Behavioral Health Integration Treating the whole person MARKETINSIGHTS © The American Hospital Association, 2019 2 Behavioral Health Integration Physical health and mental health Hospital and health system executives know the behavioral health statistics, which include mental illness and substance use disorders. live in the same body. They see the tragedies in their own emergency departments (EDs) and can trace their roots, We have to stop treating in part, to the lack of effective, integrated care for these conditions. They understand how the dearth of coverage for and access to behavioral them as if they are health services leads to poor health outcomes and higher health care costs. two separate things. The question for many, though, is: What can we do about it? As behavioral health research is transforming the diagnosis and treatment of these disorders, one answer is behavioral health integration. For hospitals and health systems, this means integrating behavioral health services into every aspect of patient care, as well as coordinating and connecting with community resources. It means treating LEARN MORE | Visit AHA.org/center 3 the whole patient. It also means creating a continuum of 4 | Open behavioral health urgent care centers that are integrated DATA care that reflects integration at each point in a patient’s jour- into urgent care centers that treat physical illnesses and injuries. ney to better health. 5 | For people with serious mental illness and substance-use disorders, develop a behavioral health home option. This Market Insights report from the AHA Center for Health In- 1 in 5 novation offers options on how hospitals and health systems can improve the availability and coordination of behavioral To help extend behavioral health access and care into the community, hospitals and health systems can: Number of U.S. adults suffering health services in three areas of patient care. 1 | Collaborate with, joint venture with, or merge with a com- from any type of munity mental health center, certified community behavioral behavioral issues On the ED/inpatient side, hospitals and health systems can: health center, and/or a variety of other community-based in 2017. 1 | Make behavioral health assessments routine for all patients, providers and stakeholders. Source: National Institute either directly or through telemedicine services, and have apro- 2 | Partner with other providers and community services to of Mental Health cess in place for referral/treatment if needed. invest in data integration and develop innovative service 2 | Use their electronic health record (EHR) systems to prompt delivery models for patient-centered care. clinicians to assess all patients for behavioral health issues and 3 | Make virtual behavioral health triage services available to ensure that they are shared with and addressed by all providers. community groups, their members and federally qualified 3 | Open geriatric psychiatric (geropsych/complexity interven- health centers. tion) units that are equipped to treat elderly patients‘ chronic physical conditions in addition to their psychiatric needs, or The net results of successfully integrating behavioral health med-psych units that specialize in treating patients with dual services are better behavioral and physical health for patients physical and behavioral health diagnoses. and their communities and better fiscal health for all. • On the outpatient side, hospitals and health systems can: ABOUT THIS REPORT: The AHA Center for Health Innovation devel- 1 | Embed behavioral health clinicians in outpatient settings in a oped this Market Insights report for hospital and health system executives collaborative care model. who are working to integrate behavioral health into all care settings and collaborate with their communities to improve health care delivery for bet- 2 | Equip and educate affiliated primary care practices with ter health outcomes. This report is based on information and insights from a number of sources, including interviews with hospital and health system evidence-based behavioral health screening and assessment leaders and other health care experts, surveys of hospitals, and health care tools to use during each patient care visit. reports and research articles. A complete list of sources and other resourc- es appears on Page 15 of this report. The AHA Center for Health Innovation 3 | Document behavioral health screening, diagnosis and treat- thanks everyone for their contributions to this report. ment in EHRs to improve care coordination. LEARN MORE | Visit AHA.org/center 4 Creating One System of Care for Physical and Behavioral Health Patients’ physical and behavioral health are inex- Percentage of hospitals reporting routine DATA tricably entwined. Yet, historically, the health care integration of behavioral health services into system developed along two separate and distinct the following areas. Integration ranges from lines: one that treats physical illnesses and another that treats behavioral health disorders. Efforts to co-located physical and behavioral providers, end stigma, breakthroughs in brain science research with some screening and treatment planning, 51% and parity for coverage are all part of the shift to to fully integrated care where behavioral and 57.4% remove the social and systemic barriers for those living with behavioral health disorders. physical health providers function as a true team in a shared practice. Percentage of Source: AHA Annual Survey, 2017 U.S. adults with One patient. Two separate systems that attempt to behavioral illness collaborate with each other at best and that don’t Emergency in 2017 who talk to each other at worst. The result is a fragment- ed approach to caring for the whole patient who has services did not recieve different but related medical issues. behavioral health Hospitals and health systems are working hard to services. change that: to create one system of care with mul- Source: National Institute tiple entry points for patients with multiple medical of Mental Health issues and to integrate behavioral