July 2011

eSolutions is a monthly e-newsletter bringing you practical solutions and resources on primary and behavioral health care integration from across the United States.

Process Mapping to Create ‘Activated’ Consumers

Jeff Capobianco, MA, Coordinator, Evaluation and Performance Measurement, SAMHSA-HRSA, Center for Integration Health Solutions

While providers in today’s healthcare environment may struggle to determine what to measure, choosing well will create a story about the services an agency provides. Process mapping helps gain the stakeholder buy-in needed to determine what to measure. However, before mapping can begin, it is important to understand the three types of people served by behavioral health agencies. In the simplest of terms these people can be described as “Satisfied,” “Dissatisfied,” and “Delighted”; they focus on creating delighted customers who will buy more of their service or product. In healthcare, the focus is on engagement, treatment and education, and the goal is to encourage customers to become "activated" to improve their own health and develop collaborative relationships with their healthcare team.

The “delighted consumer” is analogous to the healthcare customer who is activated.  The “satisfied consumer” has a relationship with the healthcare team and shows up when he or she feels the need, or to get a prescription filled. The “dissatisfied consumer” sees no value in engaging and is often forced to receive treatment due to a disability requiring acute treatment, or even a court order that mandates treatment.

So what does this have to do with process mapping? 

Process mapping involves describing how a process looks from beginning to end from the customer's perspective. The process may seem foreign to many behavioral health employees who see their services as necessary and helpful. While this may be true, customers must also value the services provided – or they may become “no shows,” or dissatisfied consumers.

The concept of value is the cornerstone of process mapping. “Value” is defined by the customer and can help guide service flow. If an agency understands what a customer values, it is better positioned to develop a service flow that will lead to an activated customer. After all, the tremendous success of motivational interviewing is due to its one singular focus: what the consumer values in his or her life.

Process mapping, also known as Value Stream Mapping
(VSM), is a necessary tool for engaging both customers and staff in healthcare system design and redesign. The steps are as follows:

• Understand what the customer values in healthcare services and how this intersects with the agency’s mission and strategic plan.
• Identify one key area of service delivery to map out from within the overall flow a customer experiences from intake to discharge.
• Draw a current state map on the wall with the team who does the work (ideally with large pieces of paper, sticky notes, and markers).
• After the current state is mapped, draw a future state map outlining the optimum flow.
• Identify the key process variables that need to be changed or created to move from the current state to the future state.
• Develop an implementation plan to move from the current to the future state, including details regarding accountable staff, resources required, objectives, measures, timelines, and a communication plan.
• Repeat.

Every detail a customer experiences should be mapped − from advertising and referral source engagement, to how front desk staff interacts with customers on the phone, right through to discharge. This is part of continuous quality/performance improvement. As customers become more activated, new approaches to care will emerge to better meet customers’ needs. An agency’s quality improvement employees are often the best resource to help with process mapping.

The Center for Integrated Health Solutions can assist in process mapping for integrated primary and behavioral healthcare. There are also an abundance of resources online, most of which can be found at websites dedicated to "Lean” process improvement. Process map created by Shawnee Mental Health Center, Inc.

For more information, visit www.CenterforIntegratedHealthSolutions.org
or call 202.684.7457.

PROFILES OF PRIMARY AND BEHAVIORAL HEALTHCARE INTEGRATION

CIHS provides training and technical assistance to the Substance Abuse and Mental Health Services Administration’s Primary and Behavioral Health Care Integration grantees. Each issue of eSolutions profiles a grantee’s work.

The Providence Center

Since 1998, the Providence Center has incorporated exercise and nutrition activities into standard clinical practices for 450 Assertive Community Treatment team consumers. In 2007, TPC expanded wellness programming to all of its consumers through a grant from the Rhode Island Office of Minority Health. Consumers benefit from bilingual, culturally-competent services at TPC and exercise classes at the YMCA. They take walks in local parks, participate in an annual family barbecue and join health promotion events.

