Print Page | Your Cart | Sign In
Best Of: Curated Posts from our Email ListServ
Moderator(s):
|<
<
1 |
2
| 3
>
>|
Forum Actions

Topics   Replies Score Author Latest Post
Integrated Care promotional video 1 K. Hill https://www.youtube.com/watch?v=xMW1RdHG86E&t=27s
by P. Hawley
Thursday, October 31, 2019
Gender affirming care in Primary Care 1 J. Schoff Jen, I have not heard of a clinic using CoCM specifically having a protocol for gender transitioning evaluations, however I don't see much of a reason why you couldn't. The main issues is how strictly you adhere to the CoCM model. Since the model is focused on depression outcomes it does not attend to gender identity or other behavioral issues specifically, but you could create a sub-protocol for individuals struggling with depression AND gender identity issues that allows/encourages the team (particularly the team members performing the behavioral intervention component) to address the gender issues and possibly perform an evaluation for suitability for transitioning if so qualified. The issue is really one of how much you are willing to flex from the CoCM model. At the very least a reasonable goal would be that the team is educated on gender identity issues so that the care is informed by this training. Hope that helps some.
by N. Serrano
Thursday, October 3, 2019
Burnout 0 L. Edwards After 18+ years of practice in underserved areas. I’ve seen a number of staff and providers experience burnout ( exhaustion, cynicism and inefficacy). It is a difficult thing to witness, and I really never expected I would experience it myself. Seems like we are seeing more focus on it in the media.  So I’ve started looking into it more closely, and I ran across this article from the National Academy of Medicine which outlines some of the issues, so as to promote discussion.  <http://cirrus.mail-list.com/cfha/61373580.html>  I am wondering if people on this list serve are seeing similar trends in their health centers and if so, what you might have tried to remedy the situation?  Thank you for sharing the article. Papers in this field date back at least to 1982 (McCue, NEJM, 306:458-463) but I'm not aware much has been done in response. A neglected but important source of burnout is patients with psychophysiologic disorders (medically unexplained symptoms or MUS, chronic functional syndromes and chronic pain not linked to organ/structural problems).  McCue calls them "problem patients" and points out that the amount of time spent on them has increased dramatically.  Imagine being a professional in any field who had no formal training in how to solve 30-40% of the problems they faced every day.  That is the situation in most practices because of these patients. Fortunately, with the appropriate techniques, psychophysiologic disorder (PPD) patients can be diagnosed and treated as successfully as any other. One primary care office that learned and uses this approach found that it "put the joy back into my practice" for most of them.  (personal communication, Community Care, Albany NY). An introduction to these ideas will be presented during the MUS SIG webinar on Thursday, July 11.  Hi Everyone, I am glad to see others interested in the problem of physician burnout, as this is my research interest and part of what I intend to explore in my dissertation work.  I agree that little research has been done examining burnout with primary care physicians who work extensively with patients with behavioral health needs. As a social worker in such a practice, I advocate for the inclusion of social workers on integrated teams to provide support and trauma informed care education to physicians as a means of helping to mitigate burnout. I find that treating these patients as a team and working to make sure the physician feels supported can be a big help. I am always up for collaborating in this area for those that have an interest. I have attached the report from the Harvard T.H. Chan School of Public Health that came out this year about physician burnout for those of you that may have missed it. This is an important and salient topic in healthcare at large and those of us working in healthcare settings see elements of burnout all around us much of the time. I’m curious to hear as well from those of you who either are experiencing, have experienced or see others around you experiencing burnout, how CFHA could support you and your teams. We recently just finished up a Wellness workshop with our new resident and behavioral health intern cohort... we have a couple of themes: 1. You can't have wellness in a context that doesn't promote wellness – our goal in this discussion is that to 1) normalize burnout as a response to a demanding context. We start this conversation by asking residents/interns to come up with a list of what makes a human being healthy. We then discuss how realistic is it for us to engage in these activities when they are in inpatient service, or working all day clinic and have 20 charts to complete before going home. The goal isn't to paint the picture as "dead on arrival" but more so to encourage a sense of kindness and compassion that burning out is not necessarily a fault or lack of ability of the provider. It isn't because providers aren't being mindful or exercising or eating right enough (those can definitely contribute), but that the system/context they are in often promotes burnout. We then transition into the second part, which is a discussion of how we can set up the environment to promote wellness/resilient. We actually have the residents look around the clinic for ways of making it a more resilient producing space. This could be putting pictures up of family, having music playing, streamlining workflows, etc. 2. Connect to your why and express gratitude. This is something new we are doing this year but we are striving to allow the residents/interns to be more engaged with their "why" of family medicine/psychology, as well as their overall values. We do values clarification exercises, as well as reflective writing on a patient experience that reflects their value of family medicine. We also do a gratitude exercise that prompts the trainees to think of people that have supported them during difficult times. New this year is that we will actually have the residents write thank you cards expressing this gratitude and appreciation towards these individuals. To me and reading through the literature on this topic (definitely not an expert) but burnout out is largely due to having systems that do not promote wellness (research in this area shows the best way to prevent burnout is not through provider driven interventions, rather, interventions geared towards changing systems) and do not reinforce the "why" and "value" of being a primary care provider. And, as we end these wellness talks, even doing those two things won't cure/eradicate burnout entirely. I remember a presentation in where the speaker said, "disengaged people don't burnout, engaged people do." This is where the self-compassion and kindness comes in that we can be kind towards ourselves when burnout is present and, most likely, is appropriate given the context. Sorry for the tangent! Provider burnout has been a hot topic - in only one of our eight centers. I've been working on the "why" of this for a number of months and there seem to be several factors: 1) the perception that other centers have "less work" - thus leadership needs to tackle the perception of inequity 2) that there are "burnout leaders" in our one center - a couple of individuals who are convincing others that they are burned out (and it seems only a few are susceptible to these suggestions) 3) the fact that there are some real factors and providers do actually feel burned out - they work in our highest-volume center, the patient needs are great, they feel like they are spinning their wheels with some patients, etc. To tackle the third point, I have started a monthly lunchtime group where providers can talk about their struggles with a challenging patient population. Using a peer-support model, with my facilitation, providers have a safe space to talk about their own feelings of inadequacy, ineffectiveness, frustration, anger, sadness, etc.   We discuss strategies (mindfulness, exercise, time off, taking breaks, etc) for self care, and allow for honest communication about feeling around their work.   We have had some decent success with this, as those who choose to participate have reported feeling more supported, less alone, and having validation of these feelings. We do not allow for complaining about the work environment, but we do encourage open dialogue with administration about those issues.   Our medical director and CMO are very focused on addressing burnout, so we do have significant administrative support. I'm also trying to prevent burnout from discussing burnout! I think the biggest thing CFHA and all of us can do is destigmatize "burn out" and have frequent, honest conversations about the pressures of working in stressful environments that are often in high demand and provided limited resources. Too often "burn out" is associated with some type of character flaw and only further pressures providers to fix this problem on their own. Burn out is a product of vicarious trauma, work stress, and a variety of other factors (many of which we are not in control of). Supporting one another and being leaders in changing workplace policy, supporting trauma informed care approaches, and providing options for those who are dealing with functional impairment due to this are all great places to start.  I would also like to add that it is not just medical and BH providers who experience burn out--clinical staff, administrators, business staff, among others are also affected. To the degree that we can implement system-wide interventions, we will be better able to support each other and have a positive impact on patient care and staff engagement.  I like the idea of destigmatization as a step in the right direction. It is almost like we need a hashtag for it, like #metoo, but for providers and staff experiencing the burdens of caring for patients and for themselves and their teams. I certainly hope that this list serve is a safe space for people to share their experiences, especially when they find themselves in systems of care that are not as attentive and proactive as some of the great examples posted on this thread. This is so true and something we've been discussing here. Also, your fixing poverty with psychotherapy is right on! I have a line that I've been using for several years in burnout (and physician depression and suicide) talks and then last year in a grand rounds talk I gave on our roles outside of clinical (including advocacy, education of the general public, writing op eds, etc)...which is that I got really tired of treating poverty with prozac (I guess AND psychotherapy!), when I know that isn't going to do much (and my patients acknowledge that as we have these discussions openly and I tell them that I think their depression/anxiety/etc is maybe a small percentage biological...or a larger percentage biological that is induced by the psychosocial/spiritual). The advocacy talk I did was requested by a psychiatry resident working with me who heard me go on about how doing advocacy work and trying to fix these bigger issues more broadly was like burnout prevention for me, as it made me feel less helpless in the clinical  setting. I'm glad that Social Determinants of health are finally getting their due, but we have a long way to go to spend the amount of money necessary to address the gaps we have there...even if that means spending a bit less on health care. I so enjoy these threads. Stimulating! And burnout preventing, for me, to hear from such thoughtful and compassionate colleagues. Primary Care Progress (a non-profit stationed out of MA focused on revitalizing primary care) has a blog, and many of their articles are focused on provider burnout and the idea of moral injury.  One of the components spoken about a lot, which I can't recall being brought up (but I may have missed it!) is the administrative burden put on providers being one of the largest contributors to burn out. What I find most interesting, is that in most of the articles, the take away message is: form community.  Bring people together, allow them to talk about their struggles, hear one one another, feel one another, and they can heal. XXX referenced it in his email, just talking to one other helps. I've copied the link to primary care progress's "progress notes" page, which is their blog.  You'll find some great articles.  I've also pasted a link to one of my favorite articles called "Breaking Bread" which is all about the power of sitting down and having a meal together. Simple, but what a wonderful way to start, no? <https://catalyst.nejm.org/breaking-bread-burnout-community/> <https://www.primarycareprogress.org/progress-notes/> I got so excited by seeing XXX’s comments that are in line with many of our thinking that I failed to share some of what we’ve done. While we don’t have as robust of a wellness program as I’d like, we have had for a decade, since before this was being discussed so much, biweekly case consultation meetings at our clinics. I think we often find these as not just helpful for tips from respected colleagues for our patients we are  struggling to help, but even more so for the sense of shared mission and experience (and struggles). Collegial support and understanding cannot be overstated. We are also constantly looking at ways we can take some of the administrative burdens off of our clinicians and let them be present with patients and do what they were trained to do. It’s hard with EHRs, insurance company prior auths and other paperwork, and other administrative “interference”. I think so many of us are looking at how to bring humanism and compassion back  to the forefront, because that’s what brought many of us to our professions in the first place. Many of you have probably read much of the burnout literature. It is true that individual interventions do less than organizational and systemic ones, and even many of the individual interventions that have shown benefits are not long lasting BY THEMSELVES. Having said that, a number of things I’ve read have shown benefit case consultation, Balint groups, or other similar things in that category. We are all humans, interconnected and in this together, after all. This has been a lengthy and robust conversation as always so I have not felt the need to offer 'my two cents' regarding the evidence for specific interventions and so forth as I think many of the responses have included some really sound ideas. Nevertheless I wanted to acknowledge and validate the personal difficulty that Dan Mullin shared in his response yesterday.  For those that missed it, following his reliably astute assessment of the role that research must play in this, he shared some very personal struggles related to his effectiveness in meeting the very complex needs of his most vulnerable patients.  I have felt very similarly to him at times in the past, frustrated and hopeless that my sound training in evidence-based behavioral interventions was letting me down.  I heard you XXX.  I always read your contributions to this forum with interest, but I especially appreciated your openness and candor this time around. Hang in there, friend.  You're doing great work and you're not alone. I want each of you to know that your hard work, dedication, and commitment to helping others does make a difference, does change lives, in ways you may never know. If it were not for the kindness of people like you, I would not be here today. I was the person/patient/client who missed my appointments. I was the person/patient/client who did not adhere to prescribed medications. I was the person/patient/client who slept under the overpass in the downtown area. I was the person/patient/client who had multiple physical and behavioral health diagnosis. I was the person/patient/client who used mind-altering substances to numb my fear and pain. I was the person/patient client that no one believed would make it, but Because of my encounters with people who cared, and the kindness they showed me, I was able to regain my health, attend college, and successfully earn a fantastic education that I can now use to help others. You do not always get to see the successes of your work, but I want you to know you have changed lives, you have made a difference. Thank YOU! Also, the thread is spot on, it is the system in which we find ourselves that needs changing.   We have spent years and millions of dollars testing and developing interventions to understand how to change people, when our efforts are best spent creating interventions and strategies that strengthen the system, building a foundation that will withstand the changes in any political environment. Thanks all for sharing, and especially thank you Vickie! This is why we do what we do! This seems like a very valuable discussion for a conference presentation. And very parallel to the feelings of family docs who are burned out.  How to we keep this from being contagious? Such an important discussion. A year or so ago, we used the Maslach Burnout Inventory to assess our medical, dental, and behavioral health staff in a large FQHC in Memphis. I was actually shocked that although the providers all reported verbally being burned out (hence prompting the survey), they showed up as actually being better than average when compared to other healthcare providers in the very  large normative sample. What surprised me even more was that it was the administrative staff (billing, IT, etc.) that appeared the most burned out! I was left with so many questions following our internal research. I wondered about how our setting really compared to the norms. I cannot imagine there are many in that sample that have more complex (socially or medically) patients than those we see day in and out in inner city Memphis. But, yet... our team seems to have some resilience! So, what are those factors and how do we describe and cultivate them more broadly? Additionally, for those who are burned out, what are the factors that lead to that so we can address them? Number of patients seen per day? EHR specifics? Setting? Personal characteristics? More research is certainly needed. Have any of the rest of you used the MBI in your staff? If so, what did you  find? Hi all, Thank you for a robust and informative discussion. It is hard for me to look at the topic of burnout and not expand further on XXX's point about burnout being a systemic, rather than individual problem. Just like any other labor group in the US over the past 40 years, physicians (especially PCPs) have seen declining real wages, longer work hours, and reduced bargaining power. Add to that the staggering student debt that many medical professionals (mental health providers included!) have had to deal with. Add to that national health crises like the opioid epidemic, decreased access to health care, and declining life expectancy in many areas. Frankly, every day I go to work, I am surprised more of my colleagues are not overtly succumbing to burnout. It seems to me like the whole system is indeed on a downward spiral. Implementing variety of PCBH models in the clinic has provided some relief (albeit with more struggle and pushback than many of us had hoped for), but at the end of the day often feels like we are trying to reform a system that instead needs replacing. I think there are wonderful things that can be done by organizing, and by joining other groups or organizations that may be trying to address the systematic problems that lead to burnout at our clinics. Earlier this summer, AMA almost endorsed medicare for all. There may be other allies out there. I concur that in order for healthcare workplace conditions to improve healthcare labor will need to organize.  