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Directly Observing Medical Residents to Evaluate their Relational and Other 0 E. Serrano Aloha,   I putting together a process for direct observation of our family medicine residents to evaluate their relationship and motivational skills along with their ability to consider diversity components and SDOH in their treatment planning. I wonder if anyone has any structure or forms for completing these types of observations?  I have the University of Washington patient centered observation form (see attached), which I plan to modify a bit. Before doing that, I thought see if there are other resources or processes I should integrate into this process.  Thanks for your suggestions and feedback.   Cathy The PCOF version you have is from 2016 and we ( myself, Laura Daniels, PhD, and Valerie Ross, MS) just finished revising the PCOF with a lot of changes to the Behavior change and Co-creating  a plan sections.  I attach the 2020 PCOF with and without crosswalk references to Family Medicine Milestones 2.0. I was originally enthralled with MI and even wrote two chapters about learning it in some medical student texts in the mid to late 90s.  But after trying to teach MI to residents and practicing physicians over several years I changed course.  Pure MI is in my view out of sync with the style and pace of front line primary care providers.  Last I looked ( I am retired now so Dan Mullin can set me straight) the evidence for ease of MI uptake by primary care clinicians is poor.  In contrast, the uptake by primary care docs for problem solving treatment with goals setting is more promising.  And the evidence trail  goes back to the early 1970s when it was first developed,  A theme in my career is to explore the intersection of efficiency and quality in teaching communication skills to physicians. Time management is a constant source of anxiety for PCPs. Pure MI does not fit well in that map.  The current version of the PCOF represents the newest syntheses of relevant skills.  The competency scoring recognizes that there are multiple ways to achieve behavior change including PST and the 5As. Larry I love your work, but I respectfully disagree. There are few styles of talking to patients that yield as much effectiveness as MI.  In my experience, MI doesn't receive much uptake among physicians and PCPs because the way it is trained is ineffective...vague...weak...imprecise. Most MI training is too mechanical, theoretical or esoteric. It isn't as time consuming if it is trained and implemented well.  Plus, PCPs spend 40-50 hours/week trying to speak that way and ttwice those hours each week in their personal lives speaking anything BUT MI. The practice ratio leaves little chance for success. PST, by contrast, often fosters a dependency between the pt and provider, wherein the pt takes longer to fly on his/her/their own.  We have to empower patients. With the exception of the strict PST protocol by Nezu & Nezu, the other PST approaches seem to place the provider in an advice-giving or "village old wise man/woman" role instead of truly empowering patients. And if desired, the Nezu&Nezu strategy can be implemented via self-management/empowerment via a good handout on the problem solving steps.  PCPs need better MI training, as do BH providers. IMHO that's the barrier. My response doesn't address the diversity question you raised, Catherine. It only addresses the motivation one you raised. Kent The degree of patient centeredness and dependency/autonomy of either PST or MI is more a function of how either is applied than the design of the model. .  Both models, if applied in a patient centered way, rely more on the values and preferences of the patient and instill autonomy.  And both models appear in research studies with the clinician taking over by declaring what the patient should work on.   To be clear, I am not advocating for pure PST either when used by a front line PCP.  MI use is very different when applied by a well trained behavioral health clinician or nurse..  Not sure I understand you comment about hours of use of language but I think it goes to my concern.  The culture and time pressures of primary care ( defined by language in a large sense) does not have much room for repeated reflections, for example.  I would love to see a new way of teaching MI.  The model is a brilliant synthesis and has lots of evidence supporting its use, just not by PCPs, as far as I know. Thanks for your response, Kent.  Our dialog will give interested readers plenty to chew on.  Larry "Plenty to chew on." I love how you use language! I agree entirely about the time limitations and fast pace precluding mindful reflection. It is a shame. At the same time, there are multiple attempts for practicing the same skill if one is seeing 20 patients/day. The trouble is that with such repetition, a PCP is either practicing the skill the same way (perhaps not correctly/successfully) and seldom with time for patient or peer feedback.  What I meant about hours is that MI is a distinct way of talking to people. If I'm only using that for a fraction of the total hours I interact with humans during a week or month or year, it is doubtful that I will become highly proficient - fluent in those skills. In fact, I am likely to be poor at the skill.  Kent While we trained our residents and other physicians outside the residency in MI and PST, they were often frustrated by the time constraints and did not see themselves doing it in their work.   However, they often talked about how to use the “spirit” in whatever they did, since the attitude and spirt is what makes a lot of the difference.    