integrating primary care into your behavioral health practice

Integrating Primary Care into Your Behavioral Health

Practice

Dave Cook, LICSW, Chief Executive OfficerHeather Geerts, LICSW, Clinical Director

Scott Gerdes, Chief Financial OfficerCasey Langworthy, RN, Primary Care Nurse, Care

Coordinator

Community Resource for Behavioral Health

• Providing behavioral health services to SE Minnesota since 1966– Therapy and

psychiatry– Regional detox unit– Residential/crisis

treatment facility– Community support

programs

• 150 total employees

Community Resource for Behavioral Health

• Provide continuum of behavioral services to SE Minnesota and state-wide– Community mental

health center primarily for Olmsted, Fillmore county residents

Unique Patient Demographics

Zumbro Valley Mental Health Center provides services to 5,000 people annually– 84% of these patients enrolled in publicly funded insurance

options– Medicaid expansion in 2014 will add 4,700 new enrollees in

Olmsted County Many of these patients have significant behavioral and

medical conditions– Over 70% of publicly funded patients diagnosed with serious

mental illness (SMI) or severe and persistent mental illness (SPMI)

– 1 of 3 patients utilize multiple services– More than 70% of patients seen in Psychiatry have a serious co-

morbid condition:• Morbid obesity

• Hypertension• Diabetes

• Asthma• Chronic pain• Heart disease

Challenges

• Mental health centers across state facing variety of challenges – Low reimbursement rates for expanding

Medical Assistance and Medicare populations

– Growing need for treatment of people with dual diagnoses and co-morbid conditions

– Difficulty finding and retaining qualified behavioral health professionals

– Transforming care to meet rapidly changing demands of diverse populations

Services Prior to Integrated Care Model

• Case management

• Adult Rehab Mental Health Services

• Homeless outreach

• Intensive Community Rehab Services

Community Support Programs

• Youth Behavioral Health

• Child Adult Relationship Enrichment

• Psychiatric services

Children's Services

• Psychiatry• Medication

management• Therapy -

individual and group

Outpatient Therapy

• Intensive Residential Treatment Services

• Crisis services

Residential

Services

• Detox• Recovery

programs• Choices

program (adults and adolescents)

Chemical Health

Services

Adding to the Continuum of Care

April May June July August0

200

400

600

800

1000

QoL meds

Scripts

April May June July August0

50

100

150

200

250

Apple Tree Dental

Patients Visits

Pre-Primary Care Model

•Case management

•Adult Rehab Mental Health Services

•Intensive Community Rehab Services

Community Support

Programs

•Youth Behavioral Health

•Day treatment•Psych services•Detox

Children's Services

•Psychiatry•Therapy - individual and group

Outpatient Therapy

•Intensive residential treatment

•Crisis services

Residential Services

•Detoxification•Recovery programs

•Choices program (adults and adolescents)

Chemical Health Services

Pharmacy

Dental Electronic M

edical

Record

Intake

Co-morbidity is the Rule, Not the Exception

• Data-mining of Electronic Medical Record revealed 74% of psychiatric patients diagnosed with serious medical condition

• Research shows that people living with serious mental illness die an average of 25 years earlier than the general population1

– Lack of access to primary medical care

– Preventive health services

47.2%21.5%

16.4%

Likelihood to Use Zumbro Valley for Primary Care

Very Likely Likely Somewhat Likely1 Colton, CW, Manderscheid, RW. “Congruencies in Increased Mortality Rates, Years of Potential Life Lost and Causes of Death among Public Mental Health Clients in Eight States.” Preventing Chronic Disease, vol. 3, no. 2, 2006.

Co-morbidity is the Rule, Not the Exception

• Integrated model of care incorporates mental health, chemical health, case management, housing, dental and pharmacy services with primary care

• Goal is to significantly improve clinical outcomes for area’s underserved populations

Steps Toward Integration - Research

• Mental disorders and medical co-morbidity– The Synthesis Project.

Robert Wood Johnson Foundation. 2011.

– Basis for project rationale

• Correlation between childhood maltreatment and later-life health and well-being– Adverse Child Experiences

(ACE) Study. Centers for Disease Control and Prevention. 2010.

