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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
Adherence to PCBH model 0 L. Edwards Good afternoon colleagues, Apologies if our list serve has addressed this before. But, our system is looking for a relatively simple and validated measure to assess our present degree of integration with regard to the PCBH model. We have about 50 BHCs working in 50+ rural primary care clinics across a 4 state footprint and have about 17 more clinics where we are doing tele-BH outreach. We are observing that different hubs of our organization are "drifting" in different directions away from our original intent to build and sustain a PCBH model (generalist clinicians, access as a priority, team based philosophy, shorter sessions and briefer interventions, etc.). Part of this drift, I suspect, is driven by the perception of need to generate more RVUs and I suspect some of our BHCs are slowly defaulting back to a more specialty mental health model where they are packing in 7-8 45 minute sessions during the day and we are hearing a few rumblings from PCPs that they are not "available."  This was a red flag for us and we want to find a "yardstick" (so to speak) to give us an idea of where we are drifting and where to put our energies in coming back to the center line of integration. Any suggestions for a survey, self-study questionnaire, or what have you that could guide our energies? Thanks for your collective wisdom. Jeff Hi Jeff - I know of a couple options you might try. One is called the PPAQ and I believe It was developed at the VA. There is also a similar tool in Robinson & Reiter's PCBH text that comes in both long & short versions. I've attached them all for you here! <http://cirrus.mail-list.com/cfha/40176361.html>   <http://cirrus.mail-list.com/cfha/72919577.html> <http://files.mail-list.com/m/cfha/PPAQ-Survey-10-2017gm.pdf>   Mike Hi Jeff Have you considered The Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) - Beehler and colleagues created it? It's a measure of fidelity to the PCBH model specifically. More information about it is available here including reference articles and a version to download - https://www.mirecc.va.gov/cih-visn2/PPAQ.asp We use it routinely in VA to measure fidelity. We also routinely measure wRVU productivity as well so sometimes see the same struggle you denote here. Happy to talk off line about the strategies we have taken to address that with leadership. Hope this is helpful! Lisa My understanding of the PPAQ is that it is a measure of BH Providers' adherance to the model rather than your organization's level of integration. For that, you might consider the Integrated Practice Assessment Tool (IPAT) put out by SAMSHA. Sherri This is great, Mike.  Thanks! Jeff Lisa, Thanks for this.  Mike also recommended the PPAQ. Appreciate the input very much! Jeff The practice integration profile (PIP) http://pip.w3.uvm.edu/pip.php is a good measure of integrated behavioral health in general. It operationalizes the AHRQ Lexicon from 2013. I would imagine the PPAQ along with one of these tools should give you a good picture of the practice as a whole and clinician adherence to a PC practice pattern. The IPAT is also a good tool. While not PCBH specific, these should help. An overview of assessing levels of integration is discussed in the CFHA podcast and can be accessed here: <http://cirrus.mail-list.com/cfha/67066606.html> Hope this is helpful. Warm regards, Deepu Thanks, Deepu.  Most helpful. Jeff In 2015, I developed a matrix of the available measures comparing key items - <http://cirrus.mail-list.com/cfha/02134068.html> The left column provides a set of proposed broader domains. C.R. From that matrix, the attached evaluation form was developed incorporating Peek's Three Worlds as an additional guiding framework (i.e., clinical, operational, and financial).  Each item provides behavioral anchors and specific target areas for the evaluator to focus the evaluation (attached). <http://cirrus.mail-list.com/cfha/72356959.html> C.R. Greetings Jeff and Everyone! Jeff, I sympathize with your challenge. I am assisting with two separate large-scale regional networks, one in early in integration and one a decade into integration.  In my experience, I was seeing episodes of this similar drift, of BHC  "sharking" for cold calls and scheduling lots of appointments to meet RVU/productivity standards and reduced frequency of direct handoffs from provider to BHC/ unavailability of BHC . Natalie Levkovich, with the Health Federation of Philadelphia, has been innovative in working with our primary insurer to build in an annual check-up, a multidisciplinary meeting in each FQHC to discuss integrated care and review the state of integration. We just found out we will be presenting our findings on this work at CFHA in Denver this Fall, and I am glad to talk further back channel.  We have some very positive results that showed a potential beneficial ROI for the following procedure.... In short, we asked health centers to set-aside 60-90 minutes to assess the health of integrative care, and did four things... 1. Reviewed everyone's impressions on the benefits, progress, and challenges of having integrated services across representatives of PCPs, BHCs/BH providers, Quality Officer,  medical assistant, care management, and key administration. 2. We had each individual complete the IPAT as a level set, and reviewed the results as a whole group 3.  Then, a facilitator who was non-partial to the site and very familiar with PCBH (but we could discuss other permutations) utilized selected questions from the AHRQ Playbook Self-Assessment (based on IPAT level)  to assess different domains of integration and provide feedback on degree of Co-Location, Patient Experience, Clinical Delivery, Practice Organization, and Business Model. https://integrationacademy.ahrq.gov/products/playbook/integrating-behavioral-health-and-ambulatory-care-self-assessment-checklist 4. Then, germane to the model of PCBH and what the site was striving for "to level up" and improve overall communication/precision, SMART goals and action steps were set, with a review meeting on progress scheduled. These meetings were very validating for all involved---teams often stated there are many times to meet as a team, but integrated care and its roll-out specific to the sites needs and BHCs capabilities are often just not addressed.   This format of a little time invested over a lunch or pre-post clinical morning/late day meeting led to some significant practice change and better BHC focus on availability to providers, and reciprocal improvements in the degree of referrals. Best Travis Travis - Your message was full of interesting & helpful nuggets; thanks for sharing! HealthSource is early into building a PCBH program, so this is great stuff for me to be thinking about proactively as we expand. Looking forward to seeing the presentation in Denver this Fall! Mike Travis and others, Thanks for your great feedback!  Your directions are really helpful.  Travis, I appreciate the step by step plan your organization chose to take.  I think  one of our challenges is that we have so many clinics with a BHC (~50) spread out over 4 states all with different PC leaders and different cultures. Trying to get everyone heading in one direction is the proverbial "herding of cats" so to speak. But, this protocol could be helpful if we chose 1-2 pilot clinics that could do some self- examination and reflection. The list serve alone is worth the dues for CFHA! Jeff
by L. Edwards
Wednesday, June 5, 2019
Traditional therapy vs. PCBH 0 L. Edwards Does anyone have any literature with parameters of when a patient should be referred to traditional therapy versus using the Primary Care Behavioral Health Model?  Kathleen Hi Kathleen, Although the basics are covered in Behavioral Consultation and Primary Care by Robinson & Reiter, I don't remember this being discussed in significant detail. One specific thing I recall is that they suggest no more than 10% of the patients a BHC sees should be seen more than 4 times in a year. I'll definitely be interested to hear if anyone is aware of lit looking at this specifically. This may not be anything new for you, but I can say a bit about my training around the topic. I was taught that there are three primary variables to consider: 1) Diagnosis 2) Symptom Severity 3) Patient Engagement The biggest pitfall is making decisions based only on the first two variables - the third is often unconsidered, but in fact the most important. Even if someone has really severe mental illness, if they have no motivation to see a therapist, making the referral is unhelpful at best! Similarly, we may automatically plan to refer someone out who is really motivated & asking for therapy, but if their symptoms/diagnosis aren't very severe, they're probably a prime candidate for us to take care of. Hope this is helpful; happy to say more if there are questions/comments/concerns. Mike  Another variable that is often under-appreciated is the availability of referral sources.  Working in rural systems without easy access to specialty mental health colleagues often forces a decision about fidelity to the PCBH model vs doing what we can to help a patient who has few other options. Additionally, we are torn between the ethic of striving for population health (ie., offering as many as possible who may benefit from our services a chance to have a taste of IBH consultation) vs the needs & readiness of an individual patient (ie, a patient with significant PTSD who has no access to the type of more regular & intensive therapy that might be most helpful). Our PCP colleagues struggle with some of the same issues-- the bar for referring out is necessarily higher in remote rural practices and systems  than it is for colleagues working in larger cities or more populous areas  with greater availability of specialized services. James  Well stated, James.  Our BHCs follow a soft target of referring patients out if they can't complete a treatment plan in 4-6 brief sessions.  Problems requiring more than that are referred to specialty mental health....in theory. But, access to specialty mental health (weeks to months) often derails that plan.  Also, the pressure of generating RVUs sometimes leads our BHCs to "keep patients longer" as they feel more confident in the revenue certainty of an ongoing patient or they feel more clinically confident with a particular diagnosis or problem.  And, sometimes the PCP will make a special request that a patient be "kept" in primary care.  In our rural Midwest geography, sometimes the weather is a deciding factor. Drive through the snow for 30 miles to see the psychologist or psychiatrist or see the BHC at the local PC clinic in my hometown. We are trying to solve that approach with increased use of telemedicine platform. Jeff Here is one brief summary <http://cirrus.mail-list.com/cfha/83003544.html> Alexander  Hi All - many thanks for the robust discussion of this topic, there have been some great PCBH posts here lately. Thought I’d comment on this one because it is especially important - and because it is often confusing for BHCs. 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! Jeff This is an important discussion because just under  the surface lurk unanswered questions that transcend models that attempt to estimate when a patient should be referred out of mental health service in primary care. The first question is: should mental health service in primary care serve to offload work from primary care clinicians ( MDs, DOs, NPs, PAs) but not increase the proportion of the population that would improve in " usual care". Or, should mental health clinicians in primary care attempt to increase the proportion of patients who improve compared to what is accomplished in usual primary care. Combining data from existing studies gives us some clues.  To my knowledge, there are no PCBH studies that have more than 49% of patients showing significant improvement. All these studies are not controlled but we dohave a wealth of data about usual care from scores of controlled studies where the control groups do not exceed this same proportion of the population( about 40 to 50%).  In all the PCBH studies, the vast majority of visits number between 2 and 4. There is one study sometimes cited as a PCBH study and sometimes viewed as unique that gives us some valuable insight. The Katon, Robinson, et al study," A Multi-Faceted Intervention to Improve Treatment of Depression in Primary Care" (Arch Gen Psychiatry. 1996;53:924-932). In this trial, 43% of the control group with major depression ( usual care) showed at least 50% improvement on the SCL-90 compared to 74% of the experimental group.( The SCL-90 was state of the art then before the PRIME MD was released in 1999) So what was the intervention? All intervention patients had a 1 hour initial visit with the mental health providers. They were given a booklet explaining the biology of depression and use of anti-depressants and a booklet on cogntive behavioral strategies. They were also given a 20 minute video * to view with their spouse* that covered material addressed in the written handouts. Patients were asked to participate in 6 face to face visits ( 84% completed 5 visits and 76% completed 6 visits) and *they received 4 follow up phone calls* ( mean 3.4).  