This report describes the RAND Corporation's examination of approaches to integrated care implemented by New York state community mental health centers for adults with serious mental illness. The purpose of the project was to generate information that will help state policymakers streamline the adoption of promising approaches to improving the overall wellness and physical health of people with serious mental illness by making primary medical services available in or coordinated by staff in the mental health settings where this population already receives care. To do this, we characterized, compared, and contrasted three integrated care initiatives operating in the state. From this information, we generated recommendations to state policymakers, clinical providers, and technical assistance providers, as well as suggestions for future evaluation to further strengthen initiatives ongoing in New York state.
Background
Adults with serious mental illness have a wide range of medical, behavioral, social, and other service needs (see Table 1). Consequently, comprehensive care for this population is best achieved by a system of care in which providers of multiple types work together to ensure that all of these needs are met. In this report, we focus on a modest, but critical, piece of this systems and services puzzle: the integration of primary medical and mental health services.
Table 1. Needed Services for Adults with SMI
| Behavioral Health | General Medical | Psychosocial |
|---|---|---|
|
|
|
We focus on the integration of primary medical and mental health services for adults with SMI because the excess morbidity and mortality in persons with SMI is a public health crisis. Compared with people without mental illness, individuals with SMI (e.g., schizophrenia, other psychoses, bipolar disorder, and severe depression) have higher rates of chronic medical conditions, including hypertension, diabetes, obesity, cardiovascular disease, and HIV/AIDS; higher frequency of multiple general medical conditions; and more than twice the rate of premature death resulting from these conditions (Kelly, Boggs, and Conley, 2007; Mauer, 2006; Parks et al., 2006; Sokal et al., 2004; Saha, Chant, and McGrath, 2007; Laursen et al., 2013).
Numerous factors contribute to the excess burden of general medical conditions among persons with SMI, including low levels of self-care, medication side effects, substance abuse comorbidity, unhealthy lifestyles, and socioeconomic disadvantage (Burnam and Watkins, 2006; CDC, 2012; Druss, 2007). Within the health care system, attention is focused on barriers to care that result from the organizational and financial separation of behavioral and general health care sectors. These barriers, it is widely believed, contribute to disparities in access to and the quality of general medical care for people with SMI (Alakeson, Frank, and Katz, 2010; Bao, Casalino, and Pincus, 2013; Druss, 2007; Horvitz-Lennon, Kilbourne, and Pincus, 2006). Consequently, integration of care, in particular the integration of primary care into mental health settings, has become a focus of several state and federal policy initiatives.
Some different perspectives on and approaches to integrated care are reflected in three recent initiatives promoting the integration of primary care and mental health services for adults with SMI being implemented in New York state. These include:
- The Substance Abuse and Mental Health Services Administration's (SAMHSA's) Primary and Behavioral Health Care Integration (PBHCI) Grants program
- New York state Office of Mental Health (OMH) Physical Health Incentives for Health Monitoring and Health Physicals clinics
- New York state Medicaid Health Homes.
Additional detail about each of these initiatives is provided below.
PBHCI
SAMHSA's PBHCI service grant program is intended to improve the health status of adults with SMI and/or co-occurring substance use disorders by making available an array of coordinated primary care services in community mental health centers and other community- based behavioral health settings. PBHCI grantees receive up to $500,000 per year to enhance screening and coordinate access to primary care services, including four required program features:
- Screening/referral for needed physical health prevention and treatment
- Developing a registry/tracking system for physical health needs/outcomes
- Care management
- Prevention and wellness support services.
The PBHCI grants program provides a solution to the one-time costs associated with establishing a new program of integrated care through finances to support infrastructure development (e.g., renovations to space), and other administrative tasks (e.g., data and reporting, evaluation). It also provides short-term (grant period) financing for other nonbillable services such as peers and wellness services that may be of particular value to consumers.
Since the start of the PBHCI initiative in September 2009, SAMHSA has awarded eight PBHCI grants to clinics in New York state. At the time of this report, more than 100 PBHCI grantees have been awarded, with another cohort (of unknown size) scheduled for funding in fiscal year 2015.
