The Integration of Health and Behavioral Health Workgroup had its final meeting on Thursday, May 27. We took only 4 hours of our scheduled all day meeting to review and give input into the 12 recommendations that were provided to us in draft form by our work group leaders (Tom Valentine and Ricky Garcia from the Texas Health and Human Services Commission [HHSC], the agency charged with providing recommendations to the legislature by August 1). We were told that we could share background and the recommendations documents, but comments are due back by June 15. Sherry Reisman has graciously posted these documents for your review on the TPA website at:
http://www.texaspsyc.org/associations/246/files/Integration%201.pdf
http://www.texaspsyc.org/associations/246/files/Integration%202.pdf
If you have any comments to share about them, please send those to me before June 15 at OllieSeayPhD@austin.rr.com
Briefly, the recommendations and some of the comments shared in our meeting are as follows:
Establish local healthcare integration planning – We suggested that be changed to “Include integrated healthcare in local planning.” It was felt that some of this could occur through already established Provider Network Advising Councils (PNACs) through community mental health centers, Regional Health Districts through DSHS, and hospital districts. Inclusion of public and private sector providers was seen as crucial.
Eliminate systemic barriers to healthcare integration – While this recommendation primarily focused on making the Department of State Health Services (DSHS) contracts with local mental health centers more flexible, we suggested that evidence based approaches should be used to do this and that consumer access to services issues should be included here as well as the need to be able to bill for and have behavioral health services paid for in physical health settings.
Create a State Healthcare Integration Leadership Council – We thought the membership should be made up of the same types of members as the Integration of Health and Behavioral Health Workgroup. (Note: the recommendations refer to the Health and Human Services Enterprise meaning all the agencies under HHSC, but we recommended that HHSC be used since that is a more familiar term).
Create and support a focus on healthcare integration in Texas – Basically, this is for reference materials and technical assistance for organizations looking to provide integrated care. We felt that, since the Hogg Foundation had already provided some funds in the past for public health clinics to demonstrate integration, it might be a good idea to look at a pilot project with a private organization that operates health clinics such as Austin Regional Clinic or some similar organization.
Encourage adoption of confidential health information technology and information sharing – We felt that we needed to consider ways to establish and share electronic records among health and behavioral health providers and that perhaps a special group composed of representatives of these entities and vendors of electronic records systems could come together to discuss ways to make this happen. It was also noted the The Centers for Medicare and Medicaid (CMS) had been providing resources and funding for physical health providers to develop such records, but behavioral health had not been at the table. Model consent forms were also addressed here.
Develop systems for meaningful and functional outcome measurement and tracking – We discussed having the state collaborate with academia to develop process and outcome measures for integration of health and behavioral health in state programs and through voluntary participation by organizations inthe private sector. More work with the Texas department of Insurance was encouraged so that private sector insurance issues could be addressed.
Integration efforts should be implemented as part of federal health requirements – This was meant to address issues of parity in insurance coverage for health and behavioral health issues as well as the yet to be developed regulation for healthcare reform.
Routine health and behavioral health screening should be universally provided to Texans during patient assessments, no matter where those assessments are provided – Here we felt we should add more about the “health home” concept and that any assessments should be evidence-based. It was further noted that, if assessments were going to be done, there needed to be resources for addressing any problems identified. It was further noted that there should be some type of coding system for these assessments so data could be used for future planning. Finally, other non-medical settings, such as public schools, should be included as locations for such screenings.
Training related to integration of services for Texas physicians and allied health professionals should be early in their professional education and continue through their course of study – This recommendation was written just after they leaders talked the with Texas Medical Association, and the language is reflective of that organization’s way of referring to their members and to trainees. We suggested the targeted group should just be called “health professionals’ and that undergraduate and graduate programs should include such information. We also discussed the need for competency-based education, not just exposure to concepts.
The tenets of integration should be incorporated into continuing education requirements for physicians, allied health professionals, and other related professionals – Again, we felt the targeted group should simply be called “health professionals” and that continuing education credits in the ethics area covering these issues should be encouraged for all health professionals.
Creative solutions should be developed through workforce utilization – Here we discussed not just looking at co-housing of health and behavioral health providers, but sharing best practices of various models. We also felt that some recent efforts of peer-to-peer services were left out and that barriers to the use of telecommunication should be addressed to help maximize the use of this resource. Billing codes need to be developed and used for these types of services. Further, we felt that professionals, other than physicians, should be able to use and bill for telehealth services.
Address reimbursement barriers to healthcare integration – This recommendation was aimed at reducing barriers to payment for behavioral health services that are provided in health settings and vice versa. Also, this is a problem for all types of providers not just primary care physicians. Another issues that was suggested for a discussion with “the right people” was why there are different rates of reimbursement for different types of providers for the same service (e.g., physicians get one rate, psychologists another, and social workers yet another for individual psychotherapy codes). This comes down from CMS, so the idea was to get the reasoning behind the differential pay. We also felt that we could learn from some of the providers who presented their models to the workgroup in the April meeting that have found ways to get paid for providing integrated care.
