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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
More PCBH data from your friends at CHCW! 0 L. Edwards Hey all!  As always, love bragging on the team at CHCW and wanted to share some of our July numbers (we had a good month!).  At our "mothership" clinic, CWFM, our core BHCs (four psychologists and one LMFT) produced the following stats:   - *4.8 patients per clinic* (clinic being a half day, so 9.6 patients per day; as always, our visits only count if they are billable visits, no meet & greets)   - *1.8 handoffs per clinic per BHC* (clinic being a half day, so 3.6 handoffs per day per BHC; we usually have 3 BHCs on during the day, so in total, the clinic averaged 10.8 handoffs per day)   - *2.34 visits per clinic were paired with a PCP visit per BHC* (either through a handoff or prescheduled paired visit; so 4.68 paired visits per day per BHC; meaning, with 3 BHCs being on in a day, our clinic averaged 14 visits being paired with a BHC and PCP)   - Within the month, *368 unique patients* were served by these five providers, who equate to 3.0 FTE of clinical coverage. What makes the above numbers even more impressive, IMO, is that July is our onboarding/orientation month for our new FM residents and BH interns, which means the BHCs are being shadowed by eager interns, as well as having low provider census due to orientation responsibilities. AND!!! August appears to be shaping up to be a great month, as yesterday in our afternoon clinic, *15 handoffs were completed between PCPs and BHCs*. Again, within a four-hour clinic, 15 handoffs that resulted in billable visits!!! As always, would love to hear other stats/data from other programs!!!  -- David Thank you, David, for your productivity rates.  The access to to BH services is impressive. Do you also have data on patient outcomes in relationship to BH contacts? How do we as a profession,  measure outcomes beyond PHQ9s. I think  we need to move the needle forward to investigating what "dosage"  and  types of BH interventions align best with patient symptoms/stressors/functioning.  Identifying the intensity, frequency and duration of treatment should be part of our quality improvement processes and evidence building strategies.  I am cautious that these "access" numbers could too easily translate into "More equals better".  More is better for access and billable services that support BH staff and some support for patient care but the greater goal of patient sustainable outcomes still needs our attention. Our physician colleagues are trying to move away from this productivity model since the  current acute-care productivity approach does not mesh well with the  quadruple-aim or chronic disease model of care.  The movement toward a value driven model may hold more promise to meet the needs of patient-centered, chronic disease management for our patients and communities. I would be interested in exploring the metrics of PC and BH that could help us demonstrate  outcomes for patients and communities.  As a discipline, I think we could benefit from differentiating  dimensions of quality indicators--intensity, type and duration along with  quantity of care--frequency and access. In my opinion, this is a complex evaluation and research process that needs our full attention and brain power. Mary Hey Mary! Couldn't agree more with your assessment and that productivity only tells a portion, albeit an important portion, of the story. In our system, we look at a variety of different metrics and the data is quite compelling. Specifically, patient satisfaction with the clinic as a whole (i.e., satisfaction with their experience, front desk staff, pharmacy, etc.) improves when patients see a BHC (and their satisfaction with the services are sky high), patient outcome metrics such as A1C/BP metrics, likelihood of completing well-child/vaccination requirements improve when they see a BHC, our provider satisfaction is approaching a ceiling effect (off the charts, actually) in that providers find the BHCs vital to their ability to practice (the last arm of the quadruple aim that we need to focus on is the cost, which we will try to tackle next!) To me, however, the importance of productivity is helping primary care achieve its goals of the four C's 1) First contact (aka access) 2) continuity of care 3) comprehensive care and 4) coordination of care. When primary care does those four things well, we know the population of a community improves. Thus, us striving to see the entire population of our health center, which allows us to help PC achieve the four C's... and, :-), having the aforementioned outcomes also motivates us to get that out to our population... we want our community to be healthier, as well as our on-demand access helping support our PCP colleagues (who, as said above, continually rate our services high)!  Would love to hear others thoughts on the outcome piece, because, as Mary said, it needs to be multifaceted!!!  David  All:  I appreciate David's work to push the needle on models of care, get the word out, and spark some thinking about how to measure it.  In re: ACCESS, mark your calendar to check out our editorial in Families, Systems, & Health  - coming mid-September - in which we address measurement of this "god term," and provide some starting points. CFHA members can read the journal for free with one click on the www.cfha.net. FSH Editors await your rigorous quality improvement project, program evaluation, or research study of implementation outcomes like "access!" Send them in! Jodi Thanks, Mary.  I agree strongly with your remarks.  I love reading David's successes as they inspire me to keep working on how to improve our team's activity.  And, yet, sometimes I wonder how we know that what we do makes a difference.  Certainly, we know anecdotally that patients are grateful and frequently are gushing in their appreciation for what we do.  But, on a larger scale, WHAT do we do that is essential?  What is less so?  I truly believe in the relational aspects of BH work and others argue more in favor of the content of what we provide.  Is it the singer or the song? Probably both. We've started trying to measure, in outcome terms, in our organization, what BHCs do for our clinics above and beyond RVU production.  Knowing the right dependent variable is challenging.  Less ED visits?  More completed (less no shows) visits?  Physiological variables (A1C, BP, weight)?  Loving the journey to discovery and look forward to the wisdom of this group. Jeff Hi! A tool that we utilize to measure outcomes is Partners for Change Outcome Management System. PCOMS uses two, four item scales to solicit patient feedback regarding factors proven to predict success regardless of treatment model or presenting problem: early progress (using the Outcome Rating Scale) and the quality of the alliance (using the Session Rating Scale). It takes about 1m to administer and then you utilize it throughout your visit as a talking point to help guide goals and change. We just participated in a multi-site study looking at its effectiveness in the primary care setting with positive results. We are still exploring its effectiveness in co-visits versus one-on-one follow-up sessions. There is a paper and electronic version for tablets. Sherri Hi All - great discussion, as always.  I think Mary raises the right concern, but I’m not sure it's the right question. We BH providers always wonder about the effectiveness of our treatments/interventions. But I’ve never been sure how important that really is when it comes to integration. For starters, I’m not sure how possible it is to actually answer. Researchers in specialty mental health have been trying in vain for decades to answer the question of what dosage of what intervention works for whaty person under what circumstances; but still don’t know. We just don’t have the research methods. If we are being honest with ourselves, I also don’t think we have even really demonstrated value at a population level of the mental health system. We certainly all know that sometimes what specialty MH does seems to benefit patients more than they would have benefited from no or other treatment, and we can say as a whole that certain therapy approaches are more likely to be beneficial for certain problems than others (at least for the short term). But that’s about it. But as I say, I’m not even sure how important the question is for a BHC. One thing I know for certain:  no matter how effective I am as a BHC, I will never have the population reach that a PCP does. As a result, I am much more interested to know how I can help tge team to be more effective - not just with patients the PCP refers to me, and not just with patients who have behavioral health issues - but rather with all of their patients. To that end, I actually think that easy access to the BHC (and perhaps also - relatedly - high productivity) might be one of the most, if not the most, important components of BHC work. One reason is that it might help PCPs identify and engage more with behavioral issues in patients. We both assume and know, for example, that a very real contributor to poor PCP identification of behavioral issues in patients is the PCP’s fear of opening Pandora’s box; the fear of asking about behavioral issues because of the lack of support for helping patients with whatever gets identified. Personally, I believe that PCPs quite commonly know/suspect when a patient has significant behavioral issues; they just may be fearful of bringing those to light and then being on their own to manage them. But what if the PCP knows there is a highly accessible BH provider at the ready, who will be immediately able to help them manage whatever is identified? My guess is that they will feel more comfortable asking about behavioral issues in that situation; they might bring in the BHC or might just handle the problem on their own. But either way, the behavioral issue gets addressed. We probably could do away with a lot of these screening tools that are rapidly and increasingly bogging down primary care, if only the clinic had more readily accessible BH help. There’s a research question in there that I think could be very worth evaluating, but it has little to do with the effectiveness of the BHC’s interventions.   Continuing along this line, how does it affect the PCPs care of other patients (i.e., those w/o bx issues and/or not seen by the BHC) if the PCP has such readily accessible BH help? That is, when a PCP is able to hand off a patient for immediate help from a BHC, the PCP may be able to spend more time with other patients who otherwise might have been shorted on time. To my mind, that would suggest that better care is being provided for the other patients, merely as a result of having a highly accessible BHC. (Of note, this benefit may still accrue even if the individual patients seen by the BHC fare no better than they would have if seeing the PCP alone; i.e., immediate BHC access alone may result in benefits even if the BHC’s patients don’t improve.) Again, there are more than a few research questions embedded here that I would consider more important to ask than the effectiveness of a BHC with individual patients s/he sees.(Gouge 2016 started to answer this question- great study.) The bottom line is that I wish we in the integration community would think more about how to help primary care broadly, and worry a bit less about how effective we are with the individual patients we see as BHCs (odd as that may sound). Not at all to say that we should not care about our patient outcomes or disregard the question of BHC competence - most PCPs won't handoff a patient to a BHC they perceive as unhelpful for patients or lacking in competence, even if the BHC is standing right outside the exam room door begging for patients. We do absolutely need for our BHCs to be skilled and knowledgeable clinicians who are capable of doing something meaningful with patients. But the basic point I am trying to make is just that primary care is the system that has been shown to have tremendous value to the population if done well - the mental health system (and, by extension, BHCs in primary care) are not likely to ever demonstrate such value. As such, we need to start thinking more about how to improve primary care broadly; we need more “PRIMARY CARE behavioral health” and less “primary care BEHAVIORAL HEALTH”. One final point (really) - the other reason that our obsession with individual BHC outcomes hampers integration is because it inevitably leads to BHC-imposed guardrails on their involvement with patients. If my goal as a BHC is to improve patient outcomes, then why would I engage in the care of a patient with schizophrenia? Severe substance use disorder? Chronic, treatment-resistant depression? Severe PTSD? etc etc There is no evidence that a BHC can improve outcomes for these conditions with a 30-minute max visit, so the only feasible option seems to be disengaging and referring the patient to specialty mental health. The problem with this approach (well, there are many problems with this approach, but the one most pertinent to this discussion) is that it fails to recognize that there may in fact be much a BHC can do to help the PCP and team manage these patients - even if they don’t get better; and to the extent a BHC can take work off the PCP’s plate, that allows the PCP to help other patients. There are, in other words, always two gains that can accrue from engaging with a patient - one is that the patient *might* benefit from the additional BHC help, but the other is that the team may be better able to help other patients. In my mind, either is a win. Hopefully this all makes sense, and I welcome the thoughts of others. PS the data Dave Bauman presents from CHCW, while admittedly not yet subjected to rigorous peer review, is in my mind exactly the kind of data PCBH services should be keeping and exactly the outcomes one would hope to see from a service. Kudos to him and his team! Cheers - Jeff Jeff, I really appreciate your comments and suggested refocus.  