PROVIDENCE – When the contract was recently signed to create the first accountable entity in Rhode Island as a partnership between the state Medicaid office, UnitedHealthcare, and Care New England, one of the featured programs of that new partnership was not explicitly discussed in the news release: what is known as a Type Two accountable entity to create a system of coordinated care for adults diagnosed with serious mentally illness and serious and persistent mental illness.

The accountable entity initiative is one of several now underway in Rhode Island to develop a better coordinated, integrated approach to behavioral health and mental health within a team-based approach – both to better serve the needs of the patients and meet the increasing demand for services as well as to reduce the medical cost burden on the overall health care delivery system.

ConvergenceRI recently sat down to talk with Garry Bliss, the program director for the Medicaid Accountable Entity that is part of the Integra Community Care Network, the hospital-wide accountable care organization at Care New England, to get a better understanding of the approach being taken with the Type Two accountable entity.

As Bliss explained it, the new accountable entity partnership covers, in total, some 20,000 patients that are currently enrolled in Medicaid. Some 16,000 will be part of what is known as a Type One accountable entity, based upon their current primary care provider and his or her affiliation with Care New England, or a Care New England Medical Group, or South County Health.

Another 4,000 patients who are currently enrolled in Medicaid will receive care coordinated through the Type Two accountable entity.

These are adult patients, Bliss explained, who meet the state’s definition of having been diagnosed as having “serious mental illness” or “serious and persistent mental illness.” It includes the results of a functional assessment that analyzed the impact of that diagnosis upon the ability to function.

“These patients may be assigned to the Type Two accountable entity based upon the diagnosis, not based upon the primary care provider,” Bliss told ConvergenceRI. Currently and historically, Bliss continued, these patients received treatment through The Providence Center.

“The recognition is that this is a population with an overriding medical condition that really defines their well being,” Bliss said. “What defines their ability – and inability – to consume care efficiently is their mental health diagnosis. And, if you’re going to address this person’s needs holistically, in terms of integrated health care, the care provider who should be at the front, in the lead for these folks, is the behavioral health care provider.”

Here, then, is the ConvergenceRI interview with Garry Bliss.

ConvergenceRI: Can you explain to me what is happening with Integra at Care New England and the new accountable entity with the state’s Medicaid Office?
BLISS: The Integra accountable entity will be serving Mediaid patients. We have signed our contract with UnitedHealthcare, with about 16,000 [covered lives] in primary care and another 4,000 or so in what’s called the Type Two accountable entity.

Type Two is for folks with SMI or SPMI – the seriously mentally ill or the seriously and persistently mentally ill population.

[Under the Type One accountable entity], folks become part of the Integra accountable entity based upon their primary care provider.

So, if their primary care provider is Care New England or a CNE medical group. the R.I. Primary Care Physicians Corporation or South County Health and they are enrolled in Medicaid, they will be assigned to the Integra Accountable Entity.

For those folks who meet the state’s definition of SMI and SPMI, in terms of diagnoses and also as the result of a functional assessment, you might be assigned to the Type Two accountable entity.

Currently and historically, [these patients have] received treatment through the Providence Center.

ConvergenceRI: Will the behavioral health care provider be a member of a team?
BLISS: Care will be delivered by a team. And, in response to a question that is often raised: what about primary care for that person?

Those who are [part of] the Type Two accountable entity will be seeing primary care providers who are, and who are not, Integra primary care providers.

The patients will continue to see that primary care provider who they have [been seeing]; they will get connected to a PCP if they haven’t one. For these folks, the coordination will be the responsibility of the Providence Center.

ConvergenceRI: In the publicity that went out about the first accountable entity to sign a contract with the state’s Medicaid office, there was no real discussion of this Type Two accountable care entity. Why was that?
BLISS: I think that there were still some issues that hadn’t been completely fine-tuned.

I think, as well, understandably, there was a desire to speak to the overwhelming majority of the population [being served], 16,000 vs. 4,000 lives.

We are having our kickoff meeting this week with UnitedHealthcare to work out some of the details about how we are going to [build] our partnership.

This care is now being provided, and individuals are being referred to the team for care.

These referrals can happen a number of different ways. It could be a primary care practice has a patient that they have been seeing, and they suspect that there is a very high level of behavioral health need with that patient. Or, a patient could be in an outpatient program at Butler Hospital. Or, they could have an episode that results in their being seen or admitted at Butler Hospital.

