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A Composite of Information Regarding Documentation and Records for Family M 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
Distribution of BH clinicians in primary care vs outpatient MH 0 J. McLean All,  I'm seeking information/data examining the distribution of BH clinicians across the entire spectrum of care, including BH in primary care and other traditional MH settings (e.g., community mental health centers, inpatient mental health, independent provider network, etc.). This is in the context of wanting to expand access/service utilization across the entire system of care. I strongly suspect that having more integrated behavioral health clinicians in primary care can help get more people actually seen for BH service and help streamline access to other settings, such as "specialty mental health" to address needs of higher severity. The data/literature on what a redistribution of the BH workforce (more clinicians in primary care) might look like seems limited. Can anyone help point me in the right direction? Thanks!!!    Jonathan Muther, PhD   The person I know who has done the most with using BH clinicians across an entire spectrum of care in a health system, specialty MH (inpatient, step down and OP MH), primary care and specialty medical settings is Tim Osner. I suggest you reach out to him. Tim Osner <tim.osner@tcosner.com>    Alexander Blount, EdD   The USAF has completed a study pertinent to your question. I think they have a publication accepted on what they call “Shifting the Point of Access”. Whenever it’s published, I’ll be sure to announce it on the list serve.    Basically, they shifted many BH clinicians (including assistant level) from specialty MH to PC and asked patients to seek MH care initially in the PC setting. Their study included collection of data for a year prior to the shift and during the year of the shift and their sites included one small, one medium, and one large clinic. Very interesting results — with increased  visits completed and increased number of unique patients seen in both the PC and specialty MH settings. It’s really a game changer type of study.    Patti Robinson, PhD   Fascinating. I was involved in the very early USAF efforts at this (their term was Behavioral Health Integration) in the 1990s. So good to see this come to fruition and the rest of the health care system using this model.   James A. Bourgeois, O.D., M.D.   Thank you for your response on this Patti. Do you happen to know the role of the clinician that was newly working in the Primary Care setting? Were they co-located doing traditional therapy as they would have in their outpatient setting, or did they become trained in brief assessments/screening/consultation/warm handoff, etc. as in the PCBH model?  Thanks!    Jonathan Muther,
by J. McLean
Thursday, July 19, 2018
Fat Shaming and Integrated Care 0 L. Edwards   Hello Colleagues, As I know you are aware, there is a major anti fat-shaming movement where not only medical personnel but also BHCs may receive great criticism for attempting to help patients with weight loss. While the BHC may not consider their motivations or actions "fat shaming", many advocates would disagree. Recently, I listened to the podcast below that is very insightful in terms of how therapists involved in this movement think about attempts to help individuals. I am interested in different opinions on this subject, and in particular your thoughts on this podcast if you choose to listen to it. The Radical Therapist #048 – Anti-Fat Bias and Weight Stigma in Psychotherapy w/ Hilary Kinavey & Carmen Cool: https://chrishoffmft.podbean.com (Copy and Paste link into web browser.) Robin Landwehr   ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------  Haven't listened to the pod-cast, but at our organization we do market to patients and providers that we can help with obesity...however, our BHCs promote helping patients make healthy eating habits and increasing their activity level. I address "fat shaming" head on many times and actually talk with them that the goal is to help them live a life they want to live....vs merely "weight loss." Again, I address the stigma directly with the patient. We work on understanding the context to see if physical activity and healthier eating habits is in line with what they are looking for to live in line with their stated values... Our BHCs stay in constant contact with the PCPs about what we are doing with the patient....it can happen where we get a hand off for "obesity" and then we work on something else...but our PCPs trust our judgement and our open communication helps do some bi-directional, interprofessional upskilling...many times a patient has a medical condition that impacts their ability to be physically active so I make sure I talk with the medical provider about any physical barriers the patient may be experiencing...   Bridget Beachy --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------  Thanks, Dr. Beachy. Yes, and we also discuss weight stigma, but I have had conversations with therapists who still believe this is collusion with a system of fat shaming. They firmly believe we are not having a real discussion about health, especially if not all people have access to healthcare options. Many will completely disagree that weight has anything to do with health outcomes. They will cite research to support this. I would imagine this could be very confusing for patients. To have one set of professionals tell them that weight is relevant, and another tell them it isn't. I agree with many of these advocates, in that sometimes weight is blamed for every health problem a patient presents. A typical example is something like knee pain. If an overweight person has knee pain, many report that they are simply told to lose weight. If a thin person has knee pain, it is thought to be a problem with the knee, or perhaps a sports injury. It just seems to be a conversation that BHCs should be having. In this podcast, the therapist endorses the Health at Every Size model from Dr. Linda Bacon. I know some health care providers criticize her model. So, there is definitely a difference of opinion about all of this. The presenters on this podcast have spoken at conferences for the National Eating Disorder Association, so they have a lot of support for their opinions. Thank you to anyone reading this.   Robin Landwehr   -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------  While the negative health effects of obesity are real, it is important to take a long hard look at the evidence for addressing obesity in primary care. The truth is that primary care based conversations about weight rarely result in any improvement in health. PCPs and BHPs tend to overestimate the benefits of conversations about diet and exercise. As this thread is suggesting, we may be simultaneously underestimating the harms of these conversations. This is a bad combination. We will tend to remember our few successes and not notice all of the patients who disengaged from care rather than face another conversation about weight. If/when we have conversations about obesity in primary care we should be focused on strengthening the patients own commitment to engaging in a structured weight management program like the diabetes prevention program or similar. For BHPs and PCPs the “target behavior” for these interventions should be engagement with these structured programs rather than the typical targets of portion size, number of steps, and so on. I think there are strong arguments that the real potential for addressing obesity is at the public health level rather than the 1:1 primary care encounter level.   Daniel Mullin   -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------  Great point, Dan. Putting this in the context of the social determinants of health, eating in a healthy way is very costly. Whereas, eating unhealthy food is not only less expensive, but it much more readily available for Americans, especially in economically depressed areas. This speaks to the importance of resource allocation (in addition to the very real behavioral economics at play). One other point that I think we should be careful about is the idea of knee pain and weight loss that was mentioned in an earlier thread. The stark reality is that diagnosiong and treating in medicine often involve a "process of elimination." Putting aside the evidence base for weight loss in primary care, if a provider assesses that one factor potentially exacerbating knee pain is the amount of weight the patient is carrying, losing weight is a very logical, practical and inexpensive step for treatment. If we think about behavioral economics, it is also easy for the provider to recommend, because most of the work is on the patient. That's not to say it is easy for the patient. It also may be system centered instead of patient centered - an entirely separate and important discussion. There SHOULD be different knee pain recommendations for the patient with a BMI of 22 versus the patient with a BMI of 35. Each patient has different biopsychosocial variables that relate to his or her pain. How the provider (and/or BHC) addresses it with the patient is probably the best opportunity to prevent and eliminate fat shaming. That's where it sounds like we need some extra training for the field more broadly.   