cihs health homes core clinical features

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Behavioral health homes For

PeoPle With mental health &

suBstance use conditions

the core clinical Features

May 2012


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2SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS, MAY 2012

A c k n o w l e d g e m e n t s

acknowledgeMents

Behavioral Health Homes or People with Mental Health & Substance Use Conditions: The Core Clinical Features was developed

or the SAMHSA-HRSA Center or Interated Health Solutions with unds under rant number 1UR1SMO60319-01 rom SAMHSA-

HRSA, U.S. Department o Health and Human Services. The statements, ndins, conclusions, and recommendation are those o the

author(s) and do not necessarily refect the view o SAMHSA, HRSA, or the U.S. Department o Health and Human Services.

Special thanks to Laurie Alexander, PhD, Alexander Behavioral Healthcare Consultin, and Benjamin Druss, MD, MPH, Rollins School

o Public Health, Emory University, or authorin the document.

saMHsa-HRsa centeR FoR IntegRated HealtH solUtIons

The SAMHSA-HRSA Center or Interated Health Solutions (CIHS) promotes the development o interated primary and behavioral

health services to better address the needs o individuals with mental health and substance use conditions, whether seen in specialty

behavioral health or primary care provider settins. CIHS is the rst national home or inormation, experts, and other resources

dedicated to bidirectional interation o behavioral health and primary care.

Jointly unded by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Adminis-

tration, and run by the National Council or Community Behavioral Healthcare, CIHS provides trainin and technical assistance to 64

community behavioral health oranizations that collectively received more than $39 million in Primary and Behavioral Health Care

Interation rants, as well as to community health centers and other primary care and behavioral health oranizations.

CIHSs wide array o trainin and technical assistance helps improve the eectiveness, eciency, and sustainability o interated

services, which ultimately improves the health and wellness o individuals livin with behavioral health disorders.

1701 K Street NW, Suite 400

Washinton, DC 20006

(202) 684-7457

[email protected]

www.interation.samhsa.ov


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A c k n o w l e d g e m e n t s

table oF contents

ACKNOWLEDgEMENTS........................................................................................................2

SAMHSA-HRSA Center or Interated Health Solutions ................................................................2

Executive Summary ...........................................................................................................4

Behavioral Health Homes or People With Mental Health & Substance Use Conditions ........................7

Introduction ..........................................................................................................7

Health Homes and the Aordable Care Act....................................................................7

Patient-Centered Medical Home..................................................................................8

Four Principles o Eective Care ......................................................................................... 10

Clinical Features o the Behavioral Health Home ..................................................................... 12

Framework: The Chronic Care Model........................................................................... 12

Sel-Manaement Support.................................................................................. 13

Delivery System Desin .......................................................................................... 15

Practice Team .................................................................................................15

Care Manaement............................................................................................ 17

Decision Support.................................................................................................. 20

Access to Medical Specialists ............................................................................. 20

Embeddin Clinical guidelines ............................................................................ 21

Clinical Inormation Systems ................................................................................... 22

Community Linkaes .............................................................................................. 24

Structurin the Behavioral Health Home ............................................................................... 26

In-House Model .................................................................................................... 26

Co-Located Partnership Model ................................................................................. 27

Facilitated Reerral Model ....................................................................................... 28

Conclusion ................................................................................................................... 29

Appendix A: Compendium o Tools Reerenced in Report........................................................... 30

Appendix B: CMS Health Homes guidance............................................................................. 31

ENDNOTES .................................................................................................................... 60


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eXecUtIVesUMMaRy

eXecUtIVe sUMMaRy

The 2010 Patient Protection and Aordable Care Act (ACA) established a health home option under Medicaid that serves enrollees

with chronic conditions. Behavioral Health Homes or People with Mental Health & Substance Use Conditions: The Core Clinical

Features proposes a set o core clinical eatures o a behavioral health home (i.e., a behavioral health aency that serves as a health

home or people with mental health and substance use disorders). It provides context to the development o the health home optionand its relationship to the person-centered medical home; outlines established principles o eective care and the chronic care model

or servin people with chronic illnesses; applies the chronic care model as the ramework or the behavioral health homes clinical

eatures; and describes multiple oranizational models or structurin the behavioral health home.

HealtH HoMes

Federal health home uidance lays out service requirements stemmin rom the ACA and well-established chronic care models.1 The

required services (also termed provider standards in the uidance) include:

YEach patient must have a comprehensive care plan;Y Services must be quality-driven, cost eective, culturally appropriate, person- and amily-centered, and evidence-based;

Y Services must include prevention and health promotion, healthcare, mental health and substance use, and lon-term care

services, as well as linkaes to community supports and resources;

Y Service delivery must involve continuin care strateies, includin care manaement, care coordination, and transitional care

rom the hospital to the community;

Y Health home providers do not need to provide all the required services themselves, but must ensure the ull array o services

is available and coordinated; and

Y Providers must be able to use health inormation technoloy (HIT) to acilitate the health homes work and establish quality

improvement eorts to ensure that the work is eective at the individual and population level.

Individuals served by a health home must have one or more chronic conditions such as a mental health or substance use condition,

asthma, diabetes, heart disease, or be overweiht. Reardless o which conditions states select or ocus, states must address mental

health and substance use disorders prevention and treatment services and consult with the Substance Abuse and Mental Health

Services Administration (SAMHSA) on how it proposes to provide these services.

The Medicaid health home option oers the opportunity to create a behavioral health-based health home or people with serious

mental health and substance use disorders. The challene or behavioral health aencies is how to create a behavioral health home

that serves not only as an administrative entity, but also possesses the capacity to improve consumer outcomes.

FoUR PRIncIPles oF eFFectIVe caRe

For health homes to work eectively, they must apply principles o quality care delivery. At a 2011 summit on interation o care

sponsored by the Advancin Interated Mental Health Solutions Center (AIMS) at the University o Washinton, health systems experts

articulated our principles o eective care that can inorm the development o care in eneral and health homes in particular.2 These

principles, detailed below, apply to any primary care, mental health, or substance use treatment settin with the Triple Aim o improv-

in healthcare, containin costs, and improvin health outcomes.

8 Person-centered care. Basin care on the individuals preerences, needs, and values. With person-centered care, the

client is a collaborative participant in healthcare decisions and an active, inormed participant in treatment itsel.

8 PoPulation-based care. Strateies or optimizin the health o an entire client population by systematically assessin,

trackin, and manain the roups health conditions and treatment response. It also entails approaches to enain the

entire taret roup, rather than just respondin to the clients that actively seek care.


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eXecUtIVesUMMaRy

8 data-driven care. Strateies or collectin, oranizin, sharin, and applyin objective, valid clinical data to uide treat-

ment. Validated clinical assessment tools monitor response to treatment and inormation systems such as reistries track

the data over time.

8 evidence-based care. The best available evidence uides treatment decisions and delivery o care. Both the behavioral

health aency and its health provider partner (i applicable) must deliver evidence-based services.

clInIcal FeatURes oF tHe beHaVIoRal HealtH HoMeConsumers o mental health and substance use treatment services typically receive the bulk o their care in a settin such as a com-

munity mental health center. Many o these individuals may be unable or unwillin to receive care in a primary care clinic and even

when they do, coordination between behavioral health and medical services may be poor. Thus, it has been arued that or those

individuals who have relationships with behavioral health oranizations, care may be best delivered by brinin primary care, preven-

tion, and wellness activities onsite into behavioral health settins.3

The Chronic Care Model provides a useul oranizin ramework or behavioral health homes and has been proposed as an oranizin

ramework or health homes in eneral4. As with the AIMS principles, the ollowin eatures o the chronic care model apply enerally

to improvin healthcare and health outcomes and containin costs or persons with mental and substance use conditions. 5

8 self-management suPPort. Activated consumers possess skills to sel-manae their care, collaborate with providers,

and maintain their health. The behavioral health home helps activate consumers by assessin their activation level and thenaddressin decits throuh sel-manaement support strateies that include both education and coachin components.

