More PCBH data from your friends at CHCW!
As always, love bragging on the team at CHCW and wanted to share some of our July numbers (we had a good month!).
At our "mothership" clinic, CWFM, our core BHCs (four psychologists and one LMFT) produced the following stats:
- *4.8 patients per clinic* (clinic being a half day, so 9.6 patients per day; as always, our visits only count if they are billable visits, no meet & greets)
- *1.8 handoffs per clinic per BHC* (clinic being a half day, so 3.6 handoffs per day per BHC; we usually have 3 BHCs on during the day, so in total, the clinic averaged 10.8 handoffs per day)
- *2.34 visits per clinic were paired with a PCP visit per BHC* (either through a handoff or prescheduled paired visit; so 4.68 paired visits per day per BHC; meaning, with 3 BHCs being on in a day, our clinic averaged 14 visits being paired with a BHC and PCP)
- Within the month, *368 unique patients* were served by these five providers, who equate to 3.0 FTE of clinical coverage.
What makes the above numbers even more impressive, IMO, is that July is our onboarding/orientation month for our new FM residents and BH interns, which means the BHCs are being shadowed by eager interns, as well as having low provider census due to orientation responsibilities.
AND!!! August appears to be shaping up to be a great month, as yesterday in our afternoon clinic, *15 handoffs were completed between PCPs and BHCs*. Again, within a four-hour clinic, 15 handoffs that resulted in billable visits!!!
As always, would love to hear other stats/data from other programs!!!
Thank you, David, for your productivity rates. The access to to BH services is impressive.
Do you also have data on patient outcomes in relationship to BH contacts?
How do we as a profession, measure outcomes beyond PHQ9s. I think we need to move the needle forward to investigating what "dosage" and types of BH interventions align best with patient symptoms/stressors/functioning. Identifying the intensity, frequency and duration of treatment should be part of our quality improvement processes and evidence building strategies. I am cautious that these "access" numbers could too easily translate into "More equals better". More is better for access and billable services that support BH staff and some support for patient care but the greater goal of patient sustainable outcomes still needs our attention. Our physician colleagues are trying to move away from this productivity model since the current acute-care productivity approach does not mesh well with the quadruple-aim or chronic disease model of care. The movement toward a value driven model may hold more promise to meet the needs of patient-centered, chronic disease management for our patients and communities.
I would be interested in exploring the metrics of PC and BH that could help us demonstrate outcomes for patients and communities. As a discipline, I think we could benefit from differentiating dimensions of quality indicators--intensity, type and duration along with quantity of care--frequency and access.
In my opinion, this is a complex evaluation and research process that needs our full attention and brain power.
Couldn't agree more with your assessment and that productivity only tells a portion, albeit an important portion, of the story. In our system, we look at a variety of different metrics and the data is quite compelling. Specifically, patient satisfaction with the clinic as a whole (i.e., satisfaction with their experience, front desk staff, pharmacy, etc.) improves when patients see a BHC (and their satisfaction with the services are sky high), patient outcome metrics such as A1C/BP metrics, likelihood of completing well-child/vaccination requirements improve when they see a BHC, our provider satisfaction is approaching a ceiling effect (off the charts, actually) in that providers find the BHCs vital to their ability to practice (the last arm of the quadruple aim that we need to focus on is the cost, which we will try to tackle next!)
To me, however, the importance of productivity is helping primary care achieve its goals of the four C's 1) First contact (aka access) 2) continuity of care 3) comprehensive care and 4) coordination of care. When primary care does those four things well, we know the population of a community improves. Thus, us striving to see the entire population of our health center, which allows us to help PC achieve the four C's... and, :-), having the aforementioned outcomes also motivates us to get that out to our population... we want our community to be healthier, as well as our on-demand access helping support our PCP colleagues (who, as said above, continually rate our services high)!
Would love to hear others thoughts on the outcome piece, because, as Mary said, it needs to be multifaceted!!!
I appreciate David's work to push the needle on models of care, get the word out, and spark some thinking about how to measure it.
