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Practical steps toward integration: behavioral healthcare providers should start small and retain their recovery focus throughout integration with primary care.

This fall, the Substance Abuse and Mental Health Services Administration (SAMHSA) provided 53 behavioral healthcare organizations with $20.9 million in grants to encourage one of healthcare's fastest-emerging trends: the integration of primary and behavioral healthcare services. This push for integrated care follows the "medical home" model emphasized in the Patient Protection and Affordable Care Act, where clients can access a one-stop shop for all of their person-centered healthcare needs.

For the behavioral healthcare industry this is, at first glance, great news. Individuals with severe mental illness (SMI) suffer a 25-year disparity in life expectancy, due largely to under- or untreated chronic medical conditions. The effort to bring treatments for these ailments onsite with behavioral healthcare services is essential to closing the life expectancy gap and ensuring parity.

But at what cost to behavioral healthcare as an industry? As organizations from the historically-siloed healthcare sectors come together, could behavioral health's recovery-oriented care be forgotten?

A new model for traditional philosophies

If Suzanne Clifford, consultant and former director of the Indiana Division of Mental Health and Addiction, has anything to do with integration, the answer to that question is a firm "no."

"Identity changes when you get involved in any type of integrated care, but not necessarily in a bad way," Clifford says. "The system I'd like to see is one that's very collaborative and leverages deep expertise in both primary care and behavioral health, so that we're really focused on what a client needs and how we can come together as a team of organizations to serve that person."

Clifford, co-author of the Implementation Guide for Integrating Behavioral Health and Primary Care in Ohio (published by the BeST Center, see "A step-by-step guide for integration projects of every size"), has helped behavioral health providers across the U.S. integrate various levels of primary care into their existing services through her work with Inspiring Transformations, a consulting group she founded in 2005. While she encourages the behavioral health organizations she works with to integrate care for the benefit of those they serve, she emphasizes the need to keep recovery-oriented services intact.




"That's one of the cautions I have for people looking at integrated care," Clifford says. "You have to understand the medical model of primary care, but integrate that into a recovery-oriented approach."

Step 1: Take inventory, then action

Clifford is quick to point out that though the push for integration is widely supported, its final destination is not one-size-fits-all. "There are a lot of different approaches," she says. "One model is not better than another; it depends on the specific situation, the needs of the clients, and the needs of the communities."

To determine the right approach for a given organization, Clifford recommends assessing the needs of the population served and the availability and scope of primary care resources in the community. Start by studying a representative sample population as a reliable way to project the needs and behaviors of clients relative to primary care.

"Determine, for that sample, are they being connected to primary care? How are their health outcomes?" Clifford says. "If people are doing well, which unfortunately is not the norm right now, there may be smaller changes to the system. But if we see that there are significant health challenges, then a much bigger intervention is needed."

Then, consider access. Take an inventory of accessible community primary care providers--in terms of both distance and reimbursement. Understand the type and extent of services they offer to your clients, as well as those they lack.

Example: Centerstone Research Institute (CRI) of Bloomington, Ind. had trouble identifying a single community resource that could accommodate all of its clients due to clients' varying levels of reimbursement. The local Volunteers in Medicine clinic--a CRI community partner--could only accept clients without insurance, leaving those with Medicare, Medicaid, and private insurance to find another option.

After surveying its patient population to determine if clients were, in fact, seeking other options, CRI realized that "28 percent of clients with SMI did not have a primary care provider at all," says Bethany Murray, CRI's project director. "Even those with insurance were not accessing healthcare and getting treated."

To make up for this disparity, CRI developed the Building Exceptional Wellness (BE Well) program, a primary care clinic within CRI's Bloomington behavioral health clinic, which received a $2 million grant from SAMHSA this fall. The clinic will provide primary care services to 250 of CRI's current clients beginning in late 2010 or early 2011.

Step 2: Establish referral partnerships

For those organizations who find that primary care options in their communities are prevalent, Clifford suggests forging collaborative referral partnerships, rather than building out costly, duplicate services.


"Every behavioral healthcare provider has to have a strong referral system and a process of following up and collaborating," she says. "That really is at a minimum what is needed for every behavioral healthcare provider."