We did have some good success in training a volunteer group of nurses and MA’s who felt they could have focused behavior change visits and it added to their job satisfaction and sense of having interactions that made a difference.  Particularly nurses who were often were the ones answering phones all day.    Bill This is fantastic discussion and relevant to some work we are doing to train physical therapists in psychologically-informed practices. Thought: Perhaps we could think about the “way” we have been trying to train non-BH people in MI.  1/2 day to 2-day trainings in “MI” are common. These may unfortunately communicate that one can understand and do MI with so little time “soaking in” and practicing the concepts and practices.”   I am thinking about developing a standing “learning lab” at our IPC Institute that MI learners and practitioners of all kinds can come to monthly on an ongoing basis.   I got the thought from my experience with ongoing Balint groups.  These groups grow psychological thinking overtime in non BH folks...and the growth is embedded in monthly working through the complexities of real live patient care in an interesting way. Would something like this be useful? Would it have potential to address the pervasive problems in uptake “or becoming” particularly found in non BH trained folks? Thank you all for your work to move forward primary care! Julie Hi Julie, we also trained physical therapists in this. Turns out about 25% of their cases on average needed this kind of approach for their patients.  Mostly they were “sent” by primary care to prove they failed PT for a variety of reasons.  75% of their patients were in the Action phase and were scared by loss of function for whatever reason.   The PTs really liked it and most felt like it gave them something to do to engage the patients rather than “fight or flight”  Bill
by E. Serrano
23 hours ago
Same day appts with Psych Nurse Practitioners and Psychologist 0 E. Serrano I am being asked if we will get paid if a patient has same day appointments with a psych nurse practitioner for medication management and psychologist for psychotherapy on the same day. Does anyone know how this works? We bill psychotherapy (CPT)  and health coaching (H&B)  the same day as PCP visits (E&M). Cathy The prohibition on same day billing is a function of state regulations. You must ask your state’s DHS Medicaid office. I don’t think you will find it online. It’s ridiculous that states like California prevent someone in the Medicaid  population from getting dental care and medical care in the same trip. Double the work loss, double the transportation cost, double the child care cost, etc. Worst of all from our perspective, half the people referred to behavioral health will not or cannot keep their appointments. It is an equity issue. Four times Jerry Brown vetoed legislation to correct this for budgetary reasons. David My understanding (in NC) is that same-day billing is an issue only if the NPI attached to the claim is for the agency rather than the provider.  In that case you may have a claim “bounce,” because there are two for the same patient, on the same day, with the same NPI (even in the case of duplicate NPIs this doesn’t always cause a problem, but can per David’s comment).  As long as the claims for the patient on the same day are submitted with different NPIs (the distinct NPI of each individual provider), there should be no issue.  For some specialized services (for example, intensive in-home) all claims from work by different providers within the same agency are submitted under the agency NPI, but at least in my experience this is not typically the practice for billing for primary care medical and BH providers. Aubry
by E. Serrano
Sunday, October 4, 2020
Intimate Partner Violence Screening 0 E. Serrano Can someone recommend a good resource on the most updated screening recommendations for intimate partner violence in healthcare settings, including screening tools/algorithms? I’ve come across some good material but want to make sure I’m not missing anything!   Many thanks,  Talia I would start here for the highest quality evidence: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening They recommend screening all women of reproductive age, and give this recommendation a “B” which certainly means the evidence for screening this population is comparable to other common screening done in primary care. Here is my anecdotal concern.  I was recently in a meeting that included an experienced medical assistant.  I asked the medical assistant how often she asks the standard JACHO question that targets IPV, it is something like this “Do you feel safe at home?”  She responded that she asks all patients as part of the rooming process.  So, then I asked her “How often in the past 10 years has a patient responded that she does not feel safe at home?”  The medical assistant replied “Never.”  I think this medical assistant’s experience is common. So what exactly are we doing?  If lifetime prevalence of IPV is 20-30% then what conclusions can we draw from this medical assistant's experience? Implementing screening is the easiest part of practice transformation.  Implementing screening that actually results in improved patient outcomes is one of the hardest things to do. If you would like to hear more about my thoughts on this on related topics feel free to join the session at CFHA I will be leading with my colleague Sarah Pearson - "Should We Screen for ACEs? - Yes. No. Maybe?” Daniel I am very much in alignment with Dr. Mullin on this one. I would suggest considering the CUES method of Universal Education instead of direct screening. You can learn more information on the Futures Without Violence website: https://www.futureswithoutviolence.org/ And you can learn more about CUES (Confidentiality, Universal education, Support) here: https://www.futureswithoutviolence.org/wp-content/uploads/CUES-graphic-Final.pdf And here for more information about how to use this approach virtually: https://www.futureswithoutviolence.org/wp-content/uploads/Home-Visitation-Virtual-CUES-to-support-survivors-FINAL.pdf Joan