In re: ACCESS, mark your calendar to check out our editorial in Families, Systems, & Health - coming mid-September - in which we address measurement of this "god term," and provide some starting points. CFHA members can read the journal for free with one click on the www.cfha.net.
FSH Editors await your rigorous quality improvement project, program evaluation, or research study of implementation outcomes like "access!" Send them in!
Thanks, Mary. I agree strongly with your remarks. I love reading David's successes as they inspire me to keep working on how to improve our team's activity. And, yet, sometimes I wonder how we know that what we do makes a difference. Certainly, we know anecdotally that patients are grateful and frequently are gushing in their appreciation for what we do. But, on a larger scale, WHAT do we do that is essential? What is less so? I truly believe in the relational aspects of BH work and others argue more in favor of the content of what we provide. Is it the singer or the song? Probably both. We've started trying to measure, in outcome terms, in our organization, what BHCs do for our clinics above and beyond RVU production. Knowing the right dependent variable is challenging. Less ED visits? More completed (less no shows) visits? Physiological variables (A1C, BP, weight)? Loving the journey to discovery and look forward to the wisdom of this group.
Hi! A tool that we utilize to measure outcomes is Partners for Change Outcome Management System. PCOMS uses two, four item scales to solicit patient feedback regarding factors proven to predict success regardless of treatment model or presenting problem: early progress (using the Outcome Rating Scale) and the quality of the alliance (using the Session Rating Scale). It takes about 1m to administer and then you utilize it throughout your visit as a talking point to help guide goals and change. We just participated in a multi-site study looking at its effectiveness in the primary care setting with positive results. We are still exploring its effectiveness in co-visits versus one-on-one follow-up sessions. There is a paper and electronic version for tablets.
Hi All - great discussion, as always. I think Mary raises the right concern, but I’m not sure it's the right question. We BH providers always wonder about the effectiveness of our treatments/interventions. But I’ve never been sure how important that really is when it comes to integration. For starters, I’m not sure how possible it is to actually answer. Researchers in specialty mental health have been trying in vain for decades to answer the question of what dosage of what intervention works for whaty person under what circumstances; but still don’t know. We just don’t have the research methods. If we are being honest with ourselves, I also don’t think we have even really demonstrated value at a population level of the mental health system. We certainly all know that sometimes what specialty MH does seems to benefit patients more than they would have benefited from no or other treatment, and we can say as a whole that certain therapy approaches are more likely to be beneficial for certain problems than others (at least for the short term). But that’s about it.
But as I say, I’m not even sure how important the question is for a BHC. One thing I know for certain: no matter how effective I am as a BHC, I will never have the population reach that a PCP does. As a result, I am much more interested to know how I can help tge team to be more effective - not just with patients the PCP refers to me, and not just with patients who have behavioral health issues - but rather with all of their patients.
To that end, I actually think that easy access to the BHC (and perhaps also - relatedly - high productivity) might be one of the most, if not the most, important components of BHC work. One reason is that it might help PCPs identify and engage more with behavioral issues in patients. We both assume and know, for example, that a very real contributor to poor PCP identification of behavioral issues in patients is the PCP’s fear of opening Pandora’s box; the fear of asking about behavioral issues because of the lack of support for helping patients with whatever gets identified. Personally, I believe that PCPs quite commonly know/suspect when a patient has significant behavioral issues; they just may be fearful of bringing those to light and then being on their own to manage them. But what if the PCP knows there is a highly accessible BH provider at the ready, who will be immediately able to help them manage whatever is identified? My guess is that they will feel more comfortable asking about behavioral issues in that situation; they might bring in the BHC or might just handle the problem on their own. But either way, the behavioral issue gets addressed. We probably could do away with a lot of these screening tools that are rapidly and increasingly bogging down primary care, if only the clinic had more readily accessible BH help. There’s a research question in there that I think could be very worth evaluating, but it has little to do with the effectiveness of the BHC’s interventions.