Both groups of patients had access to medication treatment but  a larger proportion of treatment group patients adhered to taking the medicine compared to controls due to experimental group physician training and built in follow up. The take away for me  is that one size  does not fit all. Simply viewing treatment as complete in 4 visits ignores some important issues if the goal is to supersede population levels of success in usual care. Not all patients with the same level of illness severity respond in the same amount of time. Patients have varying responses to different forms of treatment. Perhaps the biggest issue yet to be addressed by any researcher focused on treatment of mental health in primary care is that a large proportion of patients will get better without any professional intervention. So additional questions include: Which patients respond to which treatments? How do we predict which patients will respond to treatment who would otherwise not improve? What factors predict when a patient will respond during a treatment course?  Until we can better answer these questions, I think behavioral health clinicians working in primary care need to work with more latitude than only 4 visits. Much of what is mentioned above is discussed more thoroughly and with more citations in a 2017 editorial that I co-authored with CJ Peek and Colleen Fogarty- Families, Systems, & Health 2017, Vol. 35, No. 3, 251–256 All of the other responses to this thread have addressed why the notion of "referring out" if patients do not improve may  be generating a wave of disservice due to access problems and low patient receptivity. I particularly like Jeff Reiter's comments and his underlying philosophy. During the last 5 years that I saw patients, I served as the in house behavioral health clinician for patients who often did not improve enough in the collaborative care model also present in our clinic. Many of these patients had a lot of chronic medical conditions that were intricately affected by their mental health challenges combined with social issues, etc and so required a high level of ongoing team care. Larry Larry, your reply raises a whole host of issues and questions, but is of course spot on. To answer your first question about what the goals of integration should be, I have always felt that the goal of the PCBH model is to improve primary care - in general, and for everyone. (and again, the Reiter, Hunter, Dobmeyer JCPMS article in 2017 discusses this in much more detail.) Other models, such as the CoCM and probably also co-located therapy approaches, have the goal of improving condition-specific outcomes compared to primary care as usual. I think it is hard to do both with any single approach. While we are on the topic, I should say that a major frustration of mine is that this goal of PCBH is not widely understood. Somewhere along the line, some in the integration community developed an unfortunate misunderstanding that the goal of the PcBH model is to improve outcomes for mild-moderate conditions relative to usual primary care; and that to do so the model deploys a brief (1-4 visits) therapy model that uses simplistic interventions in primary care (suffice to say that as a frequent trainer of BHCs, I’ve witnessed enough handouts and breathing training to last a lifetime). This misunderstanding is, to be slightly over-dramatic, the bane of my existence. It results in, for starters, passive BHCs who wait in their office for PCPs to do the hard work of screening, diagnosing and starting treatment, and then handing off the neatly wrapped package for a few brief visits. After all, if my role is to be a brief therapy provider then I should let the PCPs do their job and wait for referrals, right? It also results in inflexibility that runs completely contrary to the goals of the model. For example, BHCs with this misunderstanding reason that if a patient seems complex then s/he must be referred out immediately; s/he could not possibly be helped with just a few 30-minute visits, so therefore the BHC best not engage at all. Such practice behaviors will be the downfall of a service, because the patients PCPs most want/need help with are not generally the mild-moderate patients; they are mostly the complex patients. So if the BHC waits for the mild-moderate patients the PCPs don’t feel they need help with, and if they refuse to see the complex patients - then who exactly is left for them to see? That said, I do understand this inflexibility. As I said, it comes *partly* from this misunderstanding of the goals of the PCBH model. It also comes from disease model thinking that ties certain “diseases” to certain EBI’s that are not feasible for BHC work - e.g., if my patient has borderline pdo and I can’t offer traditional DBT protocols, then I can’t possibly help this person, right? Better refer out! Our graduate training has prepared us well for depriving care to people. Closely related to this is the magical belief that we can predict which patients are beyond our ability to help (our graduate training has also prepared us well for pathologizing and giving up on people). Frankly and unfortunately, a lack of knowledge/skills for how to intervene with a broad range of problems and ages is also a factor in this inflexibility (our graduate traing has *not* prepared us well for that). This misunderstanding of the model, along with these other factors and the resulting inflexibility, have become a huge thorn in the side of PCBH. It needs to be extracted because it is spreading infection. My hope is for our community to realize: 1) the goal of PCBH is to help improve prinary care in general, for everyone. Of course we want to improve individual outcomes for behavioral issues where possible, but our goal is much broader; 2) to that end, we must seek to help anywhere our clinic needs help. Limiting ourselves to mild-mod, acute  patients won’t suffice; and for that matter, limiting ourselves just to providing interventions won’t suffice - there are many other ways we can help improve primary care; 3) there is often much we can offer to even complex pts. They are not diseased; they have learned maladaptive coping that we can help them correct. And primary care, as the only part of the healthcare system with longitudinal relationships at its core, is often the perfect place to support such learning over time (not with weekly visits - with brief  but highly accessible/timely touches as needed over time); 4) we can often help PCPs *manage* complex patients even if they do not improve clinically; 5) none of this runs contrary to the PCBH model. It is a team-based model that requires flexibility. It is perfectly possible to do all of this while still maintaining 30-min visits and a consultative follow-up structure. So my plea is for BHCs to join in the controlled chaos of primary care. Don’t draw firm boundaries around yourself and wait for the “right” patients to come your way. They’re *all* the “right” patients! And don’t forget to look for ways to help your PC team members all throughout the day. If you’re doing this work right, it should be the hardest work  you’ve ever done, not the easiest (but also the most rewarding). You don’t have to lengthen visits and switch into therapist mode; you don’t have to sacrifice access or decrease your visit volume. There is plenty you can do to help while maintaining fidelity to the BHC role. More details about all of this are in the Reiter, Hunter, Dobmeyer 2017 JCPMS article. Thanks for reading! I hope everyone had a great weekend. :) Jeff
by L. Edwards
Wednesday, June 5, 2019
Billing for Hallway Handoffs and Phone Meetings 0 L. Edwards Good morning everyone - the order has come down from on high that we muststart billing patients for everything as of 5/1. My team and I have historically done all our hallways handoffs as no charges and also our phone calls asfreebies if we miss the patient while they are in the office. We have billedfor any short term therapy and coaching (90791, 90832, 90834). Apparentlythe team is costing too much and they want to see us even the playing fieldto at least try to break even. The most stressful concern for me is having to say something to the patientupon entering the room or starting the phone call about insurance and money.I feel so conflicted - this does not sit well with my values and the reasonwhy I feel integrated care exists. We are going to be choosing between thefollowing codes: 99484 (which can be used on the phone), 90832 - these 2will be the most often used, 90791, and then the Collaborative Care codes,for which consent is needed anyway. Has anyone developed to a script to inform patients that they may have aresponsibility? I am thinking something along the lines of, "I work as apart of the team here and accept the same insurance, so our meeting todaywill go through like your doctor's visit does and you may have a co-pay orsome small co-insurance. Is this ok with you?" But after 15 years of workingwith patients and never having to discuss this I am having to negativeautomatic thought that every patient will say no. Please share any experiences, good or bad - and thank you in advance! Hello, before billing it is important to know both the rules and the realitiesof reimbursement. Most programs don't bill for a warm hand-off because itdoesn't match the regs around billing for a 90832 - primarily that it needsto be 16 minutes or more. In addition you need to be able to justify thatyou had a therapeutic interaction with a purpose. This can be defined eitherspecifically e.g. diagnosis and intervention, or less so e.g. distress andcoping strategy...but the documentation needs to support the work. And, youneed to have actually delivered a therapeutic service. The 90791 is a one-time code that involves many elements - presentingsituation, some pertinent history, a diagnosis, etc. You probably don't wantto use this for a brief warm hand-off. The 99484 is only actually reimbursed by some of the payers and there arerules about how and when this can be billed. Probably you can do things to maximize your billing, but not only should theorganization be asking how you can "break even", but also should be asking how your behavioral health services positively impact the overall cost ofcare. For examples are the medical providers more productive because patients who need more time for their behavioral health issues, can see the BHC? Isthere less unnecessary ED use in your system, or more preventable IP visitsdue to behavioral health interventions? Are the providers happier? Your question about the conversation with the patient is important andshouldn't be the first interaction you have. Possibly it will be easier to script once you are clear exactly when you plan to bill, e.g. for 20 - 30minutes, vs. when you probably won't be billing - e.g. a warm hand-off of3-5 minutes. Then if you have 20 - 30 minutes you can talk with the patientabout how you could use that time...and then talk about the insurancebilling. Good luck with all of this. Mary Jean Thank you, Mary Jean. For those of you interested in learning more, markyour calendars for the PCBH SIG Webinar titled Financial savviness for theBHC: Practical strategies and tips Date: May 23, 2019 Time: 11 am PST / 12 MST / 1 pm CST / 2 pm EST Register in advance:https://zoom.us/webinar/register/165954ff7f06ec14c5b9141539e44ee6 Speaker: Mary Jean Mork, LCSW  Deepu  I agree with what Mary Jean has shared.  Sandy Blount who frequently contributesto this list serve has weighed in on this historically with some great wisdom. I will paraphrase what he has shared with one my posts to a similarquestion as you are asking though hopefully he'll weigh in himself.  If youhave to justify the BHC's value purely on RVUs in and salary/benefits out,it can be a tough calculation. I'd encourage you to broaden the "are they worth it" conversation by lookingat other variables, as Mary Jean posits, such as provider satisfaction, improvement in chronic disease indicators, improved depression/anxietymanagement, less trips to the ED, patient satisfaction, and as Sandy referenced (I hope I'm not butchering his words) a few months ago, the removal of"schedule busting patients" from the PCP's day.  When the PCP can do a warm handoff to the BHC of a complicated, emotionally struggling patient, itallows them to move on and see X number of additional patients that might have not been possible without the BHC's presence. In our health system, we are currently struggling to preserve the "purity"of our BHCs access for immediate consultations and handoffs, but getting alot of pressure from our finance leadership to have them see more patients,thus pushing our initiative towards a more embedded role rather than an integrated one.  This feels like an ongoing push and pull to find a way tojustify the model without losing dollars.  