Missouri's Department of Mental Health (DMH) has taken up the challenge of goal 1 of the President's New Freedom Commission (1), "Americans understand that mental health is essential to overall health," by working across state agency lines to transform the public mental health system in Missouri. As a result of the department's work in 2005 with the Missouri Medicaid state agency, the legislative Missouri Medicaid Reform Commission acknowledged that Medicaid reform must take place in the context of the public mental health system transformation being led by DMH. This provided a unique opportunity for Missouri to develop a pilot program for integrating care between the state's federally qualified health centers (FQHCs), the most important group of public-sector primary care providers, and its community mental health centers (CMHCs), which serve as the entry point for the public mental health system in Missouri. Together, the primary care system of the FQHCs and the behavioral health system of the CMHCs form the foundation of Missouri's public health safety net.
Editor's Note: This column is the 15th in a series of reports addressing the goals that were established by the President's New Freedom Commission on Mental Health. The series is supported by a contract with the Substance Abuse and Mental Health Services Administration (SAMHSA). Jeffrey A. Buck, Ph.D., and Anita Everett, M.D., developed the project, and Dr. Buck and Kenneth S. Thompson, M.D., are overseeing it for SAMHSA.
However, one system often treated primary care needs as though mental health issues did not affect other physical health problems, and the other acted as though mental health problems could be adequately addressed without addressing issues related to general medical care. In other cases, these systems were duplicating services and fighting over scarce resources, instead of looking for ways to improve efficiency through collaboration. Consequently, DMH secured new state funding to promote collaboration between FQHCs and CMHCs and mend the safety net through the integration of primary and behavioral health care at seven sites in Missouri involving FQHC-CMHC collaborations.
Integration has often meant introducing behavioral health professionals into a primary care team. However, the Missouri initiative was also designed to address the findings of a report by the National Association of State Mental Health Program Directors (2) that documented that individuals with serious mental illness are dying 25 years earlier than the general population "largely due to treatable medical conditions that are caused by modifiable risk factors such as smoking, obesity, substance abuse, and inadequate access to medical care." Therefore, the Missouri initiative, while requiring the more typical integration of behavioral health professionals into primary care settings, also requires bringing primary care directly into CMHC settings to ensure that individuals with serious mental illness have ready access to primary care that is integrated with their comprehensive behavioral health care. It is expected that this bidirectional approach will also help to build a robust collaboration between medical and mental health providers in support of sustainability.
In September 2007 DMH invited FQHCs and CMHCs to collaboratively submit proposals for funding of integration initiatives that addressed the following requirements: location of FQHC primary care clinics at CMHC treatment sites and integration of behavioral health professionals employed by the CMHCs into FQHC primary care teams; full documentation in the on-site client records of the care provided; appropriate adoption of evidence-based, best, and promising practices and care management technologies; and receptivity to consumer-driven services, person-centered planning, and consumer empowerment. DMH encouraged applicants to use the four-quadrant model developed by the National Council for Community Behavioral Healthcare (3) to describe their proposals and the populations to be served. Although the integration initiative was developed by DMH's Division of Comprehensive Psychiatric Services, screening for and treatment of alcohol and drug use disorders or referral for screening and treatment were also required.
Successful applicants were awarded $100,000 for the period January 1, 2008, to June 30, 2008, and $200,000 a year for the three succeeding fiscal years to be shared equally by the FQHC and CMHC partners each year. A panel of independent reviewers selected seven sites from among the 13 applications received. One-time planning grants ($30,000 each) were awarded to the six applicants that were not selected for full funding to allow them to lay the groundwork to apply for full funding in subsequent years.
Each of the fully funded sites proposed to integrate one or more behavioral health professionals employed by the CMHC (licensed social worker, licensed professional counselor, psychiatric nurse practitioner, or psychiatrist) into one or more FQHC clinics and to establish an FQHC primary care clinic staffed by one or more primary care professionals within a CMHC facility (registered nurse, licensed practical nurse, advanced practice nurse, or physician). The successful applicants include collaborative initiatives from urban, suburban, and rural communities. One successful applicant is a CMHC that is also an FQHC located in one of the state's fastest growing suburban areas. The six sites that received planning grants also represent urban and more rural areas.
