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Title: The Primary Care Behavioral Health Model (PCBH) of Service Delivery: Key Strategies for Operations, Practice, Program Evaluation and Payment


1
The Primary Care Behavioral Health Model (PCBH)
of Service Delivery Key Strategies for
Operations, Practice, Program Evaluation and
Payment
Session PC2 October 16, 2014
  • Christopher L. Hunter, PhD ABPP
  • Jeffrey T. Reiter, PhD, ABPP
  • Patricia J. Robinson, PhD
  • Neftali Serrano, PsyD
  • Kent A. Corso, PsyD, BCBA-D
  • Bill Rosenfeld, MC, LPC

Collaborative Family Healthcare Association 16th
Annual Conference October 16-18, 2014
Washington, DC U.S.A.
2
Faculty Disclosure
  • We have not had any relevant financial
    relationships during the past 12 months.

Primary Care Behavioral Health Model
3
Learning ObjectivesAt the conclusion of this
session, the participant will be able to
  • List the main components of the Primary Care
    Behavioral Health Model of service delivery.
  • Describe the characteristics of a behavioral
    health consultant that work well in this model.
  • Describe important program evaluation and quality
    improvement variables.
  • Practice Tools or Practical Skills
  • 1. Participants will know how to interview and
    select a behavioral health consultant that is
    likely to be a good fit for a PCBH model of
    service delivery.
  • 2. Participants will be able to discuss the
    importance of process outcome metrics that can
    demonstrate clinical population health impact
    and how that data can be used for ongoing program
    evaluation and justification for funding.
  • 3. Participants will know the financial model
    that can work with this model and how to get
    those funding streams work in their settings.

Primary Care Behavioral Health Model
4
Learning Assessment
  • A learning assessment is required for CE credit.
  • A question and answer period will be conducted at
    the end of this presentation.

Primary Care Behavioral Health Model
5
Primary Care Behavioral Health Model Jeffrey T.
Reiter, PhD, ABPP
2014 Annual Conference
Primary Care Behavioral Health Model
6
  • The WHY?

Primary Care Behavioral Health Model
7
Why PCBH?
Primary Care Behavioral Health Model
8
Why PCBH?
  • Wide range of behavioral issues, ages
  • Chronic disease mgmt
  • Somatic complaints with lifestyle/stress
    component
  • Sub-threshold problems
  • Preventive health
  • All manner of psychiatric, substance abuse
    problems
  • Infants through older adults

Primary Care Behavioral Health Model
9
Why PCBH?
  • Patients with psychosocial issues are higher
    utilizers
  • Of 14 common sx in primary care, only 16 had
    organic etiology (Kroenke 1989)
  • Anxiety, loneliness drive visits (Fries, 1993)
  • Half of high-utilizers have a psych or CD problem
    (Friedman, 1995)
  • Patients with psych disorder utilize 50 more
    physical health services (Simon et al, 1995)

Primary Care Behavioral Health Model
10
Why PCBH?
  • Primary care providers cant do it alone
  • 10 or 15 mins per visit
  • 3 complaints on average/visit
  • Insufficient training in behavioral interventions
  • Over 3 dozen urgent but unpaid tasks everyday
  • 15,000 new PCPs needed to meet new demand from
    the ACA
  • Overworked, underpaidstressed!

Primary Care Behavioral Health Model
11
  • The HOW?

Primary Care Behavioral Health Model
12
The How First, be Different
  • Avoid the barriers of specialty MH
  • Why dont people go to specialty MH?
  • Lack of insurance
  • Stigma
  • View their problem as physical
  • Inconvenience (including long waitlists)
  • Better familiarity, comfort with PCP
  • Prior negative experiences

Primary Care Behavioral Health Model
13
The How Second, be Helpful
  • Be a GATHERer
  • Generalist
  • Accessible
  • Team-based
  • High productivity
  • Educator
  • Routine care component

Primary Care Behavioral Health Model
14
Not All Integration is the Same
  • WA State care coordination model (IMPACT)
  • Started in 2007 in 2 counties
  • Expanded to 100 CHCs and 30 CMHCS state-wide in
    2009
  • 25,000 pts total (all years, all 130 clinics) as
    of 2012
  • PCBH model
  • 8,000 pts in 2012 alone at HealthPoints 11
    clinics

Primary Care Behavioral Health Model
15
PCBH Different and Helpful!
  • Consultant model
  • Member of primary care team, work side-by-side
  • Goal is to improve PCP mgmt of behavioral issues
  • Wide variety of interventions and goals
  • Brief visits, limited follow-up
  • Immediate feedback to PCP
  • Any behaviorally-based problem, any age
  • Aim for immediate access, minimal barriers
  • Rooted in population health principles

