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Transcript of NWX-SAMHSA CSAT Web Event

January 19, 2011
1:00 pm CT

Coordinator:  At this time all participant lines are in a listen-only mode and will remain in a listen-only mode for the duration of today’s conference. Today’s conference call is being recorded. If you have any objections to this you may disconnect at any time. If you are having technical difficulty with the net portion today, please press star then 0 at any time or you may dial 1-800-857-7777 for technical assistance. Now I would like to turn the call over to your host Ms. Pam Rainer. Please begin.

Pam Rainer:  Okay. Thank you (Brad) and welcome everyone — consumers, family members, advocates, service providers and administrators. We’re pleased you could join us all today. As the operator mentioned, today’s event is being recorded and it will be archived on SAMHSA’s CODI Web site. And that Web site address will appear on a few of our slides today.

Today’s Webinar, Integrating Behavioral Health into the Person Centered Healthcare Home, is being sponsored by SAMHSA’s co-occurring disorders, integration and innovation CODI project. My name is Pam Rainer. And on behalf of SAMHSA it is my pleasure to serve as your moderator for today’s presentation. This is the fourth webinar of the CODI Building Block Series centered around SAMHSA’s eight strategic initiatives. All past webinars are available to be viewed at your convenience. And these include - sorry. Okay the first webinar, Co-occurring Disorder and Justice Involve People was held on April 13. The second, Healthcare Reform, Implications for Behavioral Health Providers held on September 21st. And the third webinar, Understanding and Addressing Trauma Among People Receiving Behavioral Health Services was held on November 9. Each webinar and transcript has been archived on the CODI Web site in the resources section.

We have a full agenda today and hope to provide concrete information to help you understand integration from both a theoretical and practical standpoint. We have an esteemed panel to present four models of integration. Before we begin I’d like to draw your attention to some important logistics. You may submit your questions at any time through the Q&A dialogue box located along the toolbar at the top of your screen. Type in your question and hit the Ask button. We will pose the questions to the presenters during the Q&A. But you may submit your question at any time. All participants will also receive a follow-up email with a link to an evaluation form. We really appreciate everyone’s feedback and will use it in developing future webinars.

We would now like to take a quick poll to gather information about who’s on the call with us today. (Brad) you may now go ahead and post the first question.

Coordinator:  Thank you. Polling Question Number 1, are you a substance abuse and mental health services administration employee? Please press star 1 for yes, or press star 2 for no.Once again, the question is, are you a substance abuse and mental health services administration employee? Please press star 1 for yes or press star 2 for no. Please register your vote at this time. Polling is being saved for the first session. Please stand by.

Polling Question Number 2, are you a substance abuse and mental health services administration grantee? Please press star 1 for yes or press star 2 for no. Once again, are you a substance abuse and mental health services administration grantee? Please press star 1 for yes or press star 2 for no. Please register your vote at this time. Polling will conclude in a moment. Polling has completed. Please go ahead with the conference.

Pam Rainer:  Thank you (Brad). It is a pleasure to now turn this presentation over to our guest facilitator Kathy Reynolds. Kathy is a Program Specialist for Integrated Health for the National Council for Community Behavioral Healthcare. Kathy has a long history of supporting systems change in this area and is co-author of raising the bar, moving toward the integration of healthcare. Welcome Kathy and you may begin your presentation.

Kathy Reynolds:  Thank you Pam. I’d like to echo my welcome to you as part of the CODI webinar on integrating behavioral health into the patient centered healthcare home. My first task is going to be introducing Ms. Trina Dutta who is from SAMHSA and served as a public health analyst there. She also is the Grant Project Officer for the recently funded primary care and behavioral health integration projects across the country. So Trina would you please go ahead and start our introductory comments? Trina Dutta:  Okay thank you Kathy. And I want to thank the organizers for inviting me to speak at today’s webinar. I’m just going to give some very brief kind of overview comments about some of the work that SAMHSA’s doing around integrating behavioral health into the primary care setting, the prison center and health home. And then I’m also going to touch a little bit on the Affordable Care Act, in particular the legislation that has authorized work around the prison center and health home. So we’re going to touch on the primary and behavioral healthcare integration Grant Program that SAMHSA runs and again, the Affordable Care Act Legislation.

So I think that this is — I don’t need to belabor the point about why this integration is important. We know a variety of different things. We know that people with serious mental illness that folks are dying on average at the age of 53. We know that there’s a number of reasons that this is happening due to barriers to appropriate care, stigma associated with serious mental illness, lack of training around the workforce in both the primary care setting, the behavioral health setting. And I’ll say that when I say behavioral health I’m including substance use and mental health and then just a general lack of access to primary care services. And so this lack of primary care for people with SMI has lead to increased rates of hypertension, diabetes, obesity, cardiovascular disease, other health issues. And these are only made worse by some of the health practices or unhealthy practices I should say that this population often engages in which includes smoking. We’re very aware of the high smoking rates amongst people with serious mental illness, poor nutrition, the side effects of psychotropic medications, et cetera. So SAMHSA’s really focused on how do we provide or connect people with serious mental illness to get primary care? Now why is this direction of innovation important?

And what you see on the screen here is the four quadrant model that was developed by the National Council for Community Behavioral Healthcare from Kathy’s organization.And I don’t know if you can see it that well on the screen, but the X axis there is looking at physical health risk and status. And then the Y axis is looking at behavioral health risk. And we know that folks with serious mental illness tend to have some pretty extreme health issues that I just outlined, and so they kind of fit into this Quadrant 4 if you will on the upper right-hand side. It has the red circle around it. But what we also know is that a lot of the research that’s been done sort of in the field at large today is really focused on how do you bring behavioral health into a primary care setting?

But there’s not quite as much being done around how do you bring primary care into a behavioral health setting, in particular how do you connect folks with serious mental illness with primary care? So SAMHSA with this program really wanted to try to address that gap, that perceived gap in the field around the knowledge that’s being developed around integration.

So what is PBHCI? I apologize for the acronym, Primary and Behavioral Health Care Integration? This program’s purpose is really to improve the physical health status of people with Serious Mental Illness. And the way we’re doing that is by using these grants dollars to support communities to both coordinate with and integrate primary care services into their behavioral health systems and settings.

So the outcome that we expect is that grantees will develop some sort of partnership with a primary care entity and that that will result in improved health status. And the population that we’re focusing on again are those - are adults 18 and over with Serious Mental Illness who are getting public behavioral health services. And the folks that were able to apply for this are community behavioral health agencies. So that could be a community mental health center, a community substance abuse provider or it could be a federally qualified health center with a behavioral health designation from HRSA. So with regards to the services that these grantees are delivering, there’s sort of a couple main areas that they have to focus on. Other than that, they’re kind of open to whatever they need to do to make this integration happen. So part of that is providing or ensuring that some sort of primary screening and assessment is happening and then at times what’s more important is really that there are referrals for the perceived needs and treatment needs in the community that individual is living in.

Grantees are asked to develop a registry or some sort of tracking system that holds all of the primary healthcare needs and then the associated outcomes from the care that individual is receiving. We want them to really focus on building the processes around not only referral but also the follow-up. And I’ll tell you that that’s been an issue for a number of the grantees is really the follow-up piece is you can do as many referrals as you want, but how do you really make sure that an individual is actually getting the care that is being recommended? And then grantees are asked to spend a minimum of 10% of their dollars on some — on prevention of wellness activities. And so these can include tobacco cessation. It can include weight loss.

