We're creating a decision tree (or algorithm or swim lane) for staff education and decision-making support regarding appropriateness for care within our clinic vs referral to outside resources. We are mostly a PCBH model but do have limited slots for the typical 4-6 sessions. Does anyone have a good example of a decision tree that would guide providers in assessing the appropriate level of care and understanding the population health nature of PCBH services?
We do NOT do any type of algorithm at our PCBH clinics and we rather
encourage staff and providers to send patients BHCs' way!
See Jeff Reiter's previous response (pasted below) from May 30,
2019....which to me gives me a great explanation behind this....
"First, here are suggested referral criteria in the PCBH model: 1) the
is not improving after several visits; 2) the PCP requests specialty help;
3) there is an emergency need; 4) the patient requests specialty care.
JCPMS article that I, Chris Hunter and Anne Dobmeyer published in 2017
discusses this in more detail.
In general, the goal in PCBH is to engage patients first in primary care.
This is because, for starters, we know that many patients will improve in
primary care - but we can’t predict in advance which patients will improve
(a 2012 JCCP study by Bryan et al. even showed that more severely impaired
patients improved faster.) In addition, we know that most patients who are
referred to specialty mental health simply don’t go; indeed, this is the
reason we are in primary care to begin with. (And while it’s true that
rural communities are often particularly underserved, success with
referrals can be just as low in urban areas.) So if we don’t engage with
patients in primary care, and they don’t go to specialty care…then we
are right back where we started.
Thus, it is very important to jump in and help, regardless of the problem.
But perhaps most important is not whether one refers to specialty care, but
rather how that referral is handled. I have nothing against utilizing
specialty mental health; I have referred hundreds, if not thousands, of
patients over the years (and I think a few have actually gone!). :) The key
is to frame such referrals in a way that does not pathologize the patient,
undermine your longitudinal relationship with the patient, or leave the
patient without care.
For example, I often witness BHCs telling patients they are “too
for primary care, or “beyond primary care’s ability to help”. This
is not only horribly pathologizing; it also effectively removes the BHC
perhaps the PCP, too) as a potential source of help for the patient in the
future. (And again, considering that most patients will not go to a
referral, this leaves the patient without any help.)
As another example, I often observe BHCs making the mistake of ending
meaningful follow-up after making a specialty referral, as if the job is
done. Sometimes they actually cease planned follow-up once the pt accepts
the referral (even though the pt is not yet engaged in care). Other times
they do follow-up, but cease their therapeutic efforts; follow-ups become
merely a check-in to see if the patient has begun specialty care yet. This
is problematic because - again - many of these patients will never engage
with specialty care and so once again end up with no care.
I have a couple of recommendations for avoiding these problematic referral
behaviors. First, instead of framing patients through the “either/or”
lens (i.e., either they can be treated in primary care or they need
care), I recommend framing a specialty referral as an “addition” to the
help you can provide in primary care. For example, “Ms. Jones, it seems
we’re not improving your depression like we had hoped. I’d like to bring
a specialist in on your care.” A referral, in other words, should be
framed as expanding the care team, rather than replacing the care team.
in mind that the backbone of primary care is the longitudinal relationship;
don’t sever it. (For this reason, I don’t agree with conceptualizing
PCBH as the first step in a “stepped care model”. It should never be
implied nor stated that patients are “stepping” out of primary care.)
Second, if the patient agrees to a specialty referral, be sure to stay
until s/he is firmly established in specialty care. Continue working on
therapeutic interventions - not merely checking with the patient on the
status of their specialty appt.
Third - perhaps most important - have some faith that you might actually be
able to help patients in primary care. More often than not there is a
tremendous amount that primary care can offer to patients, but because it
doesn’t look like traditional specialty care we sell it short. We join in
the grand delusion that only specialty mental health can save the day, so
we opt out and write a referral. Those of us who are mental health
have spent a lot of time in school learning how to help - don’t deprive
patients of your knowledge and skills just because you have shorter visits
in this model. You might be surprised how much you can help if only you
yourself to engage. (But if you do refer to specialty care - please avoid
the pitfalls described above!)
Thanks again for getting this discussion going!"
