National Council magazine 2009, Issue 1
The National Council has played a leading role in advocating for policies and practices that break down barriers to integration and collaboration, developing clinical and business models that support seamless and comprehensive healthcare, and fostering collaborative opportunities. Advocating for funds to bring primary care services to behavioral health organizations has been a National Council legislative priority. We've also been active on the practice improvement front and have helped member organizations and their primary care partners overcome clinical, cultural, and communication barriers to collaboratively provide comprehensive healthcare.
Published on: Mar 3, 2016
Transcripts - National Council magazine 2009, Issue 1
A quarterly publication from the National Council for Community Behavioral Healthcare winter 2009
magazine Sharing BeSt PracticeS in Mental health & addictionS treatMent www.thenationalcouncil.org
A Two-Way Street
Behavioral Health and
Primary Care Collaboration
Getting Well in My Mind and Body, Page 3
A New ‘Home’ for Persons with Serious Mental Illness, Page 6
Revised Four Quadrant Model, Page 10
From the Field: Making Whole Health Work, Page 24
Team Solutions: Psychoeducation Tools for Treatment Teams, Page 44
PDF available at www.TheNationalCouncil.org
M A G A Z I N E
2 Together We Will Save and Improve Lives
in My own wordS
3 Getting Well in My Mind and Body
4 Promoting Whole Health for the Mentally Ill
6 A New ‘Home’ for Persons with Serious Mental Illness
10 National Council’s Revised Four Quadrant Model
12 Financing Integrated Healthcare:
Working Creatively With Existing Opportunities
14 Learning Collaboratives Enhance Population Health
Barbara Mauer, Laura Galbreath
18 Primary Care Screenings Connect Patients to Specialized Care
20 Consumers Take Charge of Wellness
22 Life as an FQHC for a Behavioral Health Provider
Interview with Karl Wilson
FroM the Field
24 Making Whole Health Work
42 Physical Health Screenings for the Mentally Ill: Key Health Indicators
Joseph Parks, Alan Radke, Noel Mazade
44 Team Solutions: Psychoeducation Tools for Treatment Teams
46 Smoking Cessation Along the Road to Recovery
National Council Magazine is published quarterly by the
National Council for Community Behavioral Healthcare,
tech noteS 1701 K Street, Suite 400, Washington, DC 20006.
50 Sharing Patients Requires Sharing Data www.TheNationalCouncil.org
Editor-in-Chief: Meena Dayak
54 EHRs Improve Care and Increase Revenue in Integrated Settings
Specialty Editor, Healthcare Integration: Laura Galbreath
Editorial Associate: Nathan Sprenger
56 Ensuring Patient Safety through Medication Management
Charles Klein Editorial and advertising queries to
tiPS and toolS 202.684.7457, ext. 240.
60 Resources for Healthcare Collaboration
Together We Will Save and Improve Lives
linda rosenberg, MSw, President & CEO, National Council for Community Behavioral Healthcare
I f someone told you they had access to specialty cardiology treatment but
not to primary care, you’d find it ironic. If someone told you they are being
treated for their cancer but not for their co-occurring diabetes, it would seem
care, sharing of patient information, and cross-training of staff. We’re proud of
our members’ work and applaud their commitment.
The National Council’s job is to help our member organizations do their jobs
ridiculous. Yet that is exactly what we’ve done to persons with serious mental — saving and improving lives. We’ve played a leading role in advocating for
illness. policies that break down barriers to integration and collaboration, develop-
The National Association of State Mental Health Program Directors 2007 study ing clinical and business models that support seamless and comprehensive
Morbidity and Mortality in People with Serious Mental Illness, which revealed healthcare, and fostering collaborative opportunities. Advocating for funds
that, on average, people with severe mental illness die 25 years earlier than the to bring primary care services to behavioral health organizations has been
general population, was a bombshell. But the tragic report findings corrobo- a National Council legislative priority. And last week, we achieved a small but
rated what those in the trenches — community behavioral healthcare providers significant legislative victory when the 111th Congress authorized one of the
— suspected, we’re helping people recover from mental illness when their lives key provisions in the Community Mental Health Services Act championed by the
are endangered due to neglect of other serious health issues. National Council — a new $7 million grant program, housed at the Substance
The barriers to complete care seem daunting. A National Council survey of Abuse and Mental Health Services Administration, giving people with serious
community behavioral organizations revealed that although over 90% consider mental illnesses the promise of a healthcare home.
general healthcare for consumers a priority, only one in two organizations has In addition to our legislative activity, we’ve been active on the
any general healthcare capacity, and less than one in three has the capacity practice improvement front. The National
to provide the services onsite. The most common barriers to obtaining general Council Four Quadrant Model is widely
medical services are problems in reimbursement, workforce limitations, physi- used to guide collaborative efforts across
cal plant constraints, and lack of community referral options. the country. Our Primary Care-Behavioral
The National Council’s report, “The Person-Centered Healthcare Home,” Health Collaborative project —currently
featuring an overview of evidence-based approaches makes a strong case in its third phase — has provided a
— to policymakers, planners, and providers of general healthcare and behav- wealth of guidance and hands-on
ioral health services — for creating a patient-centered healthcare home for training, helping member organiza-
people with serious mental illnesses either by creating general healthcare tions and their primary care part-
capacity within the behavioral health care organization or through a seam- ners to overcome clinical, cultural,
less collaborative relationship with a primary care provider. and communication
We also cannot ignore the large unmet need for mental health and sub-
stance abuse specialty services within general healthcare. A 2007 Health
Affairs article notes that community health centers reported that over 40%
of uninsured patients and 20% of Medicaid patients had difficulty access-
ing mental health services; and over 50% of uninsured patients and
30% of Medicaid patients were challenged in accessing substance
abuse treatment. Primary care needs the staff and skills to assess
behavioral health conditions; and behavioral health care providers
need the capacity to accept and treat the complex cases referred to them from
There are community behavioral health organizations that have implemented
innovative clinical and financing models that make possible the provision of
comprehensive care in collaboration with primary care centers. As you will see
in the range of model programs showcased in this issue of National Council
Magazine, collaboration is evident in colocated mental health and primary
care services, enhanced referral processes between mental health and primary
2 / NATIONAL COUNCIL MAGAZINE • WINTER 2009
In My Own Words
barriers to collaboratively provide comprehensive healthcare. And
using web-based technologies, we’ve formed virtual Learning Com- Getting Well in My Mind and Body…
munities where behavioral health and primary care professionals
share information and offer feedback and advice. cassandra Mccallister, Board Member, Washtenaw Community
The National Council has added staff with expertise and a special
passion for healthcare collaboration. Laura Galbreath, our Director “I had been diagnosed with depression but was not properly diagnosed with bipolar disorder
of Policy and Advocacy, is leading the development and launch of a until 2003. Fortunately, I was able to find help at Community Support Treatment Services in
National Council Resource Center for Primary Care and Behavioral Michigan. I joined a wellness group, and between this service and my medications, I haven’t
Health Collaboration at www.TheNationalCouncil.org/Resource- had a hospitalization in more than 5 years. I am also proud to say that I have been sober
Center. And we’re very pleased to have Kathy Reynolds, former for 15 years.
