SM-17-008 Individual Grant Awards

Project Title: Utah Promoting Integration of Primary and Behavioral Health Care (U-PIPBHC) Project Summary/Abstract: The U-PIPBHC proposes to fully integrate primary and behavioral health care services using the Intermountain Healthcare Mental Health Integration Care Process Model or the Primary Care Behavioral Health Model to address the physical and behavioral health needs of low-income, uninsured residents through the provision of evidence-based treatment and support services. The populations of focus will be adults experiencing mental illness who have co-occurring physical health conditions or chronic diseases, and individuals with a substance use disorder including transition age youth. The Utah Department of Human Services, Division of Substance Abuse and Mental Health (DSAMH) will work with three local partnerships of community health centers and qualified community behavioral health centers in Box Elder, Iron, Utah, and Washington counties to develop and implement U-PIPBHC programs. U-PIPBHC aims to accomplish several goals. Goal 1: Optimize Primary Care/Behavioral Health systems and collaboration in co-located organizations to improve patient experience and quality of care. Objectives include cross training staff in evidence-based screening tools, intervention techniques, and shared protocols, and consents, and measuring and reporting physical and behavioral health services and outcomes. Goal 2: Improve health outcomes for patients experiencing co-occurring physical health and behavioral health conditions. Objectives include cross-training staff in evidence-based recommendations for assessing physical and behavioral health in culturally sensitive processes and integrated tracking, measuring and reporting of outcomes. Goal 3: Reduce inappropriate use of high-cost health care services by reducing fragmentation of care and improving Transitions of Care in co-located behavioral health and physical health settings. Objectives include the development of an integrated team and care approach with: multidisciplinary meetings; shared documentation; protocols; billing; data analytics; tracking of community service use; and analyzing trends to identify service gaps. Goal 4: Develop a state-wide learning community to share best practices on treating high cost/high utilization patients with co-morbid conditions. Objectives include the creation of a steering committee and leadership team made of a broad array of partners. Goal 5: Strengthen and improve state partnerships to ensure program sustainability. Objectives include regular steering and leadership meetings to address unified data, reporting and results; evaluation of program outcomes; and sustainability planning. Estimated number of people to be served as a result of the award of this grant: Year 1: 300; Year 2: 400; Year 3: 500; Year 4: 600; Year 5: 700 Total Across 5 Years: 2,500

Award Number Grantee Organization Name Grantee City Grantee Statesort ascending Project Director Last Name Project Director First Name Award Amount
SM080257-01 UTAH STATE DEPARTMENT OF HUMAN SERVICES SALT LAKE CITY UT CHRISTENSEN JEREMY $2,000,000

RIPIPBHC will target 1000 children with serious emotional disturbances (SED) and co-occurring chronic health conditions ages 0-17 and adult family members with mental illness and co-occurring chronic health conditions. The initiative will focus on 2-3 high need communities designated as medically under-served by HRSA. The program’s goal is to identify, screen and assess youth and their families, at risk or experiencing chronic health issues and SED. This grant will fund engagement, outreach, screening, assessment and the implementation of evidence based practices, as well as, assist the lead agencies in developing practices that fully integrate health and behavioral health care in primary care settings or other settings identified by the communities. In order to treat the youth or adolescent holistically this program will serve family members, as identified by the youth, with mental illness, substance use disorder and chronic health conditions. The program goals and objectives include: 1) Promote full integration of clinical practices between primary and behavioral health care. Objective 1.1: Increase the number of organizational policy changes that support integrated care. Objective 1.2: Increase the number of centers with co-located services. Objective 1.2: Increase the number of centers sharing resources. 2) Institute integrated care models for primary care and behavioral healthcare to improve overall patient health. Objective 2.1: Increase the number of evidence-based practices used in centers. Objective 2.2: Increase the number of centers using tele-health services. Objective 2.2: Increase the number of staff trained in co-occurring physical and behavioral health conditions. Objective 2.4: Increase the numbers centers using coordinated treatment plan. 3) Promote use of integrated care services. Objective 3.1: Increase the number of individuals screened for mental health and substance use disorders and chronic health conditions. Objective 3.2: Increase the number of health centers conducting screening for trauma. Objective 3.3: Increase the number of behavioral health centers conducting smoking cessation. Objective 3.4: Increase the number of health centers offering peer recovery support services.

