1. Making Integrated Care Work
MI Primary Care Association
September 28, 2012
Laura Galbreath, MPP
Director, Center for Integrated Health Solutions

2. Agenda
-About the Center for Integrated Health Solutions
-Lessons Learned from Grantees and Others
• PC/BH Partnership - Communication
• Workforce Development
• Health Homes
• Health Behavior Change
• Operations and Administration
• Financing and Billing

3. About the Center
In partnership with Health & Human Services (HHS)/Substance Abuse
and Mental Health Services Administration (SAMHSA), Health
Resources and Services Administration (HRSA).
Goal:
To promote the planning, and development and of integration of primary and behavioral
health care for those with serious mental illness and/or substance use disorders and
physical health conditions, whether seen in specialty mental health or primary care safety
net provider settings across the country.
Purpose:
 To serve as a national training and technical assistance center on the bidirectional
integration of primary and behavioral health care and related workforce development
 To provide technical assistance to PBHCI grantees and entities funded through HRSA
to address the health care needs of individuals with mental illnesses, substance use
and co-occurring disorders

4. The Center for Integrated Health Solutions is
dedicated to increasing the number of:
 Individuals trained in specific behavioral health related practices
 Organizations using integrated health care service delivery
approaches
 Consumers credentialed to provide behavioral health related
practices
 Model curriculums developed for bidirectional primary and
behavioral health integrated practice
 Health providers trained in the concept of wellness and behavioral
health recovery

5. Center for Integrated Health Solutions
Target Populations
 SAMHSA Primary & Behavioral Health Care Integration (PBHCI) Grantees
 HRSA Grantees
 General Public
Services
 Training and Technical Assistance
 Knowledge Development
 Prevention and Health Promotion/Wellness
 Workforce Development
 Patient Protection and Accountable Care Act Monitoring and Updates

6. Technical Assistance Menu
Individual Technical Assistance:
 Phone consultations, e-mail, site visits
Group Learning Experiences:
 Learning Communities
 Webinars
 Trainings
 Practical Web-Based Resources (CIHS website, e-newsletter,
discussion boards)
Tools:
 Toolkits/Guidelines
 Training Curricula
 Fact Sheets

7. SAMHSA Primary and Behavioral
Health Care Integration (PBHCI)
Grant Program

8. PBHCI Program
Program purpose:
 To improve the physical health status of people with SMI by supporting
communities to coordinate and integrate primary care services into
publicly funded community-based behavioral health settings
Expected outcome:
 Grantees will enter into partnerships to develop or expand their offering
of primary healthcare services for people with SMI, resulting in
improved health status
Population of focus:
 Those with SMI served in the public behavioral health system
Eligible applicants:
 Community behavioral health agencies, in partnership with primary
care providers

9. SAMHSA PBHCI Learning Communities
West Region (1) Northeast &
14 Grantees Mid-Atlantic Region (5)
Central Region (2) 17 Grantees
9 Grantees VT
WA Midwest Region (4) ME
15 Grantees
MT NH
ND
OR MN
NY
MA
ID WI
SD
MI CT RI
WY PA
NJ
CA IA
NV NE DE
OH
UT IL IN
WV DC
CO
MO MD
KS KY
VA
OK NC
AZ NM AR TN
SC
AK MS AL GA
HI TX LA Southeast Region (3)
9 Grantees
FL