8 delivery system design.The behavioral health home redesins the care system in key ways, includin the ormin mul-

tidisciplinary practice teams and providin care manaement. Providers work as part o a team responsible or addressin

consumers comprehensive care needs. Whether housed under one roo or stationed in dierent settins, team members

must unction as a sinle unit, which means maintainin clear roles, a sinle care plan, eective communication, and mecha-

nisms or coordinatin care between team members.

Care management, a component o delivery system design, is a key strategy or ensuring that consumers do not all

through the cracks. Consumers most likely to benet will include those living with a mental health and/or substance

use disorder with higher utilization o services and those living with numerous comorbid conditions. Care manage-

ment ocuses on client activation and education, care coordination, and, when working with a treating provider, moni-toring consumers participation in and response to treatment.

8 decision suPPort. Involvin specialists and embeddin evidence-based uidelines in the routine provision o care are key

decision support strateies or ensurin that clinical care is provided in line with best practices.

8 clinical information systems. Clinical inormation systems oranize population-level data to maximize the outcomes

or a dened roup o consumers. They also oranize consumer-level data to optimize individual outcomes. A patient reistry

is an inormation tool that enables eective trackin o all consumers with a particular condition or set o characteristics

seen in a practice. Electronic reminders are a key unction o eective clinical inormation systems, alertin providers to is-

sues that need attention at the consumer or population level such as when consumers need a preventive procedure, like a

colonoscopy.

8 community linkages. Behavioral health homes aument the services they can oer by linkin consumers to communityresources such as peer support oranizations, sel-help roups, senior centers, exercise acilities, and home care prorams.

stRUctURIng tHe beHaVIoRal HealtH HoMe

The uidance rom the Centers or Medicare and Medicaid Services (CMS) reardin the Medicaid health home option indicates that

health homes do not need to provide the ull array o required services themselves, but must ensure such ser vices are available and

coordinated. This ives a behavioral health aency several options or how to structure the behavioral health home, dependin on its

resources (e.., physical acilities, number o consumers served, available workorce, nancin options, community partners).


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eXecUtIVesUMMaRy

In the - , the behavioral health aency provides and owns the complete array o primary care and specialty behavioral

health services. The aency must ensure communication across providers and service coordination that allow it to deliver care that

is interated rom the consumers perspective.7 Havin all the necessary providers under one roo does not uarantee that they will

work toether to provide health home services eectively, just as the interated primary and behavioral healthcare literature has

demonstrated that co-location alone does not ensure true interation.

For behavioral health aencies without the capacity or desire to provide all services in-house, partnerships with outside healthcare

providers can still make the behavioral health home easible. In a - pp , the behavioral health aency ar-

ranes or healthcare providers to provide primary care services onsite. The co-located partnership approach may be particularly

appropriate or mid-sized oranizations that have the inrastructure to develop partnerships but lack the resources and economies o

scale to develop an in-house model.

A third structural option is a . In this approach, most primary care services are not provided onsite at the

behavioral health aency; however, the aency has processes in place to ensure the coordination o care that is provided osite. The

aency conducts physical health screenins, links clients to primary care providers in the community, and acilitates communication

and coordination between the behavioral health aency and health providers typically with the support o a medical care manaer.

given the low cost and relative fexibility o the acilitated reerral model, such a structure may be most easible or smaller aencies

and may also serve as a transitional model or those that intend to implement co-located partnership or in-house models in the uture.

conclUsIon

The CMS Medicaid health home option oers an opportunity or behavioral health aencies to optimize the overall health and well-

ness o clients, build on the experience they have been developin in interated healthcare, and carve out an important niche in the

evolvin healthcare system. Becomin a behavioral health home will require a major shit in the roles, processes, and care an aency

provides. It will require embracin (or or some, strenthenin) a new culture o care based on key principles o quality improvement

and chronic illness manaement. These principles can be applied to improvin care in specialty mental health and substance use

settins with a oal o addressin the broader oals o better quality, improved outcomes, and reduced costs o care.


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beHaVIoRalHealtHHoMesFoRPeoPlewItHMentalHealtH&sUbs

tanceUsecondItIons

beHaVIoRal HealtH HoMes FoR PeoPle wItH Mental

HealtH & sUbstance Use condItIons

the core clinical Features

IntRodUctIon

Research literature documents that persons with serious mental illnesses8,9 and substance use disorders10 die youner than the eneral

population mainly due to preventable risk actors (e.., smokin) and treatable conditions (e.., cardiovascular disease11 and cancer12).

This research has led the behavioral health eld to seek ways to improve access to preventive services, wellness prorams, and medi-

cal care.13 The mental health and substance use treatment communities have been workin on developin interventions to reduce

and eliminate this early mortality ap. An important thread o this work has ocused on how to improve access to primary care, either

by strenthenin linkaes to community primary care providers or by brinin primary care providers in-house.14

At the same time, the healthcare eld has been workin on addressin quality aps in how it provides and coordinates medical

services or people with chronic health conditions throuh mechanisms such as the chronic care model and the patient-centered

medical home. Now, throuh authority ranted by the Patient Protection and Aordable Care Act (ACA), state Medicaid prorams and

providers have the opportunity to establish health homes or Medicaid beneciaries with chronic illnesses, includin mental health

and substance use disorders.

This paper outlines a proposed set o core clinical eatures o a behavioral health-based health home that serves people with mental

health and substance use disorders, with the belie that application o these eatures will help oranizations succeed as Medicaid

health homes. The introduction provides context or the development o the health home option and its relationship to the person-

centered medical home. Subsequent sections outline established principles o eective care, as well as the chronic care model or

servin people with chronic illnesses. The chronic care model is then applied as the ramework or clinical eatures o a behavioral

health home. The last section describes multiple oranizational models or structurin the behavioral health home.

This paper uses the term behavioral health home or multiple reasons: 1) to acknowlede the potential role o a diverse rane o

providers in providin care in these settins; 2) to hihliht the broader rane o nonmedical needs that should be addressed in these

settins,15 particularly or persons with mental health and substance use disorders; and 3) to hihliht the option o situatin these

homes in specialty mental health and substance use settins.

16

The ACA oers an opportunity to develop such models or Medicaidenrollees with chronic conditions, includin mental health and substance use disorders.17

HealtH HoMes and tHe aFFoRdable caRe act

The ACA, passed in 2010, creates a new option or state Medicaid prorams to provide health homes or enrollees with chronic condi-

tions, includin mental health and substance use conditions.18 The option became available to states on January 1, 2011, subject to

CMS approval via a state plan amendment.

The new option contains nancial incentives or states. For the rst eiht quarters o a states health home benet, the ederal medical

assistance percentae or health home-related service payments will be 90%.19 States may propose alternative payment models or

health home services (e.., bundled payments), and may taret a certain population, reion, or dianostic roup. The ACA authorized

state plannin rants that are unded at the Medicaid administrative ederal matchin rate o the requestin state.CMS health home uidance lays out service requirements contained in the ACA and well-established chronic care models. 20 The

required services (also termed provider standards in the uidance) include:

8 Each patient must have a comprehensive care plan;

8 Services must be quality-driven, cost eective, culturally appropriate, person- and amily-centered, and evidence-based;

8 Services must include prevention and health promotion, healthcare, mental health and substance use, and lon-term care

services, as well as linkaes to community supports and resources;


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8 Service delivery must involve continuin care strateies, includin care manaement, care coordination, and transitional care

rom the hospital to the community;

8 Health home providers do not need to provide all the required services themselves, but must ensure the ull array o services

is available and coordinated; and

8 Providers must be able to use health inormation technoloy (HIT) to acilitate the health homes work and establish quality

improvement eorts to ensure that the work is eective at the individual and population level.