It is interesting to me that some healthcare professions like nursing have a strong history of organizing. In the age of corporate healthcare it seems likely other members of the team would benefit from organization. CFHA can support this organization by surveying the workforce, working conditions, salaries, and workforce needs.  Making this information available in a timely and transparent way can help increase bargaining power. I like your statement and your question. "... our team seems to have some resilience! So, what are those factors and how do we describe and cultivate them more broadly? How can we address the fourth aim in the Quadruple Aim?  Improving the work life of clinicians and staff.  *   Does working in interdisciplinary teams impact burnout?  *   Does working in interdisciplinary teams impact work-life quality (WLQ)?  *   Are their differences in perception between professionals?  *   How have technological advances impacted clinical and staff burden?  *   How have peer navigators impacted clinical and staff burden?  *   How do we measure clinician and staff well-being? A recent article discusses an interesting model Brigham, T., Barden, C., Dopp, A. L., Hengerer, A., Kaplan, J., Malone, B., ... & Nora, L. M. (2018). A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. NAM Perspectives. <http://cirrus.mail-list.com/cfha/88251204.html> Ditto to these conversations: It is affirming and depressing to read these posts.  The impact of an overwhelmed system of care on providers, staff and patient just reaffirms the mulitiple layers and interactions of these issues.  I am struck with the challenges we face from different levels:  the personal relationship dynamic and the organizational-policy issues. 1. The struggle of being in relationships that actually mean something--with patients, families, and colleagues, takes time and emotional bandwidth.  The resource of time is an essential ingredient that needs to simmer, and the flavors need to mature to develop a human connect that can make a difference.   Organizational systems need to provide the resource of time and emotional re-charge space and time to engage in this work--individuals needs to protect these relationships. 2.  As everyone has been saying:  The organizational systems are toxic to wellness.  Yet, we are not well trained in organizational change, advocacy processes and pushing policies.  As everyone is recognizing, we need more intentional organizational strategies to change healthcare systems.  At the end of my career, I am just figuring out and getting woke to the importance of this work.  So, I hope invest more to support advocacy -professional organization to these processes that focus on organizational and policy changes at the local, state and federal levels.  And, we need to train our providers, residents, and other colleagues in these advocacy-policy strategies to make sustainable changes.  This has been a robust and impactful conversation (thanks Hunter for starting it!). I too want to chime in and recognize all of you out there who are feeling the effects of burnout or precursors of it. I have been there and it is not fun. This conversation has also elicited some potentially actionable ideas for CFHA including Dan’s great idea about a workforce survey (has been in my idea parking lot but may be moved soon!) and the notion of embedding this issue into policy advocacy. I have always thought that the most important contribution of integrated care to healthcare was simply making life better for the providers in the system. Finally, there will be two sessions at this year’s conference dedicated to the issue: one is an Extended Learning Opportunity (Thursday of the conference) for Behavioral Health Leaders (frankly any discipline would benefit so all are invited) to explore and proactively shape their careers (including avoiding or working through burnout) and the other is a concurrent session review of a wellness program for physicians. Obviously we could do more, but alas there is only so much content space. As you think of ideas or if you want to be a part of making change happen, please let us know and we/ CFHA can get you “in the game." I have been gripped by the moving and heartfelt sentiments expressed her. Recently I learned about 3rd Conversation (https://www.3rdconversation.org/). This organization convenes groups of providers and patients around the county to talk together about the ways that healthcare has changed and the impact of these changes on both. I have found this to be an interesting and even exciting response to the way healthcare is delivered. Check it out. This is striking so many nerves, it feels like secondary trauma.  I have a friend leaving family medicine after 25 years for all the reasons mentioned in this thread and another surgeon who is so beaten down with the financial and administrative politics that her system is on the verge of malpractice because it is run by MBA's.  I think organizing needs to happen to expose these horror stories that constitute institutional abuse.  It would make an important segment on 60 minutes and is already beyond epic proportions. At the same time, I'm thinking that burnout is no longer the correct term. To me, these are times of trauma and they should be called what it is. For the wounded, I think wellness should include witnessing as well as more mindfulness built into our cultures.  I've seen  a study on mindfulness with medical students.  I'll look for the reference.  For many survivors of abuse, mobilizing in the community and claiming their voice is a relevant part of healing.  However, survivors in our settings are largely still being wounded by the system everyday. If this was a patient, we would be helping them to find a safe place.  That's why I think organizing would be an important strategy.  It could be the macro intervention while mindfulness and trauma services help individuals to stem the tide of the personal toxicity.  Just like in the military, we have a practice culture that doesn't look kindly on vulnerability. Like so many of you, I have been following this tread with great interest. I have stayed silent to this point for multiple reasons- a sense that I have nothing to add beyond what has already been said, feelings of being overwhelmed by other tasks that inhibit ability/readiness to formulate a worthy response, among some others.  After a week of reading moving and well-written contributions, I finally feel ready to lend a voice. When I have read the comments shared over the past week, I have noticed three primary reactions: 1) Wow, that is so well said!  I am honored to consider members of this listserve colleagues, mentors, and friends.  The responses show a beautiful combination of courage, insight, and analytical thought that most organizations would struggle to match.  I both empathize with and  admire the sentiments shared here. 2) Oh my, I had no idea that so many of us struggle with these feelings.  Granted, there is likely some significant selection bias (I suspect that there are colleagues reading who do not feel burned out, but have enough empathy for colleagues about whom they care to not state that publicly in this thread), but nonetheless, the number of folks willing to lay bare the emotional experiences of burn out and secondary trauma have been striking. Those two thoughts have been shared (and better written than above) previously in this thread, but there is a third aspect of my reaction that I have not yet seen articulated: shame.  I feel ashamed to have feelings of burnout. I have a job that I generally love that offers a chance experience relative autonomy, a chance to help people in a real and meaningful way, and to be able to make a comfortable living doing so.  And yet still-- I feel a sense of burnout at times.  I compare myself to my physician & NP/PA colleagues and think "wow, they have so much more on their plates than do I.  What right do I have to feel (let alone speak) of burnout?"  Also...how privileged am I?  I am a white, straight, cisgendered male over 6 feet tall.  My ACES score is low, my family is stable....isn't any talk of my feelings of burnout just whining?  Do I not have it better than most?  Objectively, it would seem that the answer is "yes" on many dimensions....yet the feelings remain. So...what does that say about me?  It feels like it suggests that I am weak. Seeing that I am not alone (and in fact that very respected colleagues suffer in some similar ways) is helpful.  Thank you to all who have shared, and to CFHA for creating a forum to discuss.  Organizing feels like a useful approach. More research into effective (and sustainable) tactics to mitigate effects of burnout also seems worth considering. I look forward to seeing many of you in Denver this Fall.  Stay gold colleagues....I really do believe that our efforts make a difference, and our discomfort is not for nothing. Thank you for being so vulnerable in this forum of relative strangers...i have no idea what the number of colleagues on this listserve is, but I imagine it is a lot. We are doing a lot to make it ok to talk about these things. I can tell you that you are far from alone in these feelings - I'd bet many of us can relate - I know I can. I've been doing a lot of work (for personal reasons AND for professional reasons, to be able to better help my patients and colleauges) around this lately, including reading some of Brene Brown's work. I also think that the fact that Menninger decided to have their annual Symposium on shame speaks volumes - I do not think it was just for professional reasons, but also because there is a recognition that many of us could benefit from looking at shame ourselves. While I trained at BCM/Menninger and am still voluntary faculty there (supervising residents at my FQHC employer), I have no reason to share their symposium info with you other than on the chance it is of interest to anyone who might want to attend, and you may not know about it, I wouldn't want that opportunity to be missed. A number of us in Houston are going. I hope  that sharing this is appropriate. Link below. <http://themenningerclinic.camp9.org/event-3405128>  I'm running between consults, so my apologies if this has already been said. It's worth searching the phrase "moral injury healthcare" to see if that captures some of the experience that's being described. It's a concept that was introduced to me within the last year and has been quite enlightening. Look forward to connecting with folks in person in October. So grateful for this group. Thank you! Also feeling grateful for this discussion and group. I saw that Neftali  mention two ELO sessions at this year’s conference dedicated to the issue,  however, if there are non-ELO sessions on "moral injury healthcare" aka  burnout or interested parties plan to convene for a discussion please let  me know. Thank you  This has been a great discussion and I sent several responses yesterday which all got bounced back to me! My email configurations were not working but were reset so at the moment I just want to see if I can reply to the list messages. Look forward to seeing everyone at the conference! I've been thoroughly impressed by sharing and openness. The pain of shame when supportive light can be brought to one's experience.  Only then can we work toward finding alternatives, to address and prevent the root causes. This has been a great thread and want to share one thing.  In, Philadelphia, a large slew of new BHCs received their "boot camp" training provided to BHCs less than "one year old."  We ended by talking about this thread our intensive experience. It is great to learn competencies and skills, but self-care matters from the start to sustain the role. This email thread helped prompt consideration of personal practices to work against burnout and how we support coworkers. So thank you for the great timing!  I'm so late to the party secondary to vacation and a heavy plate, and sorry I missed such a rich conversation.  I agree that morality, and subsequent violations, are included in the process of burnout for medical and behavioral providers.  However, I would encourage everyone to look into the literature regarding "moral injury" vs. "moral distress."  Our research is focused on moral distress and burnout and we believe that moral injury reflects more of a posttraumatic distress while moral distress better reflects the "death by a million paper cuts" many providers describe. One definition of moral injury is, “lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations," Litz, 2009.    A link:  <http://moralinjuryproject.syr.edu/about-moral-injury/> A definition of moral distress, "An instance of moral distress occurs when an individual believes she knows what the ethical course of action to take is, but is prevented from implementing that course or must do or cooperate in doing otherwise, due to external or internal constraints; and in doing so, she acts (or is complicit in, or views herself as acting complicity) in a manner contrary to her personal or professional values, undermining integrity and authenticity."  Kondrat, 2016.  Another link: <http://moraldistressproject.med.uky.edu/moral-distress-home> In other words, the death of a patient who was not allowed treatment at the ED despite the provider's ability to effectively treat, and the provider's reaction to this horrible outcome, is an example of moral injury.  Moral distress reflects the reaction of the appropriately trained and experienced provider, who knows the "correct" medication to treat the presenting illness, is unable to prescribe the medication based on the patient's insurance company's unwillingness to pay for it. We certainly see a lack of research of the impact of moral distress upon primary care medical providers as well, of course, behavioral providers. Ultimately, it is our belief that moral distress, the frequent violations of the provider's ethical, Hippocratic and moral values, better reflects the experience of providers in primary care and certainly encourage more discussion and research in this area. Thank you! Thank you for this precious and important conversation.  The National Academy of Medicine is conducting ground breaking work in this arena.  You can learn more and access many fantastic resources on their website <https://nam.edu/initiatives/clinician-resilience-and-well-being/> Their focus is on the organizational and social systemic factors that impact resilience, above and beyond personal factors (e.g. self-care). Check out this richly detailed article that weaves the work of the National Academy with Maslow Hierarchy of Needs https://www.amjmed.com/article/S0002-9343(18)31155-0/fulltext Finally, Z Dogg has been powerfully articulate on this topic.  Check out his videos (prepare yourself for the strength and power of his discontent and reframe as moral injury) at https://www.youtube.com/watch?v=L_1PNZdHq6Q  and the more tender and heartfelt expression at:  https://www.youtube.com/watch?v=jV9RyXQyQ7Q  Thanks for this excellent information on moral injury - the links and these youtubes.  Great information! Some years ago, when I was at the University of Louisville, our med school had the Arts in Medicine Program for our med students.  It promoted and encouraged our students to maintain their humanity through the arts.  At the time of graduation, there would be a special program to witness participants' contributions to the arts. Poetry, music and other forms of creativity.  One year, a student displayed a violin he made by hand during the 4 years of med school.  I thought I would share this as a way of combating burnout and these moral injuries.  A way of empowering and honoring everyone's voice.  This accesses a dimension separate from my earlier post on organizational change.  We need it all! Thanks for the inspiration in all these posts. Thanks for all the wonderful posts and ideas. I think health centers will need implement programs to assess and intervene in order to stem the tide of burnout.   Does anyone work for or know of a healthcare org has such a program?                                                      
by L. Edwards
Friday, August 23, 2019
Positive cutoff for PHQ2 0 L. Edwards Hi - We are moving forward with standardizing our depression screening across our primary care clinics.  There is debate regarding the best cutoff score to consider a PHQ2 positive.  I believe the highest PPV for MDD is a score of 3. A score of 1 has a similar PPV for all depressive disorders. I appreciate your thoughts. Thanks in advance.  Diane Hi Diane, We have been using 3 at Mayo. Best wishes, Mark  Hi Diane, At Sanford Health, we are using a cutoff score of 3 on the PHQ2 to cascade to the full PHQ9. At that threshold, sensitivity is 82.9 and specificity is 90.0 for MDD with a 38.4 PPV.  For any depressive disorder it is 62.3 and 95.4 respectively with a PPV of 75. This comes from the Kroenke, et. al., article, 2003, (41), 1284-1294, Medical Care. Regards, Jeff Hi - I have been a bit of an outlier on this, but have done so with the knowledge (and maybe approval) of Kurt Kroenke, the developer of the PHQ-2/9. One of the advantages of the PHQ-9 is that it is aligned with the DSM criteria for diagnosing depression. The PHQ-2 screens for depression by asking about the 2 cardinal symptoms of depression - depressed mood and anhedonia. One should not make a diagnosis of depression without the patient endorsing at least one of those symptoms at least half the time for the past 2 weeks - which is the way the question is asked. An answer of 2 on either of those questions would be consistent with a possible diagnosis of major depression and should lead to the full PHQ-9. So I worry less about the total score and more about the answers to each individual question. But I know that most people do what Mark suggested and use the score of 3 - you will just have some false negatives with this approach. I have also heard of people using the PHQ-2 as yes/no questions and a yes on either would then trigger a full PHQ-9. Thanks, Neil Neil, this is also how our facility uses the PHQ. It also means most patients only complete two items, though the research finding people who are negative on the PHQ-2 sometimes still endorse suicidality would suggest the value of always administering that item. Bob Does anyone have a well-organized plan to address positive suicide items? We are looking at using one of the Columbia scales but the challenge of many  false positives, who does the screening, etc. is coming up.  A group in Minnesota I believe has segmented the population such that only those with a higher score get the screening. Thanks, Mark
by L. Edwards
Friday, August 23, 2019