health services 38% into every patient‘s experience when and where patients need them to effectively treat the whole patient — both their physical and behavioral health care needs. Before a hospital or health system integrates be- Primary care havioral health services into its operations, it should know what integrated care means. Integrated services care is the systematic coordination of physical and behavioral health care in acute care, primary care, 17% 46% emergency care, post-acute care, health homes and community-based services, when needed. Integrat- ed care goes beyond collaboration or coordination between separate physical care and behavioral care providers. The aim of integrated care is one system of care for physical and behavioral health delivered by the care team with different clinical specialties Extended care Acute inpatient along the entire care continuum. services LEARN MORE | Visit AHA.org/center 5 Impact on Outcomes and Cost without a behavioral health disorder. Clinical integration leads to better outcomes and lower costs. Many com- munities mistake financial integration for clinical integration. Financial Also, people with behavioral health disorders are more likely to have other integration without clinical integration leads to reduced access, worse chronic medical conditions like asthma, diabetes, heart disease, high blood clinical outcomes, and generally greater overall total cost of care. Be- pressure and stroke. In addition, those with physical health conditions (e.g., havioral health carve-outs are also a challenge to integration. As health asthma or diabetes) also report higher rates of substance-use disorders and care is moving toward coordinated care, separation of funding places a “serious psychological distress. As a result, those with behavioral health ” significant burden on practices, patients and families as they try to work disorders — and co-occurring physical health conditions — are likely to use between two systems. more services like hospital and ED care, which increase costs. Behavioral health disorders have significant impact on individual and Increased access to behavioral health services is associated with improved community health, utilization of services and costs. Costs are 75% health outcomes, patient satisfaction and quality as well as lower overall higher for people diagnosed with both behavioral health and other com- health costs. Research demonstrates that models that incorporate behav- mon chronic conditions than for those without a co-occurring behavioral ioral health into other medical settings are associated with positive impacts health diagnosis. In Medicaid, the cost of care is two to three times on behavioral and physical health outcomes as well as reductions in the use higher for beneficiaries with co-occurring behavioral health and chronic of acute services. To learn more about how increasing access to behavioral conditions. Patients with behavioral health disorders also have signifi- health services can improve outcomes and lower costs, download the AHA cantly greater spending for general medical conditions than patients report “TrendWatch: Increasing Access to Behavioral Health Care. ” Integrating Behavioral Health into ED/Inpatient Care In the Emergency Department use telehealth to integrate behavioral health into their routine emergency As hospitals and health systems well know, the rate of ED visits is on the care services. rise. A 2018 study in JAMA Open Network found that nearly 30 percent of patients who visited a hospital ED had at least one behavioral health Some hospitals and health systems are experimenting with behavioral health 2-3x diagnosis. Also, the more severe the initial behavioral health diagnosis, apps and kiosks in their EDs to assist patients and help doctors assess and the more frequently the same patient visited the ED the next year. evaluate patients’ behavioral health needs. After ED staff are able to rule out a life-threatening event, the patient answers survey questions that provide data Consequently, integration of physical and behavioral health services in to the practitioner using the self-help kiosk rather than waiting for a doctor to In Medicaid, the ED can provide added value to the patients, providers and health do the same thing. The kiosk sends the patient-reported information to the ED the cost of care care systems. That means making behavioral health clinicians available doctor, who can discuss it with the patient during the ED visit. is two to three in the ED to assess, evaluate and initiate/refer to treatment patients regardless of the reason for which they came to the ED. Behavioral To learn more about the telehealth technologies and services available times higher health clinicians can either personally assess and evaluate the patient, to hospitals and health systems, download “Telehealth: A Path to Virtual for beneficiaries or consult with the ED physician who assessed the patient. Integrated Care, a recent Market Insights report from the AHA Center for ” with co-occur- Health Innovation. If your organization is starting a telebehavioral health ring behavioral Telebehavioral Health and Digital Tools in the ED program or strengthening an existing one, the AHA and the National Quali- Experts agree that, given the advancements in technology, every hospi- ty Forum have collaborated to produce “Redesigning Care: A How-to Guide health and for Hospitals and Health Systems Seeking to Implement, Strengthen and tal and health system has expanded opportunities to provide access to chronic behavioral health services in the ED. For example, in areas with shortag- Sustain Telebehavioral Health, a playbook which describes actionable strat- ” conditions. es of behavioral health professionals, hospitals and health systems can egies and interventions and links to a variety of other tools and resources. LEARN MORE | Visit AHA.org/center 6 In Units and on Patient Floors A patient admitted to the hospital for a physical illness or injury medications, a clinician can incorporate behavioral health questions, also should undergo