Steps Toward Integration – Pre-Planning (Phase 1)

• A pre-planning group of community leaders, Zumbro Valley staff and board members was assembled to discuss the research and subsequent efforts to address the problem

• Zumbro Valley conducted an internal patient survey and review of records that determined approximately 85% of psychiatric clients have a serious co-morbid medical condition

Steps Toward Integration – Pre-Planning (Phase 1)

• Conduct literature review on the service models for integrated care

• Evaluate how primary care services have successfully been integrated in community mental health centers within Minnesota and other parts of the country

• Determine the financial model required for operation

• Develop the space and specifications needed for on-site services

• Explore the need for other resources

Steps Toward Integration – Planning (Phase 2)

• Developed on-going Community Advisory Committee to assist Zumbro Valley board and leadership team in the development and implementation of the Primary Care Clinic Mayo Clinic Olmsted Medical

Center Olmsted County Rochester Area

Foundation MN Dept. of Health Olmsted Public Health United Way of MN Dept. of Human

Olmsted County Services


• Committee agreed community required integrated care model and primary care services for area’s under-served populations Hired consultant to develop business plan

and assist with financial pro forma Developed guiding principles, goals,

performance outcomes, community benefits, etc.

Formalized clinical model of care, with clinical integration manager serving as hub


• Trust major issue for target population– People diagnosed with

a serious mental illness significantly less likely to trust others

– Lack of follow-through by these clients with community medical providers

– Survey found clients view Zumbro Valley MHC as their primary care provider


• Planning workgroup developed project goals to assess short- and long-term outcomes– Improve health outcomes by enhancing the diagnosis of

chronic health conditions and providing treatment of these conditions

– Improve quality of health by increasing focus on wellness and healthy lifestyles

– Provide person-centered care and whole-person-centered care approaches

– Contain health care costs– Improve care coordination between behavioral and

primary care services– Improve the patient experience

Steps Toward Integration - Implementation

Clinical

Integration

Manager

Mental

Health

CD/

Detox

IRTS

ARMHSCase

Managem

ent

Children

Services

CSP

Referral Source

Call to Zumbro Valley

Hunt Line

Pharmacy

Denta

l

Primary Care

Clinic

Electronic M

edical

Record


• The Primary Care Clinic team consists of a primary care provider (nurse practitioner) and support staff (registered nurse) Perform ancillary services –

vital signs, measuring BMI, etc.

Process lab samples and send out for results

Provide medical exam and any ongoing care

Refer patients to community specialty care providers


Current Model• RN care coordinator performs both

clinical and care coordination duties• Primary responsibilities:– Performs triage of new and ongoing patients

to determine level of care needed– Coordinates care for clinic patients with

internal and external providers– Provides regular follow-up contact to affirm

adherence to treatment plan


Future Model• Primary care clinic also has an intake

worker (BA level social worker) to assist with care coordination

• Primary responsibilities:– Answer calls within 30 seconds– Triage level of care needed: crisis, urgent,

routine– Arrange for logistics: transportation,

community resources, insurance enrollment, etc.

– Make appointment reminder calls


• Each new patient is assigned a clinical integration manager (nurse practitioner or clinical social worker) for the course of treatment

• Primary responsibilities:– Conduct diagnostic assessment– Triage risk level: high, medium, low– Monitor and evaluate risk levels– Refer to appropriate behavioral/medical

provider– Lead weekly clinical care conferences– Track patient outcomes

Steps Toward Integration - Benefits

• Improved quality of life for clients– Increased medical and

behavioral compliance– Wellness programs

that compliment medical and behavioral services

– Ability to share clinical information via EMR

– Improved overall health and well-being


• Appropriate Level of Care = Reduced Costs– Reduced ER visits and

inpatient hospital days– Decreased utilization of

after-hours crisis/ambulance services

– Visits can be routine (primary care) rather than acute (emergency department)

– Fewer psychiatric visits due to medical stability


• Enhanced Access to Care = Improved Outcomes Proper medical care contributes to overall housing

stability Improved medical health results in better overall

health of clients Ability to share clinical information with other

health care providers via electronic medical record

Steps Toward Integration - Payment

• Developing a strong financial pro forma key to successful plan Where do we start? What pieces are

different than mental health?