10. SAMHSA PBHCI Grantees
West Region (1)
AK: Alaska Islands Community Services (III)
AK: Southcentral Foundation (IV) Southeast Region (3) Northeast & Mid-Atlantic
CA: Alameda County Behavioral Health Care
Region (5)
Services (II) FL: Apalachee Center, Inc(III)
CA: Asian Community Mental Health Services (III) FL: Coastal Behavioral Healthcare (III) CT: Bridges...A Community Support
CA: Catholic Charities of Santa Clara County (IV) FL: Community Rehabilitation Center (III) System (I)
CA: Glenn County Health Services Agency (III) FL: Lakeside Behavioral Healthcare (III) CT: Community Mental Health
CA: Mental Health Systems, Inc (I) FL: Lifestream Behavioral Center (III) Affiliates (III)
CA: San Francisco Department of Public Health (IV) FL: Miami Behavioral Health Center (III) MA: Community Healthlink ,Inc (III)
CA: San Mateo County Health System (III) GA: Cobb/Douglas Community Services Board (III) MD: Family Services, Inc (III)
CA: Tarzana Treatment Centers, Inc. (III) SC: South Carolina State Department of Mental Health (III) ME: Community Health & Counseling
OR: Native American Rehabilitation Association of VA: Norfolk Community Services Board (IV) Services (III)
the Northwest (II)
NH: Community Council of Nashua (I)
WA: Asian Counseling and Referral Service (III)
NJ: Care Plus NJ (I)
WA: Downtown Emergency Service Center (III)
NJ: Catholic Charities, Diocese of
WA: Navos (IV)
Trenton (III)
Midwest Region (4) NY: Bronx-Lebanon Hospital Center
(III)
IL: Heritage Behavioral Health Center (III)
NY: Fordham Tremont CMHC (III)
IL: Human Service Center (I)
NY: ICD-International Center for the
Central Region (2) IL: Trilogy, Inc(III)
Disabled (II)
IN: Adult & Child Mental Health Center (III)
NY: Postgraduate Center for Mental
AZ: CODAC Behavioral Health Services (I) IN: Centerstone of Indiana (II)
Health (III)
CO: Mental Health Center of Denver (I) IN: Health & Hospital Corporation of Marion County (IV)
NY: VIP Community Services (I)
LA: Capital Area Human Services District (IV) IN: Regional Mental Health Center (II)
PA: Horizon House (III)
OK: Central Oklahoma Community MH Center (I) KY: Pennyroyal Regional MH/MR Board (I)
PA: Milestone Centers (II)
OK: NorthCare Community Mental Health Center (III) MI: Washtenaw Community Health Organization (III) RI: Kent Center for Human &
TX: Austin-Travis County Integral Care (III) OH: Center for Families & Children (I) Organizational Development (III)
TX: Lubbock Regional MH & MR Center (II) OH: Community Support Services (IV) RI: The Providence Center (II)
TX: Montrose Counseling Center (II) OH: Greater Cincinnati Behavioral Health Services (III)
UT: Weber Human Services (III) OH: Shawnee Mental Health Center (I)
OH: Southeast Inc. (I)
WV: Prestera Center for Mental Health Services (III)

11. Integrated health care
11
“…in essence integrated health care is the
systematic coordination of physical
and behavioral health care. The idea is
that physical and behavioral health
problems often occur at the same time.
Integrating services to treat both will yield
the best results and be the most
acceptable and effective approach for
those being served.” Hogg Foundation for Mental Health,
Connecting Body & Mind: A Resource Guide to Integrated Health Care in
Texas and the U.S., www.hogg.utexas.edu

12. 12
Consumers’ take on integration
“Around the time that my bipolar condition was identified, I
was diagnosed with kidney disease. Between the two
disorders, it was a pretty upsetting time in my life… My
doctors, dialysis clinic staff, and mental health case manager
are well connected. They take a team approach, and they
each check on the status of my health... Today I have control
over my health; it doesn’t have control of me. The
coordinated care allows me to feel like I can go out and be a
part of the community.” – Cassandra McCallister, Board
Member, Washtenaw Community Health Organization,
Ypsilanti, MI

13. PC/BH Partnerships

14. Primary Care and
Behavioral Health
It goes together like
Peanut Butter and
Jelly!

15. Communication with Your Partners
“The Four Agreements,” Don Miguel Ruiz
• Be impeccable with your words. Clarify your partnership’s goal and
recognize that you have created a process that requires constant
nurturing and communication.
• Don’t take anything personally. Disagreements will occur. Learn to
manage the process, not the personality, and recognize and understand
your differences.
• Don’t make assumptions. Involve both boards, schedule weekly
administrative meetings, hold regular treatment team meetings,
communicate between team meetings, and create a specialized data
collection position.
• Do your best. Involve state and local stakeholders, seek training for staff
in care coordination, bring in outside experts such as CIHS for guidance,
and engage other organizations that do similar work.

