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

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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.
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Faculty Disclosure

• We have not had any relevant financial
  relationships during the past 12 months.

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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.

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Learning Assessment

• A learning assessment is required for CE credit.
• A question and answer period will be conducted at
  the end of this presentation.

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

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Why PCBH?
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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

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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)

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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!

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• The HOW?

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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

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The How Second, be Helpful

• Be a GATHERer
• Generalist
• Accessible
• Team-based
• High productivity
• Educator
• Routine care component

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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

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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

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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
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A Day in the Life of a BHC
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jeffreiter2_at_gmail.com
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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

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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

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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

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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

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• Does it Work?

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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)

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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

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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

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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

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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

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REMEMBER THIS!

• Worry less about effectiveness
• and more about productivity!

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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

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Questions?
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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
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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.

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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 
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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
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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

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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

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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

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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.

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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.

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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.

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Questions?
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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)
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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)

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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

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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

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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

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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

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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

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Questions?
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Effectively Implementing the ModelHealth
Federation of Philadelphia Neftali Serrano,
PsyD
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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

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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

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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

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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

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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

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Questions?
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Hiring the Right Behavioral Health Consultant
Jeffrey T. Reiter, PhD, ABPP
2014 Annual Conference
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Hiring a Behavioral Health Consultant

• Qualities to look for
• Clinical
• Skills
• Knowledge
• Experience
• Personality
• Interests
• Degree

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Interview Questions and Desired Responses
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Training a New BHC

• Reading
• Shadowing
• Mentoring
• Online Continuing Education
• Conferences
• Academic Training
• Core Competency Tool

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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

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Questions?
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Ethical-Legal Practices in PCBH Neftali
Serrano, PsyD
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Overview

• Informed Consent Procedures
• Documentation in the Medical Record
• Access to EHR Data
• Releasing Information
• Exemplars

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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

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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.

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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.

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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

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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

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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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Session Evaluation

• Please complete and return theevaluation form to
  the classroom monitor before leaving this
  session.
• Thank you!