Project Name: Primary Care & Behavioral Health State Learning & Action Collaborative
The Delivery System Reform Incentive Payment (DSRIP) program is the main mechanism by which New York State sought to implement the Medicaid Redesign Team (MRT) Waiver Amendment. The intention of DSRIP was to reinvest in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over 5 years and achieving defined results in system transformation, clinical management, and population health. In its fifth and final year, the DSRIP program increasingly focused on rewarding collaboration between providers and on transitioning providers to Value Based Payment (VBP) arrangements. Supported by funds from The Delta Center for a Thriving Safety Net and RCHN Community Health Foundation, CHCANYS and the NYS Council for Community Behavioral Health (NYS Council) collaborated to identify policy synergies among community health centers (CHCs) and behavioral health organizations, and worked together to develop member capacity in the transition to VBP and integrated care. During the initial project period, CHCANYS identified policy and regulatory barriers to care integration and facilitated member dialogue regarding value-based payment contracting incorporating both behavioral health and primary care.
The project coincided with the global public health emergency brought on by the rapid proliferation of COVID-19. In response to the COVID-19 pandemic, many community health centers shifted virtually overnight to conducting patient visits via telehealth. Federal and State flexibilities granted during the COVID-19 public health emergency, including reimbursement for in-person and video visits, drove care delivery in new directions. Seeking to build on the rapid expansion of remote care delivery and ensure ongoing support for and successful implementation of telehealth beyond the pandemic, the second stage of the project focused on evaluating the provider and patient experience with telehealth during the pandemic, and understanding how these might affect post-COVID care.
CHCANYS goal in year one was to position health centers throughout New York State to build strong cross-sector partnerships and succeed in a VBP environment.
Year-one project objectives were to:
- Promote collaboration across and between CHCs, and between CHCs and behavioral health care providers;
- Support the ability of the state’s health centers to provide high quality care;
- Build thriving partnerships across the primary care and behavioral health sectors;
- Advance policy changes that incentivize collaboration and service integration;
- Develop model for data sharing; and
- Foster practices of a learning organization.
Year One Project Activities:
- Established a multidisciplinary advisory committee comprised of behavioral health providers and FQHCs to inform the project effort and advance the policy integration goals;
- Documented and assessed the range of existing VBP arrangements;
- Convened two rounds of in-person regional meetings of CHCs and behavioral health providers;
- Convened CHCANYS members, NYSC members, policymakers, payers and industry thought leaders for a half-day meeting focused on VBP implementation and models for integrating care;
- Based on best practices shared at Delta Center convenings, developed new, common resources for behavioral health and CHC providers; and
- Offered webinars, fact sheets and toolkits to enhance learning.
Year One Project Outcomes:
- In partnership with the NYS Council for Community Behavioral Healthcare, promoted collaboration and group learning among health centers and behavioral health organizations by convening: three regional collaborative meetings throughout NYS in Manhattan, Rochester, and Albany; a meeting between Behavioral Health Care Collaboratives (BHCCs) and health center-led independent practice associations (IPAs); and an Integrated Care Summit with attendees from behavioral health organizations, health centers, health center IPAs, and BHCCs;
- Established a learning collaborative to highlight best practices regarding clinical integration models, data sharing tools, and governance;
- CHCANYS and the Council provided coordinated responses to State’s DSRIP 2.0 waiver amendment request, recommending that the State dedicate at least 25% of DSRIP funds to community-based Value-Driving Entities where health centers and/or behavioral health organizations are the lead entity;
- Submitted comments on the Federal Government’s proposed changes to 42 C.F.R. Part 2, Confidentiality of Substance Use Disorder Patient Records. Comments submitted by CHCANYS and many other key stakeholders led to important changes to the rule to better facilitate care integration among federally-assisted programs and promote whole-person health care; and
- In response to a need identified by the advisory committee, CHCANYS presented an FQHC 101 webinar to help behavioral health partners better understand the landscape in which CHCs work.
