SAMHSA Primary and Behavioral Health Care Integration (PBHCI)

Program Grantees: Part 3

Freddie Smith, MPH, Project Director Alameda County Behavioral Health Care Services

Faith Elizabeth Fuller, MBA, Project Evaluator

ILC Meeting #41 February 25, 2015

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SAMHSA PBHCI Program

SAMHSA’s Primary and Behavioral Health Care Integration program (PBHCI) provides federal grant funding to promote the integration of primary care services for adults with serious mental illness (SMI) into community-based behavioral health settings, to increase access to care and improve consumer health through better coordination of care.

http://www.integration.samhsa.gov/pbhci-learning-community

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Region 9 PBHCI Grantees

Poll Question

We are/I am: 1. A current PBHCI grantee 2. Applying for a PBHCI grant Feb 2015 3. Exploring PBHCI funding for 2016 4. Not applicable, or none of the above

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PATH Project (Promoting Access to Health)

)

SAMHSA/PBHCI Cohort 2 Alameda County Behavioral Health Care

Services, Northern California Manuel Jimenez, Director

Adult Client Population Psychiatric Profile

Fiscal Year 13-14

2,814 Adult Clients (18-65 years old) assigned to Service Teams

Diagnosis Breakdown # Clients Served Percentage

Schizophrenia Disorders 1824 65%

Bipolar Disorders 372 13%

Depressive Disorders 289 10%

Psychotic Disorders 243 9%

Anxiety Disorders 63 2%

Adjustment Disorders 5 1%

Health Characteristics of BH Clients served by Service Teams

1. 228% more likely to be diagnosed with diabetes

2. 62% more likely to be diagnosed with hypertension

3. 61% more likely to be diagnosed with asthma

4. 53% more likely to be diagnosed with heart disease

Prevalence of Hypertension, Obesity, Diabetes

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Hypertension 44% Obesity 42% Diabetes 20%

US

Alameda County

BHCS SMI Clients

PATH SMI Clients

Federally Qualified Health Center(s) co-locate a satellite primary care clinic

in a county-operated mental health center. The site becomes the “Medical Home” for seriously mentally ill

adults in the county’s Adult System of Care. Oakland, CA Fremont, CA

LIFELONG MEDICAL CARE:

“Safety net” primary care provider since 1976 for uninsured residents with complex health needs in Berkeley, Oakland, Albany, and Emeryville, California

TRI-CITY HEALTH CENTER:

“Safety net” primary care provider since 1970 for uninsured and under-served residents in Fremont and Union City, California

September 2011: LifeLong Medical Care PATH Clinic opens at the Oakland Adult Community Support Center (200 participants)

August 2012: Tri-City Health Center PATH clinic opens at the Tri-City Adult Community Support Center / Fremont (50 participants)

Goals of PATH Project

1. Improve Access to primary care services for SMI clients

2. Create a “Medical Home” for SMI clients served in County Mental Health Centers, with the goal of improving health outcomes 3. Develop a “Sustainable Financial Model” to expand PATH Clinics and integrated care to additional Centers

A PATH Clinical Team

From the FQHC: • Primary Care Providers

(Physicians or NP’s) .4 FTE • Medical Assistant .5 FTE • Clinic Coordinator 1 FTE

manages clinic operations • Care Assistant 1 FTE

coordinates appointments, schedules, and enters patient information into health information systems

From the Mental Health Center: • BHCS Psychiatrists provide

consultation to primary care providers as needed

• Nurse Care Coordinator 1 FTE • Peer Support Counselor 1 FTE

facilitates wellness activities, assists with care coordination

• Case Managers assist getting clients to appointments and referrals to specialty care

• Average visit with the Primary Care Provider takes 30 minutes (after relationship is established)

• Care Assistant makes reminder calls & covers “no shows” with walk-ins

• Peer Support helps clients get to their appointments, interprets, plans wellness activities

• The Team meets at the end of each half -day clinic for a 30 minute “debrief” to discuss care for each client seen that day

• Nurse coordinates referrals and follow ups, medication refills, blood draws, triage

How the PATH Clinic Works

Health and Wellness Activities Led by peers or student interns, provide socialization, education, engagement,

inclusion; a colorful calendar is posted monthly on the bulletin board

Community Connections, field trips to farmer’s markets, bowling, movies

Cooking Class, teaching nutrition, self sufficiency, healthy eating (free lunch!)

Living Well Class, participants set health goals based on Whole Health Action

Management plan (WHAM) developed by SAMHSA-HRSA

Tobacco Cessation, group and one-on-one coaching (“Bye Bye Butts”)

Meditation/ Movement, yoga, walking, for exercise, stress reduction (“Fun and Games”

and “Feel Good Fridays”)

Lunch and Learns, medical staff present a topic and answer questions

The PATH Café for socialization and relaxation for clients to use before or after receiving

primary care or wellness services

Outcome 1: Improving Access to Primary Care

Clients who hadn’t engaged in primary care now access care more often

Annual visits for

heavy users

closer to the

national average

0%

10%

20%

30%

40%

50%

60%

70%

Improved A1c Improved BP Improved BMI

40%

56%

22%

52%

64%

54%

Non-PATH (N=720) PATH (N=159)