To make matters more interesting,our health system is very rural and there are few BH professionals in manyof our locales, making recruitment and retention very challenging.  As such,private practice is a lucrative alternative for many of our employees. Jeff Hi Elizabeth, We have been in a similar situation since we started our PCBH program last September - we did not bill for the first few months while we got a handle on things, but I explained in my intro that we would begin submitting charges for visits after the first of the year (which we did). Although I think the feedback you've gotten from others is very valuable, I've shared your questions and concerns so thought I'd give my 2 cents. First - don't sell yourselves short! You provide a vital service, and deserve to be paid for it as much as any healthcare professional does! I felt very similar to how you are feeling about this, and still do at times. There is that pull to justify yourself to the patient, and even apologize for having to bill them. Going to the last CFHA conference and talking about this with colleagues, and hearing the above message repeatedly from them, really helped to put me at east and frankly to more highly value the services I provide. Secondly and similarly, more experienced colleagues have pointed out to me that our patients have at least a general sense of their healthcare coverage, and will generally have an accurate expectation of whether a service will cost them money. For example, our medicaid patients expect, accurately, that they will have a copay for neither their PCP nor their BHC visit. In contrast, our commercial patients do not assume that BHC visits are free, just as they know their PCP visits aren't free. I acknowledge that the double copay for a same-day PCP & BHC visit can be a challenge, but this brings me back to my first point. If, instead of seeing the patient, you sent her/him to a counselor (which involves a lot of inconvenience that you are saving them), they'd still have a co-pay. It just feels wrong because it's all on the same day. When we started, we discussed at length how much detail we needed to go into with patients about the billing. After going to CFHA last year, we decided that going too deeply into the subject could imply we were burdening the patient instead of providing an important service in a manner far more convenient than otherwise possible. We realized we might actually cause the reaction we were afraid of. Ultimately, we decided that I would add the following verbiage at the end of my BHC intro: "We often piggy-pack my visits with your PCP visit, to make it more convenient, but it is considered a separate visit." I invite questions about any part of my introduction, and of course answer any the patient has about charges, but very rarely has anyone asked about the billing. I have yet to have a patient decline the visit, and we haven't had anyone complaining later that they were charged. To be fair, there have been 2-3 people who have declined a follow-up due to financial concerns, and in those cases I have still gone in for a very brief check-in to make sure there are no acute/crisis concerns, and to ensure there aren't any easy solutions (e.g., they have no insurance but haven't been set up for the sliding fee scale). Good luck with this huge change you're undertaking! And thanks to everyone in this community for always being so helpful. Mike Mike makes a very good case for explaining the billing to patients andfamilies, and as long as people are not getting a surprise bill, and havethe option to opt out, there should be no difficulties. Another way to think about it is to consider other areas of health care wherethere are multiple providers.   If you have surgery done at an outpatientsurgery center, you will have a bill and co-pay from the surgeon, theanesthesiologist and the surgery center, there will be 3 bills, sometimesfrom 3 different organizations. The same is true if you are admitted to a hospital, you will have a billfor physician services and for hospital charges. Some specialty pain clinics may have an outpatient see a physician and aphysical therapist on the first visit, again two bills, two co-pays. My point is that integrated care in primary care is not unique in terms ofbilling considerations, patients experience this in other settings. We canlook to those settings for examples of how it is managed. Doug In my experience running a service in the FFS world, I would say that manyadministrators get the argument that an integrated service can help financiallyin various ways, yet the bottom line is that they are running a businessand unless you’re heavily supported by grants (or can clearly demonstratethese other financial benefits - a very difficult thing to do), you probablyneed to at least come close to breaking even with your service at some point.One of the things that struck me though about billing was how few complaintswe received about bills, even after billing thousands of patients. To Doug’spoint, the vast majority of people are very familiar with getting bills forhealthcare services, and with being uncertain regarding what the finalbilled amount will be. Yes you need to provide informed consent, and yesyour documentation and clinical activities need to be sufficient for billing.But if you do that and you provide a high-quality service, most patients inmy experience are quite accommodating when it comes to bills. Jeff I agree with all the points made so far, and I appreciate the discussion as I find it very valuable to learn what other people are doing with these questions. We also bill for same-day visits when they meet criteria to do so. Typically, when I am asked to do a warm hand-off I introduce myself to the patient and then go through a script describing informed consent. It includes something along the lines of "Because I am a health care provider in this clinic, if you choose to stay for an appointment with me it will be billed through your insurance. If you would like to check with your insurance company first to ensure coverage, we can always schedule something on another day." We have a cheat sheet at our front desk of in-network and out-of-network payers that helps us shape the conversation and move the hand-off more towards 5-10 intervention and triage to another office if we are out-of-network for a patient. As Mike had stated earlier, we get very few refusals. I think I have maybe had 2 or 3 people in almost 3 years refuse on the basis of payment concerns. Even when patients have to pay some portion out of pocket, they are appreciative of the service and access and express that to us. Wishing you luck in finding out what works best for you! Kim Can I ask a related question to all of the experts on this list serve please? Do any of you have trouble with warm handoffs due to needing to pre-certify mental health benefits before you see the patient? How do you handle that? Thank you in advance for all of these insightful answers! I just started a job this week at a private healthcare organization where I am tasked with starting integrated behavioral health care. I was previously at an FQHC and therefore, did not run into these billing issues. Laura Hi Laura - The only time we've run into this issue is w/ Tricare. We go ahead and see the patient, knowing we probably won't be reimbursed, but go ahead and submit the PA so that we have it for future visits. We do submit the charges for the 1st visit as well, on the off-chance we can manage to get paid retroactively. Mike It is at the warm hand off that we tell the patient about billing for services and give them a cheat sheet that instructs them how to check with their insurance on their benefits coverage and make an appt. If it turns out that the patient is out of network or benefit and does not want to pay out of pocket we then just cancel the first appointment. Beth Hey all! Chiming in real quick! As I have stated in past posts, within the state of WA, we are able to bill Medicaid for same day behavioral and medical visits without an additional co-pay. Further, our organization has at the board level decided for insurances that require an extra co-pay (e.g., Medicare and some private insurances), our health center will not pass along that extra co-pay to the patient and essentially "eat the cost." We will still bill the insurance company but the health center will absorb the cost of the additional co-pay, not the patient. Further, and as someone indicated before, our handoffs ALWAYS include a sound introduction to services, a Contextual Interview, and intervention/goal setting, which allows for the time requirement of 16 minutes for a psychotherapy to be met, as well as other requirements of psychotherapy code. Thus, we bill for all of our handoffs. Lastly, I think this is an important conversation for all of us to have with our billing department. Most health centers have tremendous resources such as billers and coders that we often overlook to reach out to and ask about how to resolve a lot of these concerns. Our Director of Behavioral health, Bridget Beachy, regularly meets with the billing team to address any denials and/or concerns, as well as continue to learn how to make billing more efficient and effective (down to how to have our templates so our notes do not get denied). The one benefit of being in a FQHC is that licensed behavioral health providers are able to bill the established encounter rate for the FQHC, meaning, a BHC visit is just as valuable to the organization as a PCP visit. Further, BHC visits also count towards UDS visits, and last year, our BH department that is made up of 10 licensed BHCs and 4 BH trainees accounted for *10%* of our organizations UDS visits... a significant chunk of visits that is undoubtedly tied to funding! Hope that helps! David In our system, we've instructed our BHCs to not get into a prolonged debate about whether the patient's insurance will cover the session or not.  Rather, we frame it as "the PCP needs your help, see the patient at least this once, even if we don't get paid, because there is benefit to the larger team."If it turns out that the patient's insurance has no MH benefit or for some reason the BHC is not credentialed with that payer, we work to try to liaison with the patient and steer them towards a provider that is reimbursable if they need extended services. Bottom line is that we don't want the PCP to have the perception that theBHC will "cherry pick" only those patients that can be effectively billed for that first visit.  We figure the PCP wants help, we want to serve that request, and we will sort out the payer issue after we've met the patient and done our assessment.  We want to build confidence that if the PCP asks, we will respond, at least for an initial assessment. I'm not saying we don't care about getting paid.  But, by the BHC seeing the patient regardless of pre-qualifying them, it can "save" dollars down the road through more diagnostic specificity, hooking them up with resources that will address their underlying psychosocial concerns, etc. Jeff Absolutely. We bill out the co-pay on warm handoff. We do tell patients that is our practice. If a patient returns for a “piggyback” appointment, in which they already plan to be handed off from physician to BHC, the co-pay is collected at check-in. The business office did not love this plan at first, but it removes barriers for patients in that they don’t have to go back up to registration and re-register. For tricare, registration staff are notified via instant message. A PA is started and is ready for me to complete and hand back for faxing as soon as I have a chance. This is a great conversation, thanks everyone. In my setting we have also set up a cap on patient responsibility to help simplify things since we work with so many payors. We guarantee patients will never have to pay us more than $40 for a behavioral health visit (and it is discounted to $32 if they pay at the time of the appointment), even if their insurance declines the claim.  We have it written up on a small handout that is available at the front desk and around the clinic/with BHCs. Of course for Medicaid plans there is a guarantee of $0. For warm handoffs that become an assessment/intervention we are sure to inform the patient there will be charges. If we are unable to adequately gain consent for this we do not bill for that encounter. Katie
by L. Edwards
Thursday, May 9, 2019
