America’s Voice for Community Health Care

2. America’s Voice for Community Health Care The National Association of Community Health Centers (NACHC) represents Community and Migrant Health Centers, as well as Health Care for the Homeless and Public Housing Primary Care Programs and other community-based health centers. Founded in 1971, NACHC is a nonprofit advocacy organization providing education, training and technical assistance to health centers in support of their mission to provide quality health care to medically underserved populations.

3. The NACHC Mission To promote the provision of high quality, comprehensive and affordable health care that is coordinated, culturally and linguistically competent, and community directed for all medically underserved populations.

4. For further information about NACHC and America’s Health Centers Visit us at www.nachc.com

5. Mind and Body Reunited: How Community Health Centers Successfully Integrate Primary Care and Behavioral Health Services Jaime Hirschfeld Director, Health Center Growth and Development April 23, 2013

6. What is NACHC? • National Association of Community Health Centers is a membership-supported organization, providing training, technical assistance, group purchasing programs, leadership and professional development, lobbying/advocacy, and group purchasing programs. • NACHC provides strong advocacy before Congress and with federal administrative and regulatory bodies on all major issues that affect health centers and our mission.

7. A non-profit, community-based provider of high quality, affordable primary care and preventive services See patients regardless of insurance status or ability to pay Improve access to care in medically underserved communities Often provide the following services on-site: Dental Pharmaceutical Behavioral health What is a Community Health Center (CHC)?

8. Must Serve a high needs area (designated Medically Underserved Area or Population) Comprehensive healthcare and related services based on the needs of the community Open to all regardless of insurance status or ability to pay Governed by the community (51% of board members MUST be patients) Held to strict accountability and performance measures for clinical, financial and administrative operations by Health Resources and Services Administration(HRSA) Five Characteristics of a CHC

9. Difference Between a CHC and FQHC • A CHC designation comes from Health Resource Services Administration • FQHC designation comes from CMS and is a payment mechanism • For the purpose of this conversation we will use them interchangeably

10. Community Health Centers serve a variety of underserved populations and areas (Section 330) Migrant Health Centers serve migrant and seasonal agricultural workers (Section 330g) Healthcare for the Homeless Programs reach out to homeless individuals and families and provide primary care and substance abuse services (Section 330h) Public Housing Primary Care Programs serve residents of public housing and are located in or adjacent to the communities they serve (Section 330i) Types of FQHCs

11. FQHC Look-a-Like is similar to a CHC and meet all requirements under Section 330. However they do not receive: Federal grant money Federal Tort Claims Act (FTCA) coverage. Look-a-likes are designated by HRSA and certified by the Centers for Medicare and Medicaid Services (CMS) as and therefore can receive Prospective Payment System (PPS) benefits. Types of FQHCs

12. The Governing board has at least 9 but no more than 25 members, as appropriate for the organization. Minimum of 51% of the board must be patients of the health center. The remaining non-consumer members of the board shall be representative of the community in which the center's service area is located. No more than half of the non-consumer board members may derived no more than 10% of their income from the health care industry. Health Center Board Governance

13. Who are health center patients? Collectively, health centers are the Health Care Home for 24 Million Americans • 1 of 7 Uninsured Persons, including • 1 of 5 Low-income Uninsured Persons • 1 of 7 Medicaid Beneficiaries • 1 of 3 Individuals Living in Poverty • 1 out of 4 Minority Individuals Living in Poverty • 1 of 7 Rural Americans • 923,400 Farmworkers • 1.1 Million Homeless Persons Source: NACHC, 2012. Includes patients of federally-funded health centers, non-federally funded health centers, and expected patient growth for 2012.

14. Who are health center patients? Health Center Patients Are Predominately Low Income Source: Federally-funded health centers only. 2010 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Note: Federal Poverty Level (FPL) for a family of three in 2010 was $17,600. (See http://aspe.hhs.gov/poverty/08poverty.shtml.) Based on percent known. Percents may not total 100% due to rounding.

15. Who are health center patients? Most Health Center Patients are Uninsured or Publicly Insured Other public may include non-Medicaid SCHIP and state-funded insurance programs. Source: Federally-funded health centers only. 2010 Uniform Data System, Bureau of Primary Health Care, HRSA, DHHS. Note: Percents may not total 100% due to rounding.