And there’s a wide variety of different things that the grantees are doing. Some are very creative and people have really thought out of the box. They’ve been quite lovely in the activities that they’ve put forward. So the next slide is kind of focused on the data. Now the grantees have to spend — can spend up to 20% of the money really collecting data around this project. So we want them to get a personal and family history of the health issues that are listed there, get a medication history and their current medication list with dosages. Because it’s a really big issue with sort of this making sure that we know if the medications on the behavioral health side, with the primary care side, et cetera. What are the social supports that an individual is receiving? And then at that individual level we really want to know what is a person’s body weight, so body mass index? Some folks — some sites are doing waist circumference. But we’ve listed body max index here, collect their blood pressure, have information on their blood glucose and their lipid profile. And then overall we want to know how many of those individuals, how many of the clients are being screened for a variety of health issues and then how many are actually are receiving the primary care services after those screenings have been done.

The last sort of big chunk of this grant program is the infrastructure development part. And that again they have up to 25% of the grant dollars. And that’s through things like focus on workforce development if they’re — if they need to do policy changes to help support the collaborations with their primary care partners. If they need to look at their electronic health records systems or their health management systems, that’s been a really big area of focus for a number of grantees. So that’s another area that the grantees are working on. Now because SAMHSA realized that this is an area that hasn’t had as much exploration in the field, we’re working with our sister agency within HHS, the Office of the Assistant Secretary for Planning and Evaluation, ASPE. And we’re working with them on a cross side evaluation. And the evaluation has three main areas of focus. One is looking at, you know, does this integration, does it lead to improvements in both the behavioral and physical healthcare for individuals with serious mental illness? Is it possible to integrate these services between primary care and behavioral health? And then more particularly, what are actually those different approaches to integration that are happening at the different sites? And then the third component which is I would say is arguably the most challenging one is what are the models or more interesting for us, what are the actual features of the different models of integration that are ultimately leading to some of this improved behavioral and physical health outcomes. And we’re working with the RAND Corporation on that evaluation.

So I’m just going to quickly flip through the next couple slides. So right now we have awarded 56 grantees. And these are again, community behavioral health providers. The grantees, we have three cohorts of grantees so far. The cohort you’re looking at right now is Cohort 1. And that was awarded over a year ago.

And then we have two more cohorts. We have Cohort 2. And you can see where these folks are. I’m sorry, I know you can’t read this very well. And then we have Cohort 3. We have a whole boatload in Cohort 3. And I should say that Cohort 3 was actually funded through the Affordable Care Act through the Secretary’s Prevention Trust Fund. So right now we have 56 grantees total.

Okay so another component, a pretty major component of this primary behavioral healthcare integration grant program is a training and TA center that SAMHSA is doing in partnership with our sister agency HRSA. And HRSA, the Health Resources and Services Administration. And my colleague Alex Ross is going to speak with you in just a few moments. But we’re doing this in partnership with HRSA as I said. And the goal of this Center for Integrated Health Solutions is really to promote the planning and development of integrated primary behavioral healthcare. And the purpose is not only to serve a national audience with training and TA needs, and I should say that while the grantees that I talked about earlier are looking at integrating primary care into behavioral health, this TA Center is really looking at the bidirectional integration. So primary care into behavioral health and behavioral health into primary care. So the TA Center is serving a national audience. And then they’re also providing specific TA to both the grantees I just talked about and also to the grantees that HRSA funds.

So there’s a number of things that the TA Center is — we’ve — we’re expecting them to do. I’m not going to read through these. But you can see that this is a very well funded TA Center. It’s co-funded again by SAMHSA, HRSA. And again we received some money from the Secretary’s Prevention Trust Fund which comes from the Affordable Care Act. And so there are a couple main areas that the TA Center is going to focus on, knowledge development and dissemination. And these are things that any good TA Center would focus on I should say. Also knowledge application, so that’s really where the training and TA part comes in. The policy analysis, prevention and health promotion and workforce development. And I’m sorry, I was remiss in saying that this cooperative agreement has gone to the National Council for Community Behavioral Healthcare. And Kathy Reynolds who introduced me on today’s call is actually the lead for that TA Center. So that’s been a really nice partnership so far. And again, the audience is our SAMHSA grantees, HRSA grantees and the general public.

So the last piece I’m going to talk about just very briefly is the Affordable Care Act in Section 2703. And that is technically the state option to provide health home for (MLE)s with chronic conditions. And that is basically a fancy way of saying the person center at health home. Now the goal of this project is really to enhance integration and coordination of both the primary, acute, behavioral health and long term services for both with chronic services. And so the health home is really is — the focus of this is to provide an opportunity so that there’s a person centered system of care that achieved ultimately improved outcomes and so that there’s value added for the state Medicaid program. And this program is being coordinated per the legislation by the Centers for Medicaid and Medicare I should say. So there’s a couple discreet populations of people who are being served, folks who are on Medicaid who have chronic conditions. And they fall into one of these three areas.

Either they have two chronic conditions. They have a chronic condition and they are at risk for a chronic — for a second chronic condition or they have a serious and persistent mental health condition. And this is all laid out in the legislation, the Affordable Care Act Legislation. And these chronic conditions, you can see these can include a mental health disorder, a substance abuse disorder, asthma, diabetes, heart disease or being overweight. And the secretary, it’s at the secretary’s discretion to add to this list of chronic decisions as she sees fit. So there’s a couple of required services that these health homes have to provide. And so the states as they’re preparing their SPAs or their State Plan Amendments they have to show how these required services are being provided through their health home. And we recognize that there’s some overlap through these services, but these are what was in legislation. So we’re really trying to work with the states right now in understanding how does this — how does — how can this be operationalized through their health home? And that’s comprehensive care management, care coordination, health promotion, transitional care from inpatient to other settings, patient and family support, referral to community and social support services when appropriate. And then a very important piece is the use of health information technology to make sure that the services are linked. So CMS has actually required states to consult with SAMHSA as they develop their approaches to the health homes. And this is because there’s such a strong emphasis on behavioral health disorders in the legislation.

And so we feel really lucky that we get to consult with states. These consolations have to happen before the states submit their state plan amendments. And so the process is that states will email us at the email address you see noted there providing the information that’s in the bulleted — the bullets there, a brief overview of what they plan on doing, what they may have questions on. And then after that consultation then they will connect with CMS with their actual application.

And I would encourage you all to actually visit our SAMHSA site on health homes. If you go to the SAMHSA Web site underneath the Health Reform button you can go to health homes. And we have a lot of material is on screening tools, outcomes, models, research and everything relevant that we could find that’s relevant to health homes and behavioral health. And I feel like behavioral health is somewhat of a new part of this conversation. So we’re really excited to have this opportunity. I think that wraps up. I hope I didn’t speak too quickly. I apologize if folks are not able to understand me if I was talking too fast.

I now have the pleasure of introducing Dr. Alexander Ross. Alex is — I mentioned earlier, he is my sort of partner in crime around this Center for Inter Data Help Solutions. And it’s been a pleasure to work with him. He’s a senior health policy analyst on behavioral health issues for the Health Resources and Services Administration. In that capacity he works with a full range of HRSA programs, a variety of different agencies both within HHS at the national, state and local level. He’s very much focused on behavioral health and primary care services and those services being available in the community.And I’ll say that Alex has just - he’s shown quite a high level of dedication both at the department level and beyond that around making sure that behavioral health is really recognized and remembered in these primary care settings.