You have given voice to some of my own thoughts and generated so many other issues that we could explore more fully.  I would suggest moving this discussion to a master document that can be contributed to and commented on more easily. <http://cirrus.mail-list.com/cfha/12320088.html>  C.R. Hello everyone, I am new to this List Serve and enjoying the conversation! I am looking for someone from Idaho who can talk to me briefly about the State of the Union on Medicaid and Primary Care BH integration from a payment standpoint.  Can anyone point me in the right direction and/or allow me to bend your ear for a minute? Thanks all! Laura This is a great discussion and I'd like to share with you a question that has been rolling around in my head: How do we think about "intended" outcomes and whether we are reaching them. For example, let's say that I choose a brief parenting intervention to support parents whose children are exhibiting negative behaviors and this is implemented clinic-wide among all BHCs. If I choose this based on the knowledge that RCTs showed a 25% reduction in problem behaviors, then how do I think about how my outcomes measure up to the intended outcomes? What about for something less specific, like behavioral interventions for treatment engagement. Of course, I recognize the myriad of differences that occur when BHCs distill elements of an intervention to core components to use in a brief setting, and that we are thinking about apples and oranges when comparing brief interventions to RCTs meant for typical therapeutic settings. I am just wondering how others think about a "gold standard" by which we can say that something is or is not achieving the intended outcomes. Do others think about outcomes in this way? Could it be helpful or is it too murky? Thanks all! Julie  
by L. Edwards
Wednesday, November 13, 2019
Integrated Care promotional video 1 K. Hill https://www.youtube.com/watch?v=xMW1RdHG86E&t=27s
by P. Hawley
Thursday, October 31, 2019
Gender affirming care in Primary Care 1 J. Schoff Jen, I have not heard of a clinic using CoCM specifically having a protocol for gender transitioning evaluations, however I don't see much of a reason why you couldn't. The main issues is how strictly you adhere to the CoCM model. Since the model is focused on depression outcomes it does not attend to gender identity or other behavioral issues specifically, but you could create a sub-protocol for individuals struggling with depression AND gender identity issues that allows/encourages the team (particularly the team members performing the behavioral intervention component) to address the gender issues and possibly perform an evaluation for suitability for transitioning if so qualified. The issue is really one of how much you are willing to flex from the CoCM model. At the very least a reasonable goal would be that the team is educated on gender identity issues so that the care is informed by this training. Hope that helps some.
by N. Serrano
Thursday, October 3, 2019
Burnout 0 L. Edwards After 18+ years of practice in underserved areas. I’ve seen a number of staff and providers experience burnout ( exhaustion, cynicism and inefficacy). It is a difficult thing to witness, and I really never expected I would experience it myself. Seems like we are seeing more focus on it in the media.  So I’ve started looking into it more closely, and I ran across this article from the National Academy of Medicine which outlines some of the issues, so as to promote discussion.  <http://cirrus.mail-list.com/cfha/61373580.html>  I am wondering if people on this list serve are seeing similar trends in their health centers and if so, what you might have tried to remedy the situation?  Thank you for sharing the article. Papers in this field date back at least to 1982 (McCue, NEJM, 306:458-463) but I'm not aware much has been done in response. A neglected but important source of burnout is patients with psychophysiologic disorders (medically unexplained symptoms or MUS, chronic functional syndromes and chronic pain not linked to organ/structural problems).  McCue calls them "problem patients" and points out that the amount of time spent on them has increased dramatically.  Imagine being a professional in any field who had no formal training in how to solve 30-40% of the problems they faced every day.  That is the situation in most practices because of these patients. Fortunately, with the appropriate techniques, psychophysiologic disorder (PPD) patients can be diagnosed and treated as successfully as any other. One primary care office that learned and uses this approach found that it "put the joy back into my practice" for most of them.  (personal communication, Community Care, Albany NY). An introduction to these ideas will be presented during the MUS SIG webinar on Thursday, July 11.  Hi Everyone, I am glad to see others interested in the problem of physician burnout, as this is my research interest and part of what I intend to explore in my dissertation work.  I agree that little research has been done examining burnout with primary care physicians who work extensively with patients with behavioral health needs. As a social worker in such a practice, I advocate for the inclusion of social workers on integrated teams to provide support and trauma informed care education to physicians as a means of helping to mitigate burnout. I find that treating these patients as a team and working to make sure the physician feels supported can be a big help. I am always up for collaborating in this area for those that have an interest. I have attached the report from the Harvard T.H. Chan School of Public Health that came out this year about physician burnout for those of you that may have missed it. This is an important and salient topic in healthcare at large and those of us working in healthcare settings see elements of burnout all around us much of the time. I’m curious to hear as well from those of you who either are experiencing, have experienced or see others around you experiencing burnout, how CFHA could support you and your teams. We recently just finished up a Wellness workshop with our new resident and behavioral health intern cohort... we have a couple of themes: 1. You can't have wellness in a context that doesn't promote wellness – our goal in this discussion is that to 1) normalize burnout as a response to a demanding context. We start this conversation by asking residents/interns to come up with a list of what makes a human being healthy. We then discuss how realistic is it for us to engage in these activities when they are in inpatient service, or working all day clinic and have 20 charts to complete before going home. The goal isn't to paint the picture as "dead on arrival" but more so to encourage a sense of kindness and compassion that burning out is not necessarily a fault or lack of ability of the provider. It isn't because providers aren't being mindful or exercising or eating right enough (those can definitely contribute), but that the system/context they are in often promotes burnout. We then transition into the second part, which is a discussion of how we can set up the environment to promote wellness/resilient. We actually have the residents look around the clinic for ways of making it a more resilient producing space. This could be putting pictures up of family, having music playing, streamlining workflows, etc. 2. Connect to your why and express gratitude. This is something new we are doing this year but we are striving to allow the residents/interns to be more engaged with their "why" of family medicine/psychology, as well as their overall values. We do values clarification exercises, as well as reflective writing on a patient experience that reflects their value of family medicine. We also do a gratitude exercise that prompts the trainees to think of people that have supported them during difficult times. New this year is that we will actually have the residents write thank you cards expressing this gratitude and appreciation towards these individuals. To me and reading through the literature on this topic (definitely not an expert) but burnout out is largely due to having systems that do not promote wellness (research in this area shows the best way to prevent burnout is not through provider driven interventions, rather, interventions geared towards changing systems) and do not reinforce the "why" and "value" of being a primary care provider. And, as we end these wellness talks, even doing those two things won't cure/eradicate burnout entirely. I remember a presentation in where the speaker said, "disengaged people don't burnout, engaged people do." This is where the self-compassion and kindness comes in that we can be kind towards ourselves when burnout is present and, most likely, is appropriate given the context. Sorry for the tangent! Provider burnout has been a hot topic - in only one of our eight centers. I've been working on the "why" of this for a number of months and there seem to be several factors: 1) the perception that other centers have "less work" - thus leadership needs to tackle the perception of inequity 2) that there are "burnout leaders" in our one center - a couple of individuals who are convincing others that they are burned out (and it seems only a few are susceptible to these suggestions) 3) the fact that there are some real factors and providers do actually feel burned out - they work in our highest-volume center, the patient needs are great, they feel like they are spinning their wheels with some patients, etc. To tackle the third point, I have started a monthly lunchtime group where providers can talk about their struggles with a challenging patient population. Using a peer-support model, with my facilitation, providers have a safe space to talk about their own feelings of inadequacy, ineffectiveness, frustration, anger, sadness, etc.   We discuss strategies (mindfulness, exercise, time off, taking breaks, etc) for self care, and allow for honest communication about feeling around their work.   We have had some decent success with this, as those who choose to participate have reported feeling more supported, less alone, and having validation of these feelings. We do not allow for complaining about the work environment, but we do encourage open dialogue with administration about those issues.   Our medical director and CMO are very focused on addressing burnout, so we do have significant administrative support. I'm also trying to prevent burnout from discussing burnout! I think the biggest thing CFHA and all of us can do is destigmatize "burn out" and have frequent, honest conversations about the pressures of working in stressful environments that are often in high demand and provided limited resources. Too often "burn out" is associated with some type of character flaw and only further pressures providers to fix this problem on their own. Burn out is a product of vicarious trauma, work stress, and a variety of other factors (many of which we are not in control of). Supporting one another and being leaders in changing workplace policy, supporting trauma informed care approaches, and providing options for those who are dealing with functional impairment due to this are all great places to start.  I would also like to add that it is not just medical and BH providers who experience burn out--clinical staff, administrators, business staff, among others are also affected. To the degree that we can implement system-wide interventions, we will be better able to support each other and have a positive impact on patient care and staff engagement.  