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Collaborative Efforts

The final panel of the workshop featured five presenters who have been directly involved in planning, spearheading, and implementing collaborative change efforts in financing and reimbursement, training, and innovative health care delivery models. They noted many opportunities for federal

agencies, states, professional organizations, health care payers, foundations, and others to work collaboratively on issues affecting the behavioral health of children, youth, and families.

TRAINING SUPPORTED BY THE MATERNAL AND CHILD HEALTH BUREAU

The Maternal and Child Health Bureau, which is part of the Health Resources and Services Administration within the U.S. Department of Health and Human Services (HHS), emphasizes workforce development training across its programs, said Lauren Raskin Ramos, director of the Division of Maternal and Child Health Workforce Development. Just as the bureau works across the life span to improve health for women and children, it works across maternal and child health to develop the behavioral health workforce.

The bureau’s workforce development programs, which are designed to support current and future leaders in maternal and child health in a range of disciplines, range from the undergraduate to graduate to practicing levels (see Table 7-1). They all have certain core characteristics, she explained. They are systems oriented, so that people who come through the programs not only can provide excellent clinical care, but also are able to influence policy, systems, and programs more broadly in maternal and child health. They are interdisciplinary, so that trainees learn to be part of a team and become familiar with the role of their own disciplines within such teams.

TABLE 7-1 The Maternal and Child Health (MCH) Bureau’s Workforce Development Programs

SOURCE: Ramos (2016).

They include a focus on diversity and health equity, both in the curriculum through, for example, the teaching of cultural linguistic competence and also in focusing on the recruitment of diverse trainees. They focus on family leadership by recognizing families as part of training programs and as part of the workforce. Finally, Ramos said, they are collaborative within the bureau’s agencies, so that individual training programs look beyond the walls of particular offices and consider the needs of state and local maternal and child health programs more broadly.

Five of the bureau’s programs have a particular focus on behavioral health professionals. The Developmental-Behavioral Pediatrics and the Leadership Education in Neurodevelopmental and Related Disabilities programs train health professionals to screen, diagnose, and provide intervention services for children and youth with autism and other developmental disabilities. The Leadership Education in Adolescent Health Program and the training programs at the Pediatric Pulmonary Centers are producing a cadre of social workers to care for children and youth, with a focus on adolescent health and critical pulmonary health issues. And the Collaborative Office Rounds Program helps pediatricians partner with child psychiatrists to do more screening and referral.

The bureau’s leadership programs reach more than 33,000 trainees annually, with psychology, public health, medicine, and social work having the most trainees. Five years after completion of the programs, according to tracking data, 84 percent of graduates are demonstrating leadership in maternal and child health, 75 percent are working in an interdisciplinary manner to serve mothers and children, and 76 percent are working with underserved populations or vulnerable groups. One-third are in clinical settings, while others are in a wide range of other settings, including government agencies, private practices, and schools and school systems. The intention is to have trained professionals available anywhere that children are present, said Ramos.

Other maternal and child health programs also integrate behavioral health across the life span. The Healthy Start program, which is an infant mortality reduction program targeting high-risk communities across the country, trains Healthy Start workers and community health workers in substance abuse, maternal depression, and trauma-informed care services. The Maternal, Infant, and Early Childhood Home Visiting Program, which provides services to pregnant women and parents with young children, uses nurses, social workers, and early childhood educators to prevent child abuse and neglect, encourage positive parenting, and promote child development. In partnership with the American Academy of Pediatrics, the bureau developed the Bright Futures guidelines for child and adolescent well visits, including screening for psychosocial development, depression

screening, and alcohol and substance use.¹ “We know that Bright Futures is being used in clinical training programs, and we continue to support this as an opportunity to make sure this is part of every visit with a primary care practitioner,” she said. Finally, the bureau, in addition to training health professionals in adolescent health, is working to develop the capacity of the workforce that may encounter adolescents by ensuring that preventive health visits include attention to behavioral health needs.

