1. PSP Child and Youth Mental Health
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PSP master PowerPoint template specifications
Font throughout: Myriad Pro
Title font colour: RGB
All text font colour: RGB
Title slide:
Title: 44 font
Speaker: 32 font
Place and date: 20 font
Content slide (positions from top left corner):
Title: 32 font; title text box: horizontal 0.56” vertical 0.25”
Main text box: horizontal 0.56” vertical 0.25”
Footnote: 12 font; horizontal 0.56” vertical 7.25”
Font sizes and bullets: see slide 2
PSP slide master specifications
Title and ending slides
Position of graphics and text from top left corner:
Top graphic: horizontal -.01” vertical 0.05”
Bottom graphic: horizontal 0” vertical 8.16”
PSP logo: horizontal .84” vertical 1”
GPSC logo: horizontal 4.49” vertical 7.19”
Master title: horizontal 0.56” vertical 3.5”
Speaker: horizontal 0.56” vertical 5.08”
Date and place: horizontal 0.56” vertical 5.92”
Information box: horizontal 1.64” vertical 3.17”
Main slides:
PSP logo: horizontal 9.28” vertical 7.18”
Page number: horizontal 10.14” vertical 7.72”
PSP Child and Youth Mental Health
Learning Session 4
© 2012 British Columbia Medical Association and Dr. Stanley P. Kutcher.  Health educators and health providers are permitted to use this publication for non-commercial educational purposes only.  No part of this publication may be modified, adapted, used for commercial or non-educational purposes without the express written consent of the BCMA and Dr. Kutcher.

2. Reminder…
A few housekeeping items: cells, washrooms. We know emergencies sometimes come up, please feel free to leave the room if you need to take a call Of importance you will note we are having a break at:

3. Faculty/Presenter Disclosure
Faculty’s Name: Speaker’s Name
Relationship with commercial interest:
Grants/Research Support: PharmaCorp ABC
Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
Consulting Fees: MedX Group Inc.
Other: Employee of XYZ Hospital Group
Personal relationships with commercial interests (one slide per faculty member/presenter).

4. Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [desribe support here – e.g. educational grant]
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support]
Potential for conflicts(s) of interest:
[Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose products are
being discussed in this program].
[Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program. [Enter generic
and brand name here].
Specific outline of connections/support for development/presentation of the program from commercial entities or organizations including educational grants, in-kind services (eg, logistics) AND specific aspects of the faculty/presenter connections that a reasonable program participant might consider relevant to the presentation, (eg, products made by companies named in Slide 1 that could be germane to the presentation).

5. Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
Specific outline of connections/support for development/presentation of the program from commercial entities or organizations including educational grants, in-kind services (eg, logistics) AND specific aspects of the faculty/presenter connections that a reasonable program participant might consider relevant to the presentation, (eg, products made by companies named in Slide 1 that could be germane to the presentation).

6. Objectives By the end of this session, you will be able to:
Share at least one idea from another practice that you want to try
Describe the next steps in collaborating with services in your community
Describe ways to collaborate with local school boards
Identify 1-3 actions you will take to increase the likelihood your changes will be sustained

7. Local Resources

8. A mind that is stretched by a new experience can never go back to its old dimensions.
-Oliver Wendell Holmes, Jr.

9. Sharing our experiences
What have you tried in the last action period
What has gone well?
What has not gone well?
What can help to move this work forward?
Facilitators note: This can be done in a variety of ways from round circle sharing guided by these questions with Q&A (not recommended fro groups over 12-15), to formal presentations and storyboards. Feel free to select a method that best suits your group. Stor borad template follows.

10. T.

11. Those Involved Mom Family Doctor CYMH Intake Child Psychiatrist
Elementary School Counselor
Teacher
Grandmother
Our team aim statement:

12. How did it go?

13. Changes Tested or Implemented
Communication

14. Taking the plunge

15. From this testing, we have learned
There’s only so much that the school system can do
Intake process at CYMH
Contacting the Child Psychiatrist
Pediatrics referral??
Go slow, there’s no rush most of the time!

16. We are surprised by Request for Pediatric referral!
How well everything is working for the child

17. Next, we wonder if we should

18. PC feedback from practice visits/observations
GPs aren’t screening
GPs are assessing and referring
TALK THE TALK, BUT NOT WALKING THE WALK…Despite positive reviews of the learning sessions, engagement with patients and use of tools is not happening… WHY?