MAT Research 0 L. Edwards I am a BHC at a FQHC in Augusta, GA. We have recently had one MD and a PA get their waiver to start MAT treatment. There is some controversy at the clinic regarding us providing those services and a few docs have even cited research advocating against MAT. I am presenting with the PA on MAT and wanted to include recent research regarding its efficacy. Therefore, I wanted to reach out to the CHFA community to see if any of you has a bibliography with the recent research and perhaps some recent meta analyses on the topic. If you all have any resources over viewing the brain science of SUDs and OUDs specifically then that would also be appreciated. Reach out if you think you could be of help and thank you for your time in advance,    Zachary   Wow. Hard to believe this is even a question anymore with the death rate. Lot of easy retrievable things like the CDC and SAMHSA guidelines.  Lori  When I encounter people with strong objections to MAT for OUD they have tended to think about the issue in one of these ways: 1) They expect that treatment for OUD should be exactly like treatment for Alcohol Use Disorder, and they believe strongly in the value of 12 step approaches. 2) They mistakenly believe that buprenorphine has the same risk/benefit profile as other controlled substances, or that it is somehow even more dangerous than other controlled substances. 3) They bring an ethical/moral worldview that objects to harm reduction in all, or nearly all forms. When their perspective is grounded in items 1 or 2 they will sometimes change their perspective when offered peer review literature. More often they change their perspective by observing a trusted colleague begin the use of MAT. You might try engaging them generally in conversations about harm reduction. How do they think about birth control for adolescents? Finally, I would want to make sure they understand that you agree that MAT for OUD is not perfect.  It does not cure all patients.  But it keeps more people alive and functioning than alternative treatments. And this is the same standard providers use for treating other chronic conditions like diabetes and hypertension. As far as peer reviewed evidence and opinion pieces that summarize the evidence here are a few good options from the last 2 years: Volkow ND, Jones EB, Einstein EB, Wargo EM. Prevention and Treatment of Opioid Misuse and Addiction: A Review. JAMA Psychiatry. January 2018. doi:10.1001/jamapsychiatry.2018.3126. Moreno JL, Wakeman SE, Duprey MS, Roberts RJ, Jacobson JS, Devlin JW. Predictors for 30-Day and 90-Day Hospital Readmission Among Patients With  Opioid Use Disorder. J Addict Med. January 2019. doi:10.1097/ADM.0000000000000499. Martin SA, Chiodo LM, Bosse JD, Wilson A. The Next Stage of Buprenorphine Care for Opioid Use Disorder. Ann Intern Med. 2018;169(9):628-635.  doi:10.7326/M18-1652. Wakeman SE, Barnett ML. Primary Care and the Opioid-Overdose Crisis - Buprenorphine Myths and Realities. N Engl J Med. 2018;379(1):1-4.  doi:10.1056/NEJMp1802741. Carroll KM, Weiss RD. The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review. Am J Psychiatry. 2017;174(8):738-747.  doi:10.1176/appi.ajp.2016.16070792. Bhatraju EP, Grossman E, Tofighi B, et al. Public sector low threshold office-based buprenorphine treatment: outcomes at year 7. Addict Sci Clin  Pract. 2017;12(1):7. doi:10.1186/s13722-017-0072-2. Daniel Great answer, Dan. And great references. There is as much stigma toward MAT as toward OUD itself. That includes professional stigma. Barry I've read this thread with great interest, as we have introduced MAT into our Community Mental Health Centers (CMHCs) over the past year. What you describe is not uncommon.  What I consider to be the most important consideration of any new MAT introduction is the culture shift that occurs  or will need to occur.  As described previously, there are many myths related to MAT that are perpetuated out of a lack of understanding, or said more  directly, ongoing institutional stigma that exists regarding the comprehensive treatment of substance use disorders -- despite the great need, the lives lost, the clear beneficial outcomes, and the great expense to the broader healthcare system related to untreated substance use disorders.  In addition  to this, providers do not necessarily have the education, training or experience with MAT itself, as well as in the specific dynamics of a population with OUD.  If a provider does not have confidence in one's abilities to provide the service, or if the provider does not believe that there will be enough ongoing support, there will be a hesitancy to participate. A year and a half ago, we had only one waivered provider in addition to me. We now have eleven.  This takes time -- with a few initial adopters to build confidence and spread the word -- but it is possible. I highly recommend reviewing the Providers Clinical Support System website -- https://pcssnow.org/ . Great trainings and mentorship opportunities.  I would also consider SAMHSA a great resource for information and technical support. Thanks, Jeffrey
by L. Edwards
Thursday, May 9, 2019
BHPs and MAT 0 L. Edwards I am wondering if anyone has experience as a BHP working with patients undergoing MAT.  I had someone describe what they might do before induction, during induction, following induction.  Have also had some discussions about how you might support families/caregivers as they go through the process with the patient. Any experience with this as this field continues to grow? Lori  I have been doing this work for the past 9 years or so. The evidence to guide this practice is relatively limited.  Here are few take aways: - not all patients need counseling to recover from OUD, buprenorphine should never be withheld from someone who declines counseling - patients should be initiated an bup as quickly as possible, don’t build systems that require “ BH intakes” or “ BHscreening” by BH providers,  these systems act as barriers to treatment and put patient’s lives at risk. Most patients entering treatment already know how to use bup safely - home induction is just as safe as office based induction, practices should move to home based induction as soon as possible - patients and families benefit education about harm reduction and buprenorphine, for example: "yes this is trading one drug for another. This is trading a  drug that will kill you for a drug that won’t kill you." - rates of trauma are very high in this population, use a universal precaution approach to trauma informed care. - that said, OUD is a life threatening condition and some patients can recover from OUD without addressing trauma, nobody should be “forced” to deal  with trauma - some patients will not engage in group treatment for a variety of reasonable reasons - providers will find MI skills (empathy + evoking and reinforcing change talk) very helpful in this work - practical relapse prevention focused interventions are also very helpful - BH providers should help train all staff in practice about MAT and address issues of stigma Daniel  Thanks Daniel – I am trying to get at the specific skill set for the BHP and some experience/stories about what it has been like working in this emerging area of practice.  Is it rewarding, how might is change PCP acceptance of doing MAT, changing other staff attitudes towards patients with OUD and the MAT approach, heartwarming story, interaction with families of the patient.  What are the lessons learned so far from being a BHP in and around MAT treatment? The CFHA submission deadline closes tomorrow too so if there is a critical mass of input on this theme we might be able to spread the experience?  Lori  Hi Lori - in my previous job I worked with a number of PCPs who prescribed bup. They said it was actually among the easiest and most rewarding work they did as a PCP, though of course they had a cap on how many such patients they would follow, and were selective regarding the patients they would  take on. As a BHC in that setting, I got to know a lot of the patients who were on bup, and I really enjoyed the population. I think most crucial is for the BHC to be accessible. Not uncommonly these patients have setbacks and/or present in crisis, and esp in the beginning of tx the PCPs often appreciate having a partner to help them set and keep clear boundaries with patients who are struggling. In such cases, being available to help in the moment is crucial. Most of these patients either don’t want ongoing therapy/counseling, or in some cases are already engaged in specialty treatment, and they won’t come in for scheduled appts with a BHC at some later date. But they do greatly appreciate having a trusted BHC working alongside their PCP, to help them navigate into their new life and manage their way through setbacks that occasionally occur. So typically (like most pts seen in the pcbh model) I would see patients for one visit here, two visits there, often worked in just before or just after a PCP appointment on the same day, to lend additional assistance beyond the PCP’s for whatever issue was going on. It saved the PCPs from having to take additional time during their visits, gives the PCPs the added support they find helpful, and  provides additional help for the patients who typically are very grateful. I have a video somewhere with a couple of patient testimonials and comments from PCPs. If I can find it I’ll send it to you.   Jeff
by L. Edwards
Thursday, May 9, 2019
Cost Effectiveness in Integrated Care 0 L. Edwards Good morning list mates, My organization is looking at expanding integrated behavioral health services in primary care (currently have ~40 clinics already doing that) but as is often the case, the pro forma based on revenues and costs can show BH services struggling to break even.  Anecdotally, primary care docs love our program but we need to be able to make a renewed case to leadership that the "cost" of such an initiative is small (or favorable) compared to the benefit on overall patient health, not just depression, anxiety, etc. I have collected numerous articles here and there looking at cost offset of integrated behavioral health but wondering if anyone knows of a position paper, report, or what have you, done recently, that nicely summarizes the impact of BH on things like diabetes, hypertension, obesity, etc.  Again, mostly looking for an organized report as I can also go searching for individual articles.  But, did not want to re-invent the wheel if one of my colleagues knew of such a recent position document. Thanks for any help you all can offer! Best wishes, Jeff  It is difficult to make general statements about the cost effectiveness of integrated care that are true for all integrated settings. Before we can answer we need to know about about the payer environment.  Is it purely a fee for service environment?  If it isn’t purely fee for service, what is the nature of the other contracts? If your patient’s health improves who makes more money?  If your patient’s health gets worse who makes more money? One group’s cost savings are usually another group’s lost revenue opportunity. With regards to the satisfaction of your primary care providers, this is really important.  PCP burnout is a huge problem.  Recruiting and on boarding a new PCP costs hundreds of thousands of dollars per provider. In rural communities these costs are even higher.  If it is true that your PCPs choose to work in your practices because of integration this finding needs to documented and presented to leadership. - Dan  Well said. Cost offset and Cost effectiveness are related but different. I know of no other healthcare endeavors that are required to bring in more than they cost (though Laboratory services generally do). Milliman (Steve Melek) papers are useful though are projections Andrew  Your case depends on how broad an analysis they will allow.  In places that want to know if the BHC will pay for themselves through billing, it is a close call.  Although if you think about the BHC in the same terms one uses to assess the impact of a new nurse, for instance, it changes a bit.  No one says "Is that nurse going to pay for herself?"  They say, will she improve care enough to help our patients or to lower costs.  A BHC, in those terms is like a nurse who almost pays for herself. If you look at the evidence a little more broadly, the impact on PCPs is very quick with provider satisfaction going up reliably and provider retention documented in a few settings.  If the central administration connects this proposal not to their worry about losing a little money, but to their worry about maintaining their provider workforce, that may be an important refocusing of the analysis. Finally, and still within the data available to the health system, in several settings (I don't have time to dig these up this morning) where there was open scheduling for part of the day, the efficiency of the PCPs was shown to go up when a BHC was added.  The ability to hand off health behavior teaching, or "schedule busting" problems, to the BHC has allowed the providers to see more patients.  It only takes a little improvement to pay for the BHC time though only a few places have captured this effect in their analysis.  In many settings it is written up as an unexplained increase in efficiency of the PCPs and the BHCs are still under the gun for not bringing in more billing.  You can see that the more the whole program is analyzed, the more flexibility for BHCs and true integration is supported, whereas the more the BHCs are assessed only for their billing, the more it pushes them to a co-located model where they see patients in scheduled sessions all the time. If there can be cooperation with the payers who have the data on total health costs of patients, a whole new world of documented savings opens up.  