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Billing with Behavioral health care managers or BHCs? 2 T. Chohfi Thank you Dr. Serrano! That answered my question!!
by T. Chohfi
2 hours ago
"Incident to" Billing 1 L. Edwards Along with Patty, I'm also interested in learning about whether 'incident to' billing is possible for a licensed MH provider (I'm an LCSW) and if so, how? I looked at the attachment from Arissa (thank you) but it's still unclear to me....I'm so new to this that I didn't understand a lot of what was in the attachment.I'm trying to find out if the PCCs can bill for any of my interventions (as we work in collaboration of course) without me being paneled with insurances as a provider? Thanks!
by A. Cotton
Monday, May 4, 2020
Behavioral Health Diagnostic Assessment in Primary Care Behavioral Health 0 E. Serrano Hello CFHA’ers,  My colleagues and I have been discussing the topic of PCBH providers conducting assessments and diagnostic clarification around behavioral health disorders (e.g. Mental Health and SUD Dx) and we would love input from this community.  We are finding quite a divide between those that believe  it is absolutely in scope for a BHC to provide BH diagnostic assessment (usually conducted over 1-3 brief visits, e.g no more than 30 to 40 min. etc.) and those that believe it is not in scope for BHCs to provide BH assessment but more that they could offer BH diagnostic clarification and referral to co-location BH or specialty BH for the BH assessment.  If you happen to be of the believe that it is in the scope for BHC to offer BH assessment within a PCBH model can you please offer any guidance on how you avoid getting clogged down with lengthy BH assessments that leave you unavailable for your team and patients, etc.  Thank you so much for any thoughts on this matter!  Respectfully,  Laura  I reject the premise that the “model” should dictate the organization of the service.  What do the PCPs want from the BH services? What services will lead to improvements in patient outcomes? What is the availability of specialty services in the community? How does this vary based on payer? However, your question also raises a broader question about the role of assessment in primary care.  I would propose that primary care clinicians (including BHPs) ought to have a fundamentally different relationship with diagnosis and assessment than specialists. The scope of diagnosis and assessment should be limited to questions that will influence the delivery of an intervention that can be expected to improve outcomes.  Stated more bluntly - there is limited value in clarifying a diagnosis if that clarification does not impact treatment.  In most cases this is the standard the best primary care physicians use when making decisions about screening and assessment, and it is the standard that BH providers in primary care should be holding themselves to. Consider three common scenarios: 1) A patient experiencing a depressive episode seeks treatment for that condition, but is absolutely unwilling to consider medication.  The team wonders if this patient has a unipolar or bipolar mood disorder.  The patient feels strongly that he has bipolar disorder.  I am proposing that in this circumstance it probably isn’t that important to clarify the diagnosis, at least not in the near term.  The sorts of behavioral interventions we can offer this patient won’t differ in most clinical settings depending on whether this patient has MDD or bipolar disorder 2.  At this time its clear he is experiencing a depressive episode.  The immediate focus should be on engagement of the patient and behavioral interventions that address the patient’s goals - in this case improving functioning.  Time spent referring the patient for a thorough assessment and diagnostic clarity is unlikely to add value.  In fact time spent clarifying diagnosis in this scenario would be in service of the teams “needs.”  Not the patient’s needs and preferences.  This approach is potentially harmful.  It is acceptable for us to be uncertain about his “true” diagnosis.  Especially in the near term.  I would also argue that patience and time will clarify his diagnosis more accurately than testing and interviews. 2) An adult patient presents to primary care with a history of trauma.  She currently complains of excessive worry, nightmares, and panic attacks.  She seems to think and worry about the past, present, and future.  In this scenario I am not convinced that substantial effort should be spent parsing her diagnosis.  Given what we know about the low rates of success in referring patient to specialty mental health services, how much energy should be spent sending her for diagnostic clarification? If the full assessment determines she meets DSM5 criteria for Panic Disorder and GAD but does not meet criteria for PTSD, how will that change what we offer her?  Will it be substantively different than if she had met criteria for PTSD and panic, but not GAD?  Perhaps in some communities it will.  In many/most communities I don’t think it will make a difference. In this scenario, the diagnostic clarification would not even offer much guidance in terms of medications.  The efficacy of SSRIs for treatment of GAD and PTSD is generally overestimated.  The risks of benzos have bene thoroughly discussed, though clearly they make an important positive difference for some patients.  We have medications that can target nightmares with some effect, but do we need a thorough diagnostic assessment before we would try a pharmacological intervention for nightmares?  I think the answer is no.  We can provide effective treatments even while we tolerate diagnostic uncertainty. 3) A patient exhibits problematic behaviors in relation to providers and staff.  Members of the team ask “Does this patient have borderline personality disorder?”  As a BHP you think, perhaps the patient does have BPD.  Perhaps not.  But clearly her behavior is problematic.  How would referring her for diagnostic clarification be helpful?  If you are fortunate enough to live in a community that has access to a DBT program perhaps you would need the “official” diagnosis before the program would accept her.  But this is only relevant in circumstances where the patient is willing to engage with DBT services.  In this case the patient’s willingness to engage is more relevant than her “true” diagnosis.  And as the BHP, if I thought she might have BPD and a DBT program was available, and the patient was wiling to go, I wouldn’t spend any of my time worrying about her “true" diagnosis.  With her permission I’d put the diagnosis in her chart and connect her to the DBT program. Now imagine you don’t live in a community with a DBT program that has availability.  Or imagine the patient is unwilling to go anywhere other than primary care for treatment.  What would be gained by clarifying her diagnosis?  Why should we spend time on assessing a problem when the range of treatment options we have available is so greatly restricted?  Either way our job is to help the team respond to her behavior in a therapeutic way.  Maybe this would aided by giving her the diagnosis.  Maybe not.  I could provide other examples related to cognitive decline and dementia.  Or related to young children.  Or related to specific substance use disorders, such as stimulants. As a psychologist I spent nearly half of my time in graduate school learning to measure and describe and accurately label symptoms.  However, nobody ever stopped and asked - What is the value of accurately labeling or measuring or describing a problem in the absence of available, effective treatment?  Years of practice in primary care have taught me that it is critical to ask this question. Specialists are generally willing and eager to measure and describe problems they can’t fix.  Primary care behavioral health providers should work hard not fall into this trap.  Before dedicating time and energy to assessment, we must ask, what is the probability that a more thorough assessment will lead to a meaningful improvement in this patients outcome? That probably wasn’t really your question.  No matter what your team does, in-house assessment or referral for assessment, I hope that they think about the functional value of the assessment in relation to expected patient outcomes.   Daniel This is a really great question Laura! Dan’s response below is very rich and so reflective of our work in primary care.  I wanted to add a few thoughts. PCBH is a true evolution of BH care (developmental concerns, mental health concerns, substance use concerns, and concerns related to health behavior). My thoughts... Diagnostics are a common service in primary care. Diagnostics are often not time intensive. Diagnostics are an unfolding process.  Diagnostics happen after an investigation into life context (contextual interview). Primary care clinicians (PCCs) and the people we provide care to both benefit from us clarifying diagnosis within our scope of practice. The health record and PCCs are treasure troves of longitudinal information that we can use for diagnostics. Patient Reported Outcome Monitoring Information System (PROMIS) implementation across clinic systems could provide primary care teams (including BHCs) even more biopsychosocial information visit-by-visit for a variety of clinical purposes including diagnostics. Warm regards, Julie I just wanted to “thumbs up” Daniel’s & Julie’s thoughts – at the risk of going off-topic and maybe ruffling some feathers, I would take this a step further and suggest that the many issues Daniel describes illustrate some fundamental problems with our current approach to psychological diagnosis in general… Mike This thread has been both useful and validating regarding the process that our team has been over the past year. Thanks to all those who shared, what a wise group of folks (and not just because I agree with you)! Laura—to the nuts and bolts aspect of your question about not getting bogged down by lengthy assessment ( I assume you are, in part, referring to documentation):  Over the past year I have been developing a documentation template for our behavioral health team that provides a DSM 5 diagnosis where applicable.  As many called out in this thread-we have actually found that the contextual interview lends itself quite readily to documenting what I would call a provisional diagnosis (I am in the camp of questioning the overall value of being too married to the DSM as the be-all of defining functional impairment but that is another conversation). In the likely event that your current documentation template already reflects patient priority for intervention, onset and history of that problem and symptoms/functional impairment I think you will find it is not a stretch to put on your diagnostician hat and provide that provisional diagnosis.  It is definitely an additional layer to documentation but I would argue that most of us are already quite aware when we are speaking with a patient who likely is experiencing a challenge that would meet criteria for something like GAD, MDD, PDD or PTSD for example.  I just completed training for my team (LCSWs, LPCs and PsyDs) on adding a diagnosis to our documentation where applicable and have developed a template for it. It is not perfect but it is functional and I would say once acclimated to thinking and documenting in this way  it adds very little time to assessment if you are already in the habit of using screening tools such as the PHQ-9, EPDS, GAD-7.  I find that these tools really help increase efficiency. Happy to talk with you more if I can be of help! Warmly, Katie This is great Katie!  