Telehealth Utilization and Opportunities
In June 2020, CHCANYS, in conjunction with the NYS Council, jointly developed a white paper, Ensuring Sustained Access to Telehealth in the Post-Pandemic Period that recommended ways in which New York State could improve and expand access to remote care delivery. In follow-up to that paper, during the second phase of the project CHCANYS conducted a qualitative study designed to demonstrate the benefits of telehealth for patients and providers to ensure ongoing telehealth investment beyond the end of the COVID-19 emergency. The audience for this study included the state Medicaid office and Medicaid managed care plans, as well as community health center organizations in other states.
Working with investigators at the NYU Grossman School of Medicine (NYUGSoM), Department of Population Health, CHCANYS conducted interviews with 25 providers and 19 patients at eight health centers across NYS. These interviews sought to understand:
- How providers view telehealth;
- How telehealth should be used post-pandemic, and how to best accommodate in clinical workflows;
- How patients perceive telehealth, and whether patients are interested or eager to continue receiving remote care as well as the modalities they prefer for particular services;
- Factors that might hinder telehealth utilization; and
- How telehealth might address, mitigate, or exacerbate existing disparities.
Issues related to access, quality, payment, and equity, which are of great importance to policy makers and managed care organizations, were incorporated in the interview protocols. The findings from these interviews were analyzed and served as the foundation for a policy brief that builds on the principles recommended by CHCANYS in the earlier white paper and outlines key interview findings, while identifying those approaches and actions essential to supporting and sustaining telehealth post-pandemic.
Utilize telehealth to increase access and promote health equity. Access to remote care was effective for both patients and providers, increasing provider ability to deliver care and decreasing patient barriers, like lack of transportation, childcare, or time off from work. Remote care resulted in widespread reductions in appointment no-show rates and, in some cases, increases in the number of patients seen per day.
Maximize regulatory flexibilities to sustain telehealth adoption. This includes removing restrictions that limit the type of provider who may provide remote services and allowing those providers authorized to bill for in-person care to also render remote services, especially for the Medicare/ Medicaid dual eligible populations.
Clinicians, in collaboration with clients, determine when a telehealth visit is appropriate. Primary care, pediatrics, and behavioral health patients and providers agreed that remote care used in coordination with in-person visits, was an effective way to discuss lab results, conduct medication management, and offer follow up care. In behavioral health visits especially, remote visits were viewed as comparable to in-person visits. Patients and providers should be empowered to determine the best care modality.
Reimburse remote care (audio-visual and telephonic) on par with in-person visits. Providers agreed that in-person visits, audio-visual telehealth, and telephonic visits should be paid at the same rate. Telephonic visits generally take the same amount of time as audio-visual visits, and sometimes a telephone visit was necessary due to technical limitations that may have prevented a patient from joining an audio-visual call. This is especially important for the high-risk and high-need communities served by community health centers. where reimbursement parity is essential to ensuring ongoing services.
Overall, the study found that nearly all providers and patients want to continue to have the option to receive or deliver care remotely. For remote care options to remain viable, it is necessary that telephonic and audio-visual telehealth visits be reimbursed on par with in-person visits. Patients and providers alike need training, education, and IT support to bolster remote visit capacity and increase technical literacy. Finally, the study revealed an urgent need for the state to take actions to improve access to broadband internet, free wi-fi, and other technology to ensure that telehealth mitigates health inequities rather than exacerbates them.
The full report, Ensuring Sustained Access to Telehealth Post Pandemic: Patient and Provider Attitudes and Beliefs Support Use of Remote Care, is available here: https://www.chcanys.org/document/ensuring-sustained-access-telehealth-post-pandemic0pdf.
Project Partners: New York State Council for Community Behavioral Healthcare (NYS Council), a statewide nonprofit membership association representing the interests of nearly 100 behavioral health (mental health and substance abuse) prevention, treatment and recovery organizations across New York, and the NYU Grossman School of Medicine (NYUGSoM), Department of Population Health.
About the Grantee
The Community Health Care Association of New York State (CHCANYS) was established to give a voice to the state’s network of community health centers as leading providers of primary care. The oldest Primary Care Association in the country, CHCANYS today represents more than 70 community health centers that operate over 800 sites in every region of New York State. CHCANYS mission is to champion community-centered primary care in New York State through leadership, advocacy, and support of community health centers.