a behavioral health assessment and evalua- examinations, tests and treatments into the patient’s inpatient care. At tion as a routine part of his or her treatment plan. Similar to doing Cedars-Sinai Medical Center, Los Angeles, 95% of patients admitted to a history and physical, checking a patient’s vital signs or dispensing the hospital receive screening and evaluation for depression. URBAN HOSPITAL CASE STUDY Behavioral Health Assessment and Triage Center TRUMAN MEDICAL CENTERS & OTHER AREA HOSPITALS | Kansas City, Mo. A group of stakeholders in Kansas City — including representatives important resource where local EDs can refer patients who do not from law enforcement, hospitals, courts, city government, behav- need inpatient treatment, but need linkage to outpatient services. ioral health clinics and homeless shelters — developed a unique This helps increase area ED capacity and the ability to treat more solution to help those individuals with behavioral health disorders patients, those who need inpatient behavioral health services and DATA who don’t require inpatient treatment but often end up in the ED those who need other inpatient medical care, as well as improves or, worse, in jail. The group received funding from St.Louis-based the efficiency of ED operations. ” • Ascension, the city of Kansas City, area hospitals and the Missouri Department of Mental Health, and opened the Kansas City Assessment and Triage Center (KC-ATC) program in October 2016. $1.7 Individuals with mental health and substance use billion disorders — who don’t meet inpatient criteria — are referred by approved EDs and Kansas City police of- Annual compli- ficers to the KC-ATC, where they can be triaged and assessed. Individuals remain at the center voluntari- ance costs in- ly, and no walk-ins are allowed. The KC-ATC is staffed curred by inpatient by a multidisciplinary team that includes registered psychiatric facili- nurses, caseworkers, mental health technicians, licensed social workers and advanced nurse practi- ties to meet three tioners who collaborate with a psychiatrist. Currently, federal regulatory 18 slots are available at the center — nine in the requirements Sobering Unit for those currently under the influence affecting patient of a substance and nine in the Stabilization Unit for those with a primary behavioral health issue. evaluations, safe care settings and “The KC-ATC has already had a significant impact for emergency depart- the citizens of Kansas City with acute mental health or substance abuse problems, says Kevin O’Rourke, ” ment screenings M.D., director of clinical operations, emergency Source: National department, Truman Medical Centers. “It is an Association of Behavioral Healthcare, 2019 LEARN MORE | Visit AHA.org/center 7 CRITICAL ACCESS HOSPITAL CASE STUDY Modules within EHR systems or handheld clinical deci- sion-support tools can prompt clinicians to routinely collect P R O T IP that information and document the behavioral health services Use EHR provided in patients’ health records. Given the intercon- system nection between physical and mental health, those initial to prompt assessments and evaluations often uncover a comorbid be- clinicians to havioral health disorder that can start being treated while the assess and patient is in the hospital. This is especially important because evaluate every depression among hospitalized patients is often unrecog- patient for be- nized, undiagnosed and, therefore, untreated. Hospitalization havioral health represents an unrecognized opportunity to optimize both issues and mental and physical health outcomes. be capable of recording and To treat such comorbid patients, some hospitals and sharing that health systems are opening geropsych units that specialize information in caring for elderly patients with behavioral health issues with all other that are exacerbating their physical health symptoms. providers Others are opening med-psych units for patients with Geriatric Acute Behavioral Health Program along the acute dual complex physical and behavioral health diag- COTTAGE HOSPITAL | New Woodsville, N.H. patient’s noses. Such units are staffed by multidisciplinary teams continuum of caregivers that include behavioral health clinicians and Serving a large region of New Hampshire and Vermont, Cottage Hospital is a critical of care. specialists who develop and execute one comprehensive access hospital with 25 acute care beds. In October 2016, the 10-bed Ray of Hope care plan that covers both a patient’s mental/substance- Geriatric Behavioral Health unit opened at Cottage Hospital. Specifically designed use disorder and physical care needs. for older patients with persistent or late-onset mental illnesses, the interdisciplinary team, comprising a psychiatrist, gerontologists, registered nurses, licensed practical Experts also recommend that behavioral health interven- nurses, licensed nursing assistants, social workers and recreational therapists, tions start before surgery or treatment for physical care provides a holistic patient-centered approach that attends to the mental, physical needs, not just after discharge. By treating the whole pa- and psychosocial aspects of the individual. tient, they will be better prepared for surgery or treatment and for their recovery after leaving the hospital. Patients come to Ray of Hope via Cottage Hospital’s ED as well as other hospitals’ EDs, long-term care facilities, primary care physician practices and other settings. Hospitals and health systems that successfully integrate “They often come to us because something has changed recently in their mood or behavioral health services into their inpatient operations behavior, says Chief Nursing Officer Holly McCormack. “People in this age group ” can enjoy a number of clinical, operational and financial may be seeing a lot of changes in their lives, such as family members and friends benefits, including: passing away, or maybe they’re moving into a new living situation. Often, they have •Improved clinical outcomes. comorbidities. Anxiety and depression come up a lot, along with