Did we leave some things out? Yes, and some of these we noted in our meeting and are to be addressed in the final document to include veteran’s issues, assertive case management for integration of health and behavioral health for persons with severe mental illness who have great difficulty connecting to services, cultural competency issues, substance abuse inclusion, not just addressing severe mental illness when we use the term behavioral health, considering other mental disorder diagnoses besides those currently identified as severe, patient education about integration of healthcare, and public awareness about the process.
Personally, I found this to be a very productive group. There were representatives of state and private entities, consumer groups and professional associations. I think we did a good job of integrating all the input we got and provided ourselves. No one faction was allowed to dominate the entire group, though this may have led us to be more general, rather than specific, with some recommendations. There was a decision by the leaders to not get into any scope of practice issues which was probably a wise decision on their part. I was glad to have been a part of this effort and to have been representing the psychologists of Texas.
If you have other points you think should be included, be sure to get those to me before June 15 at the e-mail address above.
I will post or get links to the final document that will be sent to the legislature.
Ollie
Wednesday, June 2, 2010
Sunday, March 14, 2010
A Day of Presentations
Last Wednesday, March 10, the Integration of Health and Behavioral Health Workgroup heard from 22 programs that have integrated health and behavioral health to some extent in Texas. Our day started at 8:00 a.m. and went until 5:00 p.m. with very minimal breaks and a working lunch. My only wish was that the chairs had been more comfortable for this marathon. What a wealth of experience we have to benefit from! Let me tell you about our presentations:
SUPPORT Program – FREW Strategic Initiative (Program created as part of the settlement to a class action law suit against the state due to problems in screening and access to care for children in the Texas Medicaid program). This program puts a master’s level Licensed Professional of the Healing Arts, or LPHA (LCSW or LPC) in a demonstration project in 9 pediatric practices around Texas.
STAR Health – Superior Health Plan (Physical Health) and Integrated Mental Health Services (Behavioral Health) are co-located in teams throughout Texas and work together in a team process to serve all the foster children under the Texas Department of Family and Protective Services in a contract with Medicaid.
Galveston County School-based Community Systems of Care – A program coordinated by UTMB that encourages community partnerships with UTMB, the local mental health center, community-based social service agencies and the local school districts.
Psychiatric Advanced Practice Registered Nurses in Integrated Health – This was not one program, but a description of how APRNs participate in integrated health settings in Texas and the nation. This classification was created to deal with the shortage in psychiatrists.
CommUnityCare/Austin Travis County Integral Care E-Merge Model – A collaborative care model that uses bilingual master’s level and beyond therapists (maybe one psychologist) within the Federally Qualified Health Centers (FQHCs) in Travis County.
Integrated Behavioral Health Program People’s Community Clinic (Austin) – Collaborative care model in which the primary care provider works with a care manager, or Behavioral Health Specialist ( in this case a Master’s level social worker) to develop and implement a treatment plan for patients diagnosed with anxiety or depression.
Project Vida Health Center, Integrated Health Care Program (El Paso) – One of the 5 programs funded by the Hogg Foundation for 3 years in 2006 to demonstrate the collaborative care model. It puts a care manager, behavioral health specialist (usually a social worker) in the primary care or pediatric setting.
El Paso MHMR and El Paso First Health Plans (HMO) Integrated Health Care Initiative – Provides integrated care to 40 children and adults who receive services from both agencies. LCSWs, LPCs and RNs from each respective agency identify and treat individuals with co-morbid concerns through a co-case management model.
Harris County Hospital District Community Behavioral Health Program – Puts psychiatrists and mostly LCSWs in 16 primary care centers/programs across Harris County. Includes involvement with medical students, psychology interns, primary care residents, and psychiatry residents.
Lone Star Circle of Care: Behaviorally Enhanced Community Health Center Network (Williamson & Travis Counties) – This program embeds behavioral health specialists (psychiatrists, psychologists, LPCs and LCSWs) in pediatrics, family practice and adolescent medicine clinics in Williamson and Travis Counties. They also have 3 Behavioral Health Clinics.
UTHSC at San Antonio: Lessons Learned from a clinic-based research in integrated family ad medicine clinic – U.S. Air Force program at Lackland Air Force Base that uses a Behavioral Health Consultant (BHC) model. BHCs are psychologists or psychology interns that work in family medicine and OB/GYN clinics. Research programs were initiated to examine patient outcomes.
AMERIGROUP Community Care Case Management – Program throughout Texas that provides enhanced case management to members of the plan with co-morbid physical and behavioral health conditions.
NorthSTAR Integrated Health and Behavioral Health Intensive Case Management for High Risk/High Cost Homeless Individuals – ValueOptions implemented an integrated Behavioral Health and Physical Health intensive case management program as part of the co-located services available at the City of Dallas Bridge homeless shelter. The program is aimed at individuals who had frequent emergency room visits.
Continuum of Care model (Galveston) – This collaborative effort, led by UTMB Galveston and the Gulf Coast Center for MHMR Services (GCC), provided a holistic approach to service delivery. The intent was to offer support and referral among sites while re-connecting all GCC clients back into GCC services. GCC placed case managers at public health clinics, jails, faith-based social/health agencies, and the in-patient psychiatric hospital at UTMB. Unique to this model was the use of the GCC mobile response teams who worked with case managers to overcome transportation barriers and critical situations and improve medication and appointment compliance.