Individuals to be served by a health home must have a chronic condition, namely a mental health or substance use condition,

asthma, diabetes, heart disease, or be overweiht. The uidance rom CMS notes that this list may row over time.21 While states may

propose in their state plan amendment to address all o the eliible chronic conditions, at a minimum they must taret the proram

to people who have either: two or more chronic conditions, one chronic condition and risk o another, or one serious and persistent

mental health condition.22 It is notable that reardless o which conditions are selected or ocus, states are instructed to address

mental health and substance use services and are required to consult with the Substance Abuse and Mental Health Services Admin-

istration (SAMHSA) about how they propose to provide mental health and substance use disorder prevention and treatment.23,24 The

ull uidance provided by CMS on Health Homes is included in Appendix B.

With the Medicaid health home state options stron emphasis on mental health and substance use conditions, it is perhaps not

surprisin that a number o states are in the process o ormulatin a health home state plan amendment with a ocus on people with

serious mental health conditions.

25

So ar, only a ew states have opted to taret substance use conditions, and these are enerallyaddressed in the context o comorbidity with serious mental illnesses. This new option oers the opportunity or behavioral health pro-

vider oranizations to become health homes or the people they serve, makin real the concept o a behavioral health-based health

home.26,27 The challene or behavioral health aencies is how to create a behavioral health home that is not just an administrative

entity, but possesses the capacity to improve outcomes or people with mental health and substance use conditions.

PatIent-centeRed MedIcal HoMe

The Medicaid health home option uses the patient-centered medical home (PCMH) as its startin point.28 Initially, the term medical

home described a model or addressin the complex health needs o children with multiple medical conditions. With its adoption by

the larer healthcare eld, the medical home has come to siniy a care model in which the patient has a desinated primary care

provider who leads a care team responsible or coordinatin the patients overall healthcare needs.29

Buildin on the chronic care model,30 the PCMH has arisen as a prominent ramework or improvin healthcare or both those with

chronic conditions and, more recently, the eneral population.31 The PCMH model involves reoranizin primary care delivery such

that a desinated primary care provider leads a care team responsible or coordinatin the patients overall healthcare needs, with

the oal o improvin clinical outcomes and reducin costs.32


tanceUsecondItIons

IMPORTANT NOTE ON LANgUAgE DISCREPANCIES

Service recipients and providers in the primary care, mental health, and substance use communities use dierent terminology to

reer to people who receive care in those settings.

While patient is most commonly used in the medical eld, that term is oten viewed negatively by those receiving mental

health and substance use care due to its association with a more traditional approach to care. Instead, the mental health and

substance use elds variously use the terms client, consumer, and service recipient. It must be noted that there are dier-

ences o opinion within the mental health and substance use communities as to which o those terms is most appropriate and

respectul.

Because this paper covers literature and concepts rom all three elds and its target audiences span all three, it uses a variety o

terms or service recipients, with the recognition that a lack o shared language and the dierent treatment philosophies that

language conveys is a barrier that must be addressed when these elds work together to integrate care and serve as a health

home.


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Since the Medicaid health home option builds on the work o the PCMH,33 behavioral health home implementers can learn a reat

deal about how to set up a health home rom it. Behavioral health aencies workin to become a behavioral health home should

ensure that they have a ood understandin o the PCMH model, the research supportin it, and the relevant implementation eorts.

(See Appendix A or a compilation o resources on the PCMH model.)

In 2007, the American Academy o Family Physicians (AAFP), American Academy o Pediatrics, American Collee o Physicians, and

American Osteopathic Association issued a joint statement on the PCMHs core principles, which include:

8 A personal physician or each patient;

8 A physician-led practice team with responsibility or patients onoin, accessible, and comprehensive care across the lie

span;

8 Care that is coordinated across the health system and characterized by quality and saety; and

8 Alined payment methods.34

The model is bein implemented and tested in numerous eorts. The National Committee or Quality Assurance used this model to de-

velop its medical home reconition proram.35 The Patient-Centered Primary Care Collaborative (PCPCC), a lare coalition o employ-

ers, payers, providers, and other stakeholders, supports PCMH policy and implementation, in part throuh pilots in 20 states.v36 CMS

has pilots underway throuh the Federally Qualied Health Center Advanced Primary Care Practice Demonstration.37 TransorMED, an

AAFP subsidiary, provides trainin and support to primary care practices adoptin the PCMH model.38

A recent policy brie rom Health Aairs and the Robert Wood Johnson Foundation estimates that over 100 medical home projects

have been evaluated to date.39 The PCPCC summarized recent evaluations o the PCMH model as ollows:

Quality o care, patient experiences, care coordination, and access are demonstrably better. Investments to strenthen primary care

result within a relatively short time in reductions in emerency department visits and inpatient hospitalizations that produce savins

in total costs. These savins at a minimum oset the new investments in primary care in a cost-neutral manner, and in many cases

appear to produce a reduction in total costs per patient. 40

Research rom PCMH demonstration projects has yielded important lessons or would-be adopters. AAFP recently published the

evaluation o its medical home pilot proram, the TransorMED National Demonstration Project.41,42 The evaluation ound that adopt-

in the PCMH model requires sinicant resources, both in terms o support around the PCMH model specically, and support or

the oranization in eneral (e.., chane manaement resources). Implementers tend to underestimate the deree o chane in their

practices roles and processes required to become a PCMH. Patient experience (e.. satisaction) should be careully monitored dur-

in implementation as the evaluation ound that patient experience actually declined durin the project, or unclear reasons. Finally,

implementation takes a sinicant amount o time; two years into the project, many sites still did not have a mature proram.

This paper aims to provide states and behavioral health providers with a clear understandin o the clinical unctions o a behavioral

health home, which are most likely to yield positive outcomes or people with mental health and addiction disorders. Buildin on the

relevant research or deliverin hih quality primary care, mental health, and substance use services, the paper reviews core principles

and key clinical eatures that should uide the behavioral health homes work.vvThe paper also discusses options or how behavioral

health aencies may structure the behavioral health home and concludes with concrete steps that mental health and substance use

disorder providers can take to prepare or becomin a behavioral health home.


tanceUsecondItIons

v In 2009, the Patient-Centered Primary Care Collaborative (PCPCC) ormed a behavioral health workroup to look at how mental health and substance use care ts

within the PCMH. The PCPCC website (www.pcpcc.net) provides inormation on the workroups eorts and other materials on the PCMH model.

vv Althouh equal emphasis was iven to mental health and substance use disorders in the research conducted or this paper, readers will nd that there is

somewhat less content on substance use. This is not because substance use disorders are viewed as less relevant or important, but because the research conducted

revealed less work in the substance use disorders eld in some o the content areas covered.


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FoUR PRIncIPles oF eFFectIVe caRe

For health homes to work eectively, they need to apply principles o quality care delivery. At a 2011 summit on interation o care

sponsored by the Advancin Interated Mental Health Solutions (AIMS) proram at the University o Washinton, participants ar-

ticulated our principles o eective care that can inorm the development o care in eneral and health homes in particular43 and

that should apply to any primary care, mental health, or substance use settin aimed at improvin healthcare, containin costs, and

improvin health outcomes. These our principles posit that care should be person-centered, population-based, data-driven, andevidence-based.

Person-centered care is the principle that all care should be based on the individuals preerences, needs, and values. v This

marks a paradim shit rom the traditional medical model, in which the provider is seen as the expert who determines what and

how healthcare is provided and the consumer is a passive recipient who complies with treatment. With person-centered care, the

consumer is a collaborative participant in care decisions and an active, inormed participant in treatment itsel.

Sel-manaement support entails helpin consumers become active and inormed participants in their own care. Followin an as-

sessment o the consumers baseline knowlede, skills, belies, motivations, and behaviors around his/her conditions and treatments,

the provider works with the consumer to address any aps. The interventions provided may involve education on the individuals

conditions and prescribed treatments, collaborative oal settin, motivational interviewin to increase drive or behavior chane, and

reular ollow-up to assess proress and problem solve continuin issues.44

Shared decision-makin is a person-centered stratey or empowerin consumers to participate in healthcare decisions. 45 Instead

o the provider unilaterally decidin what treatment the consumer should have, the provider and the inormed, empowered consumer

review the best available inormation about the consumers condition and its treatments and work toether to help the consumer

arrive at a thouhtul decision about how he/she would like to proceed with care.46 Shared decision-makin involves a combination

o education (oten in the orm o evidence-based decision aids that cover inormation on available treatments and examples o real

peoples decision processes), as well as coachin by a peer, nurse, or other healthcare provider to support the consumer as he/she

oes throuh the materials and weihs the options.

