The Integration of Behavioral Health and Primary Care: Keys to Success !

1. The Integration of Behavioral Health and Primary Care:Keys to Success ! Virna Little, PsyD, LCSW-r, SAP

2. Treat mental health disorders where the patient feels most comfortable receiving care • Better coordination of care • Mind and body connection • More likely to keep appointments where multiple issues are being addressed • The majority of mental health treatment will occur in community health settings- with focus on preventive care and integration.

3. Unrecognized and untreated Mental health diagnosis often go unrecognized in primary care Primary care providers often under treat mental health diagnosis Screening alone does not improve outcomes for primary care nor is it considered integrated care

4. Less Stigma Comfortability in discussing mental health issues Established relationship with primary care provider “I am not crazy” Less stigma walking into primary care setting then mental health setting

5. Physical Health is comorbid with mental health Depression and anxiety are adverse outcomes of diabetes, heart disease and asthma and/or vice versa Bipolar Disorder Anxiety Disorder Perinatal mood disorders

6. Comorbidity

7. Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying 25 years earlier than the general population While suicide and injury account for about 30-40% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006) 7 7

8. Usual Care vs. Integrated Care • Usual Care • Rarely treated effectively • Only 1 in 5 receive treatment • Rarely treated by MH professionals • Fewer than 10 report see a MH worker • Increasing use of antidepressants in PC but treatment often not effective • Integrated Care • Most effective approach to treat mental health in PC settings • Comprehensive • Multidisciplinary approach • Fully integrated with information available to all practitioners • Cost-effective

9. Why Integrate?(Source:www.impact-wu.edu)

10. Why Integrate Mental Health In Primary Care? • People seek mental health care in primary care settings • Many completed suicides were seen by PCP • 20% on the same day • 40% within 1 week • 70% within 1 month • White men ages 85 and older highest risk • PCP referrals to mental health providers may be necessary but not sufficient to improve outcomes

11. Why Integrate Mental Health In Primary Care? • Strong evidence has emerged for collaborative/integrated care for treatment of common mental disorders • The IMPACT (Improving Mood Promoting Access to Collaborative Treatment) Model • The Three Component Model (3CM) • Insurance does not provide adequate coverage for mental health services

12. Focus: Quadrants II and IV 12

13. IMPACT Modelwww.impact-wu.edu • Design • 1,801 depressed older adults with major depression and / or dysthymia (chronic depression) • randomly assigned to IMPACT or to Care as Usual • Usual Care • Primary care or referral to specialty mental health • IMPACT Care • Collaborative / stepped care disease management program for depression in primary care offered for up to 12 months • Analyses • Independent assessments of health outcomes and costs for 24 months. Intent to treat analyses Unützer et al, Med Care 2001; 39(8):785-99

14. IMPACT Findings Robust Across Diverse Organizations 50 % or greater improvement in depression at 12 months % Participating Organizations

15. GAD 7 Tools • Generalized Anxiety Disorder 7 Tool • simplified questionnaire developed to help in the diagnosis of Generalized Anxiety Disorder, or GAD. • 7 item questionnaire • a score of 10 or more on the GAD-7 represented a reasonable cut point for identifying cases of GAD • Cut points of 5, 10, and 15 may be interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7.

18. The Patient-Centered Medical Home • Principles of the Patient-Centered Medical Home • Personal physician • Physician/Nurse Fractioned directed medical practice (team care that collectively takes responsibility for the ongoing care of patients) • Whole person orientation • Care that is coordinated and/or integrated • Quality and safety (including evidence based care, use of information technology and performance measurement/quality improvement) • Enhanced access to care • Payment structure that reflects these characteristics beyond the current encounter-based reimbursement mechanisms The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association http://www.pcpcc.net/ 18 18

19. Suggested Starts Smoking Depression Alcohol/Drug use Unsafe sex practices Frequent Utilizers Obesity Ages and Stages, MCHAT, Developmental Chronic illness 19

20. IFH Improvements

21. After 6 months-

22. Three Care Model (3CM) • systematic approach that includes certain tools, routines, and a team approach to patient care • 3 Components of 3CM • prepared primary care clinician and practice, • care management, • a collaborating mental health specialist

23. Outcome Measures What do you want to achieve? Are there diagnosis or measures your organization/department is already tracking/monitoring? Are there measures that will help us subsidize the integration work? Can this be a CQI or research project? What is realistic? Are there outcome measures that will increase organization buy-in for integration work?