suicidal ideation. ” •Fewer patients returning to the ED. Length of stay is usually between 15 and 20 days, as medication adjustments take •Fewer inpatient readmissions. time when patients are being treated for multiple conditions. Specialists in caring •Improved ED patient throughput. for older populations, Ray of Hope behavioral health program caregivers work with •Shorter lengths of stay. families to put plans in place that allow approximately 40 percent of the patients to •Lower costs in general and under value-based reimburse- be discharged back to their homes. • ment contracts. • LEARN MORE | Visit AHA.org/center 8 Integrating Behavioral Health into Outpatient Care DATA If patients with behavioral health issues reach the hospital ED or an and treatment, send the patient to the ED, admit the patient to his or her inpatient unit, it often means that their issues weren’t effectively affiliated hospital if the patient needs emergency or immediate acute managed in an outpatient or less restrictive setting of care. care services, or refer the patient to community-based services when available. For hospitals and health systems, integrating behavioral health services into the daily operations of their affiliated primary care When behavioral health competencies aren’t physically available on-site, 78% practices is a must, according to experts. That means supporting the affiliated PCPs and pediatricians with evidence-based, standard- PCPs, particularly those in geographic markets with few psychiatrists or other behavioral health specialists, may be able to access consultations Percentage of rural ized behavioral health screening and assessment tools to use with via telehealth technologies. Remote specialists can consult virtually with adults surveyed each patient visit. Doctors, nurses or other trained staff screen and them about a patient or connect with the patient virtually [see below for assess patients during their initial conversation and exam similar to most common models]. who would be com- taking a blood pressure reading. It also means teaching PCPs how fortable speaking to effectively use those tools and educating them on what to do Other hospitals and health systems are taking further steps by opening to their primary with the information from those screenings and assessments. In behavioral health urgent care centers. Some centers are stand-alone, care doctor about addition, hospitals and health systems need to establish a continu- while others are adjacent to or co-located with existing urgent care um of services to which patients can be referred. centers. behavioral health issues From there, the clinician can treat the patient during their visit, refer Whether PCPs with behavioral health specialists on staff, PCPs with the patient to a behavioral health specialist for further evaluation telepsychiatry capabilities or behavioral health urgent care centers, the Source: American Farm Bureau Federation, 2019 Leading Outpatient Behavioral Health Integration Models Some hospitals and health systems are developing formal behavioral health integration models for their PCPs. Below are three typical models from most integrated to least integrated. MODEL 1 MODEL 2 MODEL 3 Including a behavioral Co-locating a behav- Establishing an affiliation health specialist in the ioral health practice in with a behavioral health practice as a regular part the same medical office practice in a physically of the care team. building as the PCP . separate location. LEARN MORE | Visit AHA.org/center 9 clinical goal remains the same: Get patients the behavioral health and ACADEMIC MEDICAL CENTER CASE STUDY substance use disorder services they need before their conditions worsen. PCPs Leverage App for Behavioral Health Bi-directional integration: Behavioral health homes MONTEFIORE HEALTH SYSTEM | The Bronx, Westchester and for people with serious mental illness Hudson Valley, N.Y. People with serious mental illness (SMI) — defined as a mental In 2015, Montefiore Health System in New York City began implement- disorder resulting in serious functional impairment that substantially ing a program using the Collaborative Care Model (CoCM) to better interferes with one or more major life activities, such as schizophrenia serve its large population of low-income and minority patients with or bipolar disorders — are at high risk for multiple chronic disorders. significant medical and behavioral health comorbidity and socio-eco- For these patients, the integration model shifts. Instead of integrating nomic challenges. A grant from the Centers for Medicare & Medicaid behavioral health into primary care, primary care and specialty ser- Services’ Innovation Center helped Montefiore design, implement and vices are integrated into a behavioral health home model. Behavioral sustain the CoCM to increase the availability and quality of behavioral health homes are patient-centered medical homes designed for the services and test innovative reimbursement methods. specific needs of people with SMI. At the same time, Montefiore began looking for ways to leverage Behavioral health home models can improve outcomes for people digital tools, developing a behavioral health registry in the EHR and with SMI, as well as patient engagement in care. Research has shown piloting a smartphone application developed by Valera Health, to that people living with SMI have a lifespan that is 14-32 years shorter enhance care management capabilities and allow care managers than that of the general population. According to the National Institute to increase the number of patients with whom they interact. The of Mental Health, 85% of the premature deaths were due to largely program has helped the health system improve care for both pedi- DATA preventable conditions such as high blood pressure, high cholester- atric and adult patients with behavioral health conditions, including ol, diabetes and heart disease. One study reported that patients in depression, post-traumatic stress disorder, general anxiety disorder, behavioral health homes increased their use of outpatient