The Pitfall and Promise of Integrating CareDavid Freedman, Lina Castellanos, Thomas Jardon, Cynthia Rodriguez, David Fuentes, Ketia Harris, Megan Hartman, & Angela Mooss

Integrated Care: Reconnecting the Head and Body

Milliman, 2014

Cost of Co-occurring Conditions

Milliman, 2014

Cost

Cost and Disparities

Netsmart, 2013

Three-Legged Stool of Healthcare Integration

INTEGRATION, YOU SAY?

Integration Service Flow

The Four Quadrant Clinical Integration Model

samhsa.integration.gov

Accountable Care-Change Of Focus Required

Element of Change Yesterday Today

Care focus Sick care"Healthcare" wellness

and prevention, disease management

Care managementManage utilization and

cost within a care setting

Manage ongoing health

Delivery Model Fragmented/silos Care continuum and coordination

Care Setting In office/hospital In home, virtual

Quality measures Process-focused, individual

Outcomes-focused, population-based

Payment Fee-for-service Value-based

Financial incentives Do more, make more Perform better on measures, make more

Financial performance Margin per service, procedure Margin per life

SAMHSAMAI-TCE: MIAMI SITEMinority AIDS Initiative – Targeted Capacity Expansion

4.2 M for 3 Years from SAMHSA

Project Flow Chart

SAMHSA

South Florida Behavioral Health Network

Behavioral Science Research Institute

Citrus Health

JTCHC

Florida Health

SAMHSA Funding

Siloed Funding

Main Players: Behind the ScenesFlorida Health- Tallahassee and Miami Dade (DOH)◦Required grantee due to HIV impact◦Coordinated with ECHPP

South Florida Behavioral Health Network (SFBHN)◦Managing entity for behavioral health dollars

via Department of Children and Families

Behavioral Science Research Institute (BSRI)◦Evaluation team◦Crossover with Ryan White Program

Main Players: The ProvidersCitrus Health5 medical clinics and

24 schools

Hialeah area

55% female

>80% Hispanic/ Latino

52% best served in another language

28% uninsured

Jessie Trice (JTCHC)9 medical clinics and

23 schools

Liberty City area

63% female

67% Black/African-American

13% best served in another language

60% uninsured

MAI-TCE PROJECT PHASES

MAI-TCE Miami took on three distinct phases

Phase One:Gearing up for IntegrationStart Date◦February 2012

Logistics ◦Funding ◦Staffing◦ Implementation

Buy-in ◦Organizational level ◦Between partners

Logistics

Challenges SuccessesFiscal tracking

Data burden

Training/EBI’s

Staffing

Collaboration/Team building◦ SFBHN/organizational

level◦ Data sharing with

Evaluation◦ Provider MAI-TCE

teams

Capacity Building

Buy-in

Challenges SuccessesCultural differences◦ Medical vs Behavioral

health◦ HIV and Ryan White

services

Billing for services

The need is recognized and departments find relief

Integration is accepted at top-down level in theory

SFBHN assists with billing and loosening staffing regulations

Lessons LearnedMake preparations ◦Present changes to other

departments ahead of time

Collaboration is critical◦Need a team of support

Planning and persistence◦This takes time

Phase Two:Customizable IntegrationStart Date◦June 2012-May 2014

Planned changes◦Mandated by funders (TRAC vs. GAIN)◦Necessary to meet EBI requirements

Unplanned changes◦HIV testing ◦Staff turnover

Planned Changes

Challenges SuccessesEBPs/DEBIs changed◦ Client needs and

outdated practices◦ Training overload◦ Staff turnover

Systems-level funding and documentation

Flexibility in training and EBI implementation◦ Peers implementing◦ Translation of tools as needed

Data and service documentation◦ Removal of GAIN-I◦ SFBHN consistent updates

(delete orphans, etc)◦ Data became useful internally

Unplanned Changes

Challenges Successes 80% follow up rate goal

◦ Does not fit BH clients◦ Reassessment and DC lists

become unmanageable

Rapid Testing HIV mandate◦ New testing site IDs◦ Training ◦ Duplicative data ◦ Testing numbers cannot be

shared

Advanced integration model for service delivery

Advocating at all levels ◦ A true team approach◦ DOH was instrumental◦ Capacity building◦ Filling a huge need

(especially at Citrus)

Lessons LearnedThe need to truly customize cannot

be understated

Peers are critical to successful models for client satisfaction

Integration is working◦More clients are getting the services

they need and large FQHCs have fewer silos internally

Phase 3:Wrap-up and SustainabilityStart Date◦ June 2014 to present

A focus on Medicaid billing and staff coverage

Focus on implementing EHR systems that are effective

Concentration on seeking out additional funding through grants/foundations

Funding

Challenges Successes Non-Medicaid expansion

EMRs lack sophisticated technology and are expensive

SAMHSA and other billing systems are not set up for co-occurring clients

Grant funding is competitive

SFBHN advocacy for EMRs and data systems changes

EMRs responding

Funders are responding

Miami secured grant monies

Organizational Integration Culture

Challenges SuccessesStaffing ◦ Certifications for peers,

behavioral health techs, non-client specific coordinators

Organizational structure◦ What has really changed?◦ Medical and behavioral are

still separate, but…

Staffing has changed organizational practice◦ Use of peers, recognition for

coordination across sites

Other departments believe in the value of behavioral health

Healthcare culture is changing

Lessons LearnedChange happens with persistence

Generating buy-in at the organizational level can speed things up

Collaboration is key to successful integration and sustained funding

TAKE AWAY POINTS

If you don’t remember anything else… Remember this

Behavioral Health Primary Care Network Committee (BHPCNC) A committee for health integration

Guided by principles:◦ Inclusion, Collaboration, CQI, Resource savings,

Community-based, Resilience and Recovery

Vision/Mission◦ Oversee the expansion of culturally competent and effective

behavioral health services◦ To monitor and enhance the linkages between and

integration of behavioral health services in primary care

Less formal◦ A focus on training and capacity building across the

systems of care

The Miami ModelScreening (SBIRT)

Use of peers

HIV testing

EBIs

Data driven

Co-location has been extremely helpful with piloting/forming the model

Project Outcomes Reduction in days spent:

◦ Homeless◦ Hospital MH unit, detox, jail, emergency room

Reduction in unprotected sex

Increase in risk perceptions

Decrease in mental health symptoms and social support

Increase in access to comprehensive health services

Decrease in substance use◦ But not in tobacco use

System-wide ImplicationsExpansion of integration to

chronic disease management and other aspects of health

Providers are held to higher standards of care and care coordination

Focus on prevention and wellness

Go Forth and Integrate

Questions/CommentsDavid Freedman – Project Director

dfreedman@sfbhn.org(305) 860-8235