Transcript The Integration of Behavioral Health and Primary Care

The Integration of Behavioral
Health and Primary Care:
Keys to Success !
Virna Little, PsyD, LCSW-r, SAP
 Treat mental health disorders where the
patient feels most comfortable receiving
care
 Better coordination of care
 Mind and body connection
 More likely to keep appointments where
multiple issues are being addressed
 The majority of mental health treatment
will occur in community health settingswith focus on preventive care and
integration.
 Mental health diagnosis often go
unrecognized in primary care
 Primary care providers often under
treat mental health diagnosis
 Screening alone does not improve
outcomes for primary care nor is it
considered integrated care
 Comfortability in discussing mental health
issues
 Established relationship with primary care
provider
 “I am not crazy”
 Less stigma walking into primary care
setting then mental health setting
 Depression and anxiety are adverse
outcomes of diabetes, heart disease
and asthma and/or vice versa
 Bipolar Disorder
 Anxiety Disorder
 Perinatal mood disorders
Morbidity and Mortality in People with
Serious Mental Illness
 Persons with serious mental illness (SMI) are
dying 25 years earlier than the general
population
 While suicide and injury account for about 3040% of excess mortality, 60% of premature
deaths in persons with schizophrenia are due
to medical conditions such as cardiovascular,
pulmonary and infectious diseases
(NASMHPD, 2006)
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 Usual Care
 Rarely treated
effectively
 Only 1 in 5 receive
treatment
 Rarely treated by MH
professionals
 Fewer than 10 report
see a MH worker
 Increasing use of
antidepressants in PC
but treatment often not
effective
 Integrated Care
 Most effective approach
to treat mental health in
PC settings
 Comprehensive
 Multidisciplinary
approach
 Fully integrated with
information available to
all practitioners
 Cost-effective
 People seek mental health care in primary care
settings
 Many completed suicides were seen by PCP
 20% on the same day
 40% within 1 week
 70% within 1 month
 White men ages 85 and older highest risk
 PCP referrals to mental health providers may
be necessary but not sufficient to improve
outcomes
 Strong evidence has emerged for
collaborative/integrated care for treatment of
common mental disorders
 The IMPACT (Improving Mood Promoting Access to
Collaborative Treatment) Model
 The Three Component Model (3CM)
 Insurance does not provide adequate coverage
for mental health services
The Four Quadrant Clinical Integration Model
Quadrant II
BH PH 
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High
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Behavioral Health (MH/SA) Risk/Complexity
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PCP (with standard screening tools
and guidelines)
Outstationed medical nurse
practitioner/physician at
behavioral health site
Nurse care manager at behavioral
health site
Behavioral health clinician/case
manager
External care manager
Specialty medical/surgical
Specialty behavioral health
Residential behavioral health
Crisis/ ED
Behavioral health and
medical/surgical inpatient
Other community supports
Persons with serious mental illnesses could be served in all settings. Plan for and deliver
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services based upon the needs of the individual, personal
choice and the specifics of the
community and collaboration.
Quadrant I
BH PH 
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Low
Behavioral health clinician/case
manager w/ responsibility for
coordination w/ PCP
PCP (with standard screening
tools and guidelines)
Outstationed medical nurse
practitioner/physician at
behavioral health site
Specialty behavioral health
Residential behavioral health
Crisis/ED
Behavioral health inpatient
Other community supports
Quadrant IV
BH PH 
PCP (with standard screening
tools and behavioral health
practice guidelines)
PCP-based behavioral health
consultant/care manager
Psychiatric consultation
Quadrant III
BH PH 
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PCP (with standard screening tools
and behavioral health practice
guidelines)
PCP-based behavioral health
consultant/care manager (or in
specific specialties)
Specialty medical/surgical
Psychiatric consultation
ED
Medical/surgical inpatient
Nursing home/home based care
Other community supports
Physical Health Risk/Complexity
Low
High
Focus: Quadrants II and IV
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 Design
 1,801 depressed older adults with major depression and /
or dysthymia (chronic depression)
 randomly assigned to IMPACT or to Care as Usual
 Usual Care
 Primary care or referral to specialty mental health
 IMPACT Care
 Collaborative / stepped care disease management program
for depression in primary care offered for up to 12 months
 Analyses
 Independent assessments of health outcomes and costs for
24 months. Intent to treat analyses
Unützer et al, Med Care 2001; 39(8):785-99
50 % or greater improvement in depression at 12 months
Usual Care
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IMPACT
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50
%
40
30
20
10
0
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Participating Organizations
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 Generalized Anxiety Disorder 7 Tool
 simplified questionnaire developed to help in
the diagnosis of Generalized Anxiety Disorder,
or GAD.