Award Number Grantee Organization Name Grantee City Grantee Statesort ascending Project Director Last Name Project Director First Name Award Amount
SM080253-01 RHODE ISLAND DEPT OF BEHAVIORAL HEALTHCARE/DEVELOPMENTAL DISABILITIES/HOSP CRANSTON RI BROPHY MICHELLE $2,000,000

Oregon- Promoting Integration of Primary and Behavioral Health Care (PIPBHC) Abstract For more than two decades Oregon has been on the forefront of the health system transformation, and the recently implemented Certified Community Behavioral Health Clinics (CCBHC) Demonstration Project has further strengthened Oregon’s position to move towards a more integrated model of care when it comes to providing services to individuals with serious mental illness, physical chronic conditions, and substance use disorder. The Promoting Integration of Primary and Behavioral Health Care grant will enable Oregon Health Authority (OHA) to build upon existing and emerging health system infrastructure that have been central to the state’s transformation progress to date to integrate behavioral and physical health care delivery in behavioral health settings. OHA also proposes to leverage its experience with Patient Centered Primary Care Home Model, and the Federally Qualified Health Center (FQHC) Alternative Payment Methodology Pilot. OHA proposes to collaborate with eight of its 12 CCBHC provider organizations, who in turn will partner with their respective FQHCs to integrate primary care into behavioral health settings. It is estimated that in one year period between 2014 and 2015, 4.7 percent of Oregonians, 18 and older, coped with a serious mental illness and 21 percent of all adults suffered from any mental illness. The CCBHC regions, which are based on HPSA regions, have a significantly higher proportion of individuals with serious mental illness, substance use disorder, and chronic conditions. Even though Oregon has made improvements over the last few years, there is significant work to be done, especially in rural and frontier regions, when it comes to accessing behavioral and physical healthcare to achieve total community wellness. Through the PIPBHC resources in the CCBHC provider organizations, OHA anticipates significantly strengthening its existing infrastructure and direct services by ensuring comprehensive whole person care to individuals whose primary contact with the health system is through behavioral health settings. By the end of the grant period, each of the participating CCBHC provider organizations will be ready to meet Meaningful Use stage 2 criteria and will have a sustainability plan to keep primary care integrated within their behavioral health settings. 1

Award Number Grantee Organization Name Grantee City Grantee Statesort ascending Project Director Last Name Project Director First Name Award Amount
SM080259-01 OREGON HEALTH AUTHORITY DIRECTORS OFFICE FINANCIAL SERVICES SALEM OR MORRIS MICHAEL $2,000,000

