanic, David. Seizing Opportunities Under The Affordable Care
Act For Transforming The Mental And Behavioral Health System.
Health Affairs, 31, no.2 (2012): 376-382
Trend Watch; Bringing Behavioral Health into the Care Continuum:
Opportunities to Improve Quality, Costs and Outcomes. American
Hospital Association. January 2012
Multiple articles on integrated care at APA’s Practice Central
http://www.apapracticecentral.org/
(Search terms: “Integrated Care”)
31