1. The Role of Tele- Behavioral Health Services in an Integrated Behavioral and Primary Care System by Marcy Rosenbaum, LCSW, CSAC

2. Marcy S. Rosenbaum Licensed Clinical Social Worker Certified Substance Abuse Counselor Current employment: Behavioral Health Consultant for Southwest Virginia Community Health Systems (FQHC) Over 5 years experience using tele-behavioral health. Work history:  Behavioral Health Consultant, primary care  Youth Counselor, CSB  Clinical SW, psychiatric Hospital  Drug Abuse Counselor, Job Corps Center  CPS Worker, DSS  SA Prevention Specialist, CSB: in school setting  SA Residential Tech., CSB residential treatment

3. Southwest Virginia Community Healthcare Systems, Inc. Group of 4 non-profit federally qualified health care centers (FQHC) and one regional dental clinic dedicated to improving the access to affordable, quality, comprehensive and preventative healthcare in rural southwest Virginia. 2011 nominee by HRSA’s (Health Resources Services Administration) Office on Rural Health Policy as one of the best practices in the nation for providing integrated behavioral health/ primary care services. Staffed with 3 behavioral health consultants.

4. What is Integrated Behavioral Healthcare? Model of care with a systematic coordination of physical and behavioral healthcare merged into one service delivery system. PCP and Behavioral Health Consultant work together for patient’s overall health. Behavioral Health Consultant offers help with behaviors, stress, worry, emotional concerns about physical health and other life problems that interfere with overall wellness.

5. Behavioral Healthcare Physical Healthcare Service Delivery System (i.e.. hospital, school, primary care office, CSB, telehealth)

6. Why provide behavioral health services in primary care setting? Most psychiatric treatment is provided by non-psychiatric medical providers. 1 70% of primary care appointments are related to psychosocial issues. 1 Medical and emotional/behavioral issues are often co-occurring. Adults with any mental illness are more likely than adults without a mental illness to have chronic health conditions. 2 (cont.)

7. The burden of care for MH patients is greater than current MH settings can provide. Approx. 1 out of 4 patients will make it to a behavioral health appointment referred to a setting outside of PCP office. 3 Less stigma and discrimination to go to PCP office for care. Why provide behavioral health services in primary care setting?

8. Patient’s Integrated Service Needs High Blood Pressure Alcoholism PTSD Anxiolytic Abuse Depression Hepatitis

9. Behavioral Health Consultation at Southwest Virginia Community Healthcare Systems, Inc. Psychiatric assessment Psychotherapy Substance abuse counseling Health and Behavior Assessment/Intervention (medical illness specific). Psychiatric consults with UVA tele-psychiatry program.

10. Flow of Integrated Services New or Returning Patient PCP and/or nurse screen for behavioral health issue BH Screening Positive YESNO Refer to BHC (optional in exam room consult and/or appt.) Follow-up visits to BHC for brief interventions Continue with medical exam First visit to BHC for further screening and/or intervention Feedback to PCP provided throughout the entire process by phone, face to face, or electronic record.

11. Typical 30min. BHC session (5min.) Introduction (5min.) Snapshot (5-10min.) Functional Analysis (5-10min.) Problem Summary/ Behavioral Change Plan (5min.) Charting/Feedback to PCP

12. Tele-Behavioral Health Services The delivery of behavioral health services utilizing real-time or near real-time interactive audio/video connections. Does not include audio-only telephone, electronic mail message, or fax transmission. To receive insurance payment, must be at an eligible location with an eligible provider.

13. Eligible locations  Federally Qualified Health Centers  Rural Health Clinics  Hospitals  Community Mental Health Centers  Office of practitioner  Skilled Nursing Facilities  Critical Access Hospitals  Renal Dialysis Centers Eligible Providers  Clinical Psychologists  Clinical Social Workers  Clinical Nurse Specialists  Physicians  Nurse Practitioners  Physician Assistants  Nurse midwives  Registered dietitians or nutrition professionals To Bill for Tele-behavioral Health Services:

14. Reimbursement April 7 th, 2010, Virginia Governor passed joint legislative action approving insurance coverage for telemedicine services. (Not all states do.) DMAS has recognized use of telemedicine services since 2003. Practitioner providing the service bills same codes as if face-to-face and uses GT modifier.

15. Flow of Integrated Services using Tele-behavioral health New or Returning Patient PCP and/or nurse screen for behavioral health issue BH Screening Positive YESNO Refer to BHC (optional same day tele-behavioral health consult and/or appt.) Follow-up visits by telehealth to see BHC for brief interventions Continue with medical exam First visit by telehealth to see BHC for further screening and/or intervention Feedback to PCP provided throughout the entire process by phone, face to face, or electronic record.

16. Clinician use of tele-behavioral health services within the integrated care model: Schedule use of telehealth equipment with both clinic sites. Prepare the patient for the experience. Use same clinical interventions as if behavioral health visit is face-to-face. Code with GT modifier. Provide feedback to PCP. Tele-psychiatry is through UVA Center for Telehealth and is a consultative model.

17. Benefits Include: Patients have access to behavioral health services in localities that do not have BH providers. Primary Care Providers have more treatment plan intervention options for patients. Increases patient adherence to treatment plans. Reduced transportation costs (money and time) for both the patients and the health care organization. Integrated care increases the health and wellbeing of patients.

18. References 1. Robinson, P.JH. &Reiter, J.T. (2007). Behavioral Consultation and Primary Care: A Guide to Integrating Services. New York, NY:Springer. 2. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (April 5, 2012). The NSDUH Report: Physical Health Conditions among Adults with Mental Illnesses. Rockville, MD. 3. Strosahl, K. (2001). The integration of primary care and behavioral health: Type II change in the era of managed care (pp. 45-70). In N. Cummings, W. O’Donohoe, S. Hayes & V. Follette (Eds.). Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. New York: Academic Press.