PoPulation-based care entails strateies or optimizin the health o an entire client population (based on a particular condition,

set o characteristics, practice/provider roup, or other parameter) by actively and systematically assessin, trackin, and manain

the roups health conditions and treatment responses.47 The idea is that consumers with diabetes, or example, share similar health-

care needs and by applyin care uidelines to them as a roup, better outcomes can be achieved. It also entails proactive approaches

to enae all members o the taret roup in treatment and monitorin, rather than just respondin to whichever consumers happen

to show up in the providers oce.

Care manaement is a key stratey in population-based care. Care manaement entails ollowin a dened population o consumers

to monitor their treatment response and adjust care as needed.48 Once consumers have been enaed in the proram, care manae-

ment typically beins with educatin consumers about their conditions and how to participate in their manaement. The care manaer

then ollows up with the consumer on a reular basis to assess treatment response, usin a valid assessment tool as an objective

measure o response. To keep track o the client panel, the care manaer uses a patient reistry that contains basic clinical data (e..,

assessment or lab results, treatment reimen, and appointments) and allows or data sortin so the care manaer and other team

members can easily identiy who is not respondin to care or has not been seen recently or a ollow-up visit. Care manaement is

desined to ensure that members o the dened client population do not all throuh the cracks. (See the Care Management sectionor more on care manaement in the behavioral health home, and the Clinical Inormation Systems section or more on reistries.)

data-driven care is another core principle o eective care delivery. Strateies entail collectin, oranizin, sharin, and applyin

objective, valid clinical data to uide treatment. Validated clinical assessment tools are used to monitor response to treatment, and

inormation systems such as reistries are used to track the data over time. Treatment is repeatedly and systematically adjusted until

the consumers condition can be considered stable or in remission, as indicated objectively by a valid assessment instrument. An

FoURPRIncIP

lesoFeFFectIVecaRe

v Caliornias CalMEND Project recently released a roundbreakin report on client and amily perspectives on interated healthcare, Interation o Mental Health,

Substance Use, and Primary Care Services: Embracin Our Values rom a Client and Family Member Perspective. It provides a rich discussion o the core values such

as person-centered care that should inorm the interation o mental health, substance use, and primary care ser vice delivery. It can be viewed and downloaded online

at www.cimh.or/portals/0/documents/CF%20Interation%20Paper%20-%20Volume%201.pd.


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electronic health record or reistry can help the practice track scores over time. (See Clinical Inormation Systems section or urther

discussion.)

In data-driven care, the treatment response o a person livin with depression, or example, may be evaluated by trackin chanes in

his/her Patient Health Questionnaire-9 (PHQ-9) score over time,49 instead o by askin how he/she is eelin today or whether the

depression seems to be litin. For substance use disorders, scales such as the Alcohol Use Disorders Identication Test (AUDIT) can

provide similar uidance in trackin care outcomes.50

evidence-based care is a core principle o primary and behavioral healthcare, and should also uide care in behavioral healthhomes. It means usin the best available evidence to uide treatment decisions and delivery o care, includin preventive and health

promotion services, screenin, assessment, treatment, and relapse prevention. In contrast to best practices, evidence-based prac-

tices are explicitly inormed by, and rounded in, relevant clinical research demonstratin treatment eectiveness. Because there is

never sucient evidence to uide all treatment decisions, external clinical evidence rom systematic research must be combined with

individual clinical expertise.51

A 2007 National Quality Forum consensus report ocused on substance abuse treatment identied evidence-based standards o

care across our broad domains.52Identication entails screenin and case ndin, dianosis, and assessment usin standardized

tools. Initiation and Engagementinvolves brie interventions or substance use conditions in primary care and mental health settins.

Therapeutic Interventions include detoxication and clinical interventions provided in specialty substance use treatment settins.

Continuing Care entails onoin, coordinated care ollowin acute treatment.

In practice, behavioral health aencies servin as health homes will need to conduct evidence-based screenins or common health

conditions and risk actors such as lucose and lipid levels, blood pressure, weiht, body mass index, HIV, Hepatitis C, and carbon

monoxide levels.53,54 Behavioral health aencies partnerin with health providers to deliver health home services will need to ensure

that health providers are screenin or mental health and substance use conditions usin valid measures such as the PHQ-9 or

depression and the AUDIT or substance use.55,56 Behavioral health homes will also need valid instruments or establishin dianoses

and trackin consumers treatment response.57 These measures may or may not overlap with the screenin instruments, dependin

on the measures psychometric properties. SAMHSA recommends several screenin tools or mental health and substance abuse, all

o which are evidence-based and publicly available on its website at www.samhsa.ov/healthreorm/healthhomes.

Treatment must also be evidence-based. For mental health and substance use conditions, this will include empirically validated

counselin and psychotherapies such as motivational interviewin, problem solvin treatment, conitive behavioral therapy, and

interpersonal therapy, as well as uideline-inormed psychopharmacoloy. An example o evidence-based intervention in behavioralhealth is SBIRT (Screenin, Brie Intervention, and Reerral to Treatment), a model in which people who screen positive or problem

alcohol and/or other dru use are provided with a brie inter vention desined to educate them about their risky behavior and increase

their motivation to chane.v58 Healthcare services will also need to be delivered in line with clinical uidelines, reardless o whether

they are provided on or osite.

A key issue in deliverin evidence-based care is how to ensure that both providers and consumers have access to the best available

evidence when it is needed. Embeddin evidence-based uidelines in the routine provision o care is one approach to makin sure

providers and consumers have access to such evidence.59 Electronic medical records and other computerized systems can be set

up to send providers alerts when they prescribe a treatment that appears to be contraindicated, ivin the provider an opportunity to

review or explain his/her decision. Standin orders can be incorporated into these systems, streamlinin the process o orderin indi-

cated tests, procedures, or treatments. Embedded decision fow charts or various conditions can also help providers and consumers

sort throuh the evidence-based treatment options and decide upon the best course o action. (See Embeddin clinical uidelines

section or more inormation.)

With reards to both data-driven and evidence-based care, CMS is concerned with the outcomes health home providers can docu-

ment or the services they provide.60 Behavioral health aencies developin their behavioral health home model should pay close

attention to the inter ventions they select, makin sure they have a stron evidence base and are likely to yield positive outcomes. They

should also look closely at the instruments or assessin consumer outcomes, as these will be used to make the case or anticipated

success to payers.

v For an extensive annotated biblioraphy o the research literature on SBIRT, see SBIRT Colorado Literature Review Summary at www.improvinhealthcolorado.or/

les/documents/SBIRT_LIT_REV_5.pd.

FoURPRIncIP

lesoFeFFectIVecaRe


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clInIcalFeatUResoFtHebeHa

VIoRalHealtHHoMe

clInIcal FeatURes oF tHe beHaVIoRal HealtH HoMe

To unction as a behavioral health home requires a major shit in the roles, processes, and care provided in behavioral health set-

tins. To achieve this shit, the behavioral health home must reoranize care delivery in several key areas: sel-manaement support,

delivery system desin, decision support, clinical inormation systems, and community linkaes. These are the core elements o the

chronic care model, which serves as an overarchin ramework or the behavioral health home. This section provides an overview othe chronic care model and then examines each o its elements in detail.