Primary Care Behavioral Health Model
16
The Behavioral Health Consultant (BHC)
Dimension Consultant Therapist
Primary consumer PCP Patient/Client
Care context Team-based Autonomous
Accessibility On-demand Scheduled
Ownership of care PCP Therapist
Referral generation Results-based Independent of outcome
Productivity High Low
Care intensity Low High
Problem scope Wide Narrow/Specialized
Termination of care Pt progressing toward goals Pt has met goals
Primary Care Behavioral Health Model
17
A Day in the Life of a BHC
Primary Care Behavioral Health Model
18
jeffreiter2_at_gmail.com
19
Primary Care Behavioral Health Model
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(No Transcript)
21
Primary Care Behavioral Health Model
22
(No Transcript)
23
Sample Clinic Day What to Look For
  • Variety of methods for getting pt to the BHC
  • Before PCP
  • PCP and BHC in room together
  • After PCP
  • Variety of problems and ages
  • Clinical (MH, SA, Beh Med, all ages)
  • Case management/Care coordination
  • Variety in the goals of visits
  • PCP-prep
  • Treatment augmentation
  • Medication and treatment planning

Primary Care Behavioral Health Model
24
Sample Clinic Day
  • 900 PCP wants meds rec
  • 52 y/o homeless, ? ADHD vs bipolar
  • 930 Question re disability expiring
  • 64 y/o Russian-speaker, depression
  • 1000 PCP says I dont know her problem
  • 62 y/o, psychiatrist d/cd, on 3 meds from 3 Drs
  • 1030 Open?WH w/ PCP in exam room
  • 12 y/o autism, ADHD, recently showing tics, halls

Primary Care Behavioral Health Model
25
Sample Clinic Day (contd)
  • 1100 N/S?WH in exam room, PCP- prep
  • 6 y/o ADHD, insomnia, enuresis
  • 1130 Planned f/u from 1 week earlier
  • 20 y/o Spanish-speaker, depressed w/ SI
  • 100 Team mtg (15-min talk on pain, 5-min on
    tobacco cessation)
  • 200 Cx?same-day appt for NRT refill

Primary Care Behavioral Health Model
26
Sample Clinic Day (contd)
  • 230 Open?WH for CSA
  • 60 y/o severe etoh, chronic arm pain
  • 300 Planned f/u after 2 weeks
  • 47 y/o homeless, MDD w/ psychosis, acute SI due
    to meds
  • 330 Planned f/u after 1 month
  • 45 y/o homeless, MDD, trying to get disability
  • 400 Cx?WH for PCP prep on new pt
  • 16 y/o expelled from school, needs risk
    assessment
  • 430 Open?Same-day f/u after 4 mos
  • 20 y/o seeking disability for PTSD, dep

Primary Care Behavioral Health Model
27
  • Does it Work?

Primary Care Behavioral Health Model
28
General Conclusion Improving Isnt Hard
  • USPSTF recommendations
  • Various problems
  • Various intervention models
  • Various provider backgrounds
  • AHRQ (2008) review
  • Adding behavioral component improves outcome
  • No clear model superiority
  • PCP influence
  • Increased PCP use of behavioral interventions
    (Mynors-Wallace, 1998)
  • Increased PCP confidence for behavioral health
    conditions (Robinson, 2000)

Primary Care Behavioral Health Model
29
Clinical Outcomes for PCBH
  • 71 of patients improved, even the most severe
  • Patients with more severe impairment at baseline
    improved faster than less severe (Bryan et al.,
    2012)
  • Patients receiving just 2-3 visits showed broad
    improvement in sx, functioning, well-being
  • These changes were robust and stable during
    2-year follow-up
  • Ray-Sannarud et al., 2012 Bryan et al., 2009)
  • Most patients who attend 2, 3 or gt 4 visits show
    clinically significant change
  • Cigrang et al., 2006

Primary Care Behavioral Health Model
30
PCBH Dissemination, Finances
  • Many large CHC organizations
  • Cherokee, Salud, Mountain Park, Access,
    HealthPoint
  • Standard of care in all branches of the DoD
  • All now utilize a PCBH service
  • Various VISNs of the VA
  • Less common in private, for-profit organizations
  • Strong financial reports
  • Large study underway in OR

Primary Care Behavioral Health Model
31
Provider Impact
  • All PCPs reported
  • Satisfaction with the BHC service
  • Improved job satisfaction
  • Better able to address behavioral problems
  • Recommend the service for other sites
  • A majority (gt 80) said because of BHC
  • More likely to continue with HealthPoint
  • Able to see more patients in 20 minutes
  • Recognize behavioral issues better

Primary Care Behavioral Health Model
32
Patient Satisfaction
  • 90 said visit length just about right
  • 76 were satisfied w/ ability to get appt
  • 86 felt BHC understood their problems
  • 89 said it was helpful to meet w/ BHC
  • 65 said physical health improved
  • 72 said mental health improved

Primary Care Behavioral Health Model
33
REMEMBER THIS!
  • Worry less about effectiveness
  • and more about productivity!

Primary Care Behavioral Health Model
34
REMEMBER THIS, TOO!
  • Primary care is deluged with behavioral health
    needs and is ill-equipped to handle them
  • Opportunities are tremendous for integration,
    buta radically different care model is required
  • PCBH is a consultative model designed to meet the
    unique demands of primary care

Primary Care Behavioral Health Model
35
Questions?
Primary Care Behavioral Health Model
36
Effectively Implementing the Model in a Large
SystemThe Department of Defense Military Health
System Christopher L. Hunter, PhD, ABPPDoD
Program Manager for Behavioral Health in Primary
Care
Primary Care Behavioral Health Model
37
OperationsEffectively Implementing the
ModelMilitary Health System
  • Background/Context
  • History, Funding/Policy, Workforce Development
  • -Hunter, C. L., Goodie, J. L., Dobmeyer A. C.,
    Dorrance, K. A. (2014). Tipping points in the
    Department of Defenses experience with
    psychologists in primary care. American
    Psychologist, 69, 388-398.
  • -Hunter C. L., Goodie, J. L., (2012).
    Behavioral health in the department of defense
    patient-centered medical home History, finance,
    policy, work force development and evaluation.
    Journal of Translational Behavioral Medicine, 2,
    355-363.