East Texas Integrated Health-Care Project – Community Healthcore and two area partners are working on two different fronts to achieve improved primary and mental health care for individuals in the local communities. This collaborative effort began with East Texas Border Health in Marshall, Texas and the development of an FQHC. It began with Community Healthcore and spun off with its own board.
Outcomes of the Texas SBIRT Program (Harris County) – A Screening, Brief Intervention and Referral to Treatment (SBIRT) program for alcohol and drugs was conducted at multiple locations (emergency centers, hospital inpatient and outpatient departments and community clinics) within the Harris County Hospital District.
St. Edward’s University (Austin) – In March 2009, SEU opened an integrated center for delivering medical and mental health services to their university student population. The new facility, named the Health & Counseling Center, replaced the former Student Health Center and the Counseling & Consultation Center. The merger planning for these two separate departments spanned three years—with very intensive efforts conducted during the final 18 months before opening.
Peer Wellness Coaching Role to Promote Health in Persons Living with Severe Mental Illness – A proposed model developed by nutritionist and others at the Institute for Wellness and Recovery Initiatives Collaborative Support Programs of New Jersey. Wellness Coaches are prepared to assist persons living with mental illness to link to primary health care and health promotion activities. This role addresses health and wellness needs from a self-management perspective with a focus on helping reduce high risk behaviors and health risk factors such as smoking, poor illness self-management, inadequate diet, and infrequent exercise.
Via Hope Whole Health – Via Hope Texas Mental Health Resource is a new training and technical assistance center for consumers, family members, youth consumers, and professionals. It is funded by a grant from the Department of State Health Services as part of the state’s Mental Health Transformation State incentive Grant. One of Via Hope’s major initiatives is to develop and operate a statewide peer specialist training and certification program, a first for Texas. A peer specialist is an individual who is in recovery from a mental illness who uses his or her lived experience to help others with their recovery. Peer specialists who are used effectively work one on one with consumers or lead support groups; and compliment, but do not replace, the work of licensed professionals.
Vericare Integration of Health and Behavioral Health Initiatives for Skilled Nursing Facilites (SNF) - Psychological and clinical social work services have been introduced to SNF's and, typically, referrals are made at the discretion of SNF staff to address an array of mental health needs of residents. SNF initiatives may involve psychological service integration into physical and occupational therapy. Behavioral health staff actively consult with SNF staff in the development of resident's treatment plans and case conferences and conduct in-service training as well.
Department of State Health Services Money Follows the Person Behavioral Health Pilot (MFP-BH) – The MFP-BH Pilot in Bexar County is designed to help adults with behavioral health disorders leave nursing facilities and live successfully in the community. The Pilot integrates evidence-based mental health and substance abuse services, such as Cognitive Adaptation Training (CAT) and substance abuse counseling, provided through the local mental health authority with existing community-based long term and acute care services and supports provided through the State’s STAR+PLUS Medicaid managed care program.
Department of State Health Services: Texas Demonstration to Maintain Independence and Employment (DMIE) – This is a national study focused on preventing disability among workers. Texas DMIE examines whether working adults with potentially disabling physical and/or behavioral health conditions can avoid becoming disabled and dependent on federal disability benefits if they receive better integrated health, behavioral health and employment supports. Individuals from The Harris County Hospital District (HCHD) were recruited and randomized into intervention (n=904) and control groups (n=712). The control group received services normally available through HCHD. In addition, the intervention group had access to case management and enhanced medical, mental health, substance abuse, prescription, dental and vision benefits (new benefits, co-payment for existing benefits eliminated).
You can see from the not-so-brief overview that we had an infinite variety of models and players involved in these presentations. Next, we will get back into our subcommittees to discuss these models and those we studied in the last meeting. Let me say this is definitely a WORK group experience! If you have comments or information to share, please e-mail me at OllieSeayPhD@austin.rr.com or comment on this blog!
SUPPORT Program – FREW Strategic Initiative (Program created as part of the settlement to a class action law suit against the state due to problems in screening and access to care for children in the Texas Medicaid program). This program puts a master’s level Licensed Professional of the Healing Arts, or LPHA (LCSW or LPC) in a demonstration project in 9 pediatric practices around Texas.
STAR Health – Superior Health Plan (Physical Health) and Integrated Mental Health Services (Behavioral Health) are co-located in teams throughout Texas and work together in a team process to serve all the foster children under the Texas Department of Family and Protective Services in a contract with Medicaid.
Galveston County School-based Community Systems of Care – A program coordinated by UTMB that encourages community partnerships with UTMB, the local mental health center, community-based social service agencies and the local school districts.
Psychiatric Advanced Practice Registered Nurses in Integrated Health – This was not one program, but a description of how APRNs participate in integrated health settings in Texas and the nation. This classification was created to deal with the shortage in psychiatrists.
CommUnityCare/Austin Travis County Integral Care E-Merge Model – A collaborative care model that uses bilingual master’s level and beyond therapists (maybe one psychologist) within the Federally Qualified Health Centers (FQHCs) in Travis County.