Previous to Alex’s current position he was a Senior Health Policy Analyst at HRSA’s Help Systems and Financing Group. And he looked at a variety of different issues including the impact of marketplace changes on safety net providers, healthcare services for adolescents and some other areas. So Alex I will turn it over to you.

Alexander Ross:  Trina thank you so much. And I do want to thank my colleagues at SAMHSA for inviting myself to present on today’s webinar on behalf of the Health Resources and Services Administration. I’m looking forward to our speakers who are going to present a good illustration of the continuum of the integration effort that’s taking place and also to Kathy’s remarks about the schematics that are out there to visualize integration. I’m very interested to hear how their providers in today’s presentation are trying to reach the level of an effective person centered healthcare home and how they’re partnering to do that with organizations such as the ones that HRSA works with in the communities.

What every example will have in common is the effort to get patients the care they need in a coordinated fashion. We’ll be hearing about what works and we’ll also be hearing about how our speakers have overcome the barriers that they encountered along the way. I just want to spend a few minutes on HRSA and how we’re working to achieve a more fully integrated healthcare system in partnership with agencies such as SAMHSA. I’ll be referring to the PowerPoint that you have on the screen today. Let me talk a little bit about HRSA’s overall priorities.

We’re all about improving access to quality healthcare and services. We work to strengthen the healthcare workforce. We are looking to build healthy communities and improve health equity. What does that translate into? Well it translates into nearly 19 million people served through 8000 health — HRSA funded health centers including one out of every three people with income below the poverty level. Over half a million people living with HIV or AIDS receive services through more than 900 HRSA funded Ryan White clinics across the country. We have 34 million women, infant and children and adolescents who benefit from HRSA’s maternal and child health programs. And approximately 14,000 safety net providers participate in the HRSA Administered 340b low discount drug program or safety net providers around the country in which they’re able to share with the patients they see on deep discounts in the costs of medications. Currently more than 6700 National Health Service core clinicians are working underserved communities across the nation in exchange for loan repayment or scholarships provided through HRSA.

Our programs in behavioral health integration, I want to spend a couple of minutes illustrating where HRSA’s programs are working hard on the behavioral health integration effort. The Bureau of HIV and AIDS, I did want to point out that Mental Health Services are provided by approximately 73% of the community based programs sponsored by HRSA in HIV and AIDS and that the HRSA programs provide out-patient substance abuse services in HIV and AIDS clinics to over 31,000 visits. Those can be duplicated counts so I won’t refer to those as distinct individuals. But over 31,000 visits for substance abuse treatment.

In maternal and child health we have the Health E Star Program of which there are 99 sites across the country. Those sites are providing case management, depression screening and educational activities for women in areas of the country with high infant mortality and shortage of health clinicians. The Maternal and Child Health Bureau has also produced over the years the Bright Futures Guidelines. And these are periodicity guidelines. And since 1995 over 1.3 million copies of the guidelines have been distributed across the country. And they include an important chapter on drug and alcohol use and screening for youth.

One program I want to highlight for the Maternal and Child Health Bureau, under the Affordable Care Act they have now taken on responsibility for a new initiative, the Early Childhood Home Visitation Visiting Program which allows states the opportunity to provide evidenced based home visitation services to improve outcome for children and families who reside in at-risk communities. This first year of funding states are developing their plans. And this is a program I believe that affords the opportunity for states to develop the kinds of home based screening and referral for treatment in behavioral health services that I think will be very important.

I want to touch for a minute on the National Health Service Corp Program. That’s a program which under the Affordable Care Act has gotten a big boost in terms of their ability to place recent graduates from medical and nursing programs and in behavioral health disciplines in communities all across the country in return for a loan repayment for their training and education. Currently more than 7000 National Health Service Corp clinicians are working in underserved areas across the country including over 1000 who are providing behavioral services in disciplines such as psychiatry, clinical psychology, clinical social work, licensed professional counselors, et cetera. And 20% of the behavioral health awardees are engaged in substance abuse delivery services directly. Also just to note, over 80% of those scholars who are placed — loan repayers who are placed in underserved communities stay and continue to practice in those areas after fulfilling their National Health Service Corp commitment. That programs is also seeing a great expansion as I mentioned and also a fair amount of creativity in their placement including the opportunity for sharing loan repayers between organizations and communities such as community mental health centers, federally qualified health centers for example being able to split the time of the loan repayer so that we can make sure we deliver those services in an integrated fashion.

I want to talk for a moment about our Health Professions Bureau and their programs in Behavioral Health Services. They have a program in graduate psychology education training. It’s a grant program. And they also have the area health education centers which provide training and education, continuing educations for clinicians who are already in practice. And they provide a fair number of trainings around behavioral health service issues.

In the Bureau of Health Professions I’d like to highlight the National Center for Healthcare Workforce and Analysis. And it’s an important center in the collection of information and data on the current workforce. And I think that it’s an opportunity for HRSA to collaborate down the road with SAMHSA in the important work that they do to collect data on the Behavioral Health Workforce as well.

We also have an important program in rural health. For example they’ve produced a publication on integrating primary care and mental health services current practices in rural community health centers as well as the programs that they run in tele-health. And I think there’s probably some work going on in tele-behavioral health that would be worth knowing more about.

We also have regional offices across the country, ten regional offices. And I do want to point that out because for those of you working in different states, it’s good to know that there is a HRSA presence out there regionally that you can get in touch with. And they’ve been working for example in Maine on working across the state on a behavioral health integration effort. And that was something that our regional office in Boston was part of.

When we think about the Bureau of Primary Healthcare which administers the Health Center Program and you’ll be hearing today about the kinds of examples of behavioral - excuse me, health centers that are partnering with behavioral health providers across the nation, this is where we want to focus a little bit of our discussion. I think they’re a great example of the way in which we’re trying to promote the integration of behavioral health and primary care both with partners in the community and when possible within these fully integrated comprehensive health centers.

The National Association of Community Health Centers has a survey out in the field now looking at ways in which health centers are providing behavioral health centers services, excuse me. And I anticipate that within the coming months we’ll be learning from that survey a much greater sense of the profile of behavioral health service delivery in health centers. And I look forward to seeing the results of that survey. Briefly, health centers today, about 1/3 of them are providing substance abuse services and counseling on site. And about 2/3 are providing mental health services directly. In general they are serving almost 760,000 patients for behavioral healthcare needs. And screening and brief intervention referral to treatment expert is a service that we’re seeing more and more in the health center community. They have a substantial workforce unto themselves providing behavioral health services. There are over 1100 health centers across the nation. And they include 3400 behavioral health providers across those 1100 health centers. Obviously some health centers with a larger behavioral health workforce, some with a smaller workforce. But they would include psychiatrists, psychologists, social workers, substance abuse providers and other licensed behavioral health providers.

The Affordable Care Act has provided a significant increase in funding so that we can assure that we have health centers in the most underserved communities across the nation.We’re seeing opportunities for new health centers as well as expansion of existing health centers and importantly expansion of behavioral health services within existing health centers. In 2011 we’ve already seen a request for proposals for the new health centers, new starts or new access points, as well as recently the request for existing health centers that would like to enhance their provision of behavioral health services.

So just to sum up on the health center program I think it’s the type of provider that will be an important source of a health care home. What I’d like to say is that in general health centers are a preferred site for a health home, for behavioral health service delivery when appropriate, when the workforce is there and when it is not necessarily as comprehensive as one would like to have effective referral relationships with the behavioral health providers in the community.