Medicaid Incentive
The New York state OMH Medicaid Incentive is designed to encourage the provision of primary care services in mental health clinics using a market incentive mechanism. Through this mechanism, clinics add primary care services to their operating certificate, thereby expanding their billable scope of practice. New Medicaid billing codes were introduced for this purpose, and to qualify to use these codes, clinics had to first apply to OMH for permission and demonstrate that they had the personnel and facility resources to provide the services. Clinics could be approved at two levels of care intensity: A low-intensity level defined as health monitoring; and a high-intensity level that includes both health monitoring and health physicals. At both levels, the Medicaid Incentive program removes some barriers to providing physical health services in settings where adults with severe mental illness interact with the health care system most frequently. Under this program, physical health services are reimbursed on a fee-for-service basis, do not require referral, and can be billed on the same day as a mental health service. How providers and consumers perceive this shift in practice is one of the questions that we address in this study.
Medicaid Health Home
New York state Medicaid Health Homes are integrated networks of diverse health care providers designed to provide seamless multidisciplinary care to patients with complex medical needs. Health homes are managed by lead organizations, generally large health care provider agencies. Care for individual patients is managed by community-based organizations that have subcontracted with the lead organization to provide care coordination services. The care coordinators work with the network of health care providers and community providers of services such as supportive housing, legal assistance, and food assistance to provide comprehensive, integrated care to health home enrollees. New York's State Plan Amendment (SPA) prioritized the highest-risk Medicaid beneficiaries for enrollment (446,000 individuals), focusing on individuals with SMI and chronic medical conditions. Health Homes are designed to facilitate consumer access to care through coordination of services at the system level, within a network of existing providers. This is in contrast with the programs described above that aim to integrate care at the setting level, within behavioral health clinics.
About This Study
The aim of this study is to describe the operation of each of three ongoing approaches to integrated care for adults with serious mental illness implemented by community mental health centers operating in New York state. In particular, we emphasize the mental health clinic perspective on integrated services either offered or coordinated by the mental health agency, because the mental health clinic is often the gateway through which adults with SMI access the health care system (Bao, Casalino, and Pincus, 2013).
Readers should note that this is a descriptive, qualitative study in which we aim to learn from the experiences of clinics that were strategically selected due to their efforts to provide primary care services to adults with SMI. The study is not an evaluation of mental health–based primary care overall or of any of the three models that we examined, and we cannot address evaluative questions about impacts of initiatives on outcomes or total health care costs. Instead, this study is designed to highlight institutional, regulatory, and design features that help or hinder current policy efforts in New York state, on the presumption that the goals and strategies of these policies will remain a priority for policymakers.
Readers should also note that while the perspectives of substance use providers are not systematically included in this study (substance use services are overseen by a separate, third regulatory agency in New York state and are therefore beyond the scope of this project), we strongly encourage decisionmakers to consider how those services can also be integrated for adults with serious mental illness, given their high rates of comorbidity and considerable impact on the outcomes of any mental health or medical care that consumers receive.
Three specific questions guide the research in this study. These are:
- What are the shared and distinctive features of approaches to integrated care for adults with serious mental illness implemented by community mental health centers operating in New York state?
- What policies or strategies at the initiative/program level, clinic/organization level, and provider/clinical level appear to facilitate or impede implementation, operation, and sustainability of each program type and overall?
- What innovations in mental health clinics' approaches to integrated care implementation, operation, and sustainability are developing, or are already operating in New York state?
Methods
Data for this project come from two sources: visits to sites investing in innovations in the delivery of mental health–based integrated care, and surveys of mental health clinics and affiliated providers.