I agree the standard use of psychosocial measures in addition to the standard biomedical ones (BP, weight, temp, etc) in primary care practice really helps BHC efficiency.  I threw in my last comment about PROMIS because I see a future where primary care uses a measure like this visit-by-visit.  In that day, our work as BHCs in primary care teams would be more supported at the operation level and the whole operation of primary care would move closer to a biopsychosocial service for all. PROMIS implementation or something similar to it would be a lift for primary care clinics...but I hope we all move in that type of direction in primary care practice.  As IBH in PC people we are the kind of people who together move big vision into large-scale reality...:)  Warm regards, Julie I agree with Julie’s last comment. Further, it seems to me that this thread is predicated on patients who self-identify or exhibit obvious symptoms per Daniel’s three examples:  1. A patient experiencing a depressive episode seeks treatment for that condition. 2. An adult patient presents to primary care with a history of trauma.  She currently complains of excessive worry, nightmares, and panic attacks. 3. A patient exhibits problematic behaviors in relation to providers and staff. There is a case to be made for the silent majority that suffer without connecting the dots as either a topic for discussion with their PCC or a request for referral to BH.  Studies have shown a majority of BH and MH cases are untreated no matter how severe. Every day patients’ physical symptoms are addressed without adequate consideration of a potential psychosocial source, such as somatization, for their lack of wellbeing. Consider Julie’s suggestion for the delivery of a periodic, universal, and broad-based BH screening assessment to primary care patients. The patients who are pre-screened as likely for BH or MH conditions can be treated for their symptoms, when verified.  The BH team can use the constellation of symptoms identified by screening to provide more timely and efficacious treatment and avoid the problems Daniel has identified. Diagnostic indications for coding are documented, step-by-step. PROMIS is a system of outcome measures that are well suited for determining the improvement of patients during treatment, but it might not be the best instrument for broad-based BH screening assessment. Best regards, Dave Thank you Dave for adding this comment to this excellent conversation. In my experience, we need both BHC input on assisting PCPs with diagnoses in patients that have reported emotional issues. And we need to continue to increase screening of all patients for potential behavioral and mental issues.  Thanks everyone for providing meaningful information, Patty
by E. Serrano
Tuesday, April 28, 2020
Behavioral Health vs Mental Health Integration 0 E. Serrano Hello CFHA Crew, We are planning on integrating psychiatry into our existing family medicine residency aside from existing behavioral health traditional and more integrated services. In describing our program, we had a discussion around what term to use: Behavioral Health vs Mental Health Integration? I grew up in integrated primary care where we called it behavioral health integration, a term that is also widely used in the integrated care literature or throughout this listserv. However, I was informed by a faculty member, that apparently in the psychiatry world, the term mental health integration is used, rather than BH integration, which left me a bit perplexed.  So, I was wondering if someone could enlighten me about the term mental health integration and its use - specifically in the psychiatry realm and if others use the mental health integration term (vs BH) when psychiatry and BHCs work in primary care to describe the service. I was told it is a newer movement - but honestly, I have not been aware of a term/name change. I would also be grateful for any literature citations of the difference between the two terms.  Thanks in advance for your thoughts,  Verena I don’t think your source speaks for the psychiatrists most involved in integrated care.  Lori Raney wrote an authoritative book in 2014 called “Integrated Care:  Working at the Interface of Primary and Behavioral Health Care.”  I suspect any strong preferences are regional. Alexander For what it’s worth, our program at Mayo is called Integrated Behavioral Health.  Our group includes psychiatry, psychology, social work, and nursing.  I personally like the behavioral health option better since it seems to allow for addressing behavioral health issues that are not always linked to a DSM diagnosis but that impact health.  I suppose it might depend on what one sees as the denominator – all patients with mental health diagnoses, or all primary care patients?  The behavioral health option seems more inclusive.  I am not surprised that there are more than one opinions however.  Ask two psychiatrists… Mark As Mark said, Behavioral Health is more inclusive than mental health diagnosis and can include health related behaviors, such as smoking, or adherence to treatment for a medical condition, those items that are treated and billed under Health & Behavior Codes rather than mental health codes.  Its a large umbrella and mental health is one important piece of a larger group of behaviors. Doug I propose an alternative perspective that in an effort to be inclusive we may minimize the significance of mental health conditions and substance use disorders with other health behaviors.  Additionally, there is a movement back to addressing mental health and substance use without using the generic behavioral health label.  If we want to be inclusive, let’s just say “integrated health services. “  Dave I have been following this thread and enjoying it immensely! I love this idea that Dave suggests! “Integrated service delivery is “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.”   WHO 2008 Laura As a nurse I prefer integrated care.  I absolutely agree that when discussing integration using behavioral health over mental health is more inclusive. Training and teaching new staff and students I find it is more accurate, less intimidating and more reflective of the care provided.  Marcy I use the term integrated care to describe the integration of behavioral health, physical health, and social services.  I believe behavioral health encompasses both mental health and substance abuse disorders.   Integrated care describes the setting in which services are offered and collaborative care describes the process of providing interdisciplinary patient-centered care. My work focuses on people at risk for and diagnosed with HIV.  The rates of behavioral health conditions in this population are higher than the general population and people are often in need of patient-centered coordinated care to address their complex health and social service needs. Vickie BLUF:  my comments below notwithstanding, this discussion may seem important to us but is irrelevant to our patients.  Our goal is to achieve integrated healthcare whether in primary care, surgery, oncology, rehab or whatever. That said, someone needs to lie down in the road in front of this bandwagon.  This is really nothing new, but started when the National Council defined itself with the term “behavioral” 25 years ago.  In numerous focus groups with patients in multiple settings over many years I’ve heard people being helped with pain management, tobacco cessation, etc  bristle at the term mental and individuals with mental illnesses bristle at their mood or hallucinations being called behavior.  Thus I still keep the terms separate.  Common lexicon does use behavioral as the overarching term but I reserve the right to ignore that in my work and thought. Again, it matters little to patients if we simply address what’s important to them without calling it anything. Andrew Just a bit of context, building on Andrew’s comments-  the term “Integrated care” has a much broader meaning to most health care administrators and “behavioral health” barely makes the conversation.  Examples of integrated care are Kaiser, The V A, and compared to the US, many of the health systems around the world.  I feel a bit presumptuous and overstepping  using “integrated” with out “behavioral health”.  For more information, as an example, read the recent WHO report on integration ( http://www.euro.who.int/__data/assets/pdf_file/0005/322475/Integrated-care-models-overview.pdf) You will see that behavioral health or psychology or mental health are barely mentioned.  It’s the same application of systems thinking as we apply in our behavioral health world but on a much grander scale.   Larry
by E. Serrano
Tuesday, April 28, 2020
Outcome Measures for Young Children 0 E. Serrano What kinds of outcome tools are people using for children under 12? Specifically for anxiety and depression. Shanda We use the PSC-17 and collect it at every BHC visit.  Arissa I used the SCARED for anxiety. Spoke to the developer who said the subscales can be utilized by diagnosis (GAD, Social Anxiety, etc) for measuring progress and outcomes. Lori Hey Shanda!  I’m glad you asked this question as we are thinking about shuffling around some of our measures ourselves.  We just finished writing up a manuscript on the difficulties in measurement-based care for children given their rapid development often requiring different measures for the same conditions and the complexity involved with having multiple-informants which is often important in the assessment of children.  Here is where we are at with anxiety and depression under 12: Anxiety Spence Preschool for young children: https://www.scaswebsite.com/index.php?p=1_28 SCARED for school-aged children: http://www.midss.org/content/screen-child-anxiety-related-disorders-scared (make sure you grab the scoring excel sheet, makes scoring SO much easier) Depression We were using the CDI, but are likely switching to publically available measures either: CES-DC (6-17): https://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf Or MFQ (6-19):  The RCADS and subscales are also pretty good options and we have been considering due to number of languages available:https://www.childfirst.ucla.edu/resources/https://www.corc.uk.net/outcome-experience-measures/revised-childrens-anxiety-and-depression-scale-and-subscales/ Hope that helps, looking forward to continuing this discussion.  Sounds like this might be a great topic for the PEDS SIG for either a quicknotes or facilitated discussion during one of our monthly calls. Cody In case it’s helpful, our lab just published a review of 37 different freely-available, validated measures for the most common youth MH problems: Andrews, J. H., Cho, E., Tugendrajch, S. K., Marriott, B. R., & Hawley, K. M. (2020). Evidence-based assessment tools for common mental health problems: A practical guide for school settings. Children & Schools, 42(1), 41–52. https://doi.org/10.1093/cs/cdz024 We modeled it as an update and extension of Beidas and colleagues 2015 review of free, brief, and validated measures; with a narrower scope of target problems and ages, but greater attention to practical features like Cody highlighted (available languages, scoring and training tools, etc.) that often matter most when deciding which measure will really meet your needs. It was published in a special issue of a school social work journal, so the text emphasizes school-based applications, but the core information is equally applicable to primary care or any other context. To make it easier to access and compare the different measures, we also compiled copies of as many of them as we could plus their manuals, scoring instructions, etc. in a google drive folder accessible here: https://youthmentalhealth.missouri.edu/MeasurementTools.html I’m happy to share the full article backchannel with anyone who’d like a copy. Feedback and questions are always welcome as well :) Jack