So what will HRSA be doing in the future to promote behavioral healthcare? I just want to talk about that briefly before we move on. I think some of the areas that we like to, I think, engage in further include medically assisted treatments in both the health centers and in the HIV and AIDS clinics for example. I think we’re doing some work with SAMHSA to try to build on the ability of the primary care providers to provide the medically assisted treatment services. I think we’d like to introduce the concepts of recovery and resiliency in the provision of services in the primary care setting which I think reflects the same interest that SAMHSA holds to see those terms used broadly. I mentioned that the National Health Service Corp is growing in terms of its behavioral health workforce as well as in its flexibility and placement. We’re going to be placing some emphasis on the concept of motivational interviewing in the primary care setting and of course addressing the overall workforce concerns. And an important part of our work will be what Trina mentioned before, our collaboration on the Center for Integrated Health Solutions. We achieved these goals through our partnerships within the department particularly with SAMHSA and our colleagues at CMS for example through the TA Center and through our work with our state-level partners and our local grantees.

I would like to leave you with a number of slides that emphasize the tools that are available to you. I think slides - this slide and the next slide and the one after these are great resources that you can have as you’re moving ahead in your work. I’m really looking forward to hearing the examples of the integration effort that is going on out there today. At this point I’m very pleased to turn the microphone over to Kathy who’s going to describe a bit about the kinds of ways in which we can conceptualize integration as well as introduce our speakers. Kathy.

Kathy Reynolds:  Thank you very much, Alex and Trina; that’s very good. Appreciate your coming on today to provide some context from the federal level in terms of what’s going on.

Those of you who normally participate in these CODI Webinars may be thinking you’ve tuned into the wrong one given the content. But today’s Webinar actually provides us with a very unique opportunity to bring the work of the CODI TA Center together with the Center for Integrated Health Solutions. And I’m just very pleased to have that opportunity as a person who goes between the projects leading a community on bringing co-occurring services into primary care and then leading the Center for Integrated Health Solutions it provides a unique opportunity for me to help bring the projects together and help bring the work together.

Most of our work in the area of integration has been the integration of mental health into the primary care setting. But as you saw from Alex’s slide primary care clinics are doing expert services, they are providing substance abuse services and as we put together this Webinar one of our issues or one of the things we looked for was to try to find a substance abuse program that was providing primary care. So interim services and a whole series of things are required under the Block Grant finding a substance abuse program that could or would serve as a healthcare home is a new conversation in this discussion so that’s why this is such an exciting Webinar and why we needed that background from Trina and Alex to hear what’s happening from the federal level to make that happen. I don’t need to spend a lot of time on this slide because Trina already talked about why we’re doing this and the issues that come from that. I just want to do highlight that in fact 50% of the claims in low income primary care clinics tend to be coded for a behavioral health issue. So we need to be thinking about ways that we can bring mental health and substance abuse into the primary care setting. And those folks who have been doing it you’re going to hear from some of the leaders in the field here in just a minute — can talk about cost efficiencies and improved health outcomes that come from doing this. So what I want to talk about is when you think about integration you want to think about what your outcomes are that you’re looking for and what level of collaboration that you want to have. And this chart again, as some of Trina’s were, is a little bit hard to see. But integration is not one thing; and that’s the only point that I want to make before we get into our panel of speakers is that there’s not one model for doing this in fact there’s really four or five what we call strategies. And you’re going to hear from four of those strategies today from folks who have actually done this and will be working on this with you and be available to help you if you’re looking at doing this.

The fifth strategy is what I was talking about of actually having a substance abuse program implemented at the healthcare home. And we don’t have a model of that to do yet so that we’re hoping that those of you on the call today will sign in, log in, give us some information about that. So as you’re looking at doing integration you can go all the way from a fully integrated program where you have one set of services, one treatment plan, one reception area.

The other point I want to make on this slide is in the middle you can have basic collaboration on site or services on site even within the same organization and not have them integrated. And I think one of our speakers will talk about that particularly as we go forward. So I want to leave plenty of time for the speakers so what we have today is four people who have actually done this. We’re going to start out with Kim Shontz from Community Support Services in Akron, Ohio. And Kim’s program brought a private primary care provider into a community behavioral health setting. And again as you see the word behavioral health think mental health and substance abuse so they’ll talk a little bit about both of those aspects. We also then have from HealthLinc in Valparaiso, Indiana, Beth Wroble, who’s going to talk about how her federally qualified health center brought healthcare into a community behavioral health system and what that looks like. Stephanie Saunders from Chase Brexton Health System, an FQHC system in Baltimore had behavioral health in the FQHC but has been working with us in our learning community about bringing it more — in a more integrated fashion into the primary care setting. And then we’ll end with Karl Wilson from Crider Center. They were a community behavioral health center that actually became a federally qualified health center.

So as I’ve said we’ve got four models here and I’m going to turn it over now to Kim Shontz; has a master’s degree in social work and 30 years experience in the mental health field. And I’ve had the pleasure to work with Kim over the last almost three years as they’ve been developing their integrated health program. So, Kim, do you want to take over control of the presentation and talk about your integrated program and how you went about doing that.

Kim Shontz:  Thank you. Yes, I will — welcome all. We are located in Akron, Ohio, a large community mental health center. We have spent two years in the planning of our clinic and then we’ve been up and running for two years. So I’m going to spend about seven or eight minutes on four years so if there are questions, you know, feel free to add those later but I’m going to try to get through as much as I can. As I said we’re a large community mental health center. We decided to - we call it going it on our own. And we decided to bring some local groups together and see if we couldn’t develop primary care within our community health center. In the planning stage we did look at becoming a partner with our local FQHC. At the point where we were ready to jump off on that they were not ready to do that so that would have been a good option for us and it is for everyone it just didn’t work in terms of timing. And we did not want to wait so we really felt like this was important enough for us to move on and to try to do it on our own that we partnered with our local mental health board and we partnered with local universities, Northeast Ohio College of Medicine and Pharmacy as well as Akron University our large local university. And we brought a lot of these folks together as well as a local large provider of primary care sort of a consortium physician group and sort of brainstormed for two years to figure out how we could do this.

So we implemented this using a nurse practitioner from our local university which was an excellent fit because they also have a free clinic and so this person was kind of used to working in a similar kind of setting to ours and some crossover in the population. And then we used a physician from this large consortium to get started. The population we serve is about 2500 clients with severe and persistent mental illness predominantly schizophrenia and the schizophrenia spectrum disorders. And we looked at all clients being eligible for the integrated service. We currently have after two years a little over 600 consumers who are working in the integrated care clinic. And anybody with insurance was able to use this service. But what we’ve done is we’ve really tried to collaborate with a local free clinic and if a person who needs our service doesn’t have insurance we try to see them one time in the clinic and then bridge them over to that other clinic. And then we work very hard at getting them insured and them bring them back into our clinic so that ultimately they do end up here in terms of the integrated piece. I’ll say a little bit...

Kathy Reynolds:  Kim, what percentage of your consumers have a co-occurring diagnosis?

Kim Shontz:  We estimate conservatively 70% have a use or abuse disorder. At the point of their intake into our system they’re evaluated for both a mental health and substance abuse issues and then if they have co-occurring disorders they come to our agency. We do have a lot of services for co-occurring; we have a sort of a residential team that works with co-occurring disorders, a vast array of groups and other supportive services for folks with that co-occurring disorders.