Site Visits
RAND staff visited a total of nine mental health clinics throughout New York state. Sites were selected with three goals in mind: (1) geographic diversity, representing New York City as well as rural and urban upstate areas; (2) representation of all three of the integrated care initiatives available to clinics currently ongoing throughout the state; and (3) active and innovative efforts to improve the provision of primary care services to their adult clients with SMI. We strategically visited innovative sites in order to identify solutions and other promising practices from clinics, administrators, and clinicians who are actively working on the challenge of mental health–based integrated care. As a result of this selection strategy the clinics in this study are not representative of mental health clinics in the state and may be biased toward clinics that have more effective service delivery systems overall. Site visits were conducted between October 2013 and March 2014.
The overarching goal for the site visits was to gain a broad understanding of how primary care services fit into the mental health service delivery system. During visits, we toured facilities and conducted interviews with as many different types of clinic staff as time and scheduling allowed. We also met with groups of consumers at most sites. Topics covered during site visits included (but were not limited to) clinic structures, range of services provided, composition of the care team, target population and consumers served, clinical work flow, Health Information Technology (HIT), use of data for practice management and continuous quality improvement, clinic culture of integration, and sustainability, as well as policy impacts, barriers to integration, and promising integrated care practices being developed by the clinics.
Surveys
We also fielded two separate yet complementary surveys to (1) mental health clinic administrators, and (2) providers affiliated with mental health clinics providing or coordinating integrated care. The sampling frame included all OMH licensed Article 31 behavioral health clinics in New York state. All the PBHCI grantee clinics were included in the sample. A stratified, random sample of remaining clinics was selected from a list of all licensed Article 31 clinics in the state provided by OMH. The sample was selected to have equal numbers of clinics with and without OMH Medicaid Incentive licenses and to be equally distributed across regions of the state. Survey topics were the same as those covered during site visits.
The final clinic administrator survey sample included data from a total of n=22 mental health clinics, located in four out of five regions of the state, and all three integrated care initiatives examined in this report. Provider survey data came from n=34 unique providers (from across the participating clinics) and included primary care, mental health, and case manager/care coordinator positions. The survey response rate to the provider survey was acceptable for a web-based survey (69 percent). Although survey respondents broadly represented the array of clinics and providers meant to be included in the study, the overall response rate to the clinic survey was low (20 percent).
Results
Research Question 1: Shared and Distinctive Features
Shared
All participating mental health clinics were Health Home affiliated and typically affiliated with more than one Health Home. Clinics of all types offered on-site screening and monitoring of physical health conditions, and at almost all clinics, mental heath care records were maintained in an electronic format; few of these records, however, were integrated with records from primary care or other physical health care providers. Case manager/care coordinator notes were almost always maintained in a separate electronic system, as well. Providers of all disciplines described closer collaborative relationships at clinics offering a broader scope of physical health services on site (even when the scope of these services was limited, as in Medicaid Incentive clinics), suggesting that providers who work together in the same space may have more opportunities to build trust and respect related to the provision of integrated care. Overall, providers from all clinic types reported that they perceived that their integration efforts were improving consumer access to physical health care services and outcomes.
Participating clinics were quite diverse, varying in location (urban/suburban/rural), size, and other features, with notable differences between clinics participating in each integrated care initiative. All of the PBHCI clinics were located in the metropolitan New York City area (including all the PBHCI clinics in NYS that did not participate in this study). The PBHCI clinics were larger, serving more adults with SMI than other clinic types, and more likely to be situated within agencies with a medical hospital affiliation (potentially facilitating access to primary and other medical services, plus other infrastructure to support physical health care such as HIT). PBHCI clinics were more likely to report using registries to support clinical care (note that clinical registries were a core component of PBHCI). Importantly, PBHCI clinics were more likely than other clinic types to have obtained (on their own or via a partner organization) a Department of Health (Article 28) license to provide comprehensive, on-site primary care. Licenses and availability of grant funding likely affected staff membership on the care team: PBHCI clinics were more likely to employ case managers, peers, and wellness specialists. PBHCI clinic administrators described a broader role for case managers than at other clinics, and perhaps relatedly, PBHCI clinic staff also reported greater success enrolling consumers in integrated care initiatives, including Health Homes.
