Using a Continuum-Based Framework for Behavioral Health Integration Into Primary Care in New York State

The Delivery System Reform Incentive Payment (DSRIP) is a transformational model funded via a Medicaid 1115 waiver that rewards providers for performance on delivery system transformation projects that improve care for Medicaid patients. In NYS, the DSRIP has the explicit statewide goal to reduce avoidable hospital use by 25% over five years (7). Of note, integrated behavioral health is the only transformation project (among a menu of more than 20 possible projects) unanimously chosen as a focus by all funded regional collaborations, dubbed Performing Provider Systems (PPS), participating in New York’s DSRIP (8). NYS DSRIP offers two integration models in primary care that can be chosen: an enhanced colocation model or a collaborative care/IMPACT model (9). Each model has significant regulatory, staffing, and workflow requirements, and participating practices and systems tend to be larger and better resourced than nonparticipants. The NYS framework can be used by PPSs participating in DSRIP for assessment of the baseline state, as a roadmap for practice integration for the two models, and for assessment of progress over time.

NYS received a state innovation model grant in 2014 supporting its use of the advanced primary care (APC) model to achieve the triple aim. APC is an augmented patient-centered medical home model that will be supported by Medicare, commercial, and Medicaid payers. APC complements DSRIP by allowing practices with majority Medicare and commercially insured patients to participate in primary care transformation projects. APC prioritizes processes and outcomes related to integration, with the overall aim of ensuring that 80% of New Yorkers are receiving value-based care by 2020. Indeed, one of the five “strategic pillars” for transformational change, as outlined by the state, is that patients receive health care services through an integrated care delivery model, with a systematic focus on prevention and coordinated behavioral health care (10).

The APC model has less onerous resource and workflow documentation requirements than DSRIP, making it more feasible for smaller, independent practices to implement integration, but nonetheless has significant requirements for achieving quality measures (11).

Practices joining APC will be required to demonstrate the achievement of milestones along with acceptable performance on a robust set of quality measures. The NYS behavioral health integration framework can be used to help practices develop a plan to progress through the “gates” or core practice competencies, in behavioral health integration. For example, at gate 1, it is expected that primary care practices perform a practice self-assessment as well as set concrete goals to achieve the gate 2 milestones of screening, evidence-based treatment, and referral. The framework is uniquely positioned to help practices achieve these initial gates. At gate 3, there is an expectation that sites will be using either the collaborative care model or some form of colocation model. In order to support value-based payment at these gates, practices will need to attest to completion of these goals (subject to audit) as well as be measured on several key behavioral health plan measures developed for APC, such as clinical depression screening and follow-up, antidepressant management, and initiation and engagement of treatment for alcohol and drug dependence. [The APC framework is illustrated in the online supplement to this column.]

Thrive NYC (https://thrivenyc.cityofnewyork.us) is an initiative to transform the public mental health system of New York City (NYC) (12). Launched in 2015, it involves many city agencies, including NYC Health and Hospitals, the New York Police Department, the Department of Education, and the Department of Health and Mental Hygiene, and is funded by the City of New York, which invested $850 million over four years, with 54 initiatives. Thrive NYC is founded on six guiding principles: change the culture, act early, close treatment gaps, partner with communities, use data better, and position government to lead. Improving access to mental health treatment is a priority, and Thrive NYC has created the Mental Health Service Corps (MHSC) to promote integration of behavioral health into primary care using an enhanced colocation model similar to NYS DSRIP. It does so by recruiting early-career mental health clinicians for placement in primary care, substance use treatment, and mental health settings citywide with supervision by a psychiatrist. MHSC is using the behavioral health framework to assess the state of integration from selected primary care practices in order to develop a strategic plan to implement elements of its integrated care model, such as an electronic registry, case consultations, and stepped-care referrals, and to measure progress toward performance targets. Finally, the framework will be used to measure the progress of advancing the integration level for MHSC sites (G. Belkin, personal communication, 2016).