David Freedman, Lina Castellanos, Thomas Jardon, Cynthia

The Pitfall and
Promise of
Integrating Care
David Freedman, Lina Castellanos, Thomas
Jardon, Cynthia Rodriguez, David Fuentes, Ketia
Harris, Megan Hartman, & Angela Mooss
Integrated Care: Reconnecting
the Head and Body
Cost of Co-occurring Conditions
Milliman, 2014
Cost
Milliman, 2014
Cost and Disparities
Netsmart, 2013
Three-Legged Stool of
Healthcare Integration
INTEGRATION,
YOU SAY?
Integration Service Flow
The Four Quadrant Clinical
Integration Model
samhsa.integration.gov
Accountable Care-Change Of Focus Required
Element of Change
Yesterday
Today
Care focus
Sick care
"Healthcare" wellness and
prevention, disease
management
Care management
Manage utilization and cost
within a care setting
Manage ongoing health
Delivery Model
Fragmented/silos
Care Setting
In office/hospital
Quality measures
Process-focused, individual
Outcomes-focused,
population-based
Payment
Fee-for-service
Value-based
Financial incentives
Do more, make more
Perform better on
measures, make more
Financial performance
Margin per service,
procedure
Margin per life
Care continuum and
coordination
In home, virtual
SAMHSA
MAI-TCE:
MIAMI SITE
Minority AIDS Initiative – Targeted Capacity Expansion
4.2 M for 3 Years from SAMHSA
Project Flow Chart
SAMHSA
Behavioral
Science
Research
Institute
Florida Health
South Florida Behavioral
Health Network
JTCHC
Citrus Health
SAMHSA Funding
Siloed Funding
Main Players: Behind the Scenes
Florida Health- Tallahassee and Miami Dade (DOH)
◦ Required grantee due to HIV impact
◦ Coordinated with ECHPP
South Florida Behavioral Health Network (SFBHN)
◦ Managing entity for behavioral health dollars via
Department of Children and Families
Behavioral Science Research Institute (BSRI)
◦ Evaluation team
◦ Crossover with Ryan White Program
Main Players: The Providers
Citrus Health
Jessie Trice (JTCHC)

5 medical clinics and
24 schools

9 medical clinics and
23 schools

Hialeah area

Liberty City area

55% female

63% female

>80% Hispanic/
Latino

67% Black/AfricanAmerican

52% best served in
another language

13% best served in
another language

28% uninsured

60% uninsured
MAI-TCE Miami took on three distinct phases
MAI-TCE
PROJECT
PHASES
Phase One:
Gearing up for Integration

Start Date
◦ February 2012

Logistics
◦ Funding
◦ Staffing
◦ Implementation

Buy-in
◦ Organizational level
◦ Between partners
Challenges
Successes

Fiscal tracking

Data burden
◦ SFBHN/organizational level

Training/EBI’s
◦ Provider MAI-TCE teams

Staffing

Collaboration/Team
building
◦ Data sharing with
Evaluation

Capacity Building
Logistics
Challenges

Successes

The need is recognized and
departments find relief
◦ HIV and Ryan White
services

Integration is accepted at
top-down level in theory
Billing for services

SFBHN assists with billing
and loosening staffing
regulations
Cultural differences
◦ Medical vs Behavioral
health

Buy-in
Lessons Learned

Make preparations
◦ Present changes to other departments
ahead of time

Collaboration is critical
◦ Need a team of support

Planning and persistence
◦ This takes time
Phase Two:
Customizable Integration

Start Date
◦ June 2012-May 2014

Planned changes
◦ Mandated by funders (TRAC vs. GAIN)
◦ Necessary to meet EBI requirements

Unplanned changes
◦ HIV testing
◦ Staff turnover
Challenges

EBPs/DEBIs changed
Successes

◦ Client needs and outdated
practices
◦ Peers implementing
◦ Translation of tools as needed
◦ Training overload
◦ Staff turnover

Systems-level funding
and documentation
Flexibility in training and
EBI implementation

Data and service
documentation
◦ Removal of GAIN-I
◦ SFBHN consistent updates
(delete orphans, etc)
◦ Data became useful internally
Planned Changes
Challenges

80% follow up rate goal
◦ Does not fit BH clients
◦ Reassessment and DC lists
become unmanageable

Rapid Testing HIV
mandate
◦
◦
◦
◦
New testing site IDs
Training
Duplicative data
Testing numbers cannot be
shared
Successes

Advanced integration
model for service
delivery

Advocating at all levels
◦
◦
◦
◦
A true team approach
DOH was instrumental
Capacity building
Filling a huge need
(especially at Citrus)
Unplanned Changes
Lessons Learned

The need to truly customize cannot be
understated

Peers are critical to successful models
for client satisfaction

Integration is working
◦ More clients are getting the services they
need and large FQHCs have fewer silos
internally
Phase 3:
Wrap-up and Sustainability

Start Date
◦ June 2014 to present

A focus on Medicaid billing and staff
coverage

Focus on implementing EHR systems
that are effective

Concentration on seeking out additional
funding through grants/foundations
Challenges

Non-Medicaid expansion

EMRs lack sophisticated
technology and are expensive


SAMHSA and other billing
systems are not set up for cooccurring clients
Grant funding is competitive
Successes

SFBHN advocacy for EMRs
and data systems changes

EMRs responding

Funders are responding

Miami secured grant
monies
Funding
Challenges

Staffing
◦ Certifications for peers,
behavioral health techs,
non-client specific
coordinators

Successes

◦ Use of peers, recognition for
coordination across sites

Other departments believe
in the value of behavioral
health

Healthcare culture is
changing
Organizational structure
◦ What has really changed?
◦ Medical and behavioral are
still separate, but…
Staffing has changed
organizational practice
Organizational
Integration Culture
Lessons Learned

Change happens with persistence

Generating buy-in at the
organizational level can speed things
up

Collaboration is key to successful
integration and sustained funding
If you don’t remember anything else… Remember this
TAKE AWAY
POINTS
Behavioral Health Primary Care
Network Committee (BHPCNC)

A committee for health integration

Guided by principles:
◦ Inclusion, Collaboration, CQI, Resource savings,
Community-based, Resilience and Recovery

Vision/Mission
◦ Oversee the expansion of culturally competent and
effective behavioral health services
◦ To monitor and enhance the linkages between and
integration of behavioral health services in primary care

Less formal
◦ A focus on training and capacity building across the
systems of care
The Miami Model

Screening (SBIRT)

Use of peers

HIV testing

EBIs

Data driven

Co-location has been extremely helpful with
piloting/forming the model
Project Outcomes

Reduction in days spent:
◦ Homeless
◦ Hospital MH unit, detox, jail, emergency room

Reduction in unprotected sex

Increase in risk perceptions

Decrease in mental health symptoms and social support

Increase in access to comprehensive health services

Decrease in substance use
◦ But not in tobacco use
System-wide Implications

Expansion of integration to chronic
disease management and other
aspects of health

Providers are held to higher standards
of care and care coordination

Focus on prevention and wellness
Go Forth and Integrate
Questions/Comments
David Freedman – Project Director
[email protected]
(305) 860-8235