Outcome 2: Improvements in Health Indicators

1. Plan to document outcomes for charts, graphs, presentations, and grant applications and proposals 2. Prepare a Financial Plan and Service Model to show how implementation and operating costs can be covered 3. Develop strong collaborative Partnerships with primary care partners (data sharing, transparency, for a win-win) 4. Build Support from BH Executive Staff, elected officials, and community and consumer groups

Outcome 3: Sustainability Focus

What are the costs of a PATH clinic? Ongoing Operations

Primary Care / CBO FTE Primary Care Physician 0.4 Clinic Coordinator 1.0 Medical Assistant 0.5 Care Assistant 1.0 Salaries $ 187,000 Medical Supplies $ 55,000 Other costs $ 28,000

$ 270,000 BH / County FTE Nurse Care Coordinator 1 Peer Support Counselor 1 Salaries $ 220,000 Supplies $ 18,000 Other costs $ 20,000

$ 258,000

Annual Direct Costs: $ 528,000

Exam Room Set up and Computers Equipment Units Office Computers 3 Printers/Fax Machines 2 Exam Table 1 Weighing Scale 1 Blood Pressure Monitor 1 Thermometer 1 Pulse Oximeter 1 Otoscope 1 Ophthalmoscope 1 Halogen Exam Light 1 Medical refrigerator 1 Hazard Container 1 File Cabinets with locks 2 Cost: $ 15,000

Note: Sinks, Rent, IT Services in-kind

Breakeven Analysis (Primary Care, FQHC)

Primary Care Clinic: Annual Operating Expenses $270,000

Medi-cal reimbursement rate per visit $206

# Annual visits required for break even (95% insured) 1376

# visits per 4 hour shift (about 30 min. each) 7

Breakeven # of shifts required a year 197

Available weeks per year [net of holidays, vacation, sick] 49

Breakeven # of half-day clinics/week 4.0

Can BH find ways to Cover Costs? Setting up MAA and TCM billing to help cover operating costs of approx.

$250,000 a year per clinic (200 participants) County Leadership approved allocation of California Mental Health

Services Act funds to sustain PATH and expand to 2 new sites San Francisco Foundation grant for sustainability planning and data

analysis Tobacco Cessation grants (MHSA) Blue Shield Foundation grant to improve county-wide interagency data

sharing USC/Cal State University Schools of Social Work Integrated Health Interns

(in-kind donation of services) UC Berkeley collaborative proposal to NIMH for SMI sleep improvement

study begins next month

Challenges For the organizations: • The bureaucratic processes (everything takes time); hiring, purchasing,

MOU’s • Primary Care has “productivity” targets (different from BH) • Getting “billing” up and running on the Behavioral Health side • Challenges in data sharing, 3 systems that don’t talk to each other, and

getting data for comparison groups .. And we have all of these reassessment interviews! For the consumers: • Staff changes can be upsetting • Substance use can affect engagement and compliance • Challenges with transportation; limited access to healthy food • Some consumers prefer one-on-one and do not like group activities

Tips (Clinical Team)

Schedule a team “de-brief” after each clinic day to share information and problem solve (improves care coordination and helps build relationships)

Convene “Lunch and Learns” so providers can introduce themselves to consumers, present different health topics, and encourage discussion (consumers feel less isolated)

Orient consumers on “how to be an effective patient” Get Peers involved early on, to help design service delivery,

communication, and educational materials that makes sense to your consumers

Tips (Data and Outreach) Work with your Evaluator and clinical team to plan what data to

collect, when, how, and why. Measure blood pressure, weight, breath CO, blood sugar, cholesterol

levels (for example). Track number of primary care visits, before and after integration. Make charts and graphs for a “data wall” and disseminate your

successes widely; integration is a hot topic! A weekly cooking class attracted participants, as did outings and

events, and created a “culture” of wellness The “PATH Café” created a welcoming, colorful environment Consumers contributed artwork, provided input into outreach

materials and a colorful monthly calendar

Annual Visioning Retreats Ask Stakeholders “IS IT WORKING?” TOPIC: “Strategies for improvement” • Health Education/Wellness Activities • Recruitment/Enrollment/Outreach • Clinic Operations and Communication • Information Sharing and Data Utilization

Consumers, PATH Staff & Family Members

Collaborative Leadership

Take ownership of your partner’s measures of success

Build trusting, dependable working relationships with all project staff

Always be willing to listen, and help solve issues that might impact the collaboration

Be willing to think “outside the box”

Goals for the Future Open primary care clinics at additional MH sites

Integrate Substance Abuse Treatment

Continue to collect and analyze data to identify the benefits of integration / added value to the system, i.e. measure impacts on Emergency Room visits Hospitalizations (psychiatric and medical) Criminal Justice System Contacts Cost savings to the public health care system

QUESTION & ANSWER

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Reminder: Please mute your phone line by pressing *6. You may ask a question by pressing *7 on your phone to un-mute yourself.

CONTACT

Freddie Smith, Alameda County BHCS fsmith@acbhcs.org

Faith Elizabeth Fuller, FAS Services

faith@faithfuller.com

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For more information on the ILC…

Meeting Summaries http://uclaisap.org/integration/html/learning-collaborative/ Archived Recordings http://vimeo.com/channels/ilcintegration Mailing List http://lists.ucla.edu/cgi-bin/mailman/listinfo/ilc E-mail cteruya@ucla.edu with additional questions!

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