FRaMewoRk: tHe cHRonIc caRe Model

The chronic care model serves as the oundation or the patient-centered medical home structure and collaborative care approaches

to the manaement o common mental disorders in primary care. With support rom the Robert Wood Johnson Foundation, Edward

Waner and his colleaues at the MacColl Institute or Healthcare Innovation at group Health Cooperative o Puet Sound developed

the chronic care model in the 1990s, with the oal o improvin treatment o chronic health conditions in primary care settins.61,62

The model rew out o the awareness that primary care tends to be oranized to provide acute care, but conditions such as asthma

and depression require a system that can provide onoin treatment and support. To shit rom an acute care model to a continuin

care model requires the entire primary care practice to chane. More recently, the chronic care model has been conceptualized as

describin how care includin preventive and primary care should be delivered or all health issues, decouplin it rom the oriinal

ocus on chronic conditions.63

At the base o the chronic care model are productive interactions between an inormed, activated patient and the prepared, proactive

practice team.65 Bein inormed and activated, the patient is able to participate as a ull partner in his/her care. Multidisciplinary sta

members work as a team with clear roles and a shared plan. Rather than simply respondin to whatever issues happen to come up

durin the encounter, they approach each contact with the patient with oals and a plan or the interaction. The patient and practice

teams work is supported by the reoranization o care delivery in several interdependent areas, includin sel-manaement support,

Figure 1.A schemAtic of the chronic cAre model64

Th Chonc Ca Mod

impovd Otcoms

Commntyrsocs and Pocs

Sf-Manamnt

Sppot

infomd,

Actvatd Patnt

Ppad,

Poactv

Pactc Tam

Dvy

Systm Dsn

Dcson

Sppot

Cnca

infomaton

Systms

Hath SystmsOanzaton of Hath Ca

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intactons


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delivery system desin, decision support, clinical inormation systems, and community linkaes. Success is urther ensured by the

aencys leadership, which demonstrates support or the initiative at all levels o the oranization, establishes learnin opportunities

and quality improvement eorts, and implements policies that support the initiatives sustainability.

Research has shown the chronic care model to be an eective approach or manain conditions like diabetes and

asthma.v 66,66,67,68,69,70,71 The available research suests that adopters obtain better outcomes when their implementation hews

closely to the model, incorporatin most i not all its components.72

Numerous studies have shown the chronic care models value in improvin the delivery o behavioral healthcare in primary caresettins,73 and o primary care in mental health and substance use treatment settins. 74,75,76,77 In the case o primary care intera-

tion, collaborative care incorporates a behavioral healthcare manaer and consultin psychiatrist into the primary care settin. Care

manaers are trained behavioral health proessionals or paraproessionals responsible or educatin consumers about their mental

health and substance use conditions and treatments and reularly monitorin their response to treatment with valid clinical assess-

ment tools. A consultin psychiatrist reularly reviews the care manaers panel o clients, providin treatment recommendations that

are passed on to the treatin primary care provider. The collaborative care model is backed by extensive research demonstratin that

it can improve care, particularly or common mental health78 and substance use conditions79,80 in primary care. It has also served

as a oundation or research examinin strateies to improve delivery o primary medical care in specialty behavioral settins.81,82

The key eatures o the chronic care model can be supported in behavioral health homes or people with mental health and substance

use conditions. The ollowin subsections examine the core clinical eatures o the behavioral health home, as inormed by the chronic

care models conceptualization o service delivery reoranization via sel-manaement support, delivery system desin, decision sup-

port, clinical inormation systems, and community linkaes.

selF-ManageMent sUPPoRt

The Institute o Medicine denes sel-manaement as the tasks that individuals must undertake to live well with one or more chronic

conditions, includin havin the condence to deal with the medical manaement, role manaement and emotional manaement

o their conditions.83 The benet o sel-manaement support is evident when considerin, or example, the minimal time people

with diabetes spend in a providers oce compared to the time they spend on their own, makin decisions about diet, exercise, and

medication adherence that dramatically impact their outcomes.

In eneral, research has shown sel-manaement support prorams to be benecial. Formal sel-manaement support prorams have

been ound to be a key element in successul implementations o the chronic care model and eective in improvin outcomes or


VIoRalHealtHHoMe

v See the Improvin Chronic Illness Care website or an extensive annotated biblioraphy o research on the chronic care model at www.improvinchroniccare.or/

index.php?p=Chronic_Care_Model_Literature&s=64.

TAble 1. crosswAlk between the four Aims principles of effective cAre And the chronic cAre models key elements

aims core PrinciPles oF eFFective care

c ca m fa

baa ha h

p-

c

pa-

badaad

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a variety o chronic health conditions.84,85 As previously noted, such prorams are more likely to be eective when they include both

education and skill buildin components (as opposed to education alone).

The behavioral health home helps consumers become activated throuh sel-manaement support strateies. The emphasis on sel-

manaement support stems rom the awareness that consumers will not be able to achieve true health and wellness unless they play

a substantial role in their own care.87,88 The activated client is a concept that applies to manaement o mental, substance use, and

medical conditions and care; it is consistent with the understandin o recovery dened as a process o chane throuh which indi-

viduals improve their health and wellness, live a sel-directed lie, and strive to reach their ull potential. 89 Behavioral health aencies

partnerin with medical providers or the behavioral health home may nd it useul to share their experience with recovery concepts

and empowered consumers and to establish a shared lanuae o recovery.

A particularly well researched and widely implemented sel-manaement proram or chronic health conditions is the Chronic Disease

Sel-Manaement Proram (CDSMP).90,91,92 CDSMP is comprised o six 2-hour sessions led by two trained leaders, one or both o

which are peers (i.e., people who have a chronic health condition themselves). People livin with dierent chronic conditions partici-

pate toether in sessions that cover topics such as exercise, nutrition, dealin with atiue and pain, appropriate use o medications,

eective communication with loved ones and health proessionals, and evaluatin new treatment options.

CDSMP has been implemented around the world or a rane o chronic health conditions, includin behavioral health. The proram

has been piloted in its oriinal orm with people who have mental health conditions,93 and adapted specically or people with these

conditions.94

Sel-manaement prorams have been also developed specically or people with mental health and substance use conditions. The

Wellness and Recovery Action Plan (WRAP) proram is a peer-led intervention that helps people with a mental illness monitor the

eelins and behaviors that concern them and develop strateies or reducin or eliminatin them.97,98 In substance use, SMART (Sel-

Manaement and Recovery Trainin) eatures online and in-person meetins durin which participants learn skills to enhance their

motivation to quit, cope with ures to use illeal substances, challene irrational thouhts, eelins, and behaviors around usin drus,and create a balanced lie.99 Sel-manaement support is also a key element o SBIRT (Screenin, Brie Intervention, and Reerral to

Treatment), in which people who screen positive or problem alcohol or other dru use are provided with a brie intervention desined

to educate them about their risky behavior and increase their motivation to chane.v100


VIoRalHealtHHoMe

IN PRACTICE

The Health and Recovery Peer (HARP) program is an adaptation o CDSMP or mental health consumers.95 In this manualized,

six-session intervention, peer leaders help participants become more eective managers o their chronic illnesses. Sessions o-

cus on health and nutrition, exercise, and being a more eective consumer. The HARP programs modications o CDSMP involved

adding content on mental health and its interaction with general health and tailoring diet and exercise recommendations or the

socioeconomic status o a public sector population. Like CDSMP, HARP helps individuals become more activated consumers o

healthcare, but does not provide any direct linkage with medical services.

A pilot trial randomized 80 consumers with one or more chronic medical illness to either the HARP program or usual care.96 At

6-month ollow-up, HARP participants demonstrated a signicantly greater improvement in patient activation and were morelikely to have had one or more primary care visits than those in usual care. HARP participants also ared better in physical

health-related quality o lie (HRQOL), physical activity, and medication adherence. Improvements in HRQOL were largest among

medically and socially vulnerable subpopulations. The size o the dierences between the HARP group and the usual care group

was similar to those seen or CDSMP in general medical populations.

v For an extensive annotated biblioraphy o the research literature on SBIRT, see the SBIRT Colorado Literature Review Summary at www.improvinhealthcolorado.

or/les/documents/SBIRT_LIT_REV_5.pd.