Kathy Reynolds:  So those folks would be served in your integrated program?

Kim Shontz:  Absolutely. As a matter of fact a lot of the folks with the real chronic problems that we’re seeing are those co-occurring folks so yes they are being seen. So we’re basically looking at a — sort of a large scale collaboration with these local entities. And the other piece — when I keep saying integrated is we felt very strongly that our clinic needed to be truly integrated. So the offices literally sit within the mental health center and we actually designed it around being in the middle of the hallway where the psychiatrists are. So, you know, if you want to call them curbside consults or sort of, you know, hallway, you know, hey what about this. So we get a lot of that between the two disciplines and we planned that on purpose. We also have the lobby area that’s a combined lobby so people don’t come and sit in a different lobby if they’re here for integrated care of behavioral healthcare it’s all integrated.

The budget — total budget and budget for our integrated services — I kind of put that up there — we are right now in the process after two years — we had the great fortune to have a local foundation provide us with two years of startup for our nurse practitioner. And we have 20 hours a week of nurse practitioner and 6 hours a week of an MD. So we’re right now looking at our billings and developing what that’s going to look like. Actually that’s sort of coming in the next month or two. The integration strategy for us was again to focus on everything, the whole person. And what we have done is we have made it a priority for each client to have a goal on their treatment plan that addresses medical care.

In the past that often happened or didn’t happen depending on, you know, sort of, you know, who was in charge of the treatment plan and that’s now sort of an expectation across the board. It doesn’t mean they have to come to our clinic; obviously if clients still have a provider in the community that they, you know, that they have a relationship with we don’t want to undo that. But we do expect that that be on the treatment plan so we know we’re addressing it with each and every client. And that’s been different for us to make sure that that’s a priority. We do screen for mental health and substance abuse. And we also sought to integrate care including our intake and discharge planning process when it involves being new to the agency or when people are coming out of the hospital. We schedule at the point of intake we can schedule their physical healthcare.

We also schedule an appointment with an RN. We also schedule an appointment with a pharm-D — pharmacy person who’s basically on site working with us through the Northeast Ohio College of Medicine and she does medication reconciliation both at intake and at the point of discharge from either a medical or a psychiatric hospital stay. And that’s really been important in terms of making sure we have adequate information both from the medical hospitalizations and the psychiatric hospitalizations. And again that’s a little different twist for us really focusing on both rather than just the psych and behavioral health.

When we expanded to include all services we also included a lab and a freestanding pharmacy that’s embedded in our agency. Both of these are outside providers who we’ve contracted with and they have office space here. And they have been instrumental in making sure things are integrated. The other piece that truly integrates us is that we have a truly integrated record. We have an electronic medical record that has both the primary care case management, behavioral health, psychiatry, vocational, every service we offer are all using the same EMR. So at any given time any provider or practitioner can look at all of the notes so there’s not - you have to go look at a separate chart because that’s the primary care chart; it’s all in one. And that has really just occurred through 2010. Our psychiatrists were the last folks to kind of get on board with the EMR. And that has not been successful. Our opportunities have been that we’ve been able to expand services to our consumers that have been absolutely wonderful improving the quality of service coordination and the convenience to our consumers. And many of our consumers just rave about the fact that they don’t have to go two places to get care. And our nursing staff have been extremely supportive of the primary care collaboration. And then a huge opportunity for us has been that opportunity to collaborate with these local universities. We have nurse practitioner students, RN students and pharmacy students here pretty much all the time. And those are the future workforce that we’re looking towards to kind of move this forward.

And we’ve also been able to do a little bit locally with other agencies trying to do this same kind of thing in our state trying to sort of be an advisor to folks and that’s been a nice opportunity. The challenges we have faced have been largely in the billing process. We have, you know, a lot of expertise around the billing and — on the psychiatric side, behavioral health side but really didn’t have a lot of that experience. And it’s obviously a lot more in depth than billing, you know, there’s many more codes, many more procedures. And so our billing staff have really had to get up and running. And so my recommendation around this challenge would be if anyone was trying to do this on their own would be to use somebody early on as a consultant for that billing and coding. We did end up in the end of our first year consulting with an outside billing and coding and really getting some expertise. But I would do that from the front-end.

Another challenge we faced was in our state we were unable to bill Medicaid. We had to get a separate accreditation and that was AAAHC which is the ambulatory healthcare accreditation. And we chose to be accredited as a medical home. And that was a pretty rigorous survey process and it will be rigorous going forward in terms of the standards that we will have to meet to comply with the medical home. But it was an excellent learning experience going through that and meeting those standards really helped us become more of a medical home.

Again one of the benefits as well as the challenge was the EMR. The providers that we ended up having in our primary care just by chance did not have EMR experience. And so there was a struggle early on to develop that flow with being able to look the client in the eye but yet still use the computer because they didn’t have that experience. And so they really probably took longer early on with visits and really getting moving with the flow. I will say both have now really gotten good at this but it was quite a struggle early on.

Another thing that we struggled with is we did not have a registry for tracking patient diseases and outcomes when we started. And now we will be working in collaboration with the national council at implementing a registry. That’s coming to us here within the next month or two. And we’re really looking forward to having — be able to show because we know anecdotally that we have a lot of success with our clients but we can’t prove it and we don’t have the outcomes to prove it.

Kathy Reynolds:  Kim, this is Kathy. I’m going to need to move us along just so we give everyone a chance to speak here.

Kim Shontz:  Sure.

Kathy Reynolds:  So I — sorry we didn’t get to your financing slide but if you can wrap up here in just a few seconds that would be great.

Kim Shontz:  That’s fine. The financing slide sort of speaks for itself. And anyone who has questions can ask those at a later point.

Kathy Reynolds:  All right thank you very much.

Kim Shontz:  Thank you.

Kathy Reynolds:  Our next speaker is Beth Wroble from HealthLinc. Beth is the CEO with an interesting background as an engineer. So, Beth, would you talk a little bit about your integration with Porter-Starke and bringing healthcare services to folks in a community behavioral health setting?

Beth Wroble:  Yes, thank you Kathy and thanks for giving me the opportunity to talk about what I think is probably one of the more exciting things that we’ve done here at HealthLinc with our great community mental health center Porter-Starke Services. We’re located in Valparaiso, Indiana, Northwest Indiana about an hour from Chicago. And we’ve been partnering with Porter-Starke for over 10 years in some way or the other. We just didn’t know we were doing this.

The last six years, thanks to a grant — some seed money from the United Way of Porter County we were able to bring some of Porter-Starke staff — behavioral health consultant, LCSW, and a psychiatrist to our locations in — with primary care. And as we always like to say we put the neck back into the body. We were going along very well and in — two years ago they came to us and said would we consider bringing primary care to the community mental health center in about three different areas.

First they have an inpatient care that needed primary care; it’s an 18-bed inpatient unit. And they wanted us to be the primary care provider for that. They also have a methadone clinic and in the state of Indiana it’s a requirement that they have physicals before they start their methadone and then continue to get monthly checkups so we do that. And then we started working with their day treatment group. And we started as a pilot; we called it the Fab 5. We picked five of their most seriously ill mental illness patients but also had chronic diseases that went with them. We also — the potential group there is about 225 day treatment patients. Over at HealthLinc we have about 15,000 patients that we serve. Our budget at HealthLinc is about $9.3 million this year of which the reverse integration where we have providers over at Porter-Starke Services is about $88,000. The strategy we’re using the federally qualified health center partnering with our community behavioral health — community mental health center.