26. Integration and Collaboration

27. Models of Care

28. Who to hire for integrated care? Able to use behavioral activation techniques with patients as an adjunct to other treatments Able to provide optional evidence-based, brief structured psychotherapy Able to establish quick rapports to a wide range of individuals Ability to make patients feel that they are being listened to and supported

29. Workflows Screening Referral Assessment Education Discuss Treatment options with patient Coordinate care with PCP Referral to psychiatrist Start Initial Treatment Plan Arrange follow-up Contact Documentation Referral to outside resources (if necessary)

30. Barriers to Integrated Care • Clinical Barriers • Traditional separation of mental health issues from general medical issues • Lack of awareness of mental health screening tools in the primary care setting • Physicians' limited training in psychiatric disorders and their treatment • Financial Barriers • Lack of insurance parity for psychiatric disorders • Medicaid's low payment rates • Billing restrictions

31. Barriers to Integrated Care • Policy Barriers • Physical health and Mental health funding streams • Difficulty of sharing information due to HIPAA regulations (progress notes) • Organizational Barriers • Shortage of mental health professionals • Limited communication between medical and mental health providers • Lack of agreement between medical and mental health providers

32. Abstract Dollars Can help support integration work Will vary by organization/setting/payor mix Time spent with PCP No show rates for PCP, specialty care Medication adherence Emergency room visits/utilization Productivity for behavioral health

33. HRSA Medicaid Guide, 2003

34. Goldberg & Oxman, 2004 Medicare Reimbursement: 908xx codes can be used by non-mental health professionals Commercial Payers:Sometimes do not allow use of 908xx by PCPs (usually because of ‘carve-out’ to third party) Medicaid:Psychiatry codes must be billed by licensed MH provider in PA 34

35. Mauer, NCCBH; 2006 CPT codes adopted in 2002 to address primary-care-based BH services delivered in coordination with PCP services. Adopted by Medicare Adoption by Medicaid and private sector plans is occurring on state-by-state basis

36. Health and Behavior Assessment Documentation Guidelines Specific validated interventions for assessing readiness to change Identification of barriers to change Advising behavioral changes Assisting by providing specific suggested actions Motivational counseling Behavioral Activation Arranging for follow-up services

37. Health and Behavior Assessment Documentation Guidelines Behavior change services are performed as part of treatment of condition related to or exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in illness

38. Health and Behavior Assessments Focus is NOT on mental health but bio-psychosocial factors relating physical health Focus is on improving patients health and well being Focus on utilizing evidence strategies, behavioral observations, health oriented questionnaires Focus on reduction of disease related problems Focus on treatment adherence These are NOT preventative medicine counseling codes( 99401-99412)

39. CPT Codes for Medical Case Conferences 99366-Medical team conference with interdisciplinary team of health care professionals, face to face with patient and/or family, 30 minutes or more, participation by non-physician qualified health care professional. 99367-Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more participation by physician. 99368-Participation by non-physician qualified health care professional.

40. Documentation Guidelines A complete patient history with a focus on current problems and symptoms An exam focusing on presenting problems Medical review , impression and decision Counseling and/or coordination with care team, may include patients family 15 minute visit

41. Documentation for Case Conferences Each participant should document participation in team conference Documentation should include contributed treatment recommendations Documentation should include role of individual in patients care Documentation should include subsequent treatment recommendations

42. Telephone Consultation Not traditionally covered by payors Can be completed by physicians and qualified non physician providers Must be established patient or collateral Cant be within 7 days following an appointment or prior to next appointment 98967- 11-20 minutes of medical discussion 98968- 21-30 minutes of medical discussion 98966- 5-10 minutes of medical discussion

43. Documentation Guidelines 90801 Document reason for visit and describe presenting problem, current symptoms Obtain psychosocial history including supports, substance abuse, legal, family, trauma Obtain psychiatric history including medication, treatment Mental Status Multi-axial Clinical impressions Treatment recommendations

44. Documentation Guidelines 90804 and 90806 Include reason for visit diagnosis (most payors do not reimburse for “v”codes) Include previous symptoms and current symptom assessment (quantify if possible) Utilize tools and report results ( GAD 7, Phq9) Describe clinical interventions provided in session Discuss progress towards treatment goals and discharge from treatment

45. Questions ???