Session # PC2
October 16, 2014
The Primary Care Behavioral Health Model (PCBH)
of Service Delivery: Key Strategies for Operations,
Practice, Program Evaluation and Payment
Christopher L. Hunter, PhD ABPP
Jeffrey T. Reiter, PhD, ABPP
Patricia J. Robinson, PhD
Neftali Serrano, PsyD
Kent A. Corso, PsyD, BCBA-D
Bill Rosenfeld, MC, LPC
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
• We have not had any relevant financial relationships during the past 12 months.
Primary Care Behavioral Health Model
Learning Objectives
At the conclusion of this session, the participant will be able to:
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List the main components of the Primary Care Behavioral Health Model of service delivery.
Describe the characteristics of a behavioral health consultant that work well in this model.
Describe important program evaluation and quality improvement variables.
Practice Tools or Practical Skills
1. Participants will know how to interview and select a behavioral health consultant that is
likely to be a good fit for a PCBH model of service delivery.
2. Participants will be able to discuss the importance of process & outcome metrics that can
demonstrate clinical & population health impact and how that data can be used for ongoing
program evaluation and justification for funding.
3. Participants will know the financial model that can work with this model and how to get
those funding streams work in their settings.
Primary Care Behavioral Health Model
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
Primary Care Behavioral Health Model
2014 Annual Conference
Primary Care Behavioral Health Model
Jeffrey T. Reiter, PhD, ABPP
Primary Care Behavioral Health Model
2014 Annual Conference
The WHY?
Primary Care Behavioral Health Model
Why PCBH?
2014 Annual Conference
Primary Care Behavioral Health Model
Why PCBH?
2014 Annual Conference
● Wide range of behavioral issues, ages
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Chronic disease mgmt
Somatic complaints with lifestyle/stress component
Sub-threshold problems
Preventive health
All manner of psychiatric, substance abuse problems
Infants through older adults
Primary Care Behavioral Health Model
Why PCBH?
2014 Annual Conference
● Patients with psychosocial issues are higher utilizers
○ Of 14 common sx in primary care, only 16% had organic
etiology (Kroenke 1989)
○ Anxiety, loneliness drive visits (Fries, 1993)
○ Half of high-utilizers have a psych or CD problem (Friedman,
1995)
○ Patients with psych disorder utilize 50% more physical health
services (Simon et al, 1995)
Primary Care Behavioral Health Model
Why PCBH?
2014 Annual Conference
● Primary care providers can’t do it alone
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10 or 15 mins per visit
3 complaints on average/visit
Insufficient training in behavioral interventions
Over 3 dozen urgent but unpaid tasks everyday
15,000 new PCPs needed to meet new demand from the ACA
Overworked, underpaid—stressed!
Primary Care Behavioral Health Model
2014 Annual Conference
The HOW?
Primary Care Behavioral Health Model
The How: First, be Different
2014 Annual Conference
● Avoid the barriers of specialty MH
● Why don’t people go to specialty MH?
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Lack of insurance
Stigma
View their problem as “physical”
Inconvenience (including long waitlists)
Better familiarity, comfort with PCP
Prior negative experiences
Primary Care Behavioral Health Model
The How: Second, be Helpful
2014 Annual Conference
● Be a GATHERer:
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Generalist
Accessible
Team-based
High productivity
Educator
Routine care component
Primary Care Behavioral Health Model
Not All “Integration” is the Same
2014 Annual Conference
● WA State care coordination model (IMPACT)
○ Started in 2007 in 2 counties
○ Expanded to 100 CHCs and 30 CMHCS state-wide in 2009
○ 25,000 pts total (all years, all 130 clinics) as of 2012
● PCBH model
○ 8,000 pts in 2012 alone at HealthPoint’s 11 clinics
Primary Care Behavioral Health Model
PCBH: Different and Helpful!
