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Health centers have historically held a holistic view of patients. Challenges of stigma, privacy, and a siloed approach to treatment have in the past created barriers to this holistic approach. As more health centers are breaking down those barriers, collaboration with or integration of behavioral health care has been strengthened, although data integration remains difficult. This brief discusses some of the approaches, successes, and challenges in integrating behavioral health data within primary care services.
Models of Behavioral Health Collaboration + Integration
The Center for Integrated Health Solutions (CIHS), a program funded jointly by HRSA and SAMHSA, has developed the Standard Framework for Levels of Integrated Healthcare. Many health centers find this framework useful in order to think about the way care they provide is currently organized in relationship to the behavioral health services that their patients are receiving, and how they would like to approach such 
patient care in the future.
Changing Models and Implementing New Workflows
A number of factors can influence a health center’s decision to change or add additional framework models. These factors can include better serving the patient population, changes in the services available within the community, or shifts toward value based care. Medicaid, Medicare, and private payers all have a number of different bundled payments, incentive programs, Accountable Care Organizations, and other models of value based payments. These factors create added incentive to increase Behavioral Health collaboration and integration. Health centers can seek foundation grant support as many states and health centers have as well as federal government funding to support such integration activities. For example, in 2014 HRSA released $54.6 million in mental health funding. In 2017, SAMHSA announced $110 million in funding of integrated primary and behavioral health services. As health centers consider how they might change or augment their current service model, it might be helpful to utilize the Center for Integrated Health Solutions’ Quick Start Guide to Behavioral Health Integration for Safety-Net Primary Care Providers. This Quick Start Guide helps health centers think through areas of administration, workforce, clinical practice, and technology with a number of useful links to resources.
Integrated behavioral health services take time to plan, implement, and become profitable. In their primary care clinics, Intermountain Healthcare, a health system based in Salt Lake City, Utah, has developed a model for Mental Health Integration within their primary care sites. Their model has five major components, and has been implemented in more than 130 sites. At this stage in their development, Intermountain estimates that it takes two years to implement a program and have it to become revenue-neutral or -positive.
It is important to have a change management process that has strong leadership support and engages many of those that will be involved in the implementation, operations, management, and evaluation of any significant change. Zufall Health has an Integrated Behavioral Health Task Force, which focuses on the integration work of the health center. The health center recently decided to implement the GAD-7, an anxiety screening tool, within primary care. In a recent interview, Dr. Rina Ramirez, Zufall Health’s Chief Medical Officer, said: “We like to have the team together figure out how we’re going to use [the GAD-7], who’s going to use it, and how we’re going to monitor [its usage].”
Integrating Data Internally
Adoption of EHRs has been nearly universal for health centers: as of 2016, 95% of Federally Qualified Health Centers actively use an EHR. Health centers have employed different means to configure their EHRs to enable behavioral health providers to document the care provided to their patients. A Journal of the American Board of Family Medicine article highlighted a number of primary care practices using EHRs that integrated primary care and behavioral health. The EHRs used in these practices were: Allscripts TouchWorks, eClinicalWorks, e-MDs, GE Centricity, Health Connect, NextGen, and Siemens EDM.
In configuring an EHR and granting access rights, health centers must consider 42 CFR Part 2, which protects substance use data about a patient, as well as HIPAA’s Privacy Rule, which protects psychotherapy notes. In 2017, the HITEQ Center conducted a webinar on 42 CFR Part 2, which can help guide a health center to be compliant.
Zufall Health uses eClinicalWorks (eCW) as its EHR. When they implemented the EHR in 2009, it did not have a specific behavioral health module, so Zufall Health modified eCW’s Subjective, Objective, Assessment, Plan note (SOAP note) to fit the model of documentation needed for behavioral health - a practice they also used for their dental services. As the behavioral health department grew, they added standardized screening and assessment tools. As Brian Whang, Zufall Health’s Chief Information Officer, said in a recent interview: “We started using specific assessment tools… that we built into eCW as structured data fields, so [that management] can pull any type of report that is necessary from that structured data field.” Now that eCW has a behavioral health module, Zufall Health is evaluating whether to adopt it. One consideration, according to Brian Whang, is that “putting in a brand new module with different bells and whistles [will] end up changing our workflow. The workflow we’ve implemented now just seems to work very nicely. Our LCSWs are all comfortable with it. They get trained with the structured data fields to do their assessments.” Health centers need to consider the tradeoffs anytime they consider upgrading or switching EHRs.
Central City Concern is a nonprofit agency in the Portland, Oregon metro area serving single adults and families who are impacted by homelessness, poverty, and addiction. Since its founding in 1979, it has developed a comprehensive continuum of services focused on housing, medical care, and employment and vocational services for the 14,000+ individuals they serve. They use GE’s Centricity as their EHR, and have found it flexible enough to meet their needs. They have adapted the EHR so it’s more modular, and better suits the function of the different clinical roles. In a recent interview, David Caress, Central City Concern’s Director of Quality Management, spoke about how they added a new EHR assessment as the EHR was being implemented within their Substance Use Disorder Services (SUDS) programs. “There’s not one solution that fits all [programs], so we have to figure out how we can make [the EHR] modular.” The EHR now has a SUDS Assessment in addition to the Mental Health Assessment which was already built in the EHR. “The domains are a little different … because the ASAM criteria is different than a mental health workup.” Central City Concern continues to think through how they can cross-populate some of the data in the future, or even build an integrated assessment that covers both SUDS and mental health.