We started small. When we talk about strategy I think this is one of the things that we really did well. We started small and were ready to make mistakes. So like I said we picked the five chronically mentally ill patients that they had, day treatment, and we had to bribe them a little bit. At first they were a little apprehensive and we gave them gift cards for things that they liked to do. We did have some issues. We’ve added 25 more and we’re going to be adding another 40 of those patients. And we have — we ran into a couple of issues. One of the patients had gained 100 pounds the year before because of the meds he was on. So we started really teaching him about the — his weight and how it could affect his overall health. Well we didn’t realize it but we ended up sending him into inpatient which was not good so we had to make sure we were very careful when we addressed those health issues.

Over at HealthLinc again we started small; we started with one of our providers and one part time behavioral health clinician and we built up. We also screen for mental health and substance abuse at all our locations. And we’ve really spent a lot of time training staff before we added them into the system. Kind of the things that we did well too is we kept the state and federal stakeholders informed. To be able to do this we had to go back — we are a HRSA grantee — and we had to go back and ask for a change of scope. And I know that scares a lot of community health centers but it was really — we showed our project officer why we needed it. And it really isn’t as scary as they — that people think it is.

Indiana Medicaid allowed us to be able to change primary medical providers for these patients to HealthLinc. This was an issue because Indiana had just — Medicaid had started a one-year lock in so some of these patients that we wanted to take care of at Porter-Starke Services already had another provider so they allowed us to do that. And a lot of this was keeping them informed of what we’re doing. We have a very strong buy-in from top leadership at both organizations. We schedule weekly meetings. And we sit there and we talk about what we’re going to be doing for the next week. Like when we have visitors their first comment is we don’t know who is whose employee. And that was really what we were striving for because we are one team with the patient in the center. We’ve also found that to get qualified staff in there you’ve got to form the teams between the two organizations. And if you do that right you really start to see the outcomes. We documented health needs and improvement. And here’s just - with our group after two — about two and a half months here’s some of the things we were monitoring, weight, waist circumference, cholesterol, triglycerides, smoking status, exercise, PHQ-9, CAGE and GAD. And you can see as the health outcomes improved so did the screenings that we were doing so that was really promising and we’re continuing to monitor those.

We needed to — we realized we have to do a lot of education and training of both organizations. And that’s from the front desk on so that when we first started all this especially at HealthLinc the — we had some problems where staff were saying are you here for mental health or physical health and we said no that’s not acceptable; they’re here for an appointment. We also have struggled to find some of the employees who were up for the challenge on both sides. This is not your typical mental health or primary care operations and so we really had to — we had some false starts there too. We have found other areas of collaboration. One of the things that I didn’t even think about and one day I was walking by our dental clinic and our behavioral health consultant was over in the dental clinic because one of out dental patients was having anxiety attack about being at the dental clinic so they were in there working. And so now our dentists know that that’s something that they can call on. I believe this improved the financial stability of both organizations. Indiana has had some cuts on the community behavioral health center side. We’re able to do some of those services for them that they were cut. It also improves the efficiency of our medical providers. Instead of them having to — a doctor or nurse practitioner having to spend extended time because they thought that this patient here was for strep throat but it was really a mental health issue they can call in right there on the spot a behavioral health consultant to work with that consumer. Our electronic health records, it’s a little bit easier when they’re here at HealthLinc. We have both the behavioral health and the mental health providers using the same electronic health records so they can see everything. At Porter-Starke what we’ve had to do is use for — medical side use our medical EHR so we hooked it all up at their system. We print off the encounter form and the report and scan it into Porter-Starke so we need to work to make that more streamlined. I talked about finding the right staff for the opportunities. And there’s assignment of the consumers to the primary care provider other than HealthLinc but we’re able to get over that issue.

We — again for the severely mentally ill population we went to Medicaid we made — from the financing this is actually a very easy thing to do — we made it a site under our grant. We bill the nurse practitioner or primary care physician at our enhanced FQHC rate. And that also includes our nurse care manager that we bring over to — at Porter-Starke. Porter-Starke Service uses the Medicaid rehab option for the case management that they’re doing with the chronically mentally ill. At our — at HealthLinc the behavioral health into primary care we bill with the 96150 codes. What we do with our uninsured they only pay for the one visit on the medical side and we write off the other visit for the behavioral health side. It improves our productivity, again, our providers aren’t dealing — they’re dealing with the physical side and not the behavioral health side. And I believe that we’ve had better provider retention and we use it as a recruitment tool. We do have National Health Service Corp providers, loan re-payers, that’s been great. But we have seen as we start to interview providers here if we tell them that we have integrated behavioral health you can just see the light bulbs go off and I think it’s helped us recruit new providers.

And with that I think I’ve covered everything.

Pam Rainer:  Hi, Kathy, we can’t hear you if you’re trying to speak so if you’re having technical difficulty we’re going to turn over to (Laura Galbraith).

(Laura Galbraith):  All right thank you. We’ll go ahead over to our next presenter. As you can see here with her bio that’s on your screen Stephanie is the Director of Behavioral Health at Chase Brexton. Stephanie, we look forward to hearing from you about your program and work with co-occurring disorders. Stephanie if you’re with us if you can unmute your line.

Kathy Reynolds:  Hi, (Laura). Do you want to move onto Carl and we’ll see if we can get Stephanie back?

(Laura Galbraith):  That’d be great, thank you. So we’re going to come back to Chase Brexton. And at this time we’ll go to Karl Wilson from the Crider Center. Karl are you with us?

Karl Wilson:  Certainly.

(Laura Galbraith):  Welcome. As you can see here Karl Wilson is the President and CEO of Crider Health Centers which started as a community mental health center that became a larger safety net community health and mental health. And so we look forward to hearing more about your program.

Karl Wilson:  Let me start just by giving a little environmental context geography. We’re in the counties around St. Louis. We have a growing area that’s both a combination of suburban, small town and rural. We have within our four counties about 523,000 people. And of those our target population are the 88,000 plus who are uninsured. So we have — we have a total budget this year that we just started of $22.5 million. Of that about $6.8 million is for our integrated services. We have — our integrated strategy actually began about five years ago. We looked around the country for good models in terms of how to take care of the primary healthcare needs of the people that we were working with who were seriously mental ill and also even seriously emotionally disturbed kids. We even found that we had difficulties in getting dental care for kids that were seriously emotionally disturbed and had to drive long distances in order to get emergency care for them. And found that some of these kids we were helping them to get permanent teeth extracted which affected the rest of their life and their overall potential. So we felt that we needed to take a more holistic approach, our board changed our mission. And we went for FQHC status which we obtained about three and a half years ago. And over that period of time we’ve worked first on the establishing of the dental care and pediatrics and primary healthcare and integrating behavioral healthcare services and using (Cherokee) model embedding a behaviorist into the primary healthcare pediatric setting.