16. Where are health centers located? There are more than 1,200 health center organizations serving more than 24 million patients in over 8,000 rural and urban communities. >>Locate a Community Health Center<<

17. All Services Provided to All Ages Primary Health Care Dental Care Behavioral Health Pharmacy *Please refer to Program Requirements as this is not a complete list of services. Basic Lab Emergency Care Radiological Services Transportation Case Management After Hours Care Hospital/Specialty Care Services Provided by CHCs Note: all services required on site or through established written arrangements/referrals

18. Health Centers eliminate disparities in health outcomes for poor, minority, and medically underserved populations. The Institute of Medicine recognizes CHCs as models for screening, diagnosing, and managing chronic conditions: Diabetes Depression Cardiovascular Disease Cancer Asthma HIV Record of Achievement: cited by Institute of Medicine, Office of Management and Budget & General Accounting Office for excellence in care, disparities reduction, cost-effectiveness, and community benefit. Effective Management of Chronic Illness

19. Health Centers saved an estimated $1,262 per patient in 20091 Health Center efforts have led to improved health outcomes for their patients, as well as lowered the cost of treating patients with chronic disease2 Health centers generated $20 billion in economic activity for low income communities in 20093 Community Health Centers are Cost -Effective 1 Shi, L et al. (2004). “America’s Health Centers: Reducing Racial and Ethnic Disparities in Prenatal and Birth Outcomes” Health Services Research, 39(6), Part I, 1881-1901. 2Chin M. (2010) “Quality Improvement Implementation and Disparities: The Case of the Health Disparities Collaboratives.” Medical Care, 48(80):668-75 3 Community Health Centers: ROI Fact Sheet November 2010

20. Why support health centers?

21. Federal Grant – around $650,000 for basic grant but many opportunities exist to increase funding thereafter (New Access Points, Service Expansion, and Expanded Medical Capacity) All federal $ to be used exclusively for the care of the uninsured. Medicaid – Prospective Payment System (PPS). A reimbursement mechanism roughly based upon the cost of a patient encounter. Rate is increased yearly by Medicare Economic Index (MEI). Medicare – Prospective Payment System – similar to the Medicaid system, cost report is filed yearly with CMS. Private Insurance – accepted just like private practices. Uninsured – Patients below 200% of the Federal Poverty Level (FPL) pay on a sliding fee scale based upon ability to pay. Funding for CHCs

22. Health Centers’ Revenue Sources Do Not Resemble Those of Private Physicians Source: Private Physician data: 2009 National Ambulatory Medical Care Survey (visits). NACHC, 2012. Based on Bureau of Primary Health Care, HRSA, DHHS, 2010 Uniform Data System. Note: Private Physicians does not equal 100% due to reporting in NAMCS.

23. Income Sources for Health Centers

24. How do health centers… Integrate primary care and Behavioral health?

25. Health Centers & Behavioral Health • 70% provide mental health counseling and treatment • 40% provide substance abuse counseling and treatment • 20% offer 24-hour crisis intervention services • All provide referrals to substance abuse and mental health services

26. Behavioral Health in a Health Center • About 4,000 mental/behavioral health providers work in health centers • Account for approximately 5% of all patient visits

27. Why Integrate Behavioral Health & Primary Care?

28. Why is it important for health centers to integrate care? • Depression is the third most common reason for a visit to a health center after diabetes and hypertension • Primary care visits last an average of 13 minutes and include an average of six patient problems • A visit to a psychiatric professional typically lasts at least 30 minutes and is focused on a clearly defined issue.

29. Why is it important for health centers to integrate care? • 87.5% of family physicians said it was their responsibility to treat depression • 35% were very confident and 48% were mostly confident about their overall ability to manage depression • 80% of patients with depression present initially with physical symptoms such as pain or fatigue or worsening symptoms of a chronic medical illness. • These patients are not likely to seek care through the mental health system.

30. Visit Types • The majority of health centers that offer behavioral health services provide a same-day visit for primary care and behavioral health if needed • Warm Hand-off • Traditional Therapy • Behavioral Health Coaching

31. Warm Hand-Off • Physician invites the behaviorist into the exam room to make the introduction OR • Walks the patient down the hall to the behaviorist’s office and makes the introduction • Behaviorist then spends 15 minutes with the patient • OR schedules a visit for another time

32. Warm Hand-Offs • 40% show rate when PCP makes referral to behavioral health without a warm hand-off • 76% show rate when PCP makes the introduction! (UMASS Certificate program in Primary Care)Integration)

33. Traditional Therapy & Treatment • 30, 45, 50 – minute counseling sessions • Cognitive behavioral therapy • Supporting client in trying new perceptions and behaviors that will assist them in achieving their goals

34. Behavioral Health Coaching • 15 minute sessions in the primary care service area or pod • Offered by licensed clinician or unlicensed health educator • Empathy and motivational interviewing techniques to help clients: • Modify behaviors • Solve problems • Schedule pleasant events • Reach other behavioral or physical health goals