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Sel-manaement support may be provided by proessional sta (e.., a nurse, social worker, medical assistant), lay workers such as a

trained peer (i.e., people who have chronic diseases themselves), community health worker, or health naviator. It is oten delivered aspart o care manaement. (See care manaement section.) There are advantaes to havin trained peers, community health workers,

or health naviators serve in this role, iven their increased ability to connect with consumers because o shared experience and/or

backround. Research has shown these individuals to be eective in providin sel-manaement support.104,105,106,107,108,109

Reardless o who assumes this role, the entire behavioral health home team should be aware o the consumers sel-manaement

oals and challenes and reinorce sel-manaement strateies and skills durin their interactions with the consumer.110

Behavioral health aencies wantin to learn more about sel-manaement support approaches that they may consider incorporatin

into a behavioral health home may nd two summary reports particularly useul. A 2007 RAND report developed or the Aency or

Healthcare Research and Quality examined the actors that purchasers and proram desiners should consider when they are decid-

in on proram components, presentin key ndins rom a literature review and expert interviews, as well as recommendations or

developin a sel-manaement support proram.111

A 2010 Caliornia HealthCare Foundation report authored by Bodenheimer andAbramowitz provides case studies o a wide rane o prorams, as well as a list o trainin curricula in sel-manaement support.112


VIoRalHealtHHoMe

delIVeRy systeM desIgn

The chronic care model calls or the reoranization o the care system in a way that is proactive and responsive to the needs o

consumers with chronic illnesses. The behavioral health home requires the care delivery system to be reoranized in two key ways:

8 Providers must orm multidisciplinary practice teams capable o workin toether to eectively ensure consumers ull rane

o care needs is met.

8 Care manaement must be in place so that consumers do not all throuh the cracks.

PRactIce teaM

The behavioral health home requires providers to work toether as part o a multidisciplinary team that shares responsibility or ad-

dressin consumers comprehensive care needs. The team may be housed under one roo or unction virtually with members stationed

in dierent settins. Reardless o location, it is essential that the members unction as a sinle unit. This means havin clear roles,

a shared plan, eective communication, and mechanisms or coordinatin care between team members.

The membership o the team will depend on the individual consumers needs. For people with severe behavioral health conditions re-

ceivin care in a behavioral health home, the team would consist, at a minimum, o their current behavioral health clinician and a pri-

IN PRACTICE

The Wisconsin Initiative to Promote Healthy Lifestyles uses SBIRT to help persons with alcohol and drug use problems in primary

care. The program is oered in more than 20 primary care centers around the state and targets both adults and adolescents.101,102 The program has expanded to address smoking, poor nutrition, lack o exercise, depression, and domestic violence, as well.

Nurses or medical assistants administer our questions on alcohol and other drug use once a year during a routine primary

care visit. Patients who screen positive or problematic substance use conditions are reerred to a health educator or one to

three 20-minute interventions that use motivational inter viewing and the stages o change103 approach. Health educators have a

bachelors degree and a minimum o 2 years human services experiences. They are trained in cultural competence to meet the

needs o Wisconsins diverse population; they must pass a 3-week intensive training and are supervised through weekly calls and

reviews o audiotaped sessions.

The program is associated with strong sta and patient satisaction, and has been documented to decrease regular and maximal

drinking. SBIRT has also been shown to be highly cost eective, and in early 2010, the Wisconsin Medicaid program began cover-

ing the program.


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mary care provider who may be on or osite. Reardless o how the health home is constructed or what specic model it employs, the

primary care clinician, who may be a physician or a mid-level provider (e.., a nurse practitioner), plays a key role as the provider o

actual primary care services.v The individuals team may also include a care manaer who tracks the individuals treatment response

and coordinates care between team members, a peer specialist who provides wellness and recovery support, and/or a community

health worker who serves as a health naviator. To round out the teams ability to address the individuals rane o health, mental

health, and substance use condition needs, a nutritionist, medical specialists (e.., endocrinoloist), pharmacist, and other provider

types may be involved. (See the care manaement section or additional inormation on care manaer unctions and trainin.)

Team members must be clear on their roles in carin or consumers. This is particularly important when team members are housed in

dierent locations and when a consumers needs require someone other than his or her usual providers to ser ve as the lead provider

on a temporary or permanent basis (e.., i the individual develops cancer), in which case a care coordination areement can help

the team establish which provider is responsible or what aspects o care and its coordination.113 The rane o needed tasks should be

distributed across team members in a way that allows or the most ecient care, a process known as task shitin.114 For example,

medical assistants or ront desk sta may be trained to take on simple screenins or behavioral assessments, a role traditionally

reserved or nursin and similar sta.

The team works rom a sinle care plan desined to address all physical health, behavioral health, and wellness needs. The care plan

is developed collaboratively with the consumer. All team members need access to the care plan so they can use it when plannin

their interactions with the consumer and update it as needed.

To work well as a team, the members must have rapid and eective communication and be able to coordinate care delivery with each

other. For this to happen, there must be mechanisms in place or in-the-moment communications about current consumer needs or

team activities. Team members must be able to nd out who has seen the consumer and or what reason. I an acute need arises, the

appropriate team members must be notied so they can respond. Team members must be able to mobilize quickly to work toether


VIoRalHealtHHoMe

v CIHS (www.interation.samhsa.ov) has compiled a number o resources to assist primary care providers deliverin care in behavioral health settins, includin

webinars, reerence materials, and trainin prorams.

IN PRACTICE

The Connected CareTM Program, a joint venture o the Community Care Behavioral Health Organization and University o Pitts-

burgh Medical Center (UPMC) Health Plan with support rom the Center or Health Care Strategies Rethinking Care Program,

ocuses on improving the connection to and coordination o care or health plan members with serious mental illnesses in south-

western Pennsylvania.116 Based on the patient-centered medical home model, Connected Care uses an integrated care team and

care plan to address consumers comprehensive medical, behavioral, and social needs.

Care team members have access to the web-based integrated care plan, which pulls in client data rom the participating physi-

cal and behavioral health plans. Care managers can access and update client inormation through an online interace, and the

care plan is reviewed and modied during team meetings. The care plan is inormed by input rom the client and/or caregivers,

the primary care provider, behavioral health providers, health plan sta, medical director, nurses, social worker, and pharmacist.

Program sta has ound regular team meetings, during which they review the care plan, to be particularly helpul in developing

a clear, shared understanding o the medical and behavioral health services consumers have received, gaps in care, and their

treatment regimens.

Researchers conducted a pre-post analysis o 5,463 Medicaid recipients with serious mental illness and a history o requent

emergency department and/or inpatient utilization who participated in the program. Participants demonstrated a decline in

hospital readmissions (rom 64.1 per 1000 to 46.5 per 1000), in ED admissions (rom 1975 per 1000 to 1963 per 1000) and

costs, resulting in an estimated $609,000 savings in behavioral health expenses and $1.3 million dollars in savings on general

medical care.117

Connected Cares integrated care plan template can be accessed at www.chcs.org/usr_doc/Integrated_Care_Plan_Template.pd.


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when problems arise. These communications can occur eectively and eciently via an electronic medical record (EMR) or a reistry.

(See clinical inormation systems section). For teams workin in an aency without an EMR or reistry, axes, encrypted emails, and

secure online shared documents can acilitate communication and coordination.

There should also be mechanisms in place or routine communication between team members. For some practices, this means

startin o each day with a team huddle, in which the roup reviews the consumers to be seen that day. Teams may meet weekly to

review and discuss consumers, typically ocusin on those in treatment who are not respondin well to the current care plan. Teams

may also nd it useul to meet monthly or quarter ly to discuss their work processes, troubleshoot problem areas, exchane proram

inormation and lessons learned, and urther build a sense o their identity as a team.

