State Efforts (Except CA)
The care integration movement has gained so much momentum across the country that it is impossible to compile and describe all the current activities in this area. What follows is just a smattering of the hundreds of programs underway. See also the HEALTH HOMES section of this website for initiatives in that arena.
To improve access and quality, control costs and reduce both stigma and health disparities, states around the country have initiated pilots to integrate health and behavioral health services, using federal Medicaid waivers, grants, and the blending of federal, state and local funding. The Robert Wood Johnson: “Integrating Publicly Funded Physical and Behavioral Health Services: A Description of Selected Initiatives” reviews integrated behavioral health efforts in nine states. In 2006, the Human Resources and Services Administration (HRSA) convened representatives from several states to discuss their accomplishments and barriers faced in establishing integrated behavioral care programs. “Evaluation of the Closing of the Gap on Access and Integration: Primary and Behavioral Care Summits Final Report” is a report of that convening and Participant Feedback gives the state and county points of view.
The August, 2006 issue of the National Association of County and City Health Officials (NACCHO) explores efforts undertaken by counties and states to achieve collaboration in delivering mental health and health care in “Lessons Learned: Mental Health, Public Health and Primary Care Collaboration“.
The Colorado Access, originally funded by RWJ, involves depression screening using the PHQ-9, mental health clinicians trained as care managers, supervising psychiatrists, and stepped care in collaboration with the primary care provider. A study of 341 Medicaid clients found a savings of $170 per enrollee per month, for a total of $755,000 per year. ACT, a four-year project sponsored by the Colorado Health Foundation, brings together behavioral health, substance use and primary care communities to coordinate care. Another Colorado Initiative,Advancing Care Together (ACT) funds 11 integration demonstration projects based in private practices, HMO’s, FQHC’s and community mental health providers throughout the state. They hope to identify and test promising models by studying process and outcome data and then disseminate best practices.
Minnesota‘s DIAMOND program was created by medical groups, health plans, the Minnesota Department of Human Services, employer groups and patients to improve health care for people with depression in primary care. The program, based on the IMPACT model for treating depression, is groundbreaking because it changes the way care is given and paid for in the primary care setting. Under the pay model, the health plans give medical groups a monthly fee that covers the bundle of DIAMOND services, including a care manager. DIAMOND was launched in March 2008 and is involved through 74 primary care clinics in Minnesota.
Cherokee Health in Tennessee, the granddaddy of integrated care, is both a community mental health center and an FQHC in rural East Tennessee. Of their 40,000 clients in 2001, 56% sought behavioral care and 44% primary care.
North Carolina and Massachusetts are the first states to officially run integrated pilots in the public sector. Buncombe County, North Carolina, has an especially active integrated program. The North Carolina Center for Excellence in Integrated Care is an expert resource for the support of health care providers in the integration of medical care with behavioral health care.
Rhode Island is also very active bringing in commercial insurers into the mix. Washtenaw County, Michigan has forged a financial and legal partnership between a university, a Medicaid managed health care plan, and the county to provide integrated behavioral health and substance abuse.
New York’s Center for Excellence in Integrated Care was created by the New York State Health Foundation in association with NYS Offices of Mental Health and of Alcohol & Substance Abuse Services to improve outpatient services for New York State residents who are struggling with co-occurring mental health and substance use conditions. The Center’s primary goal is to increase the capacity of New York’s more than 1,200 addiction and mental health outpatient clinics to provide integrated clinical care for people with co-occurring conditions. The New York State Office of Mental Health has also funded demonstration programs for Integrated Physical and Behavioral Health Care for the Elderly.
Thanks to the efforts of the Hogg Foundation, several primary care clinics in Texas participated in demonstration projects incorporating four basic elements of the integrative model: a mental health assessment tool; a clinical care manager; a patient registry; and psychiatric supervision and consultation. Clinics used the Impact model to address depression, anxiety and attention deficit disorders and collected data via the HITS program. In 2004, Baylor College’s Department of Psychiatry, which provides behavioral services to Texas’ Harris County Hospital District, outstationed psychiatrists at three community health centers as part of a pilot program to augment mental health services. The program, subsequently expanded, recently won an APA award for achievement. More information can be found in “Integration of Community Psychiatry into Primary Care Centers in Harris County, Texas“, 2007.
The Ohio Coordinating Center for Integrating Care (OCCIC) was created by the Ohio Department of Mental Health to share information and resources about integrating and coordinating physical and mental health care. The Center shares information and provides networking opportunities; determines need and solutions; advocates for integrated care and evaluates efficacy.
In Oregon, Multnomah County published a report about its integrated care efforts, giving a conceptual framework for this initiative as well descriptions of other programs across the country and its own model. The included forms, tables, and questionnaires may be particularly useful to other local governments considering or initiating integrated behavioral healthcare.
The National Academy for State Health Policy has issued a report detailing how two states – Missouri and Tennessee – have approached integrated relationships between key safety net health systems – community health and mental health centers. The May, 2010 report, A Tale of Two Systems: A Look at State Efforts to Integrate Primary Care and Behavioral Health in Safety Net Settings, looks at strategies, challenges and lessons learned.
Ranked among the nation’s top 100 integrated delivery networks, MaineHealth has taken a leadership role in developing programs to improve chronic illness care in Maine through its Clinical Integration programs.
Missouri has pioneered a community mental health center-based program for Medicaid beneficiaries with severe mental illness that provides care coordination and disease management to address the “whole person,” including both mental illness and chronic medical conditions. Missouri’s mental health home model leverages an existing mental health system, with added training for providers on chronic conditions as well as the use of data and analytic tools. In October 2011, Missouri became the first state to apply for and be awarded a Medicaid State Plan Amendment to enable Health Homes in both primary care and behavioral health. See the HEALTH HOMES section of this website for more information about this program.
As part of the “Rethinking Care” program, Pennsylvania is designing and testing innovative care delivery models for Medicaid with mental illness and physical co-morbidities that could be replicated statewide. “Early Lessons from Pennsylvania’s SMI Innovations Project for Integrating Physical and Behavioral Health in Medicaid” (May, 2012) chronicles the progress of four state pilots implementing new strategies to improve health while containing costs for Medicaid’s highest need population.
With funding from the Agency for Healthcare Research and Quality, the Pittsburgh Regional Health Initiative is leading a three-year initiative, called Partners in Integrated Care, to disseminate and implement evidence-based depression and unhealthy substance use services in primary care settings. PIC consists of a multi-state partnership among organizations that are experienced in implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) for unhealthy alcohol and other drug use and Improving Mood-Promoting Access
to Collaborative Treatment (IMPACT) for collaborative depression care management in primary care.
Some locales are offering primary care services in mental health settings, rather than vise versa. Thresholds Psychiatric Rehabilitation in Chicago linked up with the University of Chicago College of Nursing to do so. Western Psychiatric Institute in Pittsburgh teamed up with the University of Pittsburgh Medical Center to offer comprehensive care services. The Massachusetts Behavioral Health Partnership has three primary care projects embedded in psychiatric day programs in three cities. The Excel Group in Arizona has undertaken a comparable program. As mentioned above, Missouri has established health homes in a community-based mental health settings.
The Commonwealth Fund’s 2014 paper “State Strategies for Integrating Physical and Behavioral Health Services in a Changing Medicaid Environment” explores approaches states are deployng to address or eliminate system-level barriers to integration.
For more information, though certainly not an exhaustive listing about what’s happening throughout the country, go to the SYSTEM-WIDE COLLABORATION section of this website.