DMH and the professional associations representing the CMHCs and FQHCs collaborated to create a technical assistance team to assist the local partners in addressing the many changes in policies, procedures, understandings, and attitudes required for successful implementation and to help identify and address needed changes in state policies and procedures to ensure the sustainability of the initiative. The three-member technical assistance team provides centralized training and on-site consultation for the behavioral health professionals who are making the transition to a primary care setting. The team also provides consultation and training for the primary care staff at the FQHC sites to help them understand how they can best utilize the newly integrated behavioral health professionals. The team members are committed to the initiative on a half-time basis.
A grant from the Missouri Foundation for Health supports the team, which is composed of a senior administrator with significant experience in Missouri's public mental health system, the clinical program manager from the FQHC professional association, and a clinical psychologist with experience in providing behavioral health services in primary care settings.
During the first year of the initiative we learned, or were reminded of, a number of lessons that may be helpful to others who are interested in transforming systems of care, promoting collaboration between FQHCs and CMHCs, integrating primary and behavioral health care, and improving access to care for individuals with serious mental illness.
Major system transformation initiatives of this magnitude require a project management capacity that includes both the experience and the time to successfully implement and monitor the program. In practice, the technical assistance team has served as a project management team. This was possible because the team includes both a senior administrator, who served for many years in DMH, as well as the clinical program manager for the FQHCs professional association, who transferred some of her existing duties to other staff in order to devote considerable time to the initiative. This enabled the team not only to provide individual consultation to the sites but also to help design the evaluation of the initiative, collect performance data, develop contracts, and work with state and federal authorities to coordinate oversight responsibilities and with the state's Medicaid authority to ensure that DMH start-up funding for the FQHCs is handled in a manner consistent with Medicaid reimbursement rules.
Site visits are conducted every two or three months. During key development stages, some sites have monthly visits or teleconference meetings.
Upfront funding is important to address the concerns of capital-strapped CMHCs and FQHCs regarding the cost of start-up and of care for the uninsured, as well as to free partners to focus on establishing a strong collaboration without being stymied by turf and resource issues.
Concerns over a lack of capital have limited the development of collaborative efforts to integrate care in Missouri, and the availability of start-up funding was important in getting interested parties to commit to collaboration. The seed funding has been critical in motivating sites to work through the many logistical details and challenges involved in implementing this initiative, especially where the partners had no history of collaboration.
The volume of clients in need of care at a given site appears to be an important factor determining the financial viability of these new clinics. It remains to be seen whether there is adequate volume to financially sustain the new services, particularly for the new satellite FQHCs that have opened in CMHCs.
Myths, misunderstandings, and real differences
Many myths and misunderstandings exist within the public health and public mental health systems regarding the advantages enjoyed and constraints faced by their sister system. It is important to recognize and dispel these myths and misunderstandings early in the transformation process, while acknowledging the real differences between the systems that need to be addressed.
CMHCs and FQHCs generally do not understand the complexities of each other's funding sources and financing mechanisms. In Missouri, some CMHCs erroneously believed that FQHCs did not have to worry about "the bottom line" because of the Medicaid cost-based reimbursement they receive, and some FQHCs mistakenly believed that CMHCs were required to serve everyone who met certain diagnostic criteria because the CMHCs received DMH funding. Misunderstandings about the constraints under which each system operates also led some representatives from both systems to harbor feelings that their sister agency was guilty of "dumping" patients on them.
Among the real differences between the two systems that require attention are their approaches to consumer financial participation. In Missouri, Medicaid clients are charged a copayment by FQHCs but not by CMHCs, and each FQHC establishes its own sliding fee scale, whereas CMHCs use a DMH sliding fee scale. Therefore, individuals who receive service from both an FQHC and a CMHC as part of the integration initiative could be subject to different copayment and sliding fee approaches.
Even with a shared goal, there will be different problems, solutions, and levels of progress and success at each site. Local conditions dictate nearly every aspect of the actual form, progress, and success of implementation. Each site is different. In some cases, the FQHC and CMHC have worked together successfully before, in other cases they have come to the collaboration with some suspicion based on their history, and in still others the collaboration represents the first time their staff members have met one another. Each site has different resources that it is able to commit to the initiative. Each site proposed a somewhat different model for integration and had a somewhat different understanding of the challenges it would face in implementation.