Integrated Behavioral Health Program People’s Community Clinic (Austin) – Collaborative care model in which the primary care provider works with a care manager, or Behavioral Health Specialist ( in this case a Master’s level social worker) to develop and implement a treatment plan for patients diagnosed with anxiety or depression.
Project Vida Health Center, Integrated Health Care Program (El Paso) – One of the 5 programs funded by the Hogg Foundation for 3 years in 2006 to demonstrate the collaborative care model. It puts a care manager, behavioral health specialist (usually a social worker) in the primary care or pediatric setting.
El Paso MHMR and El Paso First Health Plans (HMO) Integrated Health Care Initiative – Provides integrated care to 40 children and adults who receive services from both agencies. LCSWs, LPCs and RNs from each respective agency identify and treat individuals with co-morbid concerns through a co-case management model.
Harris County Hospital District Community Behavioral Health Program – Puts psychiatrists and mostly LCSWs in 16 primary care centers/programs across Harris County. Includes involvement with medical students, psychology interns, primary care residents, and psychiatry residents.
Lone Star Circle of Care: Behaviorally Enhanced Community Health Center Network (Williamson & Travis Counties) – This program embeds behavioral health specialists (psychiatrists, psychologists, LPCs and LCSWs) in pediatrics, family practice and adolescent medicine clinics in Williamson and Travis Counties. They also have 3 Behavioral Health Clinics.
UTHSC at San Antonio: Lessons Learned from a clinic-based research in integrated family ad medicine clinic – U.S. Air Force program at Lackland Air Force Base that uses a Behavioral Health Consultant (BHC) model. BHCs are psychologists or psychology interns that work in family medicine and OB/GYN clinics. Research programs were initiated to examine patient outcomes.
AMERIGROUP Community Care Case Management – Program throughout Texas that provides enhanced case management to members of the plan with co-morbid physical and behavioral health conditions.
NorthSTAR Integrated Health and Behavioral Health Intensive Case Management for High Risk/High Cost Homeless Individuals – ValueOptions implemented an integrated Behavioral Health and Physical Health intensive case management program as part of the co-located services available at the City of Dallas Bridge homeless shelter. The program is aimed at individuals who had frequent emergency room visits.
Continuum of Care model (Galveston) – This collaborative effort, led by UTMB Galveston and the Gulf Coast Center for MHMR Services (GCC), provided a holistic approach to service delivery. The intent was to offer support and referral among sites while re-connecting all GCC clients back into GCC services. GCC placed case managers at public health clinics, jails, faith-based social/health agencies, and the in-patient psychiatric hospital at UTMB. Unique to this model was the use of the GCC mobile response teams who worked with case managers to overcome transportation barriers and critical situations and improve medication and appointment compliance.
East Texas Integrated Health-Care Project – Community Healthcore and two area partners are working on two different fronts to achieve improved primary and mental health care for individuals in the local communities. This collaborative effort began with East Texas Border Health in Marshall, Texas and the development of an FQHC. It began with Community Healthcore and spun off with its own board.
Outcomes of the Texas SBIRT Program (Harris County) – A Screening, Brief Intervention and Referral to Treatment (SBIRT) program for alcohol and drugs was conducted at multiple locations (emergency centers, hospital inpatient and outpatient departments and community clinics) within the Harris County Hospital District.
St. Edward’s University (Austin) – In March 2009, SEU opened an integrated center for delivering medical and mental health services to their university student population. The new facility, named the Health & Counseling Center, replaced the former Student Health Center and the Counseling & Consultation Center. The merger planning for these two separate departments spanned three years—with very intensive efforts conducted during the final 18 months before opening.
Peer Wellness Coaching Role to Promote Health in Persons Living with Severe Mental Illness – A proposed model developed by nutritionist and others at the Institute for Wellness and Recovery Initiatives Collaborative Support Programs of New Jersey. Wellness Coaches are prepared to assist persons living with mental illness to link to primary health care and health promotion activities. This role addresses health and wellness needs from a self-management perspective with a focus on helping reduce high risk behaviors and health risk factors such as smoking, poor illness self-management, inadequate diet, and infrequent exercise.
Via Hope Whole Health – Via Hope Texas Mental Health Resource is a new training and technical assistance center for consumers, family members, youth consumers, and professionals. It is funded by a grant from the Department of State Health Services as part of the state’s Mental Health Transformation State incentive Grant. One of Via Hope’s major initiatives is to develop and operate a statewide peer specialist training and certification program, a first for Texas. A peer specialist is an individual who is in recovery from a mental illness who uses his or her lived experience to help others with their recovery. Peer specialists who are used effectively work one on one with consumers or lead support groups; and compliment, but do not replace, the work of licensed professionals.
Vericare Integration of Health and Behavioral Health Initiatives for Skilled Nursing Facilites (SNF) - Psychological and clinical social work services have been introduced to SNF's and, typically, referrals are made at the discretion of SNF staff to address an array of mental health needs of residents. SNF initiatives may involve psychological service integration into physical and occupational therapy. Behavioral health staff actively consult with SNF staff in the development of resident's treatment plans and case conferences and conduct in-service training as well.
