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Christine N. Runyan, Ph.D. Behavioral Health Consultant Mid-State Health Center Plymouth, NH trunyan@midstatehealth.org

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Collaborative Care In Action: Implementing Practice Guidelines in an Integrated Clinic Christine N. Runyan, Ph.D. Behavioral Health Consultant Mid-State Health Center – PowerPoint PPT presentation

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Title: Christine N. Runyan, Ph.D. Behavioral Health Consultant Mid-State Health Center Plymouth, NH trunyan@midstatehealth.org


1
Christine N. Runyan, Ph.D. Behavioral Health
Consultant Mid-State Health Center Plymouth,
NH trunyan_at_midstatehealth.org
Collaborative Care In Action Implementing
Practice Guidelines in an Integrated Clinic
2
Audience Check-In
  • Mental Health Provider?
  • Physical Health Provider?
  • Administrator / Financial / or Policy?
  • New to Integration Seeking Data / How To?
  • Been doing integration and want to move it
    further along?
  • Any Skeptics?

3
Why Integrate?
  • Healthcare exists in silos
  • Mental Health
  • Substance Abuse
  • Medical / Primary Care
  • Social Services
  • Integration provides improved coordination of
    care, less stigma, delivers care where patients
    go, and allows specialty mental health care to
    focus on those most in need
  • Increased access

4
Behavioral Health Continuum
Disease and normality are not distinct entities,
they are arbitrary cut-off points along a
continuum (Rose, 1992)
Traditional MH care focuses on cases
Persons
More Healthy Average
Not Healthy
Overall Behavioral Health
5
Choosing a Model of Integration
  • Population-Based sometimes people only need a
    little
  • Coordinated, stepped care for a wide array of
    preventive and chronic conditions (both risk
    conditions and disease conditions) in a system
    designed to support and measure such care
  • Model of Integration and service delivery should
    depend upon the population and goals of the
    clinic
  • Patient Preferences drive service delivery
    whether we like it or not

6
Choosing a Model of Integration
  • What is the Focus?
  • Behaviors healthy eating, physical activity,
    tobacco use, substance use, responsible sexual
    behavior
  • Chronic care conditions diseases (meet criteria)
    E.g., mood disorders, anxiety disorders, SUD,
    hypertension, cholesterol, diabetes, etc.
  • Other clinical conditions sleep, pain, obesity,
    violence
  • Medication / Treatment Plan Adherence
  • Or all of the above Treating PATIENTS, with all
    their co-morbidities
  • Capitalize on Teachable Moments
  • May only have 1 or 2 visits unless a care
    coordinator is involved and using proactive
    tracking and follow-up

7
What Stands In The Way?
  • Payment policies of healthcare
  • Attitudes and Habits
  • Physicians do not devote extra time
  • Average visit 17 minutes depression cases get
    less than 19 minutes on average
  • When mental health problems are raised with PCP
    video tape evidence suggests subject is changed
    in about 1 minute (Tai-Seale et al, 2007)
  • Cases of depression less likely to have return
    visits than other chronic conditions
  • Organization of PCP practices
  • Implementation of quality improvement efforts
    (What is on the Report Card P4P)
  • Lack of applied research

8
What Stands In The Way?
  • Evidence-based integrated care requires team work
  • Work force limitations
  • Need for postgraduate education training
  • Few providers are trained to work effectively in
    teams
  • Changes and flexibility in scopes of practice
  • Changes in scope of work are challenging
  • Measurement-based practice is a big challenge in
    mental health care / What should be measured?
  • Training needs to be an ongoing effort, ideally
    involving
  • Clinical support / supervision
  • Lack of information on how to develop templates

9
Mid-State Health Center
  • FQHC Look-Alike Clinic (Cost-based reimbursement
    but no federal operating funds)
  • Provides sound primary health care to the
    community -- accessible to all regardless of the
    ability to pay.
  • Two sites Plymouth and Bristol, NH
  • Serve 16 rural communities without regard for the
    patients ability to pay
  • Thirty percent of the service area residents have
    incomes below 200 of the poverty level 
  • All Medicare, Medicaid and medically indigent
    patients are welcomed

10
Plymouth, NH
Bristol, NH
11
Mid-State Health Center
  • Medical Director (Internal Medicine 50
    Clinical)
  • Two Other Internal Medicine Physicians
  • Four Family Practice Physicians
  • One Pediatrician
  • Four ARNPs
  • Behavioral Health Director (90 Clinical) and Two
    BH Consultants
  • In-House Pharmacy Assist / Samples
  • Montessori Child Care Center