physical panic disorder and alcohol use disorder. health services by 36%. More importantly, utilization of the model is leading to fewer ED visits and fewer admissions, and helping people Under Montefiore’s CoCM clinical initiative, PCPs who treat pa- to live healthier lives. To address the physical health care needs of the tients with behavioral health are supported by a behavioral health underserved, at-risk group of people with SMI, providers have several 57% care manager and psychiatric consultant. The behavioral health options on how to structure the behavioral health home, depending on manager provides brief behavioral interventions, supports treat- the resources available. ment initiatives delivered by the PCP and coordinates care with Percentage of the PCP and psychiatric consultant physicians and 1 | In-house model: The health system supplies and owns the com- using a shared registry to review and nurse practi- plete array of primary care and specialty behavioral health services. monitor the progress of patients. tioners surveyed A licensed clinical social worker or 2 | Co-located partnership model. The health system arranges for psychologist is also part of the team between 2015 and health care providers to supply primary care services on-site in behav- and provides diagnostic confirmation 2018 who said that ioral health settings. This approach may be suitable for midsize organi- and short-term psychotherapy when they didn’t feel ad- zations that have the infrastructure to develop partnerships but lack the appropriate. Since adoption, the app resources and economies of scale to develop an in-house model. has improved the effectiveness and equately prepared efficiency of the CoCM by allowing to screen patients 3 | Facilitated referral model. The health system conducts physical behavioral health care managers to for behavioral health screenings, links clients to primary care providers in the com- work with higher caseloads while munity and facilitates communication and coordination between the maintaining key elemnts of the health disorders or behavioral health provider and other health providers. This structure CoCM aimed at improving treatment substance use works for smaller providers and may also serve as a transitional model for those planning co-located partnership or in-house models in the outcomes. • Source: American Farm Bureau Federation future.• LEARN MORE | Visit AHA.org/center 10 Integrating Behavioral Health into Community Outreach Hospitals’ relationships with community-based organizations have made and conduct regular behavioral health screenings as part of existing them central to addressing community-wide behavioral health care community-based screening programs, such as those for cardiovascular needs. Similar to the prevention and early detection of physical disor- disease or diabetes. ders, prevention and early detection of behavioral health disorders lead to better health outcomes for patients, better health for communities Hospitals and health systems also can make virtual behavioral health and lower overall health care costs. triage services available to community groups that, in turn, can make them accessible to their members who are more comfortable discuss- It follows then, experts say, that hospitals and health systems that take ing their behavioral health concerns virtually than face-to-face with a a behavioral health integration approach to care delivery have seen clinician. improved outcomes and reduced costs, as evidenced by the continued success of Montefiore’s Pioneer ACO program. When the programs and screenings identify community members at risk for a behavioral health disorder, hospitals and health systems can One of the most effective ways for hospitals and health systems to connect those members with the appropriate level of behavioral health determine the needs of their communities is to partner with communi- services in the continuum of care before those issues become acute. ty groups to conduct formal and regular behavioral health community needs assessments (see graphic below). Ideally, hospitals and health systems would be able to integrate their population health data-collection mechanisms with those used by com- Based on the assessments, hospitals and health systems might partner munity groups and unaffiliated providers to identify at-risk patients and with one or more groups to offer behavioral health educational programs target them for early and appropriate behavioral health interventions. Community groups to partner with on behavioral health initiatives • Homeless shelters • Community advocacy groups • Other faith-based organizations • Community mental health centers • Churches • Federally qualified health centers • Certified community • Schools • Judicial system • Law enforcement agencies behavioral health clinics • Other health care providers • Employers • Social service agencies LEARN MORE | Visit AHA.org/center 11 HEALTH SYSTEM CASE STUDY For behavioral health services in the community to be successful, executive leaders need to start by setting the tone DATA within the health system. People with behavioral health conditions need just as much access to services as someone with cancer or heart disease. In nearly all cases, behavioral health services are break-even or are a service line that runs in the red. It’s imperative to collaborate on behavioral Substance Use Disorder and Community Collaborative Initiative 2,538 health services with other hospitals in the same market to be able to identify service PRESBYTERIAN HEALTHCARE SERVICES | Albuquerque, N.M. Number of delivery gaps and then augment existing Presbyterian Healthcare Services (PHS) started a statewide partnership in 2017 called the community services. Working alone will not result Substance Use Disorder and Community Collaborative Initiative to deliver compassionate, mental health in a better outcome and likely will drain high-quality, evidence-based care for patients with substance use disorder (SUD). Changing centers in substantial resources for other community the culture of care to treating