See below: The Cost Effectiveness of Embedding a Behavioral Health Clinician into an Existing Primary Care Practice to Facilitate the Integration of Care: A Prospective, Case–Control Program Evaluation Kaile M. Ross1 · Betsy Klein2 · Katherine Ferro2 · Debra A. McQueeney2 · Rebecca Gernon3 · Benjamin F. Miller1 © Springer Science+Business Media, LLC, part of Springer Nature 2018 Abstract This project evaluated the cost effectiveness of integrating behavioral health services into a primary care practice using a prospective, case–control design. New Directions Behavioral Health collaborated with a large Kansas City primary care practice to integrate a licensed psychologist (i.e., behavioral health clinician) into the practice. Patient claims data were examined 21 months prior to and 14 months after the psychologist began providing full-time behavioral health services within the practice. Claims data from patients with Blue Cross Blue Shield of Kansas City insurance (BCBSKC) who had at least one encounter with the psychologist (N = 239) were compared to control patients (BCBSKC fully insured patients at large) to calculate cost savings. The results demonstrated that integrating behavioral health services into the practice was associated with $860.16 per member per year savings or 10.8% savings in costs for BCBSKC patients. Integrating behavioral health services into primary care may lead to reductions in health care costs. Your article is protected by copyright and mall rights are held exclusively by Springer Science+Business Media, LLC.  The link must be accompanied by the following text: "The final publication is available at link.springer.com”. Vol.:(0112 33456789). Journal of Clinical Psychology in Medical Settings, https://doi.org/10.1007/s10880-018-9564-9 Alexander Sandy, This is a most articulate commentary.  I wish I could carry it around on a 3X5 card and hand it out.  I appreciate your thoughtful remarks.  I will certainly use this wisdom as a piece of my argument going forward.  And, thanks, too, for the reference below.  I will ask our health science library to dig it up. Cheers! Jeff  Here are some relevant references re the PCBH model: 3. Gouge, N., Polaha, J., Rogers, R., & Harden, A. (2016). Integrating behavioral health into pediatric primary care: Implications for provider time and cost. Southern Medical Journal, ##, pp-pp. 4. Landoll, R.R., Nielsen, M.K., Waggoner, K.K. & Najera, E. (in press). Innovations in primary care behavioral health: A pilot study across the U.S. Air Force. Translational Behavioral Medicine. 5. Lanoye, A., Stewart, K. E., Rybarczyk, B. D., Auerbach, S. M., Sadock, E., Aggarwal, A., Waller, R., Wolver, S. and Austin, K. (2016). The Impact of Integrated Psychological Services in a Safety Net Primary Care Clinic on Medical Utilization. J. Clin. Psychol.. doi:10.1002/jclp.22367 6. Reppeto, H., Tuning, C., Olsen, D.H., Mullane, A. & Smith, C. (2018). Triple Aim: Benefits of behavioral health providers in primary care. Journal of Health Psychology. DttOpsI://1d0o.i.1o1rg7/71/01.13157971/1035391085830128984029949 Jeff 
by L. Edwards
Tuesday, March 19, 2019
Seeking Input Regarding Depression Registry Management 0 L. Edwards Hello CHFA colleagues, I'm writing from UC San Diego where we have a long-standing integrated primary care system; however, we are newer to using depression registries. My question for the group is, for those of you using depression registries, what type of staff/clinician (e.g., licensed behavioral health provider, nurse, behavioral health intern, other?) is responsible for depression registry management? Thank you for your time and input! Katrin  Hi Katrin, Our research team at ASU just completed a survey of 130+ clinics and asked who was in charge of enrolling patients into registries. Here is what we learned: Medical provider: 11% Nursing staff manager: 16.4% Behavioral health provider: 9.6% Care manager: 28.8% EHR: 11.0% Other: 23.3% The other category tended to included data analytics teams. Overall, it seems that BHPs are often not primarily responsible for patient registries. Matt Hi Katrin, In our clinics at Mayo the term registry has evolved such that there is a list of depressed patients who get added electronically by the computer to a list based on diagnoses and PHQ-9 scores.  Then, for patients in an active episode of treatment as in care coordination, a nurse in our clinics will ‘activate’ a patient who is eligible and agrees to be treated.  It seems best for them to do the task as it links to the CoCM billing codes. We also have a registry for psychotherapy and the therapists (social workers and psychologists) enter data on their own patients. Best wishes, Mark Katrin, In our system, we do maintain a depression registry, using Minnesota Community Measurements as our goal.  The registry is usually co-managed by the BHC and the RN care manager.  Our goal, a modest one at best, is 11% remission at 6 months by MN standards. Jeff 
by L. Edwards
Tuesday, March 12, 2019
Questions about Implementation Survey for MAT Services in PC 0 L. Edwards Hello, here in Maine, we are working together with several integration programs to prepare and support our BHC's in delivering the behavioral health aspects of MAT in primary care. We wondered if there are any surveys or scales that help programs identify where they are on the continuum of developing integrated MAT. Let us know and we'd be happy to partner with others nationally who may be using the survey/scale. Thanks, Mary Jean  Our group here in Cincinnati would be interested in something like that as well. Thanks, Navdeep Philadelphia would be interested too! Natalie I would suggest folks review the article I cite below. The survey instrument they used would be a good place to start. I will suggest that prerequisites include: - Openness to harm reduction informed approaches to care vs. abstinence only - A commitment to providing empathic communication to those with SUD - A clear understanding of the differences between specialty care and primary care (continuity, comprehensiveness, access, and coordination of care) and how this applies to primary care treatment of SUD (minimize patient burdens for accessing care, don’t require a comprehensive mental health evaluation before offering MAT) - Ability to provide trauma informed care Wakeman, S. E., Pham-Kanter, G., & Donelan, K. (2016). Attitudes, practices, and preparedness to care for patients with substance use disorder: Results from a survey of general internists. Substance Abuse, 37(4), 635–641. http://doi.org/10.1080/08897077.2016.1187240 BACKGROUND:Previous research demonstrates that most primary care physicians feel unprepared to diagnose and treat substance use disorder (SUD). Confidence in SUD management has been associated with improved clinical practices. METHODS:A cross-sectional survey of 290 inpatient and outpatient general internists in an academic medical center evaluating attitudes, preparedness, and clinical practice related to SUD. RESULTS:149 general internists responded, a response rate of 51%. Forty-six percent frequently cared for patients with SUD. Sixteen percent frequently referred patients to treatment and 6% frequently prescribed a medication to treat SUD. Twenty percent felt very prepared to screen for SUD, 9% to provide a brief intervention, 7% to discuss behavioral treatments, and 9% to discuss medication treatments. Thirty-one percent felt that SUD is different from other chronic diseases because they believe using substances is a choice. Fourteen percent felt treatment with opioid agonists was replacing one addiction with another. Twelve percent of hospitalists and 6% of PCPs believe that someone who uses drugs is committing a crime and deserves punishment. Preparedness was significantly associated with evidence-based clinical practice and favorable attitudes. Frequently caring for patients with SUD was significantly associated with preparedness, clinical practice, and favorable attitudes. CONCLUSIONS:SUD is a treatable and prevalent disease, yet a majority of general internists do not feel very prepared to screen, diagnose, provide a brief intervention, refer to treatment, or discuss treatment options with patients. Very few frequently prescribe medications to treat SUD. Some physicians view substance use as a crime and a choice. Physician preparedness and exposure to SUD is associated with improved clinical practice and favorable attitudes towards SUD. Physicians need education and support to provide better care for patients with SUD. Cascadia (large behavioral healthcare organization in Portland metro) has recently began offering MAT services; we currently offer maintenance of buprenorphine prescribing and will soon begin induction. I don't have a readiness survey to share but would be happy to speak about our implementation process and some of the challenges we ran into along the way. Thanks, Renee
by L. Edwards
Tuesday, March 12, 2019
Pts request to see a different BHC in the same clinic 0 L. Edwards Good Friday to everyone! I have specific question that must be a common issue. However, I can see it being handled differently based on the primary care setting. *Problem: *There are instances when a pt has seen my colleague for 1-3 sessions and does not follow-up. Then the pt shows up at their physician appt a few months later with similar complaints and "I tried that counseling but it didn't work out, help,, I didn't click with her etc." or something to that effect. The physicians often offer the option of seeing me or the pt asks to see someone else. *Personal conflict: *I feel conflicted about how to handle this situation as there are many reasons why the first few BH appts did not work out for the pt. The solution of to "try a different provider" is just one option. There are reasons why we would prefer that the patient follow up with the original BHC to discuss what did not go well and revise the treatment plan (e.g. avoid splitting behaviors, role model communicating about difficult issues, already established rapport, access to care etc.). There are reasons why we may want to go with the pts willingness to try a different provider (e.g. truly did not click with original BHC, capitalize on pt motivation, access to care). *Setting: *I am on faculty in a large family medicine residency practice where we teach and follow the PCBH treatment model to the best of our abilities. There are two BHCs, myself (clinical health psychologist; time is split between education and practice) and an LPC (full time practice). We have 30 residents and 10+ attendings. *Attempts at addressing the issue: *My BHC and I have met and discussed this issue and agreed that during the warm handoff we should always encourage the pt and physician to get the pt back in with the original BHC for at least one more appt to problem-solve, revisit the treatment plan, offer options. However, pts slip through and end up on our schedule and we find ourselves in the situation described above. In practice, as you probably know, physicians are typically unaware of the ethical quandaries and/or difficult situations that this can put us in. Thus, my fellow BHC talked about how we can educate the physicians in this regard but we work in a large residency clinic so the educating piece can be an uphill never ending battle and not totally effective. *Context of BHC experience levels*:  I have by PhD and spent a significant portion of my training in integrated primary care and am still early in my career. My fellow BHC has her LPC, training in art therapy, she has practiced for 15 yrs in community mental health and came into primary care only 1.5 yr ago. She has been a quick study and wonderful sponge with regard to learning and implementing the brief model of treatment; LOVE HER!  Nonetheless, our training backgrounds and practice experiences differ significantly which has it's pros and cons for patients and for our fellow physicians perceptions as well. Feel free to back channel. Any thoughts, suggestions, or words or support would be most appreciated. Thank you, Laura  I’m sure many others will jump in with expansive wisdom on the issue, but I will say that I am glad you are posing this question as it is one of the unspoken aspects of integrated care. I look forward to other’s response on the issue. My initial response is that a credo I always live by in primary care is that the MH services we deliver should (as much as possible) mirror the primary care services delivered in that setting. Thus in most situations, patients do end up seeing multiple providers often for multiple issues. This flexibility is often built into a health home with care teams. I know it can be hard to envision this with traditional MH parameters, but I know it worked quite well in my clinic in WI. Now, that is a N of 1 and your setting might be different in important ways. However, patients seem to enjoy the variety and flexibility it offered and a side-effect of the “bee-hive” approach as we called it, was that we as a BHC team were forced to work in more systematic ways and to document well and communicate more effectively since we overlapped quite often on patient cases. I hope those thoughts are helpful. Thanks, Neftali I am moved to address your question in part because of Neftali's response. A hallmark of primary care is continuity of care.  