News Briefs

Core workforce competencies for integrated practice: Despite the increasing focus on integrated care, there is no single, widely recognized set of workforce competencies on this approach for either the behavioral health or primary care workforce. To address this gap, the Annapolis Coalition on the Behavioral Health Workforce, in consultation with content experts and leaders across the integrated care field, has developed a set of competencies in nine practice areas: interpersonal communication, collaboration and teamwork, screening and assessment, care planning and coordination, intervention, cultural competency, systems-oriented practice, practice-based learning and quality improvement, and informatics. The core competencies, which are described in a 24-page report, are intended to help provider organizations shape job descriptions, orientation programs, supervision, and performance reviews for workers delivering integrated care and to help educators develop curricula and training programs. Frontline workers can use them as a foundation for building individual skill sets and creating effective teams. The initial project goal was to develop two competency sets: one for behavioral health practitioners and another for primary care practitioners. However, developers soon realized that most competencies required for integrated care were common to both types of provider. Thus the competencies are structured as a single integrated set. They were developed under the auspices of the Center for Integrated Health Solutions (CIHS), which is funded jointly by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration. The report, Core Competencies for Integrated Behavioral Health and Primary Care, is available on the CIHS workforce Web site (www.integration.samhsa.gov/workforce), which also lists links to resources relevant to each competency.

CHCS brief offers early lessons on integrating care for “dual eligibles”: Many individuals with serious mental illnesses who are dually eligible for Medicare and Medicaid have comorbid chronic general medical conditions and substance use disorders, which greatly increase the costs of care. For this group, Medicare is the primary insurer for acute and primary care, and Medicaid covers critical “wraparound” services, rehabilitation, and home- and community-based services. System fragmentation across Medicare and Medicaid is particularly disruptive for people with serious mental illnesses. The Affordable Care Act has created new options and incentives for states to pursue integrated Medicare-Medicaid delivery systems. An issue brief from the Center for Health Care Strategies (CHCS) shows that states are taking advantage of new opportunities to address long-standing, systemic misalignments for dual eligibles. The brief describes early efforts in four states—Arizona, California, Massachusetts, and Washington—to work with newly available options. Each of the states is using different options, most of which were afforded by the 2011 Financial Alignment Initiative, which provided states with two new demonstration models—capitated and managed fee-for-service approaches. The issue brief also describes another approach, used in Arizona, which involves contracting with Medicare Advantage Dual-Eligible Special Needs Plans. The 12-page brief, made possible through support from the Commonwealth Fund and the SCAN Foundation, is available on the CHCS Web site at www.chcs.org/usr_doc/State_Approaches_to_Integrating_Physical_and_Behavioral_Health.pdf.

CHCS brief on “ACO pioneers”: The ACA and changes in the broader health care marketplace have created opportunities for reforming payment and delivery systems. Over the past few years, states have been actively pursuing new care delivery and payment models to improve the capacity of the health system to deliver high-value care and increase provider accountability, particularly for high-need populations facing multiple health and social challenges. Accountable care organizations (ACOs) offer a new vehicle for states to improve the quality and cost-effectiveness of care for Medicaid beneficiaries, who are increasing in number as many states expand their Medicaid programs under the ACA. A new publication from CHCS, Medicaid Accountable Care Organizations: Program Characteristics in Leading-Edge States, is a technical assistance tool that presents key features of ACO programs in seven of the states participating in the Medicaid ACO Learning Collaborative: Colorado, Maine, Massachusetts, Minnesota, New Jersey, Oregon, and Vermont. The centerpiece of the document is a matrix that outlines how each state has configured ACO programs in areas that they are required to address: governance, provider eligibility, covered populations, scope of accountable services, required functions, payment models, and quality measures. CHCS created the matrix, with support from the Commonwealth Fund, to help other states as they consider their own ACO approaches. The document is available on the CHCS Web site at www.chcs.org/usr_doc/ACO_Design_Matrix_022514.pdf.

