Making the Case for Behavioral Health Integration into Primary Care: A Road Map to Success and Sustainability

William J. Kuzbyt, Psy.D., JD, LHRM, CAP Behavioral Health Solutions Bonita Springs, FL www.bhsfl.com

Sponsored by:

Gulf Region Health Outreach Program Gulf Coast Behavioral Health and Resiliency Center Mental & Behavioral Health Capacity Project University of South Alabama

Objectives

I.

Understand implications of integrating Behavioral Heath into Primary Care II.

Discuss conceptual and structural models of integration III.

Discuss privacy, billing, and documentation IV.

Develop a road map for a comprehensive and sustainable Behavioral Health integrated program

Who’s Attending Today?

 Administrative  Financial  Medical Providers  Behavioral Health Providers  IT

Key Questions to be Answered

1.

2.

3.

4.

5.

6.

7.

Are there different ways to integrate behavioral health into primary care?

Are there established models of integration?

Is it appropriate and legal to integrate behavioral health records with primary care records?

What is SBIRT and how does it work?

How does the PHQ-9 work?

What are the codes utilized in behavioral health billing?

What documentation is necessary to bill?

Types of Behavioral Health Services

 Counseling  Education  Prevention  Case Management  Medication Management

Behavioral Health Continuum of Care

Screening Assessment Diagnosis Treatment

The Importance of Integration from 3 Points of View

 Philosophical  Practical  Clinical

Philosophical

 It is the right thing to do to bridge the gap between behavioral health and medical care  Helps minimize stigma and discrimination

Practical

 HRSA told us to do it  Accreditation organizations require it (NCQA, TJC, AAHC)  Many current patients present with behavioral health issues  CHCs serve patients who need behavioral health care  It is a cost effective treatment approach

Practically Speaking…

Not a new concept. More than 15 years of research supports it:  1999 Surgeon General’s report on mental health acknowledged the crucial role of primary care with that of mental health.

 2003 President’s New Freedom Commission promotes integration.

 2004 HRSA designated the integration of behavioral health as a required service to be provided by FQHC’s.

 2005 Institute of Medicine (IOM) called for integration as a best practice.

 2006 SAMHSA Transforming mental health care in America.

 2011 Accreditation organizations include behavioral health in continuum of care.

Clinical

 Mental health problems go untreated in primary care. This compromises the quality of overall treatment and outcomes for patients.

 PCP typically under-identifies mental health problems in patients.

 Mental health issues correlate higher with low-income patients and racial/ethnic minorities.

Clinical (continued)

 People with mental health issues “over-use” primary care services 3:1 as compared to average patients  A significant part of disease management requires behavior change  Clinical protocols often specify BH components (e.g. depression)  Good clinical practice requires communication between clinicians Croghan, T.W. & Brown, J.D. (2010). Integrating mental health treatment into the patient centered medical home, Agency for Healthcare Research and Quality. Rockville: MD.

Clinical (continued)

 Many primary care visits have psychosocial issues (20 - 45%)  More patients seek help through the primary care system (patient is already there)  Community mental health services cannot meet the demand for existing referrals  Most patients do not follow-up with referrals from primary care to CMHCs  Behavioral health IS a part of basic general health care (Bio-psychosocial model) Paine, J. and Mabargto, M. 2012. Integrated behavioral health and primary care. Retrieved from: http://healthcarecommunities.org/workarea/download/asset.aspxid=1343.



Do We Need Behavioral Health Providers?

Utilizing 2010 UDS data, looked at number of patients likely to need behavioral health  2.5 million patients have some level of mental illness  351,000 identified with substance abuse but not treated  For every 2,500 patients served, need:  0.9 Licensed Mental Health Provider  0.4 Mental health support staff  0.3 Substance Abuse Provider  0.1 Psychiatrist

90% of Community Health Centers stated that they are below these levels

Burke, B.T., Miller, B., Proser, M., Petterson, S. M., Bazemore, A. W., Goplerud, E., Phillips, R. L. (2013) A needs-based method for estimating the behavioral health staff needs of community health centers. BMC Health Services, 13, 245-262.