It is hard to isolate the impact o a multidisciplinary practice team rom that o the clinical unctions provided by the individual team

members, but there is some evidence that havin providers rom a rane o disciplines work toether as a team is more eective than

usual care or chronic health conditions.118 One study o chronic care teams ound that eective teams are characterized by their com-

mitment to consumer satisaction, the presence o a team champion, and a workable team size (neither too small nor too lare).119

caRe ManageMent

Care manaement has evolved as a critical component o the medical home model and collaborative care,120,121 and it will be a key

unction o the behavioral health home. Care manaement ocuses on client activation and education, care coordination, and when

workin directly with a treatin provider monitorin the consumers participation in and response to treatment.

The rst step in care manaement is identiyin consumers likely to benet rom havin a care manaer. Care manaement is a rela-

tively resource-intensive stratey with research showin that it is most eectively when used with particularly complex consumers with

chronic conditions.122 Appropriate candidates in the behavioral health home will be consumers with mental health and substance use

disorders who are hiher utilizers o services, includin ED and inpatient utilization, and those with numerous comorbid conditions,

includin mental health, substance use, and medical conditions.124 Some have ound it helpul to oer dierent levels o care man-

aement a very intensive model or the most complex consumers and a less intensive model or moderately complex consumers

who still need additional support.125

Most behavioral health providers (and healthcare providers) do not have systems in place that allow them to determine consumers

utilization o services outside the aency. However, when asked, clinicians oten have a ood idea which o their patients have com-

plex healthcare needs and are hih-utilizers. Once these initial care manaement consumers are identied, behavioral health homeswill nd it helpul to examine their common characteristics (e.., particular dianoses, comorbid mental health and substance use

conditions, chronic pain, polypharmacy), so they can develop a stratey or identiyin appropriate candidates oin orward. This

may involve collectin some supplementary consumer data, minin existin data on a reular basis, and/or usin partnerships with

outside providers (e.., pharmacists, primary care providers) to ain access to additional data.

Once consumers have been identied and recruited into the proram, care manaement typically beins with educatin consumers

about their conditions and how to manae them, includin participatin in prescribed treatments. (See sel-manaement support

section.) At this point, it is helpul or care manaers to assess consumers perceived barriers to treatment participation. For example,

a consumer may have no intention o takin the antidepressant that has just been prescribed because he has heard it makes people

shoot up post oces or causes sexual side eects. Some consumers may identiy the cost o the prescribed dru or psychotherapy

as a barrier. Others may simply not understand the need or or potential value o treatment and, thereore, are unwillin to participate.

Care manaers play a crucial role in identiyin and addressin these concerns so consumers are more likely to participate in treatment.

When a treatin provider is directly involved, the bulk o the work in care manaement ocuses on monitorin the consumers par-

ticipation in and response to treatment. The care manaer reaches out to the consumer on a reular basis (oten weekly at the start

and then more inrequently as the consumer beins to improve) to assess how he/she is doin. At each check-in, the care manaer

administers a valid assessment tool to objectively evaluate consumers response to treatment. The check-ins are brie (usually 15

to 20 minutes) and can be conducted by phone or in person. Especially or care manaers workin in the public system, telephone

contacts are oten easier because consumers may nd it dicult to travel on a requent basis due to transportation or child care

challenes. The provision o care manaement solely by telephone (i.e., with the care manaer never havin met ace-to-ace with the


VIoRalHealtHHoMe


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consumer) has not been ound to be as eective as in-person care manaement; however, doin a combination o telephone and

in-person check-ins has worked well or some providers. 128

The care manaer uses a reistry to keep track o his/her panel o consumers and to make sure that they are ollowed up with reu-

larly. The reistry contains basic clinical data such as dianoses, assessment or lab results, current and past treatment reimens,

and appointments. It may be paper-, electronic- (e.., Excel spreadsheet), or web-based. It should allow or data sortin so the care

manaer and other providers can easily identiy who is unresponsive to care or has not been seen recently or a ollow-up visit. (See

clinical inormation systems section or urther discussion o reistries.)

The care manaer meets on a reular basis (usually weekly) with a supervisor. The supervisor may be a primary care physician or other

medical specialist, i medical care manaement is bein provided in a behavioral health settin. It may be a psychiatrist or other be-

havioral health specialist, i behavioral healthcare manaement is bein provided in a primary care settin. The purpose o supervision

is to review the care manaers panel o consumers and obtain the supervisors treatment recommendations or consumers who are

new or unresponsive to care. The care manaer conveys recommendations to the treatin provider who then works with the consumer

to chane the treatment plan. Adjustments continue to be made until the consumer achieves remission or recovery. (See access to

medical specialists section or urther discussion o the specialists role.)Care manaement unctions can be taken on by dierent types o providers. The trainin and credentials o the care manaers will

determine what unctions they can appropriately and eectively take on, with more limited services bein provided by those with

less trainin. The bulk o research on chronic health conditions and collaborative care or behavioral health conditions has looked at

care manaement provided by social workers (or equivalent masters-level proessionals) and nurses.130,131 Social workers are hihly

skilled at coordination activities, whereas nurses have more backround in medical manaement and education. Trained peers, com-

munity health workers, and health naviators (more oten seen in the medical eld) oer another ood option, especially iven their

ability to connect with consumers due to shared experience and/or backround. Community health workers have eectively provided

screenin, monitorin, patient education, and sel-manaement support in multiple studies ocused on chronic health conditions


VIoRalHealtHHoMe

IN PRACTICE

Compass Health, a private nonprot community mental health center servicing our counties in northeastern Washington State,

participated in the Washington Community Mental Health Councils 2010-2011 learning collaborative on medical care manage-

ment.126 Through the pilot, sites had access to a database o Medicaid claims data developed and maintained by the state health

agency, which enabled them to identiy their clinics highest risk consumers and to see where else in the community consumers

were receiving ser vices or obtaining medications. Each pilot site had leeway to develop their own program eligibility criteria using

the database.

Compass Health used the Medicaid claims database to identiy consumers in their clinics who had the highest inpatient and ED

utilization. The database also helped them determine which medical providers in the community served the consumers, what

medications the consumers were prescribed, and where they lled their prescriptions.

Once consumers were identied through the database as eligible or the program, the nurse care manager conducted outreach

to engage them in the program. Consumers in the program regularly completed the Patient Activation Measure,127 which assessed

their knowledge, skills, and condence in managing their own health and healthcare. They met regularly with the nurse care man-

ager who provided support, education, and problem solving around their medical conditions and goals and accompanied them

to medical appointments as needed.

The program was not ormally evaluated. However, Compass identied several key lessons learned through the pilot. They ound

that eective medical care management required clear communication and close coordination between the care manager, case

manager, mental health prescriber, primary care provider, specialists, and others who interact regularly with the consumer. A

key role or the care manager was serving as the bridge between the consumer and primary care provider, especially in terms

o helping consumers prepare or appointments and understand providers instructions and inormation. Compass also ound it

was important to meet consumers where they are, remaining fexible in working on the needs and concerns they identied as

most salient.


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like diabetes and asthma.132,133 Peer support prorams have capitalized on the lived experience o individuals with mental health

and substance use disorders to oer education and sel-manaement support services with positive outcomes.134,135.136 In addition,

health naviators have been shown to be eective in providin sel-manaement support in the patient-centered medical home.137,138

Because these individuals have less trainin than nurses and social workers, the care manaement unctions they can provide will

be more limited.

Care manaement has been ound to improve consumer outcomes, includin consumer satisaction, symptom reduction, unctionalimprovement, and quality o lie.139,140 However, it oten takes time or ains to be realized. Several research studies that ound no

impact or care manaement at 12 months documented positive ains at 24 months.141 Successul care manaement prorams are

characterized by involvin amily careivers, havin care manaers work in multidisciplinary teams that include physicians, and provid-

in care manaers with adequate trainin.142

Care coordination and transitional care are two concepts that overlap closely with care manaement and are mentioned specically

in the CMS uidance or the Medicaid health home option.143 Care coordination, a common element o care manaement, involves

strateies to help providers workin with the same consumer to communicate with each other to improve the quality o care.144 Tran-

sitional care ocuses specically on care coordination or consumers movin between care settins (e.., inpatient to outpatient) and

systems (e.., pediatric to adult health systems, behavioral health to primary care settins).145 Care manaement has been shown to

be hihly eective in assistin with transitions rom inpatient to outpatient care or medically complex consumers, leadin to improved

quality, lower rates o rehospitalization, and reduced costs,146 as well as or adolescents movin into the adult health system.147 At

their core, care manaement, care coordination, and transitional care all involve providin continuin care.