Department of State Health Services Money Follows the Person Behavioral Health Pilot (MFP-BH) – The MFP-BH Pilot in Bexar County is designed to help adults with behavioral health disorders leave nursing facilities and live successfully in the community. The Pilot integrates evidence-based mental health and substance abuse services, such as Cognitive Adaptation Training (CAT) and substance abuse counseling, provided through the local mental health authority with existing community-based long term and acute care services and supports provided through the State’s STAR+PLUS Medicaid managed care program.
Department of State Health Services: Texas Demonstration to Maintain Independence and Employment (DMIE) – This is a national study focused on preventing disability among workers. Texas DMIE examines whether working adults with potentially disabling physical and/or behavioral health conditions can avoid becoming disabled and dependent on federal disability benefits if they receive better integrated health, behavioral health and employment supports. Individuals from The Harris County Hospital District (HCHD) were recruited and randomized into intervention (n=904) and control groups (n=712). The control group received services normally available through HCHD. In addition, the intervention group had access to case management and enhanced medical, mental health, substance abuse, prescription, dental and vision benefits (new benefits, co-payment for existing benefits eliminated).
You can see from the not-so-brief overview that we had an infinite variety of models and players involved in these presentations. Next, we will get back into our subcommittees to discuss these models and those we studied in the last meeting. Let me say this is definitely a WORK group experience! If you have comments or information to share, please e-mail me at OllieSeayPhD@austin.rr.com or comment on this blog!
Saturday, March 6, 2010
Group Considers Possible Solutions to Integrated Health Services
My apologies for posting this late. In our February subcommittee meetings, the Integration of Health and Behavioral Health Workgroup reviewed a number of possible solutions to problems in each of our areas: policy (my subcommittee), service delivery, and training and service delivery. The solutions were derived from a review of the literature on programs providing integrated care throughout the United States.
Key points and issues were summarized in documents circulated to members of the workgroup and each subcommittee used and “Joint Document” to consider these areas in our meetings and in e-mail requests for comments after the meetings. In the background section, it was noted that the majority of behavioral health conditions are treated by primary care physicians, many medical disorders coexist with mental disorders, diagnoses of severe and persistent mental disorders are associated with dying 25 years earlier than the general population (29 years earlier in Texas); and that behavioral health screening in primary care can catch and treat conditions before they become more severe in persons who will not go to behavioral health settings.
Best practice models of integrated care were presented. These included the Four Quadrant Model, the Systems of Care Model, the Patient-Centered Medical Home (or Person-Centered Healthcare Home) Model, the Care Model, Embedded Programs, Unified Programs, Collaborative Programs, the Collaborative Care Model, and the Primary Care Behavioral Model.
In the Joint Document, key points and issues were summarized along with barriers and possible solutions for Texas, and these were discussed in each subcommittee. The key points highlighted were, Increased Cooperation and Collaboration, Exchange of Client Information, Reimbursement of Services, Public and Provider Education, and Referral System.
In terms of barriers, the following areas were highlighted: clinical barriers (providers and their treating entities are in silos with little sharing or knowledge of the others – physical health, behavioral health & substance abuse), organizational barriers (the length of time for appointments in primary care, the lack of psychiatric services in primary care, the lack of physical health services in behavioral health care, use of psychotropic medications for children), consumer barriers (those without insurance have barriers in getting behavioral health services, higher co-pays for behavioral health services, transportation, stigma, and getting to know a new system), policy barriers (privacy laws vary among settings, electronic record sharing, publicly funded centers may be restricted in use of funds, and agencies may be limited in the populations they can serve), and financial barriers (misalignment of health care funding incentives provided through public and private third party payors, and billing and reimbursement practices).
Numerous possible solutions were suggested and discussed. For Increased Cooperation and Collaboration, these included having local networks and advisory groups, developing interagency contracts and agreements, increased use of tele-health resources, building upon the existing responsibilities of certain behavioral healthcare providers (such as psychologists, social workers, and advanced practice nurses), and increasing peer support programs. In the Exchange of Client Information area, some possible solutions included were developing HIPAA compliant release forms and ensuring that new laws for Health Information Technology (HIT) were consistent with integrated care. In terms of reimbursement, some suggestions were to review existing procedure codes to see how they might best be used in integrated care and development of new codes for this purpose and putting an end to denials of same day billing for physical and behavioral health services. On the Provider Training front, solutions suggested included making integrated health a part of training for all providers. Referral System solutions focused on examining transportation and reimbursement for consumers, use of tele-consultation, evaluating the feasibility of requiring primary care providers to refer patients with chronic health conditions to behavioral health professionals, and evaluation of ways to cover the uninsured and underinsured.
The full workgroup will meet next week on Wednesday, March 10, to hear presentations from public and private entities from across the state that have been working on integration of health and behavioral health in their organizations. There are 8 different programs presenting in two panels, one in the morning and one in the afternoon.
If you have ideas that you want to share with me, please e-mail me at OllieSeayPhD@austin.rr.com or reply to my posting.
Key points and issues were summarized in documents circulated to members of the workgroup and each subcommittee used and “Joint Document” to consider these areas in our meetings and in e-mail requests for comments after the meetings. In the background section, it was noted that the majority of behavioral health conditions are treated by primary care physicians, many medical disorders coexist with mental disorders, diagnoses of severe and persistent mental disorders are associated with dying 25 years earlier than the general population (29 years earlier in Texas); and that behavioral health screening in primary care can catch and treat conditions before they become more severe in persons who will not go to behavioral health settings.