The most accessible referral partners for behavioral health clients are typically those primary care providers that accept new Medicaid and Medicare patients. Often, these will be the local federally qualified health center (FQHC), rural health center, or FQHC-lookalike.

Example: For Greater Cincinnati Behavioral Services (GCBS) in Cincinnati, Ohio, the local FQHC sought them out, and the organization's services are all-the-better for it. The FQHC, now operated by the HealthCare Connection, Inc. (HCC), established a satellite office inside GCBS's building, allowing clients to seamlessly access all needed services in one visit.

"We call it co-located care," says Tony Datillo, CEO of GCBS. "Clients can come in, see their psychiatrist, go to the primary care office, and on the way out pick up their medications that were ordered either on one side or both. Then they go home."

The co-located clinic at GCBS has been in place for over eight years. Though it serves 800 current GCBS clients, a half- million dollar grant from SAMHSA will help increase the population to 2,000 over four years.

"We have a very active partnership with HCC; they know that we have expertise and we know they have expertise, and we rely on that," Datillo says. "We don't feel threatened by them and they don't feel threatened by us."

After prospective partners have been identified, it's time to meet with them.

"The best collaborations that I've seen have been when the behavioral health and primary care providers sit down and deeply understand what both of the organizations need," she says. "It's not one way."

Both organizations must discuss their needs and expectations to understand how they will receive what they need from the other.

If this looks promising, the next step is to name a "point person" for referral-related issues. This can be an administrator or case manager who is accountable for ensuring follow-up from one provider to the other.

Two of the most important issues facing referral partners concern billing and privacy:

* From a billing standpoint, Clifford sees referral partnerships as the most straightforward approach to integrating care: Behavioral health providers bill for the behavioral health services provided at their location, and vice versa for primary care providers.

* Before referral activities can take place, a release of information document must be developed and mutually approved so that providers can share client information. Clifford recommends that the partner organizations work with a legal expert to develop a compliant document that patients can sign to permit their records to be used by both facilities.

"Privacy should not be a barrier to collaboration," she adds.

Step 3: Pilot a joint project

For behavioral health providers that find success in their referral partnerships, the next step toward integration may be the development of a joint project.

"An easy way to start is just to collaborate for the clients engaged in services both places," Clifford says, suggesting that clinicians from each organization could begin spending a few hours per week at their partner's site to bring services straight to the client, rather than refer out. "Usually it takes some funding to get this [type of project] going, but we don't want funding to be the reason we don't do it."

Funding a pilot integration project, which often requires new equipment or technology, expansion or renovation of space, and additional administrative time or support, offers partners another way to work together.

Research local foundations, state and county mental health boards, local Medicaid managed care organizations, and federal agencies like SAMHSA for grant opportunities to cover the project's startup and operations expenses. Clifford adds that "healthcare reform is directing a significant amount of funding to the FQHCs, and some of that is anticipated to go to mental health expansion grants."

To alleviate the costs associated with providing new services, consider the value of volunteers or peer specialists.

"For the things you can't bill in other ways, it may make sense to look into what would be appropriate for a peer support specialist to do," she says. "There are good examples where peers have gone back to school to become a medical assistant and provided some very impactful services that wouldn't have been billable under a traditional primary care plan."

Example: When CRI's Murray noticed that "the state of Indiana [was] really encouraging CMHCs to use peers in a variety of positions," she thought of the BE Well program, which is required to focus 10 percent of its activity on wellness promotion. CRI hired a peer specialist with a teaching background to facilitate daily group wellness activities and individual health and wellness sessions.

"We felt that in a program where you're trying to get individuals with SMI to change their behaviors, having someone in recovery would be a good role model," Murray says. "It's not just about authority figures like doctors or nurses telling our client what to do, it's also about having some who's been there to model the behavior we're asking them to implement."

Step 4: Build on integration success--carefully

Even when a behavioral health organization has seen successful outcomes from integration projects thus far, Clifford cautions that full-on integration of services may not be the be-all, end-all.

