Improving Behavioral Health and Primary Care Integration

This article describes the Targeted Investments (TI) Program, the Arizona Health Care Cost Containment System’s (AHCCCS) strategy for incentivizing providers to develop systems for integrating physical and behavioral health. The TI Program is a five-year project that provides financial incentives totaling $285 million to eligible AHCCCS providers with the aim to reduce fragmentation between acute care, primary care, and behavioral health care; increase efficiencies in service delivery for members with behavioral health needs; and improve health outcomes for AHCCCS members. The TI Program includes approximately 150 health care organizations and consists of six areas of concentration (Adult Primary Care Providers, Adult Behavioral Health Providers, Pediatric Primary Care Providers, Pediatric Behavioral Health Providers, Criminal Justice focused clinics, and Hospitals). For each of these areas of concentration, AHCCCS has established milestone targets that support improved care coordination and clinical outcomes through use of standardized performance measures.

Historically, care coordination between primary care providers and behavioral health providers for persons with behavioral health disorders has been extremely challenging. This is due to many factors including separate payer sources, distinct clinical structures, and unaligned provider communities. The consequence is that important patient care guidelines are poorly met.  Nationally, 73% of children three to six years of age with Medicaid coverage received a well-child visit with a primary care provider in the last 12 months; metabolic monitoring for children on antipsychotic medication is 35%; diabetic screening for adults with severe mental illness on antipsychotic medications is 80%; and the ambulatory follow-up for hospitalized adults discharged for severe mental illness within 30 days is 58%. Similar to national performance, adults and children in Arizona covered under the AHCCCS program have gaps in care when compared to clinical standards.

Quality Improvement Methods that Improve Outcomes

The TI Program is currently in its fifth year. Since 2019, AHCCCS has partnered with a team from Arizona State University (ASU) led by Dr. William Riley and Dr. George Runger, from the College of Health Solutions, to develop a Quality Improvement Collaborative (QIC) for assisting the TI participating providers to meet their performance measure target.

Quality Improvement (QI) methods have been widely used in the health care delivery system over the last 20 years to successfully improve outcomes and increase value. A QIC is a common approach in health systems to improve performance and involves interdisciplinary teams sharing best practices, peer learning, and routine performance updates. Successful QICs take an active collaborative mindset, strive for improvement rather than perfection, and do not consider themselves in competition with other participating organizations. Typically, a QIC focuses on a process or outcome measure that is achieved based on the standardized delivery of evidenced based care. A QIC is facilitated by experts knowledgeable about the clinical content as well as QI methods and techniques.

The TI Program QIC consists of interdisciplinary participants from all organizations participating in the TI Program. A minimum of two designated champions from each organization, a clinical representative and an administrative representative, participate in the TI Program QIC. Participants in this QIC are eligible to receive up to 28 Continuing Medical Education/Continuing Education Units.

TI participants in the QIC use QI techniques to improve performance and gain competency with a variety of QI methods such as root cause analysis, process engineering, cause and effect diagrams, and statistical process control to better understand process problems and make progressive metric improvements. Additionally, by engaging with their peers, providers are able to identify and mitigate barriers to achieving milestone targets. TIP providers participating in the QIC are provided with timely and actionable performance metric information calculated by ASU. Each provider has access to a web-based dashboard that displays their performance on TI program measures, allowing providers to review their performance measures in a consistent, organized manner and review historical trends.