19. Reflections What is one idea that you want to try?
What is one thing you still have questions about?

20. Billing

21. Child/Youth Mental Health Billing Family Physicians
MSP
Counseling (00120)
Maximum 4 services per year per patient – not restricted to patient’s own FP
Minimum 20 minutes, see preamble definition/requirements
Office Visit (00100)
For follow-up that does not meet Pre-amble requirements of counseling (time &/or nature of visit)
Group Medical Visits (13763 [3 pts] – [> 20 pts])
New sliding scale based on number of patients billed per patient
Billed per ½ hour or greater portion to max of 3 units per patient
Removes individual face-to-face “service” requirement
Not included in HVLIP cap calculations
Counselling (xx120 billing fee code) – Refer to the SGP, GPSC or MSP websites for the most current information
Time for appointment – minimum 20 min
Counselling is defined as the discussion with the patient, caregiver, spouse or relative about a medical condition which is recognized as difficult by the medical profession or over which the patient is having significant emotional distress, including the management of malignant disease. Counselling, to be claimed as such, must not be delegated and must last at least 20 minutes.
Counselling is not to be claimed for advice that is a normal component of any visit or as a substitute for the usual patient examination fee, whether or not the visit is prolonged. For example, the counselling codes must not be used simply because the assessment and/or treatment may take 20 minutes or longer, such as in the case of multiple complaints. The counselling codes are also not intended for activities related to attempting to persuade a patient to alter diet or other lifestyle behavioural patterns. Nor are the counselling codes generally applicable to the explanation of the results of diagnostic tests.
Not only must the condition be recognized as difficult by the medical profession, but the medical practitioner’s intervention must of necessity be over and above the advice which would normally be appropriate for that condition. For example, a medical practitioner may have to use considerable professional skill counselling a patient (or a patient’s parent) who has been newly diagnosed as having juvenile diabetes, in order for the family to understand, accept and cope with the implications and emotional problems of this disease and its treatment. In contrast, if simple education alone including group educational sessions (e.g.: asthma, cardiac rehabilitation and diabetic education) is required, such service could not appropriately be claimed under the counselling listings even though the duration of the service was 20 minutes or longer. It would be appropriate to apply for sessional payments for group educational sessions. Unless the patient is having significant difficulty coping, the counselling listings normally would not be applicable to subsequent visits in the treatment of this disease.
As of Nov. 1, 2015  you are required to record the start and end time for a prolonged counseling visit (0120 series)  in the patient’s medical record, and to submit those times with your billing claim to MSP.  This change was made in order to protect GPs in the case of audit.
We know that many of you feel swamped by paperwork, including documentation requirements for fees. However, the change is considered necessary in order to protect GPs in the case of audit.  Medical inspectors look for documentation to support the billing criteria for any fee, and in the case of the 0120, there is a requirement for a minimum of 20 minutes.  Requiring start/end times to be submitted and recorded for the 0120 series brings the fees into line with the GPSC Mental Health Management fees ( ) which have the same requirements.
GENERAL PRACTICE GROUP MEDICAL VISIT
A Group Medical Visit provides 1:1 patient care in a group setting. Group Medical Visits are an effective way of leveraging existing resources; simultaneously improving quality of care and health outcomes, increasing patient access to care and reducing costs. Group Medical Visits can offer patients an additional health care choice, provide them support from other patients and improve the patient-physician interaction.
Physicians can also benefit by reducing the need to repeat the same information many times and free up time for other patients. Appropriate patient privacy is always maintained and typically these benefits result in improved satisfaction for both patients and physicians.
The Group Medical Visit is not appropriate for advice relating to a single patient. It applies only when all members of the group are receiving medically required treatment (i.e. each member of the group is a patient).
The GP Group Medical Visits are not intended for activities related to attempting to persuade a patient to alter diet or other lifestyle behavioural patterns other than in the context of the individual medical condition.
Unlike previous billing of 00100, all of which counted toward the HVLIP cap of 50 patients per day, the new fee scale does not. It is consistent with the psychiatric group psycho-therapy and the SSC specialist group medical visit schedule.