So…

Why with all this history of research and policy support are there not more FQHCs with fully integrated systems of care?

3 Quick Reasons We Often Say “No” to Integration

 Behavioral health and physical health typically operate in silos  Sharing of information can be difficult due to issues of confidentiality, HIPAA, and state laws  Payment and parity issues are restrictive

Practical, Financial, & Clinical Barriers

Administrative

 Can’t handle new project now  Can’t hire new staff and supplies  Can’t risk losing money

Financial

 Can’t bill for that service  Can’t make money

Clinical

   Medical Director says “Can’t deal with the personalities and power struggles of providers.” Provider says “I can’t treat those diagnoses, not my training.” Provider says “I don’t have time to deal with more patient issues during the office visit. I barely have time to do referrals.”

New Motivating Factors…

 Many grants (HRSA 330, HRSA HIT) and accreditation organizations (NCQA, TJC, AAAHC) are requiring integrated health care  Patient-Centered Medical Homes (PCMH)

PCMH Defined

 Care Delivery Model where the patient’s treatment is coordinated through the Primary Care Provider to ensure they receive the necessary care when and where it is needed.

 The goal is a centralized setting that facilitates partnerships between the patient, PCP and potentially, as needed and appropriate, the patient’s family.

 Key focus is on information technology, health information exchange, and other means to assure that the patient gets the needed care. Care is to be culturally and linguistically appropriate to the patient.

PCMH Defined (continued)

 Quality of care is improved and enhanced through access, planning, management, and monitoring of care.

 Better coordinated care, treating the many needs of the patient at once, and empowering the patient to be a partner in their care are basic tenets.

The Joint Commission

 New standard implemented January 1, 2014  Designed to further promote the integration of behavioral and physical health within healthcare homes 

www.apapracticecentral.org/update/2013/11-21/accreditation-standards.aspx

Recap: Integrating Behavioral Health

 FQHCs provide a significant amount of primary care in the United States  Primary Care is the “defacto” behavioral health “starting point”  Primary care settings are appropriate locations in which to provide behavioral health services  The “gold standard” is to provide fully integrated care  There are various ways to provide behavioral health services and different models available to achieve this goal

Models of Integration

Conceptual vs. Structural Conceptual: A theoretical approach or framework to describe the model Structural: The actual step by step guide to the procedures of the model

Continuum of Service Delivery

Isolated/Silo Collaborative Co-Location Integrated

Conceptual Models of Integration

 Isolated/Silo  Collaborative  Co-Location  Integrated

Isolated/Silo

 No commitment between medical and behavioral health providers to work together  Patient provides only source of history  No referral network

Collaborative

 A partnership under which a provider agrees to furnish services to those patients who are referred to it by another provider  Referral relationships may serve as a useful precursor to a more collaborative model, providing both parties with the opportunity to evaluate the partnership prior to implementing a co-location or purchase of services arrangement

Co-Location

 A partnership arrangement under which a provider agrees to treat patients who are referred by another provider, but maintains autonomy of the practice and control over the provision of the referral, and is legally and financially responsible for the patient within the practice.

 However, unlike the Silo and/or Collaborative Model, the provider furnishing the clinical services is physically located at the referring entity’s site.

Integrated

 Behavioral and medical providers are physically located at the same site  In-depth appreciation of roles and cultures of providers  Team approach to treatment for the patient which increases treatment outcomes  Shared systems and facilities in seamless bio psychosocial framework

Integrated vs. Co-Located

Integrated Care

• Embedded member of primary care team • Patient contact via hand off • Verbal communication predominate • Brief interventions • Flexible schedule • Generalist orientation • Behavioral medicine scope •

Co-Located

Ancillary service provider • Patient contact via referral • Written communication predominate • Regular schedule of sessions • Fixed schedule • Specialty orientation • Psychiatric disorders scope Cherokee Health Systems, Blending Behaviorists into the Patient Centered Medical Home, Michigan Primary Care Association Webinar January 11, 2012

Collaborative Care Categorizations At a Glance

Collins, C., Hewson, D.L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. New York: Milbank Memorial Fund.

