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

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  The provided funds for space in several RIPCPC practices

What was working…  As we see it in our practice, we see no flaws  BC recognized the value of the co- located BHP and agreed with broadening their scope

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…  Since most BVP’s were so well accepted into the practice, 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

The original plan….

What changes were made  As a result, we now rely on our BHP to provide treatment for all of our patient’s needs  Since she 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

What was working/What wasn’t working

Background  Co-Located BH has been located at FHSM, a PCMH physician office, for the past 2.5 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

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

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

BH Co-Location Workflow

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

Cons  Not really any cons to this co-location of BH within the PCMH practice

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  At times an introduction to the BH therapist is done along with the PCP or staff member who works with the patient to arrange BH counseling  Putting a face to the name within the comfort of their physician office keeps the patient engaged

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

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

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 consulatation

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

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

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

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

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

How BH provider collaborates with physicians and NCM  We work together collaboratively as past 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

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

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

Case Study

Conclusion  Provides a Holistic approach to our PCMH practice