NHMH NO HEALTH WITHOUT MENTAL HEALTH A 501(c)(3) non profit   San Francisco - Washington DC Director’s blog

August 30, 2015

We started hearing from our providers that they couldn’t manage
their patient population without a mental health benefit.”

Erin Hafer, Director, New Programs Integration &
Network Development, CHPW

The Community Health Plan of Washington (CHPW) is a not-for-profit managed care plan, formed in 1992 by the local community health centers (CHCs) of the State of Washington.  It is unusual in being the only not-for-profit health plan serving the Medicaid population in the State created by CHCs.  Its healthcare system encompasses 21 CHCs, 125 primary care clinics, 2,600 primary care physicians (PCPs) and over 14,000 contracted medical specialists.

Its 300,000 mostly Medicaid patients include primarily individuals and families, including veterans, with co-existing mental and chronic medical conditions, and having significant social support needs.

In 2004, CHPW began to enroll members of the General Assistance Unemployable (GA-U) population, a Washington State coverage program for adults deemed incapacitated due to a physical or mental health condition.  Initially, the benefit only included medical services, not behavioral health services, even though mental health conditions were highly prevalent.  CHPW began hearing from its providers that they could not manage this population without a mental health benefit.  CHPW worked with the Washington state legislature and the University of Washington’s AIMS Center to be able to provide the collaborative care model (CCM), the model of behavioral health integration into primary care with the strongest research base supporting its effectiveness both in terms of patient outcomes and lowered costs.

In 2007, CHPW began administering the Mental Health Integration Program (MHIP) throughout its community health centers system, based on the CCM developed at UW/AIMS, treating mild mental disorders such as depression and anxiety in the primary care setting.  Over time, the MHIP was expanded to include all CHPW’s adult Medicaid enrollees. Originally the State provided funding for this new care delivery approach; today CHPW sustains the CCM through a limited mental health benefit and the care cost savings it generates.

As a result of its early and sustained clinical experience providing collaborative care to a challenging complex patient population, CHPW has developed key insights to share with primary care practices considering adopting CCM.  NHMH recently spoke with Erin Hafer, a Director at CHPW, to learn more:

The Implementation Steering Committee:  Due to the unique nature of its formation and organization, CHPW has been able to convene all key parties to the table and involve them in implementation issues.  Its implementation steering committee consisted of the AIMS Center, Public Health of Seattle & King County, community health centers, community mental health centers, housing providers, and substance disorder services providers, among others.  The implementation steering committee works together collectively developing agreed workflows, protocols, etc in incorporating the crucial key components of the CCM.

QI and P4P:  As time went on, CHPW noticed patient health outcomes variations among its clinic sites.  In 2009 it instituted quality improvement and a pay-for-performance incentives, with the latter contingent on meeting several key quality indicators:

  1. Use of a patient registry-tracking tool
  2. Initial screen (PHQ9) and thereafter early and timely patient follow up (2-4 weeks from initial assessment)
  3. Weekly full patient caseload review, with entire care team, including the BH specialist who provides psychiatric consultation to the PCP for patients not showing improvement
  4. Treatment plan changes as needed to achieve outcomes improvement.

The process starts with the patient’s initial assessment and using a PHQ9 for behavioral issues.  The PHQ9 provides a baseline for monitoring any outcomes change, going forward.  Thus it is not only an initial screen, it is also a measurement tool to see who’s improving in depressive symptoms, and who’s not.

Registries and Tracking Tools: CHPW highlights the critical necessity of the patient registry-tracking system, and regular, systematic caseload reviews for implementing the collaborative care model.  That is, registries that don’t just track patient encounters, but rather constitute a care management tool, displaying the entire patient and clinic caseload in real time, and providing clinicians with ongoing identification of those patients not improving.

This is something new, as originally electronic health records (EHRs) were developed for billing purposes, not for measuring health outcomes on a continuous basis.  Now, fortunately, many IT vendors are adding this function to their EHRs.  CHPW recommends practices considering CCM be willing to commit to the expense and investment of tracking tools in their EHRs, so vital is the role they play in achieving outcomes improvement.

CHPW is also a participant in the landmark COMPASS (Care of Mental, Physical and Substance-use Syndromes) project funded by a Health Care Innovation Award from the Center for Medicare &  Medicaid Innovation (CMMI).  COMPASS tests the best of the best of collaborative care models from 80+ previous successful randomized control trials.  In COMPASS, care teams not only document behavioral status through PHQ9 and GADs, they also regularly document BP and HbA1c etc.  Interestingly, they are finding that clinicians think they are doing a better job documenting this data, than they are in fact actually doing!  This is true even for healthcare groups with robust systems in place and NCQA PCMH accreditation.  It illustrates the necessity of ensuring care indicators are being documented into tracking systems.

Tracking tools not only provide real-time transparency, and allow for treatment modification to achieve improvement, they also allow care systems to spot variations among their various primary care sites, and to drive conversations in their own “implementation steering committees” on how to deal with those outcome variations.  In other words, a new, higher level of transparency is made available to administrators.

Systematic Caseload Review: The second essential best practice needed to effectively implement CCM is regular, usually weekly, patient caseload reviews to identify status change, or no change, followed by treatment modification to enable improvement. This entails maintaining a care team including a consulting psychiatrist who, together with the PCP and care manager, engage in weekly patient caseload review to analyze patient condition status, and then advise the PCP on treatment changes as needed. It requires organizing practices to function as true teams, which in itself requires a change in culture of medical practice from the past.

Implementing the collaborative care model of integrated med/psych care is truly a new way of delivering care.  A team supported by registry and tracking tools, engaged in regular patient caseload reviews and making treatment adjustments so that no patient falls through the cracks of clinical inertia.  

This is a lot to ask, but the dividends in improved patient health outcomes and costs savings, can be tremendous and sustained over time.   A key now will be for insurers and the federal government, through CMS, to incentivize these care delivery innovations and their essential component steps.