Substance abuse, involving alcohol, drugs, or both, negatively impacts people, families and communities. The provision of services aimed at preventing and treating substance use disorders and related problems in adults and youth is critical to achieving overall behavioral and physical wellness. In Ohio, Medicaid-covered individuals depend upon primary care settings for physical healthcare as well as behavioral healthcare services. Ohio Department of Mental Health and Addiction Services (OhioMHAS) seeks to fund the bi-directional integration of physical and behavioral healthcare within three grantee facilities representing counties classified under the four geographical regions in the state. Ohio’s 2016 State Health Assessment identified mental health, alcohol and drug abuse, obesity, cardiovascular disease and diabetes as healthcare priorities from a review of 211 local public health department and hospital assessments/plans. Ohio faces many behavioral health challenges, such as poor access to care and high prevalence of depression in youth and young adults, also among the challenges, the upsurge in opioid-related deaths has positioned the state in the top of the nation’s opioid-related overdose deaths. Of Ohio’s publicly-funded services, opiate-related diagnoses (heroin and prescription opioids) accounted for 37 percent of addiction treatment admissions in 2014, a substantial increase from the seven percent in 2001. In 2015, unintentional injuries, with 84.9 percent attributed to opioid drug overdoses, and lung cancer were the two leading causes of premature death in Ohio. Addiction to opiates may be the greatest health and well-being challenges the state faces. A sharp rise in the number of babies discharged with neonatal abstinence syndrome and a staggering jump in the number of children placed in state custody due to parental opioid addiction, also suggests that the consequences of the opiate epidemic are far-reaching and will have long-term effects on Ohioans. With Ohioans’ chronic diseases, including obesity, cardiovascular disease, diabetes and cancer, combined with growing behavioral health issues, such as substance use disorder, and coupled with poor nutrition, it is not surprising that Ohio spends more on health care than most other states. Several national scorecards, including America’s Health Rankings (2015), Commonwealth State Scorecard (2015), and Gallup-Healthways Wellbeing Index (2014), placed Ohio in the bottom quartile of states for health outcomes. Ohio’s population health outcomes performance has steadily declined relative to other states over the last few decades, dropping from a rank of 27 in 1990 to 39 in 2015 according to America’s Health Rankings.

Award Number Grantee Organization Name Grantee City Grantee Statesort ascending Project Director Last Name Project Director First Name Award Amount
SM080238-01 OHIO STATE DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES COLUMBUS OH FERGUSON BETH $2,000,000

The Collaborative Care Initiative (CCI) enhances and coordinates behavioral health and primary care services for individuals with mental health and/or substance use disorders in community health centers and opioid treatment programs (OTPs), which also provide follow up care for referrals from emergency rooms after a drug overdose. By placing care coordinators, nurse care managers, psychiatrists and behavior specialists in the partnering Federally Qualified Health Centers (FQHCs) and OTPs, the initiative allows these programs to provide screening, diagnosis, prevention and treatment of behavioral health and medical conditions for their underserved populations. In accordance with the Four Quadrant Model of Clinical Integration, individuals with SUDs and/or mental health disorders will be assigned to the services that best meet their needs based on their level of medical and behavioral complexity/risk. Situated in two New Jersey counties with high number of drug overdoses, these programs will also be capable of receiving warm hand offs from local emergency rooms, where peer coaches and patient navigators are already stationed to engage those reversed after an opioid overdose and provide a warm handoff to the programs’ SUD services. The initiative increases the provision of substance use services, including medication assisted treatment, by taking advantage of the unused behavioral health treatment capacity of the FQHCs; these programs have provided few behavioral health services during a time when a critical need exists for the services, especially for those with opioid use disorders. Providing smoking cessation therapy is another component of these programs that has not been available. The CCI will also enable OTP clients to receive coordinated access to the primary care services available in the FQHCs, so that their co-morbid medical issues, including HIV and hepatitis C, can be addressed. By developing affiliations with one or more FQHCs, OTPs will ensure that their patients will receive treatment and preventative services by a consistent Collaborative Care Team that is working with their program staff. All FQHC and OTP admissions will be screened for behavioral health and medical need; based on current rates, this will total 5,158 admissions per year. Since an estimated 10% of FQHC admissions will need management by Collaborative Care Teams, while all of those at the OTP will need these teams’ services, a total of 1,198 individuals is expected to receive services from the teams in Year 1. The CCI will measure and track outcomes of the initiative, so that services and policies can be refined and improved. As state policy makers are currently examining how regulations and reimbursement for such services may have been barriers to integration efforts in the past, the hope is that the CCI will provide a sustainable integration model for the state moving forward.