by E. Serrano
Tuesday, April 28, 2020
New H&B Codes 0 E. Serrano All: This is an FYI related to new H&B Codes for 2020 (see attached). Check with your institutions for specifics of implementation as your EHRs may not yet be updated to reflect these changes and I imagine that in some cases some payers may not be exactly ready either. So, do your homework.  The long and short of it appears to be a new set of codes replacing the original set which get rid of the “re-assessment” code, consolidate the time frames so that there is one code for 16-30 minutes in length and then an add-on code for each category when a visit goes longer that 31 minutes. Fun, fun, fun. Thanks,  Neftali Thanks for sending this, Neftali. Has anything changed as far as LCSWs being able to use these codes? Neil Licensed Clinical Social Workers are still unable to be reimbursed for H & B Codes under Medicare. In 2019, Senators Debbie Stabenow, MSW (D-MI), and John Barrasso, MD (R-WY) introduced the Improving Access to Mental Health Act (S. 782/H.R. 1533), in part to address this issue. There are 3 facets to this act which target increasing Medicare beneficiaries’ access to mental health services summarized here: 1. reimbursing outside CSWs for providing mental health services to patients in skilled nursing facilities 2. reimbursing CSWs for addressing emotional and psychosocial concerns related to a health condition under Health and Behavior Assessment and Intervention (HBAI) Services 3. increasing the Medicare reimbursement rate for CSWs For more information, see link to the Act here: https://www.socialworkers.org/LinkClick.aspx?fileticket=dO4-ecE_T8Q%3d&portalid=0 I recently met with Debbie Stabenow and with one of her health care staffers about this and have been doing some advocacy here in MI. They need more support (from both sides of the aisle) to get this in order to get it passed… and hope to move it forward within the next few months.  Please consider reaching out to your representative to urge support of S.782/H.R. 1533. Thanks. Amy All this information has been very helpful.  I have another H&B code question: For shared medical visits within primary care that are co-led by a medical provider (MD) and a BH provider (psychologist), such as for obesity/weight management, hypertension, diabetes, chronic pain, etc, is it possible for both the medical provider and the psychologist (using the H&B group intervention code) to bill for the visit? More generally, would this be possible for shared medical visits for patients with a DSM psychiatric condition (e.g., substance use disorder), such as for addictions groups (e.g., within a suboxone program)?  Many thanks in advance!  Kate Hi Kate - I will be interested to hear what more experienced others say, but what I've been told is that the short answer is no; both PCP & BHC cannot bill for the same time period. That said, I've been told that if enough time is spent w/ the patient, for billing purposes you can split the time and treat it as 2 visits - a PCP visit w/ the BHC present, and a BHC visit w/ PCP present, and bill accordingly. Mike Also, if there was a DSM diagnosis I would be thinking that that cannot be used with HBI, that attaches more to a psychotherapy cpt code.   HBI diagnosis gets attached to medical diagnosis versus DSM ones, correct? When our BHCs are seeing someone in MAT for SUD diagnosis treatment planning and support we are usually billing a therapy or assessment code (90791, o4 90832 etc).  Also, can Clinical Social Workers (LISW) bill HBI codes? Interested to hear others thoughts. Kathy Hello, Clinical Social Workers cannot bill the HBI codes for Medicare, but can with some commercial insurers and some state Medicaid programs. If you state does not allow CSW’s to bill these codes for Medicaid patients, please advocate that they pick up the codes. And we should all advocate nationally that CMS and Medicare change the rules to allow CSW’s to deliver this service and get paid for it re: the link below in this email chain. What many folks are doing with the IMAT groups that include a provider and a behavioral health clinician – the provider is billing a “shared medical visit” E/M for a portion of the group, e.g. the first 30 minutes, and the CSW is billing a group therapy code 90853 for the second half of the group. So, they are billing for separate time periods and also separate foci of the group visit. So, the service, documentation and billing all connect.  Thanks,  Mary Jean Hi CFHArs, We are fortunate in NC to have masters level BHPs of all types with the ability to bill HBAI (and CoCM!) Same day, different time slots captured for psychotherapy and a PCP visit = yes Same time slot (unsplit)  for any two visits = nope Same day HBAI and PCP visit for = Not for our NC Medicaid since the billing is “Incident To” the PCP and creates two events by one provider (PCP) for same Dx and only one will be paid. It is a challenge to have patents return for  HBAI focused interventions and a same day handoff cannot always be captured in billing unless other coding options are used such as a 90832 to address or r/o comorbidities. Regardless, the intervention and opportunity to engage the Pt should take place. For Medicare same day with doctoral level BHPs - I am not sure since they can bill HBAI under their own NPI HBAI intel: https://www.apaservices.org/practice/reimbursement/health-codes/health-behavior-codes-changing https://www.apaservices.org/practice/reimbursement/health-codes/health-behavior Eric Eric: Do you know if there is any data on the utilization of these codes by MA level professionals in NC or how we could get that? It may be helpful to advocate in other states if there is data to set a precedent by and potentially ease the concerns other states may have about opening reimbursement to more providers. Thanks, Neftali
by E. Serrano
Tuesday, April 28, 2020
Policies/Guidance on Treating Co-Workers 0 E. Serrano Hello All – I imagine this has come up on the list-serve a number of times, so I apologize if I’m re-hashing.  I’m wondering if anyone has an explicit SOP on how to handle staff and/or medical providers seeking treatment from a BHC. In lieu of that, general guidance/heuristics/etc. are very appreciated. One of my direct reports recently received a warm-handoff that turned out to be one of the MAs in the clinic. The BHC & MA discussed the multiple relationship & decided that, at least for the initial consultation to assist the PCP, there was no harm in it. The BHC asked me later how to approach any follow-up care.  Frankly, having “grown up” in the PCBH model, I don’t know that I trust myself to be entirely objective here. I see the concept of rotely refusing to treat co-workers as antithetical to the model, as being more concerned about CYA than the patient, as being insensitive to the norms of medical culture, and as reinforcing the stigmatization of mental health. That being said, it’s very easy for me to say this because I’ve never actually been in the situation! I can certainly think of plenty of reasons to consider whether seeing co-workers would be appropriate in a given case, and certainly would never do so without that careful consideration. I also acknowledge and validate the natural discomfort that would inevitably come in such a situation. I’d appreciate any and all wisdom you all are willing to provide! Thank you very much; have a great one. Mike Hi Mike,  I recently looked into the ethics literature around this topic for a manuscript that I just submitted, and I found a fairly wide range of opinions.  I’d recommend reading all three of the articles below yourself (backchannel me if you like me to send the PDFs), but based on my memory, the cliff notes version is that the Kanzler et al paper aligns closest with your own instincts (argues in favor of treating colleagues as long as the ethical implications are well considered and both parties are comfortable with it), the Williamson et al. article falls more on other side side of avoiding any treatment of colleagues, and Reiter & Runyan provide more of a middle-ground case example suggesting that it may be most defensible to provide brief assessment/intervention for colleagues in crisis or other more urgent situations but may be best to avoid engaging in longer ongoing care relationships.  Kanzler, K. E., Goodie, J. L., Hunter, C. L., Glotfelter, M. A., & Bodart, J. J. (2013). From colleague to patient: Ethical challenges in integrated primary care. Families, Systems and Health, 31(1), 41–48. https://doi.org/10.1037/a0031853  Reiter, J., & Runyan, C. (2013). The ethics of complex relationships in primary care behavioral health. Families, Systems and Health, 31(1), 20–27. https://doi.org/10.1037/a0031855  Williamson, A. A., Bignall, W. J. R., Swift, L. E., Hung, A. H., Power, T. J., Robins, P. M., & Mautone, J. A. (2017). Ethical and legal issues in integrated care settings: Case examples from pediatric primary care. Clinical Practice in Pediatric Psychology, 5(2), 196–208. https://doi.org/10.1037/cpp0000157 All the best, Jack I think Dr. Bruner’s question is an important one to visit, and re-visit, since it is a potentially challenging ethical dilemma.   For me, the answer to the “do I or don’t I?” question, is a solid “it depends!”  While it would be comforting to have a standard “SOP” for this, I’m not sure that is really possible.  On the one hand, a standard refusal to see another member of the primary care team for a BH concern or question, is likely to alienate our work from the rest of the healthcare team (in my experience in primary care, it is very much part of the culture for physicians to treat other physicians), reinforce existing silos, promote stigma, and keep BH concerns in the shadows of our culture.  On the other hand, it would be potentially very challenging to treat every BH concern that is brought to the BHC and depending on where one practices (i.e. rural or smaller communities) and for how long, the overlapping relationships that can accumulate over decades can make it quite uncomfortable in some scenarios.  I practiced in a rural primary care clinic for 28 years and over time one has to be increasingly mindful of keeping all the stories straight. I’ve treated physicians in my clinic, nurses, and front desk staff.  I’ve always taken the approach that I’m happy to listen, educate, answer questions, and weigh (together with the colleague) the pros/cons of being the treating provider for this particular concern (something along the lines of “if we do this, I’ll know a lot more about your personal life than you know about mine; is that ok with you?  What do you see as the options?”).  In many cases it is not treatment per se that is being requested, rather a professional opinion about next steps or some education about a particular topic.  We just don’t know until we head into the story at least a little bit.  I would place myself firmly in the “middle ground” category of being selective about which problems I will treat and which, for any number of reasons, might be best referred to another clinician outside the walls of my clinic.  But, in the spirit of integration, I try to be a resource to collaborate with my colleague to determine what is the next best step to ethically and professionally address their personal concerns. Love to hear the wisdom of others. Jeff My thoughts match Jeff’s exactly.  I’ve been in a rural clinic for 6 years and have seen a large number of employees. I’ll admit, I don’t always love doing this and I’ve asked the question to a number of colleagues as it goes against the traditional training I received in graduate school.  At the end of the day, I had to make the decision based on the culture of our organization.  Our PCPs treat each other, they treat most of our staff (including myself), and so drawing a firm line would be quite opposite of our clinic culture.  Those of you in rural health in isolated regions know that trust and familiarity are valued probably more than anything else (including expertise), so seeing employees honors the overall ethos of my community.   Having that said, I encourage my team to voice when they feel the dual relationship is too close, to try to triage when possible, and to set boundaries when staff are pulling for more than we really ought to be giving (e.g., using BHC as a crisis service or for clinical politics).  Shay I have a firm rule that I will see anybody once. Then we see. At that point, I am at Jeff’s “it depends”. So many of these meetings allowed for education or redefinition of the problem or identification of resources for the person, that it was only in a few times that I was left with what could be called a request for “therapy”. A couple of times I went forward for a few meetings with very clear goals. Mostly the one time rule got things addressed with no feeling for me that I was entering a gray area. Alexander