Kent Corso  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   Dan has made some great points here, and the future is clearly not 1:1 conversations with clinicians, it will be more programs like the DPP (currently done at select YMCA programs) and more likely programs like Omada (a cyber implantation of DPP). As long as we are focused on health goals, that are mutually set with individuals asking for help, I really don’t see a shaming problem. Dan is also correct it is a public health issue, with major problems in our supply of healthy food, advertising of unhealthy options and the construction of an environment that discourages activity. Real change requires policy changes in agriculture, SNAP programs, transportation. Some of the payers and larger programs (e.g. Geisinger) are starting to address this at a public health level. With nearly 30 million people with metabolic syndrome or diabetes, I think we have some responsibility to creatively address these problems. Remember with DPP, rather small changes (5% body weight loss) can result in dramatic health improvements.  Doug Tynan -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   Thank you for your replies. To Kent's point about knee pain. My example was really based on what patient's say. Process of elimination makes sense to us, but patients don't necessarily care about the process, only that they are always having this conversation regardless of what they present with at the doc's office. And as you explained earlier in your post, losing weight may not be an inexpensive thing if you don't have access to healthy food. So the provider may find it logical and inexpensive, but perhaps it's not. And as Dan mentioned, it could lead to complete disengagement of the patient. That could mean that they stop coming to check-ups or preventive care appointments. I am certainly not saying these conversations shouldn't happen, but the language is really important, I think. And certainly patient perception is important.   Robin Landwehr  ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   We were recently shown this info-graphic regarding factors related to influences on obesity. Realistically there is a lot that goes into a person's weight and a primary care conversation sometimes takes too narrow of an approach which can be invalidating to a patient. I think validation of the difficulty in maintaining health sometimes can be more meaningful to a patient than telling them what they need to do. http://www.shiftn.com/obesity/Full-Map.html   Phillip B. Hawley   -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   I love this conversation! Another thought: Patient navigators who have successes and challenges working towards healthy weight behaviors can do amazing things to help engage and establish relationships between experts and learners to promote DPP. They can be the “front lines” to meet and greet people looking for options, conversations, education and alternative treatments for their diabetes or other chronic conditions that are exacerbated by food insecurity or knowledge gaps. Learn to use the resources we’ve got –(Patients!) As one of my fellow patient co-investigators says, “food is medicine!” Everyone could use more information about this topic. Public school collaborations with integrated primary care could become a routine system for public health awareness and prevention. Some examples of ingenuity: • Our elementary school here in little ole Huntington Vt is a gem of nutritional learning from preschool to 4th grade due in large part to one amazing cook (whose father is a pediatrician). She goes above and beyond her pay grade to promote healthy eating behaviors. Every class is visited once a week to learn about nutrition and food. • Practices in Boise Idaho are beginning to use screening tools for food insecurity at the primary care level and community health workers then connect needy patients with local resources. (CSAs, cooking classes, etc) • Here in Burlington Vt. Where our communities are rich in immigrant populations, the schools and parents work with established leaders to engage new community members through healthy community meals, cooking classes and farm to table programs. Perhaps if PCPs and BHPs got involved at that level, their faces and their expertise could become better known and trusted. Testimonials from patients can do so much to promote healthy behaviors and connect others to resources that are available.   Jen Lavoie   -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   I have thoroughly enjoyed following this conversation and as a registered dietitian I feel compelled to chime in. Medical facilities have been widely cited as a place where weight stigma occurs - And my own profession has been widely criticized as contributing to this as well. I'd like to emphasize Dan's comments regarding the limited utility of discussing weight, nutrition, and exercise with patients. Simply educating patients on how to eat healthy and exercise is not as effective as we'd like them to be. While this thread is discussing how we could be inadvertently fat shaming, it's helpful to think how we got here in the first place. People tend to think fat shaming is going to work because the most common example cited is the stigma associated with smoking. So they think, if shaming smokers into quitting worked, can't we shame obese people into losing weight? And no, we can't. While smoking is a behavior, weight is a physical characteristic largely determined by genetics - in fact, it's as heritable as height. An interesting article in J Exp Soc Psych by Major et al (2014) randomly assigned individuals to read an article on "lose weight or lose your job" or "quit smoking and lose your job." Afterwards, they were left alone in a room with snacks and were asked questions pertaining to dietary control. They found that shaming a person who perceives themselves as being overweight/obese leads to increased caloric consumption and shaming a person who perceives themselves as being overweight/obese inhibits their ability to control dieting behaviors. To make it all worse, weight stigma begets weight gain and continued weight gain begets stigmatization. Weight stigma is a psychological stressor that elicits a negative emotional experience. Stress-related weight stigmatization has an impact on eating behaviors where individuals tend to run to comfort foods and consume more calories than when not experiencing weight stigmatizing stress. Additionally, their body has a physiological response by increasing levels of cortisol in the body, where cortisol promotes fat storage and continued eating. And there's an emotional mechanism of shame that comes with episodes of overeating and failed weight loss attempts, which induces cortisol secretions, further promoting fat storage and continued eating. This is a positive feedback loop where weight gain due to feeling weight stigmatized, leads to more weight gain. Exiting the cycle is not easy and may not be possible for most. For starters, they could lose weight, but based on an article by Tomiyama in Appetite (2014), dieting is ineffective when people feel weight stigmatized. They could also try changing how they feel about their bodies. But, changing someone's body image in a society where thin bodies for women and muscular bodies for men are idolized, that's not likely. Finally, they could hit a physiological upper limit to their weight given genetic factors. I'm glad this conversation has been started and multiple people are considering the deleterious effects of discussing weight with their patients who are overweight/obese.   Stephanie Brennhofer   -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   Fantastic and very important conversation! Once upon a time I completed a postdoc and 3 subsequent years working in an eating disorder treatment facility. There I was exposed to paper after paper that demonstrated the failure of weight management strategies/diets to lead to long term change in body weight. At the same time, I learned about the negative health consequences of yo-yo dieting including increased risk of metabolic syndrome when compared with obese patients who had not lost and gained weight repeatedly. As many have said, telling people to lose weight doesn't work. In our culture it makes them feel shamed and inadequate. As Stephanie points out so well, feeling shamed and inadequate creates negative health consequences. Ergo, telling people to lose weight is likely to create greater negative health consequences in the long run than the patient walked in with. Hippocratic oath, anyone? I frequently talk with patients who voice displeasure about their weight about the harmful effects of self-criticism AND the biological consequences of restrictive eating and inevitable weight regain. Most patient who desire to lose weight can identify with this pattern. This opens room for motivational interviewing - looking for what people REALLY want including feeling happier and more joyful with themselves. This precludes self-critical judgment about weight and makes room for engaging in activity for the sake of enjoyment and eating for wellness, not numbing. I DO agree that BHCs who work to help patients learn how to restrict calories, monitor their macronutrients and engage in exercise for the sake of exercise (not well-being) are behaving in accordance with sizeist dictates, no less harmful than unknowingly complying with racist or sexist cultural norms. Harming others in service of their "best interest" is not health-promoting.   Emily Mohr   -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   Have you looked at a book called The Pleasure Trap by lisle and goldhamer? It is a very helpful guide for people to understand that the vast majority of weight problems are the result of the modern Western diet and what to do about it. Most important, it helps remove the feelings of guilt and inadequacy that many people experience when struggling with their weight.   Rick W. Seidel
