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HEALTH CARE INTEGRATION: BLESSINGS & BLOCKAGES
Focus on small, rural programs and communities
Tara Shepherd, MA, CADC-CASDeputy DirectorModoc County Health ServicesModoc County Behavioral Health
Twelfth Statewide ConferenceIntegrating Substance Use, Mental Health, and Primary Care Services:
Integration from the Ground Up Universal City, California
October 28-29, 2015
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What is integrated health care?“Integrated care is when health professionals consider all health conditions at the same time.”SAMHSA, Understanding Health Reform: Integrated Care and Why You Should Care, 2012.
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Why Integrate ?o People w/ serious mental illness
die 25 years earlier than general population ...
2/3 of these deaths are from preventable, treatable conditions – heart, lung, diabetes, infectious diseases
o Co-occurring MH/SU disorders worst mortality gap ...
Both SMI & SU – average age of death = 45SMI only – average age of death = 53
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Client/Patient/
Consumer
SubstanceUseServices
MentalHealthServices
PrimaryHealthcareServices
The client – and family/ significant others – must have central roles in the partnership.
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Some “blessings” of integration:
Treating the “whole person” Better, safer client outcomes Increased client satisfactionMost effective approach for people with multiple healthcare needs
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More “blessings” of integration:Coordination of diagnoses &
treatmentsMedication reconciliationInterdisciplinary care teamsContinuity of careMost effective use of resources
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Some “blockages” to integration: • Shortage of healthcare practitioners,
especially in isolated, rural areas (Medically Underserved Areas);
• 42CFR as a potential barrier to information sharing;
• Funding silos - “Carve outs,” managed care, fee-for-service, Drug Medi-Cal, Speciality MH Medi-Cal, private insurance, federal regs.
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More potential Blocks
• Different “cultures” – primary care, substance use and mental health;
• Stigma – substance use and mental health disorders.
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MODOC COUNTY
Designated by legislation as a
“Frontier County”
Service delivery is hampered by extremely low density of residents
9,147 – total County population
< 3 people per square mile
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Medically Underserved Areas (MUAs) are determined by evaluation of criteria established through federal regulation to identify geographic areas based on demographic data.
Approximately 17% of Californians live in a MUA, with MUAs in 33/58 counties.
Designation as a Medically Underserved Area
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“Medically Underserved Area” designation requests
CRITERIA . . .
Percentage of population at 100% below poverty;
Percentage of population > 65; Infant mortality rate; and Primary care physicians per 1,000 population
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Impacts of healthcare provider shortages on Integration Efforts – The Modoc County Experience Not enough medical providers, especially for a high poverty/high risk population Overworked medical providers do not have the time to take a proactive role in integration Medical providers are open (and sometimes eager) to join integration/collaboration efforts designed and led by Behavioral Health
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MODOC COUNTY – FIRST FOCUSED ON BEHAVIORAL HEALTH INTEGRATION (MH & SU)
. . . THEN BEHAVIORAL HEALTH TOOK THE LEAD ON COLLABORATION WITH PRIMARY CARE
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InModocCounty
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Pre – 2011 – Modoc County Health Services• Mental Health, Public Health, Alcohol and
Drug Services & Environmental Health2011 – at the request of Health Services Modoc CountyBOS approved combining MH and A&D Services into Behavioral Health -- Reactions varied !!
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? ? ? Buy – In ? ? ?
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Who Needs to Buy-in for BH Integration to be Successful? Staff – Clinical, fiscal & support Consumers/Clients All management/supervisory levels Other community partners
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Behavioral Health Integrationo Put together a Planning Team of MH/AOD
staff, management, clients/consumers, and other stakeholders (e.g., Collaborative Treatment Courts Coordinator, Probation,Public Health);
o 2 Meetings a month for nearly a year.
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The BH Integration Planning Team . . .o Developed a Mission Statemento Agreed on Goals and Objectiveso Designed a comprehensive Behavioral Health
system, addressing/integrating:
~ MH, SU and physical health ~ Client-centered, cultural competence, wellness and recovery
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So . . .How did we
handle 42 CFR for our BH
integration?