by E. Serrano
Thursday, October 1, 2020
Intimate Partner Violence Screening 0 E. Serrano Can someone recommend a good resource on the most updated screening recommendations for intimate partner violence in healthcare settings, including screening tools/algorithms? I’ve come across some good material but want to make sure I’m not missing anything!   Many thanks,   Talia I would start here for the highest quality evidence: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening They recommend screening all women of reproductive age, and give this recommendation a “B” which certainly means the evidence for screening this population is comparable to other common screening done in primary care. Here is my anecdotal concern.  I was recently in a meeting that included an experienced medical assistant.  I asked the medical assistant how often she asks the standard JACHO question that targets IPV, it is something like this “Do you feel safe at home?”  She responded that she asks all patients as part of the rooming process.  So, then I asked her “How often in the past 10 years has a patient responded that she does not feel safe at home?”  The medical assistant replied “Never.”  I think this medical assistant’s experience is common. So what exactly are we doing?  If lifetime prevalence of IPV is 20-30% then what conclusions can we draw from this medical assistant's experience? Implementing screening is the easiest part of practice transformation.  Implementing screening that actually results in improved patient outcomes is one of the hardest things to do. If you would like to hear more about my thoughts on this on related topics feel free to join the session at CFHA I will be leading with my colleague Sarah Pearson - "Should We Screen for ACEs? - Yes. No. Maybe?” Daniel I am very much in alignment with Dr. Mullin on this one. I would suggest considering the CUES method of Universal Education instead of direct screening. You can learn more information on the Futures Without Violence website: https://www.futureswithoutviolence.org/ And you can learn more about CUES (Confidentiality, Universal education, Support) here: https://www.futureswithoutviolence.org/wp-content/uploads/CUES-graphic-Final.pdf And here for more information about how to use this approach virtually: https://www.futureswithoutviolence.org/wp-content/uploads/Home-Visitation-Virtual-CUES-to-support-survivors-FINAL.pdf Joan
by E. Serrano
Thursday, October 1, 2020
Intimate Partner Violence Screening 0 E. Serrano Can someone recommend a good resource on the most updated screening recommendations for intimate partner violence in healthcare settings, including screening tools/algorithms? I’ve come across some good material but want to make sure I’m not missing anything!    Many thanks,   Talia I would start here for the highest quality evidence: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening They recommend screening all women of reproductive age, and give this recommendation a “B” which certainly means the evidence for screening this population is comparable to other common screening done in primary care. Here is my anecdotal concern.  I was recently in a meeting that included an experienced medical assistant.  I asked the medical assistant how often she asks the standard JACHO question that targets IPV, it is something like this “Do you feel safe at home?”  She responded that she asks all patients as part of the rooming process.  So, then I asked her “How often in the past 10 years has a patient responded that she does not feel safe at home?”  The medical assistant replied “Never.”  I think this medical assistant’s experience is common. So what exactly are we doing?  If lifetime prevalence of IPV is 20-30% then what conclusions can we draw from this medical assistant's experience? Implementing screening is the easiest part of practice transformation.  Implementing screening that actually results in improved patient outcomes is one of the hardest things to do. If you would like to hear more about my thoughts on this on related topics feel free to join the session at CFHA I will be leading with my colleague Sarah Pearson - "Should We Screen for ACEs? - Yes. No. Maybe?” Daniel I am very much in alignment with Dr. Mullin on this one. I would suggest considering the CUES method of Universal Education instead of direct screening. You can learn more information on the Futures Without Violence website: https://www.futureswithoutviolence.org/ And you can learn more about CUES (Confidentiality, Universal education, Support) here: https://www.futureswithoutviolence.org/wp-content/uploads/CUES-graphic-Final.pdf And here for more information about how to use this approach virtually: https://www.futureswithoutviolence.org/wp-content/uploads/Home-Visitation-Virtual-CUES-to-support-survivors-FINAL.pdf Joan
by E. Serrano
Thursday, October 1, 2020
Spanish speaking BHCs 1 L. Edwards Hi! We use 'consultora de salud' here in south texas. DAST and GAD are available in Spanish...did not look for audit, but I bet it is translated.