16. The Role of Leadership
Main point: Leaders who employ research informed
approaches are more likely to activate the organization to
support a change initiative:
 Communicating for buy in (what is the message? Who delivers
the message? How do we know if the workforce understands and
values the message? What practical actions can the workforce
take that promotes engagement of consumers?
 How does an organization insure that the workforce supports the
aims of the integration initiative?
 How does the organization insure that the primary care partners
understand, value and act in ways that are likely to engage
consumers.
16

17. 8.Make the
Changes Stick Steps leaders take to
7. Don’t Let Up
successfully
implement change
6. Short Term Wins
5. Empower Action
4. Build the Right Team
3. Communicate for Buy In
2. Get the Vision Right
1. Build a Sense of Urgency
Based on the work of J. Kotter (2002) The Heart of Change.
17

18. Workforce Considerations
Administrative Staff and Board of Directors – data
including prevalence, clinical and productivity
outcomes
Clinical Team – screening, clinical
protocols, motivational interviewing, how to deal with
upset patients smoothly, effectively, empathetically
Behavioral Health Clinicians – UMass
training, motivational interviewing, Psychiatric
Consultation
Front Desk, Security - Mental Health First Aid

19. The Right Temperament
Persistence
Creativity and flexibility
Enthusiasm for learning
Strong patient advocate
Willingness to be interrupted
Ability to work in a team

20. Health Homes

22. Focus on Behavioral Health
Incorporating attention to behaviors affecting health, mental health and
substance abuse
• PCMH 1: Enhance Access and Continuity
– Comprehensive assessment includes depression screening, behaviors affecting
health and patient and family mental health and substance abuse
• PCMH 3: Plan and Manage Care
– One of three clinically important conditions identified by the practice must be a
condition related to unhealthy behaviors (e.g. obesity) or a mental health or
substance abuse condition
– Practice must plan and manage care for the selected condition
• PCMH 4: Provide Self-Care and Community Resources
– Self-care support includes educational and community resources and adopting
healthy behaviors
• PCMH 5: Track and Coordinate Care
– Tracks referrals and coordinates care with mental health and substance abuse
services
• PCMH 6: Measure and Improve Performance
– Preventive measures include depression screening
Achieving NCQA Recognition as a Patient-Centered Medical Home
22
RI Statewide Learning Collaborative February 5, 2011

23. Behavior Health Change

24. Why Do People Change?
Individuals change voluntarily when they. . .
Become interested in or concerned about the need
for change
Become convinced that the change is in their best
interests or will benefit them more than cost them
Organize a plan of action that they are committed to
implementing
Take the actions that are necessary to make the
change and sustain the change

25. Person-Centered Skills:
The Basics
Utilize O.A.R.S.
• Ask Open-ended questions
(not short-answer, yes/no, or rhetorical)
• Affirm the person/commitment positively
on specific strengths, effort, intention
• Reflect feelings and change talk
• Summarize topic areas related to changing

26. Operations

27. Formal Business Process Analysis Supports
Clear, Precise, Accessible Communication
• Step-by-step financial, clinical and practice
management activities
• Promotes cross-discipline understanding of each step
• Connects multiple dimensions –billing, data collection
and reporting, clinical services, practice management,
etc.
• “Requirements Traceability Matrix” - what you do and
why you do it

28. Cleaned up

29. Analysis Examples
• Timing
• How long are activities within the process taking?
• How much time passes between activities?
• How long are the patient contact intervals within Intake? Between
Intake and Re-assessment?
• Billing
• What are the billable/non-billable events?
• Is there a way you can make non-billable events billable?
• How do these events match up to the appropriate license/credential of
the role? Are you maximizing the amount of reimbursement?
• Role License and Credentials
• Where and how are you meeting credentialing requirements?
• Do they match the billable activities?

30. Finance and Billing

31. Billing and Coding Infrastructure
• Staffing – Sample of needed expertise
• Chief Financial Officer
• Payables and Receivables staff
• Claims Processers
• Knowledge of Payer Requirements
• Private Payers
• Medicaid
• Medicare
• Technology supports
• Accurate, good documentation of services

32. The Health and Behavior Assessment/Intervention Codes
(96150 - 96155)
• Approved CPT Codes for use with Medicare right now
• Some states are using them now for Medicaid
• Behavioral Health Services “Ancillary to” a physical health
diagnosis
 Diabetes
 COPD
 Chronic Pain

33. Maximizing Who Can Bill, for What, and By
Whom – Interim Billing Worksheets
• Point in time review of each states Medicaid program on what may or
may not be reimbursable in your state for integration using currently
available codes
• Point in time review of Medicare reimbursement
• Link CPT, Diagnostic Code and Credential
• One of many tools – a place to start the conversation and billing locally
and in a state
• Do not GUARANTEE you will be paid based on the worksheet
Worksheets Available at:
www.integration.samhsa.gov

34. The resources and
information needed to
successfully Integrate
primary and behavioral
health care
Laura Galbreath, MPP
Online: integration.samhsa.gov
Phone: 202-684-7457, ext 231
Email: laurag@thenationalcouncil.org