by L. Edwards
Wednesday, July 18, 2018
Research Comparing Financial and Clinical Merits 0 J. McLean Hi all,   I have a practical dilemma some of you might find interesting.   My team and I are attempting to demonstrate the value of locating one of our behavioral health consultants on site at a for-profit primary care practice. The BHC will be in direct communication w MDs, have access to shared medical record, and be available to receive warm hand-offs. Since our BHC will NOT be employed or subsidized by the medical organization & will be expected to pay rent, they will need dedicated space (small office) for follow-up appointments with patients who can then be billed in order to financially support the BHC’s position. While we recognize this model represents less than ideal form of integrated care, it is the best we can hope for with this medical practice at current time (they have no interest in hiring a BHC themselves).   The medical practice’s response so far can be summarized by the following:   “Why should we dedicate space for your BHC when we can hire another PCP and fit them in the available space instead? The profit we will make out of the PCP will be much larger than the rent we charge your BHC. Your BHC can rent space across the street and we can send our patients there.”   In preparation for future meetings with the medical practice am looking for research demonstrating significant difference in terms of   A)     Cost of service / financial burden B)      Clinical outcomes when comparing:    - Integrated vs Traditional care    - Shared office space vs separate office space    - Shared medical record vs traditional information exchange between    medicine and psychology.   Any additional thoughts, suggestions and ideas would be very useful.   Thank you for your help!    Boris K. Todorov, Ph.D.   “Why should we dedicate space for your BHC when we can hire another PCP and fit them in the available space instead? The profit we will make out of the PCP will be much larger than the rent we charge your BHC. Your BHC can rent space across the street and we can send our patients there.” My immediate repose to this would be something like: You aren’t doing integrated care if you have separate budgets.  Integration requires risk and profit sharing.  It sounds like they want a place to refer BH patients. It doesn’t sound like they want integrated primary care. If this practice is in a fee for service environment and if the leaders of  this practice have established the above quote as the rules of the game,  then I would not agree to play the game.  I don’t think you can win.  They will almost always make more profit per square foot with a physician than a PCP.  Maybe this would be different if you were in a market where primary care practices were competing for patients, but I don’t think that is the case in most markets. If you still want to try to make this happen I would want to hear about some of their other priorities.  Its ok if profit is their number 1 priority. They don’t need to apologize for that.  But what comes after profit?  Potential answers - 1) healthier patients 2) satisfied patients 3) happier physicians (less burnout, less turnover, less on boarding of  replacements, and therefore maybe more profit) 4) prepared team to respond  if payment environment shifts to one more favorable to BH   All of these items have high face validity.  Unfortunately the quality of the evidence for items 2 and 3 is low, or at least I can’t recall good sources.  Recent reviews regarding item #1 for PCBH model are available and they may find these persuasive.  Item #4 is speculative and involves more risk than it sounds like this organization is willing to agree to.  - Dan   Daniel Mullin, PsyD, MPH Dan, Thank you for your thoughtful and complete response. I wholehearted agree with everything you stated and believe it is fear of risk and fear of change that is blocking Integrated Care. It is definitely what many patients and families want. Hope we can meet in person someday.   With warm regards, Jeanine   Jeanine M. Swenson, MD, FAAP, FACC, LMFT   Well said, Dan!  I do think that some of the insurance companies that are covering Medicaid (e.g. the Blues, Aetna) are interested in integrated care because of cost savings.  Coordinating with the care managers who are part of the insurance company is another avenue for exploring collaboration and helping to "keep" patients out of the ED- the ultimate goal for payers. It is an ever evolving work in progress. Mary Talen Dan, I appreciated your response.  The language (i.e., yours vs mine) is very concerning and reveals that the inclusion of a BHC is not a shared value.  "Our" team is missing. Your response did raise one concern for me.  You said, "Its ok if profit is their number 1 priority.  They don’t need to apologize for that.  But  what comes after profit?"  Is it truly possible for profit to be the number one priority... above patient outcomes?  ...above public health and well-being? ...above provider well-being?  If profit is the predominant priority, then there is the motivation and rationalization for cutting corners and doing  as little as possible to make as much as possible.  In a fee-for-service world, this can lead to the ordering of tests and services that are profitable but not necessary nor appropriate. If a patient-centered practice is targeting the multiple dimensions of the Quad Aim, it seems that profit would be the bi-product and natural result of satisfied patients, improving population health, and healthy providers.   CR Macchi, PhD, LMFT Thanks CR.  I agree. If I responded to them by saying “It is ok if your #1 motive is profit”  that response would be my strategic response approach for the purposes of trying to start a conversation and move them towards an attitude of “Our” like the one you describe.  It wouldn’t be an authentic response on my part.  My authentic response would suggest that people who are motivated solely by profit should find a different industry, we are trying to improve lives. Daniel Mullin I fully agree with Dan’s comments. We have a legal brief here at APA that would indicate charging rent to a consulting behavioral health professional potentially violates Stark rules law. Essentially a mental health professional is paying rent to someone who is then sending them referrals and it could be considered a kickback.  The Aetna site That I mentioned last week includes a number of business considerations when providing more collaborative forms of care William Tynan   As for the question originally posed, I'd suggest getting whatever you can. If the practice is reasonable size there may well be an office available at any given time due to illness, vacations, etc.  so you could propose joining the practice without an office. That may sound ridiculous but Integrated care rarely moves from zero to 100% in one step.  So getting a foot in the door may be the best way to start. It's very common that once the PCPs experience the miracle, they push management to do more.   Epiphanies and religious conversions usually follow experience, not published evidence. In addition to the embedded clinician, you could offer Collaborative Care support which requires only a telephone. Andrew Pomerantz Hello everyone, Great discussion and figuring out shared language. I would like to suggest two other factors they I believe are at work in the health care delivery systems. 1. We tend to overlook or look past conflict ( where one person wants one thing and the other person wants something different) in our world maybe because conflict is energy-consuming and part of the landscape. Example - the economy involves individuals who may want to hold onto their money, and corporations and companies who want them to spend it. We sometimes blame the individual when things go wrong, but don’t see or look for issues at the systemic level. 2 Second is “two choice dilemmas ( from the work of Bowen, Schnarch and Morehouse) - we want to choices, but we only get one. Example - we all want better healthcare and we all want to save money. We want two choices, but we have to choose one. Two choice dilemmas also take a lot of energy but can lead to many levels of change when worked through. Thank you for reading my long message, and considering my thoughts and ideas. Hope this isn’t redundant, I am new to the group.   Jeanine Swenson I appreciate what everyone has said in response to this problem. One additional thought is that those who oppose IBH sometimes believe that our healthcare system's status quo is okay. It isn't.   Kent Corso   As a patient partner on a research intervention to study IBHPC, I would like to add one more thought to this great conversation: If this clinic had a patient advisory group my guess is that if the topic of Behavioral  health option were to be brought up,  it would be a no brainer decision.  