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

The Primary Care Behavioral Health Model (PCBH) of Service Delivery: Key Strategies for Operations,

Practice, Program Evaluation and Payment

Christopher L. Hunter, PhD ABPPJeffrey T. Reiter, PhD, ABPP

Patricia J. Robinson, PhDNeftali Serrano, PsyD

Kent A. Corso, PsyD, BCBA-DBill Rosenfeld, MC, LPC

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session # PC2October 16, 2014

Faculty Disclosure

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

Primary Care Behavioral Health Model

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 Skills1. 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.


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 Jeffrey T. Reiter, PhD, ABPP

2014 Annual Conference


The WHY?



Why PCBH?2014 Annual Conference


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



● 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)


Why PCBH?


● Primary care providers can’t 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, underpaid—stressed!


Why PCBH?


The HOW?



The How: First, be Different

● Avoid the barriers of specialty MH● Why don’t 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



The How: Second, be Helpful

● Be a GATHERer:○ Generalist○ Accessible○ Team-based○ High productivity○ Educator○ Routine care component



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 HealthPoint’s 11 clinics



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



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



A Day in the Life of a BHC2014 Annual Conference


[email protected]



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



Sample Clinic Day

● 9:00 PCP wants meds rec○ 52 y/o homeless, ? ADHD vs bipolar

● 9:30 Question re disability expiring○ 64 y/o Russian-speaker, depression

● 10:00 PCP says “I don’t know her problem”○ 62 y/o, psychiatrist d/c’d, on 3 meds from 3 Drs

● 10:30 Open→WH w/ PCP in exam room○ 12 y/o autism, ADHD, recently showing tics, hall’s



Sample Clinic Day (cont’d)

● 11:00 N/S→WH in exam room, PCP- prep○ 6 y/o ADHD, insomnia, enuresis

● 11:30 Planned f/u from 1 week earlier○ 20 y/o Spanish-speaker, depressed w/ SI

● 1:00 Team mtg (15-min talk on pain, 5-min on tobacco cessation)

● 2:00 Cx→same-day appt for NRT refill



Sample Clinic Day (cont’d)

● 2:30 Open→WH for CSA○ 60 y/o severe etoh, chronic arm pain

● 3:00 Planned f/u after 2 weeks○ 47 y/o homeless, MDD w/ psychosis, acute SI due to meds

● 3:30 Planned f/u after 1 month○ 45 y/o homeless, MDD, trying to get disability

● 4:00 Cx→WH for PCP prep on new pt○ 16 y/o expelled from school, needs risk assessment

● 4:30 Open→Same-day f/u after 4 mos○ 20 y/o seeking disability for PTSD, dep



Does it Work?



General Conclusion: Improving Isn’t 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)



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 > 4 visits show clinically significant change○ Cigrang et al., 2006



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



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 (> 80%) said because of BHC:○ More likely to continue with HealthPoint○ Able to see more patients in 20 minutes○ Recognize behavioral issues better



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



REMEMBER THIS!

Worry less about effectivenessand more about productivity!



REMEMBER THIS, TOO!

● Primary care is deluged with behavioral health needs and is ill-equipped to handle them

● Opportunities are tremendous for integration, but…a radically different care model is required

● PCBH is a consultative model designed to meet the unique demands of primary care



Questions?





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

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 Defense’s 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.






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

● Policy/Standards ○ DoD Instruction 6490.15○ Program Standards

■Model of Service Delivery■Staffing Ratios■Expert Trainers■Training Standards■Program Managers■Oversight Committee

Primary Care Behavioral Health Model *


www.dtic.mil/whs/directives/corres/pdf/649015p.pdf


http://www.dtic.mil/whs/directives/corres/pdf/649015p.pdf

● Funding○ Argument made in context of enhancing PCMH implementation○ Based On:

■Data from Army, Navy and Air Force Programs■Veteran’s Administration Programs■Civilian Research




● Funding Argument○Expected Impact on System1. Psychological health-screening referral & engagement2. Evidence-based care-depression & anxiety consistent with CPGs 3. Engaging patients in healthy behaviors (% advised to quit smoking)4. Decrease per-member per-month cost5. Decreased use of emergency services6. Patient satisfaction with & access to comprehensive healthcare7. Primary care staff satisfaction with healthcare delivery8. Identify & effectively manage those at risk for suicide

9. Recapture family member BH services from purchased care

Primary Care Behavioral Health Model *



● 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




Challenges/Lessons Learned

1. Establish a rationale for integrated-collaborative 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.




Challenges/Lessons Learned4. 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.