I like the idea of destigmatization as a step in the right direction. It is almost like we need a hashtag for it, like #metoo, but for providers and staff experiencing the burdens of caring for patients and for themselves and their teams. I certainly hope that this list serve is a safe space for people to share their experiences, especially when they find themselves in systems of care that are not as attentive and proactive as some of the great examples posted on this thread. This is so true and something we've been discussing here. Also, your fixing poverty with psychotherapy is right on! I have a line that I've been using for several years in burnout (and physician depression and suicide) talks and then last year in a grand rounds talk I gave on our roles outside of clinical (including advocacy, education of the general public, writing op eds, etc)...which is that I got really tired of treating poverty with prozac (I guess AND psychotherapy!), when I know that isn't going to do much (and my patients acknowledge that as we have these discussions openly and I tell them that I think their depression/anxiety/etc is maybe a small percentage biological...or a larger percentage biological that is induced by the psychosocial/spiritual). The advocacy talk I did was requested by a psychiatry resident working with me who heard me go on about how doing advocacy work and trying to fix these bigger issues more broadly was like burnout prevention for me, as it made me feel less helpless in the clinical  setting. I'm glad that Social Determinants of health are finally getting their due, but we have a long way to go to spend the amount of money necessary to address the gaps we have there...even if that means spending a bit less on health care. I so enjoy these threads. Stimulating! And burnout preventing, for me, to hear from such thoughtful and compassionate colleagues. Primary Care Progress (a non-profit stationed out of MA focused on revitalizing primary care) has a blog, and many of their articles are focused on provider burnout and the idea of moral injury.  One of the components spoken about a lot, which I can't recall being brought up (but I may have missed it!) is the administrative burden put on providers being one of the largest contributors to burn out. What I find most interesting, is that in most of the articles, the take away message is: form community.  Bring people together, allow them to talk about their struggles, hear one one another, feel one another, and they can heal. XXX referenced it in his email, just talking to one other helps. I've copied the link to primary care progress's "progress notes" page, which is their blog.  You'll find some great articles.  I've also pasted a link to one of my favorite articles called "Breaking Bread" which is all about the power of sitting down and having a meal together. Simple, but what a wonderful way to start, no? <https://catalyst.nejm.org/breaking-bread-burnout-community/> <https://www.primarycareprogress.org/progress-notes/> I got so excited by seeing XXX’s comments that are in line with many of our thinking that I failed to share some of what we’ve done. While we don’t have as robust of a wellness program as I’d like, we have had for a decade, since before this was being discussed so much, biweekly case consultation meetings at our clinics. I think we often find these as not just helpful for tips from respected colleagues for our patients we are  struggling to help, but even more so for the sense of shared mission and experience (and struggles). Collegial support and understanding cannot be overstated. We are also constantly looking at ways we can take some of the administrative burdens off of our clinicians and let them be present with patients and do what they were trained to do. It’s hard with EHRs, insurance company prior auths and other paperwork, and other administrative “interference”. I think so many of us are looking at how to bring humanism and compassion back  to the forefront, because that’s what brought many of us to our professions in the first place. Many of you have probably read much of the burnout literature. It is true that individual interventions do less than organizational and systemic ones, and even many of the individual interventions that have shown benefits are not long lasting BY THEMSELVES. Having said that, a number of things I’ve read have shown benefit case consultation, Balint groups, or other similar things in that category. We are all humans, interconnected and in this together, after all. This has been a lengthy and robust conversation as always so I have not felt the need to offer 'my two cents' regarding the evidence for specific interventions and so forth as I think many of the responses have included some really sound ideas. Nevertheless I wanted to acknowledge and validate the personal difficulty that Dan Mullin shared in his response yesterday.  For those that missed it, following his reliably astute assessment of the role that research must play in this, he shared some very personal struggles related to his effectiveness in meeting the very complex needs of his most vulnerable patients.  I have felt very similarly to him at times in the past, frustrated and hopeless that my sound training in evidence-based behavioral interventions was letting me down.  I heard you XXX.  I always read your contributions to this forum with interest, but I especially appreciated your openness and candor this time around. Hang in there, friend.  You're doing great work and you're not alone. I want each of you to know that your hard work, dedication, and commitment to helping others does make a difference, does change lives, in ways you may never know. If it were not for the kindness of people like you, I would not be here today. I was the person/patient/client who missed my appointments. I was the person/patient/client who did not adhere to prescribed medications. I was the person/patient/client who slept under the overpass in the downtown area. I was the person/patient/client who had multiple physical and behavioral health diagnosis. I was the person/patient/client who used mind-altering substances to numb my fear and pain. I was the person/patient client that no one believed would make it, but Because of my encounters with people who cared, and the kindness they showed me, I was able to regain my health, attend college, and successfully earn a fantastic education that I can now use to help others. You do not always get to see the successes of your work, but I want you to know you have changed lives, you have made a difference. Thank YOU! Also, the thread is spot on, it is the system in which we find ourselves that needs changing.   We have spent years and millions of dollars testing and developing interventions to understand how to change people, when our efforts are best spent creating interventions and strategies that strengthen the system, building a foundation that will withstand the changes in any political environment. Thanks all for sharing, and especially thank you Vickie! This is why we do what we do! This seems like a very valuable discussion for a conference presentation. And very parallel to the feelings of family docs who are burned out.  How to we keep this from being contagious? Such an important discussion. A year or so ago, we used the Maslach Burnout Inventory to assess our medical, dental, and behavioral health staff in a large FQHC in Memphis. I was actually shocked that although the providers all reported verbally being burned out (hence prompting the survey), they showed up as actually being better than average when compared to other healthcare providers in the very  large normative sample. What surprised me even more was that it was the administrative staff (billing, IT, etc.) that appeared the most burned out! I was left with so many questions following our internal research. I wondered about how our setting really compared to the norms. I cannot imagine there are many in that sample that have more complex (socially or medically) patients than those we see day in and out in inner city Memphis. But, yet... our team seems to have some resilience! So, what are those factors and how do we describe and cultivate them more broadly? Additionally, for those who are burned out, what are the factors that lead to that so we can address them? Number of patients seen per day? EHR specifics? Setting? Personal characteristics? More research is certainly needed. Have any of the rest of you used the MBI in your staff? If so, what did you  find? Hi all, Thank you for a robust and informative discussion. It is hard for me to look at the topic of burnout and not expand further on XXX's point about burnout being a systemic, rather than individual problem. Just like any other labor group in the US over the past 40 years, physicians (especially PCPs) have seen declining real wages, longer work hours, and reduced bargaining power. Add to that the staggering student debt that many medical professionals (mental health providers included!) have had to deal with. Add to that national health crises like the opioid epidemic, decreased access to health care, and declining life expectancy in many areas. Frankly, every day I go to work, I am surprised more of my colleagues are not overtly succumbing to burnout. It seems to me like the whole system is indeed on a downward spiral. Implementing variety of PCBH models in the clinic has provided some relief (albeit with more struggle and pushback than many of us had hoped for), but at the end of the day often feels like we are trying to reform a system that instead needs replacing. I think there are wonderful things that can be done by organizing, and by joining other groups or organizations that may be trying to address the systematic problems that lead to burnout at our clinics. Earlier this summer, AMA almost endorsed medicare for all. There may be other allies out there. I concur that in order for healthcare workplace conditions to improve healthcare labor will need to organize.  It is interesting to me that some healthcare professions like nursing have a strong history of organizing. In the age of corporate healthcare it seems likely other members of the team would benefit from organization. CFHA can support this organization by surveying the workforce, working conditions, salaries, and workforce needs.  Making this information available in a timely and transparent way can help increase bargaining power. I like your statement and your question. "... our team seems to have some resilience! So, what are those factors and how do we describe and cultivate them more broadly? How can we address the fourth aim in the Quadruple Aim?  Improving the work life of clinicians and staff.  *   Does working in interdisciplinary teams impact burnout?  *   Does working in interdisciplinary teams impact work-life quality (WLQ)?  *   Are their differences in perception between professionals?  *   How have technological advances impacted clinical and staff burden?  *   How have peer navigators impacted clinical and staff burden?  *   How do we measure clinician and staff well-being? A recent article discusses an interesting model Brigham, T., Barden, C., Dopp, A. L., Hengerer, A., Kaplan, J., Malone, B., ... & Nora, L. M. (2018). A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. NAM Perspectives. <http://cirrus.mail-list.com/cfha/88251204.html> Ditto to these conversations: It is affirming and depressing to read these posts.  The impact of an overwhelmed system of care on providers, staff and patient just reaffirms the mulitiple layers and interactions of these issues.  I am struck with the challenges we face from different levels:  the personal relationship dynamic and the organizational-policy issues. 1. The struggle of being in relationships that actually mean something--with patients, families, and colleagues, takes time and emotional bandwidth.  The resource of time is an essential ingredient that needs to simmer, and the flavors need to mature to develop a human connect that can make a difference.   Organizational systems need to provide the resource of time and emotional re-charge space and time to engage in this work--individuals needs to protect these relationships. 2.  As everyone has been saying:  The organizational systems are toxic to wellness.  Yet, we are not well trained in organizational change, advocacy processes and pushing policies.  As everyone is recognizing, we need more intentional organizational strategies to change healthcare systems.  At the end of my career, I am just figuring out and getting woke to the importance of this work.  So, I hope invest more to support advocacy -professional organization to these processes that focus on organizational and policy changes at the local, state and federal levels.  And, we need to train our providers, residents, and other colleagues in these advocacy-policy strategies to make sustainable changes.  This has been a robust and impactful conversation (thanks Hunter for starting it!). I too want to chime in and recognize all of you out there who are feeling the effects of burnout or precursors of it. I have been there and it is not fun. This conversation has also elicited some potentially actionable ideas for CFHA including Dan’s great idea about a workforce survey (has been in my idea parking lot but may be moved soon!) and the notion of embedding this issue into policy advocacy. I have always thought that the most important contribution of integrated care to healthcare was simply making life better for the providers in the system. Finally, there will be two sessions at this year’s conference dedicated to the issue: one is an Extended Learning Opportunity (Thursday of the conference) for Behavioral Health Leaders (frankly any discipline would benefit so all are invited) to explore and proactively shape their careers (including avoiding or working through burnout) and the other is a concurrent session review of a wellness program for physicians. Obviously we could do more, but alas there is only so much content space. As you think of ideas or if you want to be a part of making change happen, please let us know and we/ CFHA can get you “in the game." I have been gripped by the moving and heartfelt sentiments expressed her. Recently I learned about 3rd Conversation (https://www.3rdconversation.org/). This organization convenes groups of providers and patients around the county to talk together about the ways that healthcare has changed and the impact of these changes on both. I have found this to be an interesting and even exciting response to the way healthcare is delivered. Check it out. This is striking so many nerves, it feels like secondary trauma.  