by E. Serrano
Tuesday, April 28, 2020
Wellness Coaches and Integrated Beh. Health Clinicians in Primary Care 0 E. Serrano Hello everyone, I am working with an FQHC that has both Wellness Coaches (non licensed, no specific training required) and licensed Beh. Health Providers.  Does anyone else out there have such a model and if so do you have job descriptions for both role or better yet some kind of grid showing the the different duties, etc. of each role This system is committed to having both roles and there is quite a bit of roll confusion between the two creating quite a bit of havac. Thanks for any input! Laura Dear Laura, Check out the Jobs link for Iora Health and click apply to see job descriptions for BHS and Health Coaches.   There is a clear distinction in Iora care model between coaching and bh intervention.  BHS providers are typically doctoral level licensed providers.  Health Coaches typically have a bachelor's degree in a health related field, are certified medical assistants and trained in strategies to advance value based care.  BHS providers train health coaches in motivational interviewing, management of chronic health conditions, person centered communication, professional boundaries, trauma informed care, etc.  Health coaches help identify patients that might benefit from BH intervention and along with PCP's arrange for warm hand offs, individual and group consultations.  Cordially, Bill
by E. Serrano
Tuesday, April 28, 2020
LGBTQ+ Support Group for Teens 0 E. Serrano Hello, Wondering if anyone has a curriculum that is evidence-based that they use or would recommend for creating a support group for LGBTQ+ teens?  Thank you! Jessi Hey Jessi,  Thanks for bringing this important topic to the list-serv. I’m not aware of any evidence-based curriculums for teens in primary care, but we have a few resources that might help get you started: 1.       Dr. Jenny Birnkrant gave a wonderful Quicknotes presentation during one of our previous PEDS SIG calls and you can find the recording here. 2.       I am attaching the didactic I use for our Pediatric BH ECHO for primary care physicians here at Nationwide Children's Hospital. 3.       You can find the WPATH standards of care here. 4.       You can find the UCSF Center for Excellence for Transgender Health Guidelines here.   Hope that helps, I anticipate you might here from some others as well who are doing some of this work. What is everyone else doing?  Cody
by E. Serrano
Tuesday, April 28, 2020
Marketing PCBH to C-Suite 0 E. Serrano Happy New Year! Several months back, someone shared a resource for justifying/marketing PCBH to health system leadership/c-suite. I thought I saved it, but I can’t find it anywhere. I think 2020 may be the magic year for expanding PCBH here, so I am working on (another) proposal. Can someone please re-send or share your best resource for this? Thanks much! Amy Amy, Not sure if this is the one you are thinking of, but here is a link to a 2016 study in JAMA with a study of 113,000 patients in the Intermountain Health System which showed that integrating mental and physical health through primary care teams results in better clinical outcomes and lower costs.  Authors stated that savings of $115/year/patient for savings in their health system of ~$13 million dollars via reduced ER visits, reduced hospital admissions and higher levels of screening and adherence to treatment protocols.   https://jamanetwork.com/journals/jama/fullarticle/2545685 Jeff This study is net total cost savings. Many other smaller studies advance patient cost of care savings but don’t fully count the program cost and thus don’t show true net savings. Another way to think about it as costs being an indicator of population well being. If total costs are down AND patients are healthier the cost reduction is due to improved health and not due to cutting services. Doug
by E. Serrano
Tuesday, April 28, 2020
Increase In Death Rates Paper. Woolf 0 E. Serrano This paper was discussed extensively in the press a few weeks ago, but there are key points here that may have been lost in translation.   first there is a clear increase in death rates starting at age 14 (figure 2) and in the 21-65 range, I think its more striking in the younger adults 25-45, due to overdose and suicide.   In particular Dr. Woolf also looks at geography and how this disproportionately affects rural areas While there have been some important advances at APA with regards to teaching psychologists on non-opioid pain management, much more is needed. There needs to be workshops not only on pain management but also on screening and treatment of opioid dependence.    This affects all clinical areas.  Those of us in child and pediatrics see the impact on families when parents are opioid dependent.  Those who work in geropsychology see the impact when grandparents suddenly have to take over raising their grandchildren.  It is a problem that impacts all of us no matter which population we are working with.   We psychologists, as a group, are not fully engaged at all in treatment of those who are opioid dependent.   We know that the primary care physician and nursing groups have been actively working to inform and teach their clinicians to overcome stigma and bias to provide medication assisted treatment, and psychiatry has joined in that effort.  There has been very little, if any, action by psychology to teach our clinicians on how to effectively treat patients with opioid dependence and how to work with primary care clinicians who are providing medication assisted treatment. We do have members working in the field doing this work to help those with opioid dependence, and presenting workshops, but their work has not been highlighted by APA.   We are many years into this crisis.  APA should be taking the lead on this, not sitting back and hoping that one workshop on one topic of pain management will solve this problem.  That workshop is a critical first step but there needs to be much more. When the AIDS crisis hit more than 30 years ago, APA was able to respond, form a committee that lasted for many years, join with other organizations and address the issue.   In the fall you can walk into APA building and see the AIDS quilts from 25 years ago.   This is a similar, and in fact, a much larger crisis.  There are the same problems of stigma and discrimination against those affected by this epidemic.   A similar response is needed now. Doug Thank you for raising these issues Doug.  As psychologists contemplate their involvement in the world of OUD treatment I would suggest they entire this work with an open mind and willingness to learn from the expertise of other disciplines.  Most of us received graduate training that is poor fit for the current realties.  A few areas to think about -  1)  The limits of SBIRT.  SBIRT only improves outcomes in settings where evidence-based “T” is available.  T = treatment.  For many substance use disorders we do not have effective interventions that can be deployed in real-world settings.  Treatment of stimulant use disorders is one example of a condition that we simply don’t know how to treat effectively.  The “S” in SBIRT is the easy part.  It is easy to setup universal screening protocols.  But screening won’t move the needle on outcomes in the absence of effective treatment.  And in most communities effective treatment is simply not available, particularly in rural communities like those discussed in the Woolf article.  Before we set up screening protocols we need to be sure we have sufficient evidence-based treatment capacity for a given condition. 2)  Primary care and public health professionals have quite a bit they can teach psychologists about harm reduction.  There are many important life saving interventions that psychologists can offer that are associated with harm reduction.  Likewise, patients who use substances have expertise they can teach psychologists about harm reduction.  Some patient’s with SUD will set abstinence as their goal.  Other patients will not.  Psychologists can help all of these patients live better lives. 3) Psychologists can aggressively advocate against the criminalization of SUD.  In 1980 the US incarcerated 40,000 individuals for drug related crimes.  As of 2016 the US incarcerated 450,000 individuals for drug related crimes.  The racial disparities in these numbers have been well documented.  Criminalizing a health problem is unethical and ineffective.  Psychologists and APA should refuse to participate in or profit from the criminalization of SUD. (https://www.sentencingproject.org/publications/trends-in-u-s-corrections/) I would also suggest people take a look at this article from Science: https://science.sciencemag.org/content/361/6408/eaau1184 This article documents a remarkable increase in mortality associated with drugs that began long before the opioid epidemic.  The current SUD crisis is not strictly a story about pain management and opioids.  It started before the current opioid crisis and its ongoing trajectory is fueled by both opioid use and non-opioids, particularly methamphetamine. Daniel
by E. Serrano
Monday, April 27, 2020