 7 item questionnaire
 a score of 10 or more on the GAD-7
represented a reasonable cut point for
identifying cases of GAD
 Cut points of 5, 10, and 15 may be interpreted
as representing mild, moderate, and severe
levels of anxiety on the GAD-7.
The Patient-Centered Medical
Home
 Principles of the Patient-Centered Medical Home
1. Personal physician
2. Physician/Nurse Fractioned directed medical practice
(team care that collectively takes responsibility for the
ongoing care of patients)
3. Whole person orientation
4. Care that is coordinated and/or integrated
5. Quality and safety (including evidence based care, use
of information technology and performance
measurement/quality improvement)
6. Enhanced access to care
7. Payment structure that reflects these characteristics
beyond the current encounter-based reimbursement
mechanisms
The American Academy of Family Physicians, American Academy of Pediatrics,
American College of Physicians, and American Osteopathic Association
http://www.pcpcc.net/
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Suggested Starts
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Smoking
Depression
Alcohol/Drug use
Unsafe sex practices
Frequent Utilizers
Obesity
Ages and Stages, MCHAT,
Developmental
Chronic illness
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Initial PHQ9 Depression Scores
(Mean Score of 14.03)
Number of Patients
152
62.6%
153
68
27.9%
68
23
9.5%
23
0
Under 10:
Mild
Depression
10-14:
Moderate
Depression
15-19:
Moderately
Severe
Depression
PHQ9 Score
20+:
Severe
Depression
Number of Patients
6 Month PHQ9 Depression Scores
(Mean Score of 7.91)
84
65.6%
84
31
24.2%
31
6
4.7%
6
Under 10:
Mild
Depression
10-14:
Moderate
Depression
15-19:
Moderately
Severe
Depression
PHQ9 Score
7
5.5%
7
20+:
Severe
Depression
 systematic approach that includes certain
tools, routines, and a team approach to
patient care
 3 Components of 3CM
 prepared primary care clinician and practice,
 care management,
 a collaborating mental health specialist
 What do you want to achieve?
 Are there diagnosis or measures your
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organization/department is already
tracking/monitoring?
Are there measures that will help us subsidize
the integration work?
Can this be a CQI or research project?
What is realistic?
Are there outcome measures that will increase
organization buy-in for integration work?