2014 Annual Conference
● Consultant model
● Member of primary care team, work side-by-side
● Goal is to improve PCP mgmt of behavioral issues
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Wide variety of interventions and goals
Brief visits, limited follow-up
Immediate feedback to PCP
Any behaviorally-based problem, any age
● Aim for immediate access, minimal barriers
● Rooted in population health principles
Primary Care Behavioral Health Model
The Behavioral Health Consultant (BHC)
2014 Annual Conference
Dimension
Consultant
Therapist
Primary consumer
PCP
Patient/Client
Care context
Team-based
Autonomous
Accessibility
On-demand
Scheduled
Ownership of care
PCP
Therapist
Referral generation
Results-based
Independent of outcome
Productivity
High
Low
Care intensity
Low
High
Problem scope
Wide
Narrow/Specialized
Termination of care
Pt progressing toward goals
Pt has met goals
Primary Care Behavioral Health Model
A Day in the Life of a BHC
2014 Annual Conference
Primary Care Behavioral Health Model
jeffreiter2@gmail.com
Primary Care Behavioral Health Model
Primary Care Behavioral Health Model
Sample Clinic Day: What to Look For
2014 Annual Conference
● Variety of methods for getting pt to the BHC
○ Before PCP
○ PCP and BHC in room together
○ After PCP
● Variety of problems and ages
○ Clinical (MH, SA, Beh Med, all ages)
○ Case management/Care coordination
● Variety in the goals of visits
○ PCP-prep
○ Treatment augmentation
○ Medication and treatment planning
Primary Care Behavioral Health Model
Sample Clinic Day
2014 Annual Conference
● 9:00 PCP wants meds rec
○ 52 y/o homeless, ? ADHD vs bipolar
● 9:30 Question re disability expiring
○ 64 y/o Russian-speaker, depression
● 10:00 PCP says “I don’t know her problem”
○ 62 y/o, psychiatrist d/c’d, on 3 meds from 3 Drs
● 10:30 Open→WH w/ PCP in exam room
○ 12 y/o autism, ADHD, recently showing tics, hall’s
Primary Care Behavioral Health Model
Sample Clinic Day (cont’d)
2014 Annual Conference
● 11:00 N/S→WH in exam room, PCP- prep
○ 6 y/o ADHD, insomnia, enuresis
● 11:30 Planned f/u from 1 week earlier
○ 20 y/o Spanish-speaker, depressed w/ SI
● 1:00 Team mtg (15-min talk on pain, 5-min on tobacco
cessation)
● 2:00 Cx→same-day appt for NRT refill
Primary Care Behavioral Health Model
Sample Clinic Day (cont’d)
2014 Annual Conference
● 2:30 Open→WH for CSA
○ 60 y/o severe etoh, chronic arm pain
● 3:00 Planned f/u after 2 weeks
○ 47 y/o homeless, MDD w/ psychosis, acute SI due to meds
● 3:30 Planned f/u after 1 month
○ 45 y/o homeless, MDD, trying to get disability
● 4:00 Cx→WH for PCP prep on new pt
○ 16 y/o expelled from school, needs risk assessment
● 4:30 Open→Same-day f/u after 4 mos
○ 20 y/o seeking disability for PTSD, dep
Primary Care Behavioral Health Model
2014 Annual Conference
Does it Work?
Primary Care Behavioral Health Model
General Conclusion:
Improving Isn’t Hard
2014 Annual Conference
● USPSTF recommendations
○ Various problems
○ Various intervention models
○ Various provider backgrounds
● AHRQ (2008) review
○ Adding behavioral component improves outcome
○ No clear model superiority
● PCP influence
○ Increased PCP use of behavioral interventions (Mynors-Wallace, 1998)
○ Increased PCP confidence for behavioral health conditions (Robinson, 2000)
Primary Care Behavioral Health Model
Clinical Outcomes for PCBH
2014 Annual Conference
● 71% of patients improved, even the most severe
○ Patients with more severe impairment at baseline improved
faster than less severe (Bryan et al., 2012)
● Patients receiving just 2-3 visits showed broad
improvement in sx, functioning, well-being
○ These changes were robust and stable during 2-year follow-up
■ Ray-Sannarud et al., 2012; Bryan et al., 2009)
● Most patients who attend 2, 3 or > 4 visits show
clinically significant change
○ Cigrang et al., 2006
Primary Care Behavioral Health Model
PCBH Dissemination, Finances
2014 Annual Conference
● Many large CHC organizations
○ Cherokee, Salud, Mountain Park, Access, HealthPoint
● Standard of care in all branches of the DoD
○ All now utilize a PCBH service
● Various VISNs of the VA
● Less common in private, for-profit organizations
● Strong financial reports
○ Large study underway in OR
Primary Care Behavioral Health Model
Provider Impact
2014 Annual Conference
● All PCPs reported:
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Satisfaction with the BHC service
Improved job satisfaction
Better able to address behavioral problems
Recommend the service for other sites
● A majority (> 80%) said because of BHC:
○ More likely to continue with HealthPoint
○ Able to see more patients in 20 minutes
○ Recognize behavioral issues better
Primary Care Behavioral Health Model
Patient Satisfaction
2014 Annual Conference
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90% said visit length “just about right”
76% were satisfied w/ ability to get appt
86% felt BHC understood their problems
89% said it was helpful to meet w/ BHC
65% said physical health improved
72% said mental health improved
Primary Care Behavioral Health Model
REMEMBER THIS!