I have a friend leaving family medicine after 25 years for all the reasons mentioned in this thread and another surgeon who is so beaten down with the financial and administrative politics that her system is on the verge of malpractice because it is run by MBA's.  I think organizing needs to happen to expose these horror stories that constitute institutional abuse.  It would make an important segment on 60 minutes and is already beyond epic proportions. At the same time, I'm thinking that burnout is no longer the correct term. To me, these are times of trauma and they should be called what it is. For the wounded, I think wellness should include witnessing as well as more mindfulness built into our cultures.  I've seen  a study on mindfulness with medical students.  I'll look for the reference.  For many survivors of abuse, mobilizing in the community and claiming their voice is a relevant part of healing.  However, survivors in our settings are largely still being wounded by the system everyday. If this was a patient, we would be helping them to find a safe place.  That's why I think organizing would be an important strategy.  It could be the macro intervention while mindfulness and trauma services help individuals to stem the tide of the personal toxicity.  Just like in the military, we have a practice culture that doesn't look kindly on vulnerability. Like so many of you, I have been following this tread with great interest. I have stayed silent to this point for multiple reasons- a sense that I have nothing to add beyond what has already been said, feelings of being overwhelmed by other tasks that inhibit ability/readiness to formulate a worthy response, among some others.  After a week of reading moving and well-written contributions, I finally feel ready to lend a voice. When I have read the comments shared over the past week, I have noticed three primary reactions: 1) Wow, that is so well said!  I am honored to consider members of this listserve colleagues, mentors, and friends.  The responses show a beautiful combination of courage, insight, and analytical thought that most organizations would struggle to match.  I both empathize with and  admire the sentiments shared here. 2) Oh my, I had no idea that so many of us struggle with these feelings.  Granted, there is likely some significant selection bias (I suspect that there are colleagues reading who do not feel burned out, but have enough empathy for colleagues about whom they care to not state that publicly in this thread), but nonetheless, the number of folks willing to lay bare the emotional experiences of burn out and secondary trauma have been striking. Those two thoughts have been shared (and better written than above) previously in this thread, but there is a third aspect of my reaction that I have not yet seen articulated: shame.  I feel ashamed to have feelings of burnout. I have a job that I generally love that offers a chance experience relative autonomy, a chance to help people in a real and meaningful way, and to be able to make a comfortable living doing so.  And yet still-- I feel a sense of burnout at times.  I compare myself to my physician & NP/PA colleagues and think "wow, they have so much more on their plates than do I.  What right do I have to feel (let alone speak) of burnout?"  Also...how privileged am I?  I am a white, straight, cisgendered male over 6 feet tall.  My ACES score is low, my family is stable....isn't any talk of my feelings of burnout just whining?  Do I not have it better than most?  Objectively, it would seem that the answer is "yes" on many dimensions....yet the feelings remain. So...what does that say about me?  It feels like it suggests that I am weak. Seeing that I am not alone (and in fact that very respected colleagues suffer in some similar ways) is helpful.  Thank you to all who have shared, and to CFHA for creating a forum to discuss.  Organizing feels like a useful approach. More research into effective (and sustainable) tactics to mitigate effects of burnout also seems worth considering. I look forward to seeing many of you in Denver this Fall.  Stay gold colleagues....I really do believe that our efforts make a difference, and our discomfort is not for nothing. Thank you for being so vulnerable in this forum of relative strangers...i have no idea what the number of colleagues on this listserve is, but I imagine it is a lot. We are doing a lot to make it ok to talk about these things. I can tell you that you are far from alone in these feelings - I'd bet many of us can relate - I know I can. I've been doing a lot of work (for personal reasons AND for professional reasons, to be able to better help my patients and colleauges) around this lately, including reading some of Brene Brown's work. I also think that the fact that Menninger decided to have their annual Symposium on shame speaks volumes - I do not think it was just for professional reasons, but also because there is a recognition that many of us could benefit from looking at shame ourselves. While I trained at BCM/Menninger and am still voluntary faculty there (supervising residents at my FQHC employer), I have no reason to share their symposium info with you other than on the chance it is of interest to anyone who might want to attend, and you may not know about it, I wouldn't want that opportunity to be missed. A number of us in Houston are going. I hope  that sharing this is appropriate. Link below. <http://themenningerclinic.camp9.org/event-3405128>  I'm running between consults, so my apologies if this has already been said. It's worth searching the phrase "moral injury healthcare" to see if that captures some of the experience that's being described. It's a concept that was introduced to me within the last year and has been quite enlightening. Look forward to connecting with folks in person in October. So grateful for this group. Thank you! Also feeling grateful for this discussion and group. I saw that Neftali  mention two ELO sessions at this year’s conference dedicated to the issue,  however, if there are non-ELO sessions on "moral injury healthcare" aka  burnout or interested parties plan to convene for a discussion please let  me know. Thank you  This has been a great discussion and I sent several responses yesterday which all got bounced back to me! My email configurations were not working but were reset so at the moment I just want to see if I can reply to the list messages. Look forward to seeing everyone at the conference! I've been thoroughly impressed by sharing and openness. The pain of shame when supportive light can be brought to one's experience.  Only then can we work toward finding alternatives, to address and prevent the root causes. This has been a great thread and want to share one thing.  In, Philadelphia, a large slew of new BHCs received their "boot camp" training provided to BHCs less than "one year old."  We ended by talking about this thread our intensive experience. It is great to learn competencies and skills, but self-care matters from the start to sustain the role. This email thread helped prompt consideration of personal practices to work against burnout and how we support coworkers. So thank you for the great timing!  I'm so late to the party secondary to vacation and a heavy plate, and sorry I missed such a rich conversation.  I agree that morality, and subsequent violations, are included in the process of burnout for medical and behavioral providers.  However, I would encourage everyone to look into the literature regarding "moral injury" vs. "moral distress."  Our research is focused on moral distress and burnout and we believe that moral injury reflects more of a posttraumatic distress while moral distress better reflects the "death by a million paper cuts" many providers describe. One definition of moral injury is, “lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations," Litz, 2009.    A link:  <http://moralinjuryproject.syr.edu/about-moral-injury/> A definition of moral distress, "An instance of moral distress occurs when an individual believes she knows what the ethical course of action to take is, but is prevented from implementing that course or must do or cooperate in doing otherwise, due to external or internal constraints; and in doing so, she acts (or is complicit in, or views herself as acting complicity) in a manner contrary to her personal or professional values, undermining integrity and authenticity."  Kondrat, 2016.  Another link: <http://moraldistressproject.med.uky.edu/moral-distress-home> In other words, the death of a patient who was not allowed treatment at the ED despite the provider's ability to effectively treat, and the provider's reaction to this horrible outcome, is an example of moral injury.  Moral distress reflects the reaction of the appropriately trained and experienced provider, who knows the "correct" medication to treat the presenting illness, is unable to prescribe the medication based on the patient's insurance company's unwillingness to pay for it. We certainly see a lack of research of the impact of moral distress upon primary care medical providers as well, of course, behavioral providers. Ultimately, it is our belief that moral distress, the frequent violations of the provider's ethical, Hippocratic and moral values, better reflects the experience of providers in primary care and certainly encourage more discussion and research in this area. Thank you! Thank you for this precious and important conversation.  The National Academy of Medicine is conducting ground breaking work in this arena.  You can learn more and access many fantastic resources on their website <https://nam.edu/initiatives/clinician-resilience-and-well-being/> Their focus is on the organizational and social systemic factors that impact resilience, above and beyond personal factors (e.g. self-care). Check out this richly detailed article that weaves the work of the National Academy with Maslow Hierarchy of Needs https://www.amjmed.com/article/S0002-9343(18)31155-0/fulltext Finally, Z Dogg has been powerfully articulate on this topic.  Check out his videos (prepare yourself for the strength and power of his discontent and reframe as moral injury) at https://www.youtube.com/watch?v=L_1PNZdHq6Q  and the more tender and heartfelt expression at:  https://www.youtube.com/watch?v=jV9RyXQyQ7Q  Thanks for this excellent information on moral injury - the links and these youtubes.  Great information! Some years ago, when I was at the University of Louisville, our med school had the Arts in Medicine Program for our med students.  It promoted and encouraged our students to maintain their humanity through the arts.  At the time of graduation, there would be a special program to witness participants' contributions to the arts. Poetry, music and other forms of creativity.  One year, a student displayed a violin he made by hand during the 4 years of med school.  I thought I would share this as a way of combating burnout and these moral injuries.  A way of empowering and honoring everyone's voice.  This accesses a dimension separate from my earlier post on organizational change.  We need it all! Thanks for the inspiration in all these posts. Thanks for all the wonderful posts and ideas. I think health centers will need implement programs to assess and intervene in order to stem the tide of burnout.   Does anyone work for or know of a healthcare org has such a program?                                                      
by L. Edwards
Friday, August 23, 2019