35. EXAMPLES: Integrated Treatment Team Meetings/ Training • Daily team huddles including a PCP & BH provider • Weekly provider meeting including psychiatrists & PCP • Weekly or monthly case management meetings • Bi-monthly meetings on integrated care • Training PCPs on psychotropic medications attended by mental health & medical providers • Monthly medication therapy management meetings • Quality assurance sessions consisting of a PCP and a licensed psychologist at a minimim

36. Screening Practices – Adults • Many CHCs offer universal screening for: • Depression • Anxiety • Other behavioral health conditions • Other that are screened include: • Diabetics • Those with hypertension and/or obesity • Individuals with HIV • New patients • Patients over 60

37. Screening Practices for Children • Some health centers screen all children (about 25%) • Children with certain diseases/ conditions such as diabetes and obesity • All children in the perinatal substance abuse treatment program • Prenatal teens • Patients ages 16 and 17 who: • Complain of depression or anxiety • Are pregnant • Are diabetic

38. How CHCs Eliminate Stigma With Accessing Mental Health Services • Do not treat behavioral health like a separate program • Minimal distinction in terms of signage and clinic names • “Integrated Care Office” • “Collaborate Care Office”

39. Challenges of Integrated Care • Shortage of behavioral health providers • Limitations of reimbursement for health centers on same day visits • Reimbursement • Managed Care • Medicaid • Medicare • Dual Eligibles • Relationship with public mental health agencies vary across the county

40. Common Barriers and Myths (to get over….quickly) • Our patients do not want to address depression or mental health. • It is “understandable” that our patients are depressed or mentally unhealthy. • It will cost too much. • Our patients need help with social and economic issues, not mental health or depression.

41. What does integration of behavioral health and primary care look like at a Health center

42. Cherokee Health SystemKnoxville, TN • Community health center & community mental health center founded in 1960 • 47 clinical sites in 13 Tennessee counties • Services: • Primary Care • Community Mental Health • Dental • School Based Health

43. Cherokee Health SystemKnoxville, TN • Serve 63,800 unduplicated individuals • 600+ employees • Psychologists – 43 • Master’s level Clinicians - 64 • Case Managers - 34 • Primary Care Physicians – 25 • Psychiatrists - 10 • Pharmacists - 9 • NP/PA (Primary Care) - 25 • NP (Psych) - 12 • Dentists - 2

44. Cherokee Health SystemKnoxville, TN • Embedded Behavioral Health Consultant on the Primary Care Team • Real time behavioral and psychiatric consultation available to PCP • Focused behavioral intervention in primary care • Behavioral medicine scope of practice • Encourage patient responsibility for healthful living • A behaviorally enhanced Healthcare Home

45. Cherokee Health SystemKnoxville, TN • Placing a VALUE on Integrated Care • Reduced ER Utilization • Reduced Inpatient Admissions • Reduced Specialty Referrals • Increased Patient Satisfaction • Increased Primary Care Utilization • Improved Outcomes

46. Cherokee Health SystemKnoxville, TN http://www.cherokeetraining.com/popup.asp 2018 Western Ave Knoxville, TN 37921 Phone: (865)934-6734

47. LifeLong Medical CareBerkeley, CA • Community Health Center (FQHC) serving Oakland, Berkeley, and Richmond, California • Ten primary care clinics • Two adult day health centers • Two Dental clinics • Supportive housing program • Frequent Users of Health Services program • Services: • Primary health and dental care • Pediatric, adult and geriatric care • Chronic disease and HIV/AIDs treatment • Integrated behavioral health and primary care • Serve over 22,000 unduplicated patients

48. LifeLong: A Model Rooted in Integrated Care • Gray Panthers founded – medical and social service to elderly to maintain independence. • Historical focus on serving the disabled and homeless, mental health and social problems with complex medical problems • Recent focus on managing chronic disease including behavioral interventions – diabetes, hypertension, asthma are all conditions that are most effectively managed through behavioral changes. • Traditional mental health model is now transitioning to a mixture of traditional services, health psychology and short term interventions as well as support groups.

49. LifeLong’s Primary Care Model • MDs, Mid-levels, Psychiatrist and LCSWs/ Psychologists on staff at every primary care site • Prescribe and provide access to psychiatric medications • Psychiatrists provide consults to PCPs – supports expanded access to psychiatric services • Coordinate with County/City Mental Health programs when person qualifies for services

50. A Spectrum of Care • Provide traditional mental health services – psychiatry, psychotherapy, long term treatment • Provide: • Short term interventions (1 – 3 sessions) • ½ hour visits • Includes case management • Focus on working with people with chronic physical health conditions (e.g. diabetes, hypertension)