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Integration on a Continuum: Models for Integrating Behavioral Health and Primary Health Care

In the recent years of Medicaid Redesign in New York State, community-based mental health agencies who serve persons with serious and complex psychiatric conditions have addressed the evolving transformation of health care in a variety of ways. Much of the response has been reactive, with agencies reorganizing and adapting their services and supports to conform to the opportunities and contend with the challenges presented first by the roll-out of Health Homes, and then of DSRIP (the Delivery System Reform Incentive Payment program). While these initiatives have been fraught with the stresses of continually changing operational time frames and procedural requirements, they are now launched and are proceeding at various stages in their development.

The next phase of the NY State Medicaid Redesign includes the carving in of mental health services into the Medicaid managed care system. Once again, this portends major changes in agency services, operations and billing procedures, and again, is proceeding in fits and starts.

Many of these changes have been stimulated by the federal Affordable Care Act (ACA), with its goals to increase access to quality care, to improve population health, and to do so at a lower cost. A major thrust of the ACA has been to encourage and incentivize increasing integration of behavioral and physical healthcare, which historically have been provided in silos of care. Community mental health agencies have embraced these noble goals and are striving to serve an expanded pool of people needing services. Some of these agencies have organized into partnerships in an effort not simply to respond to the challenges, but to innovate within the new climate of change, to create new models of integration, to more effectively assist people to move forward in their recovery.

In 2012, a group of eight leading behavioral health and developmental disability nonprofit community-based agencies serving the Lower/Mid-Hudson River Region of New York State partnered to move proactively into this new and challenging environment. They incorporated to form Coordinated Behavioral Health Services (CBHS). (CBHS IDD agencies have also partnered with the New York Integrated Network (NYIN), a group of leading providers of services to persons with developmental and intellectual disabilities to pursue innovative approaches within the similarly challenging and evolving IDD world.) The history of the CBHS partnership has previously been described in the Spring 2014 edition of Behavioral Health News.

Since that time, the CBHS behavioral health agencies have formed an IPA (Independent Practice Association), and have added new partners, the group now comprising Access: Supports for Living, Human Development Services of Westchester (HDSW), Mental Health America of Dutchess County (MHAD); Mental Health Association of Rockland County (MHAR), Mental Health Association of Westchester County (MHAW), Rehabilitation Support Services (RSS), and Westchester Jewish Community Services (WJCS). These organizations provide a vast array of services to multiple populations and are licensed by OMH, OPWDD, OASAS, DOH and OCFS in seventeen counties in the Hudson River Region.

However, as CBHS agencies moved to increase the integration of behavioral and physical healthcare internally within their organizations, they acknowledged that to best serve their clients, to more fully address complex physical and mental health needs, they needed to access additional high-quality and comprehensive physical health resources. CBHS found those in a partner, Hudson River HealthCare (HRHCare), a network of federally qualified community health centers providing primary, preventive, oral and behavioral health care in the Hudson Valley region and Long Island. HRHCare equally wished to strengthen its access to behavioral health expertise for its patients who had serious psychiatric conditions, and in 2014, HRHCare and CBHS partnered to form an IPA specifically to address the integration of their respective services. This new corporation, CBHCare IPA, has consulted with numerous national experts on models of integration of behavioral and physical health services over the course of a year, as it worked to shape its integration strategies. We have learned that integration is not an occurrence, it is a process; that it can take up to two years for organizations to meld their cultures, operations and experience so that a successful strategy may emerge that meets the objectives of the Triple Aim. CBHCare partners have contributed countless hours of administrative and direct care practice to the development of a variety of integration models and configurations, some of them highly successful and exciting ventures, and others that have struggled to evolve. A clinical subcommittee works on establishing and evaluating pilot metrics, interagency protocols, integrated record keeping, broader interoperability, risk stratification and care coordination. Following are brief descriptions of some of these endeavors:

  • CBHCare partners, WJCS and HRHCare, have long had the common goal of improving the quality of life, including the health and mental health of residents of Southern Yonkers. Located on the same street, the two institutions had served the same community and often the same patients, separately in the past. That changed in 2012, when WJCS received funding from the NYS Office of Mental Health to embed a social worker in the HRHCare pediatric practice. Starting out as co-located services, the joint venture has evolved to full integration, with the WJCS social worker working side by side with the pediatricians in addressing the overall health of youth seen in the practice. The social work and medical professionals regularly “huddle,” discussing high risk patients, interventions, and the significant overlap of problems with health, mental health and trauma. They creatively work together to bring their collective strength and knowledge to the team and enrich the lives of children served at the HRHCare practice. Recognizing the significant impact of trauma on the lives of these young patients, HRHCare was fortunate in being selected, through a SAMHSA initiative, as one of 11 teams nationwide to participate in a Johns Hopkins University Learning Collaborative “to improve pediatric primary care’s capacity to provide trauma services to young children and their families.” The pediatric team, including the WJCS integrated social worker, the pediatrician, the practice manager and a family advocate/consumer from WJCS have together attended learning sessions at Hopkins and utilized the expertise of the Hopkins leadership in moving toward trauma-informed care. The expertise of WJCS’ Treatment Center for Trauma and Abuse will further the goals of this initiative with staff from WJCS providing training and guidance to the entire pediatric clinic on becoming “trauma informed” in their practice.
  • Two Licensed Clinical Social Workers (LCSWs) employed by Access: Supports for Living, have started in January 2015 to provide behavioral health consultation and services at HRHCare sites in Walden and in Monticello, Orange County. The social workers have extensive backgrounds in working with clinically complex individuals and families and have embraced the opportunity to expand their skills and knowledge during this new venture. The Access clinicians often start their day in a “morning huddle” with the primary and specialty care providers and nursing staff to discuss patients who are scheduled to be seen that day. For part of the day, the social workers are in previously scheduled appointments, but always expecting and welcoming an interruption for a warm handoff from a physician or nurse practitioner to start to engage the patient. Whenever possible, the social workers meet with the patient right away, but often after a brief introduction, schedule an appointment for the next day. Both clinicians are recognized as members of the treatment team, most often referred to by their first names in order to reduce the stigma that often follows behavioral health challenges. They follow-up with a variety of patients who struggle with headaches, sleep problems, etc., and when the medical causes have been ruled out, the social workers then step in and start to explore psychosocial stressors that might contribute to the discomfort of the patient and identify coping skills by utilizing Evidence Based Assessment Tools and Practices. If a patient is in need of longer-term behavioral health services, a referral to CBHS clinic services is initiated.
  • MHA of Dutchess County has partnered its care managers with medical professionals in a pilot project at an HRHCare center in Poughkeepsie to improve outcomes through strengthened Health Home teamwork.
  • HRHCare centers are hosting Meet & Greet open houses so that CBHS Health Home, residential, PROS and clubhouse staff can familiarize themselves with HRHCare primary care and specialty services in support of increased integration and to facilitate positive transitions of care.

 

One of the lessons learned in the course of the last three years, is that although the relevant state departments are conceptually on board regarding integration of physical and behavioral healthcare, it has been difficult for healthcare organizations to obtain the regulatory relief that would support that integration.

Throughout the CBHCare experience, CBHS behavioral health agencies continue to be impressed with the medical expertise and the deep caring of HRHCare staff for the people we serve in common. We will continue to strengthen our alliance and improve and expand the integration of our services as the CBHCare IPA moves forward into value-based contracting with managed care organizations. We anticipate that such contracting will support the opportunity to create additional integration projects focused on the DSRIP goals of reducing avoidable emergency room and hospital admissions and readmissions in the service of the Triple Aim.

Alan Trager, LCSW, is CEO of Westchester Jewish Community Services; Amy Anderson-Winchell, LCSW, is CEO of Access: Supports for Living; Amy Kohn, DSW, is CEO of the Mental Health Association of Westchester County; Andrea Kocsis, LCSW, is Executive Director, of Human Development Services of Westchester; Andrew O’Grady, LCSW-R, is Executive Director of Mental Health America of Dutchess County; Elizabeth Kadatz, is Director of Operations at Rehabilitation Support Services; and Stephanie Madison, LMSW, is CEO of the Mental Health Association of Rockland County.

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