APA resource document on liability issues in integrated care models: Integration of primary and behavioral health care provides opportunities for psychiatrists who are interested in reaching more patients with their skills and expertise. In integrated care settings, the psychiatrist provides medical advice in the form of a consultation to the primary care provider. The advice may or may not be based on an in-person meeting with a patient or a review of the medical record. Therefore, it is important for psychiatrists to clarify malpractice liability when providing medical advice about patients for whom the psychiatrist may not be the primary prescriber. The American Psychiatric Association (APA) has recently released “Resource Document on Risk Management and Liability Issues in Integrated Care Models,” which provides an overview of various types of medical malpractice cases and distinguishes the different forms of consultation that psychiatrists offer to primary prescribers. To date, no known cases of malpractice have been brought against collaborative care treatment programs, the authors note. The document also describes the various roles that psychiatrists may undertake in integrated care settings and concludes with several risk management tips. For example, psychiatrists should identify the specific nature of their role with the referring provider. They should know whether they are providing a true consultation or an informal “curbside” consultation. They should be cautious when an informal inquiry turns into a patient’s diagnosis and treatment, which may change their role and duties to the patient. Psychiatrists should be familiar with state and federal laws and regulations pertaining to the formation of doctor-patient relationships and the provision of consultations, which vary between states. The resource document is available on the APA Web site at www.psychiatry.org/learn/library--archives/resource-documents.

IOM report on preventing disorders among military service members: Many veterans have returned from Iraq and Afghanistan with significant psychological impairments. Between 2000 and 2011, nearly a million service members or former service members received a diagnosis of a mental disorder either during or after deployment, and almost half of this group received multiple diagnoses. The U.S. Department of Veterans Affairs (VA) and Department of Defense (DOD) asked the Institute of Medicine (IOM) to examine DOD’s efforts to prevent psychological disorders among active-duty service members and their families. The resulting report assesses the evidence base for DOD’s prevention programs and makes recommendations about program development and implementation. DOD has implemented numerous resilience and prevention programs, the report notes, but there is an insufficient evidence base to support these interventions and a lack of systematic evaluation and performance measurement. In terms of treatment, the DOD and VA in many ways are at the forefront of providing evidence-based treatments. However, inconsistencies in the availability and quality of care and a lack of systematic evaluation were noted in both systems. There are also opportunities to improve processes of training and evaluating clinicians, including the incorporation of continuing education and supervision, standardized periodic evaluation, and a greater emphasis on coordination. The report recommends that DOD and VA should invest in research to determine the efficacy of treatments that do not have a strong evidence base. The 292-page report, Preventing Psychological Disorders in Service Members and Their Families: An Assessment of Programs, is available on the IOM Web site at www.iom.edu.

SAMHSA guide for practitioners on helping families support LGBT children: The Substance Abuse and Mental Health Services Administration (SAMHSA) has released a resource guide designed to help health care and social service practitioners provide greater insight to families on how they can support their children who identify themselves as lesbian, gay, bisexual, or transgender (LGBT). SAMHSA produced the guide based in part on research from the Family Acceptance Project (familyproject.sfsu.edu), which indicates that LGBT young adults who reported high levels of family rejection during adolescence were more than eight times as likely to attempt suicide as peers from families who reported no or low levels of family rejection. The guide is designed to help health, mental health, and social service practitioners implement best practices in family-focused prevention and care for LGBT youths. It is the first resource guide published by a government agency to provide core principles and research-based approaches to engage and help families to support their LGBT children. The guide encourages practitioners to be proactive in meeting parents, families, and caregivers “where they are” to build an alliance to support their LGBT children. Research has shown that even families who are very rejecting can learn to modify their behavior if practitioners provide education, guidance, and support tailored to the needs of the family. The guide includes links to multicultural family educational materials and intervention videos. The 15-page A Practitioners Resource Guide: Helping Families to Support Their LGBT Children is available on the SAMHSA Web site at store.samhsa.gov/product/PEP14-LGBTKIDS.