Executive Director of Washtenaw Community Health Organization
Around the time that my bipolar condition was identi-
the more we work
— and one of the country’s most respected integrated care experts
— join us as our Integrated Health Program Specialist.
fied, I was diagnosed with kidney disease. I am cur- out the kinks and
rently on a waiting list for a kidney transplant. Between
The National Council will continue to advocate for increased atten- the two disorders, it was a pretty upsetting time in my come to expect care
tion and resources for the whole health of our communities — but
to be effective we need your help. We need you to do four things:
life. Even so, I was excited to have my bipolar illness that looks at the whole
properly identified and to be receiving treatment. I was
Make your voice heard: Advocate within your community and your determined to do whatever it took to get well in my person, the easier it
state for resources to ensure that people with serious mental ill- mind and body.
will become for future
nesses and addictions have access to primary care. And take the My doctors, dialysis clinic staff, and mental health
message to your Congressional delegation by joining us in Wash- case manager are well connected. They take a team generations.
ington, D.C., June 9-10, 2009 for our Fifth Annual Hill Day. approach, and they each check on the status of my
Be creative: Work with existing funding mechanisms to begin to health. When I go to my primary care doctor, he asks about my mental health. When I go to
address the whole health of people with serious mental illnesses my mental health counselor, the office has the information on my health status. Today I have
and addictions. Explore all the options — Kathy Reynolds (see ar- control over my health; it doesn’t have control of me. The coordinated care allows me to feel
ticle on page 12) speaks to how we can start to overcome financ- like I can go out and be a part of the community.
ing barriers by breaking out of our silos and looking broadly at Before this kind of collaborative relationship was available, it was all on me to keep things
community resources. straight. It was hard to get all my providers communicating with each other, but I knew that it
Foster collaboration: Look for ways to begin to work with your lo- was important that they receive the same information that I was getting. If it had not been for
cal community health center or primary care practices. What might the involvement of my case manager, I don’t know that I could have navigated the healthcare
start with sending your staff to a primary care center can evolve system. Given that I was still in early recovery for bipolar disorder, my mental health provider
into a robust partnership with primary care services being deliv- was able to speak with my primary care doctors and help me think through my options and
ered within your organization. decide what I needed to get healthy. The mental health therapy I received from my counselor
has helped me react to symptoms and learn how to deal with them so that I am not paralyzed
Focus on health: Consider offering Mental Health First Aid certifi-
by them. It’s also been tremendously important to the management of my physical health.
cation programs in your community, helping people identify men-
When I’m mentally well, I am better equipped to take care of my health.
tal illnesses and respond to mental health crises (for information
go to www.MentalHealthFirstAid.org). And as the most important Over the past 3 years, I’ve made a lot of changes in my life. I walk every day, have changed
healthcare providers in the lives of people with serious mental my eating habits, and have managed to lose 97 pounds. I tell other people who struggle with
illnesses and addictions, promote healthy lifestyles and effective a mental illness and physical health conditions that collaborative care has worked for me.
management of chronic conditions. The InShape Program devel- When everyone is working together for the benefit of the consumer, the outcomes can only be
oped by Monadnock in New Hampshire is testimony to the impact positive. It can take a certain amount of determination to overcome stigma and other barri-
of physical fitness programs; and curriculums such as TeamSolu- ers, but it’s my health, and I need my care provider’s support.
tions (see page 44) offer staff and consumers state of the sci- The more we work out the kinks and come to expect care that looks at the whole person, the
ence educational tools about healthy lifestyles and management easier it will become for future generations.
My recovery: a newfound happiness, hope and helping others, my relationship with family and
Let us imagine the future — a future where we prevent illness friends, and a new kidney.”
whenever possible and when we can’t prevent, we educate, we
intervene early, and we deliver the best possible care to every per- Cassandra McCallister offered this testimony in an interview with Laura Galbreath, Director of Policy and Advocacy,
son, every place, every time. And if we imagine it — together we National Council for Community Behavioral Healthcare
will make it happen.
NATIONAL COUNCIL MAGAZINE • WINTER 2009/ 3
Promoting Whole Health for the Mentally Ill
charles ingoglia, MSw, Vice President, Public Policy
National Council for Community Behavioral Healthcare
“Only 32%afford the resources and staff they healthtoproviders
are able to
of the nation’s community mental
onsite treatment for medical conditions. But it’s ironic to address
mental illnesses and let people die from unattended medical
conditions! We must provide integrated healthcare where it is
easiest for patients to access.”