Collaborative Care Categorizations (continued)

Collins, C., Hewson, D.L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. New York: Milbank Memorial Fund.

Structural Models of Integration

 Impact  Chronic Care Model  Primary Mental Health Care  4 Quadrant Clinical Integration Model

Impact Model

 Patient’s primary care physician works with care manager to develop patient treatment plan  Care manager educates the patient or “coaches”; offers brief (8 session) consults  Psychiatric Support  Outcome  “Stepped Care” 50% reduction in symptoms within 10-12 weeks Unutzer, J., www.Impact-UW.org

Professor, University of Washington

Wagner, E. (2002). The Chronic Care Model

Primary Mental Health Care



Kirk Strosahl

Mental Health Provider (“Behaviorist”) functions as a member of primary care team  Provides consultation to Medical providers  Brief “targeted” interventions  Co-located close to exam room  15-30 minute sessions  Focus is specific “behavior” change Strosahl, K. (2002). Primary Mental Health Care, Mountainview Consulting Group, Yakima, WA.

National Association of State Mental Health Program Directors (NASMHPD). 2005. Integrating Behavioral Health and Primary Care Service: Opportunities and Challenges for State Mental Health Authorities.

Recap: Models of Integration

 Behavioral Health service delivery is on a continuum  Move from Silos to Integration  A variety of ways or “models” to achieve integration

Understanding HIPAA

  Acronyms:  HIPAA — Health Insurance Portability and Accountability Act of 1996  HHS — US Department of Health and Human Services  OCR — Office for Civil Rights Definitions:  Protected Health Information (PHI)—  Covered Entities — every health care provider, regardless of size, who electronically transmits health information  Business Associate — person or organization that you work with which involves the use or disclosure of individually identified protected health information (PHI).

 Privacy Rule—  Business Associate Agreement—defines the relationship between you and the business associate specifically regarding PHI

HIPAA—3 Rules

 Privacy  Security  Enforcement

HIPAA

 Privacy:

HIPAA

Privacy:  Major goal of the Privacy Rule is to ensure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public health and well-being.  The rule strikes a balance that permits important uses of information while protecting the privacy of people who seek care. The rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed.

Permitted Uses

 A covered entity is permitted, but not required, to use and disclose protected health information WITHOUT an individual’s authorization, for the following purposes or situations: 1.

To the individual 2.

Treatment, payment, and health care operations 3.

Opportunity to agree or object 4.

Incident to an otherwise permitted use and disclosure 5.

Public Interest and Benefit Activities 6.

Limited Data Set for research, public health, or health care operations

Treatment, Payment, and Health Care Operations

 Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.

Treatment, Payment, and Health Care Operations (continued)

 Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits, and furnish or obtain reimbursement for health care delivered to an individual and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual.

Treatment, Payment, and Health Care Operations (continued)

 Health care operations are any of the following activities: 1.

Quality assessment and improvement activities, including case management and care coordination 2.

Competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation 3.

4.

5.

6.

Conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs Specified insurance functions, such as underwriting, risk rating, and reinsuring risk Business planning, development, management, and administration Business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information, creating a limited data set, and certain fundraising for the benefit of the covered entity

Authorized Uses and Disclosures

     An authorization must be written in specific terms. It may allow use and disclosure of protected health information by the covered entity seeking the authorization, or by a third party.

Examples of disclosures requiring an individual’s authorization:  Disclosures to a life insurer for coverage purposes  Disclosures to an employer for the results of a pre-employment physical or lab test  Disclosures to a pharmaceutical firm for their own marketing purposes All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data.