12
Key Elements of Our Model
  • Using a behavioral health consultation model
  • Accept internal and external referrals
  • Brief, focused assessment and interventions
  • Target functioning and QOL
  • Shared decision-making with patient
  • Rapid feedback to PCP
  • Patient education, self-management strategies and
    skill building techniques
  • Short appointments (30 minutes) Limited number
    of visits
  • Same EMR record keeping
  • Billing 90801, 90804, HB Codes

13
Common BH Services Provided
  • Diagnosis and Problem Definition
  • Depression, Anxiety, ADHD, Life Pain, Substance
  • Recommendations for psychopharmacology
  • Monitoring medication impact (PHQ-9)
  • Refer to Specialty Mental Health all comes
    through the BHC
  • Provide BH Treatment
  • Establishing self-management / behavioral
    activation plans
  • Hypertension, Recent Medical Diagnosis, Type II
    Diabetes, and Smoking Cessation are most common
    non-psych referrals

14
Your Population Defines Your Service
  • ADHD evaluations and management
  • Other Child / Adolescent Referrals
  • Outpatient alcohol detox
  • Substance Abuse
  • Pain Management BH assessment prior to
    prescribing narcotics
  • Evaluations
  • Dementia evaluations
  • Gastric bypass pre-surgical evaluations
  • Hospital Consults

15
BHC Protocol
  • Full PHQ to all new BH Patients (Adult)
  • PHQ-9 to all follow-up depression cases
  • GAD-7 to anxiety patients
  • Pediatric Symptom Checklist to all 17 and under
  • Electronic Record allows chart-based
    recommendations
  • Internal E-mail for collaboration
  • Electronic communications
  • Electronic prescribing

16
Administrative Aspects
  • BH Template
  • 16 30-minute appointment slots per day
  • At least 2 BH providers on each day
  • At least 5 same day appointments available
  • BH Coding and Reimbursement
  • 90801
  • 90804
  • 96118
  • 96150 (BH series of codes)

17
Coding Logic
CPT CODES
Psychiatric ICD-9 CM Diagnosis (Use CPT
Procedure Codes 90801, 90804)
Physical ICD-9 CM Condition/Diagnosis (Use CPT
Procedure Codes 96150-96155)
18
Clinical Pathways
  • ADHD
  • Alcohol Detox
  • Scheduled Drugs

19
ADHD
  • On Beyond Ritalin.... By Carol Watkins, M.D. and
    Glenn Brynes, Ph.D., M.D.
  • Said Debra Ann Dilly OMalley OClad
  • Who had AD/HD and wow was it was bad,
  • Ive tried Ritalin in the morning and
    night Doses low, doses high and it just isnt
    right. Ive altered dose intervals tried the
    SR. Ive gone on-line lots talked to friends
    near and far.  Ive learned all there is on this
    darned ADD. But my mind still cant focus, just
    how can this be? My children and husband are
    ready to bust I think Ill just give up and say
    Im a klutz.       

20
  • And I said, You can stop if you want, leave it
    be,
  • Because some people stop and give up, but not
    me! 
  • Now your Ritalins great with, say, 60 percent
  • (Or 50 or 80) we get improvement.
  • In people I meet there are things we achieve
  • That we never could get if we just let things be.
  • It may take some work, but you really can mend.
  • A consultants work starts where the first-line
    stuff ends.  
  • My bag of tricks starts with these stimulants
    three.
  • Amphetamine, Desoxyn, and Cylert they be.
  • But most times just one cause Im wary of two.
  • If Desoxyns abused, the Feds might call on you
  • And the maker of Cylert warns of livers quite
    yellow
  • If your patient takes Cylert, draw blood from
    that fellow!

21
ADHD
But what if your big bag of pills doesnt
work? Now I focus and see that my husbands a
jerk. I interrupt people at home and at work. I
forget all my appointments and lose all my
friends   Oh... I did mean to mention
theres therapy too. For groups and for couples
and maybe just you. Theres coaching, day
planners all here in my hat. Dont expect me to
rhyme them They dont pay me to talk about
that.
22
ADHD Protocol
  • Any patient presenting with request for
    medication / symptoms / concern from school is
    referred
  • Clinical Interview
  • Request for records / School reports
  • Teacher and Parent Vanderbilt Assessments
  • CPT-II and other measures if indicated
  • Diagnosis Education and Discussion of Treatment
    Plan
  • PCP prescribed medication if indicated, follow-up
    by BHC
  • Weekly monitoring of sxs and side effects until
    stabilized on a medication
  • Follow-up Vanderbilt to monitor treatment impact

23
Outpatient Alcohol Detox Protocol
  • Why?
  • Rural setting no detox available locally
  • Common Impacts other health problems
  • Protocol
  • Assess if Outpatient Detox is Feasible
  • Daily clinic appointments
  • No history of previous DTs or Seizures
  • SI/HI/Psychosis/Serious Medical Condition
  • Facilitator to Assist
  • Urine Toxicology Screen No other substances

