Topic: Integration Activities in Rural Counties

SUMMARY REPORT MEETING 20

Date: Wednesday, February 27, 2013 Time: 11:00AM – 12:00PM Location: Conference Call Hosts: UCLA Integrated Substance Abuse Programs (ISAP) & CA Dept. of Alcohol and Drug Programs (ADP) Topic: Integration Activities in Rural Counties

Presenters: Barbara Pierson Director Lassen County Behavioral Health Michael Horn Director Imperial County Behavioral Health Anne Lagorio AOD Administrator Trinity County Behavioral Health

Review of ILC Meeting 19 UCLA ISAP . For the nineteenth ILC meeting, conducted on January 23, 2013, Dr. Urada presented the results of UCLA and ADP’s 2012 Integration Survey, a follow-up to an earlier survey completed in 2010. Special thanks to everyone who helped out by responding to the survey and by contributing their comments to help us better assess the progress of integration in California’s 58 counties.

Logistics . Summary and materials discussed from the previous ILC meetings are available at http://www.uclaisap.org/Affordable-Care-Act/html/learning-collaborative/index.html. Subsequent meeting materials will continue to be posted on this site. . The next ILC meeting will be held on March 27, 2013 at the CADPAAC Quarterly Meeting in Sacramento. All further meetings are scheduled to be held at 11:00AM (PT) on the 4th Wednesday of every month, unless otherwise noted.

ILC Meeting 20 Topic: Integration Activities in Rural Counties Topic Introduction – Brandy Oeser, MPH, UCLA ISAP . The topic for today’s learning collaborative is behavioral health integration in three rural counties. We will hear presentations from Barbara Pierson in Lassen County, Michael Horn in Imperial County, and Anne Lagorio in Trinity County. We believe that all counties can learn from the challenges they faced and the solutions they found, and we would like to thank our presenters for their time and effort in sharing those experiences.