Patients have great power to disrupt the status quo and support transformation.   And once patients understand what IBH can offer, in my experience, they see it as a no brainer with caveats that it be high quality and evidence based and fully supported by a strong patient centered team (with the patient as the quarterback of that team).    Patients want medical providers who will address their whole body system as well as their family system in a culturally humble, aware and sensitive way and include behavioral, social, emotional, mental, financial and physical opportunities for increased wellness. It is my understanding that there are always infinite number of possibilities as long as healthcare workers are willing to work together with their patients and commit, persevere and persist on behalf of the patients who need health guidance, education, information and support.  We can only do this together!   Jen Lavoie   Boris, We have initiated Integrated BH into many private practice primary care clinics and can sympathize with you.  We have been successful in overcoming many of the barriers you are facing and can provide some suggestions: 1.  It is much easier to deal with a private practice that is physician run and not affiliated with a hospital or health system and their related bureaucracies.  Layers of permission and approval can be a nightmare! 2.  Whenever possible, find a "physician champion" on the staff who is favorable towards having on-site BH services.  They can "run interference" with the clinic office managers who typically are very bottom line and are only concerned with revenue. 3.  When requesting space, do not ask for separate offices away from the  patient exam rooms.  In most of our 42 clinics, patients and families are seen right in the exam rooms.  This facilitates the warm hand-off process as you are right in the same area with the docs. 4.   Try to negotiate days in the clinic when each of the docs have a day off.  Then you can use their patient rooms without any additional space requirement from the practice. 5.   In negotiating for space,  keep I mind that we only require an exam room or 2.  Most are only 80-100 square feet and you may not be using them every day.  At say $25 sq ft., 200 sq ft would lease out at $5000 or so or about $425/moth. 6.  Try to make minimize imposition on the front office and nursing staff.  WE do our own scheduling, follow-up calls, EHR entry, billings, etc.  The burden on the staff equates to getting patient information and insurance on the initial session and checking patients in for sessions.  (As time goes by and your value increases, you can transfer costs over to the practice as they already have staff performing those tasks.)  If the practice is insistent on supporting staff functions, try to negotiate for them to pay for services YOU provide.  For instance, in one clinic we provided a monthly training session for staff and docs that offset costs for rent.  7.  Try to use and present data on the cost-savings for the practices when a BH provider is present.  WE have published 2 studies demonstrating that physicians spend 2X as much time when dealing with behavioral cases as they do with acute care or wellness visits.  A second study showed that Docs were collecting about $17 per minute with physical health visits and only about $6 per minute when there was a behavioral referral.  Additionally, a colleague at U of Michigan has demonstrated that physician RVUs go up when BH is part of the practice (more patient time). 8.  Progressive Physicians are most grateful to have services in their clinics.  Data suggest that only 25% to 40% of patients referred to outside BH services actually follow through with making and getting to an initial appointment. 9.  Try to keep some data on numbers of patients referred, billing and collection totals, types of referrals, number you have to refer out for more intensive, specialized services.  We have found the we can address about 90% of BH problems presenting in primary care. 10.  Expect some lean times during the initial 3 to 6 months that you implement an IBH clinic into primary care.  You will need to educate docs on the types of referrals you can handle (i.e., Not just the SMI or suicidal patients) 11.  Make sure to establish positive relationships with staff as well as the docs.  Office staff can totally undermine any attempts to "change" practice parameters.  Also, expect that a nurse or staffer will refer his/her child/relative.  This case is crucial in establishing your reputation in the clinic.  You may run into some dual relationship issues here. 12.  Despite all the hassle, within 6 months, you will find that the docs "can't do without your BH expertise."  A successful IBH clinic can be immensely reinforcing for a BH clinician as he/she is greatly appreciated and becomes an integral part of the practice.  (Many of our clinics then go ahead and try to hire the provider which means you are REALLY "in" the practice and part of the "Team." Hope these suggestions are helpful! Joe Evans   Joseph H. Evans, PhD Hello Joe,   I had a question about number 5 below. How do you integrate the involvement of family in your encounter with patients if the room is only for two people? I often involve family members in my work with patients and it sounds like this might be difficult with the room size you are describing. Thanks, Josh Joshua Bradley, Psy.D. So glad to see so many people bring up solutions that are grounded in family systems thinking. This is a big gaping hole that providers, including behavioral health, don’t know how to fill and that is often a selling point. They know and understand that the people outside the exam room have tremendous influence; however, it is hard to engage them using traditional healthcare delivery methods (e.g., small exam rooms, office hours during the day only, training in working with the patient but not the family).  We completely overlook collectivist culture methods of approaching a loved one’s healthcare decisions. We used to do this well...remember family doctor home visits?   I train family therapists to apply evidence based relational approaches that have helped healthcare teams to see the benefits on their outcomes and eventual bottom lines. We need to broaden our lens beyond a narrowly focused triadic relationship...patient, PCP, and behavioral health provider. It is patient, healthcare system, and family system. Yes, it is harder to study, tracking the outcomes is more complex, and re-training in relational approaches is necessary but the work is meaningful and important. It has been a great foot in the door for us. Jennifer Hodgson Joe I was an intern at MMI last year in one of the rural clinics. It’s nice to see how much information my old program can share with others! I was wondering about point 9. Do you notice a trend for specific referrals tending to mostly get sent to speciality, e.g., ptsd? Also, your data reflects the pediatric population, correct? I’m working in an extremely rural area this year and serving adults and children, and I notice that the overall lack of access to BH means that most people being identified for BH have rather intensive and longer treatment needs than typical in integrated. My program is new and there is no outpatient/ specialty locally to refer to. Maybe this happened over in the West NE integrated clinics? Do you have resources on how you handled it? Thanks, Leslie Blevins Thank you all so much for the thoughtful comments! I think I have taken something out of every single reply and will incorporate it in future conversations. I would love to have a formal or informal in-person follow up with some or all of you in Rochester this fall. I just don't see this topic going away barring fundamental changes in the medical system.  Joe's suggestions and Andrew's comment really hit close to home for me, since they are very consistent with my own impression of how the system is *supposed to work *-i.e. we get a foot in the door, demonstrate value, get buy-in, expand coverage, etc.  In our situation, we already have a presence within several primary care offices of this particular medical system (contract is year/multi-year long, rent is set at market value and not contingent on referrals, and there is no referral obligation in either direction - William, I would love additional feedback on how to further ensure we remain Stark law compliant).    All of our offices are converted examination rooms, and our footprint in the clinic is low-to-none. We do end up meeting the needs of 90% or more of the patients that are referred to us, and refer very few out to specialty care. We have developed multiple short-term treatment maps for our BHCs that allow them to manage most of their patients needs within 4-8 appointments + periodic behavioral health wellness check-ins. Being on-site allows for immediate communication & collaborative treatment planning with the MDs, who feel more confident prescribing psychiatric meds, and anecdotally has resulted in fewer psychiatry referrals.   