Finally, it is necessary to distinuish the care manaement under discussion here rom care manaement delivered throuh commer-

cial disease manaement prorams. Disease manaement is typically oered by payers or companies that specialize in the provision

o such services. The services are usually provided by telephone rom a remote, centralized location, coverin numerous practices.

Disease manaement is delivered as a service external to the provider practice and does not involve chane in the care provided at

the practice level, unlike chronic care approaches.148 Telephonic disease manaement appears to be less eective than onsite care

manaement in improvin clinical outcomes and reducin costs.149,150


VIoRalHealtHHoMe

IN PRACTICE

In the TEAMcare study, nurse care managers at14 Group Health Cooperative-aliated primary care clinics in the Seattle area

worked with consumers who had depression and poorly controlled diabetes and/or coronary heart disease. 129 The 12-month

intervention combined sel-management support with pharmacotherapy.

Each patient collaborated with a nurse care manager and primary care provider to set individualized clinical and sel-manage-

ment goals. Then, during structured visits every 2 to 3 weeks, a nurse care manager monitored the patients depression score,diabetes/coronary hear t disease control, and sel-management activities. The visits also included problem solving and goal set-

ting to improve the consumers medication adherence and other sel-management behaviors. An electronic registry was used to

track depression scores and diabetes and coronary heart disease indicators.

A psychiatrist, primary care provider, and psychologist supervise nurse care managers weekly, during which time they reviewed

new cases and patient progress. The supervisors made treatment recommendations, which the nurse care manager communi-

cated to the primary care provider responsible or medication management. Once guideline-based target levels were achieved on

depression, diabetes, and coronary heart disease indicators, the nurse care manager and patient developed a relapse prevention

plan that included stress reduction, behavioral goals, continued use o medications, and identication o symptoms associated

with worsening depression and diabetes control. Nurse care managers then checked in with patients by telephone every 4 weeks,

oering ollow-up visits and intensied treatment to those whose health deteriorated.

As compared to patients receiving usual care, patients in the nurse care management program experienced greater improvement

in diabetes, coronary heart disease, and depression and were more likely to have their treatment proactively adjusted. They also

had better quality o lie and greater satisaction with the care they received.


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decIsIon sUPPoRt

Decision support involves strateies or ensurin that clinical care is provided in line with best practices. The typical primary care-

based health home practice team is larely comprised o eneralists. In the behavioral health home, the team will primarily include

behavioral health experts. Reardless o settin, the practice team has responsibility or providin or coordinatin comprehensive,

evidence-based care or consumers. They can best supplement their skills and knowlede with the expertise o specialists and by

embeddin evidence-based uidelines in the routine provision o care.

access to MedIcal sPecIalIsts

Makin medical specialists available to the practice team can be an eective decision support stratey. Medical specialists may

include primary care providers and/or specialists such as endocrinoloists. Primary care providers deliverin healthcare services will

be the most common medical specialists in the behavioral health home. Such providers may be physicians or mid-level providers

(e.., nurse practitioners). Behavioral health homes workin with medical specialists need to assess their knowlede and practice o

evidence-based care.

I sucient resources are available, the behavioral health home may contract with or hire specialists to be onsite ull-time or 1-2 day

a week. This allows or inormal trainin o the clinician and more continuous contact with the same consumers. I that is not easible,

there are models or how to use even a small amount o specialist time to ood eect.

When onsite in a ull- or part-time capacity, the medical specialist may provide consultation to the practice team on consumers who

have particularly complex needs or are unresponsive to treatment. The specialist may also provide care directly to consumers, usin

a care coordination areement developed or each consumer to ormalize which provider has responsibility or the patient and how

communication between providers will happen to ensure coordinated care. Where amily members are involved in helpin care or

a consumer, they are also included in these plans.151 In its recent position paper on specialists workin with medical homes, the

American Collee o Physicians issued a useul set o uidelines or how to set up care coordination areements.152 (See Appendix

A or a reerence to these uidelines.)

What miht this look like in a behavioral health home or people with mental health and substance use conditions? The practice team

may nd, or example, that a sinicant number o consumers have poorly controlled diabetes, with devastatin physical and mental

health consequences. The practice may brin in an endocrinoloist or a primary care physician with diabetes expertise 1 or 2 days a

week to answer the practice teams questions and to see the more challenin consumers. The specialist may see these consumersjust or a consultation to enerate treatment recommendations or the practice team. In more challenin cases, he/she may end

up directly treatin some consumers diabetes over time, communicatin with the practice team as laid out in the care coordination

areement.

Some behavioral health homes may not nd it easible to hire or contract with specialists on a ull- or part-time basis, but may be able

to aord a ew hours o the specialists time each week. In this situation, the specialist is available primarily by phone or email only


VIoRalHealtHHoMe

IN PRACTICE

Health and Education Services, Inc. in Massachusetts takes an onsite approach to specialist support. This large behavioral

health network has integrated a nurse practitioner into three o its clinics to provide physical exams, lab tests, and other primary

care services. The nurse practitioner circulates among several behavioral health clinics, providing basic primary care services.

She is supervised by an experienced primary care physician, who provides consultation and supervision that supplements the

nurse practitioners level o knowledge and augments the quality o the care provided.153,154

An initial evaluation o the program ound that those who received the nurse practitioners services in the behavioral health clinic

had ewer emergency department visits and were more likely to have had a physical examination than those who did not receive

such care. Preliminary results rom a larger, more rigorous study o the program show that program participants had greater ac-

cess to primary care ser vices and elt more empowered regarding their health conditions. The program also appears to have led

to lower service costs or participants.155,156,157


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and typically does not see patients. However, he/she can still answer questions and provide treatment recommendations, a commonly

accepted practice known as a curbside consultation.

This more time-limited approach to specialist support works particularly well in the context o care manaement. (See care manaement

section or additional inormation.) Care manaers are supervised reularly by a specialist, who provides treatment recommendations

or new patients and those unresponsive to treatment. The care manaer then communicates the specialists recommendations to the

multiple providers he/she supports. This is an ecient way to use the specialists time because the minimal hours a week that the care

manaer spends with the specialist support multiple treatin providers. Althouh the specialists role is quite limited in this model, it

has been shown to be a critical contributor to the consistently positive outcomes achieved in collaborative care studies on behavioral

healthcare interated into primary care settins.158 (See the In Practice inset box or an example o collaborative care implementa-

tion.) A downside is that curbside consultations are typically not reimbursable in ee-or-service payment models. Such activities

can be included in more innovative payment models such as bundled payments, an option throuh the CMS health home option.159

eMbeddIng clInIcal gUIdelInes

Another set o strateies or ensurin the practice team has access to the best available science involves buildin evidence-based

clinical uidelines into the routine delivery o care. Research has clearly demonstrated that simply providin clinicians with such

uidelines is ineective at chanin how they deliver care.163,164,165 Behavior chane requires systematic support.

Electronic medical records and other computerized systems can make the provision o uideline-based care a routine event.166 These


VIoRalHealtHHoMe

IN PRACTICE

In Austin, Texas, Peoples Community Clinic, a nonprot health center, provides collaborative care or a range o mental health

disorders.160,161 A core piece o the collaborative care model is a consulting psychiatrist, but psychiatrists in the area are expen-

sive and in shor t supply. With the support o local oundations, Peoples contracted with a psychiatrist rom the area community

mental health center or 4 hours a week. The psychiatrist meets weekly with t

cihs health homes core clinical features

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