Primary Care Behavioral Health Model
38
OperationsEffectively Implementing the
ModelMilitary Health System
Age Total Female Active Duty Retired Family Members
0-4 307,188 49 N/A N/A 100
5-14 478,689 49 N/A N/A 100
15-17 121,014 49 N/A N/A 100
18-24 559,098 39 60 0 40
25-34 723,752 41 67 0 33
35-44a 444,297 49 56 6 37
45-64a 571,348 46 11 45 43
65 145,792 52 0 49 51
Total 3,351,178  aTotal of Active Duty, Retired and Family Members does not equal 100 due to rounding   aTotal of Active Duty, Retired and Family Members does not equal 100 due to rounding   aTotal of Active Duty, Retired and Family Members does not equal 100 due to rounding   aTotal of Active Duty, Retired and Family Members does not equal 100 due to rounding 
Primary Care Behavioral Health Model
39
OperationsEffectively Implementing the
ModelMilitary Health System
  • Policy/Standards
  • DoD Instruction 6490.15
  • Program Standards
  • Model of Service Delivery
  • Staffing Ratios
  • Expert Trainers
  • Training Standards
  • Program Managers
  • Oversight Committee

www.dtic.mil/whs/directives/corres/pdf/649015p.pdf
Primary Care Behavioral Health Model

40
OperationsEffectively Implementing the
ModelMilitary Health System
  • Funding
  • Argument made in context of enhancing PCMH
    implementation
  • Based On
  • Data from Army, Navy and Air Force Programs
  • Veterans Administration Programs
  • Civilian Research

Primary Care Behavioral Health Model
41
OperationsEffectively Implementing the
ModelMilitary Health System
  • Funding Argument
  • Expected Impact on System
  • 1. Psychological health-screening referral
    engagement
  • 2. Evidence-based care-depression anxiety
    consistent with CPGs
  • 3. Engaging patients in healthy behaviors (
    advised to quit smoking)
  • 4. Decrease per-member per-month cost
  • 5. Decreased use of emergency services
  • 6. Patient satisfaction with access to
    comprehensive healthcare
  • 7. Primary care staff satisfaction with
    healthcare delivery
  • 8. Identify effectively manage those at risk
    for suicide
  • 9. Recapture family member BH services from
    purchased care

Primary Care Behavioral Health Model

42
OperationsEffectively Implementing the
ModelMilitary Health System
  • Training/Program Fidelity
  • Service Clinical Practice Manuals
  • 4 Day Benchmark Training
  • In Clinic Benchmark Training
  • Ongoing Quarterly Program Evaluation
  • Every Provider, Every Appointment
  • Standardized Documentation
  • EMR Data Pulls

Primary Care Behavioral Health Model
43
OperationsEffectively Implementing the
ModelMilitary Health System
  • Challenges/Lessons Learned
  • 1. Establish a rationale for integrated-collaborat
    ive behavioral health that is clear,
    evidence-based, considers operational
    financial barriers within a given system.
  • 2. Include relevant healthcare professions within
    the system when developing a service delivery
    model standards. The views brought by various
    professions can strengthen the program improve
    important system stakeholder buy-in.
  • 3. Establish operationally defined and agreed
    upon integrated-collaborative care constructs to
    facilitate communication shared vision. Do not
    assume that integrated, collaborative or other
    delivery specific terms are being used
    consistently across/within professions.

Primary Care Behavioral Health Model
44
OperationsEffectively Implementing the
ModelMilitary Health System
  • Challenges/Lessons Learned
  • 4. Include key management/finance personnel in
    program development.
  • -Without funding/management support the
    best plans can get shut down.
  • 5. Identify key primary care behavioral health
    support that can lead their professions in
    program development.
  • -Strong advocates, can inform key finance,
    personnel management stakeholders
  • with expected ROI scientific data supporting
    proposed effort.
  • -Providing real world stories of patient/provider
    satisfaction/change, can facilitate
  • movement of clinical/operational worlds in the
    same direction.
  • 6. Timing is important. Determine when
    leadership may be receptive to a proposal for a
    new service delivery model.
  • -Move forward when you can present a clear
    rationale answer difficult
  • questions in thoughtful ways.

Primary Care Behavioral Health Model
45
OperationsEffectively Implementing the
ModelMilitary Health System
  • Challenges/Lessons Learned
  • 7. Develop an agreed upon set of clinical and
    administrative standards that are observable
    can be enforced.
  • -Develop methods to ensure workforce is trained
    to clinical administrative standards.
  • -Fidelity to service delivery model for desired
    outcomes to have a chance to be realized.
  • 8. Develop manuals addressing clinical,
    administrative, operational financial
    components.
  • - Guide practitioners/administrators on what
    services will will not do.
  • 9. Develop a set of process and outcome metrics.
  • -An effective evaluation design to allow
    scientifically robust conclusions to be drawn.
  • -Demonstrating return on investment results to
    management, providers and patients
  • facilitates ongoing support informs service
    delivery course changes if desired
  • outcomes are not reached.