The experience of MDs & patients has been overwhelmingly and consistently positive. The business management side remains unconvinced, often hostile. Their idea of  "hiring a provider" is to replace BHCs with a triage social worker who can facilitate transfer to specialized mental health services. We have been reluctant to do/say anything that may pit the two groups against one another - our sense is that within a large medical system, any number of MD champions we may have will quickly yield to organizational pressure to stand in line.   From our experience, in the world of larger non-profit and for-profit health organizations in competitive markets (i.e. larger urban areas), the inclusion of a BHC is certainly not a shared value. Being part of CFHA has allowed me to remain optimistic about the future of healthcare in this country. Thank you all for keeping it going!   Boris   I am new to this board and CFHA and am very happy to have found you.  I'm attaching a study that we just got published regarding our initial pilot here in KC.  My organization is an MBHO owned by 7 BCBS plans, and a very large EAP.  Together, these 2 products provide services to over 16 million people.   I am fortunate to have worked with a visionary family physician in the late-80s.  He had a clear sense of what wasn't working for his patients, and we fumbled our way to finding our version of the warm handoff and curbside consultation.  For the last several decades I've attempted to integrate, however, the large, corporate MBHOs were not flexible enough to accommodate much more than "arranged marriages" between preferred providers and HV PCPs.   For the last 8 years, I have worked as COO of New Directions - the aforementioned MBHO.  Our ownership and board have supported funding for this initial pilot and four, soon to be seven, PCBH programs.  We have stood on the shoulders of incredible people like Ben Miller (who has worked with us for over 5 years), Bill O'Donohue, Ron O'Donnell (both who came to KC and helped us immeasurably) and Patti Robinson.   Like all of you, we are looking for sustainability.  This case study measured BH screeners, biomarkers and financial impact (the latter done by Steve Melek of Milliman  I am new to this board and CFHA and am very happy to have found you.  I'm attaching a study that we just got published regarding our initial pilot here in KC.  My organization is an MBHO owned by 7 BCBS plans, and a very large EAP.  Together, these 2 products provide services to over 16 million people.   I am fortunate to have worked with a visionary family physician in the late-80s.  He had a clear sense of what wasn't working for his patients, and we fumbled our way to finding our version of the warm handoff and curbside consultation.  For the last several decades I've attempted to integrate, however, the large, corporate MBHOs were not flexible enough to accommodate much more than "arranged marriages" between preferred providers and HV PCPs.   For the last 8 years, I have worked as COO of New Directions - the aforementioned MBHO.  Our ownership and board have supported funding for this initial pilot and four, soon to be seven, PCBH programs.  We have stood on the shoulders of incredible people like Ben Miller (who has worked with us for over 5 years), Bill O'Donohue, Ron O'Donnell (both who came to KC and helped us immeasurably) and Patti Robinson.   Like all of you, we are looking for sustainability.  This case study measured BH screeners, biomarkers and financial impact (the latter done by Milliman  http://us.milliman.com .   I know that this group will be incredibly helpful to me and our program.  I need to do some background work to understand what you folks have already covered, but did want to send this along for the questions raised in this string.  Hoping you find it interesting. Peggy DeCarlis Hello Leslie,   We have a submission that has been accepted for publication in Families, Systems, and Health that is focused on a community approach to rural integrated primary care. Among other topics it speaks to the issues you highlighted.  I am unsure of when it will be available for online first access or in print but I included the citation below so you can look for it if it would be helpful to you.   Selby-Nelson, E. M., Bradley, J.M., Schiefer, R. A., & Hoover-Thompson, A. (In press). Primary care integration in rural areas: A community focused  approach. Families, Systems, and Health.   I would be happy to talk more with you if that would be helpful.   Josh Bradley        
by J. McLean
Friday, June 22, 2018
Ratio of BHC's to Primary Care Providers 1 J. McLean Hi - Diane Dougherty here. I posted the original question and have received excellent advice from our CFHA community . I presented my recommendations to our planning committee. It sounds like rhey really want to plan for future practice - so space ideas and ratios were hot topics. Thank you to CFHA list serve - outstanding.
by D. Dougherty
Friday, May 25, 2018
Resident Electives 0 J. McLean Hello, This is an inquiry directed to colleagues in residency settings.... We have a PGY3 resident that is interested in doing a two week elective with my behavioral health faculty colleague and myself.  He wants to further develop his primary care counseling skills and management of patients with behavioral health issues. Do any of you have residents work with you on encounters and patient visits?I am working on the structural pieces and am curious if any of you have residents as cotherapists? I want him to have a really good, practical experience and know that many of you may have done similar things. Any guidance appreciated. Best, Karla Hemesath, PhD, LMFT University of Iowa Carver College of Medicine Hey Karla! I work in a pediatric residency training clinic and work closely with the medical residents.  Being in the room with the resident is a really meaningful training experience and I have found it to be more effective than simply co-precepting with the medical attending.  Previously, we have just identified cases when they come up.  We are working to formalize the experience in our clinic during the residents "block month" where they are in clinic every day for a full month. Together, we set specific goals and target skills to focus on and do a mixture of co-precepting, education (readings, discussions), observations, and co-leading appointments.  We have found that setting realistic, pragmatic goals in the beginning of the experience is particularly important they often come into the experience with really eager expectations and sometimes an implicit assumption that they will master a whole field by seeing ONE, doing ONE, and teaching ONE.  We tend to lean heavier on cross cutting skills (e.g., MI, behavioral change principles, solution focused approaches) with the understanding that it's easier for them to find out WHAT to tell patient to do, much harder to coach them on HOW to do it. Happy to discuss more details if you would like. Cody Cody Hostutler, Ph.D. Pediatric Psychology  & Primary Care Red/Yellow Nationwide Children's Hospital Great question! Our family medicine residents have a two week behavioral medicine rotation with me their intern year. I created a "See One, Do One" checklist of some of the most common behavioral health concerns seen in primary care (including behavioral management of chronic conditions) where the intern is able to check off when they have seen and done various components of a BHC visit (brief eval, intervention) for different presenting concerns. The resident usually does straight shadowing the first day of the rotation. After that, they take a more active role in the visit. After receiving a handoff from another provider I turn to the resident and ask a variety of questions ("Based on the info we know, what are your differentials? What questions do you  need to ask to clarify the problem/diagnosis? What are some brief interventions you could use if that is the problem/diagnosis?). Following the visit we can review patient's readiness for change and how the resident's intervention aligned/didn't align with the patient's readiness for change and level of engagement. I'm using a couple of different evaluation measures to guide feedback to the resident as well. During their rotation they also visit a 12 step meeting and create a patient ed handout on a topic of their choice (they must make the handout interactive using their knowledge of motivational interviewing/behavior change). Hope this helps!   Danielle   Hey Karla, We (Central Washington Family Medicine) have four, one month rotations throughout the three years w/ Behavioral Medicine components.  During these rotations, we have a specific experiences: 1. BHCs observe residents during resident medical visits and provide feedback on patient centered communication 2. FM residents observe BHCs in their clinics.  This experience is progressive throughout the three years in that interns' expectation is to complete the Contextual Interview with new BHC appointments. R2 and R3 build on that experience and actually start providing psychoeducation and interventions with BHC.  It not uncommon for an R-3 resident to complete an entire BHC visit with the BHC obviously in the room. 3. Role-plays, which allows residents to practice the Contextual Interview, interventions, psycho-education and discuss philosophical concepts (e.g., what causes people to change, ACEs, etc.). 4. Coaching.  Residents are chosen weekly to be "coached" by one of our BHCs. This is different from the normal shadowing that they receive in that the BHC primes the resident to look at their schedule and identify two patients they would like to practice doing a BH intervention/technique. The BHC then shadows them doing so and provides prompt feedback. Let me know if you would want any specific information (e.g., curriculum, reading materials, evaluation materials, etc.)! David Bauman