T he National Council has long been dedicated to developing programs and
advocating for policies that improve access to effective physical healthcare
for people with mental illness.
Medicaid chronic care ManageMent deMonStration
Congress has a history of creating targeted Medicaid demonstration programs
to establish the effectiveness of particular interventions. In this spirit, the
After reviewing the policy recommendations contained in the 2006 NASMHPD National Council is seeking a $250 million Medicaid demonstration targeted
morbidity and mortality report, surveying our members on their current activities toward agencies that serve people with serious mental illness to help those
and barriers, and consulting with our Board of Directors’ Public Policy Commit- agencies better coordinate care and to provide baseline physical healthcare
tee, the National Council launched a series of policy initiatives to help close services on site.
the death and disability gap for people with serious mental illness — highlights
follow. Watch for further updates in the National Council’s Public Policy Update weekly e-newsletter. Sub-
coMMUnity Mental health ServiceS iMProveMent act scribe at www.TheNationalCouncil.org (click on the Subscriptions link at the top of the page). Email
federal policy questions and suggestions to ChuckI@thenationalcouncil.org.
People with behavioral health disorders need access to quality healthcare that
Charles Ingoglia is Vice President of Public Policy for the National Council for Community Behavioral
is timely, affordable, appropriate, and coordinated with the behavioral health Healthcare. He directs the federal affairs function of the National Council and oversees policy and
treatments and services they receive. Currently, many people served by the men- advocacy outreach to more than 1,600 member organizations across the nation. He also serves as
tal health and substance use treatment systems are not able to access care adjunct faculty at the George Washington University Graduate School of Political Management. Prior
to joining the National Council, Ingoglia provided policy and program design guidance, including the
in primary care settings due to coverage issues, stigma, and the difficulties of
review of state Medicaid Waiver applications and other health and human services regulations,
fitting into the fast-paced-visit model of primary care. to the Center for Mental Health Services at the Substance Abuse and Mental Health Services
Last week, we achieved a small but significant legislative victory when the 111th
Congress authorized one of the key provisions in the Community Mental Health
Services Act — a new $7 million grant program, housed at the Substance Abuse
and Mental Health Services Administration, giving people with serious mental Quick Facts k
illnesses the promise of a healthcare home.
health diSParitieS deSignation “Indeed, the causes of physical illness and death among
As a key first step, one of the recommendations of the morbidity and mortality psychiatric patients are much the same as those in other
report to create a federal designation for people with serious mental illness as
groups — cigarette smoking, obesity, diabetes — and are
a distinct at-risk health disparities population, followed by the development and
treatable. The problem is that people with serious mental
adaptation of materials and methods for prevention and for inclusion of this
illness tend to be low on the socioeconomic totem pole and
population in morbidity and mortality surveillance demographics.
often don’t get the best available healthcare.”
The National Council continues to work with federal agencies and with Congress
to obtain this designation as it would help to prioritize persons with serious Kate Torgovnick in “Why Do the Mentally Ill Die Younger?”
mental illness to receive physical healthcare from community health centers. TIME Magazine, Dec 3, 2008
4 / NATIONAL COUNCIL MAGAZINE • WINTER 2009
Make your voice heard on Capitol Hill
Join us in Washington, DC
JUNE 9 – 10, 2009
Join us to advocate for policies that protect and expand access to adequately
funded, effective MENTAL HEALTH and ADDICTIONS services.
JUNE 9, 2009 JUNE 10, 2009
Policy Committee Breakfast brieﬁng
One-on-one coaching Hill visits
for Hill visits Capitol Hill
Welcome reception reception
Events take place at the Washington Court Hotel and on Capitol Hill.
Bring a team—board
Register, record Hill appointments, get brieﬁng materials, and reserve discounted hotel rooms
members, medical directors,
local law enforcement allies,
state legislators, county Questions? Email Policy@thenationalcouncil.org or call 202.684.7457.
and family members.
a new “home”
For People with
Serious Mental illnesses
Barbara J. Mauer, MSw cMc, MCPP Healthcare Consulting and Senior
Consultant, National Council for Community Behavioral Healthcare
T he patient-centered medical home, along with
universal coverage, is one of the frequently rec-
ommended changes in healthcare reform. The treat-
around the patient-centered medical home with
evidence-based approaches to the integration of
primary care and behavioral health. The report also
The proposed Person-Centered Healthcare Home is
based on the stepped care clinical approach, which
assures that the need for a changing level of care is
ment of depression, anxiety, and related conditions proposes renaming of the patient-centered medical addressed appropriately for each person by creat-
in primary care requires behavioral health as an home as the Person-Centered Healthcare Home. The ing a structure for feedback from specialty care to
element of the medical home. On the other hand name change is more than cosmetic. Person-Cen- primary care.
schizophrenia, bipolar disorder, and other serious tered Healthcare Home emphasizes that behavioral The concept calls for healthcare to be implemented
mental illnesses present a unique set of challenges, health is a central part of healthcare, and such a bi-directionally:
requiring easy access to effective physical health- shift in perspective can begin to address some sig-
care services. nificant health disparities for people with SMI. A. Identify people in primary care with behavioral
health conditions and serve them there unless
The National Association of State Mental Health integration iS a 2-way road they need stepped specialty behavioral health-
Program Directors found that people living with SMI The National Council report also highlights the need care; and,
die 25 years earlier than the rest of the population, for a bi-directional approach, addressing the inte-
in large part because of unmanaged physical health gration of primary care services in behavioral health B. Identify and serve people in behavioral health-
conditions. The report found that three out of every settings as well as the need for behavioral health care that need routine primary care and step
five people with SMI died from preventable health services in primary care settings. them to their full-scope healthcare home for
conditions. A Maine study of Medicaid members more complex care.