patients with SUD as any other chronic condition, devoid of operation needs. The most beneficial and cost- judgment, is a key element of the approach. across the effective solution is to connect with these country in patients long before they end up in the ED An integrated, inpatient addictions medicine consult liaison team provides consultations for 2017 or in crisis. patients who are hospitalized for any reason. The team comprises a physician, nurse practi- tioner, physician assistant and a peer-support specialist who offer recovery support and work Source: Substance Abuse and Mental Health Partnerships with community mental with patients to identify resources throughout the state. PHS universally screens patients for Services Administration health centers (CMHCs) are integral to tobacco and alcohol use and soon will begin universal screening for problematic opioid use. providing behavioral health care services Patients with SUD are often higher utilizers of medical care and may have comorbidities, at the community level. Some hospitals such as cardiovascular disease, uncontrolled diabetes, depression or anxiety, so they require and health systems own and operate their a holistic approach to their care. own CMHCs or enter into joint ventures, while others partner with freestanding PHS has built partnerships with faith-based organizations, churches and other SUD providers P R O TIP centers. CMHCs are federally designated in New Mexico. For example, local pastors are trained to recognize signs of SUD and know behavioral health treatment facilities that where to refer parishioners for treatment. Partner with are certified to treat Medicare and Medic- major employ- aid patients. There are more than 2,500 in From 2017 to 2018, prescriptions for buprenorphine, a medication to help people reduce or ers in your operation around the country. quit their use of opioids, increased by 50%. In addition, PHS providers decreased prescrip- community tions for opioids by 16% while also dispensing more morphine-equivalent medications in a to launch an By taking an aggressive and proactive safer range. In 2018, PHS also tripled the amount of naloxone, an overdose reversal medica- ongoing be- approach to behavioral health integration tion, prescribed as a universal precaution in the event of opioid overdoses. havioral health in their communities, hospitals and health stigma-reduc- systems can see more patients using This year, PHS is expanding SUD training beyond primary care and hospitalists to specialty tion program their outpatient care services and fewer care, including obstetrics and pediatrics. PHS is also customizing the training to meet the for their patients using their EDs for behavioral needs of communities around the state and offering it to other hospitals in New Mexico. • employees disorders.• LEARN MORE | Visit AHA.org/center 12 Behavioral Health Integration Pathway Behavioral health integration involves treating the whole person in order to improve health outcomes and patient experience without significant- ly increasing health care costs — as AHA‘s 2019 Trend Watch indicates, research has shown integration effectively implemented can reduce the total cost of care. Each organization can use the integration pathway below to evaluate their organization in light of their goals for a more holistic approach to care. Shifting focus to overall health and bringing together behavioral and physical health services into a fully integrated health care system requires cultural change, executive leadership and financial investments over a long period of time. I N T E G R AT I O N L E V E L COORDINATED CARE COLLABORATION INTEGRATED HEALTH CARE CAPABILITY KEY ELEMENT: COMMUNICATION KEY ELEMENT: PHYSICAL or VIRTUAL PROXIMITY KEY ELEMENT: PRACTICE CHANGE Network: Behavioral health and primary Network: Behavioral health and primary Network: High levels of collaboration and inte- care providers maintain separate facilities care providers co-located in the same facility or gration between behavioral and primary/specialty and separate systems. Behavioral health is behavioral health services are provided through care providers. Shared concept of team care and Care continuum most often viewed as specialty care. teleconsultation. Providers may share some one integrated medical record. and provider systems. Communicate regularly about shared network Affiliation relationship: Limited criteria patients. Affiliation relationship: Shared goals and for affiliation. accountability contingent on meeting quality and management cost-management objectives. Affiliation relationship: Contracts require commitment to shared quality/utilization metrics. Clinical protocols: Screening, as- Clinical protocols: Agree on specific Clinical protocols: Population-based physical sessment and evidence-based practices screening, some EBPs and collaborative treat- and behavioral health screening is standard prac- (EBPs) based on separate practice models. ment for specific patients. tice. One treatment plan for all patients. EBPs Referrals and shared protocols based on team selected. established relationships between physical Care management: Providers may feel and behavioral health providers. as though they are part of a larger team, but Care management: Behavioral health working the team and how it operates are not clearly as part of primary care and specialties. Providers Care management: Providers view defined, leaving most decisions about patient understand the different roles team members each other as resources and communicate care to be done independently by individual need to play and have changed their practice and Case periodically about shared patients. providers. structure of care to better achieve patient goals. management Population health-management Population health-management Population health-management tools: tools: Use of disease registries and tools: Population health-management High-risk, high-need complex patients are reliably reporting. Some ability to track performance system to identify high-risk patients. Complex identified and