Barbara Pierson Lassen County Behavioral Health

Summary  Lassen County o Geography . Located in rural Northeastern California. By area, Lassen is the 8th largest county in California. o Demographics . About 34 thousand county residents. Majority are White non-Hispanic; growing percentage of Latinos. . High number of veterans- one of the highest per capita in the state. . 1/3 of the total population are inmates at the three area prisons. . Population is shifting towards more seniors. Percentage of young children is shrinking- less than 5% of the population are aged 0-5. . Lassen is rated as one of the three worst counties in California for economic well-being. The unemployment rate holds steady at around 17.1%. Out of all employed workers, 60% are employed by some type of government agency. About 41.4% of residents live below the 200% federal poverty limit. o Infrastructure . The only incorporated town is Susanville (8,000-10,000 residents), where the majority of medical, social and behavioral health services are located. Rest of the county is made up of small communities ranging from 20-1,500 residents. . Very limited public transportation throughout the county. The closest urban areas are 86 miles to 120 miles away.  Behavioral Health Integration o The Alcohol and Other Drug (AOD) and Mental Health (MH) departments began merging on July 1, 2012 to become the Department of Behavioral Health (BH). . Currently, MH and AOD services are co-located but not fully integrated. Clients have separate intakes for MH or AOD, and services are not well-coordinated. The screening process involves either AOD or MH doing a brief assessment; if an issue is detected, patients are then referred to the other side for a separate intake. The county wants to work towards using one combined assessment, but no one is sure how to bill or which staff would be responsible for administering the assessment. o The BH department is trying to become more holistic and client-centered, a process that will likely take several years. . The county plans to implement the SAMHSA-HRSA Behavioral Health Home model in its 5 BH locations (2 in Susanville, 3 in outlying areas) in order to provide better coordination of MH and AOD services. . They also plan to add primary care services, such as bringing in nurses to take patient histories, and setting up regular on-site screenings to check for potential health problems. Most clients have SUD, MH issues, and physical conditions that are sometimes co-occurring. . The Department of Health and Human Services has formed a plan to begin delivering integrated care to clients who enter any of the health and social services programs. With this roadmap, we can now focus on getting all the pieces into place. (See PPT slides.)  (1) Organizational chart for behavioral health. Work is still needed on getting some of these key staff groups into place.  (2) SAMHSA’s eight dimensions of wellness (emotional, environmental, intellectual, physical, occupational, spiritual, social, and financial). Services will be oriented towards addressing all eight dimensions for client-centered care.  (3) Common elements of integrated care, including common holistic approaches. These approaches will be put into practice in the newly integrated care settings. o Clients will receive services through care teams. . Planned Model  These interdisciplinary teams will consist of therapists, case managers, rehab specialists, AOD counselors, patient advocates, and clerical staff specifically assigned to the client.  When a new client comes in, the therapist reviews the case with the team. Team members then discuss treatment ideas and review cases on a regular basis.  Teams huddle every morning to discuss new patients, emergencies, expiring treatment plans, clients on the day’s schedule.  Care coordination is easier when a patient’s case manager, rehab specialist, and/or AOD counselor are working with their therapist. Clients can receive services from different providers within the team and be assured that staff are all familiar with their needs. . Current Progress  Getting the right personnel in the right places is still a work in progress. A patient advocate has not yet been trained, and the new intake process still needs hammering out.  So far, one clerical staff member has been hired. She coordinates and handles paperwork for no-shows and cancellations. Case managers are then assigned to follow up. The clerical staff member also handles many other important functions, such as checking whether clients still have insurance (so they can get help getting back on insurance if needed) or noticing their behavior in the front office. She then adds that information to the client’s electronic record for the client’s team to refer to.  Morning meetings started out daily, but became too burdensome. Since then, it’s become three times per week with hopes to resume the daily morning huddles at some point in the future.  Organizational Barriers o Bureaucracy. Working within a larger bureaucracy (with unions, personnel, advisory boards) can slow down the process of change, although Lassen BH has been working on combining both their advisory boards and creating new bylaws. o Limited or unstable local resources. Like in many rural areas, Lassen has limited resources with limited stability. o Organizational instability/uncertainty. Because their FQHC has recently discharged the CEO, there is instability and uncertainty about what the future of integrating with primary care will look like. o Different sets of rules, regulations. AOD and MH have different sets of rules and regulations, and different ways of doing things. Waiting for more guidance from the state to see how it will be possible to combine to become one unit, with one way of thinking and doing things. o Cultural and linguistic differences (developing a common language). AOD and MH speak different languages. Need to find the middle ground and learn each other’s language.  Challenges o Staff turnover. . Many staff members have retired, so there is a need to train new staff. The influx of new folks at different stages of the learning curve has created uneasiness for existing staff members, who are also dealing with new expectations and a new model they must learn to work with. . Trying to reassure people that everything will work out, and focus on what has already been accomplished in a short period of time. o Staff competencies. . Organizational issue: some staff, especially older staff, have not taken tests in a long time and may be uncomfortable or resistant to new performance requirements and trainings. (See below, under Suggestions.) o Building staff morale. . Prior to integrating with AOD, MH staff had teams that didn’t work as well together. Morning coffee hours were held to give MH staff an opportunity to voice their thoughts and concerns and bond together. . The group took inventory by creating a Dump/Keep/Don’t Know list and going through it every morning at coffee hour to work through each thing on the list. Systems and procedures were put on a whiteboard to consider and discuss, and staff provided input on new ideas to add. Inefficient procedures that were not working well were added to the “dump list”. Staff found this therapeutic. o Balancing competing demands. . Need to focus efforts on integration, while also dealing with other concerns. The AOD and MH systems in Lassen already faced challenges before integrating, and beginning the process without a strong foundation and clear structure made work more difficult. . Because many people have changed in and out of key county director positions, the new people coming in often want to initiate new projects. It is still important to balance these opportunities for expansion with creating a strong foundation for success in integration.  Suggestions o Educate staff about integration and get their buy-in. Explain what the process will be like. Hold frequent meetings to get feedback and obtain staff support. Clarify and communicate expectations. It helps to create manuals and discussion points and then have meetings so that staff can understand what is expected of them. Give staff opportunities to be on committees and provide input. Get everyone on the same page. . SAMHSA-HRSA has put out a behavioral health webinar which will be shown to all staff next month- it will give employees a roadmap for where the BH department hopes to be in the future. o Develop knowledge and trust to build teamwork. Staff from different disciplines should take time to educate each other on what their own roles and duties are. For instance, therapists may not necessarily know how to use case managers or AOD counselors, and vice versa. Staff should learn what the other disciplines do and trust them enough to delegate client responsibilities to them. o Eliminate silos and hierarchical thinking. Within teams, it’s important that everyone be valued equally for their expertise. Regardless of education level, different team members each have information and skills to contribute towards clients’ care. o Encourage open communication and feedback. Team members should feel comfortable voicing their concerns to their supervisor or director. Everyone should be treated as a valued partner in providing care to clients. o Acknowledge that change is difficult. Change is often difficult because employees have been trained to work in a particular way for a long time. Breaking the silos requires changing people’s mindsets. It’s easy to fall back into old patterns, and working in a rural area with limited resources can make the process of change more difficult. Be patient and sensitive to staff concerns, and break up activities or projects into smaller chunks so they don’t seem as drastic. o Provide training to improve staff competencies. Give extra help to employees. A lot of our staff have not received extra training before, once they got into the system. . We are now creating staff competencies, using NetSmart University and webinars to educate staff, and writing an employee manual to provide guidelines and expectations. It helps to hold staff accountable, but also give them assistance towards reaching those expectations.  Things that Worked o EHR Upgrade Process . As we are working to implement an EHR system, we needed to create standard, common templates for progress reports and treatment plan reports. MH and AOD still have separate assessments because we are unsure how to bill. Need to decide on common forms, common systems, and which staff had access to and responsibility for which records. Combining two ways of doing things: assessments, forms, progress notes, treatment plans. . The way we dealt with that was by having lots of meetings. It takes longer, but provides an important opportunity for staff to take part in the process and provide input. Line staff have valuable experience and knowledge to share because they are the ones who are out in the field every day, running groups, etc. o Staff Trainings . The NetSmart courses, webinars, and meetings to discuss what staff have learned have all been effective so far.  Conclusion o So that’s where we’re what. Even though our integration process seems painfully slow, we have to give ourselves credit for getting as far as we have since July considering some of the complications that we inherited. Kudos to the staff who have endured a lot of change and uncertainty.