by C. Caric-Ball
Thursday, September 24, 2020
Virtual Warm-Handoffs 1 E. Serrano Hi Kathy,Similarly to Alan's response, we also utilize the Microsoft TEAMS platform for messaging so our PCPs can send our BH team a message (either through a group or individually) to let us know that they have a patient needing to be seen, then we can coordinate either logging into the call or calling the patient immediately after our PCP visit is completed. This has been working pretty well. We've had a few instances where we don't have anyone immediately available but when that has happened, our BH team communicates with the provider to let the patient know how quickly we can call them back (such as within an hour, later in the day, etc) based on the patient's preference.Casey
by C. Powers
Thursday, September 17, 2020
JD for PCBH System Leadership 0 E. Serrano Hi all! We are in the process of creating a leadership position to oversee the development  and implementation of behavioral health integration in a several primary care practices in our health system. This role will also provide training, clinical supervision and oversight of the BHCs. If you have a similar role in your setting and would be willing to share a sample job description with me, I would be super grateful! Please and thank you ☺ Amy  Below is a description we have used at UMass for Director of Integrated Behavioral Health.  I will get this added to our website for people to download umassmed.edu/cipc [umassmed.edu]<http://umassmed.edu/cipc >  Within our department of family medicine I have argued against the creation of a “Department” or “Division” of IBH.  Consistent with this approach, all BH providers report first to the medical director of the practice they are a member of.  The Director of IBH is a secondary report for BH providers.  The Director of IBH supports the medical directors and serves as a single point of contact regarding clinical behavioral health matters in the practices (as opposed to teaching or research matters).   In my mind you can’t easily have fully integrated care if you have a separate department or division for BH providers.  In addition, if you have a separate department, then soon you may be asked to have a separate budget.  This is not ideal for BH.   Director for Integrated Behavioral Health in Family Medicine and Community Health will be responsible for directing the recruitment, development and deployment of our Behavioral Health faculty and clinicians across the Department, providing oversight to their clinical practices.  Her primary responsibilities include:  *   Represent, articulate and implement the vision and strategy for Integrated Behavioral Health for the Department   *   Provide oversight to the recruitment and deployment of Behavioral Health faculty and clinicians across Department sites and programs   *   Develop job descriptions and participate in recruitment activities and hiring decisions  *   Oversee time and effort allocations, including new requests from sites and programs  *   Serve as an informal mentor to behavioral health clinicians  *   Serve as an advocate for the integration of behavioral health into primary care within the UMass Memorial system  *   Serve as a liaison and advocate to the institution regarding integrated care documentation within EPIC  *   Assist in developing the model for integrate behavioral health  *   Provide oversight to clinical practice performed by Behavioral Health faculty and clinicians  *   Serve as a liaison for the Department with the Department of Psychiatry  *   Work with other departments seeking guidance on integrated Behavioral Health  *   Participate in annual faculty reviews conducted by Medical Directors  *   Standardize/Articulate approaches to behavioral health clinical practice across sites, including protocols and guidelines, scheduling, documentation and coding, productivity, and training Daniel  I agree with Dan 100%. Avoid creating a separate Dept or you run the risk of creating the very silo we're trying to knock down with IBH in the first place. Kent  This is an important topic with different pros and cons to having a separate Section/Division/Department of behavioral health.  I agree that there is a need to avoid having BHPs silo from their medical teams.  However, there are many advantages to BHPs having their own recognized group.  For example:  *   Being invited to the leadership table to be privy to what is happening at administrative levels and have a voice in this process; advocating for the interests of BHPs.  *   Create a medical home for BHPs  *   Standardize BH procedures across different medical specialties and quality control  We have been able to create a model that allows for a separate Section for BHPs but also avoids the silo.  BHPs are in 2 sections: behavioral health and medical.  They participate in all medical division team meetings.  In addition, they participate in BH division meetings.  Funding and RVUs are tied to the medical side.  While there is a larger commitment for BHPs to be involved in 2 sections, our BHPs find that pros of having a separate division of behavioral health outweigh the cons.  Linda  I think that all of the benefits that come in your system for having a Unit that is BH are important, but I would suggest that in many systems, all those same benefits are possible with the team or the practice as the unit of organization.  Having a Director of BH in a system does not require that s/he be the first report for each clinician.  