making the case for behavioral health integration into primary care: a road map to success and...
TRANSCRIPT
Making the Case for Behavioral Health
Integration into Primary Care: A Road Map to
Success and Sustainability
William J. Kuzbyt, Psy.D., JD, LHRM, CAP
Behavioral Health SolutionsBonita Springs, FL
www.bhsfl.com
Sponsored by:Gulf Region Health Outreach Program Gulf Coast Behavioral Health and Resiliency CenterMental & Behavioral Health Capacity ProjectUniversity of South Alabama
Objectives
I. Understand implications of integrating Behavioral Heath into Primary Care
II. Discuss conceptual and structural models of integration
III. Discuss privacy, billing, and documentation
IV. Develop a road map for a comprehensive and sustainable Behavioral Health integrated program
Who’s Attending Today?
Administrative
Financial
Medical Providers
Behavioral Health Providers
IT
Key Questions to be Answered
1. Are there different ways to integrate behavioral health into primary care?
2. Are there established models of integration?
3. Is it appropriate and legal to integrate behavioral health records with primary care records?
4. What is SBIRT and how does it work?
5. How does the PHQ-9 work?
6. What are the codes utilized in behavioral health billing?
7. What documentation is necessary to bill?
Types of Behavioral Health Services
Counseling
Education
Prevention
Case Management
Medication Management
Behavioral Health Continuum of Care
Screening Assessment Diagnosis Treatment
The Importance of Integration from 3 Points of ViewPhilosophical
Practical
Clinical
Philosophical It is the right thing to do to bridge the
gap between behavioral health and medical care
Helps minimize stigma and discrimination
Practical
HRSA told us to do it
Accreditation organizations require it (NCQA, TJC, AAHC)
Many current patients present with behavioral health issues
CHCs serve patients who need behavioral health care
It is a cost effective treatment approach
Practically Speaking…
Not a new concept. More than 15 years of research supports it: 1999 Surgeon General’s report on mental health
acknowledged the crucial role of primary care with that of mental health.
2003 President’s New Freedom Commission promotes integration.
2004 HRSA designated the integration of behavioral health as a required service to be provided by FQHC’s.
2005 Institute of Medicine (IOM) called for integration as a best practice.
2006 SAMHSA Transforming mental health care in America.
2011 Accreditation organizations include behavioral health in continuum of care.
Clinical
Mental health problems go untreated in primary care. This compromises the quality of overall treatment and outcomes for patients.
PCP typically under-identifies mental health problems in patients.
Mental health issues correlate higher with low-income patients and racial/ethnic minorities.
Clinical (continued)
People with mental health issues “over-use” primary care services 3:1 as compared to average patients
A significant part of disease management requires behavior change
Clinical protocols often specify BH components (e.g. depression)
Good clinical practice requires communication between clinicians
Croghan, T.W. & Brown, J.D. (2010). Integrating mental health treatment into the patient centered medical home, Agency for Healthcare Research and Quality. Rockville: MD.
Clinical (continued) Many primary care visits have psychosocial issues (20 -
45%)
More patients seek help through the primary care system (patient is already there)
Community mental health services cannot meet the demand for existing referrals
Most patients do not follow-up with referrals from primary care to CMHCs
Behavioral health IS a part of basic general health care (Bio-psychosocial model)
Paine, J. and Mabargto, M. 2012. Integrated behavioral health and primary care. Retrieved from: http://healthcarecommunities.org/workarea/download/asset.aspxid=1343.
Utilizing 2010 UDS data, looked at number of patients likely to need behavioral health
2.5 million patients have some level of mental illness
351,000 identified with substance abuse but not treated
For every 2,500 patients served, need: 0.9 Licensed Mental Health Provider 0.4 Mental health support staff 0.3 Substance Abuse Provider 0.1 Psychiatrist
90% of Community Health Centers stated that they are below these levels
Burke, B.T., Miller, B., Proser, M., Petterson, S. M., Bazemore, A. W., Goplerud, E., Phillips, R. L. (2013) A needs-based method for estimating the behavioral health staff needs of community health centers. BMC Health Services, 13, 245-262.
Do We Need Behavioral Health Providers?
So…
Why with all this history of research and policy support are there not more FQHCs with fully integrated systems of care?
3 Quick Reasons We Often Say “No” to Integration
Behavioral health and physical health typically operate in silos
Sharing of information can be difficult due to issues of confidentiality, HIPAA, and state laws
Payment and parity issues are restrictive
Practical, Financial, & Clinical BarriersAdministrative
Can’t handle new project now
Can’t hire new staff and supplies
Can’t risk losing money
Financial Can’t bill for that service
Can’t make money
Clinical Medical Director says “Can’t deal with the personalities and
power struggles of providers.”
