Old Ways Need to Change When Integrating Care in Huge System

Overall Care Should Be Managed by the Provider Patients See Most Often: Patients are most likely to change their health-related behaviors in response to a frequently recurring face-to-face relationship. The provider who sees the patient most often has the greatest opportunity to manage the care. Accordingly, Missouri has implemented statewide Primary Care Health Homes (PCHHs), which integrate behavioral health care out of primary care practices, and statewide Community Mental Health Center (CMHC) Health Homes, which integrate general medical care out of a CMHC.

Sharing of Patients’ Health Information Is Essential for Successful Care Management: Since 2004, all Missouri Medicaid providers have access to an electronic health record (EHR) that provides a three-year history of diagnoses, procedures, medications dispensed, dates of care, and providers for each Missouri Medicaid recipient. With the exception of substance abuse treatment provided by certified specialty substance abuse treatment organizations, behavioral health information is available at the same level of access as all other medical information. PCHHs and CMHC Health Homes both receive daily notification of patients with new episodes of hospital admission or ER visits for both behavioral and medical conditions.

Co-location Isn’t Everything, but It’s not Nothing Either: Since 2008, Missouri has provided CMHC/Federally Qualified Health Center (FQHC) immigration funding for CMHCs/FQHC pairs that contract to provide services on site within each other’s facilities and record on each other’s EHRs. During that time, the number of providers that are both CMHCs and FQHCs has increased from one to eight, which is approximately 30 percent of the CMHCs and FQHCs. We found co-location is more likely to be effective in integrating care if the primary care providers’ and behavioral health providers’ offices/exam rooms are widely interspersed.

Regulatory Support Is Important: Payers and regulators that wish to support integrated care need to be willing to remove obstacles identified by providers. Missouri allows payment of both behavioral health and primary care providers for the same diagnosis on the same day. Missouri allows mental health providers to bill for substance abuse treatment services if substance abuse treatment is necessary for successful outcome of treating mental illness and allows substance abuse providers to bill for mental health services if mental health treatment is necessary for successful substance abuse treatment outcome.

Transparent and Broad Sharing of Performance and Outcome Data Improves Both Performance and Relationships: It’s important for both primary care and behavioral health providers to have their performance measured and be accountable for both behavioral health and general medical process and outcome indicators. In Missouri, provider organizations can see how they rank compared with their peers across over 30 different measures, and organizations are all individually identified and not blinded. Nonpsychiatrist prescribers of psychiatric medications receive the same feedback and recommendations for improvement on their prescribing of psychiatric medications as psychiatrists. Prior to this approach, there were frequent conflicts about who had the sicker patients and who gave better care. This transparent, data-driven approach has changed these arguments into data analytic discussions in which disagreements are treated as testable hypotheses. This has improved everyone’s mutual understanding of what is really occurring and improved our personal and professional relationships.