EVIDENCE-BASED PRACTICES AS LEVERS FOR CHANGE

Given research results demonstrating the effectiveness of evidence-based interventions, all behavioral health providers need to receive training in delivering such therapies in primary care, said Doug Tynan, with the American Psychological Association and professor of pediatrics at Thomas Jefferson University. In this way, he said, evidence-based practices can leverage efforts to expand the workforce for behavioral health services in primary care. (A description of evidence-based programs is available in a guide from the National Adolescent and Young Adult Health Information Center [2014].)

Evidence-based evaluations are one form of training that social workers, nurse practitioners, psychiatrists, psychologists, and family therapists need, Tynan said, including training in the use of the best available tools for behavioral health evaluations. Screening tools are not evaluations, he stressed. Good evaluations include a history; interviews of the child, parent, and other adults; use of multiple data sources; and use of valid and reliable measures. Screenings and evaluations should be compatible with electronic health record systems so that the information they generate can be used effectively.

Licensed clinicians can be trained in evidence-based practices through the EffectiveChildTherapy.com Program developed by the Society for Clinical Child and Adolescent Psychology and through workshops in such programs as The Incredible Years, Parent-Child Interaction Theory, and the Positive Parenting Program. Trainees need to be supervised in clinical settings that emphasize evidence-based practice, Tynan said. One way to achieve this objective is by reimbursing for services delivered by trainees who are under supervision in primary care and other clinics.

Multiple barriers exist to impede integrated primary care that includes physical health and behavioral health services on the same day or at the same site, Tynan pointed out. Patients need a specific behavioral health diagnosis, even if just a brief checkup is done. Health and behavior Current

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¹ More information about Bright Futures is available at https://brightfutures.aap.org/Pages/default.aspx [September 2017].

Procedural Terminology codes have limits and provide low reimbursements. If a patient visits both a physical health and behavioral health provider, two copayments on the same day may be required. Also, in the absence of payments for supervised behavioral health interns and residents, clinics have no incentive to have training programs.

Incremental progress is being made, Tynan pointed out. One insurance company has instituted an integrated payment system in which a licensed provider can submit up to three 30-minute sessions using the diagnostic code of “unspecified behavior problem.” More substantial progress is possible, he asserted. Reimbursement of interns could immediately improve access while helping to prepare the future workforce. Considering evidence-based parenting programs as a preventive service would eliminate the co-payment problem and need for diagnosis. And linking parenting programs to quality and outcome measures could promote the provision of additional services, he said.

FOUNDATION SUPPORT FOR IMPLEMENTING EVIDENCE-BASED PRACTICES

The Child Health and Development Institute of Connecticut, a nonprofit subsidiary of the philanthropic Children’s Fund of Connecticut, provides the infrastructure for the training of professional licensed behavioral health and pediatric providers, reported Barbara Ward-Zimmerman, an integrated care consultant and chair of the Connecticut Psychological Association’s Health Care Reform Task Force. The institute’s Educating Practices in the Community (EPIC) Program does statewide training of pediatric and family medicine practitioners, while the Dissemination and Implementation Support Center (DISC) does statewide training of behavioral health providers.

The institute holds that training is a catalyst for practice transformation. Traditional methods of education, such as conferences, grand rounds, and distribution of literature, have little impact on changing practice, Ward-Zimmerman said. EPIC instead uses academic detailing, an evidence-based educational strategy that includes onsite visits by behavioral health professionals to primary care child health sites, to promote practice change. This model has been shown to be effective in a variety of practice areas, she said, including autism screening, asthma care, and the pain and fear associated with immunizations. The focus is on educating the entire office team, including nurses, physicians, and administrative staff, to promote a team approach to practice change, with an emphasis on change made possible by state and local resources and policies. Suboptimal areas of care are identified, and concrete information is provided to improve those areas.

Through 12 years of EPIC training, the Child Health and Development Institute has helped over 80 percent of Connecticut’s pediatric practices

improve their quality of care and expand the range of services. Training has directly contributed to increased rates of screening for developmental and behavioral health issues, maternal depression, and physical health services such as preventative oral health care and early hearing detection. As an example, Ward-Zimmerman cited the postpartum depression module, which increases knowledge about postpartum depression and about its prevalence, symptoms, and possible effects on infant and child development; encourages the universal use of screening tools to identify postpartum depression in the pediatric primary care setting; and provides information about local referral sources for postpartum depression. EPIC provides sample screening tools, guidelines for office protocols and reimbursement strategies, educational materials for families, referral resource information, and continuing medical education and maintenance of certification credits.