Challenges/Lessons Learned7. 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.




Questions?2014 Annual Conference




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 Evaluation

Mountainview Consulting Group (Mtnviewconsulting.com)

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)



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



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



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



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



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 clinics—urban, suburban, rural—implementing 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



Questions?





Effectively Implementing the ModelHealth Federation of Philadelphia

Neftali Serrano, PsyD

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




● 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




● 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 network’s assistance such as processes for “opening” cases and eliminating “termination”




● 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 BHC’s 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




▪ 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 model’s impact

– Talent, Talent, Talent: nothing replaces good talent which is why good hiring is crucial



Questions?



Hiring the Right Behavioral Health Consultant

Jeffrey T. Reiter, PhD, ABPP



Hiring a Behavioral Health Consultant

● Qualities to look for○ Clinical

■ Skills■ Knowledge■ Experience

○ Personality○ Interests○ Degree



Interview Questions and Desired Responses



Training a New BHC

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



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



Questions?





Ethical-Legal Practices in PCBH

Neftali Serrano, PsyD

Overview

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



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 patient’s 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



Example of Informed Consent In A BHC Practice Style

BHC Introduction:

“Good afternoon, my name is Dr. Serrano and I’m 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 don’t 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 don’t have to repeat a thing. With that in mind, today …”

In certain situations, using judgment, limits of confidentiality may need to be discussed further.



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/appropriate 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.



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 patient’s rights to release aspects of their record

● There is no ethical mandate, such as in the APA Ethics Code, which prohibits integration of records



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



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 don’t 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



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



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



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



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



http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html

Questions?





Research and Program EvaluationConducting Research on the PCBH Model

Kent A. Corso, PsyD, BCBA-DNational Capital Region Behavioral Health, LLC

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)



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



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 BHM’s four scales satisfied the criterion for internal consistency

reliability○ Across all three samples, internal consistency estimates were stable and ranged from

adequate to excellent (> .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 BHM’s multiple scales (r’s > .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.



Symptom Reduction

● BHC patients (N=495) 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



Decreased Psychological Distress

● Patients (N=234) 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 > 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



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



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% (N=42) via routine screening with BHM-

20○ Only 2.1% (N=7) 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.



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.



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.



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.



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.



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



Conducting Research in PCBH

● Benefits● Challenges● Importance● Tips● Future Directions



Questions

[email protected]





Reimbursement and Fiscal Supportof the Primary Care Behavioral Health Model

Bill Rosenfeld, MC, LPC

Overview

● History of Billing PCBH

● FQHC Point of View

● Care Strategy and the Financial Wheel

● Necessary Considerations

● Alternative funding potentials



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



Fiscal Sense of BHC Encounter Growth

HRSA Program Information Notice 2004-05Document Date: October 31, 2003Document #: 2004-05Document Name: Medicaid Reimbursement for Behavioral Health Services

Each State Medicaid Plan made interpretations of this PIN that had Primary Care Behavioral Health Billing Implications



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



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.



CPT Coding

96150 –Initial Health and Behavior Assessment –each 15 minutes face-to-face with patient96151 –Re-assessment –15 minutes96152 –Health and Behavior Intervention –each 15 minutes face-to-face with patient96153 –Group (2 or more patients)96154 –Family (with patient present)96155 –Family (without patient present)



FQHC Financial Model

COST BASED REIMBURSEMENTProspective 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



Necessary Billing and Reimbursement Considerations

● Point of Service

● Funding Source

● Diagnostics

● CPT Code

● Provider Type


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



State by State PCBH Financing Information

Go to www.integration.samhsa.gov/financing/billing-tools



http://www.integration.samhsa.gov/financing/billing-tools

Questions?



Bibliography / Reference

1. Hunter, C. L., Goodie, J. L., Dobmeyer A. C., & Dorrance, K. A. (2014). Tipping points in the Department of Defense’s 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.


Session Evaluation

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monitor before leaving this session.

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Documents

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