In contrast, Medicaid Incentive clinics tended to be smaller, free-standing (non-hospital-affiliated) entities. Medicaid Incentive clinics provided only the limited scope of primary care services (health monitoring, health physicals) permitted by their licenses. Participation in the incentive did not typically alter clinic infrastructure (e.g., record systems, physical space) or membership on clinics' care teams. For instance, primary care services were often provided by existing mental health staff (e.g., psychiatric nurses provided the primary care). Medicaid Incentive clinic administrators also reported a comparatively narrow role for case managers in consumers' overall care.
Finally, mental health clinics participating in Health Homes but not PBHCI or the Medicaid incentive program were varied, including academic medical center–affiliated clinics and free-standing clinics of varying resources, capabilities, and size. Among these clinics, overall, we observed that participation in the Health Home did not alter the clinic's scope of practice. As intended by the program, participation in Health Homes appeared to be associated with increased reliance on case managers and networks of agencies to get consumers access to primary care.
Research Question 2: Policies
Implementation and Operation
Overall, clinic staff reported that state-level investments in integrated care infrastructure, such as Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES), the Regional Health Information Organizations (RHIOs), and state drug databases, were helpful for characterizing and tracking consumer status and care outside of their immediate system of care. Several differences across integrated care initiatives were also observed.
Although the PBHCI grants were not a panacea (e.g., the grants did not relieve provider shortages in underserved areas), the clinics that received PBHCI grants were able to apply considerable financial resources to develop and implement their programs of integrated care, including pursuing comprehensive licensing options, hiring peers, supporting interdisciplinary case conferences, and more. The scope of services supported by the grants (including staff trainings regarding their expanded role at the clinic) helped to create an integrated care culture.
In contrast, integrated care culture change was not observed in the clinics that were using the Medicaid Incentives, despite the fact that the administrations of these clinics were committed to the same goal of whole person consumer care (albeit many of them with fewer resources to support integration from the outset). Specifically, Medicaid Incentive services were provided as part of a clinic routine, e.g. “seeing the nurse,” and not as part of a multifaceted (e.g., primary care, wellness, peers) shift in approach that involved multiple providers and an overall culture change. For instance, aside from those who were providing the specific Medicaid Incentive services, staff did not receive trainings on the importance of, or steps toward addressing consumers' physical health care needs. Overall, we found that consumers placed little value on the Medicaid Incentive–supported services because services did not address their desires for improved access to acute treatment services for physical health conditions such as headache or flu.
Health Homes represent a different approach to integration, focusing on coordinating care within a network of providers rather than developing a new or modifying a specific, existing clinical setting. The Health Home has the potential to complement any scope of primary care offered in, or coordinated by, the mental health clinic (including PBHCI and the Medicaid Incentive) because case managers are meant to be able to link consumers to any needed additional services elsewhere within the network. Health Homes' potential, however, is not yet clear since the program is in its early stages, and medical providers expected to accept SMI adult referrals contacted by Health Home case managers were often unaware that the program existed at all. Similarly, whether Health Homes truly have capacity to meet consumers' social service needs that may moderate their willingness/ability to follow through with primary care treatment (e.g., transportation, housing) requires investigation.
Characteristics of Successful Programs
We observed several clinic features that appeared to be associated with program success across initiatives. First, mental health clinics benefitted from close relationships with community programs, such as Personalized Recovery-Oriented Services (PROS). Community programs helped to create a care “center” that increased consumer contacts and trust with integrated care providers, plus increased the overall convenience and consumer-reported desirability of physical health services. Such clinics were also able to use existing groups to offer wellness services, contributing to centerwide shifts towards a culture of health and shared accountability for mental and physical health care. Second, clinics benefitted from using new consumer information and quality data systems (PSYKES, RHIOs). Clinics described having increased access to consumer information about hospitalizations, discharges, and other significant events that wasn't previously available, thereby increasing their ability to do timely follow-ups and target case management resources to consumers most in need. Third, successful clinics were eager to take advantage of the information-sharing privileges associated with the Health Home. While the newness of some of the Health Home networks made the ultimate impact of this feature difficult to assess, clinics anticipated that information sharing within the Health Home would streamline their current processes for connecting consumers to services not available on site while also supporting continuity of care. Fourth, as with many health care reforms, we observed that institutional champions were often credited for enabling clinics to implement integrated care in institutions and communities where it otherwise did not exist. In this case, champions were often individuals with particular expertise in health systems and finance who could navigate a complex policy context and leverage or flex existing resources to accommodate integration. Relatedly, some of these champions created legacies sustained through the creation of training programs (e.g., residency tracks for Medicine in Psychiatry; new programs in integrated care at nursing schools) at local institutions that funneled interested and qualified providers to integrated settings in the community.