Primary Care Behavioral Health Model
46
Questions?
Primary Care Behavioral Health Model
47
Implementing the PCBH Model in Diverse
SettingsLarge Public Health Department (SFDPH)
State Level Research (Texas Medicaid Children)
PCMH Initiatives (Oregon PCPCI)Trillium CCO
(Oregon)Yakima Pediatrics (WA)Patricia J.
Robinson, Ph.D.Director of Training and Program
EvaluationMountainview Consulting Group
(Mtnviewconsulting.com)
Primary Care Behavioral Health Model
48
2009-2012San Francisco Department of Public
Health
  • Healthy San Francisco Plan, 2007
  • Universal coverage
  • September, 2010
  • Instantly, medical access problem, similar to
    that faced in most communities now with ACA
    implementation
  • RFP (did not specify PCBH model)
  • Request for assistance with assessment of need
    for integrated BH services model development and
    implementation in SF public health PC clinics and
    other PC clinics (including SF General)

Primary Care Behavioral Health Model
49
OperationsFrancisco Department of Public Health
  • Ratification of PCBH model by senior leadership,
    manual development
  • Formal Readiness Reviews in 15 clinics
    (multiple-day site visit evaluations)
  • Summary of findings (current services, population
    demographics, staffing)
  • Clinic factors influencing integration
    (availability and training background of BH
    staff, relationship with CMH, space, language and
    culture of patients, age, most common patient
    health problems, co-located resources)
  • Recommendations and development of implementation
    plan

Primary Care Behavioral Health Model
50
Policy / Standards / TrainingSan Francisco
Department of Public Health
  • Program Evaluation Matrix
  • Go Live Training (series of 3 2010 class size
    7-28)
  • 5-day intensive for 35 BH providers
  • Mastery of manual
  • Modeling, Guided rehearsal, Role-playing
  • Core Competency Training On-site
  • Week 1 (5 days / 2 BHCs, BAs)
  • Week 2 (2/2 additional, mentor)
  • Mentor support on-going workshops, T cons

Primary Care Behavioral Health Model
51
FundingSan Francisco Public Health Department
  • Built into clinic budgets
  • No increase in public health dollars
  • Overage covered by grants, local businesses
  • Avoided use of MH dollars if possible
  • More support available from state now with
    implementation of ACA

Primary Care Behavioral Health Model
52
Challenges / Lessons LearnedSan Francisco Public
Health Department
  • Challenges/Lessons Learned
  • Challenge of starting model at same time in
    multiple clinics
  • BHCs placed rather than self-selected
  • Multi-cultural, multi-language clinics
  • Staffing ratios for street youth and homeless
    clinics
  • Assisting other area PC clinics with
    implementation with limited funding
  • Implementation in large, hospital-based PC
    residence training clinics

Primary Care Behavioral Health Model
53
Challenges / Lessons LearnedOther Dissemination
Venues
  • State of Texas Medicaid Children (SUPPORT)
  • Adequacy of training Manual, 1-day Go Live
    (recorded), phone support
  • State of Oregon (PCPCI)
  • The power of sponsors Trained 40 practices in 3
    5-day trainings (1 day team 4 days BHCs) in 4
    months
  • Trillium CCO (Oregon)
  • Multiple clinicsurban, suburban,
    ruralimplementing with PCBH Tool Kit (Can one
    model fit all?)
  • Yakima Pediatric Associates
  • Funding, pushing on a string until you get a ball
    of yarn the on-going influence of intensive,
    well-timed, and on-going training

Primary Care Behavioral Health Model
54
Questions?
Primary Care Behavioral Health Model
55
Effectively Implementing the ModelHealth
Federation of Philadelphia Neftali Serrano,
PsyD
Primary Care Behavioral Health Model
56
OperationsEffectively Implementing the
ModelHealth Federation of Philadelphia
  • Background/Context
  • A grantee organization with a focus on healthcare
    that helps network varied Federally Qualified
    Health Centers in the city of Philadelphia sought
    to help its member FQHCs develop and sustain
    integrated care
  • Over a dozen members FQHCs with multiple sites
    each (currently over 30 BHCs)
  • Most had no behavioral health prior to PCBH model
    implementation

Primary Care Behavioral Health Model
57
OperationsEffectively Implementing the
ModelHealth Federation of Philadelphia
  • Policy/Standards
  • The network helped to broker standards with the
    local managed care organization, CBH, to adapt
    documentation and billing standards from
    specialty care to the PCBH model. This included a
    crossover document so that CBH auditors could
    evaluate primary care documentation.
  • The network also helps each of the member clinics
    have baseline standards for hiring and evaluating
    BHCs

