Christine N. Runyan, Ph.D. Behavioral Health Consultant Mid-State Health Center Plymouth, NH [e-mail]

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Christine N. Runyan, Ph.D.Behavioral Health
ConsultantMid-State Health Center Plymouth,
NHtrunyan_at_midstatehealth.org
Collaborative Care In Action Implementing
Practice Guidelines in an Integrated Clinic
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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?

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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

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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
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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

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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

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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

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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

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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

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Plymouth, NH
Bristol, NH
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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

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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

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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

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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

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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

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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)

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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)
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Clinical Pathways

• ADHD
• Alcohol Detox
• Scheduled Drugs

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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
  nightDoses 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 bustI think Ill just give up and say
  Im a klutz.     

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• 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!

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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 themThey dont pay me to talk about
that.
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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

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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

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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

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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

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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
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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)

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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

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Notes on Training
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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

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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

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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

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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

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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

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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

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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

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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

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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

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