BHCs as Providers 0 L. Edwards Dear list mates, I'm not sure I've seen this issue discussed here in the past, but if not, I'm hoping your collective wisdom can help guide me. We have ~50 BHCs in about 50+ primary care clinics throughout our enterprise. They are almost all masters prepared independent clinical social workers with a few professional counselors and one psychologist.  But, more than 90% master's level social workers.  They are an awesome group, do great work, and are valuable assets to their individual primary care clinics. An issue that has come up recently, and persistently, is whether these BHCs are considered "providers."  From my perspective, they most certainly are.  They "provide" professional services, have independent licenses, generate revenue, and contribute expertise to the team that is critical.  However, our organization's definition of "provider" currently only includes physicians and advanced practice providers (APPs).  Further, our organization defines an "APP" as an advanced practice registered nurse (APRN), physician assistant (PA), CRNA, audiologist, and genetic counselor.  I should note that psychologists are bundled into the definition of 'physician' as are podiatrists and other doctorally- trained non-medical clinicians.  My sense is that the HR definitions and guidelines may pre-date the integrated care movement in  our organization and the titles perhaps have not kept up with some of the realities on the ground.  Additionally, there may be other financial obligations and realities for the organization to enlarging the definition of a provider. I would add that our system is pro-behavioral health, all things considered, and embraces the importance of this service line. How this bubbles up has been in CME dollars (providers have dollars allotted for CME while non-providers have to make a case by case request) for clinicians and, more recently, who has access to the "provider lounge." While the latter issue I don't really think centers on the access to a free cup of coffee and donut, but more so the desire for recognition as an equal participant in the system. Have other organizations faced similar questions?  If so, any guidance or insights on how you resolved this?  There are some rumblings and grumblings in our BHC cohort about who is "in" the preferred definition and who is not. I'd like to be able to respectfully respond but wanted to know what others have seen/done. Best wishes, Jeff In our organization BHCs were regarded as providers and received same compensation for CMEs and made their own decision in how to spend them. Dawn The same is true here--considered providers, part of the Concord Hospital Medical Group (the outpatient division of the hospital) and able to be members of committees, the same CME benefits as advanced medical providers.   So far, however, we have not been considered part of the Concord Hospital Medical Staff. Joni All considered "providers" but doctoral levels have larger CME stipend and greater number of days while master's level considered mid-levels. At times pay higher for bi-lingual fluency. Always find I have to reiterate that we are all "BHCs" and that that is not based on degree. Susan This is an ongoing issue for us. Our team is comprised of LICSW and Psychologists. The Psychologists are considered providers whereas the LICSWs are considered caregivers. While all the benefits end up balancing out based on contract, there are some small distinct differences that do create a divide within our team. So this is something we are actively working on to find a fix. @Jeff - I would be happy to talk offline about the steps we are taking Jenni We have a policy that governs our "mid-level providers" which includes NP's, PA's, Psychologists, social workers, etc. and they are billing providers and receive the CEU benefit. Beth Our BHCs (LCSWs and an LPC) are part of our provider group.   While we receive CME hours and money, it is less than medical providers, due to lower CME requirements in PA for LCSWs vs. medical providers.  Our PTO is distributed differently also - BHCs accrue, while medical providers (including mid-levels) get all in a package yearly. The greater difference is in perception, however.   It's an ongoing struggle to be recognized as equals to medical professionals in our settings, despite the fact that our educational and licensure requirements exceed those of mid-level medical providers.  Part of my departmental goals include building respect and visibility of our BHCs as providers integral to achieve whole care to our patients. I am very grateful for a CMO who recognizes and respects our BH providers and is fully supportive of the growth of our department, a crucial piece to this complicated and often frustrating puzzle. Eric Hi, all, In the FQHC that I recently left, where we developed Behavioral Health from scratch, BHCs were included in the "Provider" group from the start and this was irrespective of licensure (psychologist, LPC, LCSW, etc).  We were all invited to the provider meetings and were offered the same benefits in terms of Continuing Ed funds and time off for CEUs as well as PTO. In my new organization (private, non-profit), I am the first Behavioral Health provider.  It is a large organization with multiple hospitals and ambulatory care facilities.  I have been included in the medical staff and am recognized as a provider with the same continuing education funds that my physician colleagues receive.  I also have access to the "doctor's lounge" in the hospitals, which provides free lunch (which I rarely use because I am too busy to break!) and am able to park in doctor's parking, although I elect to park with the staff and leave an extra spot open for a patient. As I build my BHC team, which will include additional psychologists and LCSWs, I plan to advocate for them also receiving the same provider benefits because I do think it will enhance the respect they receive among the physicians if we are treated as providers. Now, I am different than my physician colleagues in my new organization in that I am salaried and receive PTO and the physicians are paid based on RVUs and do not receive PTO. Hope that helps, Jeff! -Laura Same here at Summit Medical Group - mid level provider designation that bill for services, salaried,  5 CEU days per year, 2K reimbursement for CEU or associated travel, eligible for annual bonus in December. Elizabeth In our multi-disciplinary, multi-specialty rural health clinic, BHCs (which are all masters-level except for myself) are treated as providers and given all the same benefits, including provider incentive benefits like 100% coverage of health insurance premiums. CME time, funds, and PTO are all congruent with MD/PA/NP providers with the exception that my clinic is an IPA, so shareholders get some unofficial benefits that others do not. Even our CSWAs (social work trainees) are given provider status and the same set of benefits. This issue feels to me to be a marker for how much administration understands and values BH work, in general. It sends an important message to staff and  patients re: our value, and I do feel like it goes a long way for BH team morale given that we can take a beating many days. Seems that any efforts to move this needle is dependent on having an admin team that really understands how much patient care BHCs take on and how patients see us as their mental healthcare provider, despite any potential discrepancies on the back end. I would also wonder when and how that decision was made, and what factors contributed to administration's decision to determine BHCs as non-providers. Sounds like they are stuck in an old mentality of care. Shay Thanks for all the great feedback from everyone on this topic!  It is much appreciated.  It seems that most (though not universally all) sites do extend 'provider' status to their master's prepared BHCs and recognize their importance in the equity of benefits that they receive.  To those who collectively, and privately, responded, appreciate your time and thoughtfulness. Best, Jeff I'll start with the disclosure that I personally dislike the term "provider", as I know a lot of other medical professionals do (I'm an RN and MD, and while I don't get hung up on titles, I believe in calling clinicians what they are...I've found that patients actually get confused when the term "provider" is used about what the credentials and roles of the clinicians they are seeing are). Having said that, our BHCs are considered providers, as are all of our traditional therapists, psychologists, and case managers. We are a nonprofit FQHC. I wonder if some of these systems are "stuck" in the traditional medical nomenclature or if there are other reasons for the differences. Our CME/CEU stipend is determined by education/licensure, as is fairly commonly done...MD/DO, NP, PA, PhD, Masters level, etc. Chad
by L. Edwards
Friday, August 23, 2019
LMFTs as BHCs 0 L. Edwards Hi - Does anyone have experience with LMFTs as BHCs in your clinics? If so, I'd appreciate your thoughts on the pros and cons of their training.  Thank you in advance -  Diane Hey, Diane!  I think more information is needed.  Are you weighing the LMFT degree against other degrees in particular?  That information would help.  As an LMFT, I can tell you that we can't bill Medicare (like LPCs, LCASs) - only psychologists and LCSWs can currently do that (if there are updates I am unaware of, I'd love to hear them : ). There is a contingent of people who consider themselves Medical Family Therapists that hold the LMFT degree.  The East Carolina University doctoral program that I graduated from is accredited through Commission on Accreditation for Marriage and Family Therapy Education.  Although the ECU program is LMFT only, there are numerous other fantastic degree programs and tracks that educate people to work in integrated care, educate residents in BH, etc, that are not LMFT specific. I think I am getting around to a point - I've always been impressed at how little degree type and how much training, personality, and passion have to do with people's goodness of fit in integrated care. But, there is that pesky Medicare issue : ) I hope this is helpful! Aubry Hi Diane, In my training and experience with integrated care I have learned that the success of a BHC is much more about the clinician than their licensure. I found my family systems training to be immensely helpful in navigating my previous roles as a BHC, to be able to attend to family wellness and illness dynamics with patients, and developing meaningful, collaborative relationships with primary care providers and clinic leadership. In my work transforming health systems, I have worked with BHCs from my sister behavioral health professions who had the same strengths in their integrated practice, but maybe not with the same family systems lens or approach that I used. I think this just highlights that in integrated care, we are all working as a team to serve the patient and if you have a clinician who is really skilled at delivering the care patients need, supporting primary care providers, and fitting into the flow of your clinic, then that might be the right clinician for you. Having said that, I am also extremely practical :) If you are considering hiring an MFT it is important to evaluate the reimbursement mechanisms in your clinic, as MFTs are not yet recognized as covered mental health professionals by Medicare, though there is movement towards that, and we hope to have it soon! (An MFT would be a good fit in a pediatric clinic if that is a barrier). I am happy to chat with you offline about best practices for recruitment and interviewing BHCs if it would be helpful. I think there are some great resources out there too that our CFHA colleagues can share. Kindly, Amelia Yes, I have a lot of experience with LMFTs being BHCs, in addition to myself being one. I have also supervised LMFTs, LP's and social workers (so have been able to compare skill level). LMFTs tend to be highly successful because they already think using a "systems approach" and are very familiar working with individuals, dyad's, and families, which is a very important skill to have in BHCs. They are also trained similar to other mental health professionals with regard to diagnosis and treatment of mental health conditions (don't do testing though). They also tend to have really good skills with communication and problem solving facilitation with patients/clients, in addition to providers. There are a few billing issues that only LP's can bill for (eg., Medicare), but they can bill for the majority of codes. Overall, I think they bring the same set of skills as LP's or social workers in BHCs and some superior skills. Jerica Dr. Dougherty – First, let me thank you for asking this question and not just assuming that an LMFT will not be a fit. While there are not as many of us as other licensures, when looking for a good fit for your clinic, it helps to have as many options as possible and I do believe that LMFTs should be considered in that mix. As others have said, I too believe in personality and fit being key. However, I think it is also about the particular program from which the MFT(LMFT) graduated. For example, I was fortunate enough to earn my masters also at East Carolina University and while the degree was Marriage and Family Therapy, as is the license, even in the masters program I was taking classes that highlighted seeing patients/clients from a biopsychosocial-spiritual lens, and also taking a class that focused on learning the medical culture, medical acronyms and how to function in a BHC role. Several of my classmates were blessed to have internships in integrated care settings, and this was over 15 years ago, and this program has only grown in its integrated care trainings/internships for the marriage and family therapy students. I believe that my background in family systems, even if I had not had the additional training and focus in integrated care and whole person care, would have served as preparation for navigating the relational dynamics needed on multiple levels in a healthcare system. My doctoral degree in Medical Family Therapy at East Carolina University (https://hhp.ecu.edu/hdfs/phd/)  prepared me even further to understand how  chronic and acute illness impacts patients and their families, health behavior change, and working within healthcare systems. In this program I was blessed enough to have an internship in a federally qualified healthcare clinic as a BHC, and while I was not the first MFT in their system, it has only continued to grow in its utilization of MFTs. I am aware that not all MFT programs focus this heavily on whole person, whole family, and integrated care, however, I would have felt negligent if I had not shared my own MFT experience and training. Happy to talk further and really grateful that you asked the question! There is much work to be done and we need all hands on deck! 😊 Lisa Hi, Well let me chime in with my two cents. Absolutely applicable. I am not an LMFT but I am an LCSW.  I have worked with multiple discipline types as BHCs ( including LMFTs) and strongly believe “fit” is essential. I think we can all find things about our disciplines training that set us apart from one another. In addition, the different graduate programs in each discipline are vastly different in preparation for the spirit of Integrated Care. If there is a clinic that has a high Medicare population and management is consumed with maximizing billing (which does not always equal quality care) then the discipline you hire matters. Otherwise, I look to see is the person a good fit for the role of a BHC, for the clinic team and the patient population (are they teachable and trainable). Don’t hesitate to incorporate second or third interview opportunities that involve the applicant interacting with patients (I’m always wanting to create “live” situations - live supervision, live interviews - it can bring an additional dynamic to the situation). Of course this takes planning, thought and liability/safety considerations. Best, Monica  Hello, all: I would absolutely concur with everything everybody has said so far. I am an LMFT who has been working in an integrated setting for 19 years now. Like many of us from the early years, I stumbled into integrated behavioral health and never left. I found that my training in systems thinking was a perfect fit.  (I was hired by an MFT, by the way.) Part of my role is to train behavioral health interns, both for integrated care and specialty mental health within a medical setting.  I agree that fit is essential, as are skills. One of our 6 IBHCs is an MFT.  Her role is to work with the prenatal and frail elder populations. I think that her training in family systems is particularly helpful with those populations. That said, I would not hesitate to hire an MFT for our primary care teams as well. I want to highlight that AAMFT published a document on core competencies for family therapists in a health care  setting. Here is a link.  https://www.aamft.org/Documents/Marketing_Communications/Competencies%20for%20Family%20Therapists%20Working%20in%20Healthcare%20Settings%2011-9.pdf I know that some of the people who contributed to this are members of CFHA, and I hope they weigh in. Joni Diane, I appreciate each of the contributions to this conversation.  My thoughts are quite consistent with what has been offered, I just consider the issue  from a slightly different frame.  I place Doctor of Behavioral Health student interns who originally received a training, supervision, and independent licensure across the range of specialty mental health professions. On average, I have not noticed any differences in the performance comparing the professions. The unique training of MFTs is focused on systems theory and a process orientation.  This can be quite useful for BHPs who collaborate with teams of providers within health systems of varying sizes and types.  As integrated healthcare continues to evolve, it is helpful to have those who can conceptualize and collaborate with others in transforming systems of care. One final thought that resonates with those that have already been mentioned... Becoming a BHP builds upon the clinician's foundation of clinical training  and experience.  Collaborating in team-based care, engaging brief, targeted assessments and interventions, and providing BH consultation and training are the skills that are built upon that foundation to perform effectively with the medical team in medical environments like primary care. C.R. I’m similar in belief to others mentioning the personality factor. After hiring clinicians from diverse licensures and varying academic experiences  over the span of our five year program implementation I believe it is imperative to hire based on key personality traits. Traits that will be most conducive to working in a hectic and constantly changing patient care environment that can at times be intimidating, difficult to breakthrough, and full of a variety of provider types/personalities. Go-getters who will pursue collaboration and seek out and advocate for their services on their own until they are operating at full capacity is invaluable. The BHC personality to be a walking talking integrated care commercial at any time makes our work at the administrative level much easier. Competency, no matter the licensure, can be taught.......but personalities that fit best in these environments have to be considered as primary to program success from my perspective. Dr. Shannon
by L. Edwards
Friday, June 28, 2019