Primary Care Behavioral Health Model
58
OperationsEffectively Implementing the
ModelHealth Federation of Philadelphia
  • Funding
  • The clinics have varied funding strategies but
    most are reimbursed through the FQHC Medicaid
    rate as managed by CBH, the managed care
    organization
  • CBH agreed to create a billing code exclusively
    for the use of BHCs
  • Adaptations of the specialty mental health
    processes were negotiated with the networks
    assistance such as processes for opening cases
    and eliminating termination

Primary Care Behavioral Health Model
59
OperationsEffectively Implementing the
ModelHealth Federation of Philadelphia
  • Training/Program Fidelity
  • The network has monthly BHC meetings that include
    debriefing and continuing education seminars
    these follow a curriculum developed around core
    competencies
  • There are formalized processes for integrating
    new BHCs into the network including
    shadowing/reverse shadowing, documentation
    review, introductory curriculum
  • There is a separate meeting of BHC program
    directors where strategy around program
    development and continuing education is developed
  • The network has developed a patient simulation
    program to evaluate BHC clinical performance

Primary Care Behavioral Health Model
60
OperationsEffectively Implementing the
ModelHealth Federation of Philadelphia
  • Challenges/Lessons Learned
  • The overall health of individual clinics and
    organizations is a key predictor of success or
    failure of PCBH implementation
  • The leverage created by a network of clinics can
    be an effective strategy to negotiate changes in
    policy and funding mechanisms
  • Training new behavioral health consultants in a
    scaled fashion requires specific, formalized
    processes that are enacted even before the hiring
    process to ensure good fit and model fidelity
  • Collecting data across disparate organizations is
    a significant challenge to be anticipated which
    can impact how well you can tell the story of the
    models impact
  • Talent, Talent, Talent nothing replaces good
    talent which is why good hiring is crucial

Primary Care Behavioral Health Model
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Questions?
Primary Care Behavioral Health Model
62
Hiring the Right Behavioral Health Consultant
Jeffrey T. Reiter, PhD, ABPP
2014 Annual Conference
Primary Care Behavioral Health Model
63
Hiring a Behavioral Health Consultant
  • Qualities to look for
  • Clinical
  • Skills
  • Knowledge
  • Experience
  • Personality
  • Interests
  • Degree

Primary Care Behavioral Health Model
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Interview Questions and Desired Responses
Primary Care Behavioral Health Model
65
Training a New BHC
  • Reading
  • Shadowing
  • Mentoring
  • Online Continuing Education
  • Conferences
  • Academic Training
  • Core Competency Tool

Primary Care Behavioral Health Model
66
Evaluating the BHC
  • Supervisor
  • Lead BHC (existing service)
  • Lead Medical Provider (new service)
  • Evaluation Tools
  • Core Competency Tool
  • Chart Review Tool
  • 360 Evaluation
  • Key Performance Metrics
  • Productivity
  • Patient Satisfaction and/or Clinical Outcomes

Primary Care Behavioral Health Model
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Questions?
Primary Care Behavioral Health Model
68
Ethical-Legal Practices in PCBH Neftali
Serrano, PsyD
Primary Care Behavioral Health Model
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Overview
  • Informed Consent Procedures
  • Documentation in the Medical Record
  • Access to EHR Data
  • Releasing Information
  • Exemplars

Primary Care Behavioral Health Model
70
Informed Consent Procedures
  • Key ethical and legal mandate is to provide
    patients with information regarding their care so
    that patients are empowered to make key
    healthcare decisions
  • The nuance in the PCBH model is that the
    patients relationship is to the clinic (and
    PCP), not uniquely to the BHC
  • Key for clinics to have up front information
    related to billing practices, confidentiality,
    HIPAA rights
  • Key for BHCs and PCPs to communicate the role of
    the BHC, limits of confidentiality when
    applicable, documentation procedures, and explain
    treatment options

Primary Care Behavioral Health Model
71
Example of Informed Consent In A BHC Practice
Style
  • BHC Introduction
  • Good afternoon, my name is Dr. Serrano and Im a
    psychologist who works here as a Behavioral
    Health Consultant. What that means is that I work
    with Dr. Tellez and her medical team - I dont
    have patients of my own - and she involves me in
    situations where she might need support helping a
    patient struggling with a lifestyle change such
    as quitting smoking or losing weight, or when a
    patient may need some ideas for how to cope with
    life stress. So, what we will do today is spend
    about 15 minutes reviewing what you discussed
    with her, hopefully come up with a good plan of
    action, and then I will communicate with her what
    we discussed and also document it in the medical
    record so that we can make sure we keep track of
    what we are working on. If we decide some
    follow-up is needed to continue to support you
    you may end up seeing one of the other members of
    the Behavioral Health Consultant team based on
    the day you come in, but rest assured we work
    very hard to communicate with each other so that
    you dont have to repeat a thing. With that in
    mind, today
  • In certain situations, using judgment, limits of
    confidentiality may need to be discussed further.

Primary Care Behavioral Health Model
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Documentation of BHC Informed Consent After A
First Visit
  • Tagged onto the end of a SOAP Note via
    dotphrase
  • The patient was informed of the following
    characteristics of their care within the primary
    care medical home at Access Community Health
    Centers a. Behavioral health providers operate
    as consultants to the medical team and not as
    stand-alone providers of care, b. All information
    discussed with team members as applicable/appropri
    ate will be documented in the shared medical
    record and visible by all members of the Access
    medical team, c. Patients have a right to a
    confidential record and when requesting a release
    of records to external agencies can restrict
    aspects of their record from being released
    including but not limited to mental health data,
    d. The Behavioral Health Team works as a group
    providing care to all Access patients and as such
    a patient is likely to work with multiple
    Behavioral Health providers.

