How Primary Care Service Fits In The Broader Continuum Of Care,
The demand to bring into primary care loftier-quality handling and management of depression, anxiety, and other mutual behavioral wellness weather has been well documented (1,2). Health care reform efforts are focusing on achieving the "triple aim": improving population health, improving patient experience of care, and reducing per-capita costs. Wellness care systems and communities increasingly realize that an integrated behavioral health strategy is essential to attain the triple aim (three). The Affordable Care Act has been encouraging wellness intendance reform through Medicaid and Medicare, and commercial insurance plans appear to exist following accommodate, thus providing an opportunity for behavioral wellness integration models to be implemented, disseminated, and sustained. While it remains unclear whether the current movement to "repeal and supervene upon" the Affordable Care Act will affect these efforts, there has been encouraging bipartisan support for legislation in the 21st Century Cures Act, which passed in December 2016. This human activity supports the prioritization of integration activities that would be likely to encourage innovation at the state level by reauthorizing grants for integration, besides every bit enforcing existing parity laws (4).
Addressing behavioral health bug in primary intendance requires significant system changes to bring about meaningful comeback. Adaptations of integrated care models will often vary co-ordinate to the size, location, and resource of a primary intendance practice. With these realities in mind, a framework for integrated care was recently created in New York State (NYS) with input from multiple stakeholders in order to back up primal statewide policy initiatives promoting integration (5). The framework is based on evidence and is structured on a continuum that can be used as a roadmap while allowing flexibility for implementation and advocacy of integration (Effigy 1). This is a divergence from previous frameworks, which tend to exist more chiselled (6). The framework is intended to aid in the assessment of the electric current country of practice integration across a range of integration domains (including instance finding, screening and referral to intendance, ongoing care management, and culturally adapted cocky-management support) and to provide specific guidance for moving forwards forth the integration continuum, with achievable goals at each footstep along a domain. The continuum construction recognizes that achieving the virtually advanced state of each domain and its components will not necessarily be the ultimate target for every chief care practice.
Effigy 1. Three domains of the New York State framework for integrated intendancea
a3 domains of the 8-domain framework are shown: case finding, screening, and referral to care; ongoing care management; and information tracking and exchange among providers. BH, behavioral wellness, CAD, coronary avenue illness; EHR, electronic health record. The v boosted domains are use of a multidisciplinary professional squad; systematic quality comeback; decision back up for measurement-based, stepped care; culturally adapted cocky-management support; and linkage with community and social services. Each domain has preliminary, intermediate, and avant-garde stages of integration. [A description of all viii domains is available equally an online supplement to this cavalcade.]
Use of the Framework in NYS
Commitment System Reform Incentive Payment.
The Delivery System Reform Incentive Payment (DSRIP) is a transformational model funded via a Medicaid 1115 waiver that rewards providers for performance on commitment system transformation projects that ameliorate intendance for Medicaid patients. In NYS, the DSRIP has the explicit statewide goal to reduce avoidable hospital apply by 25% over five years (7). Of note, integrated behavioral health is the simply transformation project (among a menu of more than than 20 possible projects) unanimously chosen equally a focus by all funded regional collaborations, dubbed Performing Provider Systems (PPS), participating in New York'south DSRIP (viii). NYS DSRIP offers two integration models in primary care that can be chosen: an enhanced colocation model or a collaborative intendance/IMPACT model (9). Each model has significant regulatory, staffing, and workflow requirements, and participating practices and systems tend to be larger and meliorate resourced than nonparticipants. The NYS framework can exist used past PPSs participating in DSRIP for assessment of the baseline state, equally a roadmap for exercise integration for the two models, and for assessment of progress over fourth dimension.
Advanced Main Care.