BHC vs. Traditional Therapist Handout 0 E. Serrano Hello CFHA!   Hope everyone is healthy and safe out there. 💖  Quick question: does anyone have a ready made handout or graphic that simply breakdowns the differences between a Primary Care BHC and a traditional, long-term therapist/counselor etc?  Thank you! Norma Hi Norma - this is a great question, as it is *very* commonly misunderstood, often with significant negative consequences for the BHC’s value. I’ll give you my take.  As I train it, the main differences have to do with ownership of care and the BHC’s f/u structure. Specifically...  …as a consultant, the PCP “owns” care; the consultant’s role is to help the PCP to provide that care. (Therapists, by contrast, own the patient’s mental health care - that is, they alone make decisions about how to intervene with the patient.)   …re f/u structure:  therapists follow patients to remission (or at least plan to). But consultants follow along with the PCP just until the patient is starting to improve and has a clear plan in place for continued improvement. At that point, the consultant backs out of the planned f/u (but of course can always be brought back into care as needed).  Think of how a psychiatry consultant is used when a PCP has a medication question. The psychiatrist joins the PCP in care for a (typically) short time. S/He assesses the patient, maybe gets the patient started on meds, then continues to follow the pt along with the PCP until the pt starts to improve and is stable with their meds plan. At that point, the psychiatrist backs out of planned f/u and the pt continues with the PCP alone, who continues the plan. If you substitute the BHC for the psychiatrist in this scenario, and substitute behavioral interventions for meds…then you have the BHC role.  Hopefully this makes sense. I’m also attaching a slide I’ve used for years that breaks down the differences further. I think the initial attribution for the slide goes to Kirk Strosahl.   I should also add that - very importantly - being a consultant should *not* imply any restrictions on the BHC in terms of the types of interventions delivered or the history gathered/visit content. I all too commonly see BHCs refusing to talk about potentially very important topics with patients such as past trauma history, or relationship problems, saying “I’m only a consultant, you can see a therapist to talk about those issues,” or some such statement. Unfortunately, BHCs who practice this way are depriving themselves of important clinical information, and thus often end up delivering simplistic symptom-reduction interventions that have little if any meaning to the patient (e.g., breathing instruction given to almost every patient). So, please don’t do that…that’s not what being a consultant is about. :)    Stay safe and be well -   Jeff Thank you, Jeff! I work as a BHC in a clinic that specializes in teen health but is housed in women's health, but due to COVID, I'm going to be seeing more adult pt's via Telehealth, and I wanted to present my higher-ups with a clearer distinction of my role since my clinics aren't fully integrated. I want to make myself as available as possible to my teen population and these new pt's in need, but I have little control over where my referrals come from in my health system. It's overwhelming at times, so I'm trying the "top down" approach where I email the primary care staff a chart like the one you and another CFHA member sent me (thanks, again Phillip!) and see if I can clear things up with the PEDs and OB/GYN docs so patients aren't getting the "wrong idea" about what services I can provide since I am not in clinic (I'm working remotely via phone and just getting into Zoom) to meet these pt's via warm-hand off. :( Norma Hi Norma, These resources from Jeff and Sandy are fantastic on this topic! I wanted to share a few slides I have used with clinicians, teams, and leaders that align with Jeff & Sandy's guidance. The metaphor of "spear fishers" and "net fishers" has worked well when I have used it.  See attached PDF. I emphasize both types of "fishers" have been long present in the medical continuum of care. This often opens up the conversation for why both types of fishers haven't been present in the behavioral health continuum of care (i.e. we have only been spear fishing in BH). Especially now, we strengthen each other, Julie Norma, I would love to hear the feedback from SLP.  My first clinic as a BHC was one that primarily served people of Mexican heritage.   It is where I first came to understand that the context of primary care provides behavioral health the opportunity to serve all people.  It is a realization that still deeply resonates with me and energizes me to continue in this work we do.:) Saying that, these slides were written for clinicians, teams, and leaders...but the metaphor may help with the people we care for...let me know what ideas bubble up!! Oh, and in terms of consultant vs. therapist...I agree with Jeff this is a super important concept to understand and work from as a BHC. I have noticed some things over time about this that I wanted to additionally share. In clinics with suboptimal BHC staffing for the amount of people served...it is extremely important to understand how to work as a consultant....as one would need to be equipped with strategies to maintain access to oneself...if we are about anything as BHCs we are about access... and primary care loves us for that...so do the people we serve. One way to maintain access is to take on a consultant/educator role and "upskill" the primary care clinician (PCC) and the team.  Being a consultant in the lives of the people we serve is also a useful way to conceptualize our work. Being a consultant to the PCC and team is one of many strategies we have as BHCs to ensure access and "spread BHC knowledge around."   In the early days of our work as BHCs, we were likely all working in clinics with suboptimal BHC staffing levels (from what we understand now is more optimal). This is why the consultant function was so very important... particularly as we got started in PCBH. The consultant function IMHO is still super important because most clinics still have suboptimal BHC staffing when considering the population intended to serve.  Particularity, many clinics are in the early stages of adopting the BHC service. In those early stages BHC staffing is generally less than what we in the field would think to be optimal.  In every clinic a BHC goes to there is a period of "proving it."  That is just the reality of this work.  When we prove it more of us are hired and staffing becomes more optimal. Also, a key feature of BHC work is tremendous appreciation for providing a cost-effective service.  Being a consultant that can "upskill" others enhances the reach of the service and its cost-effectiveness.  In team-based clinics with what I would say would be approaching more optimal BHC staffing the BHC can breathe a bit easier around the consultant concept...as one has greater ability "to spread BHC knowledge around" when not severely understaffed to the need/demand. But the consultant concept is still important...just not as critical as it is when starting in the understaffed state...it is super important in the early adoption phase of our work. Lastly, when primary care changes...as I have seen it change...  As BHCs become essential team members...and the staffing becomes more optimal...the focus on PCC as the primary customer lessens...the focus changes to shared biopsychosocial care made possible by an optimally staffed interprofessional team. Hope that helps, Julie
by E. Serrano
Monday, April 27, 2020
Collaborative Care Billing Question 0 E. Serrano Anyone out there doing Collaborative Care in Illinois and/or other states where Medicaid is NOT yet reimbursing the CoCM codes?  We're in Illinois, and although the IL Collaborative Care bill was signed into law 1/1/2020 ( mandating all payers, including Medicaid) cover the CoCM codes, we have not yet seen that happen.  We're told the CoCM codes are not on the IL Medicaid fee schedule, so therefore not billable.         AIMS Center has advised us we can, alternatively, bill psychotherapy codes for the time/work done by the care manager( since the CoCM codes were reimbursed for Medicaid patients.)  Are LCPCs permitted to bill psychotherapy codes to Medicaid in Illinois?  We've been told this was a no.      Appreciate any input!   Thanks!   Jen   Well, that is not good news. We are getting ready to launch the use of the CoCM codes.  I think we need to talk to someone about getting these codes added to the Il Medicaid fee schedule. Do you happen to have Governor Pritzker’s direct lineJ  LCPC’s cannot bill Medicaid unless there is a contract, e.g., Molina, Illinicare and Meridian.       Seriously, I wonder how we can expedite the implementation of this law.  I believe I will be calling some of our representatives.   Thanks for the information.    Gail  Unfortunately what was passed in Illinois was the American Psychiatric Associations model law which had a good goal, but as we are seeing has a number of deficits:      1.  It only included 3 of the 4 collaborative care codes that cover consultation with a psychiatrist.  IT specifically did not include the 4th code where a PCP could be reimbursed for consulting with a non-psychiatrist mental Health professional.   2.  It did not address the issue of dual co-payments by patients when seen by health and mental health in the same setting.   3.  It did not address the obstacles that some mental health providers (psychologists, counselors, social workers) run into when billing in a primary care office.       A thorough bill that was truly patient focused, rather than guild focused, would have included what is needed for psychiatry services to get paid but also included all of the other mental health professions.       Knowing how legislatures work, since this went through last year in Illinois, it will be years before you can take another shot at getting a new bill.      Doug In a way CoCM gets around the  issues below (2&3) since it entails team-based billing by the cumulative minute/month all under the PCP’s NPI. So there is no BH copay or psychiatry consult bill per patient. Psychiatrists and therapists working the model would be paid a flat rate per hour (maybe salary for therapist)  or RVUs towards their productivity totals. The practice would need to attribute revenue appropriately since the majority would not be from PCP services and I’d encourage the PCP to continue using their E&Ms to keep it all straight. For #1, NC did the same thing and did not include the 4th code. My guess is that they were nervous about runaway care management costs from agencies not running CoCM and who are using the code for filling casework gaps that are not typically reimbursed in another way.  With that said, the fourth code is valuable when a referral that does not cleanly  fit the model needs triage. Each time we use the 4th code for Medicare it MAY represent an opportunity for educating the team on appropriate CoCM referrals.   Eric The 4th code (99484) is used when the consultant is not a psychiatrist, psychiatric NP or Psychiatric PA - so the first three codes specify a prescribing consultant - and thus tip the scales toward medication as first line treatment.      Coming from a pediatric background, where disruptive behaviors such as oppositional defiant disorder and/or ADHD are the most common referrals, I think this poses a problem since behavioral parent training is the first line treatment for children under age 6 and is one of two first line treatments for children 6-12. (The American Academy of Pediatrics treatment guidelines for ADHD)  So the appropriate consultant  for the majority of cases (and nearly all cases of a child under 6 years) would be someone who is skilled in that particular intervention, not a prescriber.  So this payment model tilts services for children away from effective  first line interventions supported by AAP and towards medication.   I am not opposed to medication, I am, however, fully supportive of first line interventions being used first, and for children CoCM does not support that.       It’s curious that there are concerns about “runaway management costs” from those not running the CoCM - when the Institute for Clinical &  Economic Review of programs in 2015 clearly shows that CoCM is the most expensive integrated care option,      These codes were originally written in Medicare as Part B services, so they do have a 20% co-pay attached.  My colleagues at one major commercial insurer has emphasized that to me, saying that cannot be changed.        