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Implementing a Co-Located Behavioral Health Model in Primary CareBenefits and Challenges

October 9, 2014

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Objectives Describe the process for obtaining a collocated

behavioral health practitioner Describe the process for referring to collocated

behavioral health practitioner Describe the process for coordinating care of

patient with behavioral health practitioner, including having the behavioral health practitioner in care team meetings on patients

Describe how medical and behavioral health records/notes are shared among providers

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FHSM Background PCMH- 3 physician practice

Integrated clinicians-NCM, Dietician, Behavioral Health

CSI original pilot site

2011 NCQA Level 3 recognized

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Gateway Background Non-profit BH care organization

established in 1995

Provides a wide array of services to adults, children, & families in RI

Has 42 locations statewide, also offers free care each year to those in need-improving access

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How it all began…. The relationship with Gateway was

started as part of contract with BCBSRI that we negotiated 5 years ago

BC was willing to support the concept of a co-located BH provider

BC provided funds for space in several RIPCPC practices

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How it all began…. The concept was for the BHP to provide BH

to patients who have trouble stopping bad habits, i.e., smoking, over-eating, inability to follow a therapeutic diet, etc…

BC allowed the practices to expand the scope of the BHP to include all mental health needs while continuing to emphasize helping those requiring behavior changes to improve their physical health

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The original plan….

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What wasn’t working Timed patient encounters

Narrow scope of intervention

Focusing only on habits, not getting to root of the problem

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What was working… Increased access to BH provider

Focus on identifying underlying issues

Establishing in-roads to make real change

As we see it in our practice, we see no flaws

BC recognized the value of the co-located BHP and agreed with broadening the scope

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Pros Increased patient

compliance with BH counseling due to the PCMH relationships

Therapist seen as a member of the treatment team

Patients more comfortable seeing BH therapist in their physicians office

Decreased stigma associated with BH

Convenience to patients

Increased efficacy in meeting patient needs in a timely manner

Same message re-iterated by all members of the PCMH team

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Cons Not really any cons to this co-location of

BH within the PCMH practice

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What changes were made As a result, we now rely on our BHP to

provide treatment for all of our patient’s needs

Since BHP is employed by a larger organization, she is able to refer patients to Gateway specialists when she feels the problem is beyond her scope of expertise

In this way it truly expands the reach of the medical home to have access to treatment for virtually all BH needs

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Co-located, Collaborative Care Services

Embedded behavioral health provider This approach involves providing services to

primary care patients in a collaborative framework within primary care teams.

Behavioral health visits are provided in the primary care practice area, structured so that the patient views meeting with the behavioral health provider as a routine primary care service and medical providers are supported across a broad scope of behavioral health concerns

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Co-located, Collaborative Care The co-located, collaborative care model

involves the mental health professional as an integral component of the primary care team

BPH assists in managing the overall health of their enrolled population

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A D iff e re n t A p p ro a c h

Collaborative MH Care/Co-Location Location-On site, embedded in the

primary care setting Population -Most are healthy, mild to

moderate symptoms, behaviorally influenced problems.

Provider Communication- Collaborative & on-going consultations via PCP’s method of choice (phone, note, conversation). Focus within PCMH.

Service Delivery Structure -Brief (20-40 min.)visits, limited number of encounters(avg. 2-3), same-day as PC visit.

Approach -Problem-focused, solution oriented, functional assessment. Focused on PCP question/concern and enhancing PCP care plan. Population health model.

Mental Health Specialty Care

Location - A different floor, a different building Population -Most have mental health

diagnoses, including serious mental illness

Provider Communication-Consult requests, progress notes, Focus within mental health treatment team.

Service Delivery Structure-Comprehensive evaluation and treatment, 1 hour visits, scheduled in advance.

Approach- Diagnostic assessment, psychotherapy and psych pharmacotherapy, individual and group, recovery- oriented care. Broad scope that varies by diagnosis.

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BHP Provider BH provider provides assessment and

psychosocial treatment for a variety of mental health problems, such as, but not limited to: depression and problem drinking

The BHP's goals are to help improve recognition, treatment, and management of psychosocial/behavioral problems and conditions in the enrolled population.

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Co-located BHP Role

The BHP’s role is to provide support and assistance to both PCMH team and their patients from a different perspective

Engaging the patient in behavioral health care: Perhaps a service they would have not

previously participated in

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BH Provider Focus General service delivery for a wide range of concerns.

Likely that the majority of presenting concerns addressed involve traditional mental health problems such as depression, anxiety, PTSD and substance misuse

The intended scope of these roles encompasses all behavioral issues that impact health Such as pain management, insomnia, tobacco

dependence, weight management etc.

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Benefits of BH to the PCMH Using appointments efficiently (e.g., identify problem,

recognizing how functionally impaired is the patient, noting their symptoms, summarize to patient understanding of problem, use some time to develop and start a behavioral change plan).

Demonstrates capacity to consistently use intermittent visit strategy-what is best for the patient

Appropriately suggests the patient seek specialty behavioral health care when the intensity of service needed to adequately address the patient’s problem is beyond what the BHP scope of practice (e.g., PTSD, OCD, Marital Counseling, ETOH)

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BHP Introduction Initial patient/provider introduction helps to

make the patient more comfortable seeking BH treatment and is especially helpful within the comfort of their PCP practice.

The initial introduction is usually unscheduled; staff or patient initiated contact with the BHP for an immediate problem-focused intervention.

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BHP Initial Visit

Patient referred for a general BH evaluation or determination of level of care.

Focus on functional evaluation, recommendations for treatment and forming limited behavior change goals.

Involves assessing patients at risk because of some life stress event.