by J. McLean
Monday, December 11, 2017
Guidelines for BH Involvement in Chronic Pain 0 J. McLean Hey all,  I was hoping if you all could pass along any guidelines/best practices for BHCs to be involved in chronic pain workflows/policies in primary care, particularly CHCs. Specifically, we are looking for research/recommendations on how *often* BHCs should meet with individuals who are receiving long-term opioids. Appreciate any help! -- David Bauman, PsyD Behavioral Health Education Director   Hey David, In the Department of Defense, anyone on a pain agreement or sole provider program was required to see the BHC at least monthly. In some clinics we had the BHC appt before every medication refill so that meds could be adjusted regularly and so that the patients did not develop an expectation that meds alone will ever be the treatment plan. If the patients stopped coming to PCBH appointments, their medications we're not refilled...until they followed up with the BHC. All of these policies were included in the pain agreement and the patient signed it. We also had case management on board and family members involved when feasible. Like most sole provider programs we also had agreements (MOAs/MOUs) with local pharmacies that they would not refill these patients' pain medications at all or at least without calling us first to verify. I hope this helps. Best, Kent On Thu, Nov 16, 2017 at 11:42 AM, Greg Reicks wrote: This is a great topic and I would like to explore further.  We are trying to figure out how to use our BHCs in the most effective way with our chronic pain patients on opioids.  I had thought about Kent's program of requiring these patients to see BHC in order to get her medications refilled, but I'm wondering if that is the wrong message.  It seems that making this Requirement might lead to resentment which could  make the BHC/chronic pain patient interaction less effective.  I have heard of other clinics doing the same thing.  What kind of outcomes are they getting?  Reduction in opioids? Reduction in pain scores?  Increased functional scores?  Reduced disability? Our experience with many of these patients is that they are "stuck" on what has been called "pill Island" and cannot seem to - or are unwilling to- get on the bridge to get off the Island.  Many of these folks are not addicted per DSM criteria but certainly physically and psychologically dependent on these meds. I agree, Greg, and that is the question that I am having, as well.  In that, how do we use BHCs most effectively?  Truthfully, if we required all of our long-term chronic opioid patients to see a BHC each month, the BHCs would only see chronic pain patients. Furthermore, if we make universal guidelines, not only is there potential for the patient to become resentful but also the medical providers who may feel that they are losing their ability to care for the patient. I also struggle with the once per month idea due to it being fixed from the beginning. What if the patient is actually doing a lot better after a few visits with the BHC/PCP but is still on a small dose of pain medication? Does that patient still need to see the BHC every month? Lastly, and this goes to Greg's point, what is the outcome of having it be every month? Further, is there research/guidelines supporting this? I have reviewed some of the research and it seems that it is suggested that BH be involved but does not quantify how often that should take place... Really appreciate everyone who has commented and looking forward to other's thoughts! -David Greg and David, I appreciate your pause and I agree with you wholeheartedly. Forcing treatment is not helpful or sustainable. And, the military context/culture in which these programs exist may paint a certain picture that heightens your concern. Even if we put aside the fact that addiction and "pseudo addiction" play a substantial role here... Something I did not give ample attention to in my initial response is the idea that the programs must be communicated, marketed and run in a highly specific way. It is the key to the structure feeling forced versus supported. My concern, which I'm sure is shared by all of you, is that the message we send to patients by focusing primarily on providing medications is: "Medications are the solution to your pain (and the goal of pain management is to decrease pain)." Whereas, the goal of evidence-based pain management is to improve functioning while (hopefully) minimizing pain. The concept of improving functioning and quality of life needs to be loud and out front in these programs that require behavioral health consultation. Program design is one thing; implementation is a whole different animal. I am sure you have seen some of the same pain management practice trends I have seen in the private sector. In some cases the PCP literally refuses to see any patients who need or request opioids. Tl If the medical community (we) taught patients to use the opioids when we prescribed them, in my opinion, it's on us to re-educate them about what to do as we nation-wide tighten up and decrease opioid use. PCPs have no time for that facilitation and education. That's where we come in - although nurses have also been very helpful for this. Great conversation - let's keep the ideas flowing! Kent I provide BH services in a spinal and musculoskeletal institute, and all of  our patients are dealing with chronic pain. We using a screening tool at  intake to determine BH service necessity. If there is a positive screen, I  provide a Health and Behavior Assessment, which is a basic in-room check in. I administer the PHQ-9 and/or the GAD-7. We use those results to determine what services we offer. Some patients need therapy services, others care management, and others are receiving MH services from outside providers. I  also use a registry to track results and reassess as needed. It was important to me when creating this program that we provide patient centered care and not required care. There’s plenty of billing to be done just with patients who WANT services. Lindsay Scarpate, LMFT   Hello - The Substance Use Treatment Taskforce offered national practice guidelines. They were cited in a recent Open Minds post. Consistent with what I’ve been reading in this valuable thread, Recommendation #2 is for personalized  diagnosis, assessment and care planning.  I was thinking of offering a chronic pain management class for our long-term opioid patients who have refused evidence-based brief interventions. But, based on these guidelines I think I’ll stay away from mandates, at least until we have more research. I’d be happier if our clinic could get away from pain contracts altogether. Patty Rebeck, Ph.D., Licensed Clinical Psychologist Hello All, I appreciate Ms Scarpate's approach.  A pain patient with an organ/structural abnormality linked to their pain and with no evidence of depression, anxiety, ptsd or the prolonged impact of adverse childhood experience will have quite different needs than a patient whose pain seems disproportionate to their organ/structure issue and who suffers from one or more psychosocial stressors or mental health conditions.  A growing number of studies is showing the best outcomes are achieved when these contributing factors are addressed. Dave Clarke
by J. McLean
Monday, November 27, 2017
BHP to Medical Provider Staffing Ratios 0 J. McLean On Sep 27, 2017, at 5:56 PM, Alex Schmidt wrote:   Hi CFHA colleagues, Does anyone know of a recent reference that describes recommended staffing ratios of behavioral health providers to medical providers in     Sent: Wednesday, September 27, 2017 10:36 PM To: cfha-ml@mail-list.com Subject: Re: [CFHA] BHP to Medical Provider Staffing Ratios   This message was sent by Patty Rebeck ps.rebeck@yahoo.com   Hello - The Missouri Department of Social Services (DSS) contracts with 35 major health service providers statewide to integrate behavioral health with primary care. This is for Missouri's Medicaid enrollees who have complex health conditions. DSS requires one full time behavioral health consultant for every 750 patients.   Patty Rebeck, Ph.D. Psychologist/BHC Swope Health Services Kansas City, Mo     On behalf of Heather Summers: Subject: [External]RE: [CFHA] BHP to Medical Provider Staffing Ratios   Can you provide a definition for Complex Health Conditions?   Heather Summers MS, RN Under Secretary of Operations, Hospital and Clinics The Chickasaw Nation     Hi Heather,   You can find a copy of the MO State Plan Amendment on the Medicaid.Gov website, on the Approved Health Home State Plan amendments. http://cirrus.mail-list.com/cfha/85937450.html   here's the pdf for the MO Primary Care Health Homes http://cirrus.mail-list.com/cfha/41540838.html     This document contains the list of chronic conditions that Missouri used to identify eligible participants for Health Home services.   I will be at the CFHA conference next month if anyone would like to discuss Missouri's integration efforts.   And to the original question in this thread, "Does anyone know of a recent reference that describes recommended staffing ratios of behavioral health providers to medical providers in a family practice? Or have a recommendation based upon their work in primary care?"   It usually depends on several factors. 1. the function/role of the embedded behavioral health provider, e.g. collocated Mental Health vs. PCBH 2. the patient volume of the family practice 3. type/needs of the patient population   We often talk in terms of a 3:1 FTE ratio (PCP to BHC) for the PCBH model, but again factors 2 & 3 might change that ratio. Basically the patient volume and population needs to support a BHC seeing 8-14 patients per day. I would also point you in the direction to the works of Robinson, Reiter, & Strosahl for more on BHC staffing. Staffing ratios can be found in the PCBH toolkit on the website  https://www.mtnviewconsulting.com/   Dawn Prentice, LCSW Director of Integrated Care and Health Psychology St. Louis Behavioral Medicine Institute  