And as our speakers have already indicated, you know, that starts a level of creativity where your staff begins to get ahead of you. But some of the keys to some of the things that we’ve been doing is to have a centralized check in, you know, so that when people come in they’re — we’re going to be looking at people holistically. And this has taken a huge investment in terms of capital in order to be able to have these services brought together. At the beginning we had to have our dental clinic in some borrowed space and, you know, a mile away and that type of a thing. We also, getting the mental health professional and embedding them in the primary healthcare team, using the (Cherokee) model. We had to start out with grants in order to fund this. And we still have challenges in our state. A number of states don’t yet have the kinds of changes to their Medicaid system in order to have — to bill for those services on the same day. We’re still working with our state to make those changes. We screen every primary care patient. You’ve already heard that that’s integral to integration. We screen every psychiatric consumer for medical and dental needs. And we’ve adopted the electronic medical record and a medical record that’s capable of handling medical, dental and behavioral health. And there aren’t that many vendors out there providing an electronic medical record that can accomplish that.

So what we’ve been trying to work on is a one-stop shop for our consumers. And we have improved outcomes both on a physical side and certainly we’ve enhanced services for — on the pediatric and the primary healthcare side in terms of making the jobs easier for the — our primary care providers, our pediatricians and having a combined effort in terms of dealing with individuals’ (whole) problems. We have — this has led to these curbside consults as has been talked about before. But we also — we’ve seen that there are a number of challenges. And Kim may be ahead of this in terms of actually getting to a point where the EMR is paying off. We’re still finding that we’ve lost productivity.

And some of that is differential in terms of the cohort group. But we find that our primary care physicians and psychiatrists who have been trained a long time ago they’re having the greatest difficulty; those who are younger seem to be able to make the conversion much quicker. And that seems to have to do with the experiences that they’ve had in their training. But we’re committed to it and people are adapting. We also — there are huge costs on the electronic medical records side. And what we’re finding is that these costs are — have — that the record — the electronic medical record costs a lot more for, you know, for a vendor who is — moving from a vendor who’s only psychiatry and behavioral health to one who can handle all of this. So we’ve got some real challenges in terms of those increased costs. We’re also moving towards meeting the NCQA standards for becoming a medical home. We feel like that’s going to be critical for our future in terms of payment and also in terms of being able to carry forward with our model. We’re also moving forward on the wellness side in terms of integrating recovery and wellness together with community support workers now moving towards becoming health coaches and health navigators. We’ve worked very hard on the cultural changes that are needed and it’s taken us all of the four years that we’ve been working on this to get to the point we’re at and we’re not completely there yet. We have workforce recruitment issues and actually we’re close to a number of training sites. And so I know our rural peers are even having bigger problems with that. We’re also — our grants that have helped us to move to this point are drying up. We’ve — although on the capital side we’ve found that we were real fortunate in our timing and be able to tap into the kinds of funding that we need in order to build adequate spaces in order to do this integration. But it is a heavy commitment. And we’re going to be continuing to make that.

So we look at integration as being a process that will take us a generation. We will continue to work towards, you know, taking all these steps but it doesn’t happen in a year, two years or five years.

Kathy Reynolds:  Okay thank you very much Karl. This is Kathy Reynolds. I apologize to folks I got cut off the line and I apologize to those of you who have also been cut off a number of times so we’re working with the technology here to make that not happen. So but thank you very much for your presentation. And then Alex were you going to summarize the presentations for us?

Alex Ross:  We were hoping to bring Stephanie back on the line. Stephanie did you — were you able to hook back into the call?

Stephanie Saunders:  Yes I am reconnected so...

Alex Ross:  So we only have about 15 minutes left but, Stephanie, if you could take five minutes and then Kathy you could just open it up for questions right after Stephanie’s comments.

Kathy Reynolds:  Okay thank you.

Stephanie Saunders:  All right. Well it’s nice to be reconnected, speaking of challenges communication is important so it’s good to be back.

So I’m Stephanie Saunders. I’m the Director of Behavioral Health at Chase Brexton Health Services. We’re located in Baltimore, Maryland. And I also have Dr. Robin Mulligan with me. She’s a psychologist who’s played a very important role in both coordinating and providing the integrated services in our primary care clinic. Just a little bit about us so you can, you know, place what we’re doing in context. We were founded in 1978. We’re a private nonprofit agency. And we’ve really grown by leaps and bounds over the decades.

We started off focusing on the needs of the gay, lesbian, bisexual and transgender community and our patient population has become increasingly diverse and the majority of our patients are dually if not triply diagnosed. We serve 14,000 Maryland residents annually. And the type of services that we provide, primary care, dental care, case management, behavioral health. We have an in-house pharmacy which really allows us to address multiple needs at once. With respect to my department we have an addictions program, mental health, psychiatry and behavioral medicine services. We have 18 clinical staff, psychologists, social workers and licensed clinical counselors. Our behavioral medicine program is the focus of today because it’s really created another pathway for primary care patients to receive much needed intervention in a nonthreatening way within the context of their medical appointment. Prior to this project our behavioral medicine services weren’t routinely provided within the general flow of the primary care setting.

With respect to our target population if somebody can move the slide to the one that says the majority of consumers have co-occurring disorders that would be great.As I mentioned before our patients are diverse. But we really focused on finding common themes among them such as being dually diagnosed with respect to mental health and substance abuse disorders and multiple medical issues. And given our overall need our question was how do we focus the resources that we have? And we really decided to target patient’s challenges with adherence, their barriers to self care which we were hoping would have a positive ripple effect across the continuum of care.

Our thinking was if this — these challenges were present in one appointment likely affects others. And we found that adherence issues are influenced by this proceeded stigma of mental health treatment. Often our patients could have multiple services in one day because of their special needs and that really impairs follow up. So our current B-Med project really tested the utility of re-screenings assessments which was primarily identifying the patient’s stage of change to inform whether or not the intervention ended to be educational or action oriented. And innovations — I’m sorry, interventions with the primary care patients occurred immediately following the medical appointment. And this was not to replace our traditional mental health services but certainly to supplement them with the goal to be more fully integrated as time goes on. Our behavioral medicine providers were introduced to the primary care patients as a consultant who were available for education and intervention. And we were pleased to find that our — the patient’s primary care physician was a good starting point and their relationship with the patient likely transferred to the perception of the behavioral medicine provider because all patients asked agreed to the consultation.

If we can just move to the slide that says opportunities that would be great. And really we found that small steps contributed to considerable gains. We started to integrate more at the administrative level such as at meetings and use that information to determine the best point of entry of introduction of our services. We’re a large system and that certainly has its benefits but also its challenges in terms of integration of care. And we are located in separate buildings just right around the corner so we really needed to learn what medical was doing. And they needed to learn how we could help them. So we shadowed them, spoke with them following appointments to see how we might have been helpful for that patient. Primary care office space is an issue since we’ve grown rapidly. So our B-Med provider had a separate office right in close — it was adjacent to the medical facilities. And what would happen...

Kathy Reynolds:  Stephanie, what is a B-Med provider? And then this is Kathy we only have another minute or two, I’m sorry, for the technical problems...

Stephanie Saunders:  Okay.

Kathy Reynolds:  ...but we have to have some questions.

Stephanie Saunders:  Sure. A behavioral medicine provider is a B-Med provider. So we introduced the services gradually. And as I mentioned before there was many positive results both for the patient and the provider that the providers experienced just the rewards of the immediate affect of intervention because there was something they could do with each patient. The patients found the services — they reported them to be helpful and empowering. That they left with something they could do that day or just think about to improve their emotional or general mental health and physical health. We actually were requested to provide services in our suburban sites. We have four different sites which is great but it’s also a challenge because we don’t have the resources to do that right now. We’re not being fully utilized unfortunately in the downtown office; we’re seeing 2-3 patients when the goal is 8-10. Our goal eventually is to have a building that houses all services which will help us to lead to more fully integrated care.