I have never heard a primary care physician advocate for disregard of continuity. There is a sizable literature on the value of continuity of  care and its affect on outcomes, patient satisfaction, decreased costs, and provider satisfaction.  Is continuity of care easy to establish? No.  This is especially true in residency settings ( where I practiced and conducted research for 30 years) where residents and faculty availability ranges from 1-4 half days a week. My family has seen primary care physicians for over 35 years and we seek relationships, want to be known, understood and have our values integrated into the approach that providers offer.  We want continuity as patients, as families and this is especially true when we deal with chronic care and palliative care needs. Teams that work well together can limit fractionation of care through careful communication, close physical proximity in working space design and careful use of EHRs.   Nevertheless less, the definition of primary care is built on continuity from everything I have seen and read and this definition is translated into the definition of and assessment of the PCMH. So what about continuity in primary care behavioral health?  I am not as well read ab0ut this issue, even as a former journal editor and one who has monitored the collaboration and integration literature over a few decades. My sense is that If behavior health clinicians want to mirror primary care, then continuity would be the watchword when possible.  For those who simply site patient satisfaction studies in practices where behavioral health continuity is not a primary goal, I ask for comparison to other settings where continuity is maintained, for defined studies measuring outcomes, provider satisfaction and cost. Satisfaction with no comparison is of limited value because of the ceiling effect. The other issues you raise are important.  Clinicians and teams need to recognize splitting and also exhibit curiosity about patient dissatisfaction with care.  We ( BHCs and physicians and nurses and others on the team) should regularly inquire if what we are doing is meeting the needs of our patients. If not, maybe we need to adjust.  One of the behavioral health clinician's best allies is the primary care clinician. Patient's often lack motivation, fear an endless process that will drain the bank, and do not understand the psychotherapeutic and psycho-educational process.  Other team members, especially primary care physicians, can help patients stick and also alert BHCs to concerns. That triangle is so powerful with its product greater than the sum of its parts. And yes, sometimes we refer to a colleague who might be better positioned to provide effective treatment. But this should be the exception, not the rule or standard of care. These issues deserve debate and more research. I look forward to other comments. Larry I agree with Larry. This is an important conversation for PCBH. I have a few things to contribute. I hope it is helpful. In keeping with the season, here is a winter themed story for your reading pleasure.:) PCBH in Patient-Centered Primary Care Homes (PCPCH) is like a little snowball that has tumbled down a snowy mountain. It itself does not quite know how it has gotten so large but it has and now it is big and beautiful and plain to see. The little PCBH snowball began as a handful of people years ago.  The PCBH snowball came to understand that it had knowledge people needed. But people weren’t getting it because the PCBH snowball wasn’t in primary care where people sought it. The PCBH snowball determined to go to primary care to meet the need. The need was so large and the snowball was so small. It knew it needed to change its ways to meet the need. It accepted its small size and thought deeply about how it could change in such a way to help the most people. In the context of doing something different for the best reasons often with shaky fiscal sustainability and limited resources, the PCBH snowball astonished itself by developing ways to support many many people as part of a primary care team. At this point, the PCBH snowball slipped off the mountain and grew exponentially with little effort and with great speed. It came to and found itself at the bottom of the mountain big and beautiful. Then it looked out and saw a snowfield farther than its eyes could see and asked itself, “What now?” Yes, if you ask a complex question I may very well respond with a children’s story. :) I am telling this story to give context to my response. As Larry said, this conversation started with a seemingly simple experience and question about multiple BHCs in a clinic but it is connected to complex issues that are grist for the working and ever developing PCBH mill. I too was compelled to respond yet challenged to do so in this format. PCBH became big and beautiful quickly but we are now coming to and looking up and seeing the enormity of the PCPCH space that we now must fill. The trajectory is continued growth and becoming a standard PCPCH care team member. Becoming no different than other team members like nurses, primary care clinicians (PCCs), MAs, etc. We are working hard to ensure supply of us to meet the enormous demand. We also are developing new ways to organize our practices that mirror primary care clinician practices. This is where I get to Laura’s seemingly simple question about how patients are supported when clinics have more than one BHC, particularly in the case when each BHC comes from different BH disciplines. First of all, we are becoming like primary care which for years (at least in my state) has promoted a professionally diverse primary care clinician (PCC) workforce including physicians, physician assistants, and advanced-practice nurses all holding the role of PCC in clinics. The need for PCCs is so great we need all who can to fill the need. The same is true for BHCs. This within role professional diversity also allows each clinician the opportunity to learn and consult with others who may have special knowledge and skill.  Learning from the professionally diverse PCC practice, patients are not transferred from PCC to PCC depending on patient presentation or preference. They are only transferred with good reason and as an exception to a continuity standard. There is a sense that having a PCC be stable in a person’s life is a good thing. As a BHC and operational leader, I want to follow this approach to patient care and I believe we can. I encourage clinics to assign BHCs to 2-4 PCC panels. To “empanel” BHCs. This mirrors the PCPCH practice of building teams of professionals to care for a panel of patients and often provides a more reasonable work assignment to a BHC. In clinics with let’s say 6 PCCs, I would encourage the clinic (depending on patient population make-up and size) to hire 2 BHCs and assign each BHC to 3 PCCs and their patients. The team can then say to a panel patient, “Let me get our BHC. She can help us with...” This way of organizing BHC practice communicates to patients that they have a BHC whether or not they have ever seen one. To further illustrate the usefulness of assigning BHCs to certain PCCs, consider that PCCs don’t give patients a choice between all the nurses in the clinic when a nurse is needed. No, instead they say, “Let me get our nurse to help with...” If there is a problem between the team nurse and a patient then the problem is worked to a solution. A different nurse is not by routine asked to support in an effort to solve the problem by avoiding it. As a patient, I wouldn’t expect my PCC to solve a problem I have with a team member by getting a member of another care team to work with me. I would expect a conversation to resolve the issue with the care team member who has given me concern. Now if the team’s nurse is gone there usually is an understanding that another team will cross-cover with their nurse. Even when BHCs are panel(s) assigned, cross-coverage within the role and between teams would be indicated. PCBH has come a long way quickly and we are still developing. As we progress, I have no doubt we will continue implementing practices and operations that mirror primary care. In regards to whether or not PCBH practice is ensuring continuity, I would like to suggest we consider the reasonably sized BHC “panel(s)” assignment strategy as a method to increase the continuity of our care. I look forward to more conversation. If I can be further helpful feel free to email me directly. All the best, Julie This is a fantastic discussion, one that could help all of us define what we do a bit better.  And I am happy that I have so much respect for both the discussants. As I think of my reading and my experience, I find myself coming up with points that support both. We all have studied what makes for the best primary care, and the evidence is not in doubt, that it is about relationship, and continuity of care is a central element.  For many patients, and especially for patients with "complex" health needs (multiple chronic illness, behavioral health diagnoses, low income and/or minority, with trauma histories), the evidence says that the degree to which they experience their doctor as caring for them, as personable, willing to talk about any ruptures in the relationship, correlates with the degree to which they are likely to take actions to  care of their own health, to perform self-management tasks.   But that evidence is about relationship with their doctors, that is the longitudinal focus of studies. True, where there is one team that has all the roles that most patients might need: med, BH, care management, MA, and reception, the core longitudinal relationship for the patient might be with a team member other than the doctor, though, in terms of number of contacts or clock time together with the patient, the BHC is the least likely to be that person.  The BHC is more likely to be a support to the other relationships. In most settings, the BHC works with more than one team's worth of doctors. Between that fact, and the necessity for coverage when others are gone or off duty, it is unlikely that every doctor has only one or two BHCs uniquely serving her team, or that she is the only PCP on that team.   Patients who have BH needs will almost certainly see different BHCs to some degree. There is a narrative, that I have used myself, that what BHCs are doing is offering defined, evidence-based services in 1-3 visits, sort of like delivering widgets.  I find that narrative useful to try to help people who are trained in specialty mental health to get past the idea that a patient they work with is "their" patient and that the relationship with them is what makes all the difference in their patient's improvement. In practice, I did not experience a "widget-like" relationship with any patient, even though I did the same sort of processes for each of many, many patients. As I think back, I would say that the process and whatever skill I offered was the main characteristic of my experience of my relationship with the majority of patients, but that there were a substantial minority whose care seemed to be more about the relationship than the BH interventions. On the topic of what should an administrator do if a patient wants a different BHC, I never found that the specialty MH idea of needing to address the problems of patient and therapist with the last meeting to "come to closure" was useful.  I think that is a piece of the old MH idea that the relationship with the particular therapist is the main factor that makes the difference over time. In just about every case I remember where some sort of "healing or terminating" meeting was recommended, the patient perceived the pressure for additional process with the BHC they wanted to leave as being about power and control, or about therapist ego. I finally came to the position  that finding out if it is fixable was not worth the effort or the patient engagement it might cost. I just complied with the request, well aware that the BHC that the patient wanted to leave might well be the one who cared for the next one of "my" patients who wanted someone other than me. Hope that is a useful addition to the discussion. Sandy Wow - excellent discussion from my 40+ years of PC practice point of view and 20 yrs. of building Collaborative Care/IBH into our practice here at Laura's new home.  I would make a few summarizing points that I think apply to BOTH PC and IBH - as I too believe that the PC model does and should inform a lot of IBH practices. 1.  The distinction between continuity practice and episodic good PC OR IBH practice is how continuous the relationship actually is. Every interaction between a PCP and a patient is not nested in a warm, continuous, long-standing doctor-patient relationship. Would that it were but reality circumstances just don't support this in every case.  