Old Ways Need to Change When Integrating Care in Huge System
This month, we have the privilege of gaining insight from Joe Parks, M.D., a leader in integrated care who has led a statewide transformation of the health care delivery system in Missouri over the last 10 years. This column is the first of several contributions from Dr. Parks, and we are fortunate to learn from his experience as we work together to advance integrated care efforts around the country. —Jürgen Unützer, M.D., M.P.H.
Providing integrated care, whether in behavioral health or general medical settings, requires significant organizational effort to add and retrain staff and redesign that organization’s care delivery processes. Too often, organizations face the additional challenge of having to execute this work within a broader health care delivery, financing, and regulatory environment that is designed to support siloed care. For the past 10 years, Missouri has made substantial changes to redesign the broader health care delivery system to support integrated care by pursuing the following strategies.
Overall Care Should Be Managed by the Provider Patients See Most Often: Patients are most likely to change their health-related behaviors in response to a frequently recurring face-to-face relationship. The provider who sees the patient most often has the greatest opportunity to manage the care. Accordingly, Missouri has implemented statewide Primary Care Health Homes (PCHHs), which integrate behavioral health care out of primary care practices, and statewide Community Mental Health Center (CMHC) Health Homes, which integrate general medical care out of a CMHC.
Both types of health homes use primary care nurse managers, monitor and improve medication adherence across the same classes of medication (four psychiatric and four general medication classes) and are responsible for follow-up and medication reconciliation within 72 hours of discharge from hospitalization.
PCHHs have behavioral health consultants on site; have implemented Screening, Brief Intervention, and Referral to Treatment (SBIRT); and are responsible for integrating and coordinating behavioral care by other providers. One-third of their performance indicators are behavioral health in nature. CMHC Health Homes have primary care consultants working with primary care nurse managers to provide technical assistance, and mental health staff receive training on care management care coordination of chronic conditions and are responsible for managing general medical care outside the CMHC. All patients in CMHC Health Homes get metabolic screening at least annually and are supported in their medication adherence. Half of the performance indicators of the CMHC Health Homes track chronic medical issues.
Sharing of Patients’ Health Information Is Essential for Successful Care Management: Since 2004, all Missouri Medicaid providers have access to an electronic health record (EHR) that provides a three-year history of diagnoses, procedures, medications dispensed, dates of care, and providers for each Missouri Medicaid recipient. With the exception of substance abuse treatment provided by certified specialty substance abuse treatment organizations, behavioral health information is available at the same level of access as all other medical information. PCHHs and CMHC Health Homes both receive daily notification of patients with new episodes of hospital admission or ER visits for both behavioral and medical conditions.
Co-location Isn’t Everything, but It’s not Nothing Either: Since 2008, Missouri has provided CMHC/Federally Qualified Health Center (FQHC) immigration funding for CMHCs/FQHC pairs that contract to provide services on site within each other’s facilities and record on each other’s EHRs. During that time, the number of providers that are both CMHCs and FQHCs has increased from one to eight, which is approximately 30 percent of the CMHCs and FQHCs. We found co-location is more likely to be effective in integrating care if the primary care providers’ and behavioral health providers’ offices/exam rooms are widely interspersed.
Regulatory Support Is Important: Payers and regulators that wish to support integrated care need to be willing to remove obstacles identified by providers. Missouri allows payment of both behavioral health and primary care providers for the same diagnosis on the same day. Missouri allows mental health providers to bill for substance abuse treatment services if substance abuse treatment is necessary for successful outcome of treating mental illness and allows substance abuse providers to bill for mental health services if mental health treatment is necessary for successful substance abuse treatment outcome.
Behavioral health providers are allowed to bill for primary care and other medical services, and primary care providers are allowed to bill for mental health treatment services. With the exception of freestanding, specially certified substance abuse providers, behavioral health and primary care providers can exchange patients’ health information for care coordination and management with outpatient consent.
Transparent and Broad Sharing of Performance and Outcome Data Improves Both Performance and Relationships: It’s important for both primary care and behavioral health providers to have their performance measured and be accountable for both behavioral health and general medical process and outcome indicators. In Missouri, provider organizations can see how they rank compared with their peers across over 30 different measures, and organizations are all individually identified and not blinded. Nonpsychiatrist prescribers of psychiatric medications receive the same feedback and recommendations for improvement on their prescribing of psychiatric medications as psychiatrists. Prior to this approach, there were frequent conflicts about who had the sicker patients and who gave better care. This transparent, data-driven approach has changed these arguments into data analytic discussions in which disagreements are treated as testable hypotheses. This has improved everyone’s mutual understanding of what is really occurring and improved our personal and professional relationships.
The “secret sauce” is using data to describe which patients and which providers need to be targeted for a personal interaction to get them to address a specific care gap. Both primary care and CMHCs Health Homes have seen improvements in medication adherence, quality-of-care indicators, and general health indicators. Importantly, the health care system has seen reductions in emergency department visits, hospitalizations, and total cost of care to the state. ■