Positive cutoff for PHQ2 0 L. Edwards Hi - We are moving forward with standardizing our depression screening across our primary care clinics.  There is debate regarding the best cutoff score to consider a PHQ2 positive.  I believe the highest PPV for MDD is a score of 3. A score of 1 has a similar PPV for all depressive disorders. I appreciate your thoughts. Thanks in advance.  Diane Hi Diane, We have been using 3 at Mayo. Best wishes, Mark  Hi Diane, At Sanford Health, we are using a cutoff score of 3 on the PHQ2 to cascade to the full PHQ9. At that threshold, sensitivity is 82.9 and specificity is 90.0 for MDD with a 38.4 PPV.  For any depressive disorder it is 62.3 and 95.4 respectively with a PPV of 75. This comes from the Kroenke, et. al., article, 2003, (41), 1284-1294, Medical Care. Regards, Jeff Hi - I have been a bit of an outlier on this, but have done so with the knowledge (and maybe approval) of Kurt Kroenke, the developer of the PHQ-2/9. One of the advantages of the PHQ-9 is that it is aligned with the DSM criteria for diagnosing depression. The PHQ-2 screens for depression by asking about the 2 cardinal symptoms of depression - depressed mood and anhedonia. One should not make a diagnosis of depression without the patient endorsing at least one of those symptoms at least half the time for the past 2 weeks - which is the way the question is asked. An answer of 2 on either of those questions would be consistent with a possible diagnosis of major depression and should lead to the full PHQ-9. So I worry less about the total score and more about the answers to each individual question. But I know that most people do what Mark suggested and use the score of 3 - you will just have some false negatives with this approach. I have also heard of people using the PHQ-2 as yes/no questions and a yes on either would then trigger a full PHQ-9. Thanks, Neil Neil, this is also how our facility uses the PHQ. It also means most patients only complete two items, though the research finding people who are negative on the PHQ-2 sometimes still endorse suicidality would suggest the value of always administering that item. Bob Does anyone have a well-organized plan to address positive suicide items? We are looking at using one of the Columbia scales but the challenge of many  false positives, who does the screening, etc. is coming up.  A group in Minnesota I believe has segmented the population such that only those with a higher score get the screening. Thanks, Mark
by L. Edwards
Friday, August 23, 2019
BHCs as Providers 0 L. Edwards Dear list mates, I'm not sure I've seen this issue discussed here in the past, but if not, I'm hoping your collective wisdom can help guide me. We have ~50 BHCs in about 50+ primary care clinics throughout our enterprise. They are almost all masters prepared independent clinical social workers with a few professional counselors and one psychologist.  But, more than 90% master's level social workers.  They are an awesome group, do great work, and are valuable assets to their individual primary care clinics. An issue that has come up recently, and persistently, is whether these BHCs are considered "providers."  From my perspective, they most certainly are.  They "provide" professional services, have independent licenses, generate revenue, and contribute expertise to the team that is critical.  However, our organization's definition of "provider" currently only includes physicians and advanced practice providers (APPs).  Further, our organization defines an "APP" as an advanced practice registered nurse (APRN), physician assistant (PA), CRNA, audiologist, and genetic counselor.  I should note that psychologists are bundled into the definition of 'physician' as are podiatrists and other doctorally- trained non-medical clinicians.  My sense is that the HR definitions and guidelines may pre-date the integrated care movement in  our organization and the titles perhaps have not kept up with some of the realities on the ground.  Additionally, there may be other financial obligations and realities for the organization to enlarging the definition of a provider. I would add that our system is pro-behavioral health, all things considered, and embraces the importance of this service line. How this bubbles up has been in CME dollars (providers have dollars allotted for CME while non-providers have to make a case by case request) for clinicians and, more recently, who has access to the "provider lounge." While the latter issue I don't really think centers on the access to a free cup of coffee and donut, but more so the desire for recognition as an equal participant in the system. Have other organizations faced similar questions?  If so, any guidance or insights on how you resolved this?  There are some rumblings and grumblings in our BHC cohort about who is "in" the preferred definition and who is not. I'd like to be able to respectfully respond but wanted to know what others have seen/done. Best wishes, Jeff In our organization BHCs were regarded as providers and received same compensation for CMEs and made their own decision in how to spend them. Dawn The same is true here--considered providers, part of the Concord Hospital Medical Group (the outpatient division of the hospital) and able to be members of committees, the same CME benefits as advanced medical providers.   So far, however, we have not been considered part of the Concord Hospital Medical Staff. Joni All considered "providers" but doctoral levels have larger CME stipend and greater number of days while master's level considered mid-levels. At times pay higher for bi-lingual fluency. Always find I have to reiterate that we are all "BHCs" and that that is not based on degree. Susan This is an ongoing issue for us. Our team is comprised of LICSW and Psychologists. The Psychologists are considered providers whereas the LICSWs are considered caregivers. While all the benefits end up balancing out based on contract, there are some small distinct differences that do create a divide within our team. So this is something we are actively working on to find a fix. @Jeff - I would be happy to talk offline about the steps we are taking Jenni We have a policy that governs our "mid-level providers" which includes NP's, PA's, Psychologists, social workers, etc. and they are billing providers and receive the CEU benefit. Beth Our BHCs (LCSWs and an LPC) are part of our provider group.   While we receive CME hours and money, it is less than medical providers, due to lower CME requirements in PA for LCSWs vs. medical providers.  Our PTO is distributed differently also - BHCs accrue, while medical providers (including mid-levels) get all in a package yearly. The greater difference is in perception, however.   It's an ongoing struggle to be recognized as equals to medical professionals in our settings, despite the fact that our educational and licensure requirements exceed those of mid-level medical providers.  Part of my departmental goals include building respect and visibility of our BHCs as providers integral to achieve whole care to our patients. I am very grateful for a CMO who recognizes and respects our BH providers and is fully supportive of the growth of our department, a crucial piece to this complicated and often frustrating puzzle. Eric Hi, all, In the FQHC that I recently left, where we developed Behavioral Health from scratch, BHCs were included in the "Provider" group from the start and this was irrespective of licensure (psychologist, LPC, LCSW, etc).  We were all invited to the provider meetings and were offered the same benefits in terms of Continuing Ed funds and time off for CEUs as well as PTO. In my new organization (private, non-profit), I am the first Behavioral Health provider.  It is a large organization with multiple hospitals and ambulatory care facilities.  I have been included in the medical staff and am recognized as a provider with the same continuing education funds that my physician colleagues receive.  I also have access to the "doctor's lounge" in the hospitals, which provides free lunch (which I rarely use because I am too busy to break!) and am able to park in doctor's parking, although I elect to park with the staff and leave an extra spot open for a patient. As I build my BHC team, which will include additional psychologists and LCSWs, I plan to advocate for them also receiving the same provider benefits because I do think it will enhance the respect they receive among the physicians if we are treated as providers. Now, I am different than my physician colleagues in my new organization in that I am salaried and receive PTO and the physicians are paid based on RVUs and do not receive PTO. Hope that helps, Jeff! -Laura Same here at Summit Medical Group - mid level provider designation that bill for services, salaried,  5 CEU days per year, 2K reimbursement for CEU or associated travel, eligible for annual bonus in December. Elizabeth In our multi-disciplinary, multi-specialty rural health clinic, BHCs (which are all masters-level except for myself) are treated as providers and given all the same benefits, including provider incentive benefits like 100% coverage of health insurance premiums. CME time, funds, and PTO are all congruent with MD/PA/NP providers with the exception that my clinic is an IPA, so shareholders get some unofficial benefits that others do not. Even our CSWAs (social work trainees) are given provider status and the same set of benefits. This issue feels to me to be a marker for how much administration understands and values BH work, in general. It sends an important message to staff and  patients re: our value, and I do feel like it goes a long way for BH team morale given that we can take a beating many days. Seems that any efforts to move this needle is dependent on having an admin team that really understands how much patient care BHCs take on and how patients see us as their mental healthcare provider, despite any potential discrepancies on the back end. I would also wonder when and how that decision was made, and what factors contributed to administration's decision to determine BHCs as non-providers. Sounds like they are stuck in an old mentality of care. Shay Thanks for all the great feedback from everyone on this topic!  It is much appreciated.  It seems that most (though not universally all) sites do extend 'provider' status to their master's prepared BHCs and recognize their importance in the equity of benefits that they receive.  To those who collectively, and privately, responded, appreciate your time and thoughtfulness. Best, Jeff I'll start with the disclosure that I personally dislike the term "provider", as I know a lot of other medical professionals do (I'm an RN and MD, and while I don't get hung up on titles, I believe in calling clinicians what they are...I've found that patients actually get confused when the term "provider" is used about what the credentials and roles of the clinicians they are seeing are). Having said that, our BHCs are considered providers, as are all of our traditional therapists, psychologists, and case managers. We are a nonprofit FQHC. I wonder if some of these systems are "stuck" in the traditional medical nomenclature or if there are other reasons for the differences. Our CME/CEU stipend is determined by education/licensure, as is fairly commonly done...MD/DO, NP, PA, PhD, Masters level, etc. Chad
by L. Edwards
Friday, August 23, 2019
LMFTs as BHCs 0 L. Edwards Hi - Does anyone have experience with LMFTs as BHCs in your clinics? If so, I'd appreciate your thoughts on the pros and cons of their training.  Thank you in advance -  Diane Hey, Diane!  I think more information is needed.  Are you weighing the LMFT degree against other degrees in particular?  That information would help.  As an LMFT, I can tell you that we can't bill Medicare (like LPCs, LCASs) - only psychologists and LCSWs can currently do that (if there are updates I am unaware of, I'd love to hear them : ). There is a contingent of people who consider themselves Medical Family Therapists that hold the LMFT degree.  The East Carolina University doctoral program that I graduated from is accredited through Commission on Accreditation for Marriage and Family Therapy Education.  