NYS received a state innovation model grant in 2014 supporting its use of the advanced primary care (APC) model to achieve the triple aim. APC is an augmented patient-centered medical abode model that will exist supported by Medicare, commercial, and Medicaid payers. APC complements DSRIP past assuasive practices with bulk Medicare and commercially insured patients to participate in primary care transformation projects. APC prioritizes processes and outcomes related to integration, with the overall aim of ensuring that 80% of New Yorkers are receiving value-based care by 2020. Indeed, one of the 5 "strategic pillars" for transformational change, as outlined by the country, is that patients receive health care services through an integrated care commitment model, with a systematic focus on prevention and coordinated behavioral health care (10).
The APC model has less onerous resources and workflow documentation requirements than DSRIP, making it more viable for smaller, independent practices to implement integration, but withal has significant requirements for achieving quality measures (xi).
Practices joining APC will exist required to demonstrate the achievement of milestones along with acceptable functioning on a robust set of quality measures. The NYS behavioral health integration framework can be used to assistance practices develop a programme to progress through the "gates" or cadre practice competencies, in behavioral health integration. For example, at gate 1, it is expected that master care practices perform a practice self-assessment likewise equally set concrete goals to reach the gate ii milestones of screening, evidence-based treatment, and referral. The framework is uniquely positioned to help practices achieve these initial gates. At gate 3, in that location is an expectation that sites volition be using either the collaborative intendance model or some form of colocation model. In lodge to back up value-based payment at these gates, practices will need to attest to completion of these goals (field of study to audit) equally well equally be measured on several fundamental behavioral wellness plan measures developed for APC, such as clinical low screening and follow-upwardly, antidepressant management, and initiation and engagement of handling for alcohol and drug dependence. [The APC framework is illustrated in the online supplement to this column.]
Thrive NYC.
Thrive NYC (https://thrivenyc.cityofnewyork.usa) is an initiative to transform the public mental health arrangement of New York City (NYC) (12). Launched in 2015, it involves many city agencies, including NYC Health and Hospitals, the New York Law Department, the Section of Education, and the Section of Health and Mental Hygiene, and is funded by the Urban center of New York, which invested $850 million over four years, with 54 initiatives. Thrive NYC is founded on vi guiding principles: alter the culture, act early, shut handling gaps, partner with communities, use data better, and position government to lead. Improving access to mental health treatment is a priority, and Thrive NYC has created the Mental Health Service Corps (MHSC) to promote integration of behavioral health into main intendance using an enhanced colocation model similar to NYS DSRIP. It does and so by recruiting early on-career mental health clinicians for placement in primary intendance, substance use handling, and mental wellness settings citywide with supervision by a psychiatrist. MHSC is using the behavioral health framework to assess the state of integration from selected chief care practices in guild to develop a strategic plan to implement elements of its integrated care model, such as an electronic registry, case consultations, and stepped-care referrals, and to measure progress toward performance targets. Finally, the framework will exist used to measure the progress of advancing the integration level for MHSC sites (G. Belkin, personal communication, 2016).
Conclusions
In a fourth dimension of tremendous change in health care, it is reassuring and important that NYS and other U.Southward. locales have moved behavioral health integration into the forefront of health care reform, especially in the principal care sector. Nevertheless, given the variety of primary intendance practices around NYS, and indeed the country, a common organizing integration framework is needed along with guidance for practices based on geography (urban, suburban, and rural), workforce chapters, grooming, reimbursement, and culture change. NYS is providing substantial funds and technical assistance to reach sustainable behavioral wellness integration in master care practices, and documenting the progress both at the practise level and aggregate level volition exist key. The NYS framework builds on the SAMHSA framework by providing a high level of detail for taking concrete steps toward integration while assisting with concrete goal planning across multiple domains. Its flexible, continuum-based approach allows practices at any stage of integration to assess and advance their integration efforts. Looking forward, additional efforts to evaluate the framework for its overall utility equally well as for accumulating aggregate data on progress toward advancing integration in multiple chief care practices will be welcome to assess its generalizability for other efforts in the United states.
References
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How Primary Care Service Fits In The Broader Continuum Of Care,,
Source: https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201700085
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