Award Number Grantee Organization Name Grantee City Grantee Statesort ascending Project Director Last Name Project Director First Name Award Amount
SM080235-01 NEW JERSEY STATE DEPARTMENT OF HUMAN SERVICES TRENTON NJ FRESOLONE VICKI $1,758,843

The North Carolina State Medicaid Agency, known as the Division of Health Benefits, (DHB), and the State Mental Health Agency (SMHA) and the Single State Agency for Substance Use (SSA) of the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMHDDSAS) propose to implement a project that will promote the integration of primary and behavioral care services in high need communities. Community health programs will partner with community health centers so that primary care services can be integrated in behavioral health settings to improve the overall wellness and physical and behavioral health of adults with serious mental illness (SMI), children with serious emotional disturbance (SED), and adults and children with substance use disorders (SUD) and/or co-occurring disorders (COD). The proposed project will initially be implemented in three counties in the southeast coastal region and three in the western region and expand to the piedmont and sandhills areas. The goals of the proposed project are the following: Goal 1. To support prevention and wellness activities. Goal 2. To provide integrated and behavioral healthcare and retain participants in treatment. Goal 3. To provide recovery and support services. Goal 4. To establish a continuous quality improvement system that will assess project performance. Goal 5. To sustain the project. The proposed project will serve at least 150 in Year 1 and 500 in each succeeding year for a total of 2,150 individuals served over the grant funding period.

Award Number Grantee Organization Name Grantee City Grantee Statesort ascending Project Director Last Name Project Director First Name Award Amount
SM080244-01 NC STATE DEPT/HLTH & HUMAN SERVICES RALEIGH NC FARRINGTON DEBRA $2,000,000

The Mississippi Integrated Care Project, Promoting Integration of Primary and Behavioral Health Care (PIPBHC), will focus on adults (18+) living in Forrest and Hinds Counties with a serious mental illness (SMI) who need physical and mental health services. A large percentage of targeted counties population lives in poverty (Hinds-27.1%, Forrest-26.6%), and Hinds and Forrest Counties have a higher than average percentage of minorities (73.1% and 40.3% respectively) in comparison to the U.S. (22.9%). Research results indicate a strong correlation between poverty, minority composition, and health care access. The most common health conditions for adults with SMI include obesity, hypertension, asthma, diabetes, and heart disease. Inadequate physical activity, poor nutrition, smoking, substance use, and the long-term effects of psychotropic medication can contribute to our clients’ elevated risk of developing these serious health conditions. The PIPBHC program will bring together providers and information systems to improve client care outcomes and satisfaction with care. It will involve the implementation of person-centered treatment planning through appropriate linkages, coordination, and follow-up on needed services and supports delivered by a multidisciplinary team. The project goals are fourfold. First, a bi-directional, co-located model will be developed, utilizing FQHC primary care providers in behavioral health settings and behavioral health providers in FQHC settings, to improve access to care. It is expected that a minimum of 5% of adults with SMI will access primary care services at each CMHC, and a minimum of 150 individuals at each FQHC will access mental health care services at each FQHC. Within 4 months of notification of funding, participants will implement collaborative care EBPs to deliver integrated care. Second, the participating agencies will develop and implement a continuous quality improvement process to measure client- and system-level outcomes and improve services. At least 80% of the population will express satisfaction with PIPBHC services. Third, participating agencies will develop the capacity to collect and share electronic health data on key indicators as evidenced by implementing the needed middleware to share electronic health records, achieve interoperability, and exchange electronic health records. Fourth, the program will monitor PIPBHC service delivery, outcomes, and cost-savings. It will evaluate and monitor health and social outcomes including number of clients who see a primary care provider, mental health clinician, or substance use counselor; number of service hours engaged in health related activities; improved client outcomes in health, functioning, medication management, living situation, education, employment, social support, and substance use; and 100% timely reporting to SAMHSA and PIPBHC stakeholders. We expect to provide primary care to 5% of each of the respective counties’ client base each year (between 157-215 individuals), and to provide mental health care to between 76-100 individuals each year at the FQHCs. The total number of individuals served by the end of the project will be 2,845 people with SMI/MI.

Award Number Grantee Organization Name Grantee City Grantee Statesort ascending Project Director Last Name Project Director First Name Award Amount
SM080248-01 MISSISSIPPI STATE DEPARTMENT OF MENTAL HEALTH JACKSON MS VAUGHN VERONICA $1,881,312