managed. Principle of treating the against quality/utilization benchmarks. patients with multiple health care issues drive whole person is applied to all patients, not just the need for consultation. targeted groups. Near real-time visibility into Quality improvement: Quality improve- quality and cost performance. ment and disease-management programs Quality improvement: Shared quality exist, but are not coordinated across differ- measures and a shared history of improved Quality improvement: Key performance ent parts of the health system. outcomes. indicators in an integrated care setting are popula- tion-based health status outcomes Adapted from: Heath, B. et al. “A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions, March 2013. ” ( Continued on page 13 ) LEARN MORE | Visit AHA.org/center 13 Behavioral Health Integration Pathway (continued) I N T E G R AT I O N L E V E L COORDINATED CARE COLLABORATION INTEGRATED HEALTH CARE CAPABILITY KEY ELEMENT: COMMUNICATION KEY ELEMENT: PHYSICAL or VIRTUAL PROXIMITY KEY ELEMENT: PRACTICE CHANGE Patient physical and behavioral health needs Patient health needs may be treated All patient health needs are treated by a team Patient are treated separately with some warm separately, but collaboration may include con- that functions effectively together. handoffs. When patients are referred, barri- sistent warm handoffs with better follow-up, Experience ers (e.g., stigma, scheduling) may prevent either in person or virtually. them from accessing care. Limited information sharing with Standardize communication with Facilitated networks connect providers other providers and existing commu- providers and community partners and community partners in a system nity support services: Lack of standard- across continuum of care: Set proto- of care: Use of role-based care management ization, data quality and patient identifiers in cols for expedited referrals, collaborate on software providing care coordination, interopera- Data Exchange disparate systems. treatment and discharge planning. Use of bility, analytics, outcomes and risk stratification. electronic health information exchange for co- Addresses care transitions and long-term care ordinated information sharing among diverse needs. Highlights potential gaps in care, critical providers and treatment settings. issues and social determinants of health (SDOH). Identify and coordinate with exist- Know and engage community part- Community partners are part of the sys- ing community support services: ners across continuum of care: Ad- tem of care: Leverage community partner- Community Start a community cross-sector collabora- dress social needs in clinical encounter and ships to address SDOH and improve outcomes. Partnerships tion to address social SDOH. select an SDOH strategy to improve health by balancing and integrating health care, public health and social services. Operating units: Separate funding for Operating units: Separate or blended Operating units: Resources shared and primary care and behavioral health; may funding for primary care and behavioral allocated across whole practice. share resources for single projects. health; may share expenses, staffing costs, Operating and or infrastructure. Financial model: Global or blended funding Funding Model Financial model: Fee-for-service billing structures support integrated health care; fiscal- structures that stumble over same-day Financial model: Ability to negotiate ly justified by improved patient outcomes that billing restrictions and rarely reimburse for and manage performance for contracts with reduce overall health care cost. consultations between providers. downside risk; some risk mitigation in place. Governance: Organization leaders regular- Governance: Organization leaders identify Governance: Key performance indicators for ly share information with each other and areas of opportunity for their teams to inte- organization leaders are tied to population level their teams. grate care. metrics for both physical health and behavioral health outcomes. Governance, Culture: Some leadership in more system- Culture: Organization leaders supportive, Culture and atic information sharing. but may view behavioral health as a project Culture: Organization leaders strongly support Provider or program. integration as practice model with expected Engagement Provider engagement: Ad hoc provider change in service delivery, and resources provid- buy-in to collaborate and value placed on Provider engagement: Provider buy-in ed for development. having needed information. to make referrals work and appreciation of on-site availability. Provider engagement: Providers active in integration strategic planning. Adapted from: Heath, B. et al. “A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C. ” SAMHSA-HRSA Center for Integrated Health Solutions, March 2013. LEARN MORE | Visit AHA.org/center 14 • Figure out what already exists in the community, where the gaps are. Scaling and Optimizing Integrated Care Models Decide how you can work collaboratively for a better outcome. The patient care benefits of integrating physical and behavioral health • Use evidence-based, standardized behavioral health screening tools in all services suggest that such a strategy should be a clinical and organiza- settings and document in the EHR. tional priority for any hospital or health system making the transition from • Use technology to distribute your limited behavioral health resources fee-for-service to value-based care and population health management. more efficiently and equitably through telehealth and virtual consults. Key to developing integrated care models is the tone set by executive • Use electronic health information exchange and care management soft- leadership that incorporating behavioral health services into acute care, ware to improve collaboration, handoffs and transitions in care. primary care, emergency care, post-acute care and community-based • Familiarize providers with the growing number of consumer-facing be- services is part of an organization‘s mission and values. havioral health