Primary Care Behavioral Health Model
73
Documentation In The Medical Record
  • The only barriers to the full integration of
    mental health data in the medical record exist in
    state-specific or organization-specific instances
    based on state law or organizational policy
  • HIPAA does not treat mental health data in EHRs
    differently than other data other than providing
    patients rights to release aspects of their
    record
  • There is no ethical mandate, such as in the APA
    Ethics Code, which prohibits integration of
    records

Primary Care Behavioral Health Model
74
Documentation In The Medical Record
  • Key is to train clinical staff to write
    appropriately for the medical record,
    understanding the kinds of data that are relevant
    for the medical team (process vs. progress notes)
  • Key is to train non-clinical staff to respect all
    aspects of the record, understand patient HIPAA
    protections and as HIPAA requires have a
    mechanism to track abuses by individuals of a
    patient record

Primary Care Behavioral Health Model
75
Access To EHR Data
  • Break the glass impediments are largely
    considered to be a stop-gap method by
    litigation-fearing institutions until state-based
    laws are harmonized with HIPAA
  • Consistency in policy is key across an
    organization
  • In other words, if personnel have access to
    sensitive data, then protections within
    protections dont make sense unless you can
    defend why those extra protections do not exist
    for the other kinds of data (e.g. think STDs or
    sexual orientation)
  • Key is having solid, ethical documentation
    standards, tracking mechanisms and good general
    boundaries for the ways in which all medical data
    is shared or seen

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Releasing Information
  • HIPAA provides protections for the release of
    certain types of data including mental health
    data, dictated by patient consent
  • Key is to have a medical records department that
    can provide up-to-date HIPAA compliant releases
    and a function within that department for sifting
    records when releases are requested

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Exemplars
  • A Community Health Center
  • Transparent BHC notes, sharing an EHR with a
    larger system
  • Negotiation with larger system to maintain
    autonomy in practice
  • A Large University Medical System
  • MH BHC (new) notes behind the glass
  • Lawyers took a conservative approach but did
    allow for increased transparency and are
    revisiting this process

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Take Home Themes
  • There are no compelling reasons to...
  • separate aspects of the medical record or create
    barriers to access beyond what is required for
    the protection of the whole record
  • create cumbersome informed consent procedures
  • There are compelling reasons to
  • train clinical staff in effective and ethical
    documentation
  • train non-clinical staff in patient HIPAA rights
  • ensure that state laws do not contradict or
    supercede HIPAA protections or create special
    categories for AODA or mental health
    documentation for certain organizations or
    licenses

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Key References
  • Hudgins, C., Rose, S., Fifield, P. Y. (2013).
    Navigating the legal and ethical foundations of
    informed consent and confidentiality in
    integrated primary care. Families, Systems
    Health. 31 9-19.
  • Reiter, J., Runyan, C. (2013). The ethics of
    complex relationships in primary care behavioral
    health. Families, Systems Health. 31 20-27.
  • Your state mental health code.
  • HIPAA Federal Law http//www.hhs.gov/ocr/privacy/
    hipaa/understanding/summary/index.html

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Questions?
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Research and Program EvaluationConducting
Research on the PCBH Model Kent A. Corso, PsyD,
BCBA-DNational Capital Region Behavioral Health,
LLC
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Examples of Improved PCP and Clinic Efficiency
  • PCP Satisfaction
  • 100 refer again (Corso Corso, 2009)
  • Effectiveness
  • PCP time saved/pt 56.92 min on avg
  • Clinic time saved/pt 18.59 min on avg
  • PCPs rated impact of integrated care on
    patients health 2.07
  • (1-4 scale with 1 being resolved and 4 being no
    help)
  • (Corso Corso, 2009)

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Strong Therapeutic Alliance with a BHC
  • Patients rated their therapeutic alliance
    following a first appointment with an BHC as
    statistically stronger than alliance ratings from
    a previously reported sample of outpatient
    psychotherapy patients
  • Therapeutic alliance assessed after the first BHC
    appointment was not associated with eventual
    clinical change in mental health symptoms and
    functioning
  • Corso, K.A. Bryan, C.J., Corso, M.L, Kanzler,
    K.E., Houghton, D.C., Morrow, C.E.
    Ray-Sannerud, B. (2012). Therapeutic alliance
    and treatment outcome in integrated primary care.
    Families, Systems, Health, 30 (2), 87-100

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Measuring Clinical Outcomes
  • The Behavioral Measure 20 normed on a sample of
    military service members, veterans, and family
    members in three primary care samples (N 3072)
  • Scores on each of the BHMs four scales satisfied
    the criterion for internal consistency
    reliability
  • Across all three samples, internal consistency
    estimates were stable and ranged from adequate to
    excellent (gt .82)
  • The Well Being subscale resulted in the relative
    lowest reliability estimate (.74), likely due in
    part to it having the relative fewest number of
    items.
  • All other scales showed good to excellent
    internal consistency
  • Use of the unidimensional Global Mental Health
    score is superior to using multiple subscales
    (Well-Being, Symptoms, and Life Functioning) as
    indicated by the high intercorrelations among the
    BHMs multiple scales (rs gt .69) -- suggests
    they have considerable overlap and are measuring
    interrelated constructs
  • Bryan CJ, Blount TH, Kanzler KE, Morrow CE, Corso
    KA, Corso ML, Ray-Sannerud B. Reliability and
    normative data for the Behavioral Health Measure
    (BHM) in primary care behavioral health settings.
    Families, Systems, Health. 2014 32(1) 1-11.

