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Behavioral Health Collaborative Recommendations

Last week during the Senate Committee on Human Services Oregon Health Authority Director Lynne Saxton, with OHA Behavioral Health Director, Royce Bowlin, and Dr. Ben Miller, University of Colorado Eugene Farley Health Policy Center testified on SB51 which would create a Behavioral Health Task Force. They also all spoke of the work and recommendations of the Behavioral Health Collaborative (BHC). This work was anticipated by Sen. Sara Gelser (D-Corvallis) as it was a follow up from the Behavioral Health Town Halls that took place autumn 2015.

The BHC's almost 50 participants, representing a diversity of stakeholders, met several times over 7 months totaling 36 hours of in person meetings, in addition to offline work. The BHC had an ambitious agenda which was to transform the behavioral health system in Oregon, which is to be applauded. There are several positive takeaways from the report, as well as multiple areas which need additional clarification or exploration which will be addressed here.

The BHC recommendations are comprehensive, however, the report would be greatly enhanced with supporting documentation such as a glossary of terms, citation of sources, and timeline of completion goals. Terms that need more clarity since they could have multiple meanings depending on the setting include: “promising practices,” “preventative services,” and “trauma informed.” Since these recommendations are meant to be utilized by multiple different organizations such as payers, providers, educators, judicial staff, and others having clear definitions will ensure that everyone is using these terms in the same manner.

Statements that would be helped with reference documentation include: wage disparities in behavioral health services, peer support services effectiveness, youth suicide statistics, and a framework of current behavioral health services. These statements are made as matter of fact and without citation so the reader cannot read the original reference if they choose. We do not doubt that wage disparities exist between caregivers in behavioral health or that peer services are effective, however, without an evidence-based reference attached we are expected to take the BHC word for it which may have pro-innovation bias.

A projected timeline would be helpful to inform and encourage accountability from the stakeholders. The timeline should include expected time for creation of the geographic service areas, development of the plan and metrics, and measurement of outcomes. With the ambitious recommendations, this will not happen quickly, nor should it, but without a timeline accountability can wane.

The Director’s Message provides an overview of the process and recommendations with insight into the complexities of managing the healthcare needs with the Native American population. Ms. Saxton also emphasizes the increasing role of peer delivered services with the statement “OHA has invested in peer delivered services over the past biennium with 236%.”

The executive summary provides a high level summary of the recommendations, followed by the problem statement, and history of the BHC. This work is the result of a recognition that our healthcare system is fragmented and navigating the best path to healthcare can be challenging. The executive summary also states that the "fragmentation in the health care system has created artificial silos between physical, oral, and behavioral health care, making it harder for individuals to get their needs met." But, are these silos "artificial?" The reality is that these silos are a natural creation of downstream effects from multiple policies and regulations put into place over time. Regardless, the silos of care should be addressed and minimized as much as possible with the goal of improved patient experience, outcomes, and lower costs.

The recommendations are:
• Governance and Finance-allows for creation of regional governance model with funding structure
• Standards of Care and Competencies-creation of a standard of care competencies for behavioral health workers
• Workforce-needs assessment of the current workforce and plan on how to build the workforce
• Information Exchange and Coordination of Care-strengthen use of health information technology and data for measurement of metrics

The Governance and Finance recommendation is focused on the single point of shared accountability within each geographic area (it is not clear how many different geographic areas there will be. When OHA was asked they were also unclear as to the ideal number, and how they will be created). This service area is self-defined by principle payers (CCOs), providers, and partners within a locality. The service area must include CCOs, local public health, community mental health partners, hospital and health systems, schools, corrections, courts, primary care, behavioral health and oral health. (oral health representation was not included in the collaborative) The rationale for inclusion of justice and community safety is that they will reduce inappropriate use of jails, with no explanation as to how, and school representation is included to improve retention and graduation also with no explanation.

The financing of the system will be dependent on CCOs and other organizations contributing resources to a shared risk model with the hope that other payers will contribute funding to better coordinate services. Since these service areas are designed to be independent, there is the potential for a region with a smaller population and limited resources to have different behavioral health services for their communities than a region with more resources. The new Behavioral Health Mapping Tool, which is scheduled to be released soon may address some of the potential inequity between regions.

The standards of care and workforce recommendations are forward thinking with operational considerations to improve the competencies for behavioral health providers and address workforce needs. The BHC address the entire spectrum of needs that a patient may have with inclusion of peer delivered services, telemedicine, active recruitment, staff retention, and career advancement. These recommendations are potentially the easiest to achieve and may have the greatest impact on how behavioral health services are delivered in Oregon with recommendations on standardizing provider core competencies and promotion of the adoption of minimum standards of care for the variety of entry points that a individual or family may present with behavioral health needs.

The information exchange and coordination of care recommendations focus on metrics and provide a recommendation that the newly formed Health Plan Quality Metrics Committee establish a behavioral health metrics to identify a set of measures for the service areas to utilize. Addressing the rising youth suicide rate the BHC recommends that OHA address this by launching an initiative to use social media tools to help connect youth to behavioral health services, and appoint a Youth and Technology Council on Behavioral Health to provide information and input in using technology. The BHC thus far have required evidence based tools for implementation of services. There is no best practice listed that would endorse the use of a social media campaign to connect youth to behavioral health services. And if there was a Youth Behavioral Health Council, shouldn’t that be used to provide suggestions to reduce the suicide rate among their peers and other ideas for improving behavioral health access and outcomes? It seems short sighted to merely ask them to provide innovation and input for technology.

Time will tell how successful Oregon will be in the implementation of this “21st Century System of Care.” There are multiple challenges with funding, resource allocation, creation of the geographic service areas, and standards of care that it may be several years before any progress can be measured and determined successful or not.

Posted on March 20, 2017.