To address the need for integrated primary and behavioral healthcare, TPC partnered with community health centers to provide co-located services. Through these programs, consumers reduced risk factors that lead to chronic disease in people with serious mental illness and decreased behavioral health symptoms.

Achieving consumer engagement in the community was a turning point for TPC’s wellness programming. Bilingual Health Mentor Jetzabel Mills found that through community-based wellness activities, “consumers have the opportunity to connect with both their bodies and their communities. Many of our participants had never been exposed to exercise in a positive way before. It improves their outlook and their health.”

Owing to the positive outcomes that resulted from the TPC services with a community reach and the wide range of people served, TPC began providing population-specific wellness programs along with the integrated wellness services that are available to all TPC consumers. In Shape Seniors, a program funded by Tufts University, identifies the needs of seniors with behavioral health problems and integrates wellness activities and social engagement with behavioral health treatment and primary care using health mentors to guide participants toward achieving their goals. Fit2BHealthy, funded by the Rhode Island Foundation, teaches overweight children and their families behavioral, environmental, and physical approaches to reduce weight in collaboration with the child’s pediatrician.

For more information on the Providence Center’s efforts, visit
www.providencecenter.org.

Quick Tips:  Five Ways to Improve Access to Behavioral Health Services

An “Access Redesign Initiative” run by the National Council for Community Behavioral Healthcare and MTM Services has helped to substantially reduce lengthy wait times for assessments. Analyses have shown that for each day a consumer must wait for an appointment, his/her likelihood of showing up decreases by 1%. Open access scheduling significantly reduces ‘no-shows’ and, in some cases, eliminates them entirely.

Consumer engagement increases, improving the likelihood that consumers will show up at timely, subsequent appointments. Service capacity increases as employees spend less time with “busy work” and more time providing services, thus improving the bottom line. And intake costs decrease, further improving the bottom line.

Five change techniques used in the initiative are:

• Streamline documentation: Help organizations reduce their documentation requirements by focusing on the removal of repetitively captured data elements and data elements that are not required by funding or accreditation organizations and changing the answer formats used to capture data elements to reduce overall documentation time.
• Concurrent collaborative documentation: Eradicate post-session documentation time while increasing person-centered engagement of clients in their recovery by involving them in the creation of their clinical documentation.
• Walk-in access models: Implement a zero no-show model to offer more expedient access to care and increased engagement.
• No-show management: Use policy changes, policy enforcement, engagement specialists, and reminder back-filling programs to help clients increase their show rates and engagement levels.
• Employee engagement and maximization of staff productivity: Help providers get staff to buy-in to change so that they can achieve their direct service staff’s productivity targets. 

For more information on accessing Training and Technical Assistance from the Center for Integrated Health Solutions, visit
www.CenterforIntegratedHealthSolutions.org.

CIHS WEBINARS

Using State Claims Data to Evaluate Impact of IDDT on Service Utilization and Cost
Tuesday, August 2, 2011, 2:00-3:00 PM EDT
Hosted by Co-Occurring Disorders Integration and Innovation Task Order

Click here to register for this webinar

The implementation of evidence-based practices (EBPs) has become an expectation of many state and local mental health authorities. As behavioral health dollars shrink, and with healthcare reform a reality, policymakers are increasingly interested in the most clinically- and cost-effective interventions. While EBPs have been shown to produce better clinical outcomes, they are perceived to be more expensive services. This webinar presents the results of a cost-effectiveness study of Ohio’s implementation of Integrated Dual Disorders Treatment (IDDT, a SAMHSA-recognized EBP).

Check out recordings and presentations of the following recent webinars you may have missed:

Introduction to Effective Behavioral Health Service Delivery in Primary Care Settings
Recorded June 1, 2011
Hosted by the National Association for Community Health Centers, a CIHS subcontractor

Presenters:  Dr. Alexander Blount, Dr. Miguel Olmedo

Looking for clarification on the differences between co-located behavioral health services and truly integrated care?  This webinar provided an introduction for clinicians in Federally Qualified Health Centers and Community Behavioral Health Organizations interested in evidence-based practices for integrating behavioral health into primary care.