The Privacy Rule contains transition provisions applicable to authorizations and other express legal permissions obtained prior to April 14, 2003.

Authorized Uses and Disclosures: Psychotherapy Notes

 A covered entity must obtain an individual’s authorization to use or disclose psychotherapy notes with the following exceptions:  The covered entity who originated the notes may use them for treatment  A covered entity may use or disclose, without an individual’s authorization, the psychotherapy notes,  for its own training, and to defend itself in legal proceedings brought by the individual  for HHS to investigate or determine the covered entity’s compliance with the Privacy Rules  to avert a serious and imminent threat to public health or safety  to a health oversight agency for lawful oversight of the originator of the psychotherapy notes  for the lawful activities of a coroner or medical examiner or as required by law

Acknowledgement of Notice Receipt

 A covered health care provider with a direct treatment relationship with individuals must make a good faith effort to obtain written acknowledgment from patients of receipt of the privacy practices notice.

 The Privacy Rule does not prescribe any particular content for the acknowledgment.

 The provider must document the reason for any failure and obtain the patient’s written acknowledgment.

 The provider is relieved of the need to request acknowledgment in an emergency treatment situation.

Notice and Other Individual Rights

    Privacy Practices Notice: Each covered entity, with certain exceptions, must provide a notice of its privacy practices.

The Privacy Rule requires that the notice contain certain elements. The notice must:  Describe the ways in which the covered entity may use and disclose protected health information.

 State the covered entity’s duties to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice.

 Describe individuals’ rights, including the right to complain to HHS and to the covered entity if they believe their privacy rights have been violated.

 Include a point of contact for further information and for making complaints to the covered entity.

Covered entities must act in accordance with their notices. The Rule also contains specific distribution requirements for direct treatment providers, all other health care providers, and health plans.

Notice and Other Individual Rights

 Notice Distribution: A covered health care provider with a direct treatment relationship with individuals must have delivered a privacy practices notice to patients starting April 14, 2003 as follows:  Not later than the first service encounter by personal delivery (for patient visits), by automatic and contemporaneous electronic response (for electronic service delivery), and by prompt mailing (for telephonic service delivery)  By posting the notice at each service delivery site in a clear and prominent place where people seeking service may reasonably be expected to be able to read the notice  In emergency treatment situations, the provider must furnish its notice as soon as practicable after the emergency abates

HIPAA Privacy Authorization Form

HIPAA Privacy Authorization Form (continued)

HIPAA

Security: Specifically electronic transmission  3 Areas of Safeguards 1.

2.

3.

Administrative  Policies and Procedures Physical  Hardware  Software  Who has access?

 Access of workstations Technical  Housing of data  Authentication of entities  With which communication occurs  Documentation requests  Risk Analysis

HIPAA

Enforcement: In 2006, set civil money penalties for violating HIPAA rules and established procedures for investigations and hearings.  As of a year ago:  Total investigations  Corrective Actions  100% Compliance  Eligible cause for enforcement 72,570 19,306 9,146 44,118

Health Information Technology for Economic and Clinical Health (HITECH) Act

 The HITECH Act was enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009 and became law on February 7, 2009  It’s purpose is to promote the adoption and meaningful use of health information technology  The goal was to “create a nationwide network of electronic health records”

The Road to Success and Sustainability of Behavioral Health in Primary Care

 According to HRSA (2012), utilizing UDS data, the average percentage of Medicaid patients in Alabama is approximately 50%  Generally, if you successfully bill Medicaid, Behavioral Health programs can be sustained

Alabama Medicaid

 On May 13, Act 2013-261 Alabama Code §§ 22-6-150  Changes from fee-for-service to managed care  Creates Regional Care Organizations (RCO)  5 RCOs (§§ 560-X-37-.07)  RCO Governing Body consists of Board of Directors of 23 people  12 represent risk-bearing members  8 represent non-risk-bearing members  1 is physician from an FQHC, appointed by Alabama Primary Care Association and Alabama Chapter of the National Medical Association  RCO must establish a network of care. Psychologists, therapists, and social workers are clearly spelled out as providers in the legislation.