22. Child/Youth Mental Health Billing Family Physicians
GPSC – fees restricted to FP accepting role of MRP for longitudinal coordinated care of patient for that calendar year
Mental Health Planning Fee (G14043)
Axis 1 diagnoses only
30 minutes face to face planning visit
If longer may also bill or depending on time and nature of service ( if up to 49 min; or if 50 min or more and fulfills counseling preamble requirements)
Mental Health Management (G14044 – Counseling Equivalent)
Maximum 4 services per year per patient once four used up – restricted to patient’s FP who billed G14043
Same preamble requirements as 00120
*Patient Telephone/ Follow-up fees (G14079)
14043 Mental Health Care Plan Fee
This fee is payable upon the completion and documentation of a Mental Health Plan for patients resident in the community (home or assisted living). Patients in acute or long term care facilities are not eligible. Patients must have a confirmed Axis I diagnosis of sufficient severity and acuity to cause interference in activities of daily living and warrant the development of a management plan. This is not intended for patients with self-limited or short lived mental health symptoms (e.g.: situational adjustment reaction, normal grief, life transitions). The Mental Health Planning Fee requires a face-to-face visit with the patient and/or the patient’s medical representative. Following the successful billing of the Mental Health Planning fee, the GP will have access to 4 additional counselling equivalent mental health management fees per calendar year once the 4 MSP counselling fees have been billed. Successful billing of the Mental Health Planning fee G14043 allows access to 4 mental health management fees in that same calendar year which may be billed once the 4 MSP counselling fees (00120) have been utilised.
 Successful billing of the mental health planning fee (G14043) allows access to 5 Telephone/ follow-up fees (G14079) per calendar year in the subsequent 18 months. Patient Eligibility: Eligible patients must be living at home or in assisted living. Patients in Acute and Long Term Care Facilities are not eligible.
Payable once per calendar year per patient. Not intended as a routine annual fee unless the severity of the illness requires a comprehensive Mental Health Plan review and revision.
Minimum required face to face time 30 minutes.
Visit fee on same day only payable in addition if total time exceeds 39 minutes; counselling fee on same day only payable in addition if total time exceeds 49 minutes.
Start and end times are now required for billing submission for mental health planning fees (14043) , palliative planning fees (14063) and mental health management fees (14044, 14045, 14046, 14047, 14048). The start and end times should also be recorded in the chart.
GPSC notes: “Minimum requirement of 30 minutes face-to-face time in addition to visit time (home/office) same day. Both chart and claim must state start and end times of the total service (planning + visit).”
*Telephone/ Follow-up fees – 14079
This fee is payable for two-way communication with eligible patients, or the patient’s medical representative, via telephone or by the GP who has billed and been paid for at least one of the following GPSC incentives:
Complex Care Planning Fee (G14033)
Mental Health Planning Fee (G14043)
Annual Chronic Care Bonus for COPD (G14053)
Palliative Care Planning Fee (G14063)
Attachment Complex Care Management Fee (G14075)
Telephone calls from physician or MOA to patient or patient representative
s from physician or MOA to patient or patient representative
for the purpose of medical management of the relevant chronic condition(s); it is not payable for simple notification of office or laboratory appointments or of referrals.
Chart entry must record the name of the person who communicated with the patient or patient’s medical representative, as well as capture the elements of care discussed.