PCBH marketing strategies -- posters? 0 L. Edwards Hello all- In my quest for increased utilization of our PCBH service I'm developing some marketing strategies that will be directed towards patients/consumers.  As part of this effort we would like to develop posters for exam rooms and waiting areas. Does anyone have examples of PCBH-oriented marketing posters  that they could/would share? We don't want to copy anyone directly but just looking for inspiration or examples of something that has been well-received  or effective. Thank you for any input. Jason A health center I consult with did something pretty interesting..... They put the faces of each of their BHC on an 8 x 12 flyer,  and said "Meet Jane"   with her name and professional degrees below her name The next line said something to the effect  "Jane is our wellness expert. She helps out people with stress, depression, anxiety, health challenges, substance use, and life concerns.  Ask someone on the team to introduce you to Jane or say hi if you see her." It led to a pretty significant uptake in warm handoffs since it was put in the waiting room and on all exam room doors <http://files.mail-list.com/m/cfha/ENPCN-BHC-Poster-2019-1.pdf>  679 Kb <http://files.mail-list.com/m/cfha/BHC-Pt.Handout-FINAL.May19.pdf>  78 Kb Hello, Credit for the poster design attached goes to another network (we just changed the branding) but it has been well received in clinics so far. The patient handout has also been helpful (we've been fairly successful in reducing terms such as therapist/counsellor from the descriptors used by physicians or other staff referring to the BHC much supported by having this document to provide). We have had feedback that changing it to a trifold or other smaller format would make it more user friendly. Melodie
by L. Edwards
Friday, June 28, 2019
ADHD Integrated Care Manual 0 L. Edwards Hello, I was just scouring the internet to see if there were any brief, primary care-friendly, evidence-based pediatric ADHD treatment manuals. Several BHCs  I know are looking for this resource and I am finding a number of 10-12 session protocols Bests Travis Hey Travis! I am a psychologist in a pediatric primary care setting and generally use the PASS model (Partnering to Achieve School Success) developed by some mentors of mine at the Children's Hospital of Philadelphia.  It is a modular intervention taking the components of traditional ADHD treatments (e.g., Barkley model), adding elements of treatment engagement/crisis management, and condensing them into modules to be delivered as needed within urban primary care centers.  Modules include: Treatment Engagement; Brief Family Therapy (e.g., rewards, punishment, effective commands); Family-school Collaboration; Crisis Intervention; Medication Management.  Happy to talk more about how this looks in clinic. We are highly integrated (75-80% of our visits are co-visits with the PCP), and often deliver this intervention during med checks as a joint visit, and sometimes add in brief sessions in between med checks if needed. Citations below, may need to reach out to Drs. Mautone or Power to obtain the manual. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582374/> Power, T. J., Mautone, J. A., Marshall, S. A., Jones, H. A., Cacia, J., Tresco, K., . . . Blum, N. J. (2014). Feasibility and potential effectiveness of integrated services for children with ADHD in urban primary care practices. Clinical Practice in Pediatric Psychology, 2(4), 412-426.  http://dx.doi.org/10.1037/cpp0000056 My good friend/colleague also wrote a review of ADHD programs in Family, Systems, and health a couple of years ago (citation below): Shahidullah, J. D., Carlson, J. S., Haggerty, D., & Lancaster, B. M. (2018). Integrated care models for ADHD in children and adolescents: A systematic  review. Families, Systems, & Health, 36(2), 233-247. http://dx.doi.org/10.1037/fsh0000356 Hope you find this helpful! Cody
by L. Edwards
Friday, June 28, 2019
Food & Integrated Care 0 L. Edwards CFHA’ers: Food has been on my mind lately as one of the social determinants of health that often goes unaddressed. I’m wondering what people out there are doing  about this? Are you screening for food insecurity? Do you have relationships with food pantries? Any thoughts would be appreciated. Thanks, Neftali Both.  Everyone gets screened for food insecurity at each visit and as appropriate, given food boxes immediately and referred to our partner, Greater Pittsburgh Community Foodbank. Neftali, Our department of surgery has an established relationship with a good pantry. We collect donations throughout the year from residents and faculty and volunteer twice annually to serve meals to the local community. Lauren Hi Neftali, This is a great question! When food insecurity comes up during a visit, I immediately refer patients to a Community Health Worker (CHW). Our patients at are also given a social determinants of health screening during PCP appointments and CHWs see patients during these visits as well. The CHW meets with patients via warm hand offs and is familiar with all local resources, including transportation, food banks, bill pay assistance, housing information, and different community programs. I believe most locations with the Yakima Valley Farm Workers Clinic have a CHW. They are a really wonderful resource and are great about referring to BHC if there are additional difficulties related to stress, trauma, or making behavioral changes. Thanks! -Sarah Nef: We are using a modified version of the PRAPARE tool to screen for social determinants of health.  It is translated into many languages and can be found here: <http://www.nachc.org/research-and-data/prapare/> Our integrated team (BHCs, social workers, and dietitians) have partnered together in our clinics to start an emergency food pantry in the break room which everyone contributes to.  That way if patients come hungry, they leave with food.   Also in our diabetes group visits, each patient leaves with a bag of food which is donated in partnership with the Oregon Food Bank. We have found our patients to be very appreciative of these resources. Brian Interesting you were thinking this as I’ve been on a almost daily conversation this week with different people around SDOH and the impact. Which reminded  me of this video: https://youtu.be/Eu7d0BMRt0o In terms of what some people are doing: There’s an agency I’ve worked with that screens for SDOH and regarding food/nutrition they partner with food banks and also created a Collaborative with the local Farmers Market for families to get a voucher for up to $20 of free food on average (family size and other considerations are looked at as well). Best, Monica  Hi Neftali - Our process at Healthsource of Ohio is similar to others described. Our MA's screen for food insecurity at every visit; if we identify someone in need, we provide 1-2 family-sized meals immediately, as well as a directory of resources for ongoing assistance with food. I have recently suggested that I should see these patients to help them develop a simple action plan for connecting with these resources, etc., but haven't had the opportunity to try this yet. Mike Nef- At our FQHC the CHWs screen for food insecurity through the SDoH screener and further discuss this during a follow-up appointment (if pt agrees to  one). We typically give documents regarding the Oregon Food Bank's free food markets in the patients' surrounding neighborhood, ask if they are already  signed up for SNAP (if not, we'll help them apply), and also refer them to any groups at the clinic that have access to food (i.e. we have a patient low-cost CSA, Cooking Matters group, and we have a Gardening group). Joan The AAFP has a nice 2 question screen: 3. Within the past 12 months, you worried that your food would run out before  you got money to buy more.1 Often true Sometimes true Never true 4. Within the past 12 months, the food you bought just didn't last and you  didn't have money to get more.1 Often true Sometimes true Never true HMA Lori Neftali- I asked our Behavioral health resource specialist what she does with a WHO around nutrition/food resources and this is what she said: When I get a request for food insecurity issues (WHO or in basket) I usually share info on some of the larger food pantries around town that are open  each day M-F.  That way if they need food today they can go very soon. I discuss the benefits of shopping style pantries where they can choose their own items and make healthier choices.  We also offer patients granola bars and snacks that they are welcome to eat while we talk. I also use the Free Food Market calendars and flyers that come from the Oregon Food Bank.  Store to Door, Meals on Wheels and Urban Gleaners are other things in my Food Resource Packet. I have a separate list of places that deliver free food to those who can't get out to a food pantry. I also give out daily meals lists to those that are not housed, run out of food before the month is over or do not have kitchens. WIC (prenatal to age 5) is an important part of addressing food insecurity as is the Summer Meals Program (ages 1 to 18).  I always make sure that newcomers to our country know about the USDA Food Program at their kids schools.  Most schools (those with SUN programs particularly) have weekly food distribution on site and I have lists of those when the family's school is known to me.  This is particularly great for those who are newcomers and may only know where the school is and not much else about navigating their neighborhoods. I have a section in my food resource packet that discusses how to apply for SNAP, low cost grocers that accept SNAP and the Double Up Bucks Program that is available for those with SNAP at some Farmer's Markets. I always mention the cooking class that is sponsored by Care Oregon (our CCO). I have the big general food packet for all of Multnomah County that I bring with me to quick warm handoffs.  I tear off the things in the packet that do not apply to their situations.  When I know ahead of time where they live or when I get an in-basket request then I zero in on just places in their zip code and bring/send them more specific information. Lastly, when we distribute pool passes I also mention the food distributions that are done at the same community centers where the pool is. Healthy eating for those with specific health goals is also a part of my work. Not quite food insecurity related but many people say that eating healthy costs more.  I have a whole bunch of information to share that shows them that this is not the case. Hope this is helpful! Joan A pediatric clinic I worked with seeking to address food insecurity decided to broaden the screening for food insecurity to be inclusive of nutritional and weight concerns.  This screening was then used to refer into a clinic-based class on nutrition lead by a nutritionist. For families with food insecurity a prescription was also written for food, which was honored by a food bank, providing additional food beyond their standard distribution.  The broaden screening served to normalize the screening for all families regardless of income and food needs to address the important issue of health and nutrition. The goal is to address, lack of healthy foods, and over and underweight issues, and then provide a resource for families in preparing healthy meals. Dave We have a partnership with Hannaford (a regional supermarket chain) as a distribution site for their Hannaford Helps food boxes, via our affiliation with our town food pantry.  We keep a box in each exam room and a stash in the basement - each box contains pasta, tinned meats/tuna, tinned veggies, cereal, some other things.  They're not my product of choice for diabetics or hypertensive patients for obvious reasons, but it's something.  We have a sign over the box that says, "if you or someone you know needs food today, please take this box with you".   Takes the stigma out and promotes neighborly gestures as well from patients to their neighbors in need. Also - a local nonprofit cooks low glycemic, low sodium meals from soon-to expire supermarket or farmstand produce donated to the nonprofit (Grateful  Hearts), freezes it, and gives it to us for distribution. Great for just-discharged, elderly with difficulty shopping, etc.  Hard to stock much due to freezer space, but they re-up us when needed. We're in a tiny town, pop 3000, but serve the larger county as well.  Our small size helps make these less formal partnerships a little easier. Anje Wow! Thanks everyone for the detailed and helpful responses. I sense a couple  of themes in the responses: 1. Addressing food is a crucial aspect of integrated care. 2. Food insecurity and access to healthy food choices are both important to address. 3. Immediate, destigmatized, local solutions are important to have on hand. 4. Clearly many of you have developed relationships with food banks and other suppliers/ programs. 5. Proactive screening is important for identification. 6. Workflows can include specialized workers (eg. community health workers) but can also include BHCs and other team members. Thank you! I’m thinking that we need to make this a more front and center item going forward and this info helps establish a baseline of activity among our members. Neftali I am so glad you asked this question Neftali.   (which is why I love CFHAers!) I would add to this list that community members (patient partners and peer  navigators) embedded within the primary care system or directly on a quality improvement team could be an incredible source of wisdom and inspiration  for promoting and implementing these changes in the primary care system. Sharing the burden of connecting resources and people who need them takes  many hands and dedicated time and resources.  End users of those resources can be easily involved in generating awareness and building the base of  connectors and seekers of resources as well as celebrating and appreciating those efforts that sometimes fall on the shoulders of already overworked  BHCs.  Keep all patients in the loop of what you are doing and you will find an incredible source of joy and wellbeing going around.  Lots of patients would be willing to help if asked.   And the benefits of helping others is already pretty well known. Providers are often just as hesitant to ask for help as patients are…. Such amazing people on this email thread just make my day everytime I connect to these conversations and wisdom sharing opportunities… Thanks again, Jen
by L. Edwards
Friday, June 28, 2019
Psychiatric Collaborative Care Codes 0 L. Edwards Good morning! We are in the progress of developing a program using the Psychiatric Collaborative Care Codes, and the requirement for the psychiatrist  has been unclear. To your understanding, how often does the psychiatrist need to meet with the Behavioral Health Provider to review the case for approval? Our team had interpreted the requirements to be once per week, but wondered if that was an accurate interpretation? We need to meet all guidelines set by Medicare. Thank you! Kathleen Hi Kathleen and all - we do use these codes. The first month (99492) pays up to 70 minutes and not more, with any additional months the second code (99493) of up to 60 min (there is a 3rd code that takes it beyond that - 99494). As you probably know, for Medicare, you have to at least bill 1/2 the max to get reimbursed (so 35 min the first month and 30 min the second month). There are other conversations that make up the minutes besides just consulting with psychiatry - you talking to the PCP, you talking to the patient, you  talking to the psychiatrist, you going back to the PCP - so we never end up talking to the psychiatrist every week, it's not necessary... plus you often need to give meds time to work. A standard first month might look like the following: 10 minutes discussing the program with the patient and why Psychiatric Collaborative Care might be the right fit, and gaining consent during that  (Incidentally I just wrote a script on this today - instead of selling something, we are positioning it as saving the patient time and money overall - since they don't have to go to see a psychiatrist regularly) 5 minutes discussing with PCP to ensure they will be willing to prescribe for this patient 15 minutes presenting the case on a weekly call with psychiatry, followed by their recommendations (we all call in, even if we don't have a case - learn from listening) 5 minute follow-up with PCP to give recommendations 5 minute outreach to the patient to either pick up meds because they have been sent in or come back in for a visit 10 minute follow up call 2 weeks after starting meds to see how they are, screening tool given over phone, etc. TOTAL - 50 min A standard second month (same patient) might look like the following: 10 minute follow-up with patient 10 minute discussion with psychiatrist on dosing or titration, side effects, etc.   5 minute follow-up with PCP to give recommendations 5 minute call to patient to let them know what to do next TOTAL - 30 min Hope this helps! Feel free to reach out direct with any Q's ~ Elizabeth Elizabeth and Kathleen- It is exciting to hear you are working with your team to bill these codes and it sounds like you are doing it successfully.  Wondering in IL and NJ where you are located if you are billing other payers in addition to Medicare? Also want to chime in on the psychiatric consultant time - CMS requires that at least once during the month you have the psychiatrist review even if the  patient is stabilizing.  We often give final recommendations regarding how long a patient should continue treatment and what the PCP could do next if  the patient starts to have problems down the road.  The force multiplier of the model is we provide guidance especially for the patients who aren't getting better - focus most of our time here - in addition to providing curbsides as needed. I also wanted to note the model (and hence the codes) requires psychotherapeutic interventions - this isn't just getting meds and checking PHQ9 scores.  The  codes require brief interventions such as problem solving therapy, behavioral activation, etc which could be done in person or over the phone..  And if you have reached your time threshold you could separately bill this as a 90832 if you meet the standards. Lori 
by L. Edwards
Friday, June 28, 2019