Provider says “I can’t treat those diagnoses, not my training.”
Provider says “I don’t have time to deal with more patient issues during the office visit. I barely have time to do referrals.”
New Motivating Factors…
Many grants (HRSA 330, HRSA HIT) and accreditation organizations (NCQA, TJC, AAAHC) are requiring integrated health care
Patient-Centered Medical Homes (PCMH)
PCMH Defined Care Delivery Model where the patient’s treatment is
coordinated through the Primary Care Provider to ensure they receive the necessary care when and where it is needed.
The goal is a centralized setting that facilitates partnerships between the patient, PCP and potentially, as needed and appropriate, the patient’s family.
Key focus is on information technology, health information exchange, and other means to assure that the patient gets the needed care. Care is to be culturally and linguistically appropriate to the patient.
PCMH Defined (continued) Quality of care is improved and enhanced through
access, planning, management, and monitoring of care.
Better coordinated care, treating the many needs of the patient at once, and empowering the patient to be a partner in their care are basic tenets.
The Joint Commission
New standard implemented January 1, 2014
Designed to further promote the integration of behavioral and physical health within healthcare homes
www.apapracticecentral.org/update/2013/11-21/accreditation-standards.aspx
Recap: Integrating Behavioral Health FQHCs provide a significant amount of primary care in the
United States
Primary Care is the “defacto” behavioral health “starting point”
Primary care settings are appropriate locations in which to provide behavioral health services
The “gold standard” is to provide fully integrated care
There are various ways to provide behavioral health services and different models available to achieve this goal
Models of Integration
Conceptual vs. Structural
Conceptual: A theoretical approach or framework to describe the model
Structural: The actual step by step guide to the procedures of the model
Continuum of Service Delivery
Isolated/Silo
Collaborative Co-Location Integrated
Conceptual Models of Integration
Isolated/Silo
Collaborative
Co-Location
Integrated
Isolated/Silo
No commitment between medical and behavioral health providers to work together
Patient provides only source of history
No referral network
Collaborative
A partnership under which a provider agrees to furnish services to those patients who are referred to it by another provider
Referral relationships may serve as a useful precursor to a more collaborative model, providing both parties with the opportunity to evaluate the partnership prior to implementing a co-location or purchase of services arrangement
Co-Location
A partnership arrangement under which a provider agrees to treat patients who are referred by another provider, but maintains autonomy of the practice and control over the provision of the referral, and is legally and financially responsible for the patient within the practice.
However, unlike the Silo and/or Collaborative Model, the provider furnishing the clinical services is physically located at the referring entity’s site.
Integrated Behavioral and medical providers are
physically located at the same site
In-depth appreciation of roles and cultures of providers
Team approach to treatment for the patient which increases treatment outcomes
Shared systems and facilities in seamless bio-psychosocial framework
Integrated vs. Co-Located
Integrated Care• Embedded member of primary care team
• Patient contact via hand off
• Verbal communication predominate
• Brief interventions
• Flexible schedule
• Generalist orientation
• Behavioral medicine scope
Co-Located • Ancillary service provider
• Patient contact via referral
• Written communication predominate
• Regular schedule of sessions
• Fixed schedule
• Specialty orientation
• Psychiatric disorders scope
Cherokee Health Systems, Blending Behaviorists into the Patient Centered Medical Home, Michigan Primary Care Association Webinar January 11, 2012
Collaborative Care Categorizations At a Glance
Collins, C., Hewson, D.L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. New York: Milbank Memorial Fund.
Collaborative Care Categorizations (continued)
Collins, C., Hewson, D.L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. New York: Milbank Memorial Fund.
Structural Models of Integration Impact
Chronic Care Model
Primary Mental Health Care
4 Quadrant Clinical Integration Model
Impact Model Patient’s primary care physician works with care manager to
develop patient treatment plan
Care manager educates the patient or “coaches”; offers brief (8 session) consults
Psychiatric Support
Outcome
“Stepped Care” 50% reduction in symptoms within 10-12 weeks
Unutzer, J., www.Impact-UW.org Professor, University of Washington
Wagner, E. (2002). The Chronic Care Model
Primary Mental Health CareKirk Strosahl
Mental Health Provider (“Behaviorist”) functions as a member of primary care team
Provides consultation to Medical providers
Brief “targeted” interventions
Co-located close to exam room
15-30 minute sessions
Focus is specific “behavior” changeStrosahl, K. (2002). Primary Mental Health Care, Mountainview Consulting Group, Yakima, WA.