Remaining Challenges
Administrators described challenges integrating services at the systems (e.g., OMH-DOH, payers, and others) and clinic levels (e.g., mental health and primary care providers). At the systems level, challenges to integration included access to licenses that facilitated integrated care, maximizing existing infrastructure (e.g., space, HIT, payers), and the financial sustainability of integrated care. While administrators from all clinic types reported the belief that forthcoming managed care programs would impact sustainability (potentially in positive or negative ways), in general, financial concerns were different across clinic types. Within PBHCI clinics, administrators were concerned about the sustainability of wellness, peer, and care management services following the end of the grants. In some cases, administrators expressed concerns that payers were not keeping pace with policy and that claims for legitimate integrated services (e.g., mental health and primary care services delivered on the same day) were being rejected, requiring significant administrative effort to secure reimbursement. At Medicaid Incentive clinics, sustainability concerns were more moderate and related to perceptions that current reimbursement rates defrayed but did not cover health physicals and health monitoring costs and were not available to support any related medical needs such as follow-up on referrals to physical health treatment. Finally, sustainability was a major concern among Health Home clinics and providers. In particular, concerns were widespread that changes in reimbursements (e.g., expiration of legacy rates) and subsequent increases in caseload may reduce the quality, intensity, and clinical impact of the services that case managers can provide.
At the clinic level, clinics of all types reported concerns related to information sharing among providers on the care team, including those at affiliated agencies, and accessing appropriate and timely social services (particularly transportation and housing) to enable consumers to take advantage of integrated primary and behavioral health offerings.
Research Question 3: Innovations
Clinics of all types developed unique and innovative approaches to the delivery of integrated care. These included innovations in consumer enrollment and engagement strategies, focusing on “bottom-up approaches” such as leveraging existing professional and social networks (e.g., recruiting at health fairs, community events, asking consumers' family members about health care needs) to identify potential Health Home enrollees. They included innovations in work flow, such as weekly, interdisciplinary case conferences and a web-based care coordination platform allowing providers to communicate routinely in a virtual space, including a dashboard and real-time alerts regarding changes in consumer status (e.g., entrance to emergency department, hospitalization, hospital discharge). Case managers using the virtual space also used the platform as a clinical registry, generating lists of consumers with specific identified needs including information drawn from the local RHIO. However, a challenge of this system was that providers with only a few consumers enrolled in the Health Home were unlikely to use the system, since it required them to go outside of their local EHR.
Clinics also created innovations in the structure and composition of the care team, such as leveraging the experience of peers to model healthy lifestyle changes and engagement in wellness programs, plus creating new positions (i.e., dedicated care coordinator) to maximize staff expertise in medicine and information systems that allowed case management staff to be more active in the field. Some clinics also restructured their care teams in accordance with the Health Home model, putting the case manager at the head of the care team.
Finally, we also observed innovations in sustainability planning in clinics with Article 28 (full primary care licenses; typically PBHCI but also select Health Home clinics) such as opening medical clinics to consumers' family members and care givers, in order to increase census and increase provider opportunities to bill.
Limitations
Our research has several limitations. Briefly, site visits were conducted at a small, select sample of sites and do not represent the large and diverse population of mental health clinics in New York state. The response rate to the project survey was low, limiting the extent to which results can be widely generalized. Perspectives of clinics not participating in integrated care were not included. Finally, since the clinics that implemented each of the integrated care initiatives are likely to differ from other clinics in ways that we were not able to measure, our observational design precludes us from definitively disentangling effects of the models from underlying features of the clinics that implemented them.