These codes are odd, to say the least.  In Medicare they require a co pay like a fee for a service, but they are care management codes requiring documentation of time spent.          Good legislation would pay for consultation by psychiatry, psychology, social work and counselors, and care management, eliminate dual co pays.  Allowing all mental health professionals to work in the consultant role allows the PCP to consult with the most appropriate professional for the situation.    Doug I would like to address Doug’s assertion that it is not appropriate for a psychiatrist to provide a consultation via CoCM for ADHD evaluations. Psychiatrists, especially child psychiatrists, are experts in the evaluation and diagnosis of ADHD. They are also savvy enough to make appropriate recommendations for or against medications vs behavioral treatment. ADHD is no different than depression or anxiety in that there are roles for environmental supports as well. While behavioral interventions are the first line treatment for children under age 6, medications are the first line intervention for ages 6+ (per American Academy of Child and Adolescent Psychiatry practice parameters). There are more than 30 studies, including seminal works such as MTA and PATS to support the use of medication in ADHD. PATS defines the role of medications (when indicated) for children under 6 years. Let’s use this forum to advance the field and decrease pop culture stigma.          Megan   I did not refer to any specific profession, I was discussing pharmacological versus non-pharmacological interventions, particularly in the preschool age group.       But lets start with guidelines since that has been brought up, in the CoCM model it is the primary care clinician in charge of the case, the rest of us are consultants, then they should be following the practice guidelines of their discipline or specialty.  The AAP guidelines (which have been adopted verbatim by AAFP) are clear that parent training is first line for all children preschool through school age, and that stimulants are an alternative first line treatment for school age children.  This is based on research done in the past ten years.  With all due respect AACAP needs not to impose their older, perhaps outdated guidelines on the primary care clinicians.  Pediatricians and family practice physicians follow their guidelines not those of AACAP.      Dr Chairelli brings up the Preschool ADHD Treatment Study (PATS) an very detailed set of studies done primarily by the same group that did the Multimodal ADHD. Treatment study (MTA) in the late 90’s.   This team was led by Dr. Larry Greenhill, a very thoughtful and thorough psychiatrist and researcher.       It is a complex study, and as most complex studies its a Rorschach test, people see what they want to see.        So lets look at the actual results published between 2006 and 2015 on these children,.  First they started with 303 very, very hyperactive kids - not borderline, we are talking children who are 1.5 to 2.0 standard deviations the top 5% to top 1% , not the usual case seen in primary care.    All were enrolled in a 10 week behavior therapy (unfortunately not designed for this age group - even though Those programs were available) and after 10 weeks 120 children no longer met criteria for the study, so 40% of these very hyperactive children got better without medicine.         183 started a titration trial, a washout period, a second titration trial, and then a placebo vs treatment and then an open maintenance trial,   at that point 95 were left in the study.,  so only 31% found medication treatment tolerable and effective.  It is reported that 30% of these 95, approximately 28, had moderate to severe adverse events mostly sleep and appetite disruption.   MT Stein reported in a separate paper that of these 95, 20% had lower height over time and 55% lower weight.  So side effects are real and significant in this age group.      Of the 95 who persevered in the last part of the medication trial 21%, or 19 children of the original 303 who continued on a stimulant reached remission.    Curiously, 13% in the final placebo group (12 children) ALSO reached remission of symptoms.        So from the original 303,  all of 19 reached remission.  This is touted by some as a success.   Keep in mind, however, that of the 303, there were 120 who got better with behavior therapy.         120 vs 19 - please tell me which is more effective.       Last, just to push further,  Mark Riddle published the 6 year follow up on the kids treated with medication.  At that point in time. 89% still met criteria for ADHD, and Dr. Riddle suggested we need to work on other treatment options, that using these medications with this group is not effective.        Having spent 12 years collocated in a private pediatric office, followed by another 12 years helping to develop integration in the Nemours system, and I am very familiar with the exemplary work done by Joe Evans in Nebraska, and all of this was started by Carolyn Schroeder in Chapel Hill Peds in the 1970’s.  All of us have emphasized prevention, early intervention, helping parents with their skills, consultation with schools, and consultation with psychiatry as needed.  But the bulk of the day to day work in primary care pediatrics does need a psychiatric overseer.       What should be funded in pediatrics is a system that pays for services for all licensed mental health professionals and maternal/child nursing staff to achieve the prevention, early intervention and treatment goals.  To only fund psychiatry consultation is paying attention to the very top of the iceberg and ignoring everyone else.  Doug I seem to have killed the thread with my lengthy response, but for those who don't know me, I did run an ADHD specialty program at two major children's hospitals, was a senior consultant on mental health for Head Start at HHS (2003-2006) and was on the faculty of GWU Psychiatry Dept for 12 years and as the psychology internship director at Children's National Medical Center worked very closely with the child psychiatry fellowship directors, so I know very well how our professions are trained, and we all have strengths and weaknesses.   In my opinion both child psychiatrists and psychologist need more education in basic child development - we are way too pathology oriented.   From my read of the research literature and the conclusions of a a number of senior child psychiatrists who I greatly respect, my conclusion is that for ADHD symptoms in preschoolers, first basic parent training, if that is not sufficient then more intensive Parent Child Interaction Therapy - they have a national directory with a large number of therapists nationally.  I also recommend referral to the state IDEA Part C child find birth to three program, or the Part B IDEA for children over 4,  for an evaluation. many of the children who have these severe problems also have language delay which is not always apparent.  These children are entitled to services under the IDEA.  I see medication for this group as a last option, after you have exhausted therapy, a therapeutic Head Start or  preschool placement.  Yes there is some positive outcome, but the medicines have a high rate of side effects, and as already cited, no long term benefit.  Exhaust the other options first.  Doug   99484 - Payment for Other Models of Integrated Behavioral Health Services  Care management services for behavioral health conditions, at least 20 minutes of clinical staff time per calendar month. Must include: Initial assessment or follow-up monitoring, including use of applicable validated rating scales; Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and Continuity of care with a designated member of the care team.  99484 can only be reported by a treating provider and cannot be independently billed. For 99484, a behavioral health care manager with formal or specialized education is not required. CMS rules allow “clinical staff” to provide 99484 services using the same definition of “clinical staff” as applied under the Chronic Care Management benefit. Lori   Thanks Lori!  Very helpful.  IMHO  ...99484 is a useful code for PCBH model clinicians. ...appropriate use of it by PCBH practitioners may help to “raise up” PCBH work. ... PCBH work lacks visibility in the healthcare system because it lacks specific codes to “flag” it is happening.    In actual practice/implementation the PCBH footprint is substantial despite our low-visibility at the system-level. IMHO this says something about what we do as PCBH clinicians...   We need opportunities to highlight PCBH work at the system-level... we could use some PCBH codes!   I wanted to highlight two other things   1. Primary care clinicians will bill EM for their services. They will likely not bill 99484 except if it were in support of the work of their care team members doing the work.   2. It does not seem like this code is only intended for “one time or so” use given this statement cut from the below guidelines. Continuity of care with a designated member of the care team. Am I reading the idea of continuity wrong? All the best, Julie   Does anyone know what the patient is actually billed for on a 99484 if it is a covered service? Is it an office co-pay or co-insurance? I recognize each plan will be slightly different, but just want to gather an idea of what you've seen.  We take both medicare and all commercial insurance and are planning to start billing, but I want to ensure we are getting consent from the patient on what exactly they could be responsible for. Thank you! Elizabeth   I'm the Medical Director of BH at PacificSource, a medium sized non-profit health plan in the Northwest.  We've been able to eliminate co-pays for all CoCM codes across  all lines of business (Medicare Advantage, Commercial, Medicaid). Mike   Dr. Franz- Woah, how did you do that? Via contracting? This would go a long ways toward improving access, workflows, and patient satisfaction. Teach us your ways! Megan   I made it a priority within our leadership -- explaining that CoCM really doesn't work if there is cost-share since members will not opt into something where they could be getting multiple bills for same day primary care visits.  Then I asked our operational folks to make it so.  The ROI based on an overwhelming literature base makes this a no-brainer from the health plan perspective. Mike
by E. Serrano
Monday, April 27, 2020