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Symptom Reduction
  • BHC patients (N495) demonstrated significant
    improvements in clinical status (as assessed by
    BHM-20).
  • 72 of pts improved across appointments
  • 57 of pts demonstrated clinically meaningful
    reliable improvement
  • Improvements also seen in those with most severe
    levels of distress at baseline
  • Bryan, C.J., Corso, M.L., Corso, K.A., Morrow,
    C.E., Kanzler, K.E., Ray-Sannerud, B. (2012).
    Severity of mental health impairment and
    trajectories of improvement in an integrated
    primary care clinic. Journal of Consulting
    Clinical Psychology. 80 (3), 396-403

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Decreased Psychological Distress
  • Patients (N234) demonstrated statistically
    significant decrease in psychological distress
    over from first to last BHC appointment
  • Measure Outcomes Questionnaire-45 (OQ-45)
  • Most common diagnoses depression, anxiety,
    marital problems, chronic pain
  • 51 had 1 appt 25 had 2 appts, 12 had 3 appts,
    7 had 4 appts, 5 had gt 4 appts
  • Cigrang, J. A., Dobmeyer, A. C., Becknell, M. E.,
    Roa-Navarette, R. A., Yerian, S. R. (2006).
    Evaluation of a collaborative mental health
    program in primary care effects on patient
    distress and healthcare utilization. Primary Care
    and Community Psychiatry, 11, 121-127

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Insomnia
  • Brief behavioral intervention with BHC associated
    with decreased severity of insomnia
  • Goodie, J., Isler, W., Hunter, C., Peterson, A.
    (2009). Using behavioral health consultants to
    treat insomnia in primary care A clinical case
    series. Journal of Clinical Psychology, 65,
    294-304

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Routine Screening for Suicide
  • 338 patients referred to BHCs by their PCPs in
    the course of routine treatment
  • Suicidal ideation reported to BHC by 12.4 (N42)
    via routine screening with BHM-20
  • Only 2.1 (N7) actually reported suicidal
    ideation to their PCP
  • Applicability for PCBH routine screening via
    written methods yields higher identification of
    suicidal patients in PCBH
  • The as indicated approach is less effective as
    a population health screening method
  • Bryan CJ, Corso KA, Rudd MD, Cordero L. Improving
    identification of suicidal patients in primary
    care
  • through routine screening. Primary Care and
    Community Psychiatry. 2008 13(4) 143-147.

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Decreased Suicidal Ideation
  • Suicidal ideation generally improved over the
    course of several BHC appointments
  • 497 primary care patients who kept 2 to 8
    appointments with BHC
  • Therapeutic alliance was rated very high by
    patients
  • Alliance was not related to positive clinical
    outcomes
  • Bryan, C.J., Corso, K.A., Corso, M.L., Kanzler,
    K.E, Ray-Sannerud, B., Morrow, C.E. (2012).
    Therapeutic alliance and change in suicidal
    ideation during treatment in integrated primary
    care settings. Archives of Suicide Research, 16,
    316-323.
  • Corso, K.A., Pino, J., Clancy, J.P., Corso, M.L.,
    Kanzler, K.A., Ray-Sannerud, B., Morrow, C.E.,
    Bryan, C.J.
  • Clinical improvement and worsening in suicidal
    ideation across behavioral health appointments in
    two patient-centered medical homes. Manuscript
    submitted to Annals of Family Medicine.

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Decreased PTSD Symptoms
  • In a pilot study of 19 active duty airmen, combat
    writing (i.e., impact statement from CPT), and
    imaginal exposure yielded positive outcomes
  • Patients receiving TAU showed no clinical
    improvement
  • Exposure patients became slightly worse
  • Corso KA, Bryan CJ, Morrow CE, Appolonio KK,
    Dodendorf DM, Baker MT. Managing post traumatic
    stress disorder (PTSD) symptoms in active duty
    military personnel in primary care settings.
    Journal of Mental Health Counseling. 2009 31(2)
    119-137.

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Complex Patients
  • Among patients with suicidal symptoms,
    depression, and PTSD BHCs provided treatment
  • No direct relationship found between PTSD and
    suicide
  • Suicidal symptoms explained exclusively by
    depression
  • Applicability for PCBH if patients with trauma,
    depression, and suicide present in primary care,
    do NOT begin treating PTSD depression symptoms
    should be treated first providing suicide risk
    has already been assessed and addressed
  • Bryan CJ, Corso KA. Depression, PTSD, and
    suicidal ideation among active duty veterans in
    an integrated primary care clinic. Psychological
    Services. 2011 8(2) 94-103.