applications that patients are using, and help patients use digital health tools, when appropriate, to manage their conditions. Key strategies outlined in this report are: • Measure the effects of behavioral health integration on key clinical, oper- • Start somewhere; start small. Don’t try to integrate behavioral health ational and financial performance indicators to show continuous improve- into the entire continuum of care all at once. ment. Stress the goal of true transformation. • Know and understand your population/community and their challenges and needs. Addressing the behavioral health problems will vary from Hospitals and health systems that follow these strategies as well as other prac- community to community. It must start with a good community health tices from peers on the leading edge of behavioral health integration can move needs assessment. the needle on caring for the whole patient — both mind and body. • Expert Panel The AHA Center for Health Innovation thanks the following people, organizations and sources for the time and insights that made this Market Insights report possible: Benjamin Paul Goering, Donald Parker Gail Ryder Bill Southwick Matthew Stanley, K. Chu, M.D. M.D. President and CEO Vice president CEO D.O. Managing director Vice president of Carrier Clinic Behavioral Health Banner Behavioral Clinical vice president of Manatt Health, clinical care Hackensack Services Health Hospital Behavioral health New York City Mental health Meridian Health BayCare Mesa, Ariz. Avera Allina Health Belle Mead, N.J. Tampa, Fla. Sioux Falls, S.D. Minneapolis Molly Coye, Cynthia A. Meyer, Paul Rains, R.N. Ann Schumacher, Harsh Trivedi, Arpan Waghray, M.D. MSSW President R.N. M.D., MBA M.D. Executive-in- Chief operating officer Dignity Health President President and CEO Chief medical officer residence HealthONE Behavioral St. Joseph’s CHI Health Sheppard Pratt Well Being Trust AVIA Health Serv., Behavioral Behavioral Health Mercy Council Bluffs Health System System medical direc- Chicago Health & Wellness Center (Iowa) Baltimore tor, telepsychiatry Center at The Medical Stockton, Calif. Providence St. Joseph Center of Aurora, HCA Health, Seattle Continental Division Denver MARKET INSIGHTS © The American Hospital Association, 2019 For more information, contact Lindsey Dunn Burgstahler at 312-893-6836 | www.AHA.org/center 15 Reports, Surveys, Articles and Research • “28 Health Systems Commit to Transforming Behavioral Health in Hundreds of Communities Nationwide. AVIA, April 25, 2019. https://www.aviahealthinnovation.com/press-re- ” leases/28-health-systems-commit-to-transforming-behavioral-health-in-hundreds-of-communities-nationwide/ • “2019 Environmental Scan: Innovation and Coordination. American Hospital Association. https://www.aha.org/center/emerging-issues/market-insights/year-in-review/2019-environ- ” mental-scan-innovation-and-coordination • “2019 State of Mental Health in America” report. Mental Health America. http://www.mentalhealthamerica.net/download-2019-state-mental-health-america-report • “Are Healthcare Professionals Ready to Address Patients’ Substance Use and Mental Health Disorders?” Kognito. https://go.kognito.com/Are_Healthcare_Professionals_Ready_ Substance_Use-Mental_Health_Whitepaper.html?utm_source=&utm_medium=article&utm_content=whitepaper • “Assessment of the Data Sharing and Privacy Practices of Smartphone Apps for Depression and Smoking Cessation. JAMA Network Open, April 19, 2019. https://jamanetwork. ” com/journals/jamanetworkopen/fullarticle/2730782?guestAccessKey=f6674879-4bc8-4b8a-8750-d5c6b7f7a24a&utm_source=silverchair&utm_campaign=jama_network&utm_con- tent=weekly_highlights&cmp=1&utm_medium=email • “Evolving Models of Behavioral Health Integration: Evidence Update 2010-2015. Milbank Memorial Fund, May 12, 2016. https://www.milbank.org/publications/evolving-mod- ” els-of-behavioral-health-integration-evidence-update-2010-2015/ • “Factors Associated With Emergency Department Use by Patients With and Without Mental Health Diagnoses. JAMA Network Open, Oct. 19, 2018 https://jamanetwork.com/ ” journals/jamanetworkopen/fullarticle/2707424 • “Increasing Access to Behavioral Health Care Advances Value for Patients, Providers and Communities. AHA TrendWatch. ” • Mental Health Information. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154785 • “National Mental Health Services Survey (N-MHSS): 2017 Data On Mental Health Treatment Facilities. Substance Abuse and Mental Health Services Administration. https://www. , “ samhsa.gov/data/report/national-mental-health-services-survey-n-mhss-2017-data-mental-health-treatment-facilities • Opening session. National Association for Behavioral Healthcare Annual Meeting, March 19, 2019. Washington, D.C. https://www.nabh.org/2019-annual-meeting/speakers/ • “The Health of Millennials. Blue Cross Blue Shield Association, April 24, 2019. https://www.bcbs.com/sites/default/files/file-attachments/health-of-america-report/HOA-Millenni- ” al_Health_0.pdf • “The High Cost of Compliance: Assessing the Regulatory Burden on Inpatient Psychiatric Facilities. National Association for Behavioral Healthcare, March 19, 2019. https://www. ” nabh.org/wp-content/uploads/2019/03/The-High-Cost-of-Compliance.pdf • “Results from the 2019 National Employer Survey on Mental Health: Insights & Implications for Purchasers. National Alliance of Healthcare Purchaser Coalitions, April 2019. ” https://connect.nationalalliancehealth.org/viewdocument/insights-implications-for-purchas • “Trends in Treatment and Spending for Patients Receiving Outpatient Treatment of Depression in the United States, 1998-2015. JAMA Psychiatry, April 24, 2019 https://jamanet- ” work.com/journals/jamapsychiatry/fullarticle/2731311?guestAccessKey=fbfc67aa-e1bc-41df-8f36-271e90b7cd11&utm_source=For_The_Media&utm_medium=referral&utm_cam- paign=ftm_links&utm_content=tfl&utm_term=042419 • “Using science to sell apps: Evaluation of mental health app store quality claims. Digital Medicine, March 22, 2019. https://www.nature.com/articles/s41746-019-0093-1.pdf ” LEARN MORE | Visit AHA.org/center