Primary-Behavioral Health Integration: Successes, Barriers and Solutions

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Primary-Behavioral Health Integration Successes,
Barriers and Solutions

• Jerry Lowell LCSW
• Senior Vice President
• Behavioral Health and Community Services
• Aunt Marthas Youth Services

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Increasing Access to Vital Services
Providing BH in 10 of 17 clinics, Aunt Marthas
remains true to its founding vision to respond to
the needs of youth, families and communities by
providing access to integrated primary-behavioral
health services.
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Aunt Marthas Office Health Center Locations
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Depression diagnosis rates at Aunt Marthas
Health Centers (2009-2010)
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Access to Care

• Growth Trend 2005 2009
• 834 increase in users
• 509 users to 5.520 users
• 740 increase in encounters
• 3,107 encounters to 31,474 encounters
• 300 increase in Behavioral Health
• service users as of total users
• at Aunt Marthas 2 to 8

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Cost Effective, Integrated Services
Behavioral Health Costs as Percentage of Total FQHC Costs Behavioral Health Costs as Percentage of Total FQHC Costs Behavioral Health Costs as Percentage of Total FQHC Costs Behavioral Health Costs as Percentage of Total FQHC Costs
Year AMYSC ALL IL FQHCs National
2006 9 4 4
2007 10 4 4
2008 10 4 n/a

• We are one of the largest provider of behavioral
  health services among Illinois FQHCs.
• We are also the lead agency in the States first
  telepsychiatry network

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Our Behavioral Health Providers

• 11 Psychiatrists
• 2 Child Adolescent only
• 2 Adult only
• 6 Child Adolescent and Adult
• 5 Licensed Clinicians (LCSW, LCPC)

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Our Support Staff

• Operations Manager
• Oversight of psych operations
• Coordination with health clinic
• Supervise Care Managers
• Handle patient complaints
• Interface with community
• 10 Care Managers

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Aunt Marthas-CMHC Collaborations

• Co-location of CMHC therapist
• Provides warm hand-off access
• Encourages cross referral
• Patients integrated into Primary Care
• Staffing and billing done separately
• Establishes relationship for further
  collaborations

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Tele-psychiatry-CMHCs

• Grant from DMH supports connection to 6 downstate
  CMHCs
• Can now bill Medicaid at encounter rate
• Reimbursement rules require at least an MHP to be
  with patient at local site during session
• One-time initial equipment cost, but
  telecommunication line costs are high

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Tele-psychiatry NetworkEliminating Barriers to
Care
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Business Model Basics

• Costs have to be considered as part of whole
  system
• Service Specialty Reimbursement Rate
• Psychiatric, Medical, OB/GYN123.91
• Therapy (LCSW, LCPC)49.60
• Psychiatry has to be productive, no
  administrative time

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Medical and Business Operations which
includes 3 Regional Administrators responsible
for the fiscal and regional management of
clinics Clinic Coordinators report to the
Regional Administrator and are responsible for
administrative oversight all staff Subspecialty
Operations including OB, Behavioral Health and
Dental- comprised of 3 Operations Managers
responsible for the fiscal compliance and
management of the care management model for all
three service areas. Social Services all
supplemental services that assist
patients/clients. Operational Supports including
marketing, compliance assistance, data
management, medical records and training.
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Source National Association of Community Health
Center, June 2010
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Business Model Basics

• Operations based on staffing ratio of 2 Care
  Managers to 1 Psych provider
• Administrative overhead has to be lean
• Integration with primary and dental increases
  Medicaid revenue
• Psychiatrists are high cost driver, so operations
  and productivity have to lower the cost per visit

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Financial Integration Costs and Benefits

• Costs and benefits to the system as a whole are
  identified
• Productivity expectations are established
• Proportionate overhead costs are part of
  Behavioral Health budget

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Financial Integration Costs and Benefits

• Cross referrals synergize both clinical and
  economic outcomes
• Behavioral Health administration is part of
  overall operations management
• Outreach and marketing can call attention to the
  integrated services concept

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Limitations

• Ideal continuum for FQHC BH is less seriously
  mentally ill patients
• Who already access the FQHC for medical care
• Even though
• We already see well over 100 with a diagnosis of
  schizophrenia

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Financial Limitations

• 330 Funding provides limited funding for
  uninsured
• FQHCs cannot be the primary provider of BH
  services to the Seriously Mentally Ill

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Bi-Directional Integration

• Great potential, but
• Needs to be funded
• FQHCs need Change of Scope to provide primary
  care in CMHC
• Practice has to recognize that regular
  productivity is less

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Summary

• FQHCs can be a model for the integration of
  primary and behavioral healthcare
• Successful implementation requires effective
  systems and management
• BH should be integrated into all areas of clinic
  functioning
• FQHC-CMHC collaboration is promising but should
  not be viewed as an alternative to CMHCs for
  Seriously Mentally Ill