A full-scope Person-Centered Healthcare Home
with and without SMI revealed that people living as defined in the report would accept 24/7 ac- leSSonS FroM iMPact dePreSSion
with SMI had a significantly higher prevalence of treatMent Model
countability for a population and include preven-
major — mostly preventable — medical conditions The Person-Centered Healthcare Home report draws
tive screening/health services, acute primary care,
than did an age- and gender-matched Medicaid recommendations from a preeminent research ex-
women and children’s health, behavioral health,
population. management of chronic health conditions and end ample, IMPACT, one of the largest treatment trials
To address the gaps in current national thinking on of life care. These services are supported by en- for depression, in which Dr. Jurgen Unutzer and his
healthcare reform, the National Council for Com- abling services, electronic health records, registries, colleagues followed 1,801 depressed, older adults
munity Behavioral Healthcare is releasing, in April and access to lab, x-ray, medical/surgical special- in 18 diverse primary care clinics across the United
2009, The Person-Centered Healthcare Home, a ties, and hospital care. States for two years, utilizing care management
report that brings together current developments within a stepped care approach. The IMPACT model
6 / NATIONAL COUNCIL MAGAZINE • WINTER 2009
has been found to double the effectiveness of care
for depression, improve physical functioning and pain
The Person-Centered Healthcare Home is
status for participants, and lower long-term health- a new National Council report, releasing April 2009, that features
care costs. evidence-based approaches to a patient-centered healthcare home
Since the research trial’s end, several organizations for the population with serious mental illnesses. Prepared by
in the United States and abroad have adapted and
implemented the IMPACT program with diverse popu-
National Council senior consultant Barbara Mauer, the report
lations, serving people of all ages and expanding the presents an overview — for policymakers, planners, and providers
scope of services beyond depression to anxiety, post- of general healthcare and behavioral health services — of the
traumatic stress disorder, attention-deficit/hyperac-
tivity disorder, and other conditions frequently found
integration of behavioral health and general healthcare services in
in primary care. light of the national conversation regarding the development of
The core feature of the IMPACT model applicable to patient-centered medical homes. Access the full report at
the Person-Centered Healthcare Home is collaborative www.TheNationalCouncil.org/ResourceCenter.
care, in which the individual’s primary care physician
works with a care manager/ behavioral health con- The Person-Centered Healthcare Home emphasizes the need for
sultant to develop and implement a treatment plan
and the care manager/behavioral health consultant a bi-directional approach, addressing the integration of primary
and primary care provider consult with a psychiatrist care services in behavioral health settings as well as the need for
to change the treatment plan if the individual does behavioral health services in primary care settings.
the national council report proposes two models
cheroKee Model Behavioral health reSPonSiBilitieS
— the Partnership and cherokee models — for be-
Another excellent model is that of Cherokee Health Not all behavioral health providers can envision a
havioral health providers who envision a role as a
Systems, an organization with 23 sites in 13 Tennes- future role in a Person-Centered Healthcare Home.
Person-centered healthcare home.
see counties that is both a primary care provider and However, all behavioral health providers have a clini-
the PartnerShiP Model a specialty behavioral health provider. Integrated care cal responsibility and accountability for individuals
One approach to achieving better access to healthcare is central to the organization’s vision and mission, receiving behavioral health services. If these services
for mental health consumers is a partnership model. and this care is practiced across an array of compre- include prescribing psychotropic medications, there
In a partnership model between a behavioral health hensive primary care, behavioral health, and preven- is an additional set of accountabilities related to the
organization and a full-scope healthcare home, the tion programs and services. Cherokee is integrated risk of metabolic syndrome and the whole health of
organizations must assure mission alignment and be structurally and financially, a structure that supports the person:
deliberate about designing clinical mechanisms for the focus on clinical integration. A behavioral health >> Assure regular metabolic screening and tracking
collaboration, supported by structural and financial consultant is an embedded, full-time member of the at the time of psychiatric visits for all behavioral
arrangements appropriate to their local environment. primary care team. A psychiatrist is also available for health consumers receiving psychotropic medica-
Given the research to date, the following six research- medication consultation. The behavioral health con- tions.
based components should be included as part of a sultant provides brief, targeted, real-time interven-
tions to address the psychosocial needs and concerns >> Identify the current primary care provider for each
partnership between a behavioral health organization
in the primary care setting. individual, and when none exists, assist the indi-
and a primary care, full-scope healthcare home:
vidual in establishing a relationship with a primary
1. Regular screening and registry tracking and out- For people who need specialty behavioral health ser- care provider and accessing care.
come measurement at the time of psychiatric visits vices, a primary care provider is embedded in the spe-
cialty behavioral health team. Cherokee hires primary >> Establish specific methods for communication and
2. Medical nurse practitioners/primary care physi- treatment coordination with primary care provid-
care providers who are comfortable with mental health
cians located in behavioral health ers and assure that timely information is shared in
issues and believes that all frontline, administrative,
3. A primary care supervising physician and support staff must be essential players, commit- both directions.
4. An embedded nurse care manager ted to the holistic approach. The local community is >> Provide education and link individuals to self-man-
aware that people are treated for all types of illnesses agement assistance and support groups.
5. Evidence-based practices to improve the health
at Cherokee, and mental health consumers find that
status of the population with SMI
all are treated in the same way, which reduces the
6. Wellness programs. stigma of seeking mental health treatment.
NATIONAL COUNCIL MAGAZINE • WINTER 2009/ 7
challengeS in integration THE MEdICAl HoME ConCEpT
Organizations that have attempted to integrate
care between primary care and behavioral health
In 2007, the American Academy of Family Physicians, the American
practitioners have learned about the different cul-
tures, languages, and processes that primary care Academy of Pediatrics, the American College of Physicians, and the
and behavioral health clinicians bring to collabora- American Osteopathic Association released the Joint Principles of the
tive efforts. The success of person-centered health- Patient-Centered Medical Home (see www.pcpcc.net/node/14).
care homes depends on the field’s ability to bridge
The Joint Principles stated the following:
this set of differences at the clinical level.