23. Telephone Management Expansion
G14076 GP Attachment Telephone Management Fee
Access requires submission of Attachment Participation Code or as of January 1, 2016, registration in a Maternity Network or Unassigned Inpatient Network
$15 per 'visit'
All patients for whom that FP is community MRP
1500 per physician per calendar year limit (including locums)
Intent is to use to avert need for a visit; in practice, WIC, ER
Requires clinical discussion. NOT to be used for notification of appointments, referrals or prescription renewals
May be delegated to another College-certified healthcare professional (eg LPN, RN, NP, Social Worker – Excludes MOA)
Patients who are eligible for the GP Patient Telephone/ Follow-up Management fee (G14079) are also eligible for the new Attachment telephone fee (but not on same day)
Effective January 1, 2016, has been expanded to include those family physicians who are members of a GP Maternity Network or a GP Unassigned Inpatient Network and who provide care to patients who are not attached to them in the community, but who may be cared for in a shared care manner with the patients community Family Physician.
TIP: If covering for the physician who is patient's MRP (locum or on-call) submit with an e-note stating “covering for Dr. X billing number YYYYY”. GPSC fees cannot be correctly interpreted without reading the GPSC Preamble NOTES:
Payable only to Family Physicians who have successfully:
Submitted the GP Attachment Participation Code G14070 or on behalf of Locum Family Physicians who have successfully submitted the GP Locum Attachment Participation Code G14071 on the same or a prior date in the same calendar year; or
Registered in a Maternity Network or GP Unassigned In-patient network on the same or a prior date in the same calendar year.
Telephone Management requires a clinical telephone discussion between the patient or the patient’s medical representative and physician or College-certified allied care professionals (e.g. Nurse, Nurse Practitioner) employed within the eligible physician office.
Chart entry must record the name of the person who communicated with the patient or patient’s medical representative, as well as capture the elements of care discussed.
Not payable for simple prescription renewals, notification of office or laboratory appointments or of referrals.
Payable to a maximum of 1500 services per physician per calendar year.
G14077 payable for same patient on same day if all criteria are met. Time spent on telephone with patient under this fee does not count toward the time requirement for the G14077.
Not payable on the same calendar day as a visit or service fee by same physician for same patient with the exception of G14077.
Not payable on the same calendar day as G14079.
G14015, G14016 and G14017 not payable in addition, as these fees have been replaced by G14077 for FPs who have submitted the GP Attachment Participation Code.
Not payable to physicians who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care.
Not payable to physicians working under salary, service contract or sessional arrangements whose duties would otherwise include provision of this care.
Last updated: September 3, 2015

24. Patient Conferencing Simplification/Expansion
G14077 GP Attachment Patient Conference fee
Access requires submission of Attachment Participation Code or as of January 1, 2016, registration in a Maternity Network or Unassigned Inpatient Network
Less restrictive; replaces G14015, G14016, G14017
Removes requirement for onsite attendance
Removes need to conference with 2+ other healthcare professionals
Initiation by facility not required; either side can trigger
Any patient for whom FP is community MRP – no diagnostic restrictions
Any time either side feels is clinically warranted
$40 per 15 minutes or greater portion thereof
Max 2/calendar day, up to max 18/calendar year per patient
Effective January 1, 2016, has been expanded to include those family physicians who are members of a GP Maternity Network or a GP Unassigned Inpatient Network and who provide care to patients who are not attached to them in the community, but who may be cared for in a shared care manner with the patients community Family Physician.
Per 15 min or better portion thereof, for case conferencing with at least ONE other physician or allied care provider. This NEW case conferencing code applies no matter where the patient is, no matter how the conference occurs (telephone or in-person), or what the patient’s diagnosis is. May be initiated by the physician or the allied care provider. TIPS: When not conducted in-person, a case conference may consist of a series of two-way telephone calls with allied care provider and/or physicians, and possibly the patient as well. The time spent on the series of telephone calls is cumulative towards the time requirement for this fee.
If, as part of the conference you speak with other care provider for greater than the better portion of 15 minutes, and then call the patient , or may be billed in addition to
If the cumulative time spent conferencing with the allied care provider, followed by a call to the patient, is less than 15 minutes, then bill only
For brief simple advice to an allied care provider about a patient in community care, use MSP Fee
Phone calls to patients are not conferences and should be billed using fee codes or
GPSC fees cannot be correctly interpreted without reading the GPSC Preamble NOTES:
Payable only to Family Physicians who have successfully submitted the GP Attachment Participation Code G14070 or on behalf of Locum Family Physicians who have successfully submitted the GP Locum Attachment Participation Code G14071 on the same or a prior date in the same calendar year.
Payable only to the Family Physician who has accepted the responsibility of being the Most Responsible Physician for that patient’s care.
Payable for two-way collaborative conferencing, either by telephone or in person, between the family physician and at least one other allied care provider. Conferencing cannot be delegated. Details of the Conference must be documented in the patient’s chart (in office or facility as appropriate), including particulars of participant(s) involved in conference, role(s) in care, and information on clinical discussion and decisions made.
Conference to include the clinical and social circumstances relevant to the delivery of care.
Not payable for situations where the purpose of the call is to: - book an appointment - arrange for an expedited consultation or procedure - arrange for laboratory or diagnostic investigations - inform the referring physician of results of diagnostic investigations - arrange a hospital bed for the patient
If multiple patients are discussed, the billings shall be for consecutive, non-overlapping time periods.
Payable in addition to any visit fee on the same day if medically required and does not take place concurrently with the patient conference. (i.e. Visit is separate from conference time).
Payable to a maximum of 18 units (270 minutes) per calendar year per patient with a maximum of 2 units (30 minutes) per patient on any single day.
The claim must state start and end times of the service.
Not payable for communications which occur as a part of the performance of routine rounds on the patient if located in a facility.
Not payable for simple advice to a non-physician allied care provider about a patient in a facility.
Not payable in addition to G14015 G14016 or G14017 as these fees are replaced by G14077 for those Family Physicians who have submitted the GP Attachment Participation code.
Not payable to physicians who are employed by or who are under contract to a facility or health authority who would otherwise have participated in the conference as a requirement of their employment.
Not payable to physicians who are working under salary, service contract or sessional arrangements who would otherwise have participated in the conference as a requirement of their employment.
Last updated: September 3, 2015