Documentation in integrated care 0 L. Edwards Dear list mates, We are striving to help our BHCs learn to document their integrated care visits more efficiently and more succinctly.  Alas, since nearly all of them come from traditional mental health settings where six page intakes and 2-3 page progress notes are the norm, there has been some resistance (and, I'd say, fear) to doing a more abbreviated note that would lend itself to seeing larger numbers of patients for shorter periods of time.  We've discussed modified SOAP notes and tried to stress the importance of other team members actually having time to read the BHC note. Does anyone have advice on: 1.     Helping the BHC understand the wisdom of creating a different kind of note than what they are used to in specialty mental health (a script? An article?) 2.     Templates, smart phrases, or guidelines that you have used or would steer us to regarding optimal documentation for BHCs given the different culture of primary care. Thanks for your collective wisdom! Jeff I frame documentation to the requirements of the billing code. This helps a great deal. It also places it into perspective since most clinicians are not taught on how to document related to billing requirements. Most who were traditionally trained are documenting much more than required, which during formal documentation trainings will be highly discouraged. I typically encourage completing a review of notes according to requirements (this will allow you to have information on where to target) and then doing a training on documentation. During the training on documentation it is important to focus on the audience of the note (patient, care team, lawyers, etc), as well as the formal requirements. Hope this helps! Let me know if you have  questions or need any other support! Lesley Ditto what Lesley said. Also as a traditionally trained clinician I found conversations about progress versus process notes to be helpful conversations to have. I always say when you document consider that any and everyone will read your note (providers, attorneys, patient, family members, etc...) so be mindful  of how/what you are documenting. Best, Monica I agree with Monica! This is essential during the training as well. I am happy to assist with providing resources if needed. Dr. Lesley  I’ve always focused progress note training on the intent for documentation —  1) is it relevant to the primary care doc 2) is it written to be appropriate for the patient to read if records are released and 3) does it meet insurance documentation requirements with documentation of medical necessity and progress monitoring. A standard SOAP note is a reasonable framework to accomplish these goals. -Louise Hi CFHAers, This conversation is extremely interesting to me as a person who represents the end user or family member of Integrated Behavioral Health services. I  would want to know about and truly understand the fears of  the BHC as well as discover how those notes have been effective at maintaining strong healthy  relationships between the provider and their patients.  If they have been trained and have practiced putting the energy and effort into creating such comprehensive notes there has to be a reason for it and better to fully understand before asking them to change. You may end up throwing the baby out with the bath water for both the provider and the patient.   As several have already mentioned, writing notes that everyone  might view can have a tremendous impact on the ability of that provider to be honest.  Too broad of an audience can dilute, misinform and possibly cause a terrible conflict for the patient provider trust and reciprocal relationship foundational support. I may be taking a much too simple approach to my consideration of this topic but here is what I would want to say to my BHC about my health record notes: I want you to consider that everyone wants to learn from our work together but my health is my life that I have entrusted in your hands temporarily. Your notes will never fully describe our work together. But I can only commit to you as long as I can trust you. And so you must write your notes using language that is sensitive to my learning needs as well as sensitive to all of the members of my health team. You must prioritize your audiences in this order: 1. Me the Patient (I am looking over your shoulder and need to be assured that you have captured accurately my wisdom, my brilliance, my insight, my worthiness of your time and energy, my progress and successes and my learning opportunities and health goals. 2. Yourself: You need to do what you believe is best for a successful partnership with my health team members, your education, your wellbeing and  ultimately your own health outcomes. (what would you want in your health record?) 3. Other health team members: These are the people critical to my health outcomes including my established or potential family member support team  members. They desperately need to know how to coordinate their efforts with yours. 4. Insurance providers: We both need you need to get paid for these services so we can keep doing our good work together and to support all of the  patients you work with. 5. Practice managers: Your bosses will want to assess and learn from your work and support your ongoing education and learning opportunities so you can keep working with me and my fellow community members. 6. Peers: they will want to learn from your work ,copy what works best for their patients or engage you in co-learning opportunities. There are too few providers and too many patients!! 7. Researchers: They will want to know what is specifically working for you and your patients. 8. Your Mother: She will always want to know that you are a successful happy kind person.  ;) 9. The Universe: The Universe simply wants your pure brilliance to shine a path for all of us. Thanks, Me, your patient who also seeks the light of your brilliance.  Lesley, I would love to have any resources you have to offer! Willow As a team going on about our fifth year of working on integration the “who should see the notes” and “what do we put in the note”  conversation is often encountered (especially with 42 CFR programs). It’s exhausting. I agree with Dr. Manson that documentation is usually guided by billing entities. We have built our electronic templates verbatim from our states CMS requirements. However, our state has not set out any separate billable required documentation elements for integrated care encounters. We are sometimes in limbo because what requirements are outlined don’t always fit with brief encounters. All that to say regardless of what has to go in the record for the billing requirements the best communication I’ve seen about patient care happens outside the record entry. Outside the record the team works eye to eye to discuss whatever is needed to mutually help the patient most efficiently; so the documentation is kind of secondary to an amazing provider to BHC connection that covers all the bases via their connection. Lastly I’ve desired to create an 8th grade reading level consent document that fully explains to patients the need for communication between appropriate  parties and what things will be documented. It is often difficult for our patients who are seen in the ER to comprehend their provider in family practice can see all that took place. Shannon Thanks for all the feedback and conversation on my documentation question. This list serve is my "go to" place for expertise that is shared in a most collegial and unselfish way. Jeff <http://cirrus.mail-list.com/cfha/74828398.html> 43 Kb Maybe someone made this point earlier and I didn't see it, but if your notes do not take into account the patients' being able to read them, they should. I first blogged about this several years ago. <http://cirrus.mail-list.com/cfha/67859973.html> .   Here is another short conversation about confidentiality between clinicians  and between patients and their records. <http://cirrus.mail-list.com/cfha/07704107.html> Currently over 40 million patients have access to their notes online, and in many of those settings, that included primary care behavioral health notes  (www.opennotes.org) But what do you do about all of the billing documentation?  The payer has the right to know what was done for what reason, but not the content of interaction. The attached satisfice that for us, at least at the time. The area for narrative in the form is the part I always read back to my patients at the beginning of the next session. Alexander Hi, all - this didn't go out yesterday due to some listserv email issues that have just been resolved (thanks, Jackie!), so I am a tad late to the  game! I am so glad Jeffery started this conversation, as I was just mulling over this today.  I agree completely with those who have stated that communicative yet succinct notes in the chart (as long as they comply with billing requirements) are sufficient, and that the distinction between process and  progress notes is VERY USEFUL.  Things get complicated, however, when there are high-risk situations (suicidality, child abuse/neglect, intimate partner violence, etc.) that demand detailed documentation, and this is where I think we have to do a very careful job of educating our learners AND OUR PATIENTS as to what gets documented in the EHR.  Whereas a pt in traditional mental health likely has a very clear cut idea of who can see their chart and who can't (i.e., only those for whom they have signed an explicit ROI), the boundaries are inevitably more blurred in an integrated care setting where other care team members have access to the chart as well as (theoretically/potentially) any family members for whom the pt has signed off on access to their medical record.  My sense is that patients often fill out this "authorize to release" clinic form without much thought as to how this may apply to BH notes also documented in their chart -- in fact, they may be filling this out as a new patient before they are even aware that BH services are provided at the clinic.  And, while our integrated care spiel to new patients likely contains information about how the care team will share information with one another, I don't think we very often revisit the family member access to which the patient has previously consented but perhaps with a different (medical care only) objective in mind. All this to say that as systems (and forms) often lag behind integrated care vision and practice, it is incumbent upon the BHP and the care team to continue to educate the pt and to truly treat informed consent (to treat, document, and share information) as an ongoing process. Thanks, all! Aubry I'm glad that others are struggling with the same things we are.  This list serve is very validating! No surprise to anyone here, but something that seemingly is simple, documenting the visit, is really pretty complex.  I teach our BHCs that the purpose of  the note (in no particular order) is: 1.  To justify and substantiate billing 2. To help you recall what you are doing with this patient when you have not seen them for weeks. 3. To allow another BH professional to assume care if you are unable to do so. 4. To provide some framework for what you are doing in the event of an outside authority auditing or reviewing your records (a Board, payer, court, etc.) for a variety of purposes 5. To alert your team as to what you are doing for the patient in the spirit of collaborative care Combine these tasks with the goal of seeing numerous patients daily, fulfilling the spirit of integrated care, and not falling behind with documentation really requires some thoughtful consideration as to the process for constructing these notes and their ultimate content.  We are trying to evolve our practice one step at a time.... Thanks for all the comments. Jeff
by L. Edwards
Friday, June 28, 2019
Resources for Trauma Informed Care 0 L. Edwards Dear CFHA community: What is your go to resource/s for Trauma Informed Care for primary care? (Seminal articles, websites, videos, manuals). Our goal is to use your combined wisdom to update our curriculum for Family Medicine residents and have targeted resources for our developing PCBH team. Warm regards, Deepu  Hi Deepu, We are currently in the process of doing all-staff trainings on Trauma-Informed Care. We found this free resource to offer a few very helpful resources tailored to medical practices: https://nppcaces.org/ Best of luck! Jamie Hi Dr. George - Here is a link to a fantastic Trauma Informed Care summary report produced by the Commonwealth Fund: <http://cirrus.mail-list.com/cfha/39659419.html> Additionally, a couple colleagues and I presented these two training webinars that are available for viewing: https://vimeo.com/165051334 Overview and Current Practices in Patient Screening https://vimeo.com/170520339  TIC, Clinical Integration and Organizational Buy-In Hope this helps,  Jeffrey Andrea Garroway works with us now, focused on Internal Medicine.   Susan
by L. Edwards
Friday, June 28, 2019
Adherence to PCBH model 0 L. Edwards Good afternoon colleagues, Apologies if our list serve has addressed this before. But, our system is looking for a relatively simple and validated measure to assess our present degree of integration with regard to the PCBH model. We have about 50 BHCs working in 50+ rural primary care clinics across a 4 state footprint and have about 17 more clinics where we are doing tele-BH outreach. We are observing that different hubs of our organization are "drifting" in different directions away from our original intent to build and sustain a PCBH model (generalist clinicians, access as a priority, team based philosophy, shorter sessions and briefer interventions, etc.). Part of this drift, I suspect, is driven by the perception of need to generate more RVUs and I suspect some of our BHCs are slowly defaulting back to a more specialty mental health model where they are packing in 7-8 45 minute sessions during the day and we are hearing a few rumblings from PCPs that they are not "available."  This was a red flag for us and we want to find a "yardstick" (so to speak) to give us an idea of where we are drifting and where to put our energies in coming back to the center line of integration. Any suggestions for a survey, self-study questionnaire, or what have you that could guide our energies? Thanks for your collective wisdom. Jeff Hi Jeff - I know of a couple options you might try. One is called the PPAQ and I believe It was developed at the VA. There is also a similar tool in Robinson & Reiter's PCBH text that comes in both long & short versions. I've attached them all for you here! <http://cirrus.mail-list.com/cfha/40176361.html>   <http://cirrus.mail-list.com/cfha/72919577.html> <http://files.mail-list.com/m/cfha/PPAQ-Survey-10-2017gm.pdf>   Mike Hi Jeff Have you considered The Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) - Beehler and colleagues created it? It's a measure of fidelity to the PCBH model specifically. More information about it is available here including reference articles and a version to download - https://www.mirecc.va.gov/cih-visn2/PPAQ.asp We use it routinely in VA to measure fidelity. We also routinely measure wRVU productivity as well so sometimes see the same struggle you denote here. Happy to talk off line about the strategies we have taken to address that with leadership. Hope this is helpful! Lisa My understanding of the PPAQ is that it is a measure of BH Providers' adherance to the model rather than your organization's level of integration. For that, you might consider the Integrated Practice Assessment Tool (IPAT) put out by SAMSHA. Sherri This is great, Mike.  Thanks! Jeff Lisa, Thanks for this.  Mike also recommended the PPAQ. Appreciate the input very much! Jeff The practice integration profile (PIP) http://pip.w3.uvm.edu/pip.php is a good measure of integrated behavioral health in general. It operationalizes the AHRQ Lexicon from 2013. I would imagine the PPAQ along with one of these tools should give you a good picture of the practice as a whole and clinician adherence to a PC practice pattern. The IPAT is also a good tool. While not PCBH specific, these should help. An overview of assessing levels of integration is discussed in the CFHA podcast and can be accessed here: <http://cirrus.mail-list.com/cfha/67066606.html> Hope this is helpful. Warm regards, Deepu Thanks, Deepu.  Most helpful. Jeff In 2015, I developed a matrix of the available measures comparing key items - <http://cirrus.mail-list.com/cfha/02134068.html> The left column provides a set of proposed broader domains. C.R. From that matrix, the attached evaluation form was developed incorporating Peek's Three Worlds as an additional guiding framework (i.e., clinical, operational, and financial).  Each item provides behavioral anchors and specific target areas for the evaluator to focus the evaluation (attached). <http://cirrus.mail-list.com/cfha/72356959.html> C.R. Greetings Jeff and Everyone! Jeff, I sympathize with your challenge. I am assisting with two separate large-scale regional networks, one in early in integration and one a decade into integration.  In my experience, I was seeing episodes of this similar drift, of BHC  "sharking" for cold calls and scheduling lots of appointments to meet RVU/productivity standards and reduced frequency of direct handoffs from provider to BHC/ unavailability of BHC . Natalie Levkovich, with the Health Federation of Philadelphia, has been innovative in working with our primary insurer to build in an annual check-up, a multidisciplinary meeting in each FQHC to discuss integrated care and review the state of integration. We just found out we will be presenting our findings on this work at CFHA in Denver this Fall, and I am glad to talk further back channel.  We have some very positive results that showed a potential beneficial ROI for the following procedure.... In short, we asked health centers to set-aside 60-90 minutes to assess the health of integrative care, and did four things... 1. Reviewed everyone's impressions on the benefits, progress, and challenges of having integrated services across representatives of PCPs, BHCs/BH providers, Quality Officer,  medical assistant, care management, and key administration. 2. We had each individual complete the IPAT as a level set, and reviewed the results as a whole group 3.  Then, a facilitator who was non-partial to the site and very familiar with PCBH (but we could discuss other permutations) utilized selected questions from the AHRQ Playbook Self-Assessment (based on IPAT level)  to assess different domains of integration and provide feedback on degree of Co-Location, Patient Experience, Clinical Delivery, Practice Organization, and Business Model. https://integrationacademy.ahrq.gov/products/playbook/integrating-behavioral-health-and-ambulatory-care-self-assessment-checklist 4. Then, germane to the model of PCBH and what the site was striving for "to level up" and improve overall communication/precision, SMART goals and action steps were set, with a review meeting on progress scheduled. These meetings were very validating for all involved---teams often stated there are many times to meet as a team, but integrated care and its roll-out specific to the sites needs and BHCs capabilities are often just not addressed.   This format of a little time invested over a lunch or pre-post clinical morning/late day meeting led to some significant practice change and better BHC focus on availability to providers, and reciprocal improvements in the degree of referrals. Best Travis Travis - Your message was full of interesting & helpful nuggets; thanks for sharing! HealthSource is early into building a PCBH program, so this is great stuff for me to be thinking about proactively as we expand. Looking forward to seeing the presentation in Denver this Fall! Mike Travis and others, Thanks for your great feedback!  Your directions are really helpful.  Travis, I appreciate the step by step plan your organization chose to take.  I think  one of our challenges is that we have so many clinics with a BHC (~50) spread out over 4 states all with different PC leaders and different cultures. Trying to get everyone heading in one direction is the proverbial "herding of cats" so to speak. But, this protocol could be helpful if we chose 1-2 pilot clinics that could do some self- examination and reflection. The list serve alone is worth the dues for CFHA! Jeff
by L. Edwards
Wednesday, June 5, 2019