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Confidentiality . . .
Rise to the higher level of requirements
Mental health and SU both follow HIPPAA and 42-CFR
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We posted a notice, and mailed the notice to current clients . . .o Notification of our plans to integrate Mental
Health and Alcohol & Drug Services;o Informed current clients of new forms and
processes;o Current clients signed new forms at next
scheduled appointment.
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New “Consent for Treatment/Admission Agreement”o Addressed all regulatory requirements for MH
and SU Services;o Notification of integration, including MH and SU
staff ability to access client records;o Reviewed and approved by Attorney Linda Garrett,
Risk Management Services.
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MODOC COUNTY BEHAVIORAL HEALTHCONSENT FOR TREATMENT/ADMISSION
AGREEMENT“It is understood that MCBH is an integrated mental health and substance use treatment program, which includes integrated record-keeping, treatment planning, and treatment provision. Staff providing substance use and/or mental health services will have access to your records to the extent it is required to effectively do their jobs.”
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•Integrated Electronic Health Record; (Anasazi/Kingsview)
•Integrated scheduling;
• Integrated intake interview process
~ intro on integration, demographics, client rights, data reporting elements, collection of financial data, consent/admission agreement, privacy practices and other informing materials.
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. . . PROGRESS: Behavioral Health Integration
• Integrated Treatment Team meetings
o Monday am – Weekend crises calls review
o Tuesday – MHSA Full Service Partner Reviews
o Thursday – QI/UR
• Integrated Behavioral Health Treatment Plans
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MCBH Flow Chart of Client Services (Adults)
Mental Health Services Substance Use Services Both
Intake Interview Medical Intake History & Vitals & PCP Release
Substance Use Assessment and/or Mental Health Assessment w/ Psych Section ASI as screener w/ SU Screener
Utilization ReviewPrimary + Treatment Team Members Assigned;
Referral Needs Assessed
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Integrated BH Treatment Plan
Possible Referrals: In-houseFull MH or SU assessment (per screening), telepsych
meds assessment (MH &/or SU MAT),
meds mgmt w/ BH Nurse, case mgmt or rehab services.
Possible Tx Team Members
MH therapist, SU counselor,
case manager, BH nurse, telepsychiatric provider,
rehab specialist, peer support specialistPossible Referrals: External
Consumer-operated non-profit Wellness Center, medical, dental, vocational,
educational, legal, etc.
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BH Initiatives for Collaborating w/ Primary Care in Modoc County
• Vigorously Seek ROI w/ Primary Care Provider, & send copy to PCP;
• Medical Care Referral Form;• Medical Care Visit Form;• Medication Reconciliation with one primary
care clinic.
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. . . On-going BH Efforts for Collaborating with Primary Care in Modoc County
• To allow real-time sharing of information between BH & PC:o Through CIBHS Collaborative,
tested two registries;o High hopes for current CIBHS
initiative with eBHS.
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Where do we go from here?• Continue to pursue registry –
high hopes for eBHS (CIBHS);
• Respond to request from largest clinic in County for medication reconciliation efforts for “frequent users” among shared clients – “by hand” tabulation without registry.
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. . . Where do we go from here?• When new hospital/medical clinic is
built:o Explore possibilities for co-locating
BH at new site . . .
~ Financial barriers to full co-location;
~ Options for partial co-location.
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Resources
1.Croze, Colette, MSW, Healthcare Integration in the Era of the Affordable Care Act, for the Association for Behavioral Health and Wellness, 2015.
2.gis.oshpd.ca.gov/atlas/topics/shortage/mua.3.Mauer, B. and Weisner, C., CIMH Webinar, The Case
for Integrated Care, 2010.4.SAMHSA, Understanding Health Reform: Integrated
Care and Why You Should Care, 2012.5.www.nasmhpd.org, Morbidity and Mortality in
Persons with Serious Mental Illness, 2006.
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Thank you!