Michael Horn Imperial County Behavioral Health

Summary  Imperial County o Rural county located in Southern California. Borders with San Diego County, Riverside County, Arizona and Mexico. o County population of about 180 thousand residents. Has 500 thousand irrigated acres of farmland. Because of its dependence on agriculture, Imperial County resembles the Central Valley more than it does other Southern California counties. o Population is about 80% Hispanic/Latino, 18% Anglo, 2% other. About a quarter of the county doesn’t speak English. o Imperial County is one of the counties with the lowest per-capita income in the US, and typically competes with some of the Central Valley counties for the lowest income in the state of CA. o The average age skews young. A high percentage of the population is under 20 years old.  Behavioral Health System o The BH department used to be divided between MH (with separate systems for adults and children), and AOD services. o In the process of integrating services within the department, it has been divided into 3 systems focused on serving different age groups. The treatment options tend to be geared towards different age groups so it made sense to change the system to reflect effective practices. . Children (0-14)  The children’s system concentrates on services to schools and the foster care system.  We put a lot of time and effort into trauma-focused CBT, multidimensional treatment for foster care, developing a model for ADHD processes, and nurturing parenting. We’re close to department of social services and elementary schools.  Services are also geared towards parenting issues, managing parents, and helping parents manage children. When dealing with children, parents are kind of like the case managers (although BH does have a case management component). . Youth and young adults (14-25)  The system for youth and young adults are different, because patterns are different. Teenagers tend to be more reliant on their peers than their parents, so there are shifts in issue focus from parents to peers.  SUD becomes a bigger issue in the teenage years. We see different manifestations of MH issues: eating disorders, SUD, self-harm, anxiety disorders, conduct disorders, etc.  In young adults, we have implemented functional family therapy, trauma- focused CBT, SMART recovery, nurturing parenting again, and cognitive- processing therapy for young adults with PTSD, depression treatment quality improvement. For youth and young adults, we’re close to probation, high schools, and community colleges. . Adults and older adults (25 and older)  The adult system is organized around the idea of having recovery centers at different clinics. We implement EBPs for, and train staff to deal with, specific disorders (for example, anxiety disorders, schizophrenia, bipolar disorder, etc.).  Currently the county has one adult recovery center, with a second one starting up soon in the north end of the county. Just one clinic for youth and young adults but eventually that number will be 3.  The recovery center provides programs in medication education, family education, SMART recovery (for SUD, AOD, and smoking cessation), physical fitness, CBT, occupational services and academic services. The centers are designed to help people learn the skills to manage their illness. Once they gain skills managing their illness and physical health, they also get help learning a trade or going to college. o Location expansion. The county currently has 14 locations for the BH department, plus 8 schools where we provide MH/SUD treatment for kids on campus. By this summer we should have 3-4 more locations. There are already anxiety and depression clinics in several locations, and soon there will be 2 recovery centers and 3 youth/young adult centers. o Team-based care. All of our systems are organized around teams. In each team, there are case managers, psychotherapists, psychiatrists, and nurses all working together.  SUD and MH Integration o SUD is now being co-located into the MH clinics and offered to adolescents and adults. Everyone is assessed for both SUD and MH and then referred as appropriate. Separate SMART recovery programs for individuals with SUD and for individuals with COD.  Integration with Primary Care o Imperial has one FQHC with co-located BH staff. BH staff have been there for a couple of years. They do intakes and are eventually going to be at all the different locations: 3 main clinics and 5 satellite clinics. Hopefully, this will lead to better healthcare for MH clients, and help physical health clients get access to MH healthcare.  Conclusion o In a nutshell, Imperial BH is organized around 3 main parts of the population: children, young adults, and adults. For each group, Imperial has implemented EBPs for their unique issues.

