1. Behavioral Health in the PCMH: Making it Work in Small and Medium Sized Independent Practices Lori Zeman, PhD, Licensed Psychologist Director of Behavioral Health Integration, MedNetOne Health Solutions Lzeman@mednetone.net Michigan Primary Care Consortium Symposium 4/29/14

2. Objectives Define why it is important to integrate behavioral health into the PCMH Discuss ways behavioral health and physical health can be integrated to improve care Identify important considerations and implementation strategies for your setting

3. Join the Conversation: Behavioral Health Categories Warranting Attention in Primary Care 3 Mental Health and Substance Use Disorders Health Behaviors Psychological factors that do not meet criteria for mental heath diagnoses but exacerbate physical symptoms and impact health behaviors

4. Prevalence of Mental Health Conditions in Primary Care 4 Psychiatric disorders prevalence Major Depression 10 to 24% Panic Disorder 6 to 16% Other Anxiety Disorders 7 to 21% Alcohol Abuse 7 to 17% Any Psychiatric Diagnosis 28 to 52%

5. 50% of all life-time MH disorders start by age 14 90% of all substance addictions start in the teens First symptoms of MI typically occur 2 to 4 years before full-blown disorder Despite effective treatments, the average delay between onset of symptoms and interventions is 8 to 10 years Trajectory of Mental Illness

6. 6  50% of people with major depression do not get detected 40 to 60% of those get minimal guideline concordant care for antidepressant dose and duration <10% get empirically validated psychotherapy  67% with any behavioral health disorders do not get treatment (Kessler et al, 2005) Behavioral Health Needs Are Not Adequately Addressed

7. Primary Care Clinic Mental Health Clinic Low Follow Through to MH Referrals Patients who refuse referral tend to be high utilizers with unexplained physical symptoms

8. Join the Conversation: People Access Mental Health Care in Primary Care 49.6% of people getting MH treatment get it in primary care National Comorbidity Survey-Replication, Kessler et al, 2005 92% of all elderly patients receive MH care from PCP PCPs prescribe: ~67% of all psycho-tropics ~80% of antidepressants

9. More than 80% of all children and 70% of adolescents see a physician at least once each year, and more than 50% have routine health visits 23% of pediatricians and family physicians routinely screen their adolescent patients for MH disorders When pediatricians rely on clinical judgment 40 to 80% of children with developmental or MH problems are missed Missed Opportunities

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11. 10 Most Common Complaints in Adult Primary Care 11  Chest Pain  Fatigue  Dizziness  Headache  Back Pain  Swelling  Insomnia  Abdominal Pain  Numbness  Shortness of Breath 10 to15% had identifiable organic basis Kroenke & Mangelsdorf (1989) Am J Med; Strosahl et al. (1998); Kaiser; APA

12. Common Chronic Medical Conditions that Have Significant Behavioral Health Components Pain Hypertension Asthma Diabetes Sleep disorders HIV Cardiovascular Disease Irritable Bowel Syndrome Obesity Sexual Dysfunction 12

13. Health Behaviors 13  Behaviors or Unhealthy Behaviors Smoking25% Poor Diet30% Sedentary lifestyles50% Non-Adherence20 to 50% Risky sexual behavior Poor sleep hygiene

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15. High Costs of Unmet BH Needs and Fragmented Care BH disorders account for half as many disability days as “all” physical conditions (Merikangas et al., Arch Gen Psychiatry. 2007) Untreated mental disorders in chronic illness is projected to cost commercial and Medicare purchasers between $130 and $350 billion annually (Hertz et al, 2002) 15

16. Join the Conversation: Annual Medical Expenditures for Adults with and without a MH Condition 16 Cost without mental health condition Cost with mental health condition All adults *$1,913$3,545 Heart condition4,6976,919 High blood pressure 3,4815,492 Asthma2,9084,028 Diabetes4,1725,559 *- Refers to all adults with and without chronic conditions.. Information from U.S. Department of Health and Human Services. The 2002 and 2003 MEPS. AHRQ, Rockville, Md.