In my experience, the PCBH model works best when the instruction to PCPs is
“there is no wrong referral” (as Jeff and I suggested in the second
edition of Behavioral Consultation and Primary Care). If we remove all
barriers to patients receiving BH care and to PCP use of BHCs, I think more
people will receive behavioral health care than if we use algorithms. In
Bridget’s clinic, I think BHCs are seeing about 20% of the patients that
come to the clinic. Not sure what the penetration rate is for clinics using
algorithms; maybe someone on the list has information about this.
CHCW penetration rates for the past *12 months*...And, yeah, we operate
exactly the way Patti describes of "no wrong referral"....
All BHC Providers
As a BHC who works in Bridget's clinic, I want to add we strongly urge a no
barriers approach, even when pt is requesting something clearly out of our
purview (for example, they need a formal substance abuse assessment for the
courts, something that we do not have the structure to do and that is
outside the model)- while a medical provider may initially just assume this
is an obvious outside referral, we work very hard to see those patients,
even if it's a cold crash- we know there can be barriers, external,
contextual and behavioral- that might impact that patients ability to
access that referral, and we want to be able to support patients through
that process- in addition to remaining connected to their primary care
throughout that process. We also know substance abuse doesn't happen in a
vacuum and that connection is a core need that drives substance abuse, and
we want to help them be as connected as possible. I offer that as one
example where it might appear clear cut that a provider would refer out, as
the specific request is a service we don't provide- yet facetime with a BHC
can go a long way towards that referral actually happening and in the
patients overall health.
Thanks for this great input. I will clarify that we strive for exactly the
type of patient care that Jeff described in his email. Our model is "no
wrong referral." The struggle is more around staff education regarding
what services we can reasonably offer while still offering immediate access
to our team members. Our preference is to provide the vast majority of
services within the primary care flow, which we generally achieve. Tension
comes from physicians wanting more scheduled patient slots and from the
lack of faith in community mental health. We end up doing a lot of what
Jeff describes (i.e. pitching a community health referral as adding to the
existing team rather than changing teams) and would like a more clear way
of describing what the patient experience would look like within different
clinical pathways (i.e. 1-time consults, mostly co-visits, co-visits plus
scheduled appts, co-visits plus referral to community mental health).
I really appreciate this conversation. Here’s a thought that comes to
mind, in response to this quote from Randall:
“Tension comes from physicians wanting more scheduled patient slots and
from the lack of faith in community mental health.”
If this is the case, could one not argue for that health center at that point
in time, more scheduled slots offered may be worth consideration? It has
long struck me that in answering that question, we should be mindful of what
outcome is most important to us, our physician colleagues, our patients,
our communities and our learners. The best system for touching the most
patients or having the highest usage rate of BHCs may or may not be the best
system for clinician satisfaction or biggest change on individual patient
symptoms. I am not convinced that we have yet developed a model that is
uniformly the best across all types of clinics and settings.
Good evening! Wow, this listserv is consistently worth the whole price of
CFHA admission! Thanks for this conversation. Like James, Randall’s comment
(“Tension comes from physicians wanting more scheduled patient slots and
from the lack of faith in community mental health.”) jumped out at me. I
work across these two sectors (PC and CMHC) and I am so struck by the needed
and often missed/misunderstood opportunities to partner. When I worked
exclusively in PC, the CMHC system was a constant source of disappointment
to me. When I started to work more with CMHCs, I could see how hard it can
be to get the attention of the PC community. My sense is that we would benefit
from thinking together about how to strengthen these relationships and build
more collaborative connections. Thoughts on this or successes in this area
are appreciated! Best, Suzanne
Here are some suggestions for how CMHCs can improve their service to the
community and increase their value to primary care:
- The default needs to be collecting signed permission to collaborate with
the rest of the healthcare system in the CMHCs first contact with a patient.
Normalize signing releases. Emphasize the critical importance of collaboration
with the rest of the health system. Encourage patients to sign releases.
Do not wait until a “need” for communication arises.
- Remind staff that talking to another provider caring for a mutual patient
is NOT a HIPPA violation.
- Eliminate access barriers for interventions such as phone screening and
“intake” appointments. These are almost always manager/system centered
processes that have little value to patients and further delay meeting a
- Similarly, trust the PCPs assessment. If a PCP says a patient needs a
cardiologist, the patient meets with the cardiologist. If a PCP says a
patient needs a psychiatrist, please don’t second guess the PCP by having
the CMHC conduct its own phone screens and intakes and so on to determine
if the referral is appropriate.
- Allow PCP practices to call and schedule an appointment in CMHCs for a
patient. Nearly every other healthcare specialist allows this scheduling.
