PRJCT3.a.i BH Care for all conditions delivered under one roof by known healthcare providers. MORE PRIMARY CARE INTEGRATION BRIEF Integration of mental health and substance abuse with primary care services to ensure coordination of care for both services. GOAL LEARN INTERVENTION METRICS 1. Potentially Preventable ED Visits (for persons with BH diagnosis) 6. Follow-up care for children prescribed ADHD medications 2. Antidepressant medication management 7. Follow-up after hospitalization for Mental Illness 3. Diabetes monitoring for people with Diabetes and Schizophrenia 8. Screening for Clinical Depression and follow-up 4. Diabetes Screening for people with Schizophrenia./ Bi-polar Disorder using Antipsychotic Med. 5. Cardiovascular monitoring for people with Cardiovascular Disease and Schizophrenia. 9. Adherence to Antipsychotic medications for people with Schizophrenia 10. Initiation and Engagement of Alcohol and other Drug Dependence Treatment (IET) 1. C o-locate behavioral health services at primary care practice sites. Primary care practices must meet 2014 NCQA level 3 PCMH or Advance Primary Care Model standards by DY3. 2. D evelop collaborative evidence-based standards of care including medication management and care engagement process. 3. C onduct preventive care screenings, including behavioral health screenings (PHQ-9, SBIRT) implemented for all patients to identify unmet needs. 4. U se EHRs or other technical platforms to track all patients engaged in this project. IN FOCUS: •U niform, evidence-based BH screenings delivered at primary care site. •B H assessment & time-limited evidence-based or promising treatment interventions (EBPI) by on-site BH professional(s). •R eferral to collaborating locally-based specialty mental health and substance abuse treatment providers. • I ntegrated treatment team utilizes a single coordinated treatment plan and process. KEY ELEMENTS OF INTEGRATED CARE MODEL •H ealth Home Care Manager and/or PCMH “health navigator” address engagement, health education, and community support services. •T imely access to services through same/next day appointments; transportation barriers will be addressed. •C ultural competency is integral to success of the model; Peers are utilized for support and to bridge services. INTEGRATED CARE “KIT OF PARTS” BH Screening by Primary Care Practitioners Brief On-Site Intervention PCMH will utilize age appropriate BH screening tools (ex. PHQ-2, 9 & 9-a) to identify unmet needs. Referral for Specialty BH Care Timely consultation by on-site BH clinician for further assessment. PCP/ BH collaborative planning and treatment. BH clinician/PCMH care navigator/Health Home care manager will educate and engage individual/family and link to community support services. On-site time-limited EBPI by on-site BH clinician or PCP. Telephonic consultation with Psychiatrists for PCPs prescribing psychotropic medications. Agreements with specialty BH providers to participate in integrated model (use Evidence Based Interventions, share information, routine collaborative treatment planning). Protocols for “warm hand-off,” ensure appointment is kept, questions answered. Arrangements with Managed Care Organizations to facilitate care by collaborating. providers. HUDSON VALLEY DSRIP PPS WILL: •C onvene Regional Advisory Group to adopt protocols • Provide training on evidence based and promising assessments and interventions Visit Us Online CENTER FOR REGIONAL HEALTHCARE INNOVATION •Provide Technical Assistance & implementation support www.crhi-ny.org • Track process and performance metrics over 5 years •Address regulatory, HIT and financial barriers CONTACT: Janet (Jessie) Sullivan, MD Vice President, Medical Director, CRHI [email protected] // 914.326.4202 7 Skyline Drive / Suite 385 / Hawthorne, NY 10532 10/7/2014 Hudson Valley DSRIP Integrated Primary & BH Care Project October 9, 2014 BH Workgroup Chair: Amy Kohn, PhD, CEO, MHA of Westchester CRHI Medical Director: Janet (Jessie) Sullivan, MD CRHI Director, Research and Data Analytics: Deborah Viola, PhD CRHI Facilitator: Cindy Freidmutter, CLF Consulting Hudson Valley DSRIP Integrated Care Project Overview Model: Behavioral Health (BH) integration at primary care sites • Main sites will be FQHCs & Article 28 clinics where integration is more feasible. • Opt-in opportunity for interested primary care (PC) partners. • As needed, PPS will help “match” PC and BH partners. • Participating partners will receive training, TA and implementation supports to move along a continuum of integration to achieve program model. • Medicaid recipients of all ages will receive integrated care (IC). • People engaged with specialty BH providers will be transitioned to IC on a priority basis. • PPS will offer a population-competent model for people with IDD. • There will be measurable process and performance metrics over 5 years. • Cultural competency issues will be addressed before roll-out & ongoing. • PPS will address regulatory, HIT and financial barriers. 2 1 10/7/2014 Hudson Valley DSRIP Integrated Care Project Description: Key Elements of IC Model 1. Uniform, evidence-based BH screenings administered by the PCP (specifics TBD). 2. For those who screen positive, further BH assessment & time-limited treatment interventions by on-site BH professional(s) working for PCP or a BH partner. 3. Supplement on-site BH services with a network of locally-based specialty mental health and substance abuse treatment providers for individuals who need more specialized and/or intensive BH treatment services. 4. Integrated treatment team utilizes a single coordinated treatment plan. 5. Team-based care approach that includes joint case conferencing, information exchange and shared clinical decision-making between PCP/BH clinicians. 6. Health Home Care Manager and/or PCMH “health navigator” address need for engagement, support services, psycho-education and other resources available in community. 7. Participating providers will demonstrate timely access to services through same/next day appointments and similar strategies. 8. Transportation barriers will be addressed. 3 Integrated Care “Kit of Parts”: BH Screening by PCPs PCPs will utilize uniform BH screening tools (ex. PHQ-2, 9 & 9-a) to identify unmet needs. • Screening practices will be governed by regional protocols. • The PPS will offer training to PCPs on BH screening protocols, and follow-up procedures with on- and off-site BH clinicians. PCP will consult with BH clinician for follow-up assessment & engagement if results are positive. 4 2 10/7/2014 Integrated Care “Kit of Parts”: Brief On-Site Intervention Positive Screenings… Assessed as needing BH services… Timely consultation by on-site BH clinician for further assessment, as per established PPS protocols. PCP and BH Clinician(s) will engage in collaborative treatment planning and treatment. BH clinician or PCMH case navigator will educate & engage individual/family. • The PPS will develop an evidence based and promising intervention (EBPI) roster with training/materials. • Primary care site will offer brief on-site EBPIs as appropriate. • Clinical decision-making will be shared between PCP and BH clinicians. • Telephonic clinical consultations by BH psychiatrists will be available for PCPs prescribing psychotropic medications. 5 Integrated Care Kit of Parts: Referral for Specialty BH Care  Agreements with specialty BH providers to participate in integrated model (use EBIs, share information, team participation, etc.)  Protocols for “warm hand-off”, follow-up that appt is kept and QA.  Routine collaborative treatment planning.  Patient activation and supportive activities offered as needed.  Arrangements with MCO to facilitate care authorization by a network provider partnering with PCMH. 6 3 10/7/2014 Medicaid Depression Beneficiaries 2012 Raw Counts by ZIP Code. Each red dot represents one beneficiary. ZIP codes with fewer than 20 beneficiaries are excluded 7 8 8 4