Although the ECU program is LMFT only, there are numerous other fantastic degree programs and tracks that educate people to work in integrated care, educate residents in BH, etc, that are not LMFT specific. I think I am getting around to a point - I've always been impressed at how little degree type and how much training, personality, and passion have to do with people's goodness of fit in integrated care. But, there is that pesky Medicare issue : ) I hope this is helpful! Aubry Hi Diane, In my training and experience with integrated care I have learned that the success of a BHC is much more about the clinician than their licensure. I found my family systems training to be immensely helpful in navigating my previous roles as a BHC, to be able to attend to family wellness and illness dynamics with patients, and developing meaningful, collaborative relationships with primary care providers and clinic leadership. In my work transforming health systems, I have worked with BHCs from my sister behavioral health professions who had the same strengths in their integrated practice, but maybe not with the same family systems lens or approach that I used. I think this just highlights that in integrated care, we are all working as a team to serve the patient and if you have a clinician who is really skilled at delivering the care patients need, supporting primary care providers, and fitting into the flow of your clinic, then that might be the right clinician for you. Having said that, I am also extremely practical :) If you are considering hiring an MFT it is important to evaluate the reimbursement mechanisms in your clinic, as MFTs are not yet recognized as covered mental health professionals by Medicare, though there is movement towards that, and we hope to have it soon! (An MFT would be a good fit in a pediatric clinic if that is a barrier). I am happy to chat with you offline about best practices for recruitment and interviewing BHCs if it would be helpful. I think there are some great resources out there too that our CFHA colleagues can share. Kindly, Amelia Yes, I have a lot of experience with LMFTs being BHCs, in addition to myself being one. I have also supervised LMFTs, LP's and social workers (so have been able to compare skill level). LMFTs tend to be highly successful because they already think using a "systems approach" and are very familiar working with individuals, dyad's, and families, which is a very important skill to have in BHCs. They are also trained similar to other mental health professionals with regard to diagnosis and treatment of mental health conditions (don't do testing though). They also tend to have really good skills with communication and problem solving facilitation with patients/clients, in addition to providers. There are a few billing issues that only LP's can bill for (eg., Medicare), but they can bill for the majority of codes. Overall, I think they bring the same set of skills as LP's or social workers in BHCs and some superior skills. Jerica Dr. Dougherty – First, let me thank you for asking this question and not just assuming that an LMFT will not be a fit. While there are not as many of us as other licensures, when looking for a good fit for your clinic, it helps to have as many options as possible and I do believe that LMFTs should be considered in that mix. As others have said, I too believe in personality and fit being key. However, I think it is also about the particular program from which the MFT(LMFT) graduated. For example, I was fortunate enough to earn my masters also at East Carolina University and while the degree was Marriage and Family Therapy, as is the license, even in the masters program I was taking classes that highlighted seeing patients/clients from a biopsychosocial-spiritual lens, and also taking a class that focused on learning the medical culture, medical acronyms and how to function in a BHC role. Several of my classmates were blessed to have internships in integrated care settings, and this was over 15 years ago, and this program has only grown in its integrated care trainings/internships for the marriage and family therapy students. I believe that my background in family systems, even if I had not had the additional training and focus in integrated care and whole person care, would have served as preparation for navigating the relational dynamics needed on multiple levels in a healthcare system. My doctoral degree in Medical Family Therapy at East Carolina University (https://hhp.ecu.edu/hdfs/phd/)  prepared me even further to understand how  chronic and acute illness impacts patients and their families, health behavior change, and working within healthcare systems. In this program I was blessed enough to have an internship in a federally qualified healthcare clinic as a BHC, and while I was not the first MFT in their system, it has only continued to grow in its utilization of MFTs. I am aware that not all MFT programs focus this heavily on whole person, whole family, and integrated care, however, I would have felt negligent if I had not shared my own MFT experience and training. Happy to talk further and really grateful that you asked the question! There is much work to be done and we need all hands on deck! 😊 Lisa Hi, Well let me chime in with my two cents. Absolutely applicable. I am not an LMFT but I am an LCSW.  I have worked with multiple discipline types as BHCs ( including LMFTs) and strongly believe “fit” is essential. I think we can all find things about our disciplines training that set us apart from one another. In addition, the different graduate programs in each discipline are vastly different in preparation for the spirit of Integrated Care. If there is a clinic that has a high Medicare population and management is consumed with maximizing billing (which does not always equal quality care) then the discipline you hire matters. Otherwise, I look to see is the person a good fit for the role of a BHC, for the clinic team and the patient population (are they teachable and trainable). Don’t hesitate to incorporate second or third interview opportunities that involve the applicant interacting with patients (I’m always wanting to create “live” situations - live supervision, live interviews - it can bring an additional dynamic to the situation). Of course this takes planning, thought and liability/safety considerations. Best, Monica  Hello, all: I would absolutely concur with everything everybody has said so far. I am an LMFT who has been working in an integrated setting for 19 years now. Like many of us from the early years, I stumbled into integrated behavioral health and never left. I found that my training in systems thinking was a perfect fit.  (I was hired by an MFT, by the way.) Part of my role is to train behavioral health interns, both for integrated care and specialty mental health within a medical setting.  I agree that fit is essential, as are skills. One of our 6 IBHCs is an MFT.  Her role is to work with the prenatal and frail elder populations. I think that her training in family systems is particularly helpful with those populations. That said, I would not hesitate to hire an MFT for our primary care teams as well. I want to highlight that AAMFT published a document on core competencies for family therapists in a health care  setting. Here is a link.  https://www.aamft.org/Documents/Marketing_Communications/Competencies%20for%20Family%20Therapists%20Working%20in%20Healthcare%20Settings%2011-9.pdf I know that some of the people who contributed to this are members of CFHA, and I hope they weigh in. Joni Diane, I appreciate each of the contributions to this conversation.  My thoughts are quite consistent with what has been offered, I just consider the issue  from a slightly different frame.  I place Doctor of Behavioral Health student interns who originally received a training, supervision, and independent licensure across the range of specialty mental health professions. On average, I have not noticed any differences in the performance comparing the professions. The unique training of MFTs is focused on systems theory and a process orientation.  This can be quite useful for BHPs who collaborate with teams of providers within health systems of varying sizes and types.  As integrated healthcare continues to evolve, it is helpful to have those who can conceptualize and collaborate with others in transforming systems of care. One final thought that resonates with those that have already been mentioned... Becoming a BHP builds upon the clinician's foundation of clinical training  and experience.  Collaborating in team-based care, engaging brief, targeted assessments and interventions, and providing BH consultation and training are the skills that are built upon that foundation to perform effectively with the medical team in medical environments like primary care. C.R. I’m similar in belief to others mentioning the personality factor. After hiring clinicians from diverse licensures and varying academic experiences  over the span of our five year program implementation I believe it is imperative to hire based on key personality traits. Traits that will be most conducive to working in a hectic and constantly changing patient care environment that can at times be intimidating, difficult to breakthrough, and full of a variety of provider types/personalities. Go-getters who will pursue collaboration and seek out and advocate for their services on their own until they are operating at full capacity is invaluable. The BHC personality to be a walking talking integrated care commercial at any time makes our work at the administrative level much easier. Competency, no matter the licensure, can be taught.......but personalities that fit best in these environments have to be considered as primary to program success from my perspective. Dr. Shannon
by L. Edwards
Friday, June 28, 2019
PCBH marketing strategies -- posters? 0 L. Edwards Hello all- In my quest for increased utilization of our PCBH service I'm developing some marketing strategies that will be directed towards patients/consumers.  As part of this effort we would like to develop posters for exam rooms and waiting areas. Does anyone have examples of PCBH-oriented marketing posters  that they could/would share? We don't want to copy anyone directly but just looking for inspiration or examples of something that has been well-received  or effective. Thank you for any input. Jason A health center I consult with did something pretty interesting..... They put the faces of each of their BHC on an 8 x 12 flyer,  and said "Meet Jane"   with her name and professional degrees below her name The next line said something to the effect  "Jane is our wellness expert. She helps out people with stress, depression, anxiety, health challenges, substance use, and life concerns.  Ask someone on the team to introduce you to Jane or say hi if you see her." It led to a pretty significant uptake in warm handoffs since it was put in the waiting room and on all exam room doors <http://files.mail-list.com/m/cfha/ENPCN-BHC-Poster-2019-1.pdf>  679 Kb <http://files.mail-list.com/m/cfha/BHC-Pt.Handout-FINAL.May19.pdf>  78 Kb Hello, Credit for the poster design attached goes to another network (we just changed the branding) but it has been well received in clinics so far. The patient handout has also been helpful (we've been fairly successful in reducing terms such as therapist/counsellor from the descriptors used by physicians or other staff referring to the BHC much supported by having this document to provide). We have had feedback that changing it to a trifold or other smaller format would make it more user friendly. Melodie
by L. Edwards
Friday, June 28, 2019
ADHD Integrated Care Manual 0 L. Edwards Hello, I was just scouring the internet to see if there were any brief, primary care-friendly, evidence-based pediatric ADHD treatment manuals. Several BHCs  I know are looking for this resource and I am finding a number of 10-12 session protocols Bests Travis Hey Travis! I am a psychologist in a pediatric primary care setting and generally use the PASS model (Partnering to Achieve School Success) developed by some mentors of mine at the Children's Hospital of Philadelphia.  It is a modular intervention taking the components of traditional ADHD treatments (e.g., Barkley model), adding elements of treatment engagement/crisis management, and condensing them into modules to be delivered as needed within urban primary care centers.  Modules include: Treatment Engagement; Brief Family Therapy (e.g., rewards, punishment, effective commands); Family-school Collaboration; Crisis Intervention; Medication Management.  Happy to talk more about how this looks in clinic. We are highly integrated (75-80% of our visits are co-visits with the PCP), and often deliver this intervention during med checks as a joint visit, and sometimes add in brief sessions in between med checks if needed. Citations below, may need to reach out to Drs. Mautone or Power to obtain the manual. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582374/> Power, T. J., Mautone, J. A., Marshall, S. A., Jones, H. A., Cacia, J., Tresco, K., . . . Blum, N. J. (2014). Feasibility and potential effectiveness of integrated services for children with ADHD in urban primary care practices. Clinical Practice in Pediatric Psychology, 2(4), 412-426.  http://dx.doi.org/10.1037/cpp0000056 My good friend/colleague also wrote a review of ADHD programs in Family, Systems, and health a couple of years ago (citation below): Shahidullah, J. D., Carlson, J. S., Haggerty, D., & Lancaster, B. M. (2018). Integrated care models for ADHD in children and adolescents: A systematic  review. Families, Systems, & Health, 36(2), 233-247. http://dx.doi.org/10.1037/fsh0000356 Hope you find this helpful! Cody
by L. Edwards
Friday, June 28, 2019