Then they would get an assessment by the team, and is and when the criteria are met, that person would then [have care delivered by] the team.

In a sense, that person would have gone from being [served by] a Type One accountable entity to becoming served as a member of a Type Two accountable entity.

ConvergenceRI: What has been the focus of your work?
BLISS: My personal on focus has been on getting the systems set up to work as efficiently as possible.

What we’re finding is that there are folks who have, for an array of reasons, not being getting the level of behavioral health care services that they need.

When they are connected to the experts, those experts are able to see the real depth and scope of what their conditions are and what their needs are

I liken it to: I have a little patch here of dry skin, I look at it and I see dry skin.

If I were a dermatologist, I might say: that is eczema, and a simple moisturizer is not going to do the trick.

Not to trivialize these conditions at all, but it shows that when you connect with the right experts, then you can step in with a full team to help people..

ConvergenceRI: How collaborative is this effort? How is the new accountable entity benefiting from previous efforts?
BLISS: I think you raise an interesting point. In the HealthPath Continuum model [a pilot program developed by Care New England, The Providence Center and Blue Cross & Blue Shield of Rhode Isdland], the approach was based on lessons that we learned from the Medicaid health home model.

And, that program has leaned a great deal about how to engage with families, how to engage effectively across different care settings, how to make sure that when someone is in the community and then goes in for more intensive care, the communication is maintained, and how those relationships are built up between those providing care in one setting and those providing care in another setting.

I think there is this kind of dynamic feedback flow that informs and helps each effort to get stronger.

ConvergenceRI: How seamless is the flow of information back and forth with UnitedHealthcare?
BLISS: We have a robust information sharing policy. It is in our best interest and their best interest that we communicate, and we communicate quickly.

We are in the early stages of this partnership; it was just a few weeks ago that we signed the contract. But our staff is getting trained on tools that UnitedHealthcare has that we can now access.

We are sharing with them what information we get at different times when we engage with the patient, when we say: you are eligible for complex care management, this is what it means, and this is how we think it would benefit you.

ConvergenceRI: Is there also an effort to coordinate the flow of information around electronic health records?
BLISS: There are others who can speak in more precise detail about how this works. But the big picture is yes, there are ways for the complex care management to be inputting information with what they are doing with a patient so that it can also be seen by the patient’s original primary care provider.

It is in our interest to make sure that we know that all the providers across the spectrum of care know when a patient is being contacted, what we’re learning from that contact, what we’re recommending, and what progress we’re making.

ConvergenceRI: Waiting time and waiting lists to access services has been identified as a barrier for behavioral health and mental health care. How are you addressing that?
BLISS: We are working very hard to figure out how we can streamline and speed up services with the ability to get services for people who are identified for needing them.

ConvergenceRI: Is there a built-in research component to this work as the program launches?
BLISS: We have various measures that we will have to report on to various entities, including the state and the insurance company. We recently met with Dr. Ira Wilson at the Brown School of Public Health about a role in conducting an evaluation.

ConvergenceRI: How does this work connect with other health issues, such as substance abuse and addiction?
BLISS: I think that overall, there has been an increased understanding of the interaction of behavioral health and physical health.

I think there has also been – and this could be a byproduct of the Affordable Care Act – a recognition to the degree that SMI and SPMI populations represent super high utilizers. I think there has a growing awareness there.

What specifically drives the fact that Rhode Island has some of the highest rates of mental illness and addiction and illicit substance use, I would have to defer to other experts.

ConvergenceRI: How does this effort fit into the larger questions around population health in Rhode Island? Does there need to be a statewide plan about behavioral and mental health care?
BLISS: As part of the SIM process, there are draft reports being discussed at monthly meetings addressing population health and integrated health. The goal is to really look broadly across the landscape at the many things that are happening in health care in Rhode Island.

ConvergenceRI: Moving forward, given the growing need for services, is there a need to look at the funding issues and investments from a statewide perspective for mental health and behavioral health resources in Rhode Island?
BLISS: I think we should always be looking at our system holistically, and thinking about the big picture, and what are the ways that the system can be reformed to be made more efficient.

Behavioral health care is certainly an area, if we achieve a more seamless continuity of care, from community to intensive outpatient to partial hospitalization to hospitalization, and not see those as separate systems, but one holistic continuum, where people participate at different levels, based upon their need, I think you could have a more rational system, a more efficient system of care.