CMHCs need to give up on this idea that the patient must call for him or
- Most patients already have a health record. Instead of creating a separate
walled off health record from the rest of the healthcare system, integrate
- Do not close charts and require patients to go to the back of the line
when they decrease their participation in care, or have too many no shows.
- Do not require X number of appointments with a “counselor” before
allowing a patient to meet with a “prescriber.” Patients generally know
best what will help them. Trust them. PCPs also do a pretty good job of
knowing who needs what.
- Require psychiatrists on staff have a DEA-X number and prescribe buprenorphine.
Accept responsibility for addressing the OUD epidemic in the community by
providing easy access to evidence based interventions like buprenorphine and
naltrexone. Providing OUD detox services doesn’t count.
I offer all of these ideas with an acknowledgement that the mental health
system is unfunded and full of very good people. I also acknowledge that
collaborating with primary care practices has its own set of frustrations.
Nevertheless, these are the things I hear from primary care providers when
someone mentions CMHCs. Addressing some of the issues I described above
would go along way towards addressing the “lack of faith.” - Dan
Yes and yes and yes. I’m right with you Dan. What I’m wondering is, are
there ways that primary care can increase its value to Community Mental
At the request of CMHCs primary care could accept responsibility for ongoing
medication management and low intensity BH services for “stable” patients.
Primary care can push health systems to integrate CMHCs into a single EHR.
Good ideas - the second one would be a particular value add as nationally
many CMHCs still do not have EHRs. Unlike primary care, they did not benefit
from federal dollars to enhance care through the purchase of technology.
I’m also thinking that as a community of highly skilled collaborators
(I’m thinking now of our CFHA community) we could more actively engage
CMHCs (and other CBOs that primarily handle SDoH for instance) in developing
these same collaboration skills. I would love to see us expand our gatherings
to include multiple layers of integration. Thanks for your thoughts on this,
you always contribute in a thoughtful way to these dialogues. Suzanne
Great discussion. I think it’s important to keep in mind the CMHC’s
have unnecessary and incredibly burdensome regulations by multiple agencies
which often dictates their lengthy intake processes as well other required
activities which we may not have for BH in primary care. Moreover, they
typically have high rates of staff turnover, low reimbursement rates and
work with one of the most complex populations with high no show rates which
yields great financial losses.
Thanks for the great conversation. In Central Oregon we identified the need
to build relationships between primary care & specialty BH, particularly
with outpatient BH providers but closely followed by CMHPs. Nearly all
primary care clinics in our region have integrated behavioral health and
they identified the lack of access to and coordination with specialty BH as
a huge barrier to effective integrated care. A quote from an integrated BHC
illustrates: "Because of the dearth of specialty behavioral health, we
[integrated primary care BHCs] are filled up doing that work. This doesn't
leave us time to address chronic medical issues & health behaviors."
To address this gap, I am conducting a series of trainings/networking
events called Building Bridges Between Behavioral Health & Primary Care. So
far, we have had incredible success getting these two separate systems in
the same room, getting on the same page with terminology & understanding of
integrated care models, and creating a community willing to work together
to improve access & coordination. We were unsure if specialty BH providers
would be willing to engage, but to our pleasant surprise the first training
filled up to capacity within 2 weeks of opening registration. Many of the
primary care & specialty BH participants had never been in the same room
together. On the event evaluation survey 100% (!!) of participants said
they would attend the next training. (Don't worry, we booked a larger
This work is ongoing but we have experienced early success and learnings,
giving me hope that we can bridge the gap between primary care & specialty
BH - ultimately resulting in increased BH access and better coordination
between primary care & specialty BH. Happy to share more with anyone who
may be interested in conducting similar work in your community - it does
take careful planning.
Shameless plug: If you would like to learn more about our work, we'd love
to see you at the CFHA conference in Denver! I3: Key Factors for Advancing
Integrated Care in Central Oregon: Payer, Provider, Policy, and Technical
Assistance, Saturday @ 3:00pm
Suzanne asked for examples of successful collaborations and I think we have
some. I have worked in the CMHC world for over 40 years and some time ago
began looking at integration. We now have contracts with 4 FQHC’s in
greater Cincinnati. We provide behavioral health consultants for the 12 or
so clinic sites and have been implementing PCBH for a number of years with
varying levels of success depending on space/no space, leadership, culture,
funding etc. We have fully integrated partnerships with each FQHC that
works trying to bridge both systems and improve access in both. While not
always easy, it does work. There is a serious lack of understanding of the
limitations of community mental health agencies including who we are funded
to work with and the lack of funding as well as the many significant challenges
of the clients we work with. On the other hand, the CMHC staff often don’t
understand how primary care works and what barriers there might be and how
to provide supports and resources to help people manage their health.