Best practice models of integrated care were presented. These included the Four Quadrant Model, the Systems of Care Model, the Patient-Centered Medical Home (or Person-Centered Healthcare Home) Model, the Care Model, Embedded Programs, Unified Programs, Collaborative Programs, the Collaborative Care Model, and the Primary Care Behavioral Model.
In the Joint Document, key points and issues were summarized along with barriers and possible solutions for Texas, and these were discussed in each subcommittee. The key points highlighted were, Increased Cooperation and Collaboration, Exchange of Client Information, Reimbursement of Services, Public and Provider Education, and Referral System.
In terms of barriers, the following areas were highlighted: clinical barriers (providers and their treating entities are in silos with little sharing or knowledge of the others – physical health, behavioral health & substance abuse), organizational barriers (the length of time for appointments in primary care, the lack of psychiatric services in primary care, the lack of physical health services in behavioral health care, use of psychotropic medications for children), consumer barriers (those without insurance have barriers in getting behavioral health services, higher co-pays for behavioral health services, transportation, stigma, and getting to know a new system), policy barriers (privacy laws vary among settings, electronic record sharing, publicly funded centers may be restricted in use of funds, and agencies may be limited in the populations they can serve), and financial barriers (misalignment of health care funding incentives provided through public and private third party payors, and billing and reimbursement practices).
Numerous possible solutions were suggested and discussed. For Increased Cooperation and Collaboration, these included having local networks and advisory groups, developing interagency contracts and agreements, increased use of tele-health resources, building upon the existing responsibilities of certain behavioral healthcare providers (such as psychologists, social workers, and advanced practice nurses), and increasing peer support programs. In the Exchange of Client Information area, some possible solutions included were developing HIPAA compliant release forms and ensuring that new laws for Health Information Technology (HIT) were consistent with integrated care. In terms of reimbursement, some suggestions were to review existing procedure codes to see how they might best be used in integrated care and development of new codes for this purpose and putting an end to denials of same day billing for physical and behavioral health services. On the Provider Training front, solutions suggested included making integrated health a part of training for all providers. Referral System solutions focused on examining transportation and reimbursement for consumers, use of tele-consultation, evaluating the feasibility of requiring primary care providers to refer patients with chronic health conditions to behavioral health professionals, and evaluation of ways to cover the uninsured and underinsured.
The full workgroup will meet next week on Wednesday, March 10, to hear presentations from public and private entities from across the state that have been working on integration of health and behavioral health in their organizations. There are 8 different programs presenting in two panels, one in the morning and one in the afternoon.
If you have ideas that you want to share with me, please e-mail me at OllieSeayPhD@austin.rr.com or reply to my posting.
Friday, January 22, 2010
Integrated Health Policy Subcommittee
I requested and was assigned to the Policy Subcommittee of the Integration of Health and Behavioral Health Workgroup for the Texas Health and Human Services Commission which met on Januay 7, 2010. I am the only psychologist on this subcommittee, but I am in good company. Other members include, Lynda Frost (Hogg Foundation - Chair/Agency Rep.); Luanne Southern (Dept. of State Health Services Deputy Commissioner - Agency Rep.); Tom Valentine (HHSC- Agency Rep.); Gyl Switzer (Mental Health America Texas); Inman White (Texas Council of Community MHMR Centers); Robin Peysen (National Alliance for the Mentally Ill); Susan Milam (National Association of Social Workers); Pat Brewer (Texas Department of Insurance); Matt Wolf (Sen. Duell's Aide); and Dan Sutherland (Rep. Truett's Aide). In this first meeting, we began discussing policy related to considerations for furthering the integration of health and behavioral health. We decided to proceed by identifying various existing models and assigning each model to 2 members of the subcommittee who would idenfy potential policy issues related to the model's implementation in Texas. Our focus will be on identifying best practices, barriers, and service delivery considerations. I have alerted Lynda Frost that the January edition of the APA Monitor has reforming health care as its theme. We will get our assignments via e-mail along with the date of the next subcommittee meeting and the next full workgroup meeting. More to come after that.
Integrated Health Workgroup Gets Underway
The first meeting of the Integration of Health and Behavioral Health Workgroup created by HB 2196 was held on November 12, 2009. I am the representative for TPA. There are 17 public members, 2 aides to the legislators who sponsored the bill, and 5 agency representatives from the Texas Health and Human Services Commission (HHSC) and its related agencies. Among the members are representatives of consumer and advocacy organizations, community behavioral health organizations, representatives of behavioral health professional organizations and experts in the field of integrating health and behavioral health. There are 3 other psychologists among the members, 1 of whom is a TPA member (Dr. Jeffrey Wherry from Texas Tech). At the meeting, we reviewed our charge which is “to recommend best practices in policy, training and service delivery to promote the integration of health and behavioral health services in this state.” In addition, we had presentations from the Hogg Foundation on Mental Health and from a representative of the National Council for Community Behavioral Healthcare, discussed establishing subcommittees, and reviewed scheduling of meetings. We will be completing our work in late May or early June so that the recommendations can be presented to HHSC which must then provide its report and recommendations to the legislature by August 1, 2010. We have all now signed up for our subcommittee assignments, and we all got our first choices. My assignment is on the Policy Subcommittee. The other psychologists are on the Service Delivery Subcommittee (1) and the Training and Public Education Subcommittee (2). I will provide additional reports as the work progresses.
