Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. I. Successes and Challenges


Successes. A Blueprint staff member we spoke with for this study highlighted several major successes or advantages to Blueprint's approach:

  • The CHT concept has been a major success of Blueprint. The CHTs have increased the ability of PCPs to work with the broader community of local health, housing, and human services. The network of CHTs and local partners can be used as a vehicle to implement state or locally based initiatives that align with Blueprint's goals. As one state Blueprint staff member described it, CHTs have been "magnets for [instituting] practical, workable supports and services."

  • The comprehensiveness and flexibility of the Blueprint framework are key advantages. Blueprint developers were careful not to dictate how the program should operate locally in order to give community service providers the flexibility to adapt the framework to their local needs and resources. This approach also helps communities take ownership of their programs and prevents situations in which state-level decision-makers fail to foresee circumstances on the ground.

  • Multipayer involvement is a "great strength" of Vermont's approach. While recognizing multipayer participation is not necessary for a successful case management model, state staff noted that multipayer involvement (in conjunction with care standards set by the state) enables PCPs to offer the same services to all patients, regardless of their coverage.

  • Promising preliminary results suggest health care expenditures and ED visits decreased for patients in pilot Blueprint sites relative to similar patients in a matched comparison group, or increased at slower rates. For instance, annual per capita expenditures for Medicaid patients in the earliest pilot sites were $623 more than the comparison group in 2007 (at baseline) and $197 less than the comparison group in 2011 after three years of operation (statistical significance is not reported; DVHA 2013b). An earlier report released by Onpoint Health based on data from 2008 through 2010 also suggests favorable trends in expenditures and utilization (Finison 2012).

Challenges. The same Blueprint staff member who noted the program's successes also described two main implementation challenges, both related to the HIT infrastructure:

  • Implementing the data systems has been, by far, the biggest challenge to fulfilling the vision of Blueprint. "The whole vision around having the providers document information during their normal course of care through [EHR systems], which connect through interfaces and populate a registry, is far more complex than ever imagined in the beginning." The challenges have largely resulted from a lack of data standards across disparate systems. Vermont practices use EHR systems supplied by more than 30 different vendors, and standardization in how information is recorded in EHRs, and transmitted and received by other data systems, is lacking. A second challenge with EHRs is that they typically require practitioners to enter information into open-ended text fields, which cannot easily or readily be used in analysis. Both challenges should become less of a concern as more standards for EHRs are set at the federal level.

  • Creating an integrated community record for any staff member who views, uses, or adds to a case has presented issues. While maintaining patient privacy was not cited as a key challenge, managing the consent and authorizations for multiple users affiliated with different service systems was reported to be challenging.

Advice to other states. A Blueprint staff member advises other states to think not only about health care financing reforms, but also about the practice reforms needed on the ground to support a holistic reform strategy. For instance, states should consider what quality-improvement and measurement mechanisms and supports providers would need in order to access the information necessary to monitor and improve their care.

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