Recommendations
Based on our research findings, overall, we recommend that policymakers create initiatives and/or certifications that hold mental health clinics and their partner agencies jointly accountable for core components of integrated care programs, and that accompanying licensing and funding opportunities are coordinated, approved, and ready to be implemented under all relevant New York state agencies so that clinics themselves can implement integrated services that comprehensively meet adult consumers' health care needs. To meet this end, we recommend the following actions or changes:
Recommendations to Policymakers
- Explore state-level options that reduce administrative barriers to integrated care. Administrators expressed frustration with the time, expense, and complexity of obtaining licenses (e.g., full DOH Article 28, integrated, co- or dual license) to provide primary medical services in their mental health clinics. As such, policymakers may consider identifying and implementing policy strategies that further simplify and expedite mental health clinic licenses to provide medical services.
- Consider different licensing options for clinics that are hospital affiliated or free-standing. Our research showed that free-standing mental health clinics have less experience and fewer resources for implementing primary care services. As such, policymakers may wish to offer these clinics alternative licensing options that a) require fewer clinic structural changes than a typical primary care clinic, but b) require more investment in creating formal referral networks for primary care services that are not provided on site.
- Consider special provisions for clinics in rural settings. Site visits and survey data both showed that rural clinics experience many of the same, but also additional, barriers to care experienced in urban settings. Rural clinics reported more significant provider shortages, longer distances between consumers, clinics, hospitals and specialists, and at the same time, fewer transportation resources. Policymakers may reduce some of these barriers by further incentivizing local providers to care for mental health clinic consumers and by providing (e.g., through case management services) additional resources for transportation to and from medically necessary appointments.
- Consider whether all mental health clinics are appropriate settings for on-site primary care services. Given the scarcity of providers who are willing and able to provide primary care to adults with SMI, policymakers may wish to target integrated care resources to settings with the most potential to benefit consumers. Our research tentatively suggests that multiservice settings (e.g., PROS clinics) may show particular promise since consumers already have strong relationships with the agency and its providers, and because these clinics may be better prepared to offer complementary wellness or other services.
- As envisioned by the Excellence in Mental Health Act, consider promoting a full “package” of services (see Table 1) for adults with SMI through an Integrated Primary Care Behavioral Home. Our research suggested that mental health clinic membership in the Health Home did not increase mental health providers' behavior toward shared accountability for ensuring consumer access to medical services. As such, policymakers may wish to consider creating a mechanism of shared accountability like a behavioral health home to further incentivize all providers to provide integrated care.
- Identify and consider implementing strategies that promote joint accountability among all providers caring for, and plans covering, consumers' health care needs. For example, such strategies would help ensure that primary care providers are jointly responsible for assuring quality for general medical, mental health, and substance abuse care, and behavioral health (mental health and substance use disorder) providers are equally responsible for those services and general medical care. Strategies to instantiate joint accountability may be applied in training, practice, health plan contracts, performance incentives, and other mechanisms, including clinic and health system culture.
- Routinely/Formally build in cost/sustainability assessments into evaluation of future integrated care initiatives. Clinic administrators at all clinic types expressed concern about the sustainability of integrated care, and in some cases, concerns about sustainability made these administrators reluctant to further invest in infrastructure that would support integrated care (e.g., integrating case management records with clinics' own EHR). As such, policymakers may consider collecting cost and sustainability information during pilot tests of integrated care programs to facilitate decisionmaking among system and clinic staff who ultimately determine the uptake of integrated care programs.
- Consider creating incentives for EHR businesses to create products that interface with available clinical information systems (e.g., partner PC records, case management systems, RHIOs, PSYCKES). Clinics reported that a major barrier to information sharing and coordinating care were the costs and burden associated with expanding the functionalities of their EHRs to include information from other available data sources. As such, officials may need to take regulatory steps (such as those described by the Office of the National Coordinator [ONC] to create behavioral health EHRs with greater interoperability) that encourage EHR companies to facilitate this process.
