Montefiore Health System’s collaborative care model integrates medical care with treatment for behavioral health issues that can be handled in a primary care setting. · Patients who are identified with behavioral issues are assigned a care manager at the Montefiore Care Management Organization, who coordinates with the primary care physician and behavioral health team to develop a plan of care. · The care manager provides telephonic case management follow-up with patients after their primary care visits, educating them on their condition and helping them meet their goals as well as relaying recommendations from the behavioral health team to the primary care provider. · When the psychiatrist on the behavioral health team recommends medication, the care manager informs the primary care physician, who prescribes it.

The University of Illinois Hospital in Chicago has reduced healthcare costs by providing permanent housing for frequent ED utilizers with behavioral and medical issues who are homeless. •Patients are identified by ED staff as homeless, having one or more chronic disease, and substance abuse issues. •The Housing First model adapted by the hospital places patients in subsidized housing, then helps them with their problems. •The hospital has partnered with the Chicago Center for Housing and Health, which provides case managers to help participants navigate the healthcare system and teach them basic life skills.

Hospital staff must identify patients with behavioral health issues and physical problems, and include both conditions in the treatment and discharge plans in order to prevent readmissions. •Patients with behavioral issues often have trouble adhering to their treatment plans, which increases the financial risk hospitals are beginning to bear as healthcare shifts to value-based reimbursement. •Hospitals are beginning to integrate treatment for mental and physical issues by placing clinical social workers in the ED to screen patients, contracting with a nearby mental health clinic, and assigning their own behavioral health staff to the ED. •Case managers should refer patients to community resources, preferably with a patient-centered medical home that can provide care for both issues. •Integrated care begins in the ED, but the staff typically has little training on how to recognize and treat behavioral health disorders.

In the Inpatient Prospective Payment System proposed rule, CMS is asking for public input on how to ease the burdens on providers and how make the healthcare system less complex and bureaucratic. · The proposed rule also asks for input on additional measures that hospitals will have to report under the Hospital Inpatient Quality Reporting Program, including measures on safe use of opioids, malnutrition screening and treatment, and screening and interventions around alcohol and tobacco use. · CMS proposes that Medicare spending-per-beneficiary performance account for 50% of hospitals' Efficiency and Cost Reduction scores in the Value-Based Purchasing Program and that each of the four domains -- safety, clinical care, efficiency and cost reduction, and person and community engagement -- comprise 25% of a hospital's overall score. · As directed by the 21st Century Cures Act, CMS proposed to calculate penalties under the Hospital Readmission Reduction Program by comparing hospitals' performance with other hospitals that have a similar population of patients who are dually eligible for Medicare and Medicaid.