Spanish speaking BHCs 0 L. Edwards To all, Do any of you have the AUDIT, DAST, and/or GAD-7 screenings translated in Spanish. If so, could you potentially send those to me?   Zachary Hi all! To piggy back on this, I would love to know if there are other Spanish-speaking BHCs out there, like myself, who would be interested in doing the following: 1) Create a shareable database of resources and worksheets in Spanish (I’ve  had to translate serveral worksheets myself) 2) Have a meetup at the Denver conference 3) Discuss how you introduce BHC services in Spanish. I went through several iterations but finally settled on “consejera de bienestar” with  an additional spiel. I would love to hear from y’all! Feel free to email me directly, too. Best, Norma Just to respond to #3 directly, on what translated title/role name to use: I don't prefer “consejera de bienestar” as that translates to welfare  counselor and I do not feel that accurately captures our role in primary  care. I would encourage one of the following, but prefer the first one:   - proveedor de salud conductual = behavioral health provider   - consultor de salud conductual = behavioral health consultant   - consejero de salud = health counselor   - alguien que aconseja sobre el comportamiento de la salud = someone who  counsels on health behavior Sherri  Hello, I will add proveedor de salud emocional. Have a great day! Yaira  Hello all, I introduce myself as a “Consultante de Bienestar” and emphasize that I  work on improving wellness (bienestar) and health overall. For some reason  I find that the term “bienestar” is encompassing of what we do. It has  a clear, understandable, and positive connotation. I always include my spiel  and state several medical and mental health conditions that I work with so  patients have an idea that I see all patients. I avoid using “consejera”  or “terapeuta” as that alludes to being a therapist. I look forward to connecting with Bilingual BHC’s in Denver! Saludos desde Chicago! Mayra Hello, My name is Ingrid Solares. I am a licensed clinical social worker and my  role is behavioral health consultant. I introduce myself as consejera de  Salud. My intro goes like this. “Hola mi nombre es Ingrid, yo so consejera  de salud y soy parte de su equipo de salud aquí en la clínica. Yo trabajo  con su doctor y con los pacientes para ayudar a mejorar diferentes aspectos  de la salud emocional. Por ejemplo como manejar el estrés y estrategias  para dormir mejor y manejar el diabetes mas efectivamente. Su doctor me dijo  que usted está teniendo dificultad para dormir y le está afectando su  energía. Está bien si platicamos un ratito sobre cómo podemos trabajar  juntos para mejorar sus síntomas?” I have drawn from Neftalí Serranos you tube videos about how to do a short  intro and begin my consultations in a focused way to move the conversation  along in the short time I have with pts. Ingrid  Ay! A topic so close to my bicultural heart! There is so much here to launch from... the PCBH SIG has been wondering if  there was enough interest to do a webinar for Spanish speaking BHCs on just  these very issues, and also as a means of creating an atlas or index of  resources.  I think we have our answer! For the record I introduce myself -  "Soy la psicologa que consulta con su  equipo de salud aqui en la clinica. Sabemos que su salud fisica tiene mucho  que ver con su salud mental, y aqui en el Centro tratamos enfocar en las  dos cosas....toda la persona . " I'd like to call myself a health psychologist but that's not my actual  training and background so I go with that more descriptive sentence. I think this is the start of something great! Please email me caguilar@chcsbc.org  if you are interested in contributing to a webinar in December for Spanish  speaking BHCs!  We will follow up on getting some space together on CFHA  website for Spanish language resources!  I am also hoping we can all find a  time to connect at CFHA in Denver - more to come on that! AND, I have to throw this in there, I know you all will get the reference:  me siento muy...EXCITED!  :)  Clarissa Good morning! I would also like to add that we should be mindful to include  our indigenous brothers and sisters who do not speak spanish fluently. I  see many pts who speak an array of indigenous dialects. Also a discussion  around the different spanish speaking populations depending on what part of  the US. Here in Oregon we have predominantly patients from Mexico and  Guatemala. I have noticed an increase in Puerto Rican patients as well since  Hurricane Maria. There is so much to learn and share!  Looking forward to  rich discussions in the future! Have a great day everyone! Ingrid    
by L. Edwards
Wednesday, November 13, 2019
Confidentiality of behavioral health records in the EMR 0 L. Edwards I was wondering how people handle confidentiality of records in the EMR?  We use Cerner but some of my questions would apply no matter which EMR was used.  When the BHC documents are the notes then "blind" to the physician in the same way that a behavioral health note written in an outpatient behavioral health setting would be blind?  If not, how do you ensure that only the physician/provider can see them?  We are worried about the admin staff being able to see confidential BHC documentation. Thanks so much, Susan Several programs allow you to have setting where different providers/admin/groups must "break the ceiling" to get into BHC notes. Breaking the ceiling provides the person about to access the record information that these are confidential records and are only for those with a distinct need to know. The program then tracks when someone breaks the ceiling and you can monitor if a rogue individual is being nosy.    RobynneOur BHC notes are not glass protected or blind to the PCP – I want the provider to read our assessments! They are less likely to do this if they have to break glass each time. Our patients know that BHCs function as a part of their medical team, not a separate service, so our documentation reflects that.   As such, there’s no way for us to prevent unauthorized viewing 100% of the time, outside of the protections already in place for a patient’s medical chart. In our clinics, I’ve noticed that PCP notes FAR out detail sensitive information compared to BHC notes (e.g., PCP writes “raped by uncle”, BHC writes “h/o sexual assault”) -- so glass protecting them doesn’t truly make sense – the sensitive information already exists in the PCP notes.   If you’re separately worried about content in BHC notes, I’d ask; 1) is the content truly more detailed, salacious, etc compared to PCP notes? -  and if so, 2) perhaps re-tooling how BHC notes are written, making them more appropriate for a medical record may be needed. It’s when BHCs carry over lengthy specialty mental health habits that notes become unnecessarily detailed. I train my BHCs out of this habit when they come on board.       Shay  I hope we are moving to a time when the model of treatment that many of us use is not so focused on “pathology” and can be more focused on learning more useful ways of coping.  We had better be taking steps in that direction because the days of notes that the patients don’t read are ending.  Currently 43,566,000 people have access to the notes from their doctors online. See www.opennotes.org .   Both physicians and BH clinicians will have to learn to write notes that the their patients can read.  I found that for 20 years of my clinical work, the best way to keep from having any problems with notes was to read the note from the last visit whenever the patient came for another visit.  It meant I wrote notes that I hoped they would hear, ones that were positive clinical interventions as well as documentation.    And the groups of patients who most benefit from reading those notes are the multiply-disadvantaged patients with the most traumatic histories.  For a more complete exposition, see Blount, A. (2019). “T” is for transparent. In A. Blount, Patient-Centered Primary Care: Getting from Good to Great, www.Springer.com   Sandy Thank you, Sandy, for saying what needed to be said.  Honor the courageous.  Btw, your book is excellent.     Peggy Better yet train the staff regarding “permissions”, you can limit who can see notes by department/degree and then follow-up with log in audits for spot checking compliance with the note access policy.  Lori  Good Morning, We use Centricity which allows us to create user groups and have the BHC notes marked as Sensitive.  This allows only the clinical folks (PCP, RNs, etc.) access but does not allow non-clinical such as the front desk staff etc.  Non-clinical staff can look within appointments to see if the patient had a BHC visit just cannot see the content of the note.  Clinical staff do not have to do anything different to obtain access it is all included in what they can see in the chart.   Since we have a lot of community folks work at our clinics, this ensures that friends are not looking at friends charts.   It is important that the workflow is not different for any of the providers.  We also updated our Confidentiality policy which includes information about authorized use, unauthorized use (such as snooping).   Stacey I’m late to the party on this topic but thought I’d add my thoughts. We have discussed this at length as well but we have decided to treat our BH consult notes in the same manner that every other chart note is handled (not marking as sensitive). Our worry is that by marking BHC notes as sensitive, confidential, or private it will only perpetuate the entrenched stigma associated with behavioral health issues by sending everyone the message that these consults and problems are “different” from other health issues and BH clinicians are also “different” from other providers.   In our system we are trying to educate everyone (staff, providers, patients) that these are common health issues that need to be normalized, discussed, screened, treated, addressed in a variety ways—they are not shameful issues that need to be hidden or treated with a higher level of sensitivity.     There are a wide variety of health conditions that are serious and need to be addressed but are also potentially embarrassing or difficult for people. I’d bet money that there are a lot of people who be more sensitive about their anal fissures chart note vs. their anxiety chart note.   Jason Thank you so much for everyone who reached out to me about my question about confidentiality in the EMR.  I was able to present your feedback  to my administration who now "see the light!" Thank you thank you thank you!!! Susan
by L. Edwards
Wednesday, November 13, 2019
Billing for Collaborative Care Model: New Law in Illinois 0 L. Edwards Anyone out there with experience in billing for the Collaborative Care model?  Has this been financially sustainable?  There is a changing landscape for integrated care reimbursement here in Illinois, at least in the world of Collaborative Care.  Illinois has become the first state to sign APA's model Collaborative Care legislation into law. On August 23, Illinois Governor J.B. Pritzker signed SB 2085, Psychiatric Collaborative Care, into law, which requires private insurers in Illinois and Illinois Medicaid to cover Collaborative Care CPT codes. This will definitely change the conversation around financial sustainability in the near future.  The new law takes effect Jan. 1, 2020.    In the meantime, if anyone out there has experience in billing for Collaborative Care and would be willing to share a sample budget or 'pro forma' that would be great!  We're finding a tremendous need in our patient population, but having a harder time convincing administration to expand our workforce.  If we could show some figures on operating cost vs. revenue generated, we might have better success in advocating for more care managers.  We know Collaborative Care has good data too on healthcare cost savings as well. Thanks! Jen  Jen, I will loop in Steve Biljan who can provide financial data on the CoCM model dating back to mid July 2017 related to CoCM’s performance and sustainability here in Arizona where we have comprehensive coverage across the payor landscape (Medicare, Medicaid, Commercial).  We currently have 12 sites operating and all are generating positive revenue through the FFS revenue related to CoCM services.   All the best.  Erik  There is a nice resource – a Financial Modeling Toolkit – on the AIMS center and American Psychiatric Association website. You can enter the code reimbursement by payer and see the cost/revenue.    I think of it like the cost of a CoCM team (consider LCSW at $80 k with benefits and psychiatric consultant at 20k) to be 100k – the revenue for a full registry of 60-80 patients can be (depending on payer) around 115 – 125 k – so there is a margin but you have to keep the registry full and the billing team on their toes.    