Tuesday, March 11, 2008
February 2008 APA Council Meeting
Council reaffirms its stance against torture
New language more clearly expresses APA policy.
By Rhea K. Farberman
APA Monitor Executive Editor
In an on-going effort to communicate the association's strict prohibition against torture or other forms of cruel, degrading or inhumane treatment, at its Feb. 22-24 meeting, the APA Council of Representatives adopted an amendment to its 2007 resolution on torture to more clearly express APA's no-torture, no exceptions policy.
The new language, which replaces a portion of the council's 2007 statement, is as follows:
"Be it resolved that this unequivocal condemnation includes all techniques considered torture or cruel, inhuman or degrading treatment or punishment under the United Nations Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment; the Geneva Conventions; the Principles of Medical Ethics Relevant to Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and other Cruel, Inhuman, or Degrading Treatment or Punishment; the Basic Principles for the Treatment of Prisoners; or the World Medical Association Declaration of Tokyo. An absolute prohibition against the following techniques therefore arises from, is understood in the context of, and is interpreted according to these texts: mock executions; waterboarding or any other form of simulated drowning or suffocation; sexual humiliation; rape; cultural or religious humiliation; exploitation of fears; phobias or psychopathology; induce hypothermia; the use of psychotropic drugs or mind-altering substances; hooding; forced nakedness; stress positions; the use of dogs to threaten or intimidate; physical assault including slapping or shaking; exposure to extreme heat or cold; threats of harm or death; isolation; sensory deprivation and over-stimulation; sleep deprivation; or the threatened use of any of the above techniques to an individual or to members of an individual’s family. Psychologists are absolutely prohibited from knowingly planning, designing, participating in or assisting in the use of all condemned techniques at any time and may not enlist others to employ these techniques in order to circumvent this resolution’s prohibition."
The amendment was crafted by a group of council representatives who also worked on the 2007 Resolution: William J. Strickland, PhD (Div. 19, Military), Laurie Wagner, PhD, (Div. 39, Psychoanalysis), Elizabeth C. Wiggins, PhD, (Div. 41, Psychology and Law) and Judith L. Van Hoorn, PhD, and Corann Okorodudu, EdD (Div. 48, Peace).
"The amendment is a more direct statement of the intent of the 2007 resolution and removes any concerns that the 2007 resolution was unclear or contained loop-holes," said Wagner, speaking on behalf of the group.
To read the resolution, visit www.apa.org/governance/resolutions/councilres0807.html
In other action, the council:
Adopted the report of the 2007 Presidential Task Force on Integrative Health Care for an Aging Population, Blueprint for Change: Achieving Integrated Health Care for an Aging Population. (see http://www.apa.org/pi/aging/blueprint.htmlfor the full text of the report).
Voted to adopt the Resolution on the American with Disabilities Act, which reaffirms APA's policy on disabilities, strengthens the association's position on the law, and enables the association to pursue disability-related activities at the federal and state levels.
Voted to adopt as policy the revised Principles for the Recognition of Specialties in Professional Psychology, which has been updated to recognize the importance of cultural and individual differences and diversity in the education and training of specialists.
Voted to send to the full membership for vote a proposal to add new seats on council for the four ethnic- minority psychology organizations: the Asian American Psychological Association, the Association of Black Psychologists, the National Latina/o Psychological Association, and the Society of Indian Psychologists. This ballot will be a second opportunity for the membership to consider this issue; the Council strongly supports the addition of these seats and plans to include more information for the membership with this second ballot. Adding these seats would be outside the regular council representation apportionment process; no current or future division or state representation would be at risk for losing their seats due to the addition of these new seats.
Voted to send to the full membership for a vote a proposal to make the American Psychological Association of Graduate Students member of the Board of Directors a voting member of the Board.
Approved the Div. 56 (Trauma) as a permanent APA division.
Voted not to adopt a proposal to create a new division for qualitative inquiry. The proposal failed to achieve the two-thirds vote required by the APA By-Laws for establishing new divisions.
Approved an increase in the Interdivisional Grant Program funds to $25,000 per year for each of three years (2009-11). The Committee on Division/APA Relations will submit an evaluation of the projects to the council in 2011.
The council also allocated money from its 2008 discretionary fund for the following:
A task force to study council representation.
A three-day conference to provide quantitative training and support for students from underrepresented groups.
A task force to develop an APA designation process for postdoctoral psychopharmacology education and training programs. The task force is charged with creating a proposal for a designation system, which would develop the minimal standards for programs of psychopharmacology education and training programs.
The 2008 APA National Conference on Undergraduate Education in Psychology. The conference will be held June 22-27 at the University of Puget Sound in Tacoma, Wash.