Traditional therapy vs. PCBH 0 L. Edwards Does anyone have any literature with parameters of when a patient should be referred to traditional therapy versus using the Primary Care Behavioral Health Model?  Kathleen Hi Kathleen, Although the basics are covered in Behavioral Consultation and Primary Care by Robinson & Reiter, I don't remember this being discussed in significant detail. One specific thing I recall is that they suggest no more than 10% of the patients a BHC sees should be seen more than 4 times in a year. I'll definitely be interested to hear if anyone is aware of lit looking at this specifically. This may not be anything new for you, but I can say a bit about my training around the topic. I was taught that there are three primary variables to consider: 1) Diagnosis 2) Symptom Severity 3) Patient Engagement The biggest pitfall is making decisions based only on the first two variables - the third is often unconsidered, but in fact the most important. Even if someone has really severe mental illness, if they have no motivation to see a therapist, making the referral is unhelpful at best! Similarly, we may automatically plan to refer someone out who is really motivated & asking for therapy, but if their symptoms/diagnosis aren't very severe, they're probably a prime candidate for us to take care of. Hope this is helpful; happy to say more if there are questions/comments/concerns. Mike  Another variable that is often under-appreciated is the availability of referral sources.  Working in rural systems without easy access to specialty mental health colleagues often forces a decision about fidelity to the PCBH model vs doing what we can to help a patient who has few other options. Additionally, we are torn between the ethic of striving for population health (ie., offering as many as possible who may benefit from our services a chance to have a taste of IBH consultation) vs the needs & readiness of an individual patient (ie, a patient with significant PTSD who has no access to the type of more regular & intensive therapy that might be most helpful). Our PCP colleagues struggle with some of the same issues-- the bar for referring out is necessarily higher in remote rural practices and systems  than it is for colleagues working in larger cities or more populous areas  with greater availability of specialized services. James  Well stated, James.  Our BHCs follow a soft target of referring patients out if they can't complete a treatment plan in 4-6 brief sessions.  Problems requiring more than that are referred to specialty mental health....in theory. But, access to specialty mental health (weeks to months) often derails that plan.  Also, the pressure of generating RVUs sometimes leads our BHCs to "keep patients longer" as they feel more confident in the revenue certainty of an ongoing patient or they feel more clinically confident with a particular diagnosis or problem.  And, sometimes the PCP will make a special request that a patient be "kept" in primary care.  In our rural Midwest geography, sometimes the weather is a deciding factor. Drive through the snow for 30 miles to see the psychologist or psychiatrist or see the BHC at the local PC clinic in my hometown. We are trying to solve that approach with increased use of telemedicine platform. Jeff Here is one brief summary <http://cirrus.mail-list.com/cfha/83003544.html> Alexander  Hi All - many thanks for the robust discussion of this topic, there have been some great PCBH posts here lately. Thought I’d comment on this one because it is especially important - and because it is often confusing for BHCs. First, here are suggested referral criteria in the PCBH model:  1) the patient is not improving after several visits; 2) the PCP requests specialty help; 3) there is an emergency need;  4) the patient requests specialty care. The JCPMS article that I, Chris Hunter and Anne Dobmeyer published in 2017 discusses this in more detail. In general, the goal in PCBH is to engage patients first in primary care. This is because, for starters, we know that many patients will improve in primary care - but we can’t predict in advance which patients will improve (a 2012 JCCP study by Bryan et al. even showed that more severely impaired patients improved faster.) In addition, we know that most patients who are referred to specialty mental health simply don’t go; indeed, this is the reason we are in primary care to begin with. (And while it’s true that rural communities are often particularly underserved, success with specialty referrals can be just as low in urban areas.) So if we don’t engage with patients in primary care, and they don’t go to specialty care…then we are right back where we started. Thus, it is very important to jump in and help, regardless of the problem. But perhaps most important is not whether one refers to specialty care, but rather how that referral is handled. I have nothing against utilizing specialty mental health; I have referred hundreds, if not thousands, of patients over the years (and I think a few have actually gone!). :) The key is to frame such referrals in a way that does not pathologize the patient, undermine your longitudinal relationship with the patient, or leave the patient without care. For example, I often witness BHCs telling patients they are “too complicated” for primary care, or “beyond primary care’s ability to help”. This is not only horribly pathologizing; it also effectively removes the BHC (and perhaps the PCP, too) as a potential source of help for the patient in the future. (And again, considering that most patients will not go to a specialty referral, this leaves the patient without any help.) As another example, I often observe BHCs making the mistake of ending meaningful follow-up after making a specialty referral, as if the job is now done. Sometimes they actually cease planned follow-up once the pt accepts the referral (even though the pt is not yet engaged in care). Other times they do follow-up, but cease their therapeutic efforts; follow-ups become merely a check-in to see if the patient has begun specialty care yet. This is problematic because - again - many of these patients will never engage  with specialty care and so once again end up with no care. I have a couple of recommendations for avoiding these problematic referral behaviors. First, instead of framing patients through the “either/or” lens (i.e., either they can be treated in primary care or they need specialty care), I recommend framing a specialty referral as an “addition” to the help you can provide in primary care. For example, “Ms. Jones, it seems we’re not improving your depression like we had hoped. I’d like to bring a specialist in on your care.” A referral, in other words, should be framed as expanding the care team, rather than replacing the care team. Keep in mind that the backbone of primary care is the longitudinal relationship; don’t sever it. (For this reason, I don’t agree with conceptualizing PCBH as the first step in a “stepped care model”. It should never be implied nor stated that patients are “stepping” out of primary care.) Second, if the patient agrees to a specialty referral, be sure to stay engaged until s/he is firmly established in specialty care. Continue working on therapeutic interventions - not merely checking with the patient on the status of their specialty appt. Third - perhaps most important - have some faith that you might actually be able to help patients in primary care. More often than not there is a tremendous amount that primary care can offer to patients, but because it doesn’t look like traditional specialty care we sell it short. We join in the grand delusion that only specialty mental health can save the day, so we opt out and write a referral. Those of us who are mental health providers have spent a lot of time in school learning how to help - don’t deprive  patients of your knowledge and skills just because you have shorter visits in this model. You might be surprised how much you can help if only you allow yourself to engage. (But if you do refer to specialty care - please avoid the pitfalls described above!) Thanks again for getting this discussion going! Jeff This is an important discussion because just under  the surface lurk unanswered questions that transcend models that attempt to estimate when a patient should be referred out of mental health service in primary care. The first question is: should mental health service in primary care serve to offload work from primary care clinicians ( MDs, DOs, NPs, PAs) but not increase the proportion of the population that would improve in " usual care". Or, should mental health clinicians in primary care attempt to increase the proportion of patients who improve compared to what is accomplished in usual primary care. Combining data from existing studies gives us some clues.  To my knowledge, there are no PCBH studies that have more than 49% of patients showing significant improvement. All these studies are not controlled but we dohave a wealth of data about usual care from scores of controlled studies where the control groups do not exceed this same proportion of the population( about 40 to 50%).  In all the PCBH studies, the vast majority of visits number between 2 and 4. There is one study sometimes cited as a PCBH study and sometimes viewed as unique that gives us some valuable insight. The Katon, Robinson, et al study," A Multi-Faceted Intervention to Improve Treatment of Depression in Primary Care" (Arch Gen Psychiatry. 1996;53:924-932). In this trial, 43% of the control group with major depression ( usual care) showed at least 50% improvement on the SCL-90 compared to 74% of the experimental group.( The SCL-90 was state of the art then before the PRIME MD was released in 1999) So what was the intervention? All intervention patients had a 1 hour initial visit with the mental health providers. They were given a booklet explaining the biology of depression and use of anti-depressants and a booklet on cogntive behavioral strategies. They were also given a 20 minute video * to view with their spouse* that covered material addressed in the written handouts. Patients were asked to participate in 6 face to face visits ( 84% completed 5 visits and 76% completed 6 visits) and *they received 4 follow up phone calls* ( mean 3.4).  Both groups of patients had access to medication treatment but  a larger proportion of treatment group patients adhered to taking the medicine compared to controls due to experimental group physician training and built in follow up. The take away for me  is that one size  does not fit all. Simply viewing treatment as complete in 4 visits ignores some important issues if the goal is to supersede population levels of success in usual care. Not all patients with the same level of illness severity respond in the same amount of time. Patients have varying responses to different forms of treatment. Perhaps the biggest issue yet to be addressed by any researcher focused on treatment of mental health in primary care is that a large proportion of patients will get better without any professional intervention. So additional questions include: Which patients respond to which treatments? How do we predict which patients will respond to treatment who would otherwise not improve? What factors predict when a patient will respond during a treatment course?  Until we can better answer these questions, I think behavioral health clinicians working in primary care need to work with more latitude than only 4 visits. Much of what is mentioned above is discussed more thoroughly and with more citations in a 2017 editorial that I co-authored with CJ Peek and Colleen Fogarty- Families, Systems, & Health 2017, Vol. 35, No. 3, 251–256 All of the other responses to this thread have addressed why the notion of "referring out" if patients do not improve may  be generating a wave of disservice due to access problems and low patient receptivity. I particularly like Jeff Reiter's comments and his underlying philosophy. During the last 5 years that I saw patients, I served as the in house behavioral health clinician for patients who often did not improve enough in the collaborative care model also present in our clinic. Many of these patients had a lot of chronic medical conditions that were intricately affected by their mental health challenges combined with social issues, etc and so required a high level of ongoing team care. Larry Larry, your reply raises a whole host of issues and questions, but is of course spot on. To answer your first question about what the goals of integration should be, I have always felt that the goal of the PCBH model is to improve primary care - in general, and for everyone. (and again, the Reiter, Hunter, Dobmeyer JCPMS article in 2017 discusses this in much more detail.) Other models, such as the CoCM and probably also co-located therapy approaches, have the goal of improving condition-specific outcomes compared to primary care as usual. I think it is hard to do both with any single approach. While we are on the topic, I should say that a major frustration of mine is that this goal of PCBH is not widely understood. Somewhere along the line, some in the integration community developed an unfortunate misunderstanding that the goal of the PcBH model is to improve outcomes for mild-moderate conditions relative to usual primary care; and that to do so the model deploys a brief (1-4 visits) therapy model that uses simplistic interventions in primary care (suffice to say that as a frequent trainer of BHCs, I’ve witnessed enough handouts and breathing training to last a lifetime). This misunderstanding is, to be slightly over-dramatic, the bane of my existence. It results in, for starters, passive BHCs who wait in their office for PCPs to do the hard work of screening, diagnosing and starting treatment, and then handing off the neatly wrapped package for a few brief visits. After all, if my role is to be a brief therapy provider then I should let the PCPs do their job and wait for referrals, right? It also results in inflexibility that runs completely contrary to the goals of the model. For example, BHCs with this misunderstanding reason that if a patient seems complex then s/he must be referred out immediately; s/he could not possibly be helped with just a few 30-minute visits, so therefore the BHC best not engage at all. Such practice behaviors will be the downfall of a service, because the patients PCPs most want/need help with are not generally the mild-moderate patients; they are mostly the complex patients. So if the BHC waits for the mild-moderate patients the PCPs don’t feel they need help with, and if they refuse to see the complex patients - then who exactly is left for them to see? That said, I do understand this inflexibility. As I said, it comes *partly* from this misunderstanding of the goals of the PCBH model. It also comes from disease model thinking that ties certain “diseases” to certain EBI’s that are not feasible for BHC work - e.g., if my patient has borderline pdo and I can’t offer traditional DBT protocols, then I can’t possibly help this person, right? Better refer out! Our graduate training has prepared us well for depriving care to people. Closely related to this is the magical belief that we can predict which patients are beyond our ability to help (our graduate training has also prepared us well for pathologizing and giving up on people). Frankly and unfortunately, a lack of knowledge/skills for how to intervene with a broad range of problems and ages is also a factor in this inflexibility (our graduate traing has *not* prepared us well for that). This misunderstanding of the model, along with these other factors and the resulting inflexibility, have become a huge thorn in the side of PCBH. It needs to be extracted because it is spreading infection. My hope is for our community to realize: 1) the goal of PCBH is to help improve prinary care in general, for everyone. Of course we want to improve individual outcomes for behavioral issues where possible, but our goal is much broader; 2) to that end, we must seek to help anywhere our clinic needs help. Limiting ourselves to mild-mod, acute  patients won’t suffice; and for that matter, limiting ourselves just to providing interventions won’t suffice - there are many other ways we can help improve primary care; 3) there is often much we can offer to even complex pts. They are not diseased; they have learned maladaptive coping that we can help them correct. And primary care, as the only part of the healthcare system with longitudinal relationships at its core, is often the perfect place to support such learning over time (not with weekly visits - with brief  but highly accessible/timely touches as needed over time); 4) we can often help PCPs *manage* complex patients even if they do not improve clinically; 5) none of this runs contrary to the PCBH model. It is a team-based model that requires flexibility. It is perfectly possible to do all of this while still maintaining 30-min visits and a consultative follow-up structure. So my plea is for BHCs to join in the controlled chaos of primary care. Don’t draw firm boundaries around yourself and wait for the “right” patients to come your way. They’re *all* the “right” patients! And don’t forget to look for ways to help your PC team members all throughout the day. If you’re doing this work right, it should be the hardest work  you’ve ever done, not the easiest (but also the most rewarding). You don’t have to lengthen visits and switch into therapist mode; you don’t have to sacrifice access or decrease your visit volume. There is plenty you can do to help while maintaining fidelity to the BHC role. More details about all of this are in the Reiter, Hunter, Dobmeyer 2017 JCPMS article. Thanks for reading! I hope everyone had a great weekend. :) Jeff
by L. Edwards
Wednesday, June 5, 2019