by L. Edwards
Wednesday, November 13, 2019
Tracking PHQ9 scores 0 L. Edwards Any recommendations on tracking PHQ9s for response and remission from a data standpoint?  Specifically, what do you use as a starting point from which to compare future scores for response and remission? First PHQ9 score of 10 or greater? First diagnosis of MDD? What about patients with chronic, recurrent depression who have scores that go up and down over time (which is common)? The HEDIS metric on this doesn’t seem to give much guidance from what I can tell, except that it looks at scores 4-8 months from said starting point.  Thanks in advance. Chad We are working locally to develop a training on measurements and metrics for integrated care.  We are going to start with depression/PhQ9.  I have an intern who has done a lot of our research on this.    I like to look at these similar to the measurement guidelines for FQHCs – similarly to measuring an A1c.   Here is some information we have found.  We are going to have to pull several different measurement studies for this to create something robust.   “A depression screen is completed on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, either additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, or other interventions or follow-up for the diagnosis or treatment of depression is documented on the date of the positive screen. Depression screening is required once per measurement period, not at all encounters; this is patient based and not an encounter based measure.” - https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v8.html   Also – according to a presentation on new HEDIS measures (see the attached PDF): CMS Medicare ACO and PCMH measures Depression remission PHQ-9 less than five @ 12 months Depression response PH-Q9 decrease by greater than 50% @ 12 months    Preventive Care and Screening: Screening for Depression and Follow-Up Plan (Line 21), CMS2v7  http://bphcdata.net/docs/table_6b.pdf (page#9) Measure Description Percentage of patients age 12 years and older screened for depression on the date of the visit using an age-appropriate standardized depression screening tool and if positive, a follow-up plan is documented on the date of the positive screen. Universe (Column a) ■             Patients age 12 years and older* with at least one medical visit during the measurement period. *Patients born on or before December 31, 2005 Denominator (Column b) Number of records reviewed.               Numerator (Column c) Patients who: ■          Were screened for depression on the date of the visit using an age-appropriate standardized tool; and ■             If screened positive for depression, had a follow-up plan documented on the date of the positive screen. ■             Column c INCLUDES patients with a negative depression screening. Those with a negative screening do not require a documented follow-up plan to be included in the numerator.   Exclusions/Exceptions Exclude from the denominator, patients: ■             With an active diagnosis of depression or a diagnosis of bipolar disorder ■             Who refuse to participate ■             Who are in urgent or emergent situations where time is of the essence and to delay treatment would jeopardize the patient’s health status ■             Whose functional capacity or motivation to improve may impact the accuracy of results *Please refer to the UDS Manual for detailed Specification Guidance and UDS Reporting Considerations.    Not sure if that helps.  But I hope so! Kindly, Kara Hi Chad – I will be giving a talk on this at the CFHA meeting this Friday in Denver if you are going to be there.  Specifically setting up a measurement program, registry, tracking and using data on a personal basis and in aggregate form.    You can start by looking at just the past year – a combo of PHQ9>9 and a diagnosis of depression or dysthymia.  This will generate a good sized list in most clinics and then you can dig into the particulars.  The standard of care is a PHQ9 administered at least monthly until “stable”, tracking these scores over time to clinically significant response at 6 and  12 months  (NQF 1884 and 1885) or remission at 6 and 12 months  (NQF 710 and 711). And yes many patients do not get as well as we would hope – there are multiple chronic morbidities (like pain, SUD and personality do for example) that prevent a nice textbook response.  Hence set your benchmarks close to what the  literature has shown is typical in primary care – about 40-50%  will reach clinically significant response (50% reduction in PHQ9) and 15-20 % of those may hit remission which is even more difficult.  Lori   
by L. Edwards
Wednesday, November 13, 2019
H&B Group Codes Billing Question 0 L. Edwards CFHA’ers: I have a billing question from one of our TA clients which is stumping me. Anyone have thoughts/ experience billing for groups and H&B codes? Here is the question: "We are wanting to use the 96153  group code providing health education and psychological interventions to our clients. Do you know if each individual group member would  have to have a 96150 (Initial assessment) done before joining a group?      *** in specific- we have a 9 week program for pregnant Somali women.  The program starts out with 5-10 minute 1:1 medical information given by a care coordinator, then an ongoing yoga group happens during which the nurse practitioner will pull participants for an individual check up. When all the check ups are done, they all come together for a 1 hour group on various topics.  We want behavioral health to be able to bill for a few of these groups. Specifically the groups around post partum depression; stress management; and nutrition/ exercise.” Thanks, Neftali  I’m not aware of any rule that states a 96150 has to be completed before a 96153 (or a 96152 for that matter). I may be completely off on this, but we’ve been billing 96152 in the absence of a 96150 at several of our integrated clinics for a year now with no denial issues that I’m aware of.   With that said, I’m open to other peoples’ thoughts on this.    Curt GREAT question…. I have also used a 96152 without a 96150 , and I don’t think we’ve had any issues that I’m aware of… but I’ve only done it a couple of times.   And I have another for both of you….Does your group visit note (is this a DIGMA model?) look similar to your individual note?      Inquiring minds want to know!! Thank you!!!!!!!!!    Clarissa  Hello, I agree, it’s a great question and I can’t quickly find any regulations that address this. But, I wonder if there is still some value to doing some assessment prior to treatment with a group. The H&B assessment is pretty focused and can be done in 15 minute increments – so it can be done fairly quickly and usefully.   Also, I would want to make sure the other H&B rules are being followed regarding the need to have a medical diagnosis, etc.   I’ll be interested in what others have experienced. Thanks, Mary Jean Since the H&B codes rely on a medical diagnosis, I think that the original visit with the medical provider to make said diagnosis is sufficient to engage in treatment using H&B codes without 96150 being the first claim submitted – especially for group intervention. That said, a treatment plan should reflects goals appropriate to the diagnosis and group format and a quick 96510 assessment provides additional information to the clinician as well as the opportunity to set individual goal for group intervention.   Just thinking from the payer side and what we might look at in the event of an audit.   Jessica I agree with my colleagues. If using a medical diagnosis it means the patient was diagnosed by someone else, and your Intervention is to address that health related problem. Therefore I do not see the need For seperate diagnostic charge.  Doug  A helpful general resource on H&B codes: http://www.ibhpartners.org/get-started/procedures/billing-reimbursement-and-financing/ Thanks, Neftali
by L. Edwards
Wednesday, November 13, 2019
Reimbursement for BH Screening 0 L. Edwards Hello All, Could others speak to any codes/strategies they’re using to get reimbursed  for BH screeners? We get reimbursed for the PHQ-2 once per year per patient  using the depression screening G codes, but I’m wondering what else is  out there. I’ve recently set my practicum student up w/ a small project in which she spends a few minutes w/ new adult patients establishing care. She orients them to the BHC’s role in their care, and then does the PHQ-2, GAD-2, CAGE,  & 1-item ACEs (we will probably expand the list if it goes well). If anything flags, she offers a BHC visit. If the patient agrees, business as usual. If they decline, she provides a handout on the flagged issue, encourages the patient to reach out as needed, & debriefs the PCP. (Of course, if there is any indication of safety concerns we will address that either way.) I imagine many of you do something similar. We didn’t go into this w/ reimbursement in mind, but a recent training I went to sparked the idea. So far I’m seeing 96127 – looks like it might work at least some of the time. I’ve also come across 99420 as a possibility? Anyway – just wondering if those more knowledgeable than I could speak to whether there's a code likely to work for this, or if we should just be happy w/ the direct clinical & other indirect benefits! Thanks for any thoughts. Looking forward to seeing/meeting many of you in Denver soon! Mike Hello Mike, Our clinic uses a few different codes with variable success. 96127 Seems to work sometimes for anxiety, depression, and behavioral screeners. 96110 for developmental screeners, and 96161  may work for postpartum depression screeners when the patient is the child. One thing to watch out for is patients ending up with co-pays for the screening tools if you're billing for them. Some patients may then end up declining being screened. Best, Jessica To Jessica's point, our system has discontinued charges for BH screening  (PHQ/GAD) as patients would refuse re-screens (due to cost) and this left  them on our depression registries without a pathway to determine improvement.  It was also negatively impacting our integrated BH efforts.  We have tried  to conceptualize the screeners as part of the bundled visit to primary care  in the same way that we don't charge a la carte for taking your blood  pressure, weighing you, taking your temp, etc. Jeff Thanks for the thoughts Jessica & Jeff. We definitely don't want patients getting charged for this, so that will be the #1 thing for me to look into. We want to deepen our integration & increase attention to our population at large, which will of course involve a number of worthwhile benefits even if we can't directly collect on it. If others have additional thoughts I'm definitely up for learning all I can about this! Mike I think Jessica got the codes correct.  For all billing and screening codes, if your are in a primary care clinic, usually if the codes for screening are billed to the primary care provider they get paid.  If the mental health provider bills along with a bill for a dx or therapy session sometimes the screener codes don't get paid.  I would recommend billing  by the PCP. Doug Yes. My understanding is that the reimbursement is technically for the  physician's time interpreting/addressing the scores of the screen with the  patient and not for the administration of the screen (which can be done by  a variety of people, not necessarily licensed behavioral health). ~Amy    
by L. Edwards
Wednesday, November 13, 2019
PCBH algorithm 0 L. Edwards Colleagues  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? Thanks! Randall 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.... Jeff's response: "First, here are suggested referral criteria in the PCBH model:  1) the patient is not improving after several visits; 2) the PCP requests specialty help; 3) there is an emergency need;  4) the patient requests specialty care. The 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 specialty 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 complicated” for primary care, or “beyond primary care’s ability to help”. This is not only horribly pathologizing; it also effectively removes the BHC (and 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 specialty 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 now 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 specialty 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. Keep 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 engaged 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 providers 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 allow yourself to engage. (But if you do refer to specialty care - please avoid the pitfalls described above!) Thanks again for getting this discussion going!"  Bridget  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. Patti CHCW penetration rates for the past *12 months*...And, yeah, we operate exactly the way Patti describes of "no wrong referral".... PROVIDER CWFM EMC HIGHLAND NMC YPA CHCW All BHC Providers 2,490 717 138 312 1,512 5,111 All Providers 9,959 3,105 893 1,639 9,023 24,046 Penetration Rate 25.003% 23.092% 15.454% 19.036% 16.757% 21.255% Bridget  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.  Sarah  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). Randall 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. -James 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 patient’s needs. - 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 herself. - Most patients already have a health record.  Instead of creating a separate walled off health record from the rest of the healthcare system, integrate electronic systems. - 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 Health? Suzanne 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. Daniel  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, Alex 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 venue!) 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 Best, Dawn 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! Anne Combs 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 question. P.S. I also love the side conversation on coordination with CMHCs. Echo many of the thoughts shared. Thanks, Neftali 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. Shilo 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! Clarissa  
by L. Edwards
Wednesday, November 13, 2019

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