At the system level, these differences result in bar- >> Each patient has an ongoing relationship with a personal physician.
riers when primary care is integrated into behavior-
>> The personal physician leads a practice level team that
al health and when behavioral health is integrated
into primary care. Typical barriers include financ- collectively takes responsibility for the ongoing care of patients.
ing; policy and regulation; workforce; information >> The personal physician is responsible for providing for all
sharing; and the need for more research relating to
of the patient’s healthcare needs or appropriately
the costs, cost offsets, and health outcomes
arranging care with other qualified professionals.
The promise of the patient-centered medical home
can only be fully realized if it is transformed into the >> Care is coordinated or integrated across
person-centered healthcare home, with behavioral all elements of the healthcare system.
health capacity fully embedded in primary care
teams and primary care capacity inlaid in behav- >> Quality and safety are hallmarks.
ioral health teams. Moving the concept forward will
require thoughtful, deliberate, and adaptive leader- >> Enhanced access to care is available.
ship at every level and across clinical disciplines >> Payment appropriately recognizes the added value provided
and sectors that currently segment how people are
to patients who have a patient-centered medical home.
served, how the delivery of their care is organized,
how communication among providers occurs, and The clinical approach of the patient-centered medical home focuses
how care is reimbursed. For people with SMI who
on team-based care led by a personal physician who provides
are suffering from unmanaged physical health con-
ditions and dying before their time, the time for this continuous and coordinated care management and supports patients
concept to move ahead is now. in their self-management goals throughout their lifetime. In this model,
The Person-Centered Healthcare Home report care management is central to the shift away from a concentration on
also revises the well-known National Council Four episodic acute care to a focus on managing the health of defined
Quadrant Model, which describes the subsets of populations, especially those living with chronic health conditions.
the population that behavioral health and primary
care integration must address. The revised model Although the medical home model emphasizes self-care, it has not
is on page 10 of this issue. clearly defined the role of behavioral health, which the Institute of
Medicine has identified as a central part of healthcare.
Barbara Mauer is a nationally known expert in behavioral
health and primary care integration. She has more than 20
years of experience in consulting to both healthcare and be-
havioral health organizations and is a managing consultant for
MCPP Healthcare Consulting in Seattle, Washington and a Na- voices k
tional Council senior consultant. She offers consulting services
to public and private sector health and human service orga- “Clearly, overall well-being is a function of both mental and physical health. Just as
nizations on integration as well as strategic planning, quality screening and evaluation for mental illnesses and addictions is increasingly available
improvement, and project management. Mauer has authored
many papers and presented at national conferences on behav- in primary care settings, screening and evaluation for general health problems should
ioral health and primary care integration. be available to those in mental health settings.”
Linda Rosenberg, President and CEO, National Council for Community Behavioral Healthcare
8 / NATIONAL COUNCIL MAGAZINE • WINTER 2009
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National Council’s Revised Four Quadrant Model
A revised Four Quadrant Model is featured in a new National Council report, The Person-Centered Healthcare Home
(see page 6). The revised model is presented and discussed here.
T he National Council’s widely used Four Quadrant
Model represents a planning framework for the
clinical integration of health and behavioral health
impact on operations, documentation, billing,
and risk management?
most behavioral health organizations have popula-
tions in Q II and Q IV, unified program models serve
populations in all four quadrants). The principle of
>> Reimbursement factors — do payers support col-
services and focuses on the populations to be laborative care and make it easy or difficult for stepped care says that each provider needs to be
served. the behavioral health and primary care sectors to able to address needs for populations in both quad-
Each quadrant considers the behavioral health and work together? rants (e.g., adding the nurse care manager for those
physical health risk and complexity of the popula- with complex co-morbidity).
Most provider organizations will find that they are
tion and suggests the major system elements that involved in at least two quadrants (e.g., most pri- QUADRANT I
would be utilized to meet the needs of a subset of mary care clinics have populations in Q I and Q III, The Population: Low to moderate behavioral health
The Four Quadrant model is not intended to be pre-
scriptive about how care is organized in a quadrant
The Four Quadrant Clinical Integration Model
or for an individual. It is a conceptual framework
and collaborative planning tool for addressing the Quadrant II Quadrant IV
BH PH BH PH
needs of population subsets (not individuals) in
• Behavioral health clinician/case • PCP (with standard screening tools
each local system. manager w/ responsibility for and guidelines)
coordination w/ PCP • Outstationed medical nurse
While system planning requires a population-based • PCP (with standard screening practitioner/physician at
method; service planning should be person-cen- tools and guidelines) behavioral health site
• Outstationed medical nurse • Nurse care manager at behavioral
tered. Therefore, the Four Quadrant Model does not practitioner/physician at health site
Behavioral Health (MH/SA) Risk/Complexity
behavioral health site • Behavioral health clinician/case
specify in which quadrant individuals should receive • Specialty behavioral health manager
care and it should be possible to move from one • Residential behavioral health • External care manager
• Crisis/ED • Specialty medical/surgical
population subset to another over time. • Behavioral health inpatient • Specialty behavioral health
• Other community supports • Residential behavioral health
Using the evidence regarding effective clinical prac- • Crisis/ ED
tices, each community must develop its uniquely • Behavioral health and
detailed operational arrangements, depending on • Other community supports
the factors in their environment, including: Persons with serious mental illnesses could be served in all settings. Plan for and deliver
services based upon the needs of the individual, personal choice and the specifics of the
community and collaboration.
