Report: DSRIP Yields Lessons on Integrating Behavioral Health and Primary Care

NYAPRS Note: Provider teams that participated in an eight-month state program to help them integrate primary and behavioral health care were able to improve communication between clinicians, standardize patient screenings and reduce wait times, among other positive outcomes, according to a report released by the Department of Health Thursday. They also identified a number of common challenges ranging from a lack of interest among some clinicians to a superficial understanding of data. Here're some excerpts from the report.

Integrated behavioral and physical healthcare will be a featured topic at NYAPRS’ upcoming April 27-8 Annual Executive Seminar, “All Hands on Deck! Ensuring a Recovery Focus in a Changing Healthcare Environment” at the Albany Hilton.More program details and registration link next week.

DSRIP: – Medicaid Accelerated eXchange (MAX) Series Program (excerpts by NYAPRS)
Final Report

Integrating Behavioral Health and Primary Care Services

New York State Department of Health in collaboration with Joan King, Emmeline Kunst, essica Logozzo, Kara Kitts, Dr. Douglas Woodhouse

January 2017

Over the past 12 months, we have put an important focus on leading change at the front-line of patient care –where DSRIP becomes reality. The Department of Health has been proud to offer the opportunity for Performing Provider Systems (PPS) to participate in the Medicaid Accelerated eXchange (MAX) Series Program. The MAX Series Program has put front-line clinicians in a position to lead change. By enabling change at a grass-roots level, PPSs have been able to generate impressive results – Including:

1. Measurable increases in screening rates and connections to services (as these relate to integrating behavioral health and primary care services)

2. Capacity building in process improvement

3. Development of meaningful collaborations among partners, both inside and outside of provider sites.

The MAX Series focus on the integration of behavioral health and primary care services is important as New York’s behavioral health system is large and fragmented. The publicly funded mental health system serves over 600,000 Medicaid members, representing 12% of total Medicaid members across the State. This accounts for about $7 billion in annual expenditures or 13% of New York’s total Medicaid spend. With the overall goal to reduce avoidable hospital use by 25% through transforming the New York State health care system, DSRIP will focus on the provision of high quality, integrated primary specialty and behavioral health care in the community setting with hospitals used primarily for emergent and tertiary level of services.

This report highlights the work of 10 Action Teams who participated in the first year of the MAX Series Program, which focused on the Integration of Behavioral Health and Primary Care Services. Collectively, these 10 teams were comprised of over 100 clinicians, administrators and community providers. Over an eight month period, these individuals dedicated significant time to identify patients in need of behavioral health services; to develop innovative solutions to providing better care for these individuals; and to rapidly implement, test, and measure these improvements.


Eight Lessons Learned About Integrating Behavioral Health and Primary Care Services

1. Integration of care is about creating a whole new way of delivering care…not just adding another service. For years, service systems have been siloed because of funding, regulations and educational preparation. The change, to focus on whole health and wellness, challenges long-held assumptions and some very real contextual barriers. As teams begin to work together, to learn from each other, and to work towards a seamless experience for the patient, preconceived notions begin to break down. Being conscious of this shift in thinking has been a critical success factor in integration.

2. Having a clear vision about why integration fits your mission will help you keep at it when the barriers arise. Vision is the stabilizing force when resistance and barriers arise. Organizations that identify the “why” of practice change, that commit to this as a way of delivering service, and make it part of the organizational mission, have the resilience necessary to overcome the resistance and barriers that will arise. The question then becomes, not “whether we will do this” but, “how we will do this?”

3. Recognize that culture drives practice. The transformation to an integrated practice requires creativity, courage and risk taking. In cultures where there is a top-down approach, where the contributions of everyone on the team (including the front desk, the medical assistants and others) are not recognized, the development of a team-based approach to care will be nearly impossible. A culture that recognizes the unique contribution of each team member is more likely to recognize the individuality of each patient, and to be engaging and inclusive in the care delivery system. This change requires new thinking and new practices, which in time create a culture of enhanced primary care.

4. Data is the magnifying glass to identify whether what you are doing is working…for the patient and for your processes (i.e. how integration supports keeping people out of crisis). Healthcare is a demanding field to work in and each day brings another change and another challenge. Without a planned approach to collecting real data that reflects real practice and outcomes, the practice will continue to do the same things over and over whether they work or not. Data causes us to ask questions; it is in the questions that ideas for improvement of care emerge.

5. Practice Champions are key and developing the overall functioning of the team cannot be overlooked. In an ideal world, everyone in a practice gets on board quickly and with enthusiasm about this change in the care delivery system. However, this is not reality and, as such, the role of early adopters and Champions becomes particularly important. The Champion is the one who keeps saying “yes we can” in the face of doubts and who continues to work toward solutions when others only identify barriers. The Champion(s) are also the people who help the team come together, who call out conflict when it exists so it can be resolved, and who keep the project moving forward.

6. There is opportunity in understanding the effectiveness of leveraging staff outside of physicians and providers. The patient experience begins at the front door with how they are greeted, continues with how they are roomed, and ends with how they are checked out. At each step there is an opportunity to engage patients or to have them disengage. Often the staff who are involved in these key processes are overlooked and/or underappreciated. They don’t see their role as important and may not be treated as if it is. In an integrated practice they are critical in getting initial screenings completed, in communicating safety to patients, and in flagging for other staff when there may be an issue. They manage the waiting room and have a good sense of patient flow. For integrated care to be a success, these staff need to be included in huddles, in training and in process improvement.

7. Persistence is required and tackling obstacles with small tests of change will keep you moving forward. Because there are so many moving parts with any integration effort, building a team and using data effectively to help you know what obstacle to tackle next, are key ingredients for success.

8. Integration is a continuous journey, not a destination. One of the most critical hallmarks of a high-performing practice is the recognition that there is always more to do, always something to improve. The knowledge base in the field continues to expand, the team continues to improve, and the context changes – all of this requires continuous attention to growth, change and improvement.