2014 Annual Conference
Worry less about effectiveness
and more about productivity!
Primary Care Behavioral Health Model
REMEMBER THIS, TOO!
2014 Annual Conference
● Primary care is deluged with behavioral health needs
and is ill-equipped to handle them
● Opportunities are tremendous for integration, but…a
radically different care model is required
● PCBH is a consultative model designed to meet the
unique demands of primary care
Primary Care Behavioral Health Model
2014 Annual Conference
Questions?
Primary Care Behavioral Health Model
2014 Annual Conference
Effectively Implementing the Model in a Large System
The Department of Defense Military Health System
Christopher L. Hunter, PhD, ABPP
DoD Program Manager for Behavioral Health in Primary Care
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Military Health System
2014 Annual Conference
● Background/Context
○ History, Funding/Policy, Workforce Development
-Hunter, C. L., Goodie, J. L., Dobmeyer A. C., & Dorrance, K. A.
(2014). Tipping points in the Department of Defense’s experience
with psychologists in primary care. American Psychologist, 69,
388-398.
-Hunter C. L., & Goodie, J. L., (2012). Behavioral health in the
department of defense patient-centered medical home: History,
finance, policy, work force development and evaluation. Journal of
Translational Behavioral Medicine, 2, 355-363.
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Military Health System
2014 Annual Conference
Age
Total
% Female
% Active Duty
% Retired
% Family Members
0-4
307,188
49%
N/A
N/A
100%
5-14
478,689
49%
N/A
N/A
100%
15-17
121,014
49%
N/A
N/A
100%
18-24
559,098
39%
60%
0%
40%
25-34
723,752
41%
67%
0%
33%
35-44a
444,297
49%
56%
6%
37%
45-64a
571,348
46%
11%
45%
43%
65+
145,792
52%
0%
49%
51%
Total
3,351,178
aTotal % of Active Duty, Retired and Family Members does not equal 100% due to rounding
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Military Health System
2014 Annual Conference
● Policy/Standards
○ DoD Instruction 6490.15
○ Program Standards
■Model of Service Delivery
■Staffing Ratios
■Expert Trainers
■Training Standards
■Program Managers
■Oversight Committee
www.dtic.mil/whs/directives/corres/pdf/649015p.pdf
Primary Care Behavioral Health Model
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Operations
Effectively Implementing the Model
Military Health System
2014 Annual Conference
● Funding
○ Argument made in context of enhancing PCMH implementation
○ Based On:
■Data from Army, Navy and Air Force Programs
■Veteran’s Administration Programs
■Civilian Research
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Military Health System
2014 Annual Conference
● Funding Argument
○Expected Impact on System
1. Psychological health-screening referral & engagement
2. Evidence-based care-depression & anxiety consistent with CPGs
3. Engaging patients in healthy behaviors (% advised to quit smoking)
4. Decrease per-member per-month cost
5. Decreased use of emergency services
6. Patient satisfaction with & access to comprehensive healthcare
7. Primary care staff satisfaction with healthcare delivery
8. Identify & effectively manage those at risk for suicide
9. Recapture family member BH services from purchased care
Primary Care Behavioral Health Model
*
Operations
Effectively Implementing the Model
Military Health System
● Training/Program Fidelity
○ Service Clinical Practice Manuals
○ 4 Day Benchmark Training
○ In Clinic Benchmark Training
○ Ongoing Quarterly Program Evaluation
■Every Provider, Every Appointment
■Standardized Documentation
■EMR Data Pulls
Primary Care Behavioral Health Model
2014 Annual Conference
Operations
Effectively Implementing the Model
Military Health System
2014 Annual Conference
Challenges/Lessons Learned
1. Establish a rationale for integrated-collaborative behavioral health that is clear,
evidence-based, & considers operational & financial barriers within a given system.
2. Include relevant healthcare professions within the system when developing a service
delivery model & standards. The views brought by various professions can strengthen the
program & improve important system stakeholder buy-in.
3. Establish operationally defined and agreed upon integrated-collaborative care
constructs to facilitate communication & shared vision. Do not assume that integrated,
collaborative or other delivery specific terms are being used consistently across/within
professions.
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Military Health System
2014 Annual Conference
Challