1. Primary Care Milestone 15

2. QUICK FACT:
Primary care is the de facto treatment location for most patients with common mental health conditions like depression and anxiety, with 70% of all antidepressant prescriptions in the United States written by a primary care provider.
--AIMS Center, U. of Washington
Source:

3. Milestone 15 (Primary Care): Practice ensures that care addresses the whole person, including mental and physical health.
High-value primary care settings are designed to address both physical and mental health needs, for individuals and populations. 1 2 3
Practice does not have a consistent system for assessing and addressing behavioral health needs.
Practice identifies patients requiring behavioral health treatment or follow up and refers patients to providers outside the practice. Access is not always assured and no formal relationship is in place.
Practice is able to consistently provide access to behavioral health providers but information may not always be shared in a timely or consistent fashion and coordination with the primary care team is likewise inconsistent.
Practice is able to consistently provide access to behavioral health providers either within the practice or using a formal relationship so that care is fully integrated or coordinated and respective provider roles are understood.

4. Co-location of services
Many ways to meet this milestone
Collaborative Care Model
Co-location of services
Referring relationships
Integrated care (continuum)
Care team roles

5. Integrated Care
“The care that results from a practice team of primary care and behavioral health clinicians working with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.”
Integration of services (may or may not involve merging of organizations)
Integration.samhsa.gov

6. Integrated Care Continuum

7. Integrated Care Continuum
Integration.samhsa.gov

8. Referring relationships
Closest to traditional model
Tactics:
Improve screening for behavioral problems (depression, anxiety, alcohol and other drugs)
Develop relationships with BH providers and discuss expectations for care coordination
Create internal processes to close loop
Example from Nurture Pediatrics:
Screening tools are utilized at each well visit from 18 months up to determine if there are any behavioral health or substance abuse care needed in the family. Positive results are documented in the chart and followed up by referring to a list of community providers with whom a relationship has been established. In office follow ups are routinely made for any positive diagnoses to insure response to treatment. Behavioral health providers are requested to send us their visit summaries, patients are encouraged to have their providers do so.

9. Co-location of services
A good place to start for many practices
Co-locate an outside BH provider 1 or more days per week
Lower cost/lower risk, achieves some integration
Example from Plateau Pediatrics:
Patient assessments and screenings with each visit. Specific responses trigger further care needs including additional care for mental health needs, etc. We provide patients with information related to Mental Health specialists. Additionally, Plateau Pediatrics contracts with Mental Health Cooperative (MHC) and has counselors on site 4 days per week. Additionally, MHC has field case managers encompassing the region for in-home care needs.

10. Adding BH to the Care Team
Behavioral health consultants or care managers can come from a variety of clinical backgrounds:
Physicians
Psychologists
Nurses (RN, MSN/NP)
Social Workers (BSW, LCSW, MSW)
Examples:
Siloam consistently provides access to behavioral health providers within our practice and also through a formal relationship with an outside behavioral health service provider. Behavioral health care is fully integrated and coordinated and respective provider roles are understood. The LCSW has a formal relationship with Centerstone Community Health. The coordinator then follows up by phone to schedule the first appointment. The LCSW is a full-time staff member for the clinic.
Church Health has a full behavioral health staff including psychiatrists, behavioral health consultants, social workers, and nutritionists. These consultations and visits are charted in EHR. Each of our employees and incoming/new employees and trained in basic mental health in case there is an emergency.

11. Collaborative Care Model (CCM)
Evidence-based model developed at the University of Washington
Specific model of integration that involves patient, medical provider, behavioral health care manager, and a psychiatric consultant.
VMG is piloting CCM in 2018 using LCSW as care manager

12. Collaborative Care Model (CCM)
CCM Essential Elements
Element
Definition
Team driven
A multidisciplinary group of healthcare delivery professionals providing care in a coordinated fashion and empowered to work at the top of their professional training.
Population focused
The Collaborative Care team is responsible for the provision of care and health outcomes of a defined population of patients.
Measurement guided
The team uses systematic, disease-specific, patient-reported outcome measures (e.g., symptom rating scales) to drive clinical decision-making.
Evidence based
The team adapts scientifically proven treatments with an individual clinical context to achieve improved health outcomes, incl. effective medication management, psychotherapy

13. Billing
In Jan 2017 CMS began reimbursing four “behavioral health integration” codes.
3 are for general BHI (not specific to CCM)
1 is specific to the Collaborative Care Model
All are intended to support practice transformation to team-based care
Great “cheat sheet” at:
Commercial coverage is variable but expanding

14. Resources Electronic screening tools
Mental Health America free online screening tools (English/Spanish)
PHQ-9 overview: depression screening and scoring
MidSouth PTN Milestone Summary

16. Discussion What is working in your practices?
Where are the challenges?