Person-Centered Health Homes
Recorded May 16, 2011
Presenters: Chuck Ingoglia, Larry Fricks

This webinar provided an overview of the history and components of the person-centered health home model, including whole health and inclusion.

Visit www.CenterforIntegratedHealthSolutions.org for archived recordings and presentations of past webinars.

HOT TOPICS: NEWS & RESOURCES

Motivational Interviewing Website
The Mid-Atlantic ATTC and the ATTC Network launched their new Motivational Interviewing (MI) website, www.motivationalinterview.org. The website contains materials designed to facilitate the dissemination, adoption, and implementation of MI among clinicians, supervisors, program managers, and trainers, and improve treatment outcomes for clients with substance use disorders.

Words of Wellness Newsletter
The July 2, 2011 edition of the Institute for Wellness and Recovery Initiatives newsletter is available at www.welltacc.org. The monthly newsletter features valuable information and resources, including details about educational events, to help people achieve and maintain wellness.

The National Prevention Strategy
On June 16, 2011, the National Prevention, Health Promotion, and Public Health Council released the National Prevention Strategy to focus the nation on prevention and wellness. The Strategy’s four strategic directions and seven priorities include evidence-based recommendations fundamental to improving the nation’s health.

National Wellness Week:  LIVING WELLNESS
As part of National Recovery Month, SAMHSA will launch the first National Wellness Week from September 19-25, 2011. The inaugural theme, “Living Wellness,” will promote the many ways wellness can improve quality of life and increase life expectancy for people with mental and substance use disorders.

Stay tuned for more information about National Wellness Week in future issues of eSolutions or receive information directly by subscribing to the 10x10 Wellness Campaign E-Newsletter at www.10x10.samhsa.gov.

SAMHSA's New Website on Co-Occurring Disorders
SAMHSA redesigned and updated its website on co-occurring disorders to better share important information, events and news on co-occurring disorders and treatment. Visit www.samhsa.gov/co-occurring.

Medicare Proposes Coverage of Screening and Counseling for Alcohol Misuse & Screening for Depression
The Centers for Medicare & Medicaid Services (CMS) proposed adding
alcohol screening and behavioral counseling, and screening for depression, to the preventive services now covered by Medicare. Under the new proposals, Medicare would cover an annual alcohol misuse screening by a beneficiary’s primary care provider, as well as four counseling sessions per year if a beneficiary screens positive for alcohol misuse. Medicare would also cover an annual screening for depression in primary care settings that offer staff-assisted depression care.

CMS announced the proposals on July 20 and is accepting public comments for 30 days; the agency will issue final decisions later this year.To receive this newsletter and other CIHS e-mail updates,
click here to enter your e-mail address and select “News from the SAMHSA–HRSA Center for Integrated Health Solutions” from the options listed.

Our free technical assistance services can help primary and behavioral healthcare providers find integrated health solutions that work. To contact CIHS, visit www.CenterforIntegratedHealthSolutions.org, e-mail Integration@thenationalcouncil.org, or call 202.684.7457.

SAMHSA–HRSA Center for Integrated Health Solutions
Director: Kathy Reynolds, Deputy Directors: Laura Galbreath and Larry Fricks; eSolutions Senior Editor: Cheryl Holt

The SAMHSA–HRSA Center for Integrated Health Solutions, operated by theNational Council for Community Behavioral Healthcare
under a cooperative agreement from the U.S. Department of Health and Human Services, is funded jointly by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration. The CIHS promotes the development of integrated primary and behavioral healthcare services to better address the needs of people with mental health and substance use conditions, whether seen in specialty behavioral health or primary care settings.

March 2011

eSolutions is a monthly e-newsletter bringing you practical solutions and resources on primary and behavioral health care integration from across the United States.