Continuity develops, and is earned, by the circumstances of a patient's need and the efforts of the PCP to engage in and try to meet that need. There are patients on my panel and in our practice who I see very rarely, maybe once or twice - as they are healthy and/or youngish and if they develop an acute likely transient problem  - they might just as much value seeing one of my partners more conveniently and quickly than me.  And that's fine.  There are patients with             whom I am In deep soul-bonding relationships (for which I sometimes need Balint help) because they have multiple complex problems that             we grapple with on an ongoing basis or who are in real trouble (like the patient of mine who is dying of cancer who just texted me his daily             report).  For these patients continuity really does matter - a lot.  And there are patients with whom my relationship varies from intense daily contact while they are in trouble to then once every 6 mos. when they are in the clear. With them the  relationship, like with high school, college or medical school friendships, is always there to be picked up at a moment's need. Even for these patients there is evidence that significant medical outcomes like preventive services compliance or ED/hosp. incidence is better with continuity. 2.  The patient's right of choice. BEFORE a continuity PCP-patient relationship is built - by mutual consent I might add, patients always have the right and usually the opportunity to switch PCPs in most systems.  Sometimes this happens during one of those acute need visits with a partner - with whom the patient clicks and says: "Hey I like you - can you be my PCP?"  Ouch for the original PCP, but this really should be the patient's right.  The patients are the ones we are trying to serve, not our own egos.  There are logistic limits on this of course - and these are greater the             smaller the pool of available clinicians! The patient who can't find any doc in a group of 20+ clearly has a problem (I won’t get specific             here!).  And one can't do this willy-nilly - so some communication problems should indeed be worked out and PCPs need the ability and "mindful practice" skills (see Attending by Epstein) to accomplish this task.  And sometimes it really IS the doctor and they need re-treading in their own communication and doctor-patient interaction skills. And so it maybe should be with BHC-pt. relationships too. I DO like the PCBH model of briefer interventions initially for many patients - and in this model likely the therapeutic relationship, while not negligible, is less important than the technical skill of the BHC and the delivery of consistent model-dependent content. After all how much continuity can one build after only 2-3 visits?  But in our model which we call "PCBH PLUS" we are also wanting to deliver services to more challenged patients with greater needs.  Hence some of our patients receive many visits beyond the 6-8 level of PCBH, and we have added            to our model primary care psychiatry consultants as well.  This is driven also from the PCP model where there is NO community of "other"         clinicians to "turf" patients to who have greater needs (ie. community mental health).  PCP-relationships that are working ... are for life or until death do us part.  SO I am personally against shipping patients out to the community just because their needs are greater than the average PCBH construct.  If a patient starts IBH care due to one life event (say a divorce), and then another more challenging life event happens (say cancer) - our BHCs should stick in there and continue to care for that patient.  (There are of course exceptions for patients   who really do benefit from the context and perhaps more richly enabled settings of the mental health clinics.).  And then there are, analogously, patients who get initial PCBH interventions who should then take a few months to apply what they learned from insight or skill acquisition from these initial sessions.  And then in a few mos. perhaps they need a "check-up" with their continuity BHC to see how       they are doing.  And how wonderful would it be if a patient is helped through a crisis by a BHC whom they come to know and trust - and a few years later they face another crisis and can have the help of that same BHC again? Rusty
by L. Edwards
Tuesday, February 5, 2019
"Incident to" Billing 0 L. Edwards Are any of you doing "incident to" billing for the services of psychology interns or post docs, that is billing for their time for a primary care consultation, incident to the attending primary care provider? I was asked by someone who is trying to develop a post doctoral position and the physician is willing to do 'incident to' billing and also willing to pay a licensed psychologist to provide the requisite clinical supervision. If anyone is billing in this way, please let me know. Doug   We've started billing Health and Behavior Intervention codes secondary to referral by the PCP.  Haven't had a response yet from the insurance companies. John  I was not clear, my apologies. "Incident to" services are when a non-physician provider delivers a service and the physician is supervising and responsible. So, the bill goes out under the physicians billing number but it is indicated as "incident to" showing that someone else provided the service. Typically, licensed individuals in other professions (psychology, social work) do not use this billing because they are supposed to bill under their own license. However, I have heard of examples where unlicensed trainees (interns) bill in this way.  I was just wondering if any of you were doing this. Doug In our program we bill in such a way that it shows the "service provider" is the intern, while the "billing provider" is the licensed supervisor. We have commercial payers reimburse, yet know that this is not possible for patients with Medicare. William We are also interested in whether anyone is doing “incident to” billing for any licensed mental health providers doing PCBH? Thanks, Patty  I did this as a postdoc (2015-16) in Oregon. I wasn't licensed at the time. I attached a sheet that walks through when it's appropriate to use that code. Let me know if you have any questions. Arissa (LINK ATTACHED)  
by L. Edwards
Tuesday, February 5, 2019
Evidence-based articles about integrated behavioral healthcare 0 L. Edwards Dear CFHA friends, I am pulling together a reading list of the MUST READ evidence-based articles about integrated behavioral health care. While some websites have a long list of options, it can be overwhelming for someone new to sift through and find the golden nuggets. Again, I am looking for articles that are empirically grounded and useful for arguing the utility of it in health care. Feel free to email me separately if you are listserv shy (hodgsonj@ecu.edu). Thank you in advance for your time! Anyone who contributes and would like what I put together, just let me know! Best, Jennifer _________________________________________________________________________________________________________________________________________________ Thanks Jennifer. I know the REC continues to compile an ongoing list of such references as well, so syncing these may have benefit. Bill _________________________________________________________________________________________________________________________________________________ Hi Jennifer, This is a great idea! If you are looking specifically for any "late breaking" articles, I believe that Bill is referring to the REC's quarterly dissemination of recent notable research/evaluation abstracts, website located here: https://www.cfha.net/page/researchsummaries. I'd be happy to help coordinate efforts with you on your project. I'd also specifically like to plug the following review article from the Center for Integrated Healthcare (my center, just to be transparent) that summarizes the available literature for behavioral health interventions: Funderburk, J. S., Shepardson, R. L., Wray, J., Acker, J., Beehler, G. P., Possemato, K., ... & Maisto, S. A. (2018). Behavioral medicine interventions for adult primary care settings: A review. Families, Systems, & Health, 36(3), 368-399. Thanks, Julie _________________________________________________________________________________________________________________________________________________ For the PCBH model specifically, Chris Hunter et al. published a summary in JCPMS in 2017 that I’d include. Also, I am attaching my personal list of PCBH research articles, just so to give you more to consider! I’d also be interested to hear from anyone who thinks I might be missing an important PCBH article. Jeff
by L. Edwards
Monday, February 4, 2019
A Composite of Information Regarding Documentation for FM BH Providers 0 L. Edwards The long narrative below is a composite of information I provided to our own embedded Family Medicine BH providers regarding documentation/records. The information applies to all BH providers in systems with EHR's, whether embedded or not. All the underlines are active links to resource info:    The bottom line premise is that although we've traditionally combined the two, a psychotherapy/counseling note (AKA process note) and a progress note (http://cirrus.mail-list.com/cfha/61658069.html) are not the same thing. We should put only progress notes in the EHR for SO many reasons (not the least of which is we're not required to do otherwise - not by most organizations not by APA, not by TSBEP, not by insurers, not by Texas law.) You are not violating ethics or privacy to separate the two of these, nor, in most cases violating any laws. Since State laws differ, The Trust, working with APA, has developed EHR templates for use by psychologists - these also cover state-specific requirements for patient records. (http://cirrus.mail-list.com/cfha/77784102.html) By definition, anything that appears in the EHR is considered by HIPAA to be a progress note, and, although it's still private info under HIPAA, it does not have "special" protection afforded to process notes. Therefore, only the following belong in the EHR: Start and stop times, type of treatment, results of any assessments, diagnoses, functional status, treatment plan including goals and timelines, current symptoms, prognosis, and progress to data. Everything else, including (1) extensive social history (beyond basics and what's already in the chart), (2) anything not pertinent to medical treatment or necessary for insurance reimbursement, (3) justifications for formulations, (4) issues you're considering, (5) your personal musings about the patient, (6) certain details of the patient's life, etc., should go in psychotherapy/process notes that are held in a locked cabinet/drawer (or in your memory if your State doesn't require you to keep written ones). These latter notes do have special HIPAA protection and can be obtained by other parties (including the patient) only with your permission or by court order.  Things to ponder: * Many psychologists were taught to justify, rationalize or explain things like diagnoses and other formulations - these don't belong in a progress note and could give you grief in certain situations. Also, no one who reads them cares - your notes aren't going to be scrutinized by a former professor. We need to challenge some of the conventions of our training. * Progress notes are routinely sent by healthcare systems to payers to justify reimbursement. Do you want an insurance company rep reading process notes you've included in the EHR? * The trend is toward open notes - many systems already allow patients to access all documentation notes in the EHR. We're going to have to be more aware of documentation. * Some healthcare systems, including ours, ask permission before releasing our EHR notes, but this may be false security, given the growing tendency of healthcare systems to allow access to each other's patient records. This does not preclude your keeping process notes where you can put all the details you're used to recording, and which have special privacy under HIPAA, but keep them out of the EHR. * Look at one of your EHR notes and ask yourself if you'd want your patient to read it, if all information there is pertinent to medical treatment or required for reimbursement. Again, go back to those templates and stick to them for the EHR notes. See highlighted below.  The following are resources I found in a Google search covering recent years (since EHRs and integrated care) - and there are plenty more where these came from. The multiple books I have on PC and health psychology also make these points and are calling for training programs to get up to date, I might add.  1. From Blount (the guru of PC psychology): "Perhaps learning to document using a computer is a good tool; the skill that is most important is learning to do primary care notes. The "process recording" that is used in training is almost the opposite of what is needed in primary care. These need to be terse, clear summaries of the issues, progress and plans of the session. Students need to learn the difference between "psychotherapy notes" and "progress notes" and learn how to record in the latter and eschew the former."  