>> Array of and capacity of services in the commu-
nity — what services are available and is there Quadrant I Quadrant III
BH PH BH PH
access to sufficient amounts of the services that
are needed? • PCP (with standard screening • PCP (with standard screening tools
tools and behavioral health and behavioral health practice
practice guidelines) guidelines)
>> Consumer preferences — are individuals more • PCP-based behavioral health • PCP-based behavioral health
likely to accept care in primary care or specialty consultant/care manager consultant/care manager (or in
• Psychiatric consultation specific specialties)
settings? • Specialty medical/surgical
• Psychiatric consultation
>> Trained workforce — do current behavioral health • ED
and primary care staff have the right skills to de- • Medical/surgical inpatient
• Nursing home/home based care
liver planned services onsite? • Other community supports
>> Organizational support in providing services — Physical Health Risk/Complexity
do managers provide encouragement and sup- Low High
port for collaborative activities and what is the
Bold text represents revisions to incorporate concept of person-centered healthcare home.
10 / NATIONAL COUNCIL MAGAZINE • WINTER 2009
and low to moderate physical health complexity/risk.
The Model: Person Centered Healthcare Home: a pri-
each quadrant considers
mary care team that includes a behavioral health con- the behavioral health and physical
sultant/care manager, psychiatric consultant, screen-
ing for behavioral health concerns, and stepped care. health risk and complexity of the
The Providers: The primary care provider assures the population and suggests the major
full-scope healthcare home and uses standard behav-
ioral health screening tools and practice guidelines to system elements that would be
serve individuals in the primary care practice. Use of
standardized behavioral health tools by the primary utilized to meet the needs of a
care provider and a tracking/registry system focuses
subset of the population.
referrals of a subset of the population to the primary
care based behavioral health consultant/care manag-
er. The primary care provider prescribes psychotropic
medications using treatment algorithms. Psychiatric
consultation is structured to support both the primary
care provider and the behavioral health consultant/
care manager, with a focus on treatment planning for
individuals who are not showing improvement.
QUADRANT III including medical nurse practitioner/primary care
The Population: Low to moderate behavioral health physician, nurse care manager, wellness program-
The Population: Moderate to high behavioral health
and moderate to high physical health complexity/ ming, screening/tracking for health status concerns,
and low to moderate physical health complexity/risk.
risk. and stepped care to a full-scope healthcare home.
The Model: Person Centered Healthcare Home: Access to the array of specialty behavioral health
The Model: Person Centered Healthcare Home: a pri-
primary care capacity in a behavioral health set- services designed to support recovery and access
mary care team that includes a behavioral health con-
ting, including medical nurse practitioner/primary to specialty medical/surgical consultation and care
sultant/care manager, psychiatric consultant, screen-
care physician, wellness programming, screening for management.
ing for behavioral health concerns, stepped care, and
health status concerns, and stepped care to a full-
access to specialty medical/surgical consultation The Providers: In addition to the services described
scope healthcare home. Access to the array of spe-
and care management. in Quadrant II, the primary care physician collabo-
cialty behavioral health services designed to support
The Providers: In addition to the services described rates with medical/surgical specialty providers and
in Quadrant I, the primary care provider collaborates external care managers to manage the physical
The Providers: The primary care physician assures the health concerns of the individual. In some settings,
with medical/surgical specialty providers and care
full-scope healthcare home either through practicing behavioral health consultant/care manager services
managers (e.g., diabetes, asthma) to manage the
on site or supervision of the nurse practitioner, con- may also be integrated with specialty provider teams
physical health concerns of the individual. Specialty
sultation with behavioral health provider and stepped (for example, Kaiser has behavioral health consultants
healthcare and care management programs could
care. Psychiatric consultation with the primary care in OB/GYN programs, working with substance abusing
also integrate behavioral health screening and the
provider may be an element in these complex behav- pregnant women). Nurse care management is added,
behavioral health consultant/care manager into a
ioral health situations, but it is more likely that psy- along with focused goal setting and self-management
wide array of self management and rehabilitation
chotropic medication management will be handled planning, to the standard health screening/registry
programs, building on research findings regarding the
by the specialty behavioral health prescriber, in col- tracking (e.g., glucose, lipids, blood pressure, weight/
frequency and impact of depression in cardiovascular
laboration with the primary care physician. Standard BMI). Wellness programs (e.g., diabetes groups) are
or diabetes populations.
health screening (eg. glucose, lipids, blood pressure, available as secondary and tertiary preventive inter-
weight/BMI) and preventive services will be provided. QUADRANT IV ventions, incorporating recovery principles and peer
The Population: Moderate to high behavioral health leadership and support.
Wellness programs (e.g., nutrition, smoking cessation,
and moderate to high physical health complexity/risk.
physical activities) are available as primary as well Learn more about the Four Quadrant Model at
as secondary preventive interventions, incorporating The Model: Person Centered Healthcare Home: pri- www.TheNationalCouncil.org/ResourceCenter
recovery principles and peer leadership and support. mary care capacity in a behavioral health setting,
NATIONAL COUNCIL MAGAZINE • WINTER 2009/ 11
Financing Integrated Healthcare:
With Existing Opportunities
Kathleen reynolds, MSW, ACSW, Program Specialist, Integrated Health, National Council for Community Behavioral Healthcare
F inancing is probably the most common perceived barrier in implementing
integrated or collaborative healthcare. However, integrated healthcare is
fundable in nearly every state right now! Even with the state by state difference
shift that involves putting the consumers’ and community’s best interest first.
Agencies and organizations are stewards of the public money. It is a behavioral
healthcare organization’s responsibility to make behavioral health resources
in Medicaid programs, the complexity of Medicare billing, and uniqueness of available to the community as part of a package of services. This approach
healthcare coverage for those we serve, there are short term solutions that allow to financing integrated care results in creative, effective service packages that
programming to proceed and services to be provided in integrated programs. In meet everyone’s needs.