by J. McLean
Tuesday, October 17, 2017
PCBH and CoCM 0 J. McLean CBH and CoCM   Greetings all,   Regarding the new Psychiatric Collaborative Care Management Codes (specifically G0502, G0503, G0504) that took effect Jan. 1 of this year, which involves collaboration with a psychiatric consultant and behavioral health professional billed under treatment by the physician or APP; has anyone interpreted this as the medical provider (physician or APP) must actually deliver these services verses the behavioral health care manager/primary care behavioral health consultant? We are thinking that the intent was never for the medical provider to provide  these services but to oversee them... Thoughts? Sonny Pickowitz, MSW, LCSW Behavioral Health Coordinator Primary Care Behavioral Health Services  Hello- I have attached some guidance that my Health System received on the topic. We are working to operationalize these new codes in our primary care network-  not there yet!  Our hospital compliance department has interpreted the primary care provider involvement similarly to the existing CCM codes.  The work is done by a primary care team under the supervision of the PCP in consultation with a psychiatrist but the monthly charge is entered by the PCP. Hope this is helpful.  Seems like many are scrambling to implement these new codes. Darren Darren S. Boice, LCSW Director Ambulatory Behavioral Health Mission Health System   We are also trying to get them in rolled out in our health center and have not worked out a streamlined process for doing so. I agree that any and all input from trailblazers would be helpful! Thank you for this guidance. Tina Tina Runyan, PhD, ABPP University of Massachusetts Medical School Professor Dept of Family Medicine and Community Health   On Behalf Of Jeff Reiter  To my friend Rodger - I see that we agree on the goal of integration. But I feel like I lose you when you write about how to accomplish that goal. I’m not sure that I see the difference b/w Kathol vs CoCM (not that that makes Kathol wrong - just seemingly incongruent with the stated goal). I’m sure you’ll educate me on that! But if our goal is to support primary care, then why would we focus only on helping with certain populations? PCPs need help with all sorts of issues and problems throughout the day; not all are related to complicated patients. If, for example, a PCP is running behind schedule and enlists my help with completing the anticipatory guidance during a well-child check - so that the PCP can make up some time and therefore devote more time to a subsequent patient with a lot of needs - then I am helping improve primary care, as i think of it. But in the Kathol model you propose, such actions would likely fall outside of the scope of the BH provider, no? As you know, there are many factors and many different types of patients and problems that interrupt workflows and inhibit primary care from reaching its potential. Why would (truncated)  I don’t think you’re missing anything, Jeff.  I appreciate all the points made in the various posts on this topic but am concerned with the “either this or that” model approach.  Integrated care is not about a single model applied across all sites and populations.  It’s about doing what’s needed WHEN and WHERE it’s needed The VA, which has been recognized by bipartisan and nonpartisan groups as a leader in population based integrated care began implementation of a blended model of integration over 10 years ago.  This includes the core elements of CoCM and co-located collaborative care (embedded clinicians). The underlying principle is to "first, be of use" to the patients and primary care teams.  Thus, the actual structure and process may vary by facility as well as within teams, based on needs of patient, team and provider.  CoCM may support PCP treatment or it may support treatment by the embedded MH professionals on the team.   The model has various tweaks depending on local needs, but the core elements are required to be present.   Our group has developed and is in the process of implementing brief (4-6 30 minute appointments) interventions for problem solving, chronic pain, PTSD and insomnia. All are based on the longer traditional CBT approaches and serve either to take care of the problem within primary care or prepare more complex patients for more specialized care.  Support for chronic illness management is a staple in most as well.  National program evaluation has demonstrated a significant increase in identification of individuals in need of attention as well as increased engagement in treatment, either within primary care or when referred into specialty care . The real testament to the cost effectiveness of this blended model is that, since expiration of the special funding provided in 2006/7, dozens of sites have chosen to shift resources from specialized mental health clinics to integrated care, without new funding.  While the program has focused on uncomplicated conditions in primary care (the vast majority), some sites are now adding capability to manage more complex conditions (including opiate use disorder) within primary care. Andrew S. Pomerantz, M.D.  Well, this string represents why CFHA is one of the major (THE major, IMO) thought leaders in Integration. Love the robust exchange in this string! Q to Shanda: When was this tool kit dated?  Comment: IMO, what you have here is a process map or workflow for psychiatric consultation, one essential element of an overall toolkit. The visual map is really, really good and a great example of how to make this come to life within a provider org. Thanks for sharing!  We also have lots of research (peer & non-peer review) to date , so might be time to refresh the document & add updated refs. Just a suggestion. Thanks for providing the link to the Soldberg, et al 2015 pub. A great read! I would echo Andrew's comments as well. Having funded sites to do Collab  Care and sites using a blended approach over the past ten years, I can tell you (& have the specific site examples to point to), an overwhelming number of grant funded sites who started doing a form of integration versus TAU (I'm old school) continued to sustain integration programmatically once grant funding termed. How'd they sustain it? Some provider orgs (FQs, CHCs, MH clinics) sustained this through other grant funding; most through reallocating operational & programmatic funding & resources to continue integration work versus revert back to TAU. Means redefining current provider roles, deleting current vacant positions; rewriting current & new job descriptions with integration functions (& realloc these vacant salary dollars to fund positions). They chose to preserve what they considered core integration components like (not all inclusive) routinized assessments, team-based care, stepped care, care manager functions, workflows, evaluating outcomes, prescriber time & make them a part of "business as usual."  And as we know, buy-in from CEO/Exec Team/Clinical leadership is deal maker or deal breaker to successfully launching or sustaining any integration effort.  Lastly, I have heard directly from CEOs (a direct quote) "Rick, my staff would have my head on a platter if I told them we were going to go back to the old way of delivering care...we will figure it out..." And many of them have. There you go!  Thanks to everyone who contributed their thoughts/perspectives to this conversation and links to docs/resources. Look forward to seeing everyone in Houston for CFHA 2017!   Most sincerely, Rick   Rick,  Excellent input on integration and the recognition of "no turning back". In AZ, we're evolving and exploring new territory for the children's system with emphasis on family health. CFHA as a think tank is a constant value added, thanks to all our colleagues and affinity partners.  Things are moving fast, have a great week everyone!  Socorro Dominguez  Chief Operating Officer   All: I will just add to this outstanding conversation that it feels like our collective experience has been that:  1. the status quo is unacceptable (treatment as usual, which is really little to no care usually),  2. that flexibility targeted to supporting medical teams within the primary care setting (and increasingly outside of primary care) is key to better access to care, and 3. that roles for professionals within integrated care have taken on better definition over time (BHC, consulting psychiatry, care managers, peer support, PCP roles etc).  