The technical assistance team works to ensure some consistency across the sites. The team provided each site with an orientation to the integration model that is promoted by the DMH as well as in-depth training of clinical staff regarding what integration looks like in the clinical setting and the key skills needed to be successful in an integrated setting.
Nevertheless, each site retains the flexibility to structure its initiative to address local conditions and needs, and these factors affect the pace of implementation. One site, which began seeing consumers within four months of receiving start-up funds, would have had an even quicker start-up if it had not experienced information system connectivity problems. Other sites were slower to initiate integration, often because of the need to recruit and train staff. One site was delayed by the fact that both partners were moving into new facilities. At two other sites, changes were made in the staff originally selected for integration. Most sites were able to begin some integration of staff by the sixth month. Two sites were still in the initial stages of integration after nine months. No site has yet developed full caseloads.
Collaboration and culture
The hard work of team building should not be ignored or underestimated, both at the level of creating a successful collaboration between two agencies and of successfully integrating new clinical staff into a treatment team. FQHCs and CMHCs have distinct organizational cultures and operational environments. When two agencies have little or no experience working together—and may have misconceptions or even suspicions about each other—it is important to consciously attend to clarifying roles and responsibilities, understanding each other's cultures and environments, and creating trust (4).
Behavioral health professionals who are introduced into a primary care setting for the first time often have to make a number of adjustments to their accustomed ways of working. Primary care settings are faster paced, call for interventions of shorter duration, and require more flexibility in availability than most behavioral health professionals are used to. At the same time, primary care staff often do not recognize the ways in which behavioral health professionals can be helpful in augmenting the care they provide.
The most critical issues for sustainability appear to be securing Medicaid reimbursement for behavioral health services provided to assist individuals in managing chronic illnesses, such as diabetes, and to develop appropriate mechanisms for covering the cost of services to the uninsured. Many people who do not have a behavioral health diagnosis but who have chronic general medical problems require behavioral health services and supports to effectively manage their illnesses. However, these services are not currently reimbursable through the Missouri Medicaid program. Although the Medicaid agency acknowledges the importance of these services, it remains a challenge to devise a cost-effective approach to introducing reimbursement for them at a time of state budget shortfalls.
Being able to appropriately meet the needs of individuals without insurance is also a critical factor for sustainability. Both FQHCs and CMHCs have limited resources to address these needs, and yet the integration initiative is likely to increase the demand on each system. A major objective of the initiative is to determine to what extent existing funds can be leveraged to meet the anticipated increase in demand and to what extent the additional funding that has been provided to the sites by DMH for the initiative will continue to be required.
Sustainability will be a function of the ability to maintain momentum for the initiative despite changes in leadership and management at the state and local levels. At the time of this writing, Missouri state government is in transition from a Republican gubernatorial administration to a Democratic administration. In addition, like many other states, Missouri is likely to face budgetary challenges. Therefore, although the executive leadership of the DMH does not automatically change with a new administration, the new governor will have significant influence over the policies and initiatives of DMH, including the extent to which funding for the integration initiative is supported, expanded, or curtailed. (Although the DMH director is a member of the governor's cabinet, DMH is one of a handful of state agencies with a commission that has responsibility for appointing and removing the director.)
Likewise, changes in leadership at the local sites or in budgetary realities could challenge the sustainability of the initiative. Although there have, in fact, been some changes in leadership at the local level since the initiative began, the new leadership has maintained the level of commitment.
The Missouri Initiative is still in the early stages of implementation, and data collection by an independent evaluator has just begun. The evaluation will assess primary care and behavioral health care performance measures, staff attitudes, consumer experiences of integrated care, and the impact of the pilot program on access to and cost of care.
Although co-location of staff has been initiated at all sites, caseloads remain low at most sites, and changes in staffing at some sites have meant what has amounted to starting over. Many issues remain to be resolved to ensure sustainability, including making certain that integration becomes part of the culture of each organization, weathering challenging budget times, and developing secure sources of reimbursement for integrated services. Over the next two years we will be learning new lessons that should help other states and stakeholders better understand the value of, and the most successful strategies for, strengthening the public health-mental health safety net by promoting collaboration between FQHCs and CMHCs, integrating primary and behavioral health care, and improving access to primary care for individuals with serious mental illness.