2. From American Academy of Pediatrics (http://cirrus.mail-list.com/cfha/97756342.html) : "The HIPAA definition of a "psychotherapy note" is quite restrictive. A psychotherapy note per HIPAA ...[is a] written analysis of a conversation that occurred during a private counseling session that is maintained separately from the medical record. These written analyses serve as working process notes about sessions to assist the therapist, and are not put into the medical record billing document. Anything which appears in the patient's medical record cannot be categorized as a psychotherapy note under the HIPAA rule [and therefore does not have special protection]. Specific content that has been listed as not falling under the "psychotherapy note" protections include medication management information, counseling session start and stop times, the type and frequency of treatment delivered, the results of clinical tests, diagnosis summaries, functional status, treatment plan, symptoms, prognosis, and progress to date. 45 CFR 164.501.  3. From APA (http://www.apa.org/pubs/journals/features/record-keeping.pdf): "It is important to note that multidisciplinary records may not enjoy the same level of confidentiality generally afforded psychological records. The psychologist working in these settings is encouraged to be sensitive to this wider access to the information and to record only information congruent with organizational requirements and necessary to accurately portray the services provided. In this situation... the psychologist may keep more sensitive information, such as therapy notes, in a separate and confidential file."  4. From APA (http://www.apa.org/gradpsych/2007/01/track.aspx) : "Basic records, often called progress notes, cover the who, what and when of treatment. These records ... should include such information as dates and types of services, assessments, intervention plans, consultations, testing reports, releases of information, consent forms and any supporting data... In addition to these progress notes, psychologists can keep psychotherapy or process notes for their own use. These notes include a little bit more detail that some therapists like to include, perhaps information they consider relevant to hypotheses or analyses about behavior change."  5. From HIPPA (http://cirrus.mail-list.com/cfha/65797598.html): "Generally, the Privacy Rule applies uniformly to all protected health information, without regard to the type of information. One exception to this general rule is for psychotherapy notes, which receive special protections. The Privacy Rule defines psychotherapy notes as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint, or family counseling session and that are separate from the rest of the patient's medical record. Psychotherapy notes do not include any information about medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, or results of clinical tests; nor do they include summaries of diagnosis, functional status, treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes also do not include any information that is maintained in a patient's medical record. See 45 CFR 164.501. Psychotherapy notes are treated differently from other mental health information both because they contain particularly sensitive information and because they are the personal notes of the therapist that typically are not required or useful for treatment, payment, or health care operations purposes, other than by the mental health professional who created the notes. See 45 CFR 164.508(a)(2)."    Best, Judy
by L. Edwards
Monday, December 10, 2018
Warm Handoffs and Behavioral Health 0 L. Edwards Hi all, Hope everyone is well. I am wondering if anyone would be able to share what type of data they collect to evaluate warm handoffs. That is, what data elements are you capturing? Laura Sudano, PhD, LMFT  _________________________________________________________________________________________________________________________________ Hi Laura - out of curiosity, how are you defining “warm handoff”? People seem to define it in very different ways. To some it is merely a “meet and greet”, basically an administrative encounter in which the BHC meets the patient, provides a business card, and helps the patient schedule an appointment for some other day. (Editorial comment: IMHO this is largely a waste of time, and may even deter future warm handoffs because it takes up PCP time and exam room space without anything actually being done... I'm not sure that would feel worth my time if I was a PCP.) But to others, a warm handoff typically results in an actual intervention being done. Whether the BHC and the patient have 5 minutes or 30, the BHC will provide some sort of help. Also, some only really use warm handoffs after the PCP has completed his/her visit. But others routinely get pulled into the middle of PCP visits, eg, to help with some task while the PCP goes on to another patient (circling back later to reconnect with the BHC and finish with the patient); or get worked in before the PCP, eg, for pre-visit planning. Also, some call it a warm-handoff if the PCP has merely seen the patient earlier and then placed the pt onto the BHC’s schedule, without any interaction between PCP and BHC. But to others a warm handoff involves actual discussion (even if brief) between the PCP and BHC regarding the reason for referral and relevant history, and including the patient as well. I consider warm-handoffs a vital part of PCBH practice. They can help the BHC be more efficient; help ensure the pt, PCP and BHC are on the same page; demonstrate to the pt the teamwork between PCP and BHC; ensure the pt and PCP receive help same-day, even if brief (important since many patients don’t f/u as planned); along with other benefits. But I think if studying warm-handoffs it will be very important to define what exactly is meant by “warm-handoff.” And I hope my tangent here doesn’t distract from your original question(!), because it is a good question. I just wanted to toss this clarification request out there before people start chiming in. :) Jeff Reiter  __________________________________________________________________________________________________________________________________ I’ve heard from the PCPs at my site in north philly that warm-handoffs are “invaluable,” and “really help (them) focus the visit more efficiently.” Granted, they likely don’t even know what the term “warm handoff” means; they’ll usually say they want to “give me a heads-up” about a patient on their schedule for the day, if they have time to look, or more typically when they see a patient they’d like me to meet with has arrived at the clinic or is even being triaged. This allows me to come into the exam room while the pcp is still seeing other patients, to have a brief intro as to who I am, what I do, what to expect from our visit today, and a very focused conversation about the reason for the PCP’s referral. Then I’ll catch the pcp before they go into the exam room, catch them up very briefly about the patient’s *actual* focus for the visit (usually what the pcp has wanted a BHC to address with them for a long time and often different than what the patient states the reason for their visit is (e.g., “physical,” or “diabetes,” etc.)), will tell them what my assessment/intervention plan is, and the pcp will then go into the exam room and let the pt know that I informed The PCPs usually tell me after the visit that they spend a LOT less but more focused time w the pt during the visit, often saying, “you helped save me so much time!” Melissa Cruz  __________________________________________________________________________________________________________________________________  Hi Laura - I think Jeff is right that defining the scope of a warm hand-off is necessary, but I will offer a response that is a light counterpoint to his thoughts on the meet and greet, as well as a suggestion for a possible metric. In a previous clinic I worked in, we routinely performed WHOs for a range of reasons, but spent a lot of time doing meet and greets and the providers seemed to uniformly appreciate the service. It was a very large clinic and residency program with 20,000 patients and over 30 providers (including residents). Because of the amount of time spent being called out of scheduled visits, meetings,etc., we wanted to see whether it was "worth" doing. The clinic sees a high-need, underserved, and very diverse group, and no-shows to BH visits (particularly to initial evals) were common. For several months we conducted a small internal study on the effect of the meet and greet (we excluded other WHO requests, like risk assessments) on show rate. We looked at those patients who were referred to BH and scheduled with an initial visit without first being introduced to a BHC, and those who did get a meet and greet. We found that patients who had met a BHC before their initial visit were significantly more likely to show for that scheduled apt than if not. To be clear (and I think this speaks a little to Jeff's point about the lack of clarity around what a WHO includes) our version of a "meet and greet", though largely an introduction, was always done with the PCP involvement and typically included providing the pt with at least a little education about their sxs and what to expect from treatment. We didn't look more closely which components could explain the increase in show rates following one of these interactions but provider response to a survey we built suggested that virtually all of them found the warm hand off to be a good use of their time and exam room space, and the patients seemed to engage better after having one. For whatever that's worth... Alexander Brown, Ph.D. _________________________________________________________________________________________________________________________________ Hi Alex, excellent post. Yours is, I believe the first in this thread that tried to respond to the query with data. We know very little about empirical support for warm handoffs. Taking your programs small study, which should be published as a case study by the way, and turning it into a multisite trial would be an important contribution. Happy to think thru such a trial. Rodger Kessler Ph.D.ABPP __________________________________________________________________________________________________________________________________ FYI, myself and two colleagues (Drs. Beachy and Vigil) will be presenting at CFHA on data regarding Warm-handoffs, specifically on how they change management and providers' (BHCs and PCPs) perception/perspectives... Pretty interesting (awesome, we think :-)) results! David Bauman  __________________________________________________________________________________________________________________________________ All of you with warm handoff data, might consider asking for a section in FS&H to publish it as at least case reports. Those case reports lead to funding a specific study.  Roger Kessler Ph.D.ABPP __________________________________________________________________________________________________________________________________ We are submitting to FSH tomorrow our best attempt to rigorously assess the impact of warm hand-offs on follow -through with referrals to a non-same-day therapist. I do hope it advances this conversation and the science, as accurate documentation of a BHP's activities, let alone the population served, is challenging. William J. Sieber, Ph.D. __________________________________________________________________________________________________________________________________ We also have a poster that will be presented at CFHA with data from warm hand off appointments in our VA PC clinic: Perceptions about behavioral health treatment improve as a result of a brief appointment with an integrated behavioral health provider. Jennifer Wray  __________________________________________________________________________________________________________________________________ Bill, why dont you take the lead and get a section in FS&H for hand off case reports. This thread suggests 3 already. I will help you edit if you woud like. Ultimately this is frankly not about improved care, it is to determine whether we have an evidence base, and should be part of bundled payment. In one report we published a long time ago, rates of treatment initiation were 75 and 90 percent after non warm hand off referral to IBH. Rodger Kessler Ph.D.ABPP  __________________________________________________________________________________________________________________________________ We are submitting to FSH tomorrow our best attempt to rigorously assess the impact of warm hand-offs on follow -through with referrals to a non-same-day therapist. I do hope it advances this conversation and the science, as accurate documentation of a BHP's activities, let alone the population served, is challenging. William J. Sieber, Ph.D.      
by L. Edwards
Tuesday, July 31, 2018

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