- Develop a “report card” on the integration implementation agenda to monitor progress over time. Our research suggests a number of actionable items (e.g., streamlining licensing requirements, suggestions for technical assistance) that could help to facilitate the implementation of integrated care in New York state. As such, policymakers (or other groups, such as consumer advocacy groups) may wish to develop a system for tracking the implementation of these potential improvements over time and report on progress to stakeholders on a routine (e.g., biannual) basis.
Recommendations to Providers
- Orient staff to the greater purpose of physical health screening and monitoring services, particularly at MI clinics. Our research showed that the addition of health monitoring and health physicals to mental health clinics did little to improve consumer connections to primary care. It also showed that health monitoring and health physicals clinics did not train their staff to use these services as consumers' gateway to broader medical care. Clinics offering consumers any level of primary care may have more success improving consumer health if providers are trained on these expectations and provided with means to connect consumers (e.g., through enrollment in the Health Home) to treatment for any identified physical health care needs. Providers should clearly understand the notion of shared accountability for outcomes across mental health, general health, and substance abuse and their role in maintaining that accountability.
- Assess local PC access barriers and provide solutions. During site visits, consumers and staff often reported consumer barriers to accessing care that were specific to the clinic setting (e.g., unreliable bus service to the area, primary care doctor not available on the same day as a well-attended group). In order to increase consumer enrollment and use of available primary care services, administrators may consider assessing local barriers to use of available primary care services and then provide evidence-based (e.g., flexible appointment scheduling, walk-ins, same-day) and other practical solutions, as appropriate.
- Communicate directly with co-providers. Providers reported (and literature suggests; e.g., Scharf et al., 2014) that care is better integrated when providers communicate about consumer needs on a regular basis. During our site visits, we observed that interdisciplinary case conferences may be particularly useful for planning and coordinating care for complex cases. As such, regularly scheduled opportunities for providers from multiple disciplines to discuss cases are expected to build trust, lines of communication, and may also sustain or stimulate new medial provider interest in serving populations of adults with SMI.
- Relentless follow-up on referrals. Administrators, providers, and consumers described access to specialty services as a major barrier to integrated care, and one that may be even more difficult to resolve than connecting consumers to primary medical services. As such, providers making consumer referrals to specialist providers should provide consumers with needed supports to attend these appointments (e.g., reminders, transportation), and ensure that consumers attend these appointments in order to improve consumer health and preserve clinic relationships with valuable and scarce lists of specialists accepting Medicaid and willing to serve their clientele.
- Consider clarifying/operationalizing the roles and expectations of peer specialists and primary care case managers. Administrators and providers in this study reported that there were few mechanisms to support peer specialists and primary care case managers. Clearer roles and expectations for peers and primary care case managers might help to stimulate consistent and reliable billing opportunities from payers and ensure that these positions are routinely staffed by individuals with the skills and qualifications needed to maximally benefit consumers.
- Consider partnerships with Managed Care Organizations (MCOs) to implement integrated care. Mental health clinics (particularly free-standing clinics) reported low rates of using data to manage and improve quality of care. MCOs, however, may already be collecting and analyzing data that can be fed back to clinics (particularly those without infrastructure and staff for data analysis) that may be useful for informing practice. Data-driven improvements to care quality may be mutually beneficial to mental health clinics and MCOs.
Recommendations for Technical Assistance Providers
- Educate MH clinics about different models of integrated care and the accompanying available licensing options to provide integrated care. New York state is a complex policy environment with many available resources and policies to facilitate integrated care. Clinic and agency administrators may benefit from ongoing technical assistance regarding resource availability, and potential strategies for creating synergies by combining participation in complementary initiatives (e.g., Medicaid Incentive and Health Homes).
- Provide ongoing support to MH clinics around the use of data for clinical care. Mental health clinics reported low rates of using data systematically to inform care delivery. Since most clinics already have EHRs, clinics may be able to take advantage of technical assistance that demonstrates the utility of existing (or establishing) registry functions within their EHRs to promote clinical care and perhaps simultaneously satisfy initiative reporting requirements.