Relationships could be even stronger but changing cultures takes a long time,
far longer than I ever believed. There is much more to be done for us to
be a fully functioning integrated system of care. We also provide integration
in the opposite direction; two of our offices have embedded FQHC primary
care services for SPMI patients who are served at that site. We are doing
our part and hope that this trend toward integration continues to grow!
All (esp. Randall):
This is indeed another outstanding conversation. Thank you for taking the
time to contribute!
Regarding Randall’s original question, I have not seen a universal algorithm
that I would trust given that context is always king. Every clinic I visit
has constraints, values, cultural factors, community factors etc. that
dictate how behavioral services are viewed and utilized. This feels frustrating
for folks like me who like standardization, but it is a reality I have come
to accept. So, here are my two cents on the question:
1. I hope to validate your question by stating that it is a good question
to be asking AND that it is OK to develop a response that fits your clinic
& patient context.
2. I do agree with other respondents that state that an all-comers approach
or a very simplistic algorithm is usually best so that PCPs don’t have
to do a lot of thinking about the referring/handing off.
3. Use good marketing skills when thinking about your algorithm. For example,
I have used the idea of Tiers of service in communications with PCPs to
help them understand the different intensity of services offered by our
clinic. (eg. PCBH is Tier 1 for large chunks of the population; Tier 1.5 is
MAT for that population; Tier 2 is Specialty therapy visits…). But in the
end triage to the appropriate level should really not be in the purview of
the PCP but rather a “team” decision, much like any other service.
4. Be comfortable with your limits and communicate those. Mostly I have
focused on what we DO as BH team members of the care team, but there are
situations where you need to communicate boundaries. For example, we told
our PCPs that we don’t do court-mandated treatment. My suggestion here is
to have a specific short-list of those things that most frequently come up
in your context.
5. Lastly, feed data back to your PCPs about the referrals/ warm handoffs
so that they understand the impact of their actions and understand the Tiered
nature of population health interventions. For example, X% of patients
referred were handled in primary care, X% were seen in specialty care etc.
This reinforces their behavior and their understanding of the underlying
logic of the approach.
I hope this is helpful to Randall and any others who might be asking this
P.S. I also love the side conversation on coordination with CMHCs. Echo many
of the thoughts shared.
I have enjoyed reading everyone's input.
I work as an integrated psychologist in a rural primary care clinic in Central
Oregon. Since our clinic opened 5 years ago, I have been working with the
local community health programs regarding referrals and shared patients. In
order for collaboration to work well, there has to be regular communication,
interaction and relationship building with specialty mental health providers.
This is important so that medical providers can gain a better understanding
of the work specialty therapists do and vice versa. There has to be a
foundation of trust and mutual respect before successful collaboration can
occur. My experience is that specialty MH providers are often overloaded
with patients, paperwork, limited resources, etc. and that is not always
understood by people outside of that system.
This is a very late add on - but wanted to say this has been such a rich
discussion, especially as it relates to bringing the CMHCs into the fold!!!!!
For anyone interested, CFHA does have a bidirectional forum list-serve,
specifically to tackle the complexities of bidirectional integration (FQHCs
+ CMHCs and other variations!) We have a Bidirectional Integration task
force and we are still trying to find our footing! We aim to meet up again
in October at the Conference Task Force meetings! Please let me know if you
are interested in participating or joining that list-serve. We are actively
trying to make that forum more useful and helpful to folks.
In our CMHC, which has in-house Integrated Primay Care, the BHCs are seen
as the bridge between our embedded Integrated Primary Care services, and the
long-standing familiar psychiatric services. The BHC provides an important
*integrated* perspective to the treatment team and most especially to the
patient, and that INTEGRATED view is one of the most valuable gems that the
BHC provides (besides the quick, evidence-based intervention).
Team-based care becomes activated once a patient gets into our Primary Care
services. We are also getting CCBHC certified which adds to the components
of integration in the mix.
Thanks everyone for your contributions and thoughtfulness around these topics!