I speak from experience in the same system that Dan Mullin sited in a previous post, and it is possible to have standards and procedures that are unique to BH and still have the Medical Director be the first reporting relationship for each behavioral health clinician.  It means that the Dir. of BH is an important source, and often an attendant in the evaluation meetings of each BHC.  One benefit that we saw was that when the physicians in a practice were given a pool of bonus money from their productivity, they felt that the BH clinicians were part of their team and insisted that the BH clinicians get a share because they could see that they could not have been so productive without them.  Starting in the Spring, I will be offering a course for CFHA on PCBH Leadership that might be of interest to people on this thread.  I include a brief description. Alexander I don't think that this is a "one solution fits all" situation.  It very much depends on the culture of the organization.  I can only speak for my experience, but it has been of significant benefit to our BHPs to have a Section of Behavioral Health within our medical organization.  Medical organizations are often primed for the medical provider, and it important for BHPs to have a position of leadership and a respected platform from which to advocate.  In our case, we would benefit from bonus money that aligns with our medical section. Linda  The fact that we are having this conversation speaks volumes to our progress in making behavioral health primary care.  IMHO a process for this conversation is raising awareness of and balancing the need....  • for IBH to gain power in the primary care context   • Currently underpowered overall   • We are gaining power as more people are added to the work within & between organizations  • to ensure we continue to be about improving primary care and being primary care   • IMHO this is a "North Star" for our IBH in primary care field  If an opportunity presents to move IBH in primary care leadership to the "C-suite" in primary care organizations that is the ultimate goal IMHO. How can we have "parity" in the space without this ultimate trajectory? "How many direct and indirect reports do you have?"   If you are an IBH in primary care leader and cannot report growing numbers of direct and indirect reports, you are IMHO underpowered in your organization. If you are underpowered in your organization, this will directly impact your program development, sustainability, and those who depend on your leadership and advocacy.  Julie  It may be helpful for us to distinguish between having an IBH leader in your organization and having an IBH department.  In our organization we have multiple BH providers at leadership tables, and their voice is relevant to most decisions regarding primary care practice and education, not simply IBH.  There are very few risks associated with having an IBH leader.  There are some risks associated with having an IBH department, or IBH section, or IBH division on your organizational charts.  From my perspective the biggest strategic risks are budgetary.  BH has trouble balancing its own budget for a variety of well known reasons.  Even if current leadership agrees to a structure where a BH dept exists, but the BH budget is not separate from the rest of the primary care budget, I still think there is risk.  Turn over in management can easily result in change and new management may look at the org chart, see a BH department on the chart, and expect BH will be able to balance their own budget.  I don’t mean to say that there should never be an IBH department.  In very large or very mature organizations it may possible to have an IBH department without having to worry about the concerns I have listed.  I am advising that smaller or newer or more vulnerable programs should consider the risks and benefits of having a separate IBH department. Daniel  This does help. Thank you.  I agree. Holding a separate IBH budget is a risk for small and I would also say large IBH in primary care implementations.  I also think it can be in conflict with the “North Star” I brought up below.  When holding a separate IBH in primary care budget, I would be looking at whether the leadership for nursing and physicians also hold their own budgets.    If not, then I would recommend IBH leader resist and influence away from efforts tho have the IBH leader hold a separate budget from the overall mixed clinic budget.  Saying this, I think it is very important for the IBH leader to work with billing department and other senior leadership to create monthly push reports that display what kind of revenue and how much is billed (and ultimately received) by each IBH clinician. This often requires different spreadsheets that reflect the blended-payment state.  Most often each clinic (in my experience) in large multi-clinic systems holds their own budget.  This budget is often overseen by the clinic manager who reports up to the senior operational/financial leaders.   Everyone in the clinic (including IBH clinicians) work in that budget and together (and in independently accountable ways) toward the fiscal success of the clinic. Julie Thank you once again for being my brain trust. This issue has been top of mind for us at East Tennessee State University where the Dean of the College of Medicine has funded some of our time to administer an “Institute of Integrated Care.” Faculty hired as Directors of BH within COM Departments are members of those de[artments and subject to the administrative processes, lines of command, etc. The Institute stands apart as “consultative” to their work, to drive deficiencies in BH services across the College by providing a centralized clearing house for technical assistance to all departments on all things integrated care. The Institute direct reports to the CMO for the COM health system.    Jodi  