Continuing along this line, how does it affect the PCPs care of other patients (i.e., those w/o bx issues and/or not seen by the BHC) if the PCP has such readily accessible BH help? That is, when a PCP is able to hand off a patient for immediate help from a BHC, the PCP may be able to spend more time with other patients who otherwise might have been shorted on time. To my mind, that would suggest that better care is being provided for the other patients, merely as a result of having a highly accessible BHC. (Of note, this benefit may still accrue even if the individual patients seen by the BHC fare no better than they would have if seeing the PCP alone; i.e., immediate BHC access alone may result in benefits even if the BHC’s patients don’t improve.) Again, there are more than a few research questions embedded here that I would consider more important to ask than the effectiveness of a BHC with individual patients s/he sees.(Gouge 2016 started to answer this question- great study.)
The bottom line is that I wish we in the integration community would think more about how to help primary care broadly, and worry a bit less about how effective we are with the individual patients we see as BHCs (odd as that may sound). Not at all to say that we should not care about our patient outcomes or disregard the question of BHC competence - most PCPs won't handoff a patient to a BHC they perceive as unhelpful for patients or lacking in competence, even if the BHC is standing right outside the exam room door begging for patients. We do absolutely need for our BHCs to be skilled and knowledgeable clinicians who are capable of doing something meaningful with patients. But the basic point I am trying to make is just that primary care is the system that has been shown to have tremendous value to the population if done well - the mental health system (and, by extension, BHCs in primary care) are not likely to ever demonstrate such value. As such, we need to start thinking more about how to improve primary care broadly; we need more “PRIMARY CARE behavioral health” and less “primary care BEHAVIORAL HEALTH”.
One final point (really) - the other reason that our obsession with individual BHC outcomes hampers integration is because it inevitably leads to BHC-imposed guardrails on their involvement with patients. If my goal as a BHC is to improve patient outcomes, then why would I engage in the care of a patient with schizophrenia? Severe substance use disorder? Chronic, treatment-resistant depression? Severe PTSD? etc etc There is no evidence that a BHC can improve outcomes for these conditions with a 30-minute max visit, so the only feasible option seems to be disengaging and referring the patient to specialty mental health. The problem with this approach (well, there are many problems with this approach, but the one most pertinent to this discussion) is that it fails to recognize that there may in fact be much a BHC can do to help the PCP and team manage these patients - even if they don’t get better; and to the extent a BHC can take work off the PCP’s plate, that allows the PCP to help other patients. There are, in other words, always two gains that can accrue from engaging with a patient - one is that the patient *might* benefit from the additional BHC help, but the other is that the team may be better able to help other patients. In my mind, either is a win.
Hopefully this all makes sense, and I welcome the thoughts of others.
PS the data Dave Bauman presents from CHCW, while admittedly not yet subjected to rigorous peer review, is in my mind exactly the kind of data PCBH services should be keeping and exactly the outcomes one would hope to see from a service. Kudos to him and his team!
Jeff, I really appreciate your comments and suggested refocus. You have given voice to some of my own thoughts and generated so many other issues that we could explore more fully. I would suggest moving this discussion to a master document that can be contributed to and commented on more easily.
I am new to this List Serve and enjoying the conversation! I am looking for someone from Idaho who can talk to me briefly about the State of the Union on Medicaid and Primary Care BH integration from a payment standpoint. Can anyone point me in the right direction and/or allow me to bend your ear for a minute? Thanks all!
This is a great discussion and I'd like to share with you a question that has been rolling around in my head:
How do we think about "intended" outcomes and whether we are reaching them. For example, let's say that I choose a brief parenting intervention to support parents whose children are exhibiting negative behaviors and this is implemented clinic-wide among all BHCs. If I choose this based on the knowledge that RCTs showed a 25% reduction in problem behaviors, then how do I think about how my outcomes measure up to the intended outcomes? What about for something less specific, like behavioral interventions for treatment engagement. Of course, I recognize the myriad of differences that occur when BHCs distill elements of an intervention to core components to use in a brief setting, and that we are thinking about apples and oranges when comparing brief interventions to RCTs meant for typical therapeutic settings. I am just wondering how others think about a "gold standard" by which we can say that something is or is not achieving the intended outcomes. Do others think about outcomes in this way? Could it be helpful or is it too murky?