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

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

4. What is “Whole Health”of a patient?

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

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

8. Behavioral Health is a type of Upstreaming

9. 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.

10. 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 …..

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

12. 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.

13. 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)

14. Dr. Randall Reitz, example of this.

15. 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

16. Rae Sanchez, office mgr at West Elk Clinic

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

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

19. 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.

20. 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

21. 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.

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

23. 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.

24. 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

25. ….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)

26. PHQ2/GAD2 Process

27. Changes the System

28. Becky Ela, LCSW
Behavior Health Director
Delta County Memorial Hospital