The Role of Tele-Behavioral Health Services in an Integrated Behavioral and Primary Care System

byMarcy Rosenbaum, LCSW, CSAC

Marcy S. Rosenbaum Licensed Clinical Social Worker Certified Substance Abuse Counselor Current employment: Behavioral Health Consultant for

Southwest Virginia Community Health Systems (FQHC) Over 5 years experience using tele-behavioral health. Work history:

Behavioral Health Consultant, primary care Youth Counselor, CSB Clinical SW, psychiatric Hospital Drug Abuse Counselor, Job Corps Center CPS Worker, DSS SA Prevention Specialist, CSB: in school setting SA Residential Tech., CSB residential treatment

Southwest Virginia Community Healthcare Systems, Inc. Group of 4 non-profit federally qualified health

care centers (FQHC) and one regional dental clinic dedicated to improving the access to affordable, quality, comprehensive and preventative healthcare in rural southwest Virginia.

2011 nominee by HRSA’s (Health Resources Services Administration) Office on Rural Health Policy as one of the best practices in the nation for providing integrated behavioral health/ primary care services.

Staffed with 3 behavioral health consultants.

What is Integrated Behavioral Healthcare?

Model of care with a systematic coordination of physical and behavioral healthcare merged into one service delivery system.

PCP and Behavioral Health Consultant work together for patient’s overall health.

Behavioral Health Consultant offers help with behaviors, stress, worry, emotional concerns about physical health and other life problems that interfere with overall wellness.

Physical Healthcare

Behavioral Healthcare

Service Delivery System

(i.e.. hospital, school, primary care office, CSB, telehealth)

Why provide behavioral health services in primary care setting?

Most psychiatric treatment is provided by non-psychiatric medical providers. 1

70% of primary care appointments are related to psychosocial issues. 1

Medical and emotional/behavioral issues are often co-occurring.

Adults with any mental illness are more likely than adults without a mental illness to have chronic health conditions. 2 (cont.)

The burden of care for MH patients is greater than current MH settings can provide.

Approx. 1 out of 4 patients will make it to a behavioral health appointment referred to a setting outside of PCP office. 3

Less stigma and discrimination to go to PCP office for care.

Why provide behavioral health services in primary care setting?

Patient’s Integrated Service Needs

High Blood Pressure

Alcoholism

PTSD

Anxiolytic Abuse

Depression

Hepatitis

Behavioral Health Consultation at Southwest Virginia Community Healthcare Systems, Inc.

Psychiatric assessment Psychotherapy Substance abuse counseling Health and Behavior

Assessment/Intervention (medical illness specific).

Psychiatric consults with UVA

tele-psychiatry program.

Flow of Integrated Services

New or Returning Patient

PCP and/or nurse screen for behavioral health issue

BH ScreeningPositive

YES NO

Refer to BHC(optional in exam

room consult and/or appt.)

Follow-up visits to BHC for brief interventions

Continue withmedical exam

First visit to BHC for further screening

and/or intervention Feedback to PCP

provided throughout the entire process

by phone, face to face, or electronic record.

Typical 30min. BHC session

(5min.) Introduction (5min.) Snapshot (5-10min.) Functional Analysis (5-10min.) Problem Summary/

Behavioral Change Plan (5min.) Charting/Feedback to PCP

Tele-Behavioral Health Services The delivery of behavioral health services

utilizing real-time or near real-time interactive audio/video connections.

Does not include audio-only telephone, electronic mail message, or fax transmission.

To receive insurance payment, must be at an eligible location with an eligible provider.

Eligible locations Federally Qualified

Health Centers Rural Health Clinics Hospitals Community Mental

Health Centers Office of practitioner Skilled Nursing

Facilities Critical Access

Hospitals Renal Dialysis

Centers

Eligible Providers Clinical Psychologists Clinical Social Workers Clinical Nurse

Specialists Physicians Nurse Practitioners Physician Assistants Nurse midwives Registered dietitians or

nutrition professionals

To Bill for Tele-behavioral Health Services:

Reimbursement

April 7th, 2010, Virginia Governor passed joint legislative action approving insurance coverage for telemedicine services. (Not all states do.)

DMAS has recognized use of telemedicine services since 2003.

Practitioner providing the service bills same codes as if face-to-face and uses GT modifier.

Flow of Integrated Services using Tele-behavioral healthNew or Returning Patient

PCP and/or nurse screen for behavioral health issue

BH ScreeningPositive

YES NO

Refer to BHC(optional same day

tele-behavioral health consult and/or appt.)

Follow-up visits by telehealth to see BHC for brief interventions

Continue withmedical exam

First visit by telehealth to see BHC for

further screening and/or intervention

Feedback to PCP provided throughout the

entire processby phone, face to face,

or electronic record.

Clinician use of tele-behavioral health services within the integrated care

model:

Schedule use of telehealth equipment with both clinic sites.

Prepare the patient for the experience. Use same clinical interventions as if behavioral

health visit is face-to-face. Code with GT modifier. Provide feedback to PCP. Tele-psychiatry is through UVA Center for

Telehealth and is a consultative model.

Benefits Include: Patients have access to behavioral health

services in localities that do not have BH providers.

Primary Care Providers have more treatment plan intervention options for patients.

Increases patient adherence to treatment plans. Reduced transportation costs (money and time)

for both the patients and the health care organization.

Integrated care increases the health and wellbeing of patients.

References

1. Robinson, P.JH. &Reiter, J.T. (2007). Behavioral Consultation and Primary Care: A Guide to Integrating Services. New York, NY:Springer.

2. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (April 5, 2012). The NSDUH Report: Physical Health Conditions among Adults with Mental Illnesses. Rockville, MD.

3. Strosahl, K. (2001). The integration of primary care and behavioral health: Type II change in the era of managed care (pp. 45-70). In N. Cummings, W. O’Donohoe, S. Hayes & V. Follette (Eds.). Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. New York: Academic Press.