Alabama Medicaid Manual

 Relevant Chapters:  16—FQHC  23—Licensed Social Workers  34—Psychologists

Documentation Required for Medicaid Billing

Reference: Alabama Medicaid Provider’s Manual Chapter 34: Psychologists pp. 34-7 to 34-9

Client Intake

 An intake evaluation must be performed for each client considered for initial entry into any course of covered services.

 The intake evaluation process shall result in a determination of the client’s need for psychological services based upon an assessment that must include relevant information from among the following areas:  Family history  Educational history  Medical history  Educational/vocational history  Psychiatric treatment history  Legal history  Substance abuse history  Mental status exam  Summary of the significant problems the client is experiencing

January 2014 Medicaid Manual, Chapter 34--Psychologists, p.34-7

Treatment Planning

  The intake evaluation process shall result in the development of a written treatment plan completed by the fifth client visit.

The treatment plan shall:  Identify the clinical issues that will be the focus of treatment  Specify those services necessary to meet the client’s needs  Include referrals as appropriate for needed services  Identify expected outcomes toward which the client and therapist will work to have an effect on the specific clinical issues  Be approved in writing by a psychologist licensed in the state of Alabama  The (initial) Treatment Plan is valid when the recipient/legally responsible person and the person who developed the plan sign and date it. Unless clinically contraindicated, the recipient will sign or mark the treatment plan to document the recipients participation in developing /revising the plan. If the recipient is under the age of 14 or adjudicated incompetent, the parent, foster parent or legal guardian must sign the treatment plan.

Treatment Planning (continued)

 The Treatment Plan should not be signed or dated prior to the plan meeting date.

 The Treatment Plan is valid when the recipient/legally responsible person and the person who developed the plan sign and date it.

Service Documentation

       Documentation in the client’s record for each session, service, or activity for which Medicaid reimbursement is requested shall include, at a minimum, the following: The identification of the specific services rendered The date and the amount of time (time started and time ended--- excluding time spent for interpretation of tests) that the services were rendered The signature of the staff person who rendered the services The identification of the setting in which the services were rendered A written assessment of the client’s progress, or lack thereof, related to each of the identified clinical issues discussed All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. The author of each entry must be identified and must authenticate his or her entry. Authentication may include handwritten signatures, written initials (for treatment plan reviews), or computer entry (associated with electronic records—not a typed signature). A stamped signature is not acceptable.

Additional Information

 Documentation should not be repetitive (examples include, but are not limited to the following scenarios):  Progress Notes that look the same for other recipients.

 Progress notes that state the same words day after day with no evidence of progression, maintenance or regression.

 Treatment Plans that look the same for other recipients.  Treatment Plans with goals and interventions that stay the same and have no progression.

Progress Notes

 Progress Notes should not be preprinted or predated.

 The progress note should match the goals on the plan and the plan should match the needs of the recipient. The interventions should be appropriate to meet the goals. There should be clear continuity between the documentation.

 Progress Notes must provide enough detail and explanation to justify the amount of billing.

Authentication

 Authors must always compose and sign their own entries (whether handwritten or electronic). An author should never create an entry or sign an entry for someone else or have someone else formulate or sign an entry for them. If utilizing a computer entry system, the program must contain an attestation signature line and time & date entry stamp. A stamped signature is not acceptable.

 If utilizing a computer entry system, the program must contain an attestation signature line and time & date entry stamp. There must also be a written policy for documentation method in case of computer failure/power outage.