Integrated Care
Co-location
Collaborative
Care
- Systematically combining
physical and mental health
services
- Most common model of
integrated care
- Integrated health care
model
- Term care approach to
mental health based in
community health primary
care setting
- PCPs develop agreement
with mental health
providers to whom they
refer their patients with
mental health needs to onsite mental health services
-Partnership between the
physical health and mental
health providers to
manage the treatment of
mild to moderate and
stable severe psychiatric
disorders in primary care
settings
- Integration of mental
health treatment in primary
care
- PCPs typically do not
follow up on their referral
once it has been made
- May include brief
psychotherapy or simply
medication management
and patient education
Function Minimal
Collaboration
Basic
Collaboration
from a
Distance
Basic
Collaboration onSite
Close
Fully
CollaboIntegrated
ration
Partly
Integrated
Doherty,
McDaniel &
Baird (1995)
Separate
Systems
Separate
facilities
Periodic
focused
communication
; mostly written
View each
other as
outside
resources
Little
understanding
of each other’s
culture or
influence
Separate
systems
Same facilities
Regular
communication;
occasionally
face-to-face
Some
appreciation of
each others
role & general
sense of large
picture
Mental health
usually has
more influence
Some shared
systems
Same facilities
Face-to-face
consultation;
coordinated tx
plans
Basic
appreciation of
each others
role and
cultures
Collaborative
routines
difficult; time &
operation
barriers
Influence
Separate
Systems
Separate
facilities
Communicatio
n is rare
Little
Appreciation
Shared
systems &
facilities in
seamless
biopsychosocial
web
Consumers &
providers have
same
expectations of
system(s)
In-depth
appreciation of
roles & culture
Collaborative
routines are
regular &
smooth
Model 1: Mental
health staff colocated in FQHC
Community Health
Centers
Model 2: Article 31
Mental Health
Center co-located
in FQHC
Community Health
Center
Model 3:
Cooperative
Agreement with
County Mental
Health Service
Model 4: Part-time
Primary Care
Services in Mental
Health Day
Treatment Program
- A full-time Licensed
Social Worker
Family Practice
Psychiatry
- Staff includes
primary care
providers, adult and
child psychiatrists
and licensed mental
health clinicians
- FQHC Community
Health Center
partnered with
County Mental Health
provider to provide
comprehensive
specialized care
- Primary care
provider in day
treatment program
approximately 6
hours per week
- Model improved
with EHR facilitates
special populations
receiving care at
multiple Institute
locations.
- Provides excellent
ability to care for
most populations with
coordinated,
comprehensive care
- Utilizes existing
services to expand
access, continuity
and comprehensive
care, and ensure all
have access to
appropriate level of
service
- Primary care
provider ongoing
primary care as well
as urgent care to
patients who attend
day treatment
program
- Encourages
- Both services
- All patients will be
 Able to use behavioral activation
techniques with patients as an adjunct to
other treatments
 Able to provide optional evidence-based,
brief structured psychotherapy
 Able to establish quick rapports to a wide
range of individuals
 Ability to make patients feel that they are
being listened to and supported
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Screening
Referral
Assessment
Education
Discuss Treatment options with patient
Coordinate care with PCP
Referral to psychiatrist
Start Initial Treatment Plan
Arrange follow-up Contact
Documentation
Referral to outside resources (if necessary)
 Clinical Barriers
 Traditional separation of mental health issues from
general medical issues
 Lack of awareness of mental health screening tools
in the primary care setting
 Physicians' limited training in psychiatric disorders
and their treatment
 Financial Barriers
 Lack of insurance parity for psychiatric disorders
 Medicaid's low payment rates
 Billing restrictions
 Policy Barriers
 Physical health and Mental health funding
streams
 Difficulty of sharing information due to HIPAA
regulations (progress notes)
 Organizational Barriers
 Shortage of mental health professionals
 Limited communication between medical and
mental health providers
 Lack of agreement between medical and mental
health providers
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Can help support integration work
Will vary by organization/setting/payor mix
Time spent with PCP
No show rates for PCP, specialty care
Medication adherence
Emergency room visits/utilization
Productivity for behavioral health
HRSA Medicaid Guide, 2003
E&M
Psychotherapy
New
99201
thru
99205
Where?
Medical Office or
other O/P Facility
Behavior Health Office or
other O/P Facility
Behavior Health Office or
other O/P Facility
Behavior Health Office
or other O/P Facility
Medical Visit that
can include
Counseling
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10
Psychiatric
Diagnostic
Interview
Individual
Psychoth.
Insight
Oriented
Face-to-Face
W/patient
Identify and address
psychological, behavioral, emotional cognitive and social factors
important to physical
health. Patients not
diagnosed with mental
illness.
60
Min.
Who?
