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Behavioral Health Integration in Maine

Posted By Becky Boober, Neil Korsen, Thursday, July 2, 2015

This is the second in a five part series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the first post.  

Almost 50% of primary care practices in Maine now offer some level of behavioral health integration. Integrated care is an expected component of the Patient Centered Medical Home (PCMH) and Health Home initiatives in Maine, thanks in large part to the work of two statewide organizations.  

                 

The Maine Health Access Foundation (MeHAF), whose mission is to increase access to quality health care and to improve the health of all people in Maine, launched its 12-year, $14 million Behavioral Health Integration Initiative in 2005 to increase access to behavioral health services and to reduce stigma. MeHAF awarded 42 integrated care grants to projects involving over 150 partnering organizations. One-year planning and three-year implementation grants were awarded in three rounds of funding for both clinical practice and systemic transformation levels. MeHAF also supported technical assistance, evaluation and research, and a robust learning community. A self-assessment tool was developed to help practice teams examine their level of integration. MeHAF also engaged key stakeholders in a five-year public policy effort to embed integrated care into state funding and health care reform initiatives. Because of an emphasis on sustainability by MeHAF, most of those organizations are still integrated and have expanded their integrated care services, according to a follow-up evaluation completed in 2014. Stories about a few former grantee organizations are shared below.


Parallel to the MeHAF funded efforts, Maine Quality Counts, a statewide quality improvement organization, worked with other key organizations to start the multipayer PCMH pilot. As part of a grant from MeHAF, Maine Quality Counts included the integration of behavioral health and primary care as one of the 10 core expectations for pilot participants in the PCMH. Over 200 primary care practices are working to increase their level of integration as part of their engagement as  PCMH, Health Homes (Medicaid version of PCMH) , or Behavioral Health Homes (mental health agencies working on better integration of physical healthcare).


Embedding integrated care into statewide practice improvement and payment reform pilots, such as PCMH and Health Homes, proved instrumental to being able to sustain the work in practices across the state. Both public and private payers expanded support of integrated care through enhanced payments, opening of reimbursement codes, and allowance of same-day services. Use of the per-member-per-month enhance payments were sometimes used by the practices to support needed services such as care/case management and consultations. The State continues to support integrated care as a core element of its State Innovations Model initiative.


A six-year evaluation of integrated care in Maine identified factors that facilitated successful implementation, including:

  • top administrative and clinical leadership support,
  • adequate infrastructure such as reimbursement and shared electronic health records,
  • behavioral health specialists who are flexible and who market their potential contributions to the team,
  • integration of behavioral health specialists in all primary care team functions (morning huddles, warm hand offs, case reviews), and
  • tracking and using data for continuous improvement.

 

Another lesson learned was the extensive work required to build trusting relationships that bridge the cultural variances between the behavioral health and medical professions. Developing a framework was essential to guide discussions about how differently the professions perceive use of time, relationship with patients (or what to call patients/consumers/clients), confidentiality requirements, and definitions of phrases such as care/case management. Professional flexibility facilitated this process of integrating the different professional cultures. Because of issues such as this, the complexity of integrating care requires a long-term view and concerted efforts to build both relational and organizational infrastructure to support the work over time. 


 Because of all the support provided for practices to integrate, there are many stories to be told about the successes of integration in Maine. A few examples include:


  • MaineHealth has created a partnership between hospital-owned primary care practices and the regional Maine Behavioral Healthcare system to place behavioral health specialists, mostly LCSW’s, in those practices. Thanks to a number of years of MeHAF funding, MaineHealth was able to pilot a variety of approaches to integration in twenty different practices and learn a lot about what works and what doesn’t. Using that knowledge, an approach has been spread that places the LCSW at least half time in the primary care practice, uses warm handoffs or other provider referral, a focused treatment model, and includes regular (and as needed) psychiatric consultation. There are now more than 30 FTE’s of behavioral health clinicians in more than 60 different practices.  Developing population health pathways that target behavioral health services to priority populations is a next important step for the program.  


  • Tri-County Mental Health Services and Central Maine Healthcare developed a sustainable contract model between the community mental health system and the local health care system’s primary care practices. Using two MeHAF integrated care grants, Tri-County implemented integrated care by fully embedding its Licensed Clinical Social Workers (LCSW) as the behavioral specialists Central Maine Healthcare primary care practices. The LCSW participate as equal members of the care team activities, such as morning huddles, team meetings and case reviews, warm hand offs, follow up to electronic screening, brief interventions and transitions of care.


  • Tri-County also developed a toolkit for other sites interested in this model. The integrated care contracting arrangement has been so successful that it has now spread to 25 Central Maine Healthcare primary care sites and is being spread to other health care systems. It is also a critical component of the area’s developing Accountable Care Organization (ACO).


  • Penobscot Community Health Care used MeHAF grant funding to pilot integrated care in a low-income housing setting in Bangor, Maine. Since then, they have expanded integrated care into its homeless health clinic and into all 12 of its primary care clinics.   Staffing includes a licensed MHP, substance abuse clinicians, psychologists, psychiatrists, 10 psychiatric nurse practitioners, 18 licensed social workers/counselors, peer specialists, care managers and Behavioral Health Homes case managers.


  • When they build or renovate clinics, behavioral health specialists share office pods with primary and specialty care and are fully integrated into all clinical functions. Screening tools are built into the electronic health record to facilitate warm hand offs and other integrated care strategies.

 

Many Mainers now expect that when they enter the primary care practice, they will receive integrated screening, care, and follow up. Sites report improved consumer and provider satisfaction. This increased satisfaction, improved consumer health outcomes, bending health care costs, and infrastructure support across the payers and the State have made the spread of integrated care in Maine not only possible, but inevitable. 


Becky Hayes Boober, PhD, Senior Program Officer at Maine Health Access Foundation (MeHAF), leads initiatives that transform health care systems to provide Patient-Centered Care. In 2013, MeHAF established the community-based Thriving in Place initiative to keep persons with chronic health conditions, including older persons, in their homes. She also oversees MeHAF’s $14+ million investment to integrate behavioral health and primary care. Starting with 42 grants involving over 150 partnering organizations, integrated care has now spread to about 46% of primary care practices in Maine. Dr. Boober is a member of the Grantmakers In Health Behavioral Health Funders’ Network Steering Committee. Prior to joining MeHAF, Dr. Boober retired from the State of Maine with over 20 years in public policy and administrative leadership working in the Commissioners’ Offices of three state departments (Education, Health and Human Services, and Corrections). She assisted with interagency, systemic improvement initiatives.

Neil Korsen, MD, MSc is a family physician/geriatrician with 18 years of practice experience, mostly in small towns in Maine. Since 2001, he has worked for MaineHealth, an integrated delivery system in southern and central Maine. He is the medical director of the Behavioral Health Integration program for MaineHealth. He has received funding support for this work from the MacArthur Foundation, the Robert Wood Johnson Foundation and the Maine Health Access Foundation.  He has a number of peer reviewed publications related to behavioral health integration and depression in primary care, and has spoken extensively on these topics regionally and nationally. Dr. Korsen is a member of the AHRQ National Integration Academy Council, an expert panel working with AHRQ to develop resources related to behavioral health integration in primary care. He is principal investigator for the AHRQ Atlas of Integrated Behavioral Healthcare Quality Measures. Dr. Korsen received his undergraduate degree from Dartmouth College in 1975, his medical degree from Hahnemann Medical School in 1979, and a Masters of Science from the Center for the Evaluative Clinical Sciences at Dartmouth (now the Dartmouth Institute) in 2002. 


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