"The field is shifting toward behavioral health providers having stronger accountability for the overall health of their clients, and that can be through referrals and other sources," she says. "But integration is a big, strategic discussion that needs to happen at each organization to determine, 'What is our responsibility to our clients and where does behavioral health end and other healthcare begin?'"

Those organizations that have already tested the integration waters with successful, smaller projects will find it easier to secure the funding needed for larger endeavors. "If you have some measurable successes to show why integration is important, then it's easier for funders to get excited," Clifford adds.

But organizations will have to work to get their clients excited about new services, too. "It may take some education and discussion," Clifford says. "You may have to remove some of the other barriers, like unemployment or homelessness, before clients see how important it is to engage in effective healthcare."

Step 5: Recruit with integration in mind

New staff members, like doctors and nurse practitioners, trained in the traditional medical model of healthcare delivery will have to be comfortable working in an integrated environment that demands they balance the behavioral health and medical needs of patients.

In staffing CRI's BE Well program, Murray says she looked for people who were open-minded, comfortable with ambiguity and--above all--flexible.

"The key success factor there is personality," says Dennis Morrsion, CEO of CRI. "The person has to be flexible. You have to get right personality, and technical skills are not going to be as critical."

To help physicians and nurses assimilate into a recovery-oriented approach to care, Clifford suggests helping them focus on one issue at a time. "Sometimes I've seen primary care physicians that feel so concerned about so many different health issues that a consumer has, and they want to solve it all as soon as they can," she says. "But the person being served needs time to work on the most important things."

Scheduling shorter, but more frequent appointments focused on one specific issue will help clinicians take things one step at a time and prevent clients from feeling overwhelmed. Delivering care in these "manageable segments" will also allow clients to make the most of the feedback they're receiving.

"This keeps the organization focused on what that person needs and how we can come together as a team to serve that person," Clifford says. "That team approach where we put the person in the center and surround them with the services they need to move along the recovery continuum is where I want to see the system go, and where I'll advocate for it to go."

RELATED ARTICLE: National Council to lead integrated care assistance center

Along with the $20.9 million doled out by the HHS for integrated care projects in late September, the Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources Services Administration (HRSA) partnered to provide $5.3 million in grant funding to establish the National Training and Technical Assistance Center for Primary and Behavioral Healthcare Integration. The technical assistance center will be developed and led by the National Council for Community Behavioral Healthcare.

The center will be responsible for providing assistance to the 56 grantees, as well as other community health and mental health centers looking to initiate integrated care projects across the nation.

The center will focus on six areas key to successful integration of primary and behavioral healthcare services:

1. Workforce development;

2. Knowledge application;

3. Knowledge development and dissemination;

4. Healthcare reform and policy analysis issues;

5. Prevention and health promotion; and

6. Quality improvement, performance measurement, and data collection.

RELATED ARTICLE: A step-by-step guide for integration projects of every size

In 2008, a local foundation in Hudson, Ohio awarded the Northeast Ohio Universities College of Medicine and Pharmacy (Rootstown, Ohio) $5 million to establish the Best Practices in Schizophrenia Treatment Center (BeST Center). Suzanne Clifford was called in to help the design the center, which would work to ensure that consumers affected by schizophrenia and other disorders would receive state-of-the-art treatment.

One of the BeST Center's earliest endeavors was to develop a comprehensive guide for integrating behavioral and primary healthcare in Ohio, in partnership with the Ohio Coordinating Center for Integrating Care. Clifford and co-author Jonas Thorn, MA, PCC, worked with both organizations to develop 13 modules, complete with planning worksheets and case studies, which would guide organizations through the integration process.

"People were walking into this and not realizing all they needed to think about and know," Clifford says. "Our hope is that we can get as much information out there as possible. We don't want to discourage people from integrating because it is complex, but we want them to start with something easy, and then they can walk into something more complex with their eyes wide open."

The guide, titled the Implementation Guide for Integrating Behavioral Health and Primary Care in Ohio, is available for free at
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Title Annotation:INTEGRATION
Author:Barba, Lindsay
Publication:Behavioral Healthcare
Geographic Code:1U3OH
Date:Mar 1, 2011
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