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BH Symptom Improvements Maintained
  • Patients improved from their first to last BHC
    appointment, with gains being maintained an
    average of 2 years after intervention
  • Measure Behavioral Health Measure (BHM) 20
  • N 70
  • Ray-Sannerud, B., Dolan, D., Morrow, C.E., Corso,
    K.A., Kanzler, K.E., Corso, M.L., Bryan, C.J.
    (2012). Longitudinal outcomes after brief
    behavioral health intervention in an integrated
    primary care clinic. Families, Systems Health,
    30, 60-71.

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Positive Impact on the Medical System
  • Impact of PCBH Model on Access to Specialty MH
    Care (St. Louis VA)
  • Resulted in a 48 decrease in direct consultation
    to specialty mental health services by PCPs
  • With a concurrent increase in access to mental
    health services (including via warm handoffs to
    PC Psychologists) of 170
  • Martielli, Brawer, Metzger, Gaioni

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Conducting Research in PCBH
  • Benefits
  • Challenges
  • Importance
  • Tips
  • Future Directions

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Questions
  • kent_at_ncrbehavioralhealth.com

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Reimbursement and Fiscal Supportof the Primary
Care Behavioral Health Model Bill Rosenfeld,
MC, LPC
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Overview
  • History of Billing PCBH
  • FQHC Point of View
  • Care Strategy and the Financial Wheel
  • Necessary Considerations
  • Alternative funding potentials

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Funding Strategies for Primary Care Behavioral
Health
  • Historical View of Program Growth
  • 2003 single BHC program infancy
  • 2,000 encounters
  • 2014 robust Integrated Health Service Department
  • 27,000 encounters
  • 2015 Projections
  • 40,000 encounters

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Fiscal Sense of BHC Encounter Growth
  • HRSA Program Information Notice 2004-05
  • Document Date October 31, 2003
  • Document 2004-05
  • Document Name Medicaid Reimbursement for
    Behavioral Health Services
  • Each State Medicaid Plan made interpretations of
    this PIN that had Primary Care Behavioral Health
    Billing Implications

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Care Strategy and the Financial Wheel
  • Find the Win-Win Scenarios for greatest financial
    impact to be realized
  • Match the culture of your care arena
  • Physical Health Problems
  • Biopsychosocial factors important to physical
    health problems and treatments
  • Focus on Low Lying fruit
  • Prevalent chronic illness
  • Bane of the Medical Provider Existence

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CPT Coding
  • Codes Accepted Health and Behavior
    Assessment/Intervention (96150-96155)
  • Health and Behavior Assessment procedures are
    used to identify the psychological, behavioral,
    emotional, cognitive and social factors important
    to the prevention, treatment or management of
    physical health problems.

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CPT Coding
  • 96150 Initial Health and Behavior Assessment
    each 15 minutes face-to-face with patient
  • 96151 Re-assessment 15 minutes
  • 96152 Health and Behavior Intervention each 15
    minutes face-to-face with patient
  • 96153 Group (2 or more patients)
  • 96154 Family (with patient present)
  • 96155 Family (without patient present)

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FQHC Financial Model
  • COST BASED REIMBURSEMENT
  • Prospective Payment System (PPS)
  • Example
  • If it costs 40 million dollars to complete
    200,000 encounters, the cost of each encounter is
    200.00
  • 40,000,000/200,000 200

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Necessary Billing and Reimbursement
Considerations
  • Point of Service
  • Funding Source
  • Diagnostics
  • CPT Code
  • Provider Type

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Alternative Funding Potential
  • PCBH Attractive Lure for the Philanthropic or
    Grant Funded Pond?
  • Mayo Clinic
  • Az. Department of Health Services
  • Komen Race for the Cure
  • Arizona Cancer Center at the University of
    Arizona

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State by State PCBH Financing Information
  • Go to
  • www.integration.samhsa.gov/financing/billing-tools

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Questions?
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  • Bibliography / Reference
  • Hunter, C. L., Goodie, J. L., Dobmeyer A. C.,
    Dorrance, K. A. (2014). Tipping points in the
    Department of Defenses experience with
    psychologists in primary care. American
    Psychologist, 69, 388-398.
  • 2. Hudgins, C., Rose, S., Fifield, P. Y.
    (2013). Navigating the legal and ethical
    foundations of informed consent and
    confidentiality in integrated primary care.
    Families, Systems Health. 31 9-19.
  • 3. Reiter, J., Runyan, C. (2013). The ethics
    of complex relationships in primary care
    behavioral health. Families, Systems Health.
    31 20-27.
  • 4. Bryan CJ, Blount TH, Kanzler KE, Morrow CE,
    Corso KA, Corso ML, Ray-Sannerud B. Reliability
    and normative data for the Behavioral Health
    Measure (BHM) in primary care behavioral health
    settings. Families, Systems, Health. 2014
    32(1) 1-11.
  • 5. Ray-Sannerud, B., Dolan, D., Morrow, C.E.,
    Corso, K.A., Kanzler, K.E., Corso, M.L.,
    Bryan, C.J. (2012). Longitudinal outcomes after
    brief behavioral health intervention in an
    integrated primary care clinic. Families, Systems
    Health, 30, 60-71.

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