Billing Requirements

 Diagnosis—DSM-IV/DSM-5  CPT Codes  Encounter Form  Billing Form—HCFA 1500

DSM IV to DSM-5: Summary of Changes

Three Major Sections of the DSM-5 I.

Introduction and clear information on how to use the DSM.

II.

Provides information and categorical diagnoses.

III.

Provides self-assessment tools, as well as categories that require more research.

DSM IV to DSM-5: Summary of Changes

 Section II—Disorders  Organization of chapters is designed to demonstrate how disorders are related to one another.  Throughout the entire manual, disorders are framed in age, gender, developmental characteristics.

 Multi-axial system has been eliminated. “Removes artificial distinctions” between medical and mental disorders.

 DSM-5 has approximately the same number of conditions as DSM-IV.

CPT Codes

SBIRT

   Screening  Initial screening is brief (5-10 minutes)  Universal  1 or more targeted behaviors (depression, anxiety, alcohol abuse, tobacco) Brief Intervention  Defined as 1-5 sessions  Goals  Educate patient about health risk  Motivate patient to reduce risky behavior Referral to Treatment  Can be complex based upon the information _____ in the Brief Intervention  Requires strong linkages to specialty treatment  Can be incorporated into an integrated model of care

SBIRT Screening Examples

 PHQ-9  GAD-7  MAST  DSM-5 Online Measures

PHQ-9

PHQ-9 (continued)

PHQ-9 (continued)

GAD-7

MAST

MAST (continued)

Online Assessment Measures

92

SBIRT Documentation

 Documentation for billing purposes  Name, DOB, record number  Start/stop time of face-to-face  Assessment, clinical impression, and diagnosis  Plan of care (goals)  Patient progress, responses to treatment, revision of diagnosis  ICD-9, DSM-IV, DSM-5 diagnosis  Sign, title, and date the record

Key Questions to be Answered

1.

2.

3.

4.

5.

6.

7.

Are there different ways to integrate behavioral health into primary care?

Are there established models of integration?

Is it appropriate and legal to integrate behavioral health records with primary care records?

What is SBIRT and how does it work?

How does the PHQ-9 work?

What are the codes utilized in behavioral health billing?

What documentation is necessary to bill?

Roadmap for Implementation

 Acknowledgment of the Transition  New processes  New procedures  Disruptive workflow  Modification of workflow  Present a plan with a “staged” approach  Can’t do it all at once  Emphasize Continuous Quality Improvement (PDSA)

Roadmap (continued)

 Involve Leadership at every stage  Key stakeholders need to know of successes/needs for modification  Include “Technical Assistance” at all stages  Include a specific timetable for implementation at each stage  Include Performance Measures for goals  Include “Staff Training” as an “item” in the plan  Develop the “Tool Kit” for success

Premise; All FQHCs are Not Alike

 “One size does not fit all.”  All FQHC sites within the same FQHC are not alike.

 Just like we develop individual treatment plans for patients, we must develop individual behavioral health integration models for each FQHC, and possibly, each FQHC site.



Factors/Steps to Consider BEFORE Integration

Conduct a needs assessment  Determine which approach works best for your agency/patients (coordinating care, co locating, integrated)  Use data as the basis for decisions  Address the barriers, they will not leave by themselves!

 “Buy-in” needs to be top-down and “inclusive”  Select the “right” providers; establish “champions”  Use a continuance performance measure (PDSA; PDCA)  Develop BOTH a good business AND professional relationship  Flexibility!

**

Change of Scope

Normalize BH in PC Practice

Conceptually, management of mental health issues are similar to other common medical conditions Recognition (Clinical/Screening Tools) Initial Diagnosis/Assessment Treatment Plan Monitoring Adjustments Follow-Up Care For more severe cases, refer to specialist

PCP Stressors

 Lack of training to diagnose mental health patient  Time concerns for screening and treatment  Concern about effectively monitoring efficacy of treatment  Lack of access to mental health  Collaboration  Coordination  Co-change