EPIC is funded in part through funds secured through state agencies, which provides agencies with an opportunity to work together to advance each other’s agendas. The Department of Public Health helps support suicide prevention efforts and early hearing screening. The Office of Early Childhood helps support postpartum depression and infant mental health talk interventions. Hospitals coordinate with EPIC and other groups and coalitions. Local grants and donations from foundations and individuals help support the work. “It’s all about the partnerships,” said Ward-Zimmerman.

The Dissemination and Implementation Support Center helps train behavioral health providers to implement evidence-based treatments. It collaborates with state systems and agencies to translate research and state policies into practice, disseminates evidence-based behavioral health practices statewide via training, provides ongoing support to sustain practice change, and evaluates the public health impact of the change. For example, in the area of trauma-focused cognitive behavioral therapy, more than 600 behavioral health clinicians have been trained at 35 agencies over the course of 9 years, and more than 6,200 children have received the treatment (Lang et al., 2017).

Finally, Ward-Zimmerman noted the American Psychological Association has helped develop a fully accessible course in integrated primary care for psychology graduate students that serves as an adjunct to an integrated primary care practicum, internship, or postdoctoral training.

She concluded by recommending the development of an infrastructure to replicate these programs. “It will be very difficult for everyone to replicate all these wonderful programs on their own. We need partners with shared agendas, and we need diverse implemented funding streams,” she said.

INTEGRATING CARE THROUGH PAYMENT AND POLICIES

Health care in the United States is fragmented and disjointed, and behavioral health is a prime example of this fragmentation, stated Benjamin Miller, associate professor in the Department of Family Medicine at the University of Colorado School of Medicine and director of the Eugene S. Farley, Jr. Health Policy Center. Adolescents with behavioral health disorders are more likely to receive behavioral health services in school settings and in specialty behavioral health settings than in medical settings (Farmer et al., 2004). Conversely, among children receiving outpatient care for behavioral health conditions, 35 percent see only their primary care provider (Anderson et al., 2015). “That’s not a bad thing,” said Miller. “But in the hustle and bustle of health care, when we are constantly churning people in and out and we’re looking at the identified patient and not necessarily the family, the community, the larger unit, it becomes challenging to address whole-person health needs.”

Because behavioral health extends across multiple sectors, reforms similarly need to extend across sectors, Miller observed. “This is not just about figuring out a way to integrate [behavioral health] into primary care, though that is wonderful,” he said. “This is about seamlessly addressing behavioral health across our populations, in our schools, in our communities of faith, wherever you might define it.”

Roadmaps for integrating behavioral health into primary care exist (Miller et al., 2016a, 2016b), but specific policies are needed to follow the roadmaps, Miller said. First, changing payment systems changes care. In a study in Colorado, a comparison of three fee-for-service practices with three practices that had global budgets for integrated care found the global budgets yield substantial cost savings, Miller observed. “Payment reform and clinical delivery reform and training . . . must be addressed for us to truly be successful,” he said. Similarly, global payments for behavioral health services need to support team-based care and provide compensation for personnel, interventions, and related infrastructure specific to individual practices, he said.

Programs are important, in Miller’s view, but the key is systems transformation. “There is no reason why we can’t conceptualize a different approach to behavioral health that puts behavioral health clinicians all throughout our community, not just that whole ‘come to me when you’re sick’ mentality, but a ‘let me be where you are’ mentality,” Miller stated, noting people could have their needs met in a more timely and proactive manner.

Miller urged assessing how policies limit what treatment options are offered to patients. He also recommended making sure that incentives are in place to encourage primary care clinicians to work with behavioral health

providers. Carving out the behavioral health benefit may have unintended consequences on access and integration of care. Also, fragmentation at the administrative level may limit integration at the delivery level, according to Miller.

