Behavioral Health Integration Capacity Assessment (BHICA)

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1. Understanding Your Population

The following questions will help you consider how client needs may affect potential approaches to integration. You may not be able to answer all questions asked below because they may depend on your ability to measure the needs of your population (collect and interpret data on demographics and the population’s mental and physical health conditions, as well as their desire for specific service types and methods). This information, however, will help in thinking about the appropriate integration approach. For example, if 75% of the population already has primary care providers, building integration in-house may not be necessary, as the primary care needs of many individuals are already being met. In that case, building formal or informal relationships with local primary care providers may be the best option. Conversely, a population with significant physical health needs and low primary care coverage may benefit from a more intensive integration approach to best meet their needs. Your organization may find these data through a variety of sources, such as individuals’ electronic health records, claims data, conversation with individuals and providers, and other sources. For some organizations, these questions will identify opportunities to collect additional information on the population. This section will not be “scored”; rather, leaders and staff may use their responses to reflect on the needs of the population and the current organizational capacity to measure those needs. Each of the three sections in “Assessing the Optimal Integration Approach for Your Practice” includes notes about how to use this information to identify a path forward.

2. Assessing Your Infrastructure

Providers and organizations that want to move towards integration need to address five core operational capabilities: 1) Capacity to Collect Data, Exchange Information, and Monitor Population Health; 2) Progress and Outcome Tracking Capability; 3) Process for Engaging and Communicating with Individuals and Family Members; 4) Community Wellness Resources; and 5) Culture to Support Integration.

3. Identifying Your Population and Matching Care

It is important to have a process in place for identifying the population you want to serve or reach, as well as a process for matching individuals’ needs to the appropriate care. Once you decide how you wish to define the target population (e.g., individuals with more than one chronic health condition, all individuals with diabetes, or smokers), then you must develop a strategy for reliably identifying and tracking those individuals. One of the best ways to consistently identify individuals at risk for different health issues is to have a comprehensive, universal screening tool given to individuals at some predetermined time, such as during intake, annual visits, or every six months. As appropriate, given the target population, the screening tool should identify multiple conditions to help providers[1] better tailor the suite of services to offer or arrange for individuals. Once individuals within the target population have been identified, their care needs can be matched to the appropriate services.

 




[1] For the purposes of this tool, “providers” refers to behavioral health providers (e.g., therapists, psychiatrists), unless specifically noted to refer to primary care providers.

