SAMHSA Primary & Behavioral Health Care Integration (PBHCI) Program

“A Snapshot of Grantees andEarly Implementation Experiences”

Deborah Scharf, PhDCo-PI / Project Director, PBHCI Multisite Evaluation

Grantee MeetingMay 17, 2012

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RAND’s Role

• Independent program evaluation – Jointly funded by ASPE / SAMHSA

• Important opportunity to learn about the value of integrating PC & BH services for individuals with SMI and or SUDs

• Create a roadmap for replication of the PBHCI program’s successes

– Government-funded programs and/or individual agency efforts to integrate care

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RQ1 (Outcomes Evaluation): Does integration lead to improvements in the BH and PH of persons with SMI and/or SUD served?

RQ2 (Process Evaluation): In what ways is it possible to integrate the services provided by PC providers and community-based BH agencies

• i.e., what structural and clinical approaches to integration are being implemented?

RQ3 (Model Evaluation): Which models and/or respective model features of integrated care lead to better behavioral and physical health outcomes?

Evaluation Designed To Answer 3 Research Questions (RQs)

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Grantee Cohorts• Four (soon to be five!) cohorts of PBHCI grantees

• Only cohorts I-III included in multisite evaluation

Cohort N Funded Consumers Enrolled

I 13 10/1/09 02/1/10II 9 10/1/10 02/1/11III 34 10/1/10 02/1/11IV 8 10/1/11 02/1/12V* 32* 10/1/12* 02/1/13*

TOTAL 96*

*Cohort V grants not yet awarded

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Overview

• Cohorts I – III grantees – Brief review!

• Early implementation experiences – Updated!

• Population served – New!

• Services provided – New!

*BH = MH and/or SUD

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Methods

• Program-Level Data – Proposals– Structured telephone interviews or e-mails– Quarterly reports

• Consumer-Level Data– TRAC – Registries

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Assumptions

• Multisite evaluation is ongoing!

• Current data are incomplete

• Analyses based on current data may be inaccurate– No accounting for:

• Between-program differences– Clients, services, size, location, etc.

• Selective attrition• PBHCI-specific factors (no control group)

•

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Assumptions

• Be patient!–Formal evaluation complete September, 2013

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Snapshot of Grantees

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Multisite evaluation grantee programs…

• Represent multiple agencies and locations– PBHCI programs: N=56– BH agencies: N=65– BH locations: N=86

• BH agencies vary in capacity and size– Annual consumer volume: 1,585 (100 – 13,000)– Annual SMI volume: 1,000 (14 -9,800)– Total staff: 45 (5 – 400)

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Are located in different environments• Urban (78%)• 26 states represented

– n=13 states have 1 PBHCI grantee• AK, AZ, CO, GA, KY, MA, ME, MI, NH, OR, SC, UT, WV

– n=13 states have multiple grantees

0

2

4

6

CA CT FL IL IN NJ NY OH OK PA RI TX WA

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Provide multiple BH services

0

20

40

60

80

100Pe

rcen

t

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Primary care is provided by…

•Partner agencies (78%)– FQHCs (67%)– Ann. pt volume: 15,000 (2,518 – 150,000)– Various distances from BH centers

• M = 1.5mi (0 – 23)

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Grants support multidisciplinary teams

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Programs prioritize different clientele

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Programs represent multiple models of integrated care

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10152025303540

Perc

ent

ChronicCare

IMPACT Cherokee MedicalHome

MultipleModels /Features

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Models distinctive in name only

• Most models share components

• Implemented differently

• No way to group programs by model type

• Focus on model features instead – Shared or unique

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Snapshot Summary

• Many shared structural features– Urban settings, PC partner orgs (FQHC), providers co-

located in BH setting, etc.

• Many shared process features– Eligible clientele selected from larger pool, provision of

outpatient and emerg BH services, EBPs (e.g., SBIRT)

• Key program differences– Demographics, target populations, size of program, staff

team, optional program features implemented

• Rich, evaluation-worthy environment!

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Challenges and Barriers to Program ImplementationStart-Up and 1-Year

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Challenges at Start-Up

• Data collection (20%)

• Recruiting, hiring, retaining qualified staff (32%)– Especially for rural programs (80%)

• Sharing consumer information across provider groups (20%)

• Licensing and/or approvals from agency administration, city, state, HRSA, etc. (20%)

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Challenges at Start-up

• Space for PBHCI activities (18%)

• Administrative issues – e.g., billing and invoicing, dealing with patient

insurance, agency reorganization (18%)

• Merging PC and BH protocols, consumer recruitment (2-10%)

• 7% reported no barriers

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Challenges Present at Start-Up and Year 1

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New Challenges at 1-Year Follow-up

• Consumer recruitment (35%)

• Engagement / retention in PBHCI (24%)

• Adequate capacity to serve consumers (16%)

• Access to specialists (<7%)

• Transportation for consumers (<7%)

• Consumer payment / insurance (<7%)

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CONSUMERS SERVED

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Consumer and Process Data

• Calendar year 2011

• Consumers in TRAC and Registry– >85% of recorded individuals in this window

• Reminder– Unofficial results– Interim update only

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Consumers Served Last YearTotal Consumers Served: 12,508

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Consumer DemographicsCharacteristic Mean (SD) / Percent

Age 44 (12)Gender (Male) 47%Ethnicity (Hispanic/Latino) 13%Race*

Black or African American 24%Asian 4%

Native Hawaiian / Pacific Isl. 2%Alaska Native <1%

White 64%American Indian 7%

*Consumers could endorse >1 race

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Consumer Psychosocial Characteristics

Characteristic M (SD) / PercentCompleted HS/GED 71%Employed FT/PT 12%Has stable place to live in the community

63%

Arrested in past 30 days 1%

Socially connected 58%Functioning in everyday life 55%

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“At Risk” for Chronic Physical Illness

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“At Risk” for Chronic Physical Illness

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SERVICES RECEIVED

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Consumer Contacts with Multiple Provider Types

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Consumers Receiving PH Services

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Consumers Receiving MH Services

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Consumers Receiving SUD Services

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Consumers Receiving Wellness Services (Select)

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Consumer Satisfaction

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A few take-home points

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Multisite Evaluation Programs are Up and Running!

• Hundreds of consumers served per site• Thousands served across the entire program• Rich, diverse clientele• Many, many PH needs

– Most at risk for metabolic syndrome• Programs offer a wide array of services

– Most consumers receive PH and MH services– Few receive SUD services beyond screening– About 1 in 3 has no contact with case mgr

• Consumers are satisfied with PBHCI care

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PBHCI Multisite Evaluation is in Progress

• PBHCI grantees are pioneers• Programs are multifaceted

– Data collection is complex

Let us honor your hard work with careful, comprehensive, accurate data analysis

• Significant, nation-wide impacts of PBHCI– Model for future integrated care initiatives– Health Homes, Specialty Health Homes etc.

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Continuous Quality Improvement

• Further work needed in the areas of– Consumer recruitment (by grantee report)– Engagement / retention – Capacity building

• Specific service types

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If you have additional questions related to the PBHCI national evaluation…

• Participate in related break-out sessions

• Send questions to Center for Integrated Health Solutions

• Participate in future Data Jams

• Approach me!

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THANK YOU!

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Programs include many optional model features

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Perc

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Co-location ofNP/PCP

PC SupervisingPhysician

Embedded NCM EBPs

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SBIRT and MI are common EBP