And that’s what I have. So Kathy it sounds like you have...

((Crosstalk))

Kathy Reynolds:  Thank you very much, Stephanie.

Stephanie Saunders:  You’re welcome.

Kathy Reynolds:  Apologize for the technical problems. And look forward to answering some questions. We do have a few questions that have been typed in. And then, Alex, I’m going to take a few questions and then turn it back to you for a summary. And one of the first questions actually would go to Trina and Alex. It was, "Are grant dollars available for a behavioral health organization to start a medical primary care practice and a community behavioral health site?" And I think, Trina, that’s a question that came in while you were talking about the primary care behavioral health initiative grants. And then, Alex, you may want to respond to that with the new initiatives as well.

Trina Dutta:  Sure, this is Trina with SAMHSA. We don’t actually have any funds for awarding new primary and behavioral healthcare integration grants right now. Who knows what will happen. We’re always hoping we’ll get more money so that we can award more grants. I would definitely — in Alex’s slides he included a link to the SAMHSA grants page and I would definitely take a look at that because that’s updated. You’ll see if we do end up having a new grants program that would be where you would find that out if there was going to be another round of applications. What I will say though is I’d encourage folks who are interested in this work to get in touch with the Center for Integrated Health Solutions. And you can get to that Website through the National Council’s Website. That’s a resource for you to get information on a whole variety of different things. It’s not funding per se but it is technical assistance and it could be in the form of information or training or a variety of different things.

So in the mean time — but while we don’t know about further funding I would definitely take advantage of the Center for Integrated Health Solutions.

Alex Ross:  This is Alex. Just to be real brief because we want to take questions. Remember I had suggested earlier on that we went through a process of requesting applications for new health centers and expanded capacity in existing health centers. On the HRSA side it would be through the community health center program that would want to partner with a behavioral health organization to establish a community health center site within that behavioral health organization meeting all of the criteria that a health center has to meet to establish a new site. That’s if you wanted to build capacity through the health center program. That would be the way our funding could extend out into the behavioral health community. My thought here is to, for those who are interested, to start a dialogue with the health centers in your geographic area and talk about those possibilities. And then as you heard from the examples today see what fits best for your circumstance.

Kathy Reynolds:  Good. And then we have a question here for the panelists. If you could speak to the prevalence of people over 60 that are served in your programs? And we’ll start Beth — what’s the present of older adults in your programs?

Beth Wroble:  Sure. At the health center we serve all ages. And especially our adults with diabetes we’re really working to have not only the behaviorist but a pharmacist and get their diabetes under control. So that’s where we use probably the most of our behavioral health changes with our over 60 patients.

Kathy Reynolds:  Okay and then Karl or Stephanie, your percent of older adults in the programs?

Karl Wilson:  This is Karl. We don’t have a particularly large percentage of elderly people but it’s increasing without our doing any marketing because of — just the demographics of the population we’re working with. As we’re helping people to live longer or seriously mentally ill that population we’re following them, you know, in terms of whatever site that they’re in. So we’re dealing more with nursing homes again; for years we’ve been working to try and get people out of nursing homes and now we’re finding we’re dealing more with them. But in terms of the general population it’s under 10%.

Kathy Reynolds:  Okay. And then I have another question here. Kim, if you would take the first shot at this. Are both the primary care physicians and behavioral health providers working in the organization using the same screening instrument? And then what screening instruments are you using as providers? So the question is are both the mental health and — or behavioral health and primary care physicians using the same tools and what are those tools?

Kim Shontz:  Actually everybody who comes into our agency gets initial screenings that are by an intake staff, a licensed independent social worker. And they both work off that same instrument. So when somebody new comes to the agency they both have access to that instrument and they both use the same record so they can see it. And I’ll speak quickly to the geriatric piece. We do have a gerontologist psychiatrist so we have a very large population; she works in nursing homes and assisted living. And we have a lot of those in our primary care and it’s been working very well.

Kathy Reynolds:  Okay. Other questions, Beth or Stephanie, what tools are you using to screen?

Beth Wroble:  Sure, this is Beth. We’re using the PHQ-9 for all our patients. And then they’re using the GAD and the CAGE.

Kathy Reynolds:  The GAD stands for...

Beth Wroble:  I should know what it stands for...

Kathy Reynolds:  Globalized Anxiety Disorder Scale.

Beth Wroble:  Yes, for anxiety. It depends — yes, and they — depending on what the BHC sees then they add those to it.

Kathy Reynolds:  Good.

Stephanie Saunders:  And at Chase Brexton we use the PHQ-9 as well.

Karl Wilson:  Same thing for Crider Health Centers.

Kathy Reynolds:  Okay so for depression and then are folks using the CAGE-AID for substance abuse screening?

Karl Wilson:  Right, yes. You know, we’re...

Kathy Reynolds:  Okay.

Karl Wilson:  ...we just began working with the (SPERT) and we’re implementing that across the agency.

Kathy Reynolds:  Okay I have — we’re running out of time here and I do want to give Alex a minute or two to summarize and then I want to turn it back over to Pam. There are a number of questions about where the slides will be made available online. There are also some questions specifically asking people what technology product they’re using. On the screen right now you can see the email addresses of all the presenters. And so I would encourage you if you want to know what electronic medical record they’re using to email those folks directly to get that information. And really appreciate, from my perspective, this is Kathy again, appreciate everyone’s participation. And I’m going to turn it over to Alex for a brief summary of what we’ve heard here today and then back to Pam to close the conversation with where people can get access to the recording and the slides in the near future. So Alex.

Alex Ross:  Well just very briefly what this call reflected — what this Webinar reflected to me was just the tremendous effort made by providers in communities to recognize the need to collaborate as effectively as they can and to meet the needs of those individuals who are coming in for the care that they really deserve to get from providers in the safety net. And I applaud you for that.

And I know there are others on the call that are doing the same thing in their own way. What I hear is just the work we need to do at the federal level to assure that our financing, that our workforce, that our policies, that, you know, issues around the electronic records, that as much as possible we effectively serve the needs of communities so that you can do this important work as well as possible so I thank you for that.

And I think this call has been extremely rewarding.

Pam Rainer:  Okay thank you so much, Alex, for that. In closing I would like to thank everyone in our audience today again for your time and your interest in this very important topic. We have received several requests about whether or not this will be available and it will be available on the Website and the address is right there on the screen for you. It will take a little while before it’s posted but it will be — the complete archive will be posted as well as a transcript and the PowerPoint so you will definitely have that available to you. We’d also like to thank Trina Dutta from SAMHSA and Alexander Ross from HRSA for providing the federal landscape in this area. We also thank our SAMHSA project officers who helped shape the content, (Charlene Le Fauve) and (Onaje Salim) and to John O’Brien, SAMHSA’s Strategic Initiative Lead for the healthcare reform implementation.

And again a special thanks to our facilitator, Kathy Reynolds and our esteemed presenters, Kim, Beth, Stephanie and Karl for reaching across the airwaves and bringing us information on the different models of integration. We really appreciate what you’ve provided us today. Again all participants will receive a follow up email with a link to an evaluation form. We really appreciate you taking the time to complete that. Your feedback helps us do our jobs better and helps develop future Webinars. And again we thank everyone for your time today. This concludes our call. And we hope you have a wonderful day.

Coordinator:  Thank you for your participation on today’s conference call. At this time all parties may disconnect. Speakers, please stand by.

END