National Association of State Mental Health Program Directors (NASMHPD). 2005. Integrating Behavioral Health and Primary Care Service: Opportunities and Challenges for State Mental Health Authorities.
Recap: Models of Integration
Behavioral Health service delivery is on a continuum
Move from Silos to Integration
A variety of ways or “models” to achieve integration
Understanding HIPAA Acronyms:
HIPAA — Health Insurance Portability and Accountability Act of 1996
HHS — US Department of Health and Human Services
OCR — Office for Civil Rights
Definitions: Protected Health Information (PHI)—
Covered Entities — every health care provider, regardless of size, who electronically transmits health information
Business Associate — person or organization that you work with which involves the use or disclosure of individually identified protected health information (PHI).
Privacy Rule—
Business Associate Agreement—defines the relationship between you and the business associate specifically regarding PHI
HIPAA—3 Rules Privacy
Security
Enforcement
HIPAA Privacy:
HIPAAPrivacy:
Major goal of the Privacy Rule is to ensure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public health and well-being.
The rule strikes a balance that permits important uses of information while protecting the privacy of people who seek care. The rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed.
Permitted Uses
A covered entity is permitted, but not required, to use and disclose protected health information WITHOUT an individual’s authorization, for the following purposes or situations:
1. To the individual
2. Treatment, payment, and health care operations
3. Opportunity to agree or object
4. Incident to an otherwise permitted use and disclosure
5. Public Interest and Benefit Activities
6. Limited Data Set for research, public health, or health care operations
Treatment, Payment, and Health Care Operations
Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.
Treatment, Payment, and Health Care Operations (continued)
Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits, and furnish or obtain reimbursement for health care delivered to an individual and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual.
Treatment, Payment, and Health Care Operations (continued) Health care operations are any of the following activities:
1. Quality assessment and improvement activities, including case management and care coordination
2. Competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation
3. Conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs
4. Specified insurance functions, such as underwriting, risk rating, and reinsuring risk
5. Business planning, development, management, and administration
6. Business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information, creating a limited data set, and certain fundraising for the benefit of the covered entity
Authorized Uses and Disclosures
An authorization must be written in specific terms.
It may allow use and disclosure of protected health information by the covered entity seeking the authorization, or by a third party.
Examples of disclosures requiring an individual’s authorization: Disclosures to a life insurer for coverage purposes
Disclosures to an employer for the results of a pre-employment physical or lab test
Disclosures to a pharmaceutical firm for their own marketing purposes
All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data.
The Privacy Rule contains transition provisions applicable to authorizations and other express legal permissions obtained prior to April 14, 2003.
Authorized Uses and Disclosures: Psychotherapy Notes A covered entity must obtain an individual’s authorization to use or
disclose psychotherapy notes with the following exceptions:
The covered entity who originated the notes may use them for treatment
A covered entity may use or disclose, without an individual’s authorization, the psychotherapy notes,
for its own training, and to defend itself in legal proceedings brought by the individual
for HHS to investigate or determine the covered entity’s compliance with the Privacy Rules
to avert a serious and imminent threat to public health or safety
to a health oversight agency for lawful oversight of the originator of the psychotherapy notes
for the lawful activities of a coroner or medical examiner or as required by law
Acknowledgement of Notice Receipt A covered health care provider with a direct treatment relationship
with individuals must make a good faith effort to obtain written acknowledgment from patients of receipt of the privacy practices notice.
The Privacy Rule does not prescribe any particular content for the acknowledgment.
The provider must document the reason for any failure and obtain the patient’s written acknowledgment.
The provider is relieved of the need to request acknowledgment in an emergency treatment situation.
Notice and Other Individual Rights Privacy Practices Notice: Each covered entity, with certain
exceptions, must provide a notice of its privacy practices.
The Privacy Rule requires that the notice contain certain elements. The notice must:
Describe the ways in which the covered entity may use and disclose protected health information.
State the covered entity’s duties to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice.
Describe individuals’ rights, including the right to complain to HHS and to the covered entity if they believe their privacy rights have been violated.
Include a point of contact for further information and for making complaints to the covered entity.
Covered entities must act in accordance with their notices.
The Rule also contains specific distribution requirements for direct treatment providers, all other health care providers, and health plans.