Anne Lagorio Trinity County Behavioral Health

Summary  Trinity County o Trinity County is located in Northwest California, and is bordered by Humboldt, Shasta, Siskiyou, Mendocino and Tehama. The county size is about 3,000 square miles and the population consists of about 13 thousand residents. o Majority White non-Hispanic (83%). Larger percentage of Native Americans than average in California (5.2% vs. 1.7%). o Aside from small population and low population density, another issue in Trinity County is the high levels of poverty. Estimated 17% live below the poverty line, but more like 20-25%. The rural poor are the main group that BH works to serve and be sensitive to.  Behavioral Health System o Small Department Size . Trinity BH Department is housed in one building, and serves clients with both MH and AOD concerns. . Patient population is small: estimated 57 AOD clients, 209 MH clients, and 5 COD clients. . Very small staff: about 35 employees total, including administrative, clinic staff, and counselors for AOD and MH. MH has 12 clinicians; AOD has 3 counselors, 1 CPS liaison who does assessments, and 2 interns. 1 AOD director and 1 MH director. . One main clinic exists in Weaverville (county seat, with population of about 5 thousand) and one satellite clinic in Hayfork (population of 1,800). o AOD and MH Integration . Separate assessments and treatment plans for MH and AOD, although the diagnosis form is shared. Clients can be screened and referred from one end to the other. Releasing information is a challenge, so all COD and AOD clients sign a release to use their information in the shared EHR.  Trinity BH has been using an EHR provided by Kingsview for about 4 years and are comfortable with it. . Easier to give referrals to AOD clients who need MH services- simply make an appointment. . MH clients with AOD issues are often put in the dual diagnosis group at first if the issues are not as severe. The group focuses more on harm reduction and assess if referral to AOD is appropriate. AOD program itself is abstinence based. . Separate team meetings for each program, but MH and AOD also meet jointly each week to discuss clients of concern and dealing with crises, which brings the teams together. MH and AOD have joint advisory boards, as well. o Plans for Integration . Trying to become more client-centered. Have MH drop-in centers in both Weaverville and Hayfork that are open to people with both MH and SUD issues. AOD and MH are working together with their MHSA program. Easier because there are so few players and they see each other all the time. . Both the AOD director (Anne) and the MH director are involved at the state level to prepare for integration. The MH director is a member of the CMHDA executive board, and Anne is a member of the CADPAAC executive committee. Trying to be involved at the state level to stay informed about what’s to come so they can prepare and respond appropriately. . MH director is on the Health Care Reform joint committee. Both AOD and MH are trying to build collaboration within the county, between all departments, to move forward in a realigned world with limited resources. Want to do the best we can for all our often-mutual clients.  Integration with Primary Care o Specifically with primary care, Trinity has participated in the Small County Care Integration (SCCI) learning collaborative through CiMH. It has implemented an Integration Step with the PCPs and clinics by ensuring that MH clients have ROIs, and by communicating with PCPs about what medications their shared clients are on. Trinity is planning to do the same for AOD clients in the future. o Under the SCCI project, Trinity BH has also done a smoking cessation program that is going well. BH is working on building relationships with the hospitals and hospital staff. The district hospital administrator resigned recently, so we are hoping that the next one will be supportive of integration. o Trinity BH is looking to build relationships with PC physicians, clinics, district hospitals, and other agency departments: HHS, probation, and child protective services.  Conclusion o We’re taking a very holistic approach, trying to improve relationships and integrate with not only with primary care but everybody in the county to work together and serve our clients.

