1 Improving Behavioral Health Coordination and Care by Strengthening Community CollaborationWill Wilson Alyssa L Meller Supervisor, MDH Office of Rural Health and Primary Care Chief Operating Officer September 2017

2 Office of Rural Health and Primary CareWill Wilson | Supervisor September 2017

3 Agenda Landscape of behavioral health services in rural MinnesotaShortages Provider data Recent policy developments Integrated Behavioral Health Project Funding Process and methodology Initial Outcomes Questions, comments, discussion

4 Rural Health Landscape

5 Rural Health 101 #1 issue is always accessWorkforce, reimbursement and system affiliation Critical Access Hospital is usually the hub System-dominated Essentia, Mayo, Sanford, CentraCare, CHI, Avera Independent or non-system hospitals/clinics thrive, but some struggle Especially with recruitment and retention Other providers often have greater role in the community Dentists, chiropractors and mental health professionals In general, better coordination of services

6 Rural Mental Health Shortages

7 Rural Health Facilities

8 Rural Health FacilitiesRegional PPS Hospitals Critical Access Hospitals (78) Cost-based reimbursement 25 beds or fewer 96-hour rule for admissions Rural Health Clinics (89) Independent or Provider-based Can be satellite clinics from a main hub Required to have “midlevel” providers on staff

9 Recent Developments Crisis Response Protected TransportNew payment models Behavioral Health Home Certified Comunity Behavioral Health Clinic (CCBHC) Telepsych/telehealth/telemonitoring

10 Minnesota Flex Program78 Critical Access Hospitals Focus Areas Quality Finance and Operations Population Health Flex dedicated staff: Flex Program Coordinator Financial Analyst Research Analyst

11 Community Health Needs AssessmentsAnalyzed 59 CHNAs from MN CAHs Behavioral health one of two most frequently cited needs 16 said it was the top priority Identified need for community partnerships Described goals to integrate behavioral health and outreach

12 Other assessments Local Public Health Department FindingsAggregated LPH findings identified access to behavioral services was the top identified need statewide ORHPC Community Forums Need for access to behavioral health services was identified as a significant need at multiple regional community listening sessions held throughout the state

13 The Plan Identify a contractor who can: Monitor CHNAsEstablish an advisory council Identify CAHs to participate in behavioral health cohorts Conduct customized onsite and remote technical assistance to CAHs Identify measures and collect data Evaluate and share the results

14 The contractor is chosen, and the hard work begins:Rural Health Innovations (RHI), a subsidiary of the National Rural Health Resource Center Duluth, MN Alyssa Meller Kami Norland Rhonda Barcus Bridget Hart

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16 Funded By:

17 Why Integrate Behavior Health?26% of Americans 18 years + suffer from a diagnosable mental disorder 2 million people discharged from hospitals have a primary behavioral health diagnosis States cut $5 billion from mental health services nationwide from US lost 10% (4,500) public psychiatric beds Only a handful of CAHs provide inpatient psychiatric units nationwide 9 out of 10 ED physicians report that psychiatric patients were being held in their ED 28% of patient re-admissions are due to mental illness Data source:

18 What Is Health? "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Source: Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June, 1946: signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

19 Mental Health Impacts Clinical Conditions

20 Impact on Chronic Health Care Costs

21 Predictors That Affect Health Outcomes10% Clinical Care 10% Genes and Biology 40% Social and Economic 30% Behavioral 10% Environmental The ah-ha: Healthcare providers cannot change the U.S. health outcomes alone. *Determinants of Health Model based on frameworks developed by: Tarlov AR. Ann N Y Acad Sci 1999; 896:281-93; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17):

22 Project Vision To provide whole person care through the integration of behavioral health

23 Essential Organizational ComponentsLeadership Strategic Planning Patients, Partners and Communities Measurement, Feedback and Knowledge Management Workforce and Culture Operations and Processes Impact and Outcomes

24 Essential Operational ComponentsAddresses Behavioral Health Needs in Transitions of Care Screens All Patients for Depression and/or Substance Abuse Provides Support to all Patient Care Staff on Managing Their Own Behavioral Health Maintains an Updated Resource Directory Invests Times and Energy Building Relationships with Behavioral Health Resources in Their Community Have Credentialed Behavioral Health on Staff

25 Selecting Critical Access HospitalsCriteria: Strength of organizational and operational structure based on the Readiness Assessment Self identified technical assistance needs for integrating behavioral health Thoroughness of essay questions High percentage of behavioral health needs in the county based on secondary data General information to obtain diversification of selected CAHs (independent, ACO member, etc.) Geographic distribution across the state

26 Selected Hospital LocationsKami

27 Organizational Structure Assessment ResultsPercent of Total Score

28 Operational Structure Assessment Results

29 Expectations of Critical Access HospitalsParticipate in educational calls and events Identify a specific target population Convene providers and community organizations Implement at least three best practices Identify at least two organizational and two operational process improvements towards integration Create evaluation metrics Utilize a Balance Scorecard to measure and monitor progress Showcase findings statewide and nationally

30 RHI Technical AssistanceOur support is structured over 12 months, through: One in-person kick-off event One community strategic planning event Quarterly peer sharing calls Quarterly evaluation calls (Recommended Adoption Progress) Educational Webinars Workshop–focused on sustainability practices Ad hoc 1:1 calls with subject matter experts

31 In-Person Kick Off EventGet to know each other Refine the target population Identify partners Inspire collaboration

32 Target Population

33 Providers and Community Organizations

34 Community Strategic PlanningObjectives: Determine how to best work towards meeting the behavioral health needs of the target population Evaluate partnerships that can contribute towards helping meet the behavioral health needs of the target population

35 Consensus Based ApproachConfirmed target population Identified opportunities and strengths Developed strategies “What are the gaps of care in meeting this population’s behavioral health needs?” “What are you already doing to help this population with their behavioral health needs?” “What activities can be done to positively impact this population’s behavioral health needs?”

36 Community Objectives and Activities

37 Recommended Adoption Progress (RAP)Quarterly calls are held with each hospital team Conversation focuses on “telling the story” Each quarterly call “picks up the story” from the prior quarterly call Measurable outcomes are noted at each call At the end of the year, the series of RAP calls will result in a complete picture of the progress on the project

38 RAP Scores How would you rate your progress moving forward on your community strategic planning objectives?

39 Evaluation Measures

40 Essentia Health Northern PinesBehavioral Health Emergency Department Visits Increase Behavioral Health Access

41 Renville County Hospital & Clinic

42 Sanford Luverne

43 Sanford Luverne

44 Sanford Luverne

45 LifeCare Medical Center

46 LifeCare Medical CenterCreated a Roving Therapist position in January 2016 Counsels inmates with depression and anxiety Since then: Patients brought to the Emergency Department from the jail has decreased Inmates seen by the Roving Therapist in the jail have resulted in ZERO In-Patient Psych transfers

47 LifeCare Medical Centerhttps://lifecaremedicalcenter.org/minnesota-hospitals-video/

48 Sanford Luverne

49 Multi- Organizational Release of Information

50 Documenting The Project - ToolkitIntegrative Behavioral Health Project-The Process Background The Readiness Assessment The selection process Technical Assistance (TA) Evaluation of project outcomes Promising Practices Lessons Learned The Hospital and Community Teams Strategic objectives Promising practices Lessons learned Project outcomes

51 Will Wilson Alyssa L MellerContact Information Will Wilson Alyssa L Meller Supervisor, Primacy Care Financial and Technical Assistance Unit Chief Operating Officer