Notice and Other Individual Rights
Notice Distribution: A covered health care provider with a direct treatment relationship with individuals must have delivered a privacy practices notice to patients starting April 14, 2003 as follows:
Not later than the first service encounter by personal delivery (for patient visits), by automatic and contemporaneous electronic response (for electronic service delivery), and by prompt mailing (for telephonic service delivery)
By posting the notice at each service delivery site in a clear and prominent place where people seeking service may reasonably be expected to be able to read the notice
In emergency treatment situations, the provider must furnish its notice as soon as practicable after the emergency abates
HIPAA Privacy Authorization Form
HIPAA Privacy Authorization Form (continued)
HIPAASecurity: Specifically electronic transmission
3 Areas of Safeguards
1. Administrative
Policies and Procedures
2. Physical
Hardware
Software
Who has access?
Access of workstations
3. Technical
Housing of data
Authentication of entities
With which communication occurs
Documentation requests
Risk Analysis
HIPAAEnforcement: In 2006, set civil money penalties for violating HIPAA rules and established procedures for investigations and hearings.
As of a year ago:
Total investigations 72,570
Corrective Actions 19,306
100% Compliance 9,146
Eligible cause for enforcement 44,118
Health Information Technology for Economic and Clinical Health (HITECH) Act
The HITECH Act was enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009 and became law on February 7, 2009
It’s purpose is to promote the adoption and meaningful use of health information technology
The goal was to “create a nationwide network of electronic health records”
The Road to Success and Sustainability of Behavioral Health in Primary Care
According to HRSA (2012), utilizing UDS data, the average percentage of Medicaid patients in Alabama is approximately 50%
Generally, if you successfully bill Medicaid, Behavioral Health programs can be sustained
Alabama Medicaid
On May 13, Act 2013-261 Alabama Code §§ 22-6-150
Changes from fee-for-service to managed care
Creates Regional Care Organizations (RCO)
5 RCOs (§§ 560-X-37-.07)
RCO Governing Body consists of Board of Directors of 23 people
12 represent risk-bearing members
8 represent non-risk-bearing members
1 is physician from an FQHC, appointed by Alabama Primary Care Association and Alabama Chapter of the National Medical Association
RCO must establish a network of care. Psychologists, therapists, and social workers are clearly spelled out as providers in the legislation.
Alabama Medicaid Manual
Relevant Chapters:
16—FQHC
23—Licensed Social Workers
34—Psychologists
Documentation Required for Medicaid BillingReference: Alabama Medicaid Provider’s Manual
Chapter 34: Psychologists pp. 34-7 to 34-9
Client Intake
An intake evaluation must be performed for each client considered for initial entry into any course of covered services.
The intake evaluation process shall result in a determination of the client’s need for psychological services based upon an assessment that must include relevant information from among the following areas:
Family history Educational history Medical history Educational/vocational history Psychiatric treatment history Legal history Substance abuse history Mental status exam Summary of the significant problems the client is experiencing
January 2014 Medicaid Manual, Chapter 34--Psychologists, p.34-7
Treatment Planning
The intake evaluation process shall result in the development of a written treatment plan completed by the fifth client visit.
The treatment plan shall:
Identify the clinical issues that will be the focus of treatment
Specify those services necessary to meet the client’s needs
Include referrals as appropriate for needed services
Identify expected outcomes toward which the client and therapist will work to have an effect on the specific clinical issues
Be approved in writing by a psychologist licensed in the state of Alabama
The (initial) Treatment Plan is valid when the recipient/legally responsible person and the person who developed the plan sign and date it. Unless clinically contraindicated, the recipient will sign or mark the treatment plan to document the recipients participation in developing /revising the plan. If the recipient is under the age of 14 or adjudicated incompetent, the parent, foster parent or legal guardian must sign the treatment plan.
Treatment Planning (continued)
The Treatment Plan should not be signed or dated prior to the plan meeting date.
The Treatment Plan is valid when the recipient/legally responsible person and the person who developed the plan sign and date it.
Service Documentation
Documentation in the client’s record for each session, service, or activity for which Medicaid reimbursement is requested shall include, at a minimum, the following:
The identification of the specific services rendered
The date and the amount of time (time started and time ended--- excluding time spent for interpretation of tests) that the services were rendered
The signature of the staff person who rendered the services
The identification of the setting in which the services were rendered
A written assessment of the client’s progress, or lack thereof, related to each of the identified clinical issues discussed
All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. The author of each entry must be identified and must authenticate his or her entry. Authentication may include handwritten signatures, written initials (for treatment plan reviews), or computer entry (associated with electronic records—not a typed signature). A stamped signature is not acceptable.
Additional Information
Documentation should not be repetitive (examples include, but are not limited to the following scenarios):
Progress Notes that look the same for other recipients.
Progress notes that state the same words day after day with no evidence of progression, maintenance or regression.
Treatment Plans that look the same for other recipients.
Treatment Plans with goals and interventions that stay the same and have no progression.