Service
Emphasis
90801
40
Min.
Physician, NP, PA
Other Medical
Clinicians
Psychiatrist, LCSW, Clinical
Psychologist, Psych ARNP,
Other (Payer criteria)
Medical
Behavioral Health Initial
Assessment
90804
90806
90808
20
90805
90807
90809
80 Min.
Behavioral
Assessment
Codes?
What?
Est’d
99211
thru
99215
Initial Assessment
Individual
Psychoth.
w/ medical
mgmt.
All
On-going Individual
Psychotherapy
96150 thru 96155
Clinical Psychologist,
ARNP, Other for
Medicare
Biopsychosocial factors
important to Physical
Health problems and
treatments
Goldberg & Oxman, 2004
Medicare
Reimbursement:
908xx codes can
be used by
non-mental
health
professionals
Commercial Payers:
Sometimes do not allow
use of 908xx by PCPs
(usually because of
‘carve-out’ to third party)
Medicaid: Psychiatry
codes must be billed by
licensed MH provider in
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PA
Mauer, NCCBH; 2006
CPT codes adopted in 2002 to address primary-carebased BH services delivered in coordination with PCP
services.
Adopted by
Medicare
Adoption by
Medicaid and
private sector
plans is
occurring on
state-by-state
basis
Health and Behavior Assessment
Documentation Guidelines
 Specific validated interventions for assessing
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readiness to change
Identification of barriers to change
Advising behavioral changes
Assisting by providing specific suggested
actions
Motivational counseling
Behavioral Activation
Arranging for follow-up services
Health and Behavior Assessment
Documentation Guidelines
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Behavior change services are performed as
part of treatment of condition related to or
exacerbated by the behavior or when performed
to change the harmful behavior that has not yet
resulted in illness
Health and Behavior Assessments
 Focus is NOT on mental health but bio-psychosocial
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factors relating physical health
Focus is on improving patients health and well being
Focus on utilizing evidence strategies, behavioral
observations, health oriented questionnaires
Focus on reduction of disease related problems
Focus on treatment adherence
These are NOT preventative medicine counseling codes(
99401-99412)
CPT Codes for Medical Case
Conferences
 99366-Medical team conference with interdisciplinary
team of health care professionals, face to face with
patient and/or family, 30 minutes or more, participation
by non-physician qualified health care professional.
 99367-Medical team conference with interdisciplinary
team of health care professionals, patient and/or family
not present, 30 minutes or more participation by
physician.
 99368-Participation by non-physician qualified health
care professional.
Documentation Guidelines
 A complete patient history with a focus on
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current problems and symptoms
An exam focusing on presenting problems
Medical review , impression and decision
Counseling and/or coordination with care team,
may include patients family
15 minute visit
Documentation for Case
Conferences
 Each participant should document participation
in team conference
 Documentation should include contributed
treatment recommendations
 Documentation should include role of individual
in patients care
 Documentation should include subsequent
treatment recommendations
Telephone Consultation
 Not traditionally covered by payors
 Can be completed by physicians and qualified
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non physician providers
Must be established patient or collateral
Cant be within 7 days following an appointment
or prior to next appointment
98967- 11-20 minutes of medical discussion
98968- 21-30 minutes of medical discussion
98966- 5-10 minutes of medical discussion
Documentation Guidelines 90801
 Document reason for visit and describe presenting
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problem, current symptoms
Obtain psychosocial history including supports,
substance abuse, legal, family, trauma
Obtain psychiatric history including medication,
treatment
Mental Status
Multi-axial
Clinical impressions
Treatment recommendations
Documentation Guidelines
90804 and 90806
 Include reason for visit diagnosis (most payors
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do not reimburse for “v”codes)
Include previous symptoms and current
symptom assessment (quantify if possible)
Utilize tools and report results ( GAD 7, Phq9)
Describe clinical interventions provided in
session
Discuss progress towards treatment goals and
discharge from treatment
Questions ???