May include identifying if a patient could benefit from existing specialty care or community resources.

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BHP Follow-Up Visits

Arranged to support a behavior change plan or treatment target identified by the PCP on the basis of earlier consultation; often in tandem with planned PCP visits

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BH Treatment Adherence

Visit designed to help patient adhere with intervention initiated by PCP.

Focus on education, motivational interviewing, addressing negative beliefs, or strategies for coping with side effects.

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BH Educational Group Visit

Brief group interventions that supplement individual consultative treatment, designed to promote education and skill building/effective problem-solving.

Support of their peers who have similar health challenges addressed in this type of group treatment has been beneficial

Topics discussed -the change process, coping with stress and chronic illness, etc…

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Collaboration of the PCMH Team An on-going dialogue between the provider, nurse care manager, and

behavioral health. This communication should not only include consultations about direct

patient care, but should also include discussions about role expectations and the unique contributions that each position brings to the PCMH team.

When each provider type is functioning well within their roles, all three positions compliment each and blend to provide exceptional patient care.

It is recommended that initially formal meetings are scheduled, until collaborative roles, expectations, and processes for informal consultations are well established.

For example, within this framework the behavioral health coordinator can serve as an expert consultant on health behavior change to both the Physician and the NCM. Further, NCMs and Physicians can mutually refer to each other, depending on the needs of any given patient.

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BHP Approach Ability to apply the bio psychosocial model of assessment to

the PCMH setting. Ability to formulate diagnostic and treatment

recommendations.

Present findings to treatment teams (i.e., physicians, nurse care manager, dietician, and supportive staff as appropriate).

Use their specialized knowledge of evidence-based treatment for general behavioral health problems (e.g., depression and anxiety) and areas of behavioral medicine (e.g., chronic pain, obesity and sleep problems).

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Background Co-Located BH has been located at

FHSM, a PCMH physician office, for the past 3 years

Patients come in for appointments with the BH therapist at the physician office

The therapist has her own comfortable private office located near the practice NCM and physician offices

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Background The BH therapist sees patients for

individual psychotherapy The therapist works closely with PCP’s

and NCM to coordinate treatment efforts The therapist is available to the PCMH

practice to assist with staff training and education, having provided in-service education on Cultural Diversity and Conflict Management

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Background This past year the BH therapist has

assisted with group patient education classes held at the practice for our chronic disease patients,

The therapist provided educational topics on the behavioral health component The Change Process Dealing with Stress

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Referral Process Referrals are made directly from the PCP, NCM, or

the integrated Dietician The patient appointments are scheduled through a

Gateway scheduler. Also, referrals can be made through EMR Introduction to the BH therapist is done along with

the PCP or staff member who works with the patient to arrange BH counseling

Meeting the therapist within the comfort of their physician office eases the acceptance of participating in behavioral health services

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Referral Process, cont. The Gateway case manager takes the

basic demographic patient data and reason for therapy via phone intake process

The patient appointment with BH therapist is arranged

Patients eligibility and co-pay is validated at this time

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Types of patient information needed for referral Basic

demographic info Insurance and

billing info Medical issues Medications Diagnoses

PCP/NCM recommended treatment plan

Pertinent info related to reason for behavioral health referral

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How patient information is shared When there is a particularly sensitive or

pressing referral the PCMH staff will consult with BH therapist in person to make aware of the presenting issues

Helps to ensure that the patients gets an appointment booked with me in a timely manner

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How patient info is shared, cont. When the therapist meets the patient for the

first time, a discussion takes place with the patient that the therapist is part of the PCMH team

The therapist has access to patient medical record at the practice

The therapist visit notes become part of the medical record

Info is shared through therapy notes, phone messages in the EMR, and by in person consultation

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Types of therapy offered Primarily cognitive and dialectical

behavior therapy Motivational interviewing to help gauge

where the patient is in the change process

Motivation in working toward increasing confidence in their ability to make positive change

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Types of therapy, cont. Some elements of a psychodynamic

insight oriented approach to help patient’s understand how dysfunctional behaviors have been developed and maintained

Utilization of CBT/DBT techniques to establish healthier, more functional behavior patterns

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Communication with the PCMH Team Treatment is provided generally individual,

sometimes couples or family therapy Referrals will be made as are clinically

appropriate which will include inpatient, PHP, and more specialized interventions Imago couples therapy Neuro-psych testing Inpatient/Residential/Detox/Substance Abuse

treatment Psychiatry

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Communication with PCMH Team PCPs/NCM are kept updated by

treatment notes However, when patients present with

these greater needs these are the patients that the BHP and the PCPs/NCM are touching base on with brief consultations on a regular basis to ensure we are on the same page with regard to what will best meet the patient’s needs

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How BH provider collaborates with Physicians and NCM We work together collaboratively as part

of the patient’s treatment team We provide different interventions but

communicate to ensure we are all saying the same thing to the patient

Thus, we are reinforcing the work the patient is doing in all areas of their treatment

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How f/u appointments are coordinated Follow up appointments are generally

scheduled by BHP at the end of the initial appointment

Patients can also either call the BHP or the Gateway case manager directly to schedule a follow up appointment

The PCPs/NCM can request that a patient be contracted for a follow up appointment

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Costs for BH Therapy The charge for therapy is determined by

the patient’s insurance company The patient is responsible for whatever

their specialist co-pay or deductible mandates

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Case Study Patient Snapshots

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Conclusion Co-location provides a Holistic approach

to our PCMH practice Extends the access to behavioral health

services Allows for prompt feedback Promotes a care team effort

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Questions?

Thank You!

Albert J. Puerini, MD Karen Bouchard, RN, NCM Johnna Pratt, LICSW