Progress Notes
Progress Notes should not be preprinted or predated.
The progress note should match the goals on the plan and the plan should match the needs of the recipient. The interventions should be appropriate to meet the goals. There should be clear continuity between the documentation.
Progress Notes must provide enough detail and explanation to justify the amount of billing.
Authentication
Authors must always compose and sign their own entries (whether handwritten or electronic). An author should never create an entry or sign an entry for someone else or have someone else formulate or sign an entry for them. If utilizing a computer entry system, the program must contain an attestation signature line and time & date entry stamp. A stamped signature is not acceptable.
If utilizing a computer entry system, the program must contain an attestation signature line and time & date entry stamp. There must also be a written policy for documentation method in case of computer failure/power outage.
Billing Requirements Diagnosis—DSM-IV/DSM-5
CPT Codes
Encounter Form
Billing Form—HCFA 1500
DSM IV to DSM-5: Summary of ChangesThree Major Sections of the DSM-5
I. Introduction and clear information on how to use the DSM.
II. Provides information and categorical diagnoses.
III. Provides self-assessment tools, as well as categories that require more research.
DSM IV to DSM-5: Summary of Changes Section II—Disorders
Organization of chapters is designed to demonstrate how disorders are related to one another.
Throughout the entire manual, disorders are framed in age, gender, developmental characteristics.
Multi-axial system has been eliminated. “Removes artificial distinctions” between medical and mental disorders.
DSM-5 has approximately the same number of conditions as DSM-IV.
CPT Codes
SBIRT Screening
Initial screening is brief (5-10 minutes)
Universal
1 or more targeted behaviors (depression, anxiety, alcohol abuse, tobacco)
Brief Intervention Defined as 1-5 sessions
Goals
Educate patient about health risk
Motivate patient to reduce risky behavior
Referral to Treatment Can be complex based upon the information _____ in the Brief Intervention
Requires strong linkages to specialty treatment
Can be incorporated into an integrated model of care
SBIRT Screening Examples
PHQ-9
GAD-7
MAST
DSM-5 Online Measures
PHQ-9
PHQ-9 (continued)
PHQ-9 (continued)
GAD-7
MAST
MAST (continued)
92
Online Assessment Measures
SBIRT Documentation Documentation for billing purposes
Name, DOB, record number
Start/stop time of face-to-face
Assessment, clinical impression, and diagnosis
Plan of care (goals)
Patient progress, responses to treatment, revision of diagnosis
ICD-9, DSM-IV, DSM-5 diagnosis
Sign, title, and date the record
Key Questions to be Answered
1. Are there different ways to integrate behavioral health into primary care?
2. Are there established models of integration?
3. Is it appropriate and legal to integrate behavioral health records with primary care records?
4. What is SBIRT and how does it work?
5. How does the PHQ-9 work?
6. What are the codes utilized in behavioral health billing?
7. What documentation is necessary to bill?
Roadmap for Implementation
Acknowledgment of the Transition New processes
New procedures
Disruptive workflow
Modification of workflow
Present a plan with a “staged” approach Can’t do it all at once
Emphasize Continuous Quality Improvement (PDSA)
Roadmap (continued) Involve Leadership at every stage
Key stakeholders need to know of successes/needs for modification
Include “Technical Assistance” at all stages
Include a specific timetable for implementation at each stage
Include Performance Measures for goals
Include “Staff Training” as an “item” in the plan
Develop the “Tool Kit” for success
Premise; All FQHCs are Not Alike
“One size does not fit all.”
All FQHC sites within the same FQHC are not alike.
Just like we develop individual treatment plans for patients, we must develop individual behavioral health integration models for each FQHC, and possibly, each FQHC site.
Factors/Steps to Consider BEFORE Integration Conduct a needs assessment
Determine which approach works best for your agency/patients (coordinating care, co-locating, integrated)
Use data as the basis for decisions
Address the barriers, they will not leave by themselves!
“Buy-in” needs to be top-down and “inclusive”
Select the “right” providers; establish “champions”
Use a continuance performance measure (PDSA; PDCA)
Develop BOTH a good business AND professional relationship
Flexibility! **Change of Scope
Normalize BH in PC PracticeConceptually, management of mental health issues are similar to other common medical conditions
Recognition (Clinical/Screening Tools)
Initial Diagnosis/Assessment
Treatment Plan
Monitoring
Adjustments
Follow-Up Care
For more severe cases, refer to specialist
PCP Stressors
Lack of training to diagnose mental health patient
Time concerns for screening and treatment
Concern about effectively monitoring efficacy of treatment
Lack of access to mental healthCollaborationCoordinationCo-change