I for one don't really understand the gripe about PCBH given that there is really nothing better that has come along as far as a role for a mental health professional in the integrated care setting. Are we really going to go back to specialty mental health therapists in the primary care setting? PCBH, simply put, is the optimal role for a highly trained mental health professional in a primary care setting. If someone can point out an alternative role for mental health providers, I would love to be educated. It is not however the answer to all the needs in the population (e.g.. Barry's comment on high utilizers). I also feel strongly that the CoCM and SBIRT approaches make significant contributions to the monitoring and optimization of care for specific conditions. If a system is looking to improve depression outcomes for mild to moderate depression, particularly in a geriatric population, there is nobetter way we have thus far. CoCM also posits the best use of a psychiatrist in a primary care setting, which is a major contribution. As Shanda mentioned, our team at Access infused our PCBH approach with the best most sustainable version of CoCM that fit our setting and resources. And beyond this we still have the perspectives that must infuse our approaches to the varied issues within healthcare like the role of familial networks and systemic concerns like social determinants of health. Taken from this perspective, we stop talking about models battling one another and instead realize that we have come a long way towards a system that works better for the stated aims of improving access to quality care. Each of us will find our way towards operating to the top of our licenses while solving each of the pieces to the healthcare puzzle. To my mind this conversation exemplifies the progress we have made.   Neftali
by J. McLean
Monday, October 16, 2017
Highly thought provoking piece on CBT 0 J. McLean From: "Morgan T. Sammons, PhD, ABPP"   Subject: [HSP-Community] Highly thought provoking piece on CBT Date: September 25, 2017 at 10:34:20 AM PDT Colleagues, the September 21 issue of the Journal of the American Medical Association contains a short but thought provoking  article on the research database for CBT.  It is free full text.  Click on the following link or cut and paste the link into your browser for access. MTS https://jamanetwork.com/journals/jama/article-abstract/2654783?utm_source=silverchair_information_systems&utm_medium=email&utm_campaign=olf&utm_term=mostread&utm_content=widget   -----Original Message----- From: cfha@mail-list.com [mailto:cfha@mail-list.com] On Behalf Of Jeff 2 Sent: Monday, September 25, 2017 11:47 PM To: cfha@mail-list.com Subject: [Non-DoD Source] [CFHA] Fwd: [HSP-Community] Highly thought provoking  piece on CBT ---- Excellent article for anyone who thinks we should only be providing those manual-based CBT protocols that we all learned to worship in grad school (until realizing few people actually complete them in the real world) - thanks to Morgan Sammons for passing along on a different listserv. On a related note, I’m compiling studies on the long-term (in)effectiveness  (+ 2 years) of CBT. If anyone has come across such studies, I’d appreciate  you forwarding along a copy. Many thanks!! Jeff Begin forwarded message: On Sep 26, 2017, at 8:01 AM, Hunter, Christopher L CAPT USPHS DHA HEALTH: I agree with Dr. Reiter that this is a thought provoking commentary. The authors make valid scientific points related to weaknesses of CBT research,  the same criticisms would also apply to other psychotherapy research. I hope none of us would ever blindly apply a manualized treatment, but would  consider the unique factors of a given patient and apply the evidence-based/informed  components of a treatment/approach and use patient response to guide continuation/alteration of that treatment.  Not unlike your primary care provider would do. In their conclusion the authors comment: “CBT is probably the best empirically studied type of psychotherapy because  for other forms of psychotherapy, such as interpersonal therapy or psychodynamic  therapy, fewer high-quality studies are likely to exist. However, this assumption needs to be tested empirically because the risk of bias tool used  by Cuijpers et al has not yet been systematically applied to all studies of other psychotherapies while also controlling for researcher allegiance.” So the authors are not saying CBT is “bad” they are saying you can’t claim it as a “Gold Standard” given the  scientific research weaknesses in the studies and a lack of direct comparison to other treatment strategies. I encourage you to read the commentary yourself at: <http://jamanetwork.com/journals/jama/fullarticle/2654783> v/r Chris Christopher L. Hunter, Ph.D., ABPP CAPT, United States Public Health Service On Sep 26, 2017, at 8:24 AM, Mullin, Daniel: This conversation highlights a variety of interesting research methods and implementation issues. It is much easier to study manualized interventions than it is to study highly flexible, patient centered approaches. From the perspective of a researcher, determining whether or not a clinician has followed a CBT intervention for insomnia is far easier than determining if a clinician has used Motivational Interviewing for medication adherence.  Verifying treatment  fidelity of patient centered counseling requires complex and expensive methods that are challenging to organize and limited by tight research budgets. This is one of many reasons we end up with more publications that report on interventions that are relatively directive/driven by protocol. Unfortunately, this issue of treatment fidelity in counseling interventions is largely ignored within the larger world of healthcare research.  I have seen many studies published in traditional medical journals that report on outcomes of patient centered approaches without any mention of how they were assured that the intervention being studied was delivered as described.  This isn’t surprising.  When these journals publish studies of a new cholesterol lowering drug they don’t report the results of tests that verified that each pill contained the appropriate quantity of the active ingredients.  The authors and editors accept that if the pill bottle was labeled drug x than it contains drug x.  Likewise they seem to accept as fact that if a counselor says they delivered counseling intervention y, they  actually delivered y.  Those of us who counsel patients in the real world, or supervise or train clinicians to provide these interventions know that this assumption is risky.  There is surprising variability in fidelity to evidence based counseling approaches in studies and in the real world.  I am suggesting this variability is far greater with patient centered interventions.  The downstream effect of all of this is that when studies are pulled into meta-analysis the patient centered interventions often include  studies of the true intervention and other studies that claim to be the intervention but probably aren’t.  This should lead us all to be cautious about interpreting this literature.  Don’t accept what the abstract says without flipping to the methods section and checking for assurances of fidelity. I would propose that we need to consider these same issues when we are wearing our administrator or implementation hats.  Take SBIRT for example.  It is much easier to train a large group of people to do the Screening part of SBIRT with fidelity than it is to train a large group of people to do the Brief Intervention part with fidelity.  The essential steps of what makes Screening work can be broken down into concrete steps that will vary minimally between patients.  This standardization of Screening is desirable.  In contrast the Brief Intervention part requires much more patient centered flexibility.  Responding empathically to a patient with a substance use disorder and evoking their interests in addressing the problem requires the clinician to have generalized knowledge and the ability to flexibly apply skills.  The variability in the Brief Intervention is a feature, not a bug. It is likely that this personalization of the Brief Intervention is an essential active ingredient in SBIRTs effectiveness.  However, as with the research issues described above, adequately training clinicians to provide this flexible patient centered counseling costs money and time.  More time and money than simply training them to run a checklist. Daniel Mullin, PsyD ---------- Forwarded message --------- From: John Gardin   Date: Sun, Oct 1, 2017 at 5:50 PM Subject: Re: [Non-DoD Source] [CFHA] Fwd: [HSP-Community] Highly thought provoking piece on CBT To: <cfha@mail-list.com> I agree with you, Daniel.  In addition I have found after years of research into therapeutic approached to addiction in NIDA's Clinical Trials Network, that fidelity is, quite frankly, overrated.  While all studies in the CTN were and are controlled for fidelity, the implementation of the results in clinical practice is poor due to fidelity issues.  Be that as it may, no matter the actual intervention, I find consistency much more valuable and useful -  for my clinicians, our patients, and for me as an administrator. John G. Gardin II, Ph.D. Chief of Behavioral Medicine | SouthRiver CHC & ADAPT
by J. McLean
Friday, October 13, 2017

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