Billing for Hallway Handoffs and Phone Meetings 0 L. Edwards Good morning everyone - the order has come down from on high that we muststart billing patients for everything as of 5/1. My team and I have historically done all our hallways handoffs as no charges and also our phone calls asfreebies if we miss the patient while they are in the office. We have billedfor any short term therapy and coaching (90791, 90832, 90834). Apparentlythe team is costing too much and they want to see us even the playing fieldto at least try to break even. The most stressful concern for me is having to say something to the patientupon entering the room or starting the phone call about insurance and money.I feel so conflicted - this does not sit well with my values and the reasonwhy I feel integrated care exists. We are going to be choosing between thefollowing codes: 99484 (which can be used on the phone), 90832 - these 2will be the most often used, 90791, and then the Collaborative Care codes,for which consent is needed anyway. Has anyone developed to a script to inform patients that they may have aresponsibility? I am thinking something along the lines of, "I work as apart of the team here and accept the same insurance, so our meeting todaywill go through like your doctor's visit does and you may have a co-pay orsome small co-insurance. Is this ok with you?" But after 15 years of workingwith patients and never having to discuss this I am having to negativeautomatic thought that every patient will say no. Please share any experiences, good or bad - and thank you in advance! Hello, before billing it is important to know both the rules and the realitiesof reimbursement. Most programs don't bill for a warm hand-off because itdoesn't match the regs around billing for a 90832 - primarily that it needsto be 16 minutes or more. In addition you need to be able to justify thatyou had a therapeutic interaction with a purpose. This can be defined eitherspecifically e.g. diagnosis and intervention, or less so e.g. distress andcoping strategy...but the documentation needs to support the work. And, youneed to have actually delivered a therapeutic service. The 90791 is a one-time code that involves many elements - presentingsituation, some pertinent history, a diagnosis, etc. You probably don't wantto use this for a brief warm hand-off. The 99484 is only actually reimbursed by some of the payers and there arerules about how and when this can be billed. Probably you can do things to maximize your billing, but not only should theorganization be asking how you can "break even", but also should be asking how your behavioral health services positively impact the overall cost ofcare. For examples are the medical providers more productive because patients who need more time for their behavioral health issues, can see the BHC? Isthere less unnecessary ED use in your system, or more preventable IP visitsdue to behavioral health interventions? Are the providers happier? Your question about the conversation with the patient is important andshouldn't be the first interaction you have. Possibly it will be easier to script once you are clear exactly when you plan to bill, e.g. for 20 - 30minutes, vs. when you probably won't be billing - e.g. a warm hand-off of3-5 minutes. Then if you have 20 - 30 minutes you can talk with the patientabout how you could use that time...and then talk about the insurancebilling. Good luck with all of this. Mary Jean Thank you, Mary Jean. For those of you interested in learning more, markyour calendars for the PCBH SIG Webinar titled Financial savviness for theBHC: Practical strategies and tips Date: May 23, 2019 Time: 11 am PST / 12 MST / 1 pm CST / 2 pm EST Register in advance:https://zoom.us/webinar/register/165954ff7f06ec14c5b9141539e44ee6 Speaker: Mary Jean Mork, LCSW  Deepu  I agree with what Mary Jean has shared.  Sandy Blount who frequently contributesto this list serve has weighed in on this historically with some great wisdom. I will paraphrase what he has shared with one my posts to a similarquestion as you are asking though hopefully he'll weigh in himself.  If youhave to justify the BHC's value purely on RVUs in and salary/benefits out,it can be a tough calculation. I'd encourage you to broaden the "are they worth it" conversation by lookingat other variables, as Mary Jean posits, such as provider satisfaction, improvement in chronic disease indicators, improved depression/anxietymanagement, less trips to the ED, patient satisfaction, and as Sandy referenced (I hope I'm not butchering his words) a few months ago, the removal of"schedule busting patients" from the PCP's day.  When the PCP can do a warm handoff to the BHC of a complicated, emotionally struggling patient, itallows them to move on and see X number of additional patients that might have not been possible without the BHC's presence. In our health system, we are currently struggling to preserve the "purity"of our BHCs access for immediate consultations and handoffs, but getting alot of pressure from our finance leadership to have them see more patients,thus pushing our initiative towards a more embedded role rather than an integrated one.  This feels like an ongoing push and pull to find a way tojustify the model without losing dollars.  To make matters more interesting,our health system is very rural and there are few BH professionals in manyof our locales, making recruitment and retention very challenging.  As such,private practice is a lucrative alternative for many of our employees. Jeff Hi Elizabeth, We have been in a similar situation since we started our PCBH program last September - we did not bill for the first few months while we got a handle on things, but I explained in my intro that we would begin submitting charges for visits after the first of the year (which we did). Although I think the feedback you've gotten from others is very valuable, I've shared your questions and concerns so thought I'd give my 2 cents. First - don't sell yourselves short! You provide a vital service, and deserve to be paid for it as much as any healthcare professional does! I felt very similar to how you are feeling about this, and still do at times. There is that pull to justify yourself to the patient, and even apologize for having to bill them. Going to the last CFHA conference and talking about this with colleagues, and hearing the above message repeatedly from them, really helped to put me at east and frankly to more highly value the services I provide. Secondly and similarly, more experienced colleagues have pointed out to me that our patients have at least a general sense of their healthcare coverage, and will generally have an accurate expectation of whether a service will cost them money. For example, our medicaid patients expect, accurately, that they will have a copay for neither their PCP nor their BHC visit. In contrast, our commercial patients do not assume that BHC visits are free, just as they know their PCP visits aren't free. I acknowledge that the double copay for a same-day PCP & BHC visit can be a challenge, but this brings me back to my first point. If, instead of seeing the patient, you sent her/him to a counselor (which involves a lot of inconvenience that you are saving them), they'd still have a co-pay. It just feels wrong because it's all on the same day. When we started, we discussed at length how much detail we needed to go into with patients about the billing. After going to CFHA last year, we decided that going too deeply into the subject could imply we were burdening the patient instead of providing an important service in a manner far more convenient than otherwise possible. We realized we might actually cause the reaction we were afraid of. Ultimately, we decided that I would add the following verbiage at the end of my BHC intro: "We often piggy-pack my visits with your PCP visit, to make it more convenient, but it is considered a separate visit." I invite questions about any part of my introduction, and of course answer any the patient has about charges, but very rarely has anyone asked about the billing. I have yet to have a patient decline the visit, and we haven't had anyone complaining later that they were charged. To be fair, there have been 2-3 people who have declined a follow-up due to financial concerns, and in those cases I have still gone in for a very brief check-in to make sure there are no acute/crisis concerns, and to ensure there aren't any easy solutions (e.g., they have no insurance but haven't been set up for the sliding fee scale). Good luck with this huge change you're undertaking! And thanks to everyone in this community for always being so helpful. Mike Mike makes a very good case for explaining the billing to patients andfamilies, and as long as people are not getting a surprise bill, and havethe option to opt out, there should be no difficulties. Another way to think about it is to consider other areas of health care wherethere are multiple providers.   If you have surgery done at an outpatientsurgery center, you will have a bill and co-pay from the surgeon, theanesthesiologist and the surgery center, there will be 3 bills, sometimesfrom 3 different organizations. The same is true if you are admitted to a hospital, you will have a billfor physician services and for hospital charges. Some specialty pain clinics may have an outpatient see a physician and aphysical therapist on the first visit, again two bills, two co-pays. My point is that integrated care in primary care is not unique in terms ofbilling considerations, patients experience this in other settings. We canlook to those settings for examples of how it is managed. Doug In my experience running a service in the FFS world, I would say that manyadministrators get the argument that an integrated service can help financiallyin various ways, yet the bottom line is that they are running a businessand unless you’re heavily supported by grants (or can clearly demonstratethese other financial benefits - a very difficult thing to do), you probablyneed to at least come close to breaking even with your service at some point.One of the things that struck me though about billing was how few complaintswe received about bills, even after billing thousands of patients. To Doug’spoint, the vast majority of people are very familiar with getting bills forhealthcare services, and with being uncertain regarding what the finalbilled amount will be. Yes you need to provide informed consent, and yesyour documentation and clinical activities need to be sufficient for billing.But if you do that and you provide a high-quality service, most patients inmy experience are quite accommodating when it comes to bills. Jeff I agree with all the points made so far, and I appreciate the discussion as I find it very valuable to learn what other people are doing with these questions. We also bill for same-day visits when they meet criteria to do so. Typically, when I am asked to do a warm hand-off I introduce myself to the patient and then go through a script describing informed consent. It includes something along the lines of "Because I am a health care provider in this clinic, if you choose to stay for an appointment with me it will be billed through your insurance. If you would like to check with your insurance company first to ensure coverage, we can always schedule something on another day." We have a cheat sheet at our front desk of in-network and out-of-network payers that helps us shape the conversation and move the hand-off more towards 5-10 intervention and triage to another office if we are out-of-network for a patient. As Mike had stated earlier, we get very few refusals. I think I have maybe had 2 or 3 people in almost 3 years refuse on the basis of payment concerns. Even when patients have to pay some portion out of pocket, they are appreciative of the service and access and express that to us. Wishing you luck in finding out what works best for you! Kim Can I ask a related question to all of the experts on this list serve please? Do any of you have trouble with warm handoffs due to needing to pre-certify mental health benefits before you see the patient? How do you handle that? Thank you in advance for all of these insightful answers! I just started a job this week at a private healthcare organization where I am tasked with starting integrated behavioral health care. I was previously at an FQHC and therefore, did not run into these billing issues. Laura Hi Laura - The only time we've run into this issue is w/ Tricare. We go ahead and see the patient, knowing we probably won't be reimbursed, but go ahead and submit the PA so that we have it for future visits. We do submit the charges for the 1st visit as well, on the off-chance we can manage to get paid retroactively. Mike It is at the warm hand off that we tell the patient about billing for services and give them a cheat sheet that instructs them how to check with their insurance on their benefits coverage and make an appt. If it turns out that the patient is out of network or benefit and does not want to pay out of pocket we then just cancel the first appointment. Beth Hey all! Chiming in real quick! As I have stated in past posts, within the state of WA, we are able to bill Medicaid for same day behavioral and medical visits without an additional co-pay. Further, our organization has at the board level decided for insurances that require an extra co-pay (e.g., Medicare and some private insurances), our health center will not pass along that extra co-pay to the patient and essentially "eat the cost." We will still bill the insurance company but the health center will absorb the cost of the additional co-pay, not the patient. Further, and as someone indicated before, our handoffs ALWAYS include a sound introduction to services, a Contextual Interview, and intervention/goal setting, which allows for the time requirement of 16 minutes for a psychotherapy to be met, as well as other requirements of psychotherapy code. Thus, we bill for all of our handoffs. Lastly, I think this is an important conversation for all of us to have with our billing department. Most health centers have tremendous resources such as billers and coders that we often overlook to reach out to and ask about how to resolve a lot of these concerns. Our Director of Behavioral health, Bridget Beachy, regularly meets with the billing team to address any denials and/or concerns, as well as continue to learn how to make billing more efficient and effective (down to how to have our templates so our notes do not get denied). The one benefit of being in a FQHC is that licensed behavioral health providers are able to bill the established encounter rate for the FQHC, meaning, a BHC visit is just as valuable to the organization as a PCP visit. Further, BHC visits also count towards UDS visits, and last year, our BH department that is made up of 10 licensed BHCs and 4 BH trainees accounted for *10%* of our organizations UDS visits... a significant chunk of visits that is undoubtedly tied to funding! Hope that helps! David In our system, we've instructed our BHCs to not get into a prolonged debate about whether the patient's insurance will cover the session or not.  Rather, we frame it as "the PCP needs your help, see the patient at least this once, even if we don't get paid, because there is benefit to the larger team."If it turns out that the patient's insurance has no MH benefit or for some reason the BHC is not credentialed with that payer, we work to try to liaison with the patient and steer them towards a provider that is reimbursable if they need extended services. Bottom line is that we don't want the PCP to have the perception that theBHC will "cherry pick" only those patients that can be effectively billed for that first visit.  We figure the PCP wants help, we want to serve that request, and we will sort out the payer issue after we've met the patient and done our assessment.  We want to build confidence that if the PCP asks, we will respond, at least for an initial assessment. I'm not saying we don't care about getting paid.  But, by the BHC seeing the patient regardless of pre-qualifying them, it can "save" dollars down the road through more diagnostic specificity, hooking them up with resources that will address their underlying psychosocial concerns, etc. Jeff Absolutely. We bill out the co-pay on warm handoff. We do tell patients that is our practice. If a patient returns for a “piggyback” appointment, in which they already plan to be handed off from physician to BHC, the co-pay is collected at check-in. The business office did not love this plan at first, but it removes barriers for patients in that they don’t have to go back up to registration and re-register. For tricare, registration staff are notified via instant message. A PA is started and is ready for me to complete and hand back for faxing as soon as I have a chance. This is a great conversation, thanks everyone. In my setting we have also set up a cap on patient responsibility to help simplify things since we work with so many payors. We guarantee patients will never have to pay us more than $40 for a behavioral health visit (and it is discounted to $32 if they pay at the time of the appointment), even if their insurance declines the claim.  We have it written up on a small handout that is available at the front desk and around the clinic/with BHCs. Of course for Medicaid plans there is a guarantee of $0. For warm handoffs that become an assessment/intervention we are sure to inform the patient there will be charges. If we are unable to adequately gain consent for this we do not bill for that encounter. Katie
by L. Edwards
Thursday, May 9, 2019
MAT Research 0 L. Edwards I am a BHC at a FQHC in Augusta, GA. We have recently had one MD and a PA get their waiver to start MAT treatment. There is some controversy at the clinic regarding us providing those services and a few docs have even cited research advocating against MAT. I am presenting with the PA on MAT and wanted to include recent research regarding its efficacy. Therefore, I wanted to reach out to the CHFA community to see if any of you has a bibliography with the recent research and perhaps some recent meta analyses on the topic. If you all have any resources over viewing the brain science of SUDs and OUDs specifically then that would also be appreciated. Reach out if you think you could be of help and thank you for your time in advance,    Zachary   Wow. Hard to believe this is even a question anymore with the death rate. Lot of easy retrievable things like the CDC and SAMHSA guidelines.  Lori  When I encounter people with strong objections to MAT for OUD they have tended to think about the issue in one of these ways: 1) They expect that treatment for OUD should be exactly like treatment for Alcohol Use Disorder, and they believe strongly in the value of 12 step approaches. 2) They mistakenly believe that buprenorphine has the same risk/benefit profile as other controlled substances, or that it is somehow even more dangerous than other controlled substances. 3) They bring an ethical/moral worldview that objects to harm reduction in all, or nearly all forms. When their perspective is grounded in items 1 or 2 they will sometimes change their perspective when offered peer review literature. More often they change their perspective by observing a trusted colleague begin the use of MAT. You might try engaging them generally in conversations about harm reduction. How do they think about birth control for adolescents? Finally, I would want to make sure they understand that you agree that MAT for OUD is not perfect.  It does not cure all patients.  But it keeps more people alive and functioning than alternative treatments. And this is the same standard providers use for treating other chronic conditions like diabetes and hypertension. As far as peer reviewed evidence and opinion pieces that summarize the evidence here are a few good options from the last 2 years: Volkow ND, Jones EB, Einstein EB, Wargo EM. Prevention and Treatment of Opioid Misuse and Addiction: A Review. JAMA Psychiatry. January 2018. doi:10.1001/jamapsychiatry.2018.3126. Moreno JL, Wakeman SE, Duprey MS, Roberts RJ, Jacobson JS, Devlin JW. Predictors for 30-Day and 90-Day Hospital Readmission Among Patients With  Opioid Use Disorder. J Addict Med. January 2019. doi:10.1097/ADM.0000000000000499. Martin SA, Chiodo LM, Bosse JD, Wilson A. The Next Stage of Buprenorphine Care for Opioid Use Disorder. Ann Intern Med. 2018;169(9):628-635.  doi:10.7326/M18-1652. Wakeman SE, Barnett ML. Primary Care and the Opioid-Overdose Crisis - Buprenorphine Myths and Realities. N Engl J Med. 2018;379(1):1-4.  doi:10.1056/NEJMp1802741. Carroll KM, Weiss RD. The Role of Behavioral Interventions in Buprenorphine Maintenance Treatment: A Review. Am J Psychiatry. 2017;174(8):738-747.  doi:10.1176/appi.ajp.2016.16070792. Bhatraju EP, Grossman E, Tofighi B, et al. Public sector low threshold office-based buprenorphine treatment: outcomes at year 7. Addict Sci Clin  Pract. 2017;12(1):7. doi:10.1186/s13722-017-0072-2. Daniel Great answer, Dan. And great references. There is as much stigma toward MAT as toward OUD itself. That includes professional stigma. Barry I've read this thread with great interest, as we have introduced MAT into our Community Mental Health Centers (CMHCs) over the past year. What you describe is not uncommon.  What I consider to be the most important consideration of any new MAT introduction is the culture shift that occurs  or will need to occur.  As described previously, there are many myths related to MAT that are perpetuated out of a lack of understanding, or said more  directly, ongoing institutional stigma that exists regarding the comprehensive treatment of substance use disorders -- despite the great need, the lives lost, the clear beneficial outcomes, and the great expense to the broader healthcare system related to untreated substance use disorders.  In addition  to this, providers do not necessarily have the education, training or experience with MAT itself, as well as in the specific dynamics of a population with OUD.  If a provider does not have confidence in one's abilities to provide the service, or if the provider does not believe that there will be enough ongoing support, there will be a hesitancy to participate. A year and a half ago, we had only one waivered provider in addition to me. We now have eleven.  This takes time -- with a few initial adopters to build confidence and spread the word -- but it is possible. I highly recommend reviewing the Providers Clinical Support System website -- https://pcssnow.org/ . Great trainings and mentorship opportunities.  I would also consider SAMHSA a great resource for information and technical support. Thanks, Jeffrey