17. HERO study in Birmingham Alabama Study of 46,000 workers at several major US companies Medical costs 70% higher among individuals with untreated depression Medical costs 46% higher among individuals reporting uncontrolled and untreated stress Impact of Psychological Factors on Overall Health:

18. Top 10 Health Conditions Driving Costs for Employers (Med + Rx + Absenteeism + Presenteeism) Costs/1000 FTEs Loeppke, et al., JOEM. 2009. 18

19. Improved Outcomes and Lower Costs With BH Integration Medical use decreased 15.7% for those receiving behavioral health treatment while controls who did not get behavioral health medical use increased 12.3% (Chiles et al., Clinical Psychology) Depression treatment in primary care for those with diabetes $896 lower total health care cost over 24 months (Katon et al., Diabetes Care. 2006) Depression treatment in primary care $3,300 lower total health care cost over 48 months (Unützer et al., Am J of Mgd Care ) 19

20. Join the Conversation: The Affordable Care Act 20 Requires mental health and substance abuse coverage as one of the 10 essential health benefits

21. Integrated Behavioral Health Helps Meet PCMH Core Principals  Whole Person Orientation: majority of personal health care in primary care  Coordinated Integrated Care: Personalized care across acute and chronic problems, to include prevention and focus on the physical, social, environmental, emotional, behavioral and cognitive aspects of health care. 21

22. Integrated Behavioral Health Helps Meet PCMH Core Principals  Enhanced Access: Time to third available appointment and same day access to the range of health care needs the patient has to include addressing in primary care by the team mental/behavioral health and health behavior change.  Payment for Added Value Enhance evidence-based screening, assessment and intervention for mental/behavioral health, substance misuse and abuse and health behavior change, that improves acute and long-term outcome, patient and provider satisfaction, decreases monthly cost for enrolled population, decreases ER visits, and prevents/decreases hospitalizations (i.e. medical and psychiatric). 22

23. Join the Conversation: 23

24. NCQA PCMH High-Level Goal for 2014: Further Integrate Behavioral Health  Element 2E delineates unhealthy behaviors and conditions related to mental health or substance abuse and evaluates capability to provide care reminders and use clinical decision support.  Element 1E asks practices to communicate the scope of services available including how behavioral health concerns are addressed.  Element 4B (Referrals) includes specific factors on establishing relationships with behavioral health providers. 24

25. Join the Conversation: Roles for BH Providers in Primary Care 25 Screening and/or follow-up assessment (should have good diagnostic skills) Program development: evaluation, treatment and follow-up protocols 2-way coordination with community resources, schools, specialty mental health Develop referral resource book Brief interventions

26. Join the Conversation: 26 Patient education/Anticipatory guidance Handouts Workshops Consult to medical providers Address health behaviors Help medical providers around engagement with patients and families Quality improvement initiatives Roles for BH Providers in Primary Care (continued)

27. Integrated Care Models 27

28. Identify partners Preferential referral relationship Referrals followed by phone calls and ongoing collaboration Effort to reduce barriers Shared information Enhanced Referral (PCMH-N)

29. Specialist serves as consultant via telephone or video-conferencing Telehealth

30. Formalized screening PCP training Patient education Follow-up care Care manager Psychiatrist consultant/supervisor Disease/Care Management

31. . Colocated BH and PC offer services in same physical location. PCPs typically refer to BH. Each has own traditional practice patterns, separate administrative and record systems.

32. BH and primary care providers are considered part of the same team, not specialists within a clinic Care is co-managed Shared appointments, treatment plans Fully Integrated: Primary Care Behavioral Health (PCBH)

33. If you have seen one integrated care program … you have seen one integrated care program

34. One size does not fit all – Understand factors important for integration success in YOUR setting 34

35. AAP Mental Health Practice Readiness Inventory 35 What does your practice do well? What does your practice do not so well? http://pediatricmentalhealth.files.wordpress.com/2011/1 1/a8-mh-practice-readiness-inventory.pdf

36. Join the Conversation: 36 What do you want to accomplish? Who is your target population? How will they be identified? Perform a needs analysis Determine available financial mechanisms Considerations

37. Join the Conversation: 37

38. Join the Conversation: Business Arrangements With BH Provider 38 Independent contractor (e.g., an individual or an organization such as a clinic or a PO) Formal business agreement Can be billed under separate Tax ID or same Tax ID with BH provider paid via collections or flat hourly fee Employed member of practice Billed under same Tax ID Partner model Share risk Same Tax ID