Discussion:  Darren (UCLA): What funding strategies do you use in your rural counties? Do you mainly rely on federal block grant funds, or are you able to use Drug Medi-Cal or CMSP? How do you see things changing in 2014? o Anne (Trinity): . For the MH department, Medi-Cal is the main source of funding. The county generally only serves MH clients with Medi-Cal, with exceptions for crises. . The AOD department is run primarily through the SAPT block grant, a SAMHSA grant, some other grants, and a little bit of fee collection. Clients have a small copay of $25 a month, but the county treats clients regardless of ability to pay. . Trinity has recently joined CMSP and is running its first established AOD clients through the program. . The county is also in the process of applying for Drug Medi-Cal for a little extra funding for AOD, mostly in anticipation of moving forward to ACA and whatever form that’s going to take. They want to be prepared. o Barbara (Lassen): . Lassen County serves all clients regardless of insurance or ability to pay. For funding, the county bills private insurance, CMSP, Medi-Cal, Medicare, the block grant, and UMDAP for both AOD and MH services. . Lassen also receives some MHSA funds to use on services. o Michael (Imperial): . Imperial has about 60 thousand eligibles for Medi-Cal, which will increase under the ACA, but the department serves all clients regardless of insurance. . Does UMDAP but doesn’t collect much money because most clients are indigent or not eligible for Medi-Cal. . Currently the county has about 4 thousand active MH patients, with that number increasing due to an effective anti-stigma campaign and the addition of new locations. Many of those clients have Medi-Cal, but the county uses other funds to see people who don’t have Medi-Cal.

Closing Remarks – Brandy Oeser, UCLA ISAP . The next ILC meeting is scheduled to be held on March 27, 2013 at the next CADPAAC Quarterly Meeting in Sacramento. . Please remember to reference the website which holds all information and materials disseminated from the ILC: http://www.uclaisap.org/Affordable-Care- Act/html/learning-collaborative/index.html. APPENDIX 1 – ATTENDEES

COUNTY PARTICIPANTS

SMALL  Trinity (Anne Lagorio)  Plumas (Mimi Hall)  Lassen (Barbara Pierson, Anita Harsh)  Lake (Jim Isherwood)  Imperial (Michael Horn)  Calaveras (David Sackman)

MEDIUM  San Bernardino (Dianne Sceranka)

LARGE  Los Angeles (Shauna L)  Riverside (Karen Kane)

ADP PARTICIPANTS  Jonathan Graham  Craig Chaffee  Mary Dodson  Felicia Tram

UCLA PARTICIPANTS  Darren Urada  Valerie Pearce Antonini  Brandy Oeser  Cheryl Teruya  Elise Tran

OTHER PARTICIPANTS  Steve Maulhardt (CAADPE) APPENDIX 2 – AGENDA AND RELEVANT MATERIALS

 Overview of Meeting 19  Presentations – Topic: Integration Activities in Rural Counties 1. Barbara Pierson (Lassen County Behavioral Health) 2. Anne Lagorio (Trinity County Behavioral Health) 3. Michael Horn (Imperial County Behavioral Health)  Discussion

MATERIALS FOR THIS MEETING 1. PPT Presentation – Lassen County Behavioral Health

Copies of materials can be found at UCLA ISAP’s ACA Resources Website: http://www.uclaisap.org/Affordable-Care-Act/html/learning-collaborative/index.html.