A meeting of the National Standards for High School Psychology Working Group and the National Standards Advisory Panel. This meeting will serve to facilitate the second revision of the National Standards for the High School Psychology Curricula.
An APA Presidential Task Force on the Psychological Needs of U.S. Military Service Members and their Families.
The council also approved the 2008 APA budget with a forecasted surplus of $332,600.
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New language more clearly expresses APA policy.
By Rhea K. Farberman
APA Monitor Executive Editor
In an on-going effort to communicate the association's strict prohibition against torture or other forms of cruel, degrading or inhumane treatment, at its Feb. 22-24 meeting, the APA Council of Representatives adopted an amendment to its 2007 resolution on torture to more clearly express APA's no-torture, no exceptions policy.
The new language, which replaces a portion of the council's 2007 statement, is as follows:
"Be it resolved that this unequivocal condemnation includes all techniques considered torture or cruel, inhuman or degrading treatment or punishment under the United Nations Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment; the Geneva Conventions; the Principles of Medical Ethics Relevant to Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and other Cruel, Inhuman, or Degrading Treatment or Punishment; the Basic Principles for the Treatment of Prisoners; or the World Medical Association Declaration of Tokyo. An absolute prohibition against the following techniques therefore arises from, is understood in the context of, and is interpreted according to these texts: mock executions; waterboarding or any other form of simulated drowning or suffocation; sexual humiliation; rape; cultural or religious humiliation; exploitation of fears; phobias or psychopathology; induce hypothermia; the use of psychotropic drugs or mind-altering substances; hooding; forced nakedness; stress positions; the use of dogs to threaten or intimidate; physical assault including slapping or shaking; exposure to extreme heat or cold; threats of harm or death; isolation; sensory deprivation and over-stimulation; sleep deprivation; or the threatened use of any of the above techniques to an individual or to members of an individual’s family. Psychologists are absolutely prohibited from knowingly planning, designing, participating in or assisting in the use of all condemned techniques at any time and may not enlist others to employ these techniques in order to circumvent this resolution’s prohibition."
The amendment was crafted by a group of council representatives who also worked on the 2007 Resolution: William J. Strickland, PhD (Div. 19, Military), Laurie Wagner, PhD, (Div. 39, Psychoanalysis), Elizabeth C. Wiggins, PhD, (Div. 41, Psychology and Law) and Judith L. Van Hoorn, PhD, and Corann Okorodudu, EdD (Div. 48, Peace).
"The amendment is a more direct statement of the intent of the 2007 resolution and removes any concerns that the 2007 resolution was unclear or contained loop-holes," said Wagner, speaking on behalf of the group.
To read the resolution, visit www.apa.org/governance/resolutions/councilres0807.html
In other action, the council:
Adopted the report of the 2007 Presidential Task Force on Integrative Health Care for an Aging Population, Blueprint for Change: Achieving Integrated Health Care for an Aging Population. (see http://www.apa.org/pi/aging/blueprint.htmlfor the full text of the report).
Voted to adopt the Resolution on the American with Disabilities Act, which reaffirms APA's policy on disabilities, strengthens the association's position on the law, and enables the association to pursue disability-related activities at the federal and state levels.
Voted to adopt as policy the revised Principles for the Recognition of Specialties in Professional Psychology, which has been updated to recognize the importance of cultural and individual differences and diversity in the education and training of specialists.
Voted to send to the full membership for vote a proposal to add new seats on council for the four ethnic- minority psychology organizations: the Asian American Psychological Association, the Association of Black Psychologists, the National Latina/o Psychological Association, and the Society of Indian Psychologists. This ballot will be a second opportunity for the membership to consider this issue; the Council strongly supports the addition of these seats and plans to include more information for the membership with this second ballot. Adding these seats would be outside the regular council representation apportionment process; no current or future division or state representation would be at risk for losing their seats due to the addition of these new seats.
Voted to send to the full membership for a vote a proposal to make the American Psychological Association of Graduate Students member of the Board of Directors a voting member of the Board.
Approved the Div. 56 (Trauma) as a permanent APA division.
Voted not to adopt a proposal to create a new division for qualitative inquiry. The proposal failed to achieve the two-thirds vote required by the APA By-Laws for establishing new divisions.
Approved an increase in the Interdivisional Grant Program funds to $25,000 per year for each of three years (2009-11). The Committee on Division/APA Relations will submit an evaluation of the projects to the council in 2011.
The council also allocated money from its 2008 discretionary fund for the following:
A task force to study council representation.
A three-day conference to provide quantitative training and support for students from underrepresented groups.
A task force to develop an APA designation process for postdoctoral psychopharmacology education and training programs. The task force is charged with creating a proposal for a designation system, which would develop the minimal standards for programs of psychopharmacology education and training programs.
The 2008 APA National Conference on Undergraduate Education in Psychology. The conference will be held June 22-27 at the University of Puget Sound in Tacoma, Wash.
A meeting of the National Standards for High School Psychology Working Group and the National Standards Advisory Panel. This meeting will serve to facilitate the second revision of the National Standards for the High School Psychology Curricula.
An APA Presidential Task Force on the Psychological Needs of U.S. Military Service Members and their Families.
The council also approved the 2008 APA budget with a forecasted surplus of $332,600.
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