4.1. Coordinate Care
Behavioral health organizations collaborate and consult with community organizations and other providers to address the health needs of their population through better coordinating their care. To accomplish this, organizations may build relationships with community organizations that address the health, wellness, or social needs of individuals in their practice (e.g., YMCA, peer support centers, low-income housing advocates). Organizations may also build formal relationships through contracts with primary care providers or build informal networks of primary care and specialty providers. Organizations share as much data and information between providers as possible while still abiding by any federal or state information-sharing laws. As you go through the tool, it may be helpful to include in the note section the individual or provider type that is responsible for this task. If this task is not something you currently do, consider noting the individual that might be responsible for this work in the note section of the scoring tool. As you reflect on the Understanding Your Population section, this approach may be most appropriate if you serve a relatively small population with few primary care needs. In addition, this approach works well if a high percentage of the population already has a primary care provider and feels connected to that provider.
4.1.1. Referral and Communication with Community Organizations and Peer Support Agencies
4.1.1.1 Does the organization partner with other community organizations to connect people with population-specific wellness activities?
For example, nutritionists or gyms.
4.1.1.2 Does your organization follow up on referrals to community organizations?
4.1.1.3 Do community organizations give feedback to providers about individuals?
4.1.1.4 Does your organization refer individuals to peer support agencies, groups, or organizations?
A peer support agency provides services by and for individuals with mental illness that are designed to help individuals with their recovery. Peer support for substance abuse includes spiritually based groups such as Twelve Step recovery and cognitive behavioral-oriented groups, such as the Self-Management and Recovery Training (SMART) recovery program. The referral may be to internal or external resources. If no, please skip to question 4.1.2
4.1.1.5 If yes, does your organization follow up on referrals to peer support agencies?
4.1.1.6 Are peer support services, groups, and organizations a part of the individual’s care?
For example, peer support agencies may share information with providers that might include medication adherence or how well individuals perceive their treatment to be working.
4.1.2 Referrals to and Relationships with Physical Health Resources and Primary and Tertiary Care Providers
4.1.2.1 Does your organization refer individuals to primary care providers?
4.1.2.2 If yes, does your organization follow up on referrals to primary care providers?
4.1.2.3 Do providers talk with individuals about the release of their information when making a referral?
4.1.2.4 Do providers contact local primary care providers for advice about treating an individual?
This question refers to general information sharing rather than specific information about an individual.
4.1.2.5 Do providers share an individual’s history with the primary care providers?
For example, diagnoses, medications, and current treatment plans.
4.1.2.6 Do providers ask individuals about preventative health screenings?
For example, whether they have received flu shots or mammograms.
4.1.2.7 Does the organization have a trigger for providers to ask about specific services?
For example, an office visit protocol or medical record prompt to remind providers to ask individuals whether they have received preventative or other important health services.
4.1.2.8 Does the organization track which individuals successfully make it to their referred appointment?
4.1.2.9 Does the organization consistently track progress related to an individual’s medical needs?
For example, staff members receive and review updates on an individual’s physical health conditions during a visit.
4.1.2.10 Does the organization help individuals schedule appointments with community care providers, such as primary care providers or specialists?
4.1.3 Build Relationships and Exchange Information with Primary Care Providers
4.1.3.1 Does the organization have a formal agreement to share information with a primary care provider(s) or organization?
4.1.3.2 Does the organization provide individual information to the primary care provider when the primary care provider is involved in the individual’s care?
For example, patient history, care plan, labs, and medications.
4.1.3.3 Does the organization have an informed consent process through which individuals agree that their health information can be shared?
4.1.3.4 Does the organization have a financial relationship for service provision with a primary care provider(s)?
4.1.3.5 Does the organization have a written memorandum of understanding (MOU) with a primary care provider(s)?
The MOU defines clear roles and responsibilities for the partnership.
4.1.3.6 Does the organization share relevant labs and exam findings with primary care providers?
4.1.3.7 Does the organization share medication lists or formularies across providers?
4.1.3.8 Do multiple providers contribute to a shared care, treatment, and recovery support plan for each individual?
4.1.3.9 Does the organization track the progress of individuals after a referral?
4.1.3.10 Does the organization circle back with the individual to relay information and recommendations from the referral and help the individual act on it?
4.1.4 Assist Individuals without Primary Care Providers
4.1.4.1 Does the organization provide information about local primary care providers who are taking new patients?
4.1.4.2 Does the organization provide information about which providers accept Medicare, Medicaid, or uninsured individuals?
4.1.4.3 Does the organization include information about organizations that serve a high number of individuals with mental illness?
4.1.4.4 Does the organization track referrals made for individuals without a current primary care provider?