As a multi-service organization, Central City Concern has additional data systems beyond an EHR. For their housing clients, the data is tracked within HUD’s Homeless Management Information System (HMIS). Jeremy Wood came to Central City Concern as their Chief Information Officer in Fall 2015. Under his leadership, Central City Concern built a data warehouse to synthesize the EHR, HMIS, and other databases, using Microsoft Business Intelligence. David Caress says, “It is much easier now to slice and dice our data as we wish, across programs, by client.” The data warehouse also facilitates easy, consistent reporting. A recent priority of Center City Concern was timely documentation, defined as a note being completed within 72 hours of a visit. The data warehouse has allowed Central City Concern to regularly share with providers the percent of charts where notes were completed. In the year after Central City Concern rolled out dashboards to clinical supervisors and managers “the rates have improved dramatically—more than 15%”, according to David Caress.
Zufall Health has invested in IT to improve their reporting and data capabilities. They use BridgeIT, Excel, and Tableau. BridgeIT is a reporting application that Zufall Health uses to report out to Excel; then they pull the Excel reports into Tableau, a business intelligence and data visualization tool. Zufall Health has a process where they prioritize five clinical areas each year, convening task forces for each area. According to Dr. Ramirez, Zufall Health’s CMO, Tableau allows management and the task forces to “focus on those areas we need to improve, and energize the team to review the data and make the necessary changes so that we get better at… whatever it is that we’re measuring.”
Changing Care Through Collaboration and Integration
As mentioned earlier, Zufall Health wanted to provide better access to primary care for the patients with Serious Mental Illness who were receiving services at Saint Clare’s Behavioral Health. In order to do so, they needed to address some of the patient barriers: lack of social support, transportation, low income, mistrust, and fear. After the Patient Navigator had been embedded at Saint Clare’s for a period, they realized that each part of the system needed education: the primary care providers needed to learn more about the patient’s perspective on care and how to address problems; the behavioral health staff needed to learn more about the Zufall Health system; and patients needed to learn more about health, illness, and how to become more empowered to communicate their needs to their care team.
After testing a few different models, Zufall Health has settled on its current model of having the Patient Navigator onsite at Saint Clare’s full-time, and the medical van coming once weekly with a consistent care team to see patients. This model has best balanced the need for access, continuity, and enough visits to support productivity goals. The model succeeds because of the Patient Navigator. “She’s the key to our integration right now,” Dr. Ramirez says. “She’s the communicator and the link.”
Saint Clare’s and Zufall Health have a Business Associate Agreement and Data Agreement that allows them to collaborate and share data. Saint Clare’s has yet to implement an EHR. The Patient Navigator receives a written intake form for each co-managed patient from Saint Clare’s, which is then faxed to Zufall Health and scanned into the EHR, where clinicians can access the image. The treatment summary includes key data such as diagnosis, medication, and treatment plan. The Patient Navigator has full access to the Zufall EHR while at Saint Clare’s, using a laptop to connect remotely. The navigator can schedule or reschedule appointments, create flags, and message providers. The navigator also organizes specialty appointments for co-managed patients to minimize the number of trips necessary. After a medical visit, the navigator prints the visit summary and other pertinent clinical data, which is added to the patient’s paper chart at Saint Clare’s. Zufall Health and Saint Clare’s also developed a protocol to ensure consistent communication between them. The Fast Fact Form is an example; in addition, the Patient Navigator arranges communication between the assigned clinicians at Saint Clare’s and Zufall Health in order to discuss any specific issues about co-managed patients.
The co-managed patients are also flagged in eCW. This allows for reporting on the clinical outcomes of the patients. The co-managed patients “are doing better with hypertension and diabetes management than our general population, and we have increased screenings in cervical cancer and colon cancer”, according to Dr. Ramirez. From 2013 to 2017, the proportion of co-managed patients with controlled blood pressure increased from 48% to 80% - which was better than the general patient population, who had a rate of 75%. Likewise, 77% of co-managed diabetic patients had controlled diabetes, compared to 73% of the general patient population. Lastly, cervical cancer screening rates for the co-managed patients went from 52% (2013) to 70% (2017). Dr. Ramirez summarizes, “We can demonstrate the value of this program to our patients, our funders, our staff.”
Conclusion
Health centers can find creative ways to increase the collaboration and integration of Behavioral Health services within primary care. Careful planning can create data systems that support the work that is being done, and can provide outcomes data to show results.
As you consider what changes you might want to make to your models of care, also spend time thinking about how to capture data that will help you understand the success and challenges of any new program.
The Center for Health Care Strategies has an in-depth resource - Integrating Physical and Behavioral Health Care in Medicaid Toolkit - which can help your health center examine integration from many different angles.
Another resource you may find helpful is Best Practices for Sustaining Behavioral Health Integration Models in Health Centers using Health Information Technology.