Medicaid fee-for-service and capitated states there are nearly a dozen ways to GeNeRATING The WIll
fund collaborative care and integrated healthcare initiatives. In these difficult financial times it seems natural to hunker down and wait for
things to improve. Now, more than ever is the time to be creative and to stretch
healthcare resources to the maximum and assist consumers in their path to
Three fundamentals to successfully implementing
recovery. It may seem counter-intuitive but now may be when change is most
financing strategies are
possible and most effective. Now is the time to get the most creative financial
> Think of the healthcare money in a community as a minds together with the most conservative financial minds and hammer out
collaborative local resource. exactly what is possible with the funding that is received. Partnering and col-
> Generate the will to make it work within existing laboration are often keys to making money go further. This is particularly true
funding mechanisms. in integrated care where shared resources improve consumer outcomes while
enhancing the bottom line of all the partners.
> Be willing to advocate strongly with your state officials
for the implementation of currently approved CPT ADVoCATING FoR sTATe leVel MeDICAID ChANGes
codes for services provided in integrated settings. Medicaid regulations are made state by state in this country. This is both a
blessing and a curse. A blessing in that there is often more ability to influence
state policy rather than federal policy and a curse because the same work has
The CoMMUNITy’s MoNey to be done 50 times! A number of states already allow for billing two services
A consistent barrier in financing integrated healthcare services is that organiza- on one day. It is possible to get a copy of that policy work in one state and work
tions think of the funding in a siloed way. It’s not uncommon to hear “this is my with another state to implement it.
money” or “our money.” With this old approach to financing, the outcomes often TIPs FoR FINANCING seRVICes RIGhT NoW
need to benefit the organization and sometimes even the individuals within Two series of codes are already approved for commercial, Medicare and Med-
an organization. Success with financing integrated care requires a paradigm icaid billing: SBIRT (Screening, Brief Intervention, Referral and Treatment) and
12 / NATIONAL COUNCIL MAGAZINE • WINTER 2009
Improving the health status of
those we serve requires all of us to
come to the table and work within
existing financing structures to find
solutions rather than use financing
as a way to delay discussions.
the Health and Behavior Assessment/Intervention (96150-96155). The
Health and Behavior Assessment/Intervention codes can be used to bill a
behavioral health service ancillary to a primary care diagnosis. This would
include providing services regarding chronic care management such as
diabetes care, cardiac support, and consulting and assistance with COPD
management. SBIRT can be billed in the primary care setting for screening
for substance use/abuse.
In Wisconsin, case/care management services are billable for primary set-
tings working with individuals with a serious mental illness. In Michigan the
Primary Care Association has negotiated a memorandum of understanding
that allows for FQHCs to bill two services in one day (www.mpca.net). In
states where two services rendered on one day by one provider are not
billable, programs have found innovative ways to collaborate that allow
both partners to bill, using two provider numbers to provide the services.
They key here is creative, collaborative thinking that maximizes the current
financing options. Improving the health status of those we serve requires all
of us to come to the table and work within existing financing structures to
find solutions rather than use financing as way to delay discussions.
In states where capitation is used, it often provides the flexibility for local
decision-making regarding services and funding. Don’t be afraid to expand
thinking about creative ways to secure better outcomes by integrating staff
into primary care setting to provide mental health services. Often, it re-
quires no new approvals for mental health centers to provide community
based services. In fee for service states, review the regulations and find any
way you can to bill for services at a primary care site. You’ll generate better
health outcomes and support your organization’s bottom line.
Kathleen Reynolds, MSW, ACSW is a nationally recognized expert in primary care and
behavioral health collaboration. Ms. Reynolds is the former Executive Director of the Washt-
enaw Community Health Organization and an Adjunct Clinical Instructor in the University of
Michigan Department of Psychiatry. The WCHO is an integrated health system that includes
a community mental health services program, a substance abuse coordinating agency, and
primary healthcare capitation dollars for Medicaid and indigent consumers. For the past
seven years Reynolds’ primary emphasis has been developing integrated health care models
for Medicaid and indigent consumers. Reynolds has presented at numerous conferences
and conventions on the innovative programming in Washtenaw County and is the author/
co-author of several articles and has co-authored Raising the Bar: Moving Toward the
Integration of Health Care, A Manual for Providers, a National Council publication.
NATIONAL COUNCIL MAGAZINE • WINTER 2009/ 13
Learning Collaboratives Enhance Population Health
Barbara J.Mauer, MSw, cMc, MCPP Healthcare Consulting and Senior Consultant, National Council for Community Behavioral Healthcare;
laura galbreath, MPP, Director of Policy and Advocacy, National Council for Community Behavioral Healthcare
A s more communities realize the value of primary
and behavioral health collaboration, they now
have more working examples to learn from. The
Council has adopted for this project is based on 20
years of pioneering work by the Institute for Health-
care Improvement and the application of that work
> Return of stable patients to primary care fol-
low up as appropriate.
>> Establish shared methods for medical manage-
National Council’s Primary Care-Behavioral Health in the Health Disparities Collaboratives sponsored ment of patients treated in community mental
Collaborative project has provided a wealth of valu- by the Health Resources and Services. health settings who are at risk for metabolic syn-
able outcomes that will help further this growing leARNING CollABoRATIVe GoAls drome.
movement. >> Increase ability of primary care clinics to screen >> Increase capacity of both primary care and com-
A 2007 National Council survey of community for bipolar, addictions, and suicide risk as a part munity mental health organizations to document
behavioral organizations revealed that although of depression screening. and track care processes and performance.
