1. Quantifying and Tracking Productivity for Behavioral Health Clinicians in a Primary Care Practice Joni Haley, MS Bill Gunn, Ph.D. Aimee Valeras, Ph.D., LICSW NH Dartmouth Family Medicine Residency Concord Hospital Family Health Center Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session #_C3c____ Friday, October 11, 2013 or Saturday, October 12, 2013

2. Faculty Disclosure Please include ONE of the following statements: We have not had any relevant financial relationships during the past 12 months.

3. Objectives Participants will learn about the ways productivity is captured nation-wide for integrated behavioral health services within primary care. Participants will learn about one proposed model for capturing productivity for integrated behavioral health care in a medical setting, which parallels that of our medical provider partners. Participants will experience how to determine the coding levels based on different types and complexity of interactions.

4. Tracking BH productivity in primary care settings Military health services Fee-for-service Grant-funded State and local-funded Non-profit

5. Concord Hospital Family Health Center / NH Dartmouth Family Medicine Residency

6. Changing the process Created a “ranking” of types of integrated behavioral health interactions to parallel the levels that exist within the primary care world Orders were changed to reflect both amount of time spent and complexity of the interaction

8. Level 1 (i.e. 1 order) 5 minutes or less a phone call, message or email to provide a single resource print out and in-person meeting to provide a single resource phone call to follow-up on a resource previously provided brief consult with provider re: resources receiving / relaying information, including emails, from 5W Level 2 (i.e. 2 orders) 5-20 minutes providing multiple resources (transportation, medication assistance, food, finances, legal, etc) phone or in-person discussion with patient / family regarding no-shows, ER overutilization, POCC referral phone or in-person discussion with patient to providing ongoing brief support

9. Level 3 (i.e. 3 orders) spending 20 minutes or more with patient / family consultation with an MA, RN, PA, MD/DO regarding plan of care of pt consultation with BH Intern re: course of therapy, care coordination, liaison between therapist and physician coordination of a team meeting calling collaterals (DCYF, BEAS, Riverbend) for care coordination and communication providing assessment to patient involved POCC interaction

10. Level 4 (i.e. 4 orders) bridging sessions helping to resolving conflict between pt / family members and health care team working with providers / patients to make complex referrals (DCYF, DV) providing patient care (resources / crisis intervention), while coordinating with / educating provider providing patient care while working with other members of team (RN, MA, PA) for care coordination meeting with pt during Therapist’s session for care coordination

11. Level 5 (i.e. 5 orders) spending 40 minutes or more with patient / family / team visit pt in hospital per Medicine Team’s request coordination of immediate ER / hospitalization Team meeting CCC or first year observations Encounters that involve numerous above (i.e. resource referral, working with clinical team, educating resident, and calling collaterals) Nursing home / home visit group visit (10 orders per hour) ICAT or Collaborative Care note, for therapy intake or otherwise

12. Results Integrated BH clinicians had less variability in their “numbers” Better understanding of how their role on the primary care team is utilized and relied upon Consistency allowed for “big picture” planning – short staffed, downturn in economy, lack of inpatient bed availability, local crises

13. Challenges Many clinically significant interactions between Integrated Behavioral Health Clinicians and medical team and/or patients take place on a less-formal basis and are not documented. A considerable portion of Integrated Behavioral Health Clinicians work remains under-documented and/or inconsistently documented No reimbursement is currently attached to Integrated Behavioral Health Clinicians interactions (outside of formal therapy), due to current billing procedures. Role as educator is often not documented, because the learning point is about a topic, and not a specific patient.

14. In summary… Level of integration varies widely in primarily safety-net settings Lack of viable and sustainable funding sources is primary obstacle to integration becoming mainstream in health care settings across US. Current integrated settings must make best use of consistent data collection to describe “value-added” in primary care

15. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!