Making Bidirectional Care a Reality

Upcoming Integration Webinars

Profiles of Primary and Behavioral Health Care Integration

Quick Tips: Ten Questions to Improve Access to SBIRT

Hot Topics: News and Resources

Q&A Corner: BMI vs. Waist Circumference

Making Bidirectional Care a Reality

The new SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) is run by the National Council for Community Behavioral Healthcare under a cooperative agreement from the U.S. Department of Health and Human Services. CIHS promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings.

Commenting on the significance of CIHS's role, SAMHSA Administrator Pamela S. Hyde, JD, said, "The Substance Abuse and Mental Health Services Administration is excited about the focus on integrated care, which allows us to bring needed healthcare services to patients in a coordinated and convenient manner and can go a long way in helping to improve health status."

Since its launch in October 2010, CIHS has begun to provide training and technical assistance in six core areas to 56 SAMHSA Primary and Behavioral Health Care Integration grantees - workforce development, knowledge application, knowledge development and dissemination, healthcare reform and policy analysis issues, prevention and health promotion, and quality improvement. Over the next four years, CIHS will offer technical assistance and expert consultation in bidirectional care to community health and behavioral health providers nationwide.

"The National Council looks forward to working with the larger healthcare community and with consumers and patients of healthcare services to eliminate barriers between mental, substance use, and physical health. Together, we can ensure people receive the right care at the right time, in all settings," said Linda Rosenberg, MSW, President and CEO of the National Council for Community Behavioral Healthcare.

For more information about CIHS and for assistance with primary and behavioral health integration, contact us at www.CenterforIntegratedHealthSolutions.org, email Integration@thenationalcouncil.org, or call 202.684.7457.

Upcoming Integration Webinars

Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Monday, April 25, 2011 1:00 - 2:30 pm EDT

Visit www.CenterforIntegratedHealthSolutions.org for registration, past webinar recordings, and new webinar topics and dates.

Profiles of Primary and Behavioral Healthcare Integration

The CIHS provides training and technical assistance to SAMHSA's Primary and Behavioral Health Care Integration (PBHCI) grant program. Each issue of eSoutions will profile a grantee with a focus on their grant-funded initiatives.

Center for Families and Children
Shawna Lewis, LISW-S, Project Director, Integrated Health Care Project

The Center for Families and Children serves nearly 4,300 adults with severe mental illness and 500 children with serious emotional disorders each year. We are focusing our SAMHSA Primary and Behavioral Health Care Initiative grant opportunity on the roughly 40 percent of our adult clients without public or private insurance, who are unable to pay for services. These clients are especially at risk because of the complex effects of their mental illness, poverty, and the lack of community-based primary care for the indigent. In addition to the myriad physical health complications that people with serious mental illness face, their capacity to commute and keep scheduled appointments is limited.

We opened the Integrated Health Clinic at CFC on February 1, 2010. In partnership with the Cleveland Clinic, we operate two part-time primary health clinics, which are housed within two of our behavioral health sites. The SAMHSA grant has allowed us the opportunity to hire primary care and administrative staff so that we can provide free services to our uninsured clients.

Patients receive a wide range of care, including health screenings, annual exams, gynecological care, laboratory tests, and management of chronic diseases. Specialty care, including dental, vision, mammography, and podiatry, is made available offsite through various programs and providers. Tertiary care, such as general surgery, ophthalmology, endocrinology, and gynecology, is provided by the Cleveland Clinic. Prevention and wellness care is also offered.

We plan to continue providing these services beyond the grant term and are determining the model of service that will allow us to offer care to our insured as well as uninsured clients.

Quick Tips: Ten Questions to Improve Access to SBIRT

If you're implementing or planning to start SBIRT - the Screening, Brief Intervention, and Referral to Treatment program designed to help reduce drinking and substance abuse problems - be sure to ask claims payers and state Medicaid officials the following 10 questions:

   1. Are the codes 99408 and 99409 open for billing under Medicaid or other plans?
   2. If those codes are not used, has the state has implemented alternative codes for SBIRT?
   3. If the codes (or alternative codes) are open, what rate will be paid?
   4. If an Encounter Rate is paid, what is the rate for 99408 and 99409, respectively?
   5. If a patient is seen by a medical provider for a medical service and then seen on the same day for an SBIRT service (99408 or 99409), will the SBIRT service be paid for in addition to the medical service?
   6. If services are provided in a Federally Qualified Health Center, is Medicaid wraparound billing applied?
   7. If both services are billable and both providers can be paid for both services on the same day, what is the correct billing procedure for the SBIRT service?
   8. Does any specific modifier need to be included on the SBIRT service claim in order to be paid correctly?
   9. What are the restrictions, if any, on the type of provider providing the SBIRT service? That is, are only licensed psychologists or licensed social workers able to provide and bill for the service, or are other professionals able to bill for these services on the same day as  a medical service is provided?
  10. 10.  Is there any requirement for special credentialing by the behavioral health provider prior to the provider's being able to be paid for SBIRT services? That is, does the state use a specific HMO carve-out or other credentialing body?

Questions were developed by the NACHC Tennessee and Virginia SBIRT Learning Collaborative, a SAMHSA funded project.

Hot Topics: News and Resources

Visit the CIHS website for up-to-date news and resources

Behavioral Health Services in Federally Qualified Health Centers
The National Association of Community Health Centers' 2010 Assessment of Behavioral Health Services in FQHCs provides an overview of the current landscape in FQHCs and recommendations for the future.
 
Moving Toward Establishment of Health Homes
To help consumers better understand the concept of health homes and how New York is planning on implementing them, NYAPRS, a statewide coalition of people who use or provide recovery-oriented community-based mental services, focused an issue of its e-news bulletin on the topic. It includes a brief article describing health homes, excerpts from the Governor's office, and proposed budget language.

Mental Disorders and Medical Comorbidity
The Robert Wood Johnson Foundation's new Research Synthesis Report provides an overview of medical and mental comorbidity that considers the associated quality-of-care and cost burdens of comorbidity and the current evidence-based approaches for addressing comorbidity. The paper is authored by Dr. Ben Druss of Emory University.

FREE Wellness Brochures and Posters
The 10x10 Wellness Campaign is offering free brochures and posters for clinicians, community organizations, consumers and survivors, and peers who want to take action to extend the life expectancy of people with behavioral health challenges by 10 years in the next 10 years. The new resources are as follows:

   1. "Top Three Ways to Promote Wellness" poster (SMA10-4569)
   2. "Eight Dimensions of Wellness poster" (SMA10-4568)
   3. Informational brochure for primary care providers that provides strategies for talking about wellness and connecting with patients' behavioral healthcare providers (SMA10-4566)
   4. Motivational brochure for consumers/survivors/peers that describes how to incorporate the Eight Dimensions of Wellness into everyday life (SMA10-4567)
   5. Informational brochure to raise awareness about the disparity in early mortality for people with behavioral health problems and gain "champions" for the 10x10 Wellness Campaign
(SMA10-4565)

To order or download these free materials, visit http://store.samhsa.gov/product/SMA10-4566 or call toll free 1-877-SAMHSA-7 (877-726-4727).

Q&A CORNER

Each month we will feature a question from the field about making integration work.

Question: We are a behavioral health provider in the process of integrating primary care services. We are assessing which health indicators to track and want to know the value of collecting both body mass index (BMI) and waist circumference.

Response: Providers use BMI and waist circumference to understanding someone's risk for chronic disease in different ways. Measuring both allows for a better picture of health risks, including a person's risk of developing diabetes, heart disease, or other health problems.

To learn how to measure BMI and waist circumference and what they mean for health and wellness, access the "Weight and Waist Measurement: Tools for Adults" fact sheet created by the National Institutes of Health.

To receive this newsletter and other CIHS email updates, click here, enter your email address, and select "News from the SAMHSA-HRSA Center for Integrated Health Solutions" from the options listed.

SAMHSA-HRSA Center for Integrated Health Solutions
Director: Kathy Reynolds, National Council for Community Behavioral Healthcare Deputy Directors: Laura Galbreath and Larry Fricks, National Council for Community Behavioral