4.1.4.5 Does the organization track time between referral to primary or specialty care and initiation of treatment?
4.2. Co-Locate Primary Care Services
Behavioral health organizations may also integrate care by being on the same site or campus with a primary care provider or federally qualified health center. In this approach, the two co-located organizations provide team-based care with referrals between behavioral and primary care providers and, when possible, warm hand-offs (i.e., providers directly introducing the individual to the other provider at the time of the individual’s visit). The co-located organizations share as much data and information as possible. As you reflect on the Understanding Your Population section, this approach may be appropriate if you serve a population in a relatively small geographic area and the individuals seen in your practice have moderate health needs. In addition, this approach may be appropriate if a moderate number of individuals have identified a primary care provider, but a small percentage of individuals report a meaningful connection to this provider.
4.2.1 Access to Primary Care Services
4.2.1.1 Is there central coordination of scheduling between behavioral health and primary care?
4.2.1.2 Does the organization provide a warm hand-off to primary care?
A warm hand-off is when the behavioral health provider directly introduces the client to the primary care provider at the time of the individual’s visit. This can be done in person or over the phone.
4.2.1.3 Do behavioral health and primary care providers contribute to a shared care and treatment plan for each individual?
4.2.1.4 Is your organization in close physical proximity to a primary care provider?
For example, the same building or a nearby building.
4.2.2 Provide Navigation and/or Care Coordination Services
4.2.2.1 Is there someone who assists individuals in accessing an array of services within and outside the organization?
Every organization defines this role differently. This may be called a care manager, case manager, care coordinator, outreach worker, health navigator, peer support specialist, or practice coach, and the person is either paid directly by your organization or by a third party, such as a health plan or other health care provider entity. If your organization does not have an individual in this role, please skip to section 4.3.
4.2.2.2 Is there someone who assists individuals in managing medical conditions and related psychosocial problems?
For example, a staff person may help an individual improve nutritional habits in order to manage their diabetes.
4.2.2.3 Does this person engage with individuals around medical issues?
4.2.2.4 Does this person communicate information between physical and behavioral health providers?
4.2.2.5 Is there someone who connects people with the health care and social service resources they need, with the aim of increasing their appropriate use of services and integrating services?
This person would bridge physical and behavioral health care through techniques such as outreach, care coordination, personalized health coaching, or supported self-management. This person may be called a navigator and be paid directly by the organization or by a third party, such as a health plan or other health care provider entity.
4.2.2.6 If yes, is this person on-site?
4.3. Build Primary Care Capability In-House
Behavioral health organizations bring primary care providers on staff—permanently or on a contract basis—to address the physical health needs of individuals seen in their organization. General screening and wellness is offered on-site. Walk-in and advance appointments are accepted, and the behavioral and physical health providers work together to address the comprehensive needs of the individuals at the behavioral health center. As you reflect on the Understanding Your Population section, this approach may make sense if you have a high overall volume of patients with high physical and behavioral health needs. In addition, this approach may make sense if a small percentage of individuals in your practice have identified primary care providers, and if those with primary care providers report that they do not feel connected to that provider.
4.3.1 Provide Navigation and/or Care Coordination Services
4.3.1.1 Is there someone who assists individuals in facilitating an array of services within and outside the organization?
Every organization defines this role differently. This may be called a care manager, case manager, care coordinator, outreach worker, health navigator, peer support specialist, or a practice coach, and the person is either paid directly by your organization or by a third party, such as a health plan or other health care provider entity. If your organization does not have an individual in this role, please skip to section 4.3.2.
4.3.1.2 Is there someone who assists individuals in managing medical conditions and related psychosocial problems?
For example, a staff person may help an individual improve nutritional habits in order to manage their diabetes.
4.3.1.3 Does this person engage with individuals around medical issues?
4.3.1.4 Does this person communicate information between physical and behavioral health providers?
4.3.1.5 Is there someone who connects people with the health care and social service resources they need, with the aim of increasing their appropriate use of services and integrating services?
This person would bridge physical and behavioral health care through techniques such as outreach, care coordination, personalized health coaching, and supported self-management. This person may be called a navigator and be paid directly by the organization or by a third party, such as a health plan or other health care provider entity.
4.3.1.6 If yes, is this person on-site?
This service is provided by someone at the organization, not an outside entity.
4.3.1.7 Is there physical proximity between behavioral health staff and the medical staff?
4.3.2. Screening Functions
4.3.2.1 Does your organization take an individual’s blood pressure during each encounter?
4.3.2.2 Does your organization measure height and weight?
4.3.2.3 Does your organization screen for substance abuse/illicit drug use?
Screening could include substance abuse questionnaires or blood/urine screens.