25. Care Plans

26. Collaborating with School Boards

27. Improving Local Systems of care for CYMH patients
Note, this is a suggested guide of questions and planning tips that have not yet been tested (Feb 2012) as you test these conversation and learn different methods and prompts that work please share so we can update the deck for everyone!

28. What is our local system?
Step 1:
Who is in your local System of care for CYMH patients
Clinical Services – community based and specialty services
Educational services
Support services/support groups
Patient groups
Patients and their families
Allocate 1 group to each box

29. What is our local system?
Step 2:
What is the role of each of these groups?
List primary purpose of organization
Any inclusions/exclusion criteria
Add description where prompted

30. What is our local system?
Step 3:
What are the natural connection points between each group
Connect groups who have existing, active connections
Put a few words describing the connection GP
Specialist
Referral request
Consult letter

31. What is our local system?
Step 4
What are connections that need to be developed between these services
Insert a dashed arrow between the groups
Add a few words describing the new connection GP
Referral
MCFD
Clinicians
???

32. What is our local system?
Step 5
List the actions required to test the new connections in your local systems
Identify who needs to be involved
Who will do what
When will you test this

33. Are there any new connections that you would like to test?

34. Sustaining Your Gains
It’s never too early to consider how you are going to sustain your improvements. Implementing a change in practice does not guarantee it will sustain long term. In order to continue to reap the benefits from your hard work you need to focus on how to ensure your change will ‘stick’.
The risk of failing to sustain your changes is not just clinical, but can effect provider and staff satisfaction and future change efforts.
As we talk about sustainability of your changes, think about how you as a team can sustain the changes you have made.
Some strategies for holding the gains once initial improvements have been made (tested and implemented):
1. To work towards sustaining a change long term patients, staff and providers need to be clear what the benefits are in terms of patient care, workplace satisfaction, and personal practice. Using measurement to show the improvements will help to support the change. When each stakeholder can explain ‘what’s in it for me’ the change is more likely to sustain.
2. The permanence of the change should not depend on specific people, but should become embedded in the work processes. One of the ways to do this is to establish and document standard processes, so that even if there are staff changes everyone will know what the new process is and be able to follow it. Additionally, a plan for training new employees will help to ensure that the new responsibilities and new processes are understood and carried out correctly, and ensues continuity in practice over time.
3. Data collection continues so that the practice has information about whether the gains are being maintained. It may be that the data collection schedule can be reduced, with data collection occurring less frequently or with a smaller sample. The objective here is to monitor the new system, and guide improvements as they are tested and implemented.
4. One suggestion for embedding the change and making it permanent is to review job descriptions so that new personnel will know immediately what is involved in their responsibilities. Additionally, make sure that any documentations of policies and procedures reflect any change in process.
5. It is important to celebrate when an achievement has been reached, but also important to celebrate when that achievement has been sustained for a period of time. Keep focus and energy up by celebrating with your team your continued best practice and reminding yourselves of the good work you have done.

35. You can all work as one to sustain changes in practice and community!
As we talk about sustainability of your changes, think about how you as a team can sustain the changes you have made.

36. Thank you! 36