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Integrated Care Models in Managed Behavioral Healthcare Organizations

The Association for Behavioral Health and Wellness (ABHW) represents specialty behavioral health and wellness companies that provide services to treat mental health, substance use, and other behaviors that impact health. ABHW members have long histories with integrating behavioral health care and a lot can be learned from their experience. Whether carve-out entities or health plans with their own internal specialty organization for behavioral healthcare, managed behavioral healthcare organizations (MBHOs) are experts in blending services to meet the needs of individuals with complex behavioral health conditions.

Integrated care produces better outcomes and provides better care to individuals with multiple health care needs. ABHW member companies employ a variety of models to clinically align behavioral health and primary care for individuals receiving care in their networks.

Training for Primary Care Practitioners on Identification and Treatment of Behavioral Health Conditions and Screening for Behavioral Health Conditions in Primary Care Settings: Training and consultation from behavioral health providers and MBHOs can assist primary care practitioners (PCPs) in improving their identification of behavioral health concerns and conditions. Behavioral health specialists can assist primary care practices in initiating Screening, Brief Intervention, and Referral to Treatment (SBIRT) and develop systems for warm handoffs for patients who require substance use disorder (SUD) treatment. In Colorado, Beacon Health Options provides training on depression screening to primary care practices; and in Maryland, they will train PCPs on SBIRT, alcohol screening for pregnant women, and suicide risk assessment.

Since there are patients with mental health and/or substance use disorders (MH/SUD) who prefer to remain in medical settings for treatment, partnerships with PCPs are critical to improving health outcomes. Beacon Health Options’ Psychotropic Drug Intervention Program uses aggregate data and scaled clinical insight to promote integration of care at the provider level. Analyzing integrated behavioral health, medical, and pharmacy claims data, this MBHO identifies target events and intervenes with members and prescribers to educate them on best practices and changes to pharmacological treatment. Evidence-based practices drive the algorithms in the technology platform that identifies prescription-related problems. Peer-to-peer consultation staffed by psychiatrists utilizes the best available clinical guidelines to coach physicians on practice improvement while health coaches educate members and provide care coordination. As a result of this program, hospital admissions and emergency room visits decreased by 30% and inpatient spending was reduced by $90 PMPM.

Providing Consultation Services to Primary Care Practitioners: Primary care practices and the patients they serve benefit from consultation and connection with behavioral health providers, as demonstrated in various psychiatric liaison and consultation programs that support pediatricians in identifying children with MH/SUD needs and in collaborating with psychiatrists on their treatment. The long-standing Massachusetts Child Psychiatry Access Project encourages and supports PCPs integrating behavioral health resources into their practices and provides quick access to psychiatric consultation and facilitates referrals for accessing ongoing behavioral health care. The project has been so effective that it is now available in 22 states.

Co-Locating Behavioral Health and Primary Care Services and Creating Strategies for Increasing Patients’ Health Literacy and Activation: The co-location model of coordinated care involves behavioral health specialists providing services at a primary care site or PCPs working in behavioral health settings. Co-location increases communication across practitioners and significantly increases the likelihood of referrals from primary care to behavioral health. Since two-thirds of PCPs report that they are not able to access behavioral health treatment for their patients [i], and 30 to 50% of referrals from primary care to behavioral health do not make the first appointment [ii], co-location can open access substantially.

Healthfirst is contracting with a pediatric primary care practice that includes behavioral health clinicians. The behavioral health clinicians can be accessed in several ways: calling to make an appointment; scheduling an appointment prior to exiting the site, as a recommended follow-up to a PCP visit; meeting immediately following a PCP visit; visiting simultaneously with a behavioral health clinician and a PCP within the exam room, in more urgent cases. The full integration of the behavioral health clinicians under one practice, which is an enhanced co-location, means full-service needs can be met and the practice has the ease of single claims submission.

Cenpatico has supported the development of integrated services in several of its core behavioral health agencies in Arizona. These integrated clinics are housed in behavioral health agencies, allowing persons with severe mental illness to access physical health care in the settings where they are already comfortable. Cenpatico’s support has included successful advocacy at the state level to change statutes/regulations that were barriers to embedding physical health services within behavioral health agencies, technical assistance to access physical health funding streams managed by other payers, and seed funding for exercise equipment, community gardens, and green space.

In Colorado, Beacon Health Options is a partial owner of two behavioral health organizations that have carve-out contracts but are operationalizing the state’s goal that 80% of Coloradans have access to co-located healthcare by 2019. This MBHO has developed a provider self-administered survey to measure movement along the integration continuum, building on the Vermont Integration Profile (VIP). The MBHO also provides targeted disease and care management using evidence-based supports for self-care and improved health outcomes, tailoring health coaching to each member based on their response to the Patient Activation Measure (PAM).

Delivering Integrated Team-Based Behavioral Health and Primary Care: One particularly effective model for integrated treatment is the Collaborative Care Model (CCM), developed by Unutzer and patterned after Wagner’s work on the Chronic Care Model. CCM operationalizes five principles of effective patient-centered integrated behavioral healthcare: 1) Team and collaborative care so that all members of the treatment team are working in concert on whole health; 2) Population-based care that identifies cohorts of patients with common clinical conditions and tracks outcomes for each group; 3)Measurement-based (treatment to target) so that treatment effectiveness is continually monitored against targets and adjustments are made based on results; 4) Evidence-based care that has demonstrated outcomes for specific populations; and 5) Accountable care in which results are shared with patients, practitioners, and purchasers so that future treatment protocols are informed by practice-based evidence. [iii]

Involving a collaborative team of a PCP, behavioral health care manager(s), and psychiatric consultant, CCM is more effective for depression and anxiety than care as usual.[iv]  Based on Unutzer’s model, the Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) model for depression treatment has had large scale implementations across health plans, community health clinics, and PCPs.