Food & Integrated Care 0 L. Edwards CFHA’ers: Food has been on my mind lately as one of the social determinants of health that often goes unaddressed. I’m wondering what people out there are doing  about this? Are you screening for food insecurity? Do you have relationships with food pantries? Any thoughts would be appreciated. Thanks, Neftali Both.  Everyone gets screened for food insecurity at each visit and as appropriate, given food boxes immediately and referred to our partner, Greater Pittsburgh Community Foodbank. Neftali, Our department of surgery has an established relationship with a good pantry. We collect donations throughout the year from residents and faculty and volunteer twice annually to serve meals to the local community. Lauren Hi Neftali, This is a great question! When food insecurity comes up during a visit, I immediately refer patients to a Community Health Worker (CHW). Our patients at are also given a social determinants of health screening during PCP appointments and CHWs see patients during these visits as well. The CHW meets with patients via warm hand offs and is familiar with all local resources, including transportation, food banks, bill pay assistance, housing information, and different community programs. I believe most locations with the Yakima Valley Farm Workers Clinic have a CHW. They are a really wonderful resource and are great about referring to BHC if there are additional difficulties related to stress, trauma, or making behavioral changes. Thanks! -Sarah Nef: We are using a modified version of the PRAPARE tool to screen for social determinants of health.  It is translated into many languages and can be found here: <http://www.nachc.org/research-and-data/prapare/> Our integrated team (BHCs, social workers, and dietitians) have partnered together in our clinics to start an emergency food pantry in the break room which everyone contributes to.  That way if patients come hungry, they leave with food.   Also in our diabetes group visits, each patient leaves with a bag of food which is donated in partnership with the Oregon Food Bank. We have found our patients to be very appreciative of these resources. Brian Interesting you were thinking this as I’ve been on a almost daily conversation this week with different people around SDOH and the impact. Which reminded  me of this video: https://youtu.be/Eu7d0BMRt0o In terms of what some people are doing: There’s an agency I’ve worked with that screens for SDOH and regarding food/nutrition they partner with food banks and also created a Collaborative with the local Farmers Market for families to get a voucher for up to $20 of free food on average (family size and other considerations are looked at as well). Best, Monica  Hi Neftali - Our process at Healthsource of Ohio is similar to others described. Our MA's screen for food insecurity at every visit; if we identify someone in need, we provide 1-2 family-sized meals immediately, as well as a directory of resources for ongoing assistance with food. I have recently suggested that I should see these patients to help them develop a simple action plan for connecting with these resources, etc., but haven't had the opportunity to try this yet. Mike Nef- At our FQHC the CHWs screen for food insecurity through the SDoH screener and further discuss this during a follow-up appointment (if pt agrees to  one). We typically give documents regarding the Oregon Food Bank's free food markets in the patients' surrounding neighborhood, ask if they are already  signed up for SNAP (if not, we'll help them apply), and also refer them to any groups at the clinic that have access to food (i.e. we have a patient low-cost CSA, Cooking Matters group, and we have a Gardening group). Joan The AAFP has a nice 2 question screen: 3. Within the past 12 months, you worried that your food would run out before  you got money to buy more.1 Often true Sometimes true Never true 4. Within the past 12 months, the food you bought just didn't last and you  didn't have money to get more.1 Often true Sometimes true Never true HMA Lori Neftali- I asked our Behavioral health resource specialist what she does with a WHO around nutrition/food resources and this is what she said: When I get a request for food insecurity issues (WHO or in basket) I usually share info on some of the larger food pantries around town that are open  each day M-F.  That way if they need food today they can go very soon. I discuss the benefits of shopping style pantries where they can choose their own items and make healthier choices.  We also offer patients granola bars and snacks that they are welcome to eat while we talk. I also use the Free Food Market calendars and flyers that come from the Oregon Food Bank.  Store to Door, Meals on Wheels and Urban Gleaners are other things in my Food Resource Packet. I have a separate list of places that deliver free food to those who can't get out to a food pantry. I also give out daily meals lists to those that are not housed, run out of food before the month is over or do not have kitchens. WIC (prenatal to age 5) is an important part of addressing food insecurity as is the Summer Meals Program (ages 1 to 18).  I always make sure that newcomers to our country know about the USDA Food Program at their kids schools.  Most schools (those with SUN programs particularly) have weekly food distribution on site and I have lists of those when the family's school is known to me.  This is particularly great for those who are newcomers and may only know where the school is and not much else about navigating their neighborhoods. I have a section in my food resource packet that discusses how to apply for SNAP, low cost grocers that accept SNAP and the Double Up Bucks Program that is available for those with SNAP at some Farmer's Markets. I always mention the cooking class that is sponsored by Care Oregon (our CCO). I have the big general food packet for all of Multnomah County that I bring with me to quick warm handoffs.  I tear off the things in the packet that do not apply to their situations.  When I know ahead of time where they live or when I get an in-basket request then I zero in on just places in their zip code and bring/send them more specific information. Lastly, when we distribute pool passes I also mention the food distributions that are done at the same community centers where the pool is. Healthy eating for those with specific health goals is also a part of my work. Not quite food insecurity related but many people say that eating healthy costs more.  I have a whole bunch of information to share that shows them that this is not the case. Hope this is helpful! Joan A pediatric clinic I worked with seeking to address food insecurity decided to broaden the screening for food insecurity to be inclusive of nutritional and weight concerns.  This screening was then used to refer into a clinic-based class on nutrition lead by a nutritionist. For families with food insecurity a prescription was also written for food, which was honored by a food bank, providing additional food beyond their standard distribution.  The broaden screening served to normalize the screening for all families regardless of income and food needs to address the important issue of health and nutrition. The goal is to address, lack of healthy foods, and over and underweight issues, and then provide a resource for families in preparing healthy meals. Dave We have a partnership with Hannaford (a regional supermarket chain) as a distribution site for their Hannaford Helps food boxes, via our affiliation with our town food pantry.  We keep a box in each exam room and a stash in the basement - each box contains pasta, tinned meats/tuna, tinned veggies, cereal, some other things.  They're not my product of choice for diabetics or hypertensive patients for obvious reasons, but it's something.  We have a sign over the box that says, "if you or someone you know needs food today, please take this box with you".   Takes the stigma out and promotes neighborly gestures as well from patients to their neighbors in need. Also - a local nonprofit cooks low glycemic, low sodium meals from soon-to expire supermarket or farmstand produce donated to the nonprofit (Grateful  Hearts), freezes it, and gives it to us for distribution. Great for just-discharged, elderly with difficulty shopping, etc.  Hard to stock much due to freezer space, but they re-up us when needed. We're in a tiny town, pop 3000, but serve the larger county as well.  Our small size helps make these less formal partnerships a little easier. Anje Wow! Thanks everyone for the detailed and helpful responses. I sense a couple  of themes in the responses: 1. Addressing food is a crucial aspect of integrated care. 2. Food insecurity and access to healthy food choices are both important to address. 3. Immediate, destigmatized, local solutions are important to have on hand. 4. Clearly many of you have developed relationships with food banks and other suppliers/ programs. 5. Proactive screening is important for identification. 6. Workflows can include specialized workers (eg. community health workers) but can also include BHCs and other team members. Thank you! I’m thinking that we need to make this a more front and center item going forward and this info helps establish a baseline of activity among our members. Neftali I am so glad you asked this question Neftali.   (which is why I love CFHAers!) I would add to this list that community members (patient partners and peer  navigators) embedded within the primary care system or directly on a quality improvement team could be an incredible source of wisdom and inspiration  for promoting and implementing these changes in the primary care system. Sharing the burden of connecting resources and people who need them takes  many hands and dedicated time and resources.  End users of those resources can be easily involved in generating awareness and building the base of  connectors and seekers of resources as well as celebrating and appreciating those efforts that sometimes fall on the shoulders of already overworked  BHCs.  Keep all patients in the loop of what you are doing and you will find an incredible source of joy and wellbeing going around.  Lots of patients would be willing to help if asked.   And the benefits of helping others is already pretty well known. Providers are often just as hesitant to ask for help as patients are…. Such amazing people on this email thread just make my day everytime I connect to these conversations and wisdom sharing opportunities… Thanks again, Jen
by L. Edwards
Friday, June 28, 2019
Psychiatric Collaborative Care Codes 0 L. Edwards Good morning! We are in the progress of developing a program using the Psychiatric Collaborative Care Codes, and the requirement for the psychiatrist  has been unclear. To your understanding, how often does the psychiatrist need to meet with the Behavioral Health Provider to review the case for approval? Our team had interpreted the requirements to be once per week, but wondered if that was an accurate interpretation? We need to meet all guidelines set by Medicare. Thank you! Kathleen Hi Kathleen and all - we do use these codes. The first month (99492) pays up to 70 minutes and not more, with any additional months the second code (99493) of up to 60 min (there is a 3rd code that takes it beyond that - 99494). As you probably know, for Medicare, you have to at least bill 1/2 the max to get reimbursed (so 35 min the first month and 30 min the second month). There are other conversations that make up the minutes besides just consulting with psychiatry - you talking to the PCP, you talking to the patient, you  talking to the psychiatrist, you going back to the PCP - so we never end up talking to the psychiatrist every week, it's not necessary... plus you often need to give meds time to work. A standard first month might look like the following: 10 minutes discussing the program with the patient and why Psychiatric Collaborative Care might be the right fit, and gaining consent during that  (Incidentally I just wrote a script on this today - instead of selling something, we are positioning it as saving the patient time and money overall - since they don't have to go to see a psychiatrist regularly) 5 minutes discussing with PCP to ensure they will be willing to prescribe for this patient 15 minutes presenting the case on a weekly call with psychiatry, followed by their recommendations (we all call in, even if we don't have a case - learn from listening) 5 minute follow-up with PCP to give recommendations 5 minute outreach to the patient to either pick up meds because they have been sent in or come back in for a visit 10 minute follow up call 2 weeks after starting meds to see how they are, screening tool given over phone, etc. TOTAL - 50 min A standard second month (same patient) might look like the following: 10 minute follow-up with patient 10 minute discussion with psychiatrist on dosing or titration, side effects, etc.   5 minute follow-up with PCP to give recommendations 5 minute call to patient to let them know what to do next TOTAL - 30 min Hope this helps! Feel free to reach out direct with any Q's ~ Elizabeth Elizabeth and Kathleen- It is exciting to hear you are working with your team to bill these codes and it sounds like you are doing it successfully.  Wondering in IL and NJ where you are located if you are billing other payers in addition to Medicare? Also want to chime in on the psychiatric consultant time - CMS requires that at least once during the month you have the psychiatrist review even if the  patient is stabilizing.  We often give final recommendations regarding how long a patient should continue treatment and what the PCP could do next if  the patient starts to have problems down the road.  The force multiplier of the model is we provide guidance especially for the patients who aren't getting better - focus most of our time here - in addition to providing curbsides as needed. I also wanted to note the model (and hence the codes) requires psychotherapeutic interventions - this isn't just getting meds and checking PHQ9 scores.  The  codes require brief interventions such as problem solving therapy, behavioral activation, etc which could be done in person or over the phone..  And if you have reached your time threshold you could separately bill this as a 90832 if you meet the standards. Lori 
