The Domino Effect Behavioral Health Skills Training ~April13, 2018 Becky Ela, MSW, LCSW Delta County Memorial Hospital

The Domino Effect: How Implementing Behavioral Health In Primary Care Effects our Workflows

What is “Whole Health”of a patient?

Whole Health includes: Physical Health Emotional Health Spiritual Health Social Health

Upstreaming Social determinants of health that effect an individuals emotional and physical outcome. Public Health model

https://www.youtube.com/watch?v=xYeAmafTGCA

Behavioral Health is a type of Upstreaming

When we use tools/measurements such as the PHQ/GAD, we are affecting change in primary care office with the intent of mitigating crisis or an acute event in the future. Such as an ED presentation for anxiety/panic attack or worse, death by suicide.

Done in Primary Care All the Time If a patient presents to the clinic & their BP is 180/120, what do we do? =hypertensive crisis and …..

Mental health/emotional health, like HTN can go undetected, which is why universal screenings in primary care are so important

Considering starting BH or your clinic already has…? Considerations: Salesman Mavens Connectors From noted author Malcolm Gladwell’s book, Tipping Point, he talks about “the moment of critical mass, the threshold, the boiling point” when the right people and ideas combine to create change. Talk about DCMH DEO priming the Board for Integrated Care, then the community needs assessment. If you want that change to last past the initial flare, he describes 3 types of people that are critical in systems in order to carry on.

Salesman Need a staff member/colleague who can sell the idea of BH to the entire clinic staff This individual sees or has the vision, they often live the core values of what they’re selling They are the cheerleader for doing what we care about (physician champion, mid-level, MA)

Dr. Randall Reitz, example of this.

Mavens This person holds the knowledge about how things work The are the people who “get it” and understand the implication for culture in the current system

Rae Sanchez, office mgr at West Elk Clinic

Connectors People who know people Share ideas and resources so that we don’t reinvent the wheel Connect clinics with one another Alex Schmidt

Now...what does each staff role in your clinic do to impact the whole of patients in your clinic?

Staff roles in addressing whole health of patients Front desk: give patients questionnaire while patients wait for their appointment Advise patients to complete form & give to the MA Huddle in a.m. Front desk staff attend this and have appropriate questionnaires, BH consents ready in a file for each patient all day.

Medical Assistant/LPN: Take PHQ/GAD from the patient, enter it into Athena in the screening section If score is abnormal, MA/LPN verbally tells provider before they meet the patient what the score is Score=3 or less, enter into Athena in screening section, document as normal in A&P section Score=4 or more, perform PHQ9/GAD7, same as above & entered as abnormal Score=10 or higher, create referral & send to BH

Get Behavior Health Specialist or Send referral Physician/F.N.P’s: talk with patient about score, discuss available BHS Get Behavior Health Specialist or Send referral If BH is in the office, they’ll do a warm hand-off and we’ll come in to meet with patient. If we aren’t in the clinic, we get a referral and follow up with the patient with a phone call.

Behavior Health Specialist: meets with patient in exam room Meet and greet and schedule follow up appointment Can be a 10-15 min sleep hygiene or coping skills for managing anxiety Can schedule longer follow up.

Billing/Coding: Does your coder/biller know about BH billing codes? BH new field and billing portion is unknown to many. We have designated BH coder for our dept in the hospital. As the BH clinician, do you know what you can bill? I’m learning about what I can talk to someone about & bill it as; sleep, alcohol and tobacco.

Other Considerations…. Space Billing EMR~BH documentation & table space How will you introduce your BHS to patients? Licensure of your BHS (LPC, LCSW, Psychologists, LMFT’s) EMR- who has access to the note? All staff, only clinical staff, etc. We’re creating a table space within our EMR that only providers/BHS can access Intros: scripts for providers to know how to introduce the BHS

….and more Follow up for BH issues (patient navigator, nursing staff, care coordinator) How often will you screen for depression? Will you screen for anxiety? How often for these? What will you do when a patient checks question 9 on the PHQ and BH isn’t in the office that day? Will you screen for SUD? (bill for SBIRT)

PHQ2/GAD2 Process

Changes the System https://www.youtube.com/watch?v=LryDegZR-18

Becky Ela, LCSW Behavior Health Director Delta County Memorial Hospital rela@deltahospital.org