24
Outpatient Alcohol Detox Protocol
  • Protocol
  • All visits are co-visits with PCP and BHC
  • Clinical Pathway prescribed CPT codes
  • 99214 Initial and 99213 Follow-Up
  • 90804 for BH
  • Educate Patients Facilitator
  • Patient Signs Contract

25
Controlled Substances Protocol
  • Applies to Narcotics, Benzos, and Stimulants for
    Adults
  • BHC Evaluation is required to assess need,
    educate patients, and determine addiction
    potential
  • Initial urine drug screening, Breathalyzer
  • Obtain prior records if indicated
  • Follow-up random urine drug testing

26
If we want more evidence-based practice, we need
more practice-based evidence. Larry W. Green,
2004
Green LW Ottosen JM. From efficacy to
effectivenessProceedings from NIDDK Conference
From Clinical Trials to Community, 2004
27
RE-AIM Framework
  • Close the gap between research and practice
  • RE-AIM is an acronym that consists of five
    elements, or dimensions, that relate health
    behavior interventions
  • Reach the target population
  • Efficacy or effectiveness
  • Adoption by target settings or institutions
  • Implementation - consistency of delivery of
    intervention
  • Maintenance of intervention effects in
    individuals and populations over time
  • Source R. Glasgow (www.re-aim.org)

28
Seeking
  • Three behavioral health consultants desperately
    seeking interested academicians or otherwise
    interested parties to conduct applied research /
    jointly apply for grant funding to study this
    model of care, identification of cases, and
    clinical effectiveness
  • Also seeking another BHC to start in 2009

29
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30
Notes on Training
31
Before Training
  • Dont Forget the Medical Providers
  • Educate on the model and what they can expect
  • Train according to how to make their practice
    more effective and efficient
  • Core Knowledge Competencies
  • Core Clinical Competencies
  • Core Program-Level Competencies

32
Before Training
  • Make it east to do the right thing
  • Using clinic-wide screenings and algorithms
  • Examine the clinics readiness for integration
    and available support
  • Behavioral Health Assistants
  • Know the financial model of the clinic and the
    constraints
  • Coding and reimbursement for BH visits

33
Before Training
  • Acknowledge the hurdles to overcome
  • We do not speak the same language or practice
    similarly
  • Ensure common understanding of goals and model
  • Pre-Training Core Competencies
  • Cognitive-behavioral techniques
  • Dialectical behavioral therapy skills
  • Psychopharmacology knowledge
  • Motivational Interviewing Techniques
  • Integrated Care is Not for everyone

34
Does this Sound Fun or Painful? A Day in the
Life of a BHC
  • All PCPs in setting have access to refer
  • Triage nurses and medical assistants can also
    pull in a BHC for emergencies
  • Schedule 10 patients / day with 4 -5 additional
    walk-in appointments available for same day
    consultations
  • Accepts all referrals from providers, clarify
    inappropriate referrals on the back-end
  • Wide range of presenting problems
  • Expect the unexpected

35
Training BH Providers
  • Must have both didactic and experiential
    components
  • All Training Targets Core Competencies
  • Clinical Practice Skills
  • Documentation Skills
  • Consultation Skills
  • Training and Administrative Skills if relevant
  • Shadowing PCPs at the outset

36
Training BH Providers
  • Familiarize trainees with resources, screening
    tools, assessment tools (symptom based
    assessments), and BHC Handouts
  • Handouts on everything from depression and
    anxiety to hypertension and diabetes
  • Using handouts A BHC Prescription
  • Use existing or develop based on evidence
  • See One, Do One Model of Training

37
Training BH Providers
  • Documenting the BH visit
  • EMRs
  • Coding BH visits
  • Giving feedback to PCPs
  • Real-time feedback to BH trainee is key component
    in developing skill-set
  • The Backbone of BH Consultation -- The 30 Minute
    Consult

38
Follow-Ups
  • There is nothing magic about 50 minutes
  • There is nothing magic about once/week
  • Give them time to practice change plan
  • Let plan dictate when follow-up occurs (may be
    sooner than one week or much longer)
  • Be creative use of telephone follow-ups,
    coordinate with next PC visit, etc.
  • Stick to 30 minute structure patients will
    learn the structure and respond accordingly

39
Final Notes on Training
  • Ongoing consultation and support can be effective
    to maintain integrity of service
  • Consider turnover rates
  • Consider train the trainer models
  • Peer review and consultation opportunities
  • Establishing the standard of care
  • In house quality improvement to determine
    satisfaction (patients and providers) and level
    of impact
  • Are the goals for this integration effort being
    met?
  • Group Medical Appointments

40
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