- Investigate barriers to using data systems that support a population health management approach (e.g., PSYCKES, RHIOs) and offer training (or other supports as warranted) to enable use of those systems. Study participants reported awareness of population health-promoting data systems, yet use of those systems was still low. Technical assistance providers may consider investigating barriers to the use of these systems and then facilitating access to them, as study participants using the systems were likely to report finding them useful for consumer care.
- Consider providing templates (or lists of key components) of documents that mental health clinics can use to facilitate information sharing across providers on the care team. Some clinic administrators reported challenges to obtaining consumer consent for information sharing, while others did not. Similarly, some clinics reported difficulties negotiating resource sharing with local primary care partner groups while others had already resolved these issues. As such, technical assistance providers might offer templates for routine documents such as consent forms or memoranda of understanding to enable additional clinics to efficiently and effectively implement integrated care.
- Consider technical assistance for integrating health care systems approaches with business strategies. Given the extent of clinic concern about financial sustainability, clinics may benefit from technical assistance about how to make integrated care financially sustainable within existing business models.
Recommendations for Future Evaluation
- Monitor and leverage the quality and performance of the Health Home. Potential benefits from Health Homes were highly anticipated by administrators and providers, including enhanced capacity for information sharing and increased access to services for consumers, such as specialty medical care and housing; however, the degree to which these systems are functioning well in practice remains unclear. To ensure optimal function of Health Homes, policymakers may wish to track consumer flow through essential steps in the care process (e.g., screening, diagnosis, treatment, wellness, aftercare, and follow-up) and provide feedback and incentives to networks based on quality metrics. Similar standards may be applied to case management and clinic-level functions of the Health Home.
- Assess the degree to which Health Home agencies are participating in networks of care. Although agencies may be administratively (i.e., “on paper”) part of a Health Home, the extent to which they are adequately serving Health Home consumers and participating in the overall coordination of care for those individuals requires investigation. Indeed, a finding of this research was that many providers within Health Home agencies were unaware of the Health Home initiative overall. New network analysis techniques can help Health Homes and policymakers determine how well consumers are linked to services within networks, and how well case managers and case coordinators (CM/CCs) are taking advantage of the scope of services available in their networks.
- Conduct a formal analysis of the costs, benefits, and sustainability of the current Health Home Per Member Per Month (PMPM) reimbursement rate. Our research suggests widespread fears about whether the current PMPM is sufficient to cover the costs of quality case management services, particularly because current rates are bolstered by the substantially higher “legacy rates” that are set to expire. Given this upcoming change in reimbursement, policymakers should closely monitor the impacts of reductions in PMPM on quality of care.
- Explore whether changes in workforce and reimbursement policies help to improve physician participation in integrated care for adults with SMI. Under the Affordable Care Act (ACA), in 2014, Medicaid fees are now at least equal to Medicare fees. The idea behind the fee increase is to stimulate physician participation in Medicaid and to support physicians who already participate and could expand their Medicaid service. Whether these fee increases are sufficient to stimulate physician participation in integrated care programs (where attracting qualified physicians is often problematic) is unknown.
Conclusions
New York state's mental health clinics are implementing a range of integrated primary medical services for their adult consumers with SMI with support from a range of initiatives. These initiatives provide varying levels of financial and technical support to clinics and staff, and these different levels of investment are reflected in the scope and intensity of services that are made available to consumers, plus the extent of work flow and culture change occurring within clinics. In order to more effectively implement programs intended to better integrate behavioral health and primary care in the state, we recommend that policymakers create initiatives and/or certifications that hold mental health clinics and their partner agencies jointly accountable for core components of integrated care programs, and that accompanying licensing and funding opportunities are coordinated, approved, and ready to be implemented under all relevant state agencies so that clinics themselves can implement integrated services that comprehensively meet adult consumers' health care needs.
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The research described in this article was sponsored by the New York State Health Foundation and conducted in RAND Health, a division of the RAND Corporation.