What CPT codes do we need to include?

How is productivity different?


• Developing a financial pro forma – where to start?– Examination of payer mix– Research Evaluation and Management (E/M)

codes to identify appropriate types and levels– Review Medicare and Medicaid

reimbursement rates for selected services– Determine billing rates for medical services


• Developing a financial pro forma – start-up costs?– Building space– Supplies– Equipment– Furniture


E/M Codes

ZVMHCCoding

Distribution

Medicaid Fee

Schedule

Volume Year 1 (85%)

Year 2 (100%)

Year 3 (100%)

Year 4 (100%)

99201 0% $49.25 0 $0 $0 $0 $0

99202 3% $61.61 15 $2,379 $2,828 $2,870 $2,971

99203 29% $88.28 145 $30,996 $37,644 $38,209 39,552

99204 64% $134.43 320 $104,448 $126,594 $128,493 $133,009

99205 4% $166.53 20 $8,075 $9,767 $9,934 $10,283

New Patient Codes


E/M Codes

ZVMHCCoding

Distribution

Medicaid Fee

Schedule

Volume Year 1 (85%)

Year 2 (100%)

Year 3 (100%)

Year 4 (100%)

99211 0% $29.25 0 $0 $0 $0 $0

99212 7% $36.11 140 $12,257 $14,636 $14,856 $15,079

99213 32% $59.62 640 $92,480 $110,432 $112,088 $113,770

99214 54% $87.99 1,080 $228,582 $272,954 $277,048 $281,204

99215 7% $117.80 140 $39,627 $47,319 $48,029 $48,750

Established Patient Codes


Zumbro Valley MHC – Primary Care Financial Pro Forma (Revenue)

Year 1 Year 2 Year 3 Year 4

Primary Care Services $518,844 $619,581 $628,875 $638,308

Lab Services $0 $0 $0 $0

Gross Revenue $518,844 $619,581 $628,875 $638,308

Collection Ratio 41.1% 41.1% 41.1% 41.1%

Net Revenues $213,036 $254,399 $258,315 $262,088


Zumbro Valley MHC – Primary Care Financial Pro Forma (Expenses)

Year 1 Year 2 Year 3 Year 4

Salaries $288,100 $296,743 $305,645 $314,815

Benefits $87,150 $98,667 $110,796 $114,120

Locum Coverage $30,000 $30,000 $30,000 $30,000

Supplies (1% gross revenue) $5,188 $6,196 $6,289 $6,383

Other Lab Expense $0 $0 $0 $0

MNCare Tax $5,166 $6,169 $6,262 $6,356

Malpractice Ins $800 $1,200 $1,200 $1,200

Interest $10,139 $8,860 $7,511 $6,086

Depreciation $11,000 $11,000 $11,000 $11,000

Admin $55,414 $58,272 $60,795 $62,225

Total $492,957 $517,107 $539,498 $552,184

Net Revenues $213,036 $254,399 $258,215 $262,088

Net Profit/(Loss) ($279,921) ($262,708) ($281,283) ($290,096)


• Developing a financial pro forma – other costs?– Services and coding– Fee matrixes for primary care – Lab service integration


• Model for financing publically funded primary care clinic has many financial challenges Low reimbursement

rates from Medicare, Medicaid do not support expenses

Low reimbursement levels = requires higher volume of clients

Tax status change (MNCare)


• Zumbro Valley utilized variety of sources to pay for clinic– Obtained funding from Minnesota State

Legislature to pilot integrated care model– Applied for and received multiple grants from

local, state and national sources to help offset operational expenses

– Explored opportunities to obtain FQBHC, health home and behavioral health home status for higher reimbursement of services