Finally, he advocated for creating a workforce for a desired system, not the system as it exists. Eight core competencies for such a workforce were identified at a consensus conference in Colorado (Miller et al., 2016a):

1. Identify and assess behavioral health needs in primary care settings
2. Engage patients participating in integrated care in the primary care setting
3. Treat behavioral health problems and factors as part of primary care plans and teams
4. Participate in team-based care and collaboration
5. Communicate frequently with other clinicians and patients
6. Manage provider time in the primary care culture
7. Provide whole-person care with cultural competence
8. Apply professional values and attitudes in daily work

In general, Miller said, defining goals is critical. Appropriate goals can reinforce the concept of team-based care and attract and help create the workforce that is needed. Behavioral health should be seen as a critical facet of comprehensive primary care and no different than other investments in high-quality comprehensive primary care, such as practice-based care management, measurement, and other data use competencies, technology, and practice transformation support, Miller concluded.

FINANCING AND REIMBURSEMENT TO IMPROVE TRAINING

As an example of how payment systems can affect both training and care, Ellen-Marie Whelan, chief population health officer at the Center for Medicaid and CHIP Services and senior advisor at the Center for Medicare & Medicaid Innovation, spoke about delivery system reform and the federal funding of health care. The federal government has been moving toward value-based purchasing, accountable care organizations, episode-based payments, medical homes, and a focus on quality and cost transparency. “We have ‘better, smarter, healthier’ as our triple aim,” she said.

The Centers for Medicare & Medicaid Services has adopted a framework that categorizes payment to providers (see Table 7-2). The framework moves from fee-for-service payments that are not linked to value (category 1), to fee-for-service payments that are linked to value (category 2), to alternative payment models built on a fee-for-service architecture (category 3), to population-based payments (category 4). This final category “is the

TABLE 7-2 Centers for Medicare & Medicaid Services’ Categories of Payments to Providers

SOURCE: Rajkumar et al. (2014).

place where we do the best job providing integrated, team-based care in a way that is seamless to the patient and also seamless to those providing the care,” said Whelan.

In 2015, HHS Secretary Sylvia Burwell established the goal of changing Medicare from fee-for-service to either linked quality or to alternative payment models, and the initial goals were met ahead of schedule. The Medicare and CHIP Reauthorization Act of 2015 changed how Medicare rewards clinicians for value over volume. At the same time, HHS has been expanding existing models, testing new models, and creating a Health Care Payment Learning and Action Network to align incentives for payers. “We can’t do it alone,” said Whelan. “We need to be convening stakeholders, incentivizing providers, and partnering, especially with states because of Medicaid.”

In 2012, the Centers for Medicare & Medicaid Services established guidelines for integrated care models in which accountable care delivery and payment methodologies are aligned across payers and providers to ensure effective, seamless, coordinated care. Under the Affordable Care Act, health homes can coordinate care for Medicaid beneficiaries with chronic conditions, and the majority of health homes target individuals with behavioral health disorders. Additional authorities that already exist include the Early and Periodic Screening, Diagnostic, and Treatment Program; targeted care management; and managed care authorities.

HHS has clarified several issues that involve the behavioral health workforce, Whelan pointed out. It has provided information to states about their responsibilities to do behavioral health screening under the Early and Periodic Screening, Diagnostic, and Treatment Program, along with providing information about widely used and reliable screens for behavioral health and substance use disorders. It has clarified with states the option to do peer support services as part of comprehensive behavioral health and substance abuse programs. It has released an information bulletin encouraging states to adopt a continuum of care for children with behavioral health conditions. Further, work through Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute of Mental Health provides information to states regarding evidence-based practices for older adolescents and young adults who experience first-episode psychosis. And, through SAMHSA and the Administration for Children and Families, HHS gives states and other entities information on how to enhance services to children in foster care, especially to address overprescription of psychotropic medications. Additional information bulletins address screening for maternal depression, coverage for home visiting, delivery of care in schools, and coverage for housing for individuals with disabilities.

In response to a question, Whelan noted that metrics for behavioral health promotion and prevention would be a valuable input to govern-

mental reforms. Better understanding of the benefits of behavioral health promotion and prevention also would help states decide what actions to take, she said. The states have a lot on their plates, she said, but they can learn from each other and from groups that have put together information for states to use. In addition, she urged highlighting areas that have seen success.

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