by L. Edwards
Thursday, May 9, 2019
BHPs and MAT 0 L. Edwards I am wondering if anyone has experience as a BHP working with patients undergoing MAT.  I had someone describe what they might do before induction, during induction, following induction.  Have also had some discussions about how you might support families/caregivers as they go through the process with the patient. Any experience with this as this field continues to grow? Lori  I have been doing this work for the past 9 years or so. The evidence to guide this practice is relatively limited.  Here are few take aways: - not all patients need counseling to recover from OUD, buprenorphine should never be withheld from someone who declines counseling - patients should be initiated an bup as quickly as possible, don’t build systems that require “ BH intakes” or “ BHscreening” by BH providers,  these systems act as barriers to treatment and put patient’s lives at risk. Most patients entering treatment already know how to use bup safely - home induction is just as safe as office based induction, practices should move to home based induction as soon as possible - patients and families benefit education about harm reduction and buprenorphine, for example: "yes this is trading one drug for another. This is trading a  drug that will kill you for a drug that won’t kill you." - rates of trauma are very high in this population, use a universal precaution approach to trauma informed care. - that said, OUD is a life threatening condition and some patients can recover from OUD without addressing trauma, nobody should be “forced” to deal  with trauma - some patients will not engage in group treatment for a variety of reasonable reasons - providers will find MI skills (empathy + evoking and reinforcing change talk) very helpful in this work - practical relapse prevention focused interventions are also very helpful - BH providers should help train all staff in practice about MAT and address issues of stigma Daniel  Thanks Daniel – I am trying to get at the specific skill set for the BHP and some experience/stories about what it has been like working in this emerging area of practice.  Is it rewarding, how might is change PCP acceptance of doing MAT, changing other staff attitudes towards patients with OUD and the MAT approach, heartwarming story, interaction with families of the patient.  What are the lessons learned so far from being a BHP in and around MAT treatment? The CFHA submission deadline closes tomorrow too so if there is a critical mass of input on this theme we might be able to spread the experience?  Lori  Hi Lori - in my previous job I worked with a number of PCPs who prescribed bup. They said it was actually among the easiest and most rewarding work they did as a PCP, though of course they had a cap on how many such patients they would follow, and were selective regarding the patients they would  take on. As a BHC in that setting, I got to know a lot of the patients who were on bup, and I really enjoyed the population. I think most crucial is for the BHC to be accessible. Not uncommonly these patients have setbacks and/or present in crisis, and esp in the beginning of tx the PCPs often appreciate having a partner to help them set and keep clear boundaries with patients who are struggling. In such cases, being available to help in the moment is crucial. Most of these patients either don’t want ongoing therapy/counseling, or in some cases are already engaged in specialty treatment, and they won’t come in for scheduled appts with a BHC at some later date. But they do greatly appreciate having a trusted BHC working alongside their PCP, to help them navigate into their new life and manage their way through setbacks that occasionally occur. So typically (like most pts seen in the pcbh model) I would see patients for one visit here, two visits there, often worked in just before or just after a PCP appointment on the same day, to lend additional assistance beyond the PCP’s for whatever issue was going on. It saved the PCPs from having to take additional time during their visits, gives the PCPs the added support they find helpful, and  provides additional help for the patients who typically are very grateful. I have a video somewhere with a couple of patient testimonials and comments from PCPs. If I can find it I’ll send it to you.   Jeff
by L. Edwards
Thursday, May 9, 2019
Cost Effectiveness in Integrated Care 0 L. Edwards Good morning list mates, My organization is looking at expanding integrated behavioral health services in primary care (currently have ~40 clinics already doing that) but as is often the case, the pro forma based on revenues and costs can show BH services struggling to break even.  Anecdotally, primary care docs love our program but we need to be able to make a renewed case to leadership that the "cost" of such an initiative is small (or favorable) compared to the benefit on overall patient health, not just depression, anxiety, etc. I have collected numerous articles here and there looking at cost offset of integrated behavioral health but wondering if anyone knows of a position paper, report, or what have you, done recently, that nicely summarizes the impact of BH on things like diabetes, hypertension, obesity, etc.  Again, mostly looking for an organized report as I can also go searching for individual articles.  But, did not want to re-invent the wheel if one of my colleagues knew of such a recent position document. Thanks for any help you all can offer! Best wishes, Jeff  It is difficult to make general statements about the cost effectiveness of integrated care that are true for all integrated settings. Before we can answer we need to know about about the payer environment.  Is it purely a fee for service environment?  If it isn’t purely fee for service, what is the nature of the other contracts? If your patient’s health improves who makes more money?  If your patient’s health gets worse who makes more money? One group’s cost savings are usually another group’s lost revenue opportunity. With regards to the satisfaction of your primary care providers, this is really important.  PCP burnout is a huge problem.  Recruiting and on boarding a new PCP costs hundreds of thousands of dollars per provider. In rural communities these costs are even higher.  If it is true that your PCPs choose to work in your practices because of integration this finding needs to documented and presented to leadership. - Dan  Well said. Cost offset and Cost effectiveness are related but different. I know of no other healthcare endeavors that are required to bring in more than they cost (though Laboratory services generally do). Milliman (Steve Melek) papers are useful though are projections Andrew  Your case depends on how broad an analysis they will allow.  In places that want to know if the BHC will pay for themselves through billing, it is a close call.  Although if you think about the BHC in the same terms one uses to assess the impact of a new nurse, for instance, it changes a bit.  No one says "Is that nurse going to pay for herself?"  They say, will she improve care enough to help our patients or to lower costs.  A BHC, in those terms is like a nurse who almost pays for herself. If you look at the evidence a little more broadly, the impact on PCPs is very quick with provider satisfaction going up reliably and provider retention documented in a few settings.  If the central administration connects this proposal not to their worry about losing a little money, but to their worry about maintaining their provider workforce, that may be an important refocusing of the analysis. Finally, and still within the data available to the health system, in several settings (I don't have time to dig these up this morning) where there was open scheduling for part of the day, the efficiency of the PCPs was shown to go up when a BHC was added.  The ability to hand off health behavior teaching, or "schedule busting" problems, to the BHC has allowed the providers to see more patients.  It only takes a little improvement to pay for the BHC time though only a few places have captured this effect in their analysis.  In many settings it is written up as an unexplained increase in efficiency of the PCPs and the BHCs are still under the gun for not bringing in more billing.  You can see that the more the whole program is analyzed, the more flexibility for BHCs and true integration is supported, whereas the more the BHCs are assessed only for their billing, the more it pushes them to a co-located model where they see patients in scheduled sessions all the time. If there can be cooperation with the payers who have the data on total health costs of patients, a whole new world of documented savings opens up.  See below: The Cost Effectiveness of Embedding a Behavioral Health Clinician into an Existing Primary Care Practice to Facilitate the Integration of Care: A Prospective, Case–Control Program Evaluation Kaile M. Ross1 · Betsy Klein2 · Katherine Ferro2 · Debra A. McQueeney2 · Rebecca Gernon3 · Benjamin F. Miller1 © Springer Science+Business Media, LLC, part of Springer Nature 2018 Abstract This project evaluated the cost effectiveness of integrating behavioral health services into a primary care practice using a prospective, case–control design. New Directions Behavioral Health collaborated with a large Kansas City primary care practice to integrate a licensed psychologist (i.e., behavioral health clinician) into the practice. Patient claims data were examined 21 months prior to and 14 months after the psychologist began providing full-time behavioral health services within the practice. Claims data from patients with Blue Cross Blue Shield of Kansas City insurance (BCBSKC) who had at least one encounter with the psychologist (N = 239) were compared to control patients (BCBSKC fully insured patients at large) to calculate cost savings. The results demonstrated that integrating behavioral health services into the practice was associated with $860.16 per member per year savings or 10.8% savings in costs for BCBSKC patients. Integrating behavioral health services into primary care may lead to reductions in health care costs. Your article is protected by copyright and mall rights are held exclusively by Springer Science+Business Media, LLC.  The link must be accompanied by the following text: "The final publication is available at link.springer.com”. Vol.:(0112 33456789). Journal of Clinical Psychology in Medical Settings, https://doi.org/10.1007/s10880-018-9564-9 Alexander Sandy, This is a most articulate commentary.  I wish I could carry it around on a 3X5 card and hand it out.  I appreciate your thoughtful remarks.  I will certainly use this wisdom as a piece of my argument going forward.  And, thanks, too, for the reference below.  I will ask our health science library to dig it up. Cheers! Jeff  Here are some relevant references re the PCBH model: 3. Gouge, N., Polaha, J., Rogers, R., & Harden, A. (2016). Integrating behavioral health into pediatric primary care: Implications for provider time and cost. Southern Medical Journal, ##, pp-pp. 4. Landoll, R.R., Nielsen, M.K., Waggoner, K.K. & Najera, E. (in press). Innovations in primary care behavioral health: A pilot study across the U.S. Air Force. Translational Behavioral Medicine. 5. Lanoye, A., Stewart, K. E., Rybarczyk, B. D., Auerbach, S. M., Sadock, E., Aggarwal, A., Waller, R., Wolver, S. and Austin, K. (2016). The Impact of Integrated Psychological Services in a Safety Net Primary Care Clinic on Medical Utilization. J. Clin. Psychol.. doi:10.1002/jclp.22367 6. Reppeto, H., Tuning, C., Olsen, D.H., Mullane, A. & Smith, C. (2018). Triple Aim: Benefits of behavioral health providers in primary care. Journal of Health Psychology. DttOpsI://1d0o.i.1o1rg7/71/01.13157971/1035391085830128984029949 Jeff 
by L. Edwards
Tuesday, March 19, 2019
Seeking Input Regarding Depression Registry Management 0 L. Edwards Hello CHFA colleagues, I'm writing from UC San Diego where we have a long-standing integrated primary care system; however, we are newer to using depression registries. My question for the group is, for those of you using depression registries, what type of staff/clinician (e.g., licensed behavioral health provider, nurse, behavioral health intern, other?) is responsible for depression registry management? Thank you for your time and input! Katrin  Hi Katrin, Our research team at ASU just completed a survey of 130+ clinics and asked who was in charge of enrolling patients into registries. Here is what we learned: Medical provider: 11% Nursing staff manager: 16.4% Behavioral health provider: 9.6% Care manager: 28.8% EHR: 11.0% Other: 23.3% The other category tended to included data analytics teams. Overall, it seems that BHPs are often not primarily responsible for patient registries. Matt Hi Katrin, In our clinics at Mayo the term registry has evolved such that there is a list of depressed patients who get added electronically by the computer to a list based on diagnoses and PHQ-9 scores.  Then, for patients in an active episode of treatment as in care coordination, a nurse in our clinics will ‘activate’ a patient who is eligible and agrees to be treated.  It seems best for them to do the task as it links to the CoCM billing codes. We also have a registry for psychotherapy and the therapists (social workers and psychologists) enter data on their own patients. Best wishes, Mark Katrin, In our system, we do maintain a depression registry, using Minnesota Community Measurements as our goal.  The registry is usually co-managed by the BHC and the RN care manager.  Our goal, a modest one at best, is 11% remission at 6 months by MN standards. Jeff 
by L. Edwards
Tuesday, March 12, 2019
Questions about Implementation Survey for MAT Services in PC 0 L. Edwards Hello, here in Maine, we are working together with several integration programs to prepare and support our BHC's in delivering the behavioral health aspects of MAT in primary care. We wondered if there are any surveys or scales that help programs identify where they are on the continuum of developing integrated MAT. Let us know and we'd be happy to partner with others nationally who may be using the survey/scale. Thanks, Mary Jean  Our group here in Cincinnati would be interested in something like that as well. Thanks, Navdeep Philadelphia would be interested too! Natalie I would suggest folks review the article I cite below. The survey instrument they used would be a good place to start. I will suggest that prerequisites include: - Openness to harm reduction informed approaches to care vs. abstinence only - A commitment to providing empathic communication to those with SUD - A clear understanding of the differences between specialty care and primary care (continuity, comprehensiveness, access, and coordination of care) and how this applies to primary care treatment of SUD (minimize patient burdens for accessing care, don’t require a comprehensive mental health evaluation before offering MAT) - Ability to provide trauma informed care Wakeman, S. E., Pham-Kanter, G., & Donelan, K. (2016). Attitudes, practices, and preparedness to care for patients with substance use disorder: Results from a survey of general internists. Substance Abuse, 37(4), 635–641. http://doi.org/10.1080/08897077.2016.1187240 BACKGROUND:Previous research demonstrates that most primary care physicians feel unprepared to diagnose and treat substance use disorder (SUD). Confidence in SUD management has been associated with improved clinical practices. METHODS:A cross-sectional survey of 290 inpatient and outpatient general internists in an academic medical center evaluating attitudes, preparedness, and clinical practice related to SUD. RESULTS:149 general internists responded, a response rate of 51%. Forty-six percent frequently cared for patients with SUD. Sixteen percent frequently referred patients to treatment and 6% frequently prescribed a medication to treat SUD. Twenty percent felt very prepared to screen for SUD, 9% to provide a brief intervention, 7% to discuss behavioral treatments, and 9% to discuss medication treatments. Thirty-one percent felt that SUD is different from other chronic diseases because they believe using substances is a choice. Fourteen percent felt treatment with opioid agonists was replacing one addiction with another. Twelve percent of hospitalists and 6% of PCPs believe that someone who uses drugs is committing a crime and deserves punishment. Preparedness was significantly associated with evidence-based clinical practice and favorable attitudes. Frequently caring for patients with SUD was significantly associated with preparedness, clinical practice, and favorable attitudes. CONCLUSIONS:SUD is a treatable and prevalent disease, yet a majority of general internists do not feel very prepared to screen, diagnose, provide a brief intervention, refer to treatment, or discuss treatment options with patients. Very few frequently prescribe medications to treat SUD. Some physicians view substance use as a crime and a choice. Physician preparedness and exposure to SUD is associated with improved clinical practice and favorable attitudes towards SUD. Physicians need education and support to provide better care for patients with SUD. Cascadia (large behavioral healthcare organization in Portland metro) has recently began offering MAT services; we currently offer maintenance of buprenorphine prescribing and will soon begin induction. I don't have a readiness survey to share but would be happy to speak about our implementation process and some of the challenges we ran into along the way. Thanks, Renee
by L. Edwards
Tuesday, March 12, 2019

Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA
info@CFHA.net

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.