91% of respondents place high or medium priority >> Increase capacity of primary care clinics to pro-
on increasing the quality of general medical health- The Primary Care-Behavioral Health Collaborative
vide proactive follow-up and management of pa- project started with four Phase 1 sites in January
care for their clients, only one in two providers has tients identified with depression.
the capacity to provide any treatment for those con- 2007. Each site is a partnership between a men-
ditions, and one in three has the capacity to provide >> Increase community mental health organiza- tal health agency and a community health center.
the services onsite. The most common barriers to tions’ provision of psychiatry training and clini- The first sites were located in Massachusetts, Iowa,
providing general medical services were problems cal support for primary care, to enable a more Montana, and Washington.
in reimbursement (72.1%), workforce limitations comprehensive stepped care model. Phase 2, the focus in this article, expanded into an
(68.4%), physical plant constraints (60.8%), and >> Establish processes for ongoing communication additional eight sites in fall 2007:
lack of community referral options (55.8%). regarding collaborative care between primary >> Colorado: Colorado West Regional Mental Health
The National Council’s Primary Care-Behavioral care and community mental health organiza- and Summit Community Care Clinic
Health Collaborative Project — funded in part tions, including:
>> Colorado: North Range Behavioral Health and
through the generosity of AstraZeneca and Bristol- > Protocols for referral of individuals with bipo- Sunrise Community Health
Myers Squibb — is intended to help member orga- lar disorder and suicide risk from primary care
nizations and their partnering primary care sites clinics to community mental health organiza- >> Florida: Life Stream Behavioral Center and Thom-
overcome some of these barriers and collaborate tions, to assure seamless transition from pri- as E. Langley Medical Center
effectively to provide integrated healthcare. The mary care to specialty mental healthcare. >> Illinois: Heritage Behavioral Health Center and
learning collaborative model that the National Community Health Improvement Center
>> Indiana: Porter-Starke Services and HealthLinc
>>South Dakota: This site dropped out a few months
into the project due to a loss of provider capacity
The National Council Learning Collaborative in the primary care clinic
emphasizes rapid cycle improvements, >>Texas: Austin Travis Mental Health/Mental Retar-
dation and Community Care Services Department
evidence-based practices, and data collection >>Washington: Navos and Neighborcare High Point
to improve outcomes for populations served GeTTING sTARTeD
When the Phase 2 sites were convened for their
through partnerships between community initial learning session in September 2007, they
were provided training in rapid cycle improvement,
behavioral health and primary care providers. evidence-based practices related to delivering
behavioral health services in primary care, and
Continued on page 17
14 / NATIONAL COUNCIL MAGAZINE • WINTER 2009
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Continued from page 14
approaches to primary care services for the popula-
vioral Health Referrals
tion of people with serious mental illnesses in behav- Beha
ioral health. The goals for the sites are summarized by
the graphic at right — to improve the health of their
shared population through changes in services and
collaboration between the two organizations.
TesTING IMPRoVeMeNTs Collaborative
Although each site developed unique project plans,
pRIMARY CARE Health BEHAVIoRAl
collectively they worked on plan−do−study−act im- Services HEAlTH
provement cycles in the following areas:
>> Establish systematic screening and tracking pro-
>> Establish a care manager/behavioral health con-
sultant role. Health Status
>> Develop systematic referral protocols from primary
care to mental health.
>> Develop systematic referral protocols from mental about care are core system improvement tasks that Foundation, 2008). Use of a distinct registry, with
health to primary care. generally require skill development on the part of assigned responsibility, leads to closer monitoring
the organization and partnership. of treatment success.
>> Improve communication mechanisms between pri-
mary care and mental health. >> Clear responsibilities — Spreading the responsibil- >> Scale matters — Implementing change in one prac-
ity for screening and registry tracking to all practi- tice versus across a clinic results in significant dif-
>> Establish measurement protocols regarding weight,
tioners can result in less consistent screening and ferences in volumes of patients and tracking to be
lipids, and blood sugars for patients on antipsy-
follow-up than making the tasks the responsibility managed. Rapid-cycle improvement methodolo-
of an assigned person on the team. This model gies are best suited for starting small and scaling
>> Train primary care providers in mood disorder and requires strong organizational support to pursue up change within an organization. Scale should
bipolar screening and treatment. effectively. be a key factor considered in the development of
>> Establish primary care services in behavioral health >> Data constitutes clinical information — Collecting Quality Improvement strategies.
settings. data related to clinical progress in mental health The National Council’s current Phase 3 Collaborative
At the Phase 2 Learning Congress in December 2008, typically requires a change of culture, one in which Care project, initiated in August 2008, includes four
each site presented the lessons it had learned during data are used to inform clinical practice, not just sites located in Maryland, Indiana, Colorado, and
the course of the project. Each site team also devel- to document clinical encounters. Instigating this Florida.
oped plans for joint next steps. As teams reflected cultural change needs to be a focus of practice Learn more about the Primary Care —
on the improvement cycles, the following themes and reinforced at the organizational level. Behavioral Health Collaborative Project at
emerged at the end of the project: >> Registry tracking — Chart audits are time intensive www.TheNationalCouncil.org/ResourceCenter.
>> Workflows — Studying each of the steps from and don’t support real-time care management in
check-in and registration to the end of the primary the same way that registry tracking (chronic dis- See Barbara Mauer on page 8.
care visit and establishing consistent processes of ease management) systems do. Unfortunately, Laura Galbreath supports the National Council’s state and fed-
most electronic health records do not yet have eral policy initiatives and focuses on expanding opportunities for
initial screening, rescreening, and decision making 1,600+ member community mental health and addictions services
robust registry functions (see California HealthCare organizations to meet the primary health needs of the people they
serve. Galbreath has extensive experience in health policy analysis,
voices k community organizing, and project management. Before coming to
the National Council, she served as the senior director of health-
At a NAMI New York focus group to address the health concerns of persons with mental care reform at Mental Health America.
illness, patients revealed the simple desire to feel deserving of good health. “The most RefeRences
shocking thing was that people really wanted to be healthy but there was a disconnect,” California HealthCare Foundation. (2008). Electronic health re-
cords versus chronic disease management systems: A quick com-
says program associate Katie Linn, who ran the focus groups. “A lot of it came down to parison. Retrieved February 21, 2009, from http://www.chcf.org/
self-worth — they didn’t feel like they were worthy of taking care of themselves.” topics/view.cfm?itemID=133586
NATIONAL COUNCIL MAGAZINE • WINTER 2009/ 17