39. Join the Conversation: How Will BH Provider Be Compensated? 39 Percent of collections Hourly rate RVU/productivity Share of P4P

40. Join the Conversation: Funding Streams 40 Fee-for-service Capitation Pay for Performance Flexible infrastructure support Case rates to cover prevention and care management of chronic conditions Grants/Demonstration projects Carve-ins versus Carve-outs Increased physician productivity (BHP frees up PCP time)

41. Join the Conversation: Fee-For-Service Options 41 Traditional mental health codes - 90791-92, 90832, 90834, 90837, 90833, 90836, 09838, 90839, 90840, 90846, 90847, 90849, 90853 –psychiatric evaluation, psychotherapy, and psychological testing Health and Behavior codes (H & B) - 96150-96155 Chronic Care Management Codes – T1015, T1019, G- codes Interdisciplinary team conference codes – 99366- 99368

42. Join the Conversation: Fee-For-Service Options (continued) 42 Screening and Brief Intervention (SBI) for Substance Use PayerCodeDescription2012 Fee Commercial Insurance 99408 structured screening and brief intervention services; 15 to 30 min $33.41 99409 structured screening and brief intervention services; >30 min $65.51 Medicare G0396 Structured screening and brief intervention services; 15 to 30 min $29.42 G0397 Structured screening and brief intervention services; >30 min $57.69 Medicaid H0049Screening$24.00 H0050Brief intervention, per 15 min$48.00

43. Join the Conversation: Fee-For-Service Options (continued) 43 Incident-to physician billing Optimizing physician E & M coding Other – Medicare Advantage Hierarchical Condition Category (HCC) Payment Methodology HCC Code 55 (Depression) adds ~ $300 to monthly payment Not implemented yet in Michigan

44. Join the Conversation: Billing Challenges 44 Covered codes vary by payer PCP and BH not always on same insurance panels Carve-outs: disincentive for BH to address medical Multiple co-pays at same visit Some payers won’t cover 2 visits on same day Prior authorization

45. Join the Conversation: Considerations 45 What performance metrics do you want to impact? Financial implications Target your resources to priority areas Select evidence based strategies Determine appropriate metrics to evaluate success Use of patient registry Amount of BH provider time needed

46.  Logistics: Space, Scheduling, Patient flow – referral process Information sharing  Confidentiality, consent  Skill set of medical and BH staff Who is your optimal partner? Training needs 46 Considerations

47. Desirable Characteristics of MH Providers in Primary Care Clinics  Flexible, adaptable to fast pace, unpredictable schedules  Comfortable with ambiguity, think on their feet  Enjoy teamwork  Comfortable in brief, sometimes one-session interventions  Strong diagnostic skills; Trained in EBT  Understand BH problems common in primary care (somatization, chronic pain, non-adherence, lifestyle changes necessary for comorbid chronic illnesses)  Naturally gravitate towards Motivational Interviewing

48. Join the Conversation: Implementation Tips 48 Identify integration champion(s) Solicit input from people in all roles Solicit patient/family input Assess current practices Build on strengths

49. Join the Conversation: Implementing Tips (continued) 49 Map the workflow Establish tracking system - goals

50. Join the Conversation: Implementing Tips (continued) 50 Conduct staff orientations Engage all staff Inform patients and families scripts Start small, pilot first Address obstacles Modify as needed

51. Join the Conversation: Implementing Tips (continued) 51 Review progress on regular basis Integration is an ongoing process – it does not happen quickly Evaluate success of initiative Acknowledge achievements!

52. Join the Conversation: Resources 52 AIMS Center (Advancing Integrated MH Solutions) PCPCC (Patient-Centered Primary Care Collaborative) AHRQ (Agency for Healthcare Research and Quality) SAMHSA –HRSA Center for Integrated Health Solutions

53. Join the Conversation: Conclusions Behavioral and physical health integration has unique challenges but the payoff is worth it! Improved access Improved quality Improved satisfaction (patient and provider) Improved outcomes Lower costs or cost neutral What are your challenges? What are your successes? What will your next steps be?

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