by E. Serrano
Tuesday, September 8, 2020
Telehealth Behavioral Health Crisis 0 E. Serrano Hi everyone, Our nurses pool has asked our BH team to provide some explicit guidance on how to handle a range of behavioral health crises that they encounter on the phone with our pediatric patients and their parents.  They are looking for information on how to briefly assess, triage, and follow-up on issues related to suicidal ideation, substance use, etc. I thought I'd reach out to see if there is collective wisdom in this wonderful group about key issues to consider, or prior experience with workflows that have been successful in this kind of project. Please backchannel to caroline.krehbiel.phd@gmail.com<mailto:caroline.krehbiel.phd@gmail.com>. Caroline The first thing to do is to establish what services are available and provided by the state. Here in Delaware we have a child crisis response available 24/7 staffed by a non-profit clinic and paid for by the State of Delaware.   I realize that not all states have that, but check to see what your state and county has available as universal available resources so you know where to refer instead of the usual "go to the emergency department" I would think if there is a concern about suicidal ideation, then that would automatically go to your mental health person, whoever you have on call. If you have an integrated care model, then your licensed clinician needs to be contacted.  The same is true for other urgent problems, perhaps uncontrollable rage or upset.     I know you want more than I am offering right now, this would be a good workshop topic for CFHA to offer on management of behavioral emergencies in primary care - to give you some specific interviewing skills, verbally administered questions to go through.    Drs. Cynthia Pfeffer and David Schaffer reviewed this for the Academy of Child & Adolescent Psychiatry a long time ago, but I think this is still useful: "Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior" Doug There is resource on the AIMS website that might be useful: https://aims.uw.edu/resource-library/psychiatric-emergency-management-resources. Also teaching them how to do the Columbia scale? Lori
by E. Serrano
Tuesday, September 8, 2020
Collaborative Care Billing Question 1 E. Serrano Hello all, I am trying to draft something that asks patients if they want to sign up for the CoCM program, namely for medicare patients. I was going to add this to the clinics confidentiality notice. Here is what I was drafting: Rocky Ford Health Center is utilizing a Collaborative care model (CoCM) in order to deliver quality whole-person care for you and/or your family. Records are openly shared between your prescribing provider, behavioral Health Care manager, consulting psychiatrist for chart reviews and direct healthcare team members and adhere to all HIPAA protections. By initialing this box you are consenting to be enrolled in our CoCM program. Can any of you advise on the language you use to have patients use the CoCM program? I know there is a fee associated with the CoCM model and im not sure how to word this. Any suggestions or anything i'm missing?
by T. Chohfi
Tuesday, August 18, 2020
"Psychotherapy" notes are Separate from Medical Record in integrated care? 0 T. Chohfi Hello all, I have read that many of us are allowing "notes" by the BHCs to be shared with the care team to stay true to our goals for integrated care. I have read some opposing literature that if it is a psychotherapy note, then it cannot be shared with the rest of the team. (45 C.F.R. § 164.501). To be considered “psychotherapy notes”, the notes must be separate from the medical record. The 2000 commentary explains the reason for this rule along with HHS’s practical view of what constitutes “psychotherapy notes”: A psychotherapy note is defined as "Process notes": "These process notes capture the therapist’s impressions about the patient, contain details of the psychotherapy conversation considered to be inappropriate for the medical record, and are used by the provider for future sessions. We were told that process notes are often kept separate to limit access, even in an electronic record system, because they contain sensitive information relevant to no one other than the treating provider. These separate “process notes” are what we are calling “psychotherapy notes.” Does anyone have experience with this? IF we have a BHC in house and she writes her notes from a counseling session, does she have to write her own "psychotherapy notes" (Which seems to be her impression and opinions of the case) separate from her progress notes that includes: medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date (since this is allowed to be shared?) Thank you all in advance. Here is the article https://www.hollandhart.com/hipaa-psychotherapy-notes-and-other-mental-health-records
by T. Chohfi
Monday, August 17, 2020
Billing with Behavioral health care managers or BHCs? 2 T. Chohfi Thank you Dr. Serrano! That answered my question!!
by T. Chohfi
Friday, August 14, 2020
"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

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