by L. Edwards
Friday, June 28, 2019
Documentation in integrated care 0 L. Edwards Dear list mates, We are striving to help our BHCs learn to document their integrated care visits more efficiently and more succinctly.  Alas, since nearly all of them come from traditional mental health settings where six page intakes and 2-3 page progress notes are the norm, there has been some resistance (and, I'd say, fear) to doing a more abbreviated note that would lend itself to seeing larger numbers of patients for shorter periods of time.  We've discussed modified SOAP notes and tried to stress the importance of other team members actually having time to read the BHC note. Does anyone have advice on: 1.     Helping the BHC understand the wisdom of creating a different kind of note than what they are used to in specialty mental health (a script? An article?) 2.     Templates, smart phrases, or guidelines that you have used or would steer us to regarding optimal documentation for BHCs given the different culture of primary care. Thanks for your collective wisdom! Jeff I frame documentation to the requirements of the billing code. This helps a great deal. It also places it into perspective since most clinicians are not taught on how to document related to billing requirements. Most who were traditionally trained are documenting much more than required, which during formal documentation trainings will be highly discouraged. I typically encourage completing a review of notes according to requirements (this will allow you to have information on where to target) and then doing a training on documentation. During the training on documentation it is important to focus on the audience of the note (patient, care team, lawyers, etc), as well as the formal requirements. Hope this helps! Let me know if you have  questions or need any other support! Lesley Ditto what Lesley said. Also as a traditionally trained clinician I found conversations about progress versus process notes to be helpful conversations to have. I always say when you document consider that any and everyone will read your note (providers, attorneys, patient, family members, etc...) so be mindful  of how/what you are documenting. Best, Monica I agree with Monica! This is essential during the training as well. I am happy to assist with providing resources if needed. Dr. Lesley  I’ve always focused progress note training on the intent for documentation —  1) is it relevant to the primary care doc 2) is it written to be appropriate for the patient to read if records are released and 3) does it meet insurance documentation requirements with documentation of medical necessity and progress monitoring. A standard SOAP note is a reasonable framework to accomplish these goals. -Louise Hi CFHAers, This conversation is extremely interesting to me as a person who represents the end user or family member of Integrated Behavioral Health services. I  would want to know about and truly understand the fears of  the BHC as well as discover how those notes have been effective at maintaining strong healthy  relationships between the provider and their patients.  If they have been trained and have practiced putting the energy and effort into creating such comprehensive notes there has to be a reason for it and better to fully understand before asking them to change. You may end up throwing the baby out with the bath water for both the provider and the patient.   As several have already mentioned, writing notes that everyone  might view can have a tremendous impact on the ability of that provider to be honest.  Too broad of an audience can dilute, misinform and possibly cause a terrible conflict for the patient provider trust and reciprocal relationship foundational support. I may be taking a much too simple approach to my consideration of this topic but here is what I would want to say to my BHC about my health record notes: I want you to consider that everyone wants to learn from our work together but my health is my life that I have entrusted in your hands temporarily. Your notes will never fully describe our work together. But I can only commit to you as long as I can trust you. And so you must write your notes using language that is sensitive to my learning needs as well as sensitive to all of the members of my health team. You must prioritize your audiences in this order: 1. Me the Patient (I am looking over your shoulder and need to be assured that you have captured accurately my wisdom, my brilliance, my insight, my worthiness of your time and energy, my progress and successes and my learning opportunities and health goals. 2. Yourself: You need to do what you believe is best for a successful partnership with my health team members, your education, your wellbeing and  ultimately your own health outcomes. (what would you want in your health record?) 3. Other health team members: These are the people critical to my health outcomes including my established or potential family member support team  members. They desperately need to know how to coordinate their efforts with yours. 4. Insurance providers: We both need you need to get paid for these services so we can keep doing our good work together and to support all of the  patients you work with. 5. Practice managers: Your bosses will want to assess and learn from your work and support your ongoing education and learning opportunities so you can keep working with me and my fellow community members. 6. Peers: they will want to learn from your work ,copy what works best for their patients or engage you in co-learning opportunities. There are too few providers and too many patients!! 7. Researchers: They will want to know what is specifically working for you and your patients. 8. Your Mother: She will always want to know that you are a successful happy kind person.  ;) 9. The Universe: The Universe simply wants your pure brilliance to shine a path for all of us. Thanks, Me, your patient who also seeks the light of your brilliance.  Lesley, I would love to have any resources you have to offer! Willow As a team going on about our fifth year of working on integration the “who should see the notes” and “what do we put in the note”  conversation is often encountered (especially with 42 CFR programs). It’s exhausting. I agree with Dr. Manson that documentation is usually guided by billing entities. We have built our electronic templates verbatim from our states CMS requirements. However, our state has not set out any separate billable required documentation elements for integrated care encounters. We are sometimes in limbo because what requirements are outlined don’t always fit with brief encounters. All that to say regardless of what has to go in the record for the billing requirements the best communication I’ve seen about patient care happens outside the record entry. Outside the record the team works eye to eye to discuss whatever is needed to mutually help the patient most efficiently; so the documentation is kind of secondary to an amazing provider to BHC connection that covers all the bases via their connection. Lastly I’ve desired to create an 8th grade reading level consent document that fully explains to patients the need for communication between appropriate  parties and what things will be documented. It is often difficult for our patients who are seen in the ER to comprehend their provider in family practice can see all that took place. Shannon Thanks for all the feedback and conversation on my documentation question. This list serve is my "go to" place for expertise that is shared in a most collegial and unselfish way. Jeff <http://cirrus.mail-list.com/cfha/74828398.html> 43 Kb Maybe someone made this point earlier and I didn't see it, but if your notes do not take into account the patients' being able to read them, they should. I first blogged about this several years ago. <http://cirrus.mail-list.com/cfha/67859973.html> .   Here is another short conversation about confidentiality between clinicians  and between patients and their records. <http://cirrus.mail-list.com/cfha/07704107.html> Currently over 40 million patients have access to their notes online, and in many of those settings, that included primary care behavioral health notes  (www.opennotes.org) But what do you do about all of the billing documentation?  The payer has the right to know what was done for what reason, but not the content of interaction. The attached satisfice that for us, at least at the time. The area for narrative in the form is the part I always read back to my patients at the beginning of the next session. Alexander Hi, all - this didn't go out yesterday due to some listserv email issues that have just been resolved (thanks, Jackie!), so I am a tad late to the  game! I am so glad Jeffery started this conversation, as I was just mulling over this today.  I agree completely with those who have stated that communicative yet succinct notes in the chart (as long as they comply with billing requirements) are sufficient, and that the distinction between process and  progress notes is VERY USEFUL.  Things get complicated, however, when there are high-risk situations (suicidality, child abuse/neglect, intimate partner violence, etc.) that demand detailed documentation, and this is where I think we have to do a very careful job of educating our learners AND OUR PATIENTS as to what gets documented in the EHR.  Whereas a pt in traditional mental health likely has a very clear cut idea of who can see their chart and who can't (i.e., only those for whom they have signed an explicit ROI), the boundaries are inevitably more blurred in an integrated care setting where other care team members have access to the chart as well as (theoretically/potentially) any family members for whom the pt has signed off on access to their medical record.  My sense is that patients often fill out this "authorize to release" clinic form without much thought as to how this may apply to BH notes also documented in their chart -- in fact, they may be filling this out as a new patient before they are even aware that BH services are provided at the clinic.  And, while our integrated care spiel to new patients likely contains information about how the care team will share information with one another, I don't think we very often revisit the family member access to which the patient has previously consented but perhaps with a different (medical care only) objective in mind. All this to say that as systems (and forms) often lag behind integrated care vision and practice, it is incumbent upon the BHP and the care team to continue to educate the pt and to truly treat informed consent (to treat, document, and share information) as an ongoing process. Thanks, all! Aubry I'm glad that others are struggling with the same things we are.  This list serve is very validating! No surprise to anyone here, but something that seemingly is simple, documenting the visit, is really pretty complex.  I teach our BHCs that the purpose of  the note (in no particular order) is: 1.  To justify and substantiate billing 2. To help you recall what you are doing with this patient when you have not seen them for weeks. 3. To allow another BH professional to assume care if you are unable to do so. 4. To provide some framework for what you are doing in the event of an outside authority auditing or reviewing your records (a Board, payer, court, etc.) for a variety of purposes 5. To alert your team as to what you are doing for the patient in the spirit of collaborative care Combine these tasks with the goal of seeing numerous patients daily, fulfilling the spirit of integrated care, and not falling behind with documentation really requires some thoughtful consideration as to the process for constructing these notes and their ultimate content.  We are trying to evolve our practice one step at a time.... Thanks for all the comments. Jeff
by L. Edwards
Friday, June 28, 2019
Resources for Trauma Informed Care 0 L. Edwards Dear CFHA community: What is your go to resource/s for Trauma Informed Care for primary care? (Seminal articles, websites, videos, manuals). Our goal is to use your combined wisdom to update our curriculum for Family Medicine residents and have targeted resources for our developing PCBH team. Warm regards, Deepu  Hi Deepu, We are currently in the process of doing all-staff trainings on Trauma-Informed Care. We found this free resource to offer a few very helpful resources tailored to medical practices: https://nppcaces.org/ Best of luck! Jamie Hi Dr. George - Here is a link to a fantastic Trauma Informed Care summary report produced by the Commonwealth Fund: <http://cirrus.mail-list.com/cfha/39659419.html> Additionally, a couple colleagues and I presented these two training webinars that are available for viewing: https://vimeo.com/165051334 Overview and Current Practices in Patient Screening https://vimeo.com/170520339  TIC, Clinical Integration and Organizational Buy-In Hope this helps,  Jeffrey Andrea Garroway works with us now, focused on Internal Medicine.   Susan
by L. Edwards
Friday, June 28, 2019

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