Cenpatico’s program for depression treatment is based on the IMPACT model and uses depression symptom scales, behavior activation, and relapse prevention to improve treatment outcomes. Training is provided to PCPs on stepped care and IMPACT’s tenet of “treatment to target”. Predictive modeling allows the MBHO to identify members newly diagnosed with a chronic medical condition, to conduct depression screenings and assign targeted members to health coaches embedded within the primary care practice. Coaches assist patients to develop behavior activation plans to increase treatment adherence and improve outcomes.  Preliminary data shows improvements in depression scale scores and lower emergency department and inpatient costs.

The CCM has shown both reduced healthcare costs and improved patient functioning.  In the largest trial, IMPACT, participants were twice as likely as patients in usual care to have a substantial improvement in their depression over a 12-month period[v] and to have less physical pain. [vi] Additional studies have shown the model to be effective with adolescents with depression [vii], cancer patients with depression, [viii] and patients with diabetes. [ix] Analysis of the cost and savings of collaborative care produces a return on investment of $6.50 per dollar spent. [x]

In Arkansas, Humana At Home (HAH) and Humana Behavioral Health (HBH) launched a collaborative pilot focusing on members experiencing the highest complexities in both behavioral and medical disorders. The pilot is demonstrating the efficacy of partnering medical and behavioral health clinicians to conjointly provide support to the member. Structured communication channels and processes have been built into the model to ensure consistent real time collaboration between the clinicians and the member. The HAH care managers report being much better equipped to identify and address behavioral health contributions to members’ overall health challenges by partnering with the HBH. As a result, they have reported that it is easier to engage the member with the most beneficial resource or intervention to address the behavioral need. This collaboration has demonstrated improved health outcomes for Humana members while reducing costs. By synchronizing or combining existing behavioral health resources within chronic care management even further, gains in extending life-long wellbeing and cost reduction could be achieved.

To encourage medical-behavioral integration, Anthem promoted the use of the Health and Behavior Assessment and Intervention procedure codes. These codes were added to behavioral health provider fee schedules and the claim systems set up such that they could be submitted with a medical diagnosis. PCPs can refer patients with physical illnesses/ailments that either were being provoked by a behavioral health condition or can assist in providing psycho-educational consultation/intervention to assist members to manage and adhere to their medical condition treatment plans. In Maine, where the provider community engaged quickly with these codes, a study was done looking at members who were eligible for Anthem benefits over a three-year period and compared the baseline to year one for members with diagnoses of sleep disorders, headaches, chronic pain, and morbid obesity. While behavioral health costs increased, medical and pharmacy costs decreased with a net overall healthcare cost reduction of 3.2%.

One of the many ways Humana has approached integration is with the Humana Chronic Care Program (HCCP). HAH developed HCCP to improve the health of the top 25% of its sickest, most costly members with chronic illness and functional challenges, while also reducing costs. Predictive Analytic Tools were used to stratify members into four Quadrants of member need and utilization; types and frequency of care management intervention were designed for each Quadrant. The program uses a holistic approach with a primary care manager working with an interdisciplinary team of social service professionals, nurses, pharmacists, dieticians, community health educators, and a consulting geriatrician. Individuals in HCCP have had success maintaining their chronic illnesses and mental health disorders at home; hospital admissions have decreased by 51%, and the patients’ two-year odds for survival have improved by 26%.

New Directions Behavioral Health is now piloting team-based, member-centric programs in primary care settings. The programs involve the selection of a unique type of behavioral health professional who can adapt his or her services to the pace and culture of a primary care environment. These practitioners become a member of the primary care team providing brief assessment, brief intervention, referral and case management, physician consultation, stepped care, and group work with members who have medical and behavioral comorbidities. Physicians involved in these pilot programs describe the impact as “transformational” for their practices.

In carve-in and carve-out environments, MBHOs are using their experience and expertise to make significant contributions to the growth of integrated healthcare. They are creating integrated delivery systems; managing integrated benefits for persons with serious mental illness and Medicare/Medicaid beneficiaries; and partnering with health plans on integrated management of medical and behavioral health services. The result empowers providers to more effectively engage members in their own treatment and deliver integrated models of care that promote overall improvements in health status and outcomes.

References

[i] Benefits of Integration of Behavioral Health, Patient-Centered Primary Care Collaborative at www.pcpcc.org

[ii] Fisher & Ransom, Arch Intern Med 1997:6.

[iii] Unutzer, J, Collaborative Care: An Evidence-based Approach to Integrating Physical and Mental Health in Medicaid Health Homes, Integrated Care Resource Center Webinar, January 10, 2013.

[iv] Unutzer, J. Integrated Care Resource Center Webinar.

[v] Unutzer, J et al., Collaborative Care Management of Late-life Depression in the Primary Care Setting, JAMA, December 2002; 299(22).

[vi] Lin EH, et al., Effects of Improving Depressing Care on Pain and Functional Outcomes Among Older Adults with Arthritis: A Randomized Controlled Trial, JAMA. November, 2003; 290(18).

[vii] Richardson, L et al., Collaborative Care to Adolescent Depression:  A Pilot Study, General Hospital Psychiatry, January 2009; 31(1)

[viii] Ell, K et al., Randomized Controlled Trial of Collaborative Care Management of Depression Among Low-Income Patients with Cancer, Journal of Clinical Oncology, September 2008; 26(27).

[ix] Katon WF et al., Long-Term Effects on Medical Costs of Improving Depression Outcomes in Patients with Depression and Diabetes, Diabetes Care. June 2008;31(6).

[x] Unutzer, J et al., The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes, Center for Medicare & Medicaid Services Information Resource Center, May 2013.

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