– Received equipment donations from community sources such as Mayo Clinic

Steps Toward Integration - Challenges

• Project – and Qualifacts system – are using a variety of measurements to determine outcomes– Meaningful Use– Physician Quality Reporting System (PQRS)– E-Prescribing (DrFirst)– DSM-5/ICD-10 cm enhancements– Minnesota 10x10 Initiative (Minnesota MHIS)– Minnesota Depression Care and Diabetes

management


• Other Challenges – Electronic Medical Record– Configuring Carelogic to bill primary care services

required close working relationship with QSI– Key tasks included

Creating new EDI file to accommodate Minnesota Administrative Uniformity Committee

Setting up overlapping E/M codes for primary care services Organizing CPT codes and other activities Creating pricing structure based upon market data Modifying program history for admitting diagnosis Mapping new National Provider Identifier number to all

services


• Other Challenges – Laboratory services– Identify lab provider (Quest

Labs) who can interface with system

– Utilize web portal to transact information on patient lab results, submit orders, review results, etc.

– Billing for laboratory services

– Determine how payers reimburse for lab services

– Discuss use of new e-Labs program with Qualifacts


• Other Challenges – Third party contracting– Negotiate agreements

with payers to reimburse for medical codes

Medicaid Medicare Others – Blue Cross

Blue Shield, Optum, MMSI (Mayo), UCare Minnesota, South Country


• Other Challenges - Clinical Found there were numerous cultural

differences between medical and mental health settings

Success of integrated model dependent upon availability and willingness for cross-consultation

Need for seamless connection with external specialty care providers for complex care needs


• Other Challenges – Staff and training– Staffing

Identify right number of people and appropriate positions

Budget for productivity Determine type of clinicians/licenses to properly bill

for services

Training Prepare appropriate documentation Have provider choose the right codes Conduct ongoing training and note review


• Other Challenges – Care coordination and patient registry– Coordinate with area health care providers to

transition care back and forth– Use of weekly clinical conference to discuss

highest-need patients with all applicable personnel

Steps Toward Integration - Outcomes

• Clinic staff has seen nearly 100 people since opening in December 2013

• Expanding services at 7th Street office– RN to be available

8 hours per week


• Development of patient registry critical element to gauge success Track patients with

specific chronic conditions

Allow for appropriate patient staffing

Determine who, if anyone, is “falling through the cracks”

• “Jane’s Story”


• Measurement of clinic outcomes was core principle from project initiation– Contracted with third party – Wilder Research

– to measure outcomes– Wilder staff will present results of 2-year study

to Minnesota Legislature in 2015

• Collaborative effort to gather data Minnesota Department of Human Services Wilder Research Team Rochester Epidemiology Project

Steps Toward Integration – Lessons

• Important lesson learned throughout process has been having the right partners– Company with a vision– Roadmap for the future– Knowledgeable program

staff– Supportive agency

environment• Key to success of project

has been willingness of QSI and its staff to provide assistance

• Be flexible about model and funding

Steps Toward Integration - Milestones

• 2011– January: added pharmacy and dental services– July: began research of Robert Woods Johnson

Synthesis Project and Adverse Childhood Experience (ACE) studies

– September: implemented Community Advisory Committee

• 2012– January: formalized internal integration activities– June: submitted grant request to SAMHSA– July: began meetings with state leaders– July: entered Phase 2 of project and hired consultant

Steps Toward Integration - Milestones

• 2012 (continued)– October: received financial support from Community

Advisory Committee members– January – December: presented to local and regional

organizations

• 2013– January: completed business plan and Olmsted County

designated our project as a key initiative for legislative session

– July: received appropriation from State of Minnesota– August: combined internal integration activities

• 2014– January - September: received grants from Mayo

Foundation, Merchants Bank, Schmidt Foundation, Medica Foundation

Questions?

For More Information…

• David Cook, LICSWChief Executive Officer507.535.5718 or [email protected]

• Heather Geerts, LICSWClinical Director507.535.5745 or [email protected]

• Scott GerdesChief Financial Officer507.535.5717 or [email protected]

• Casey Langworthy, RNPrimary Care Nurse/Care Coordinator507.535.5616 or [email protected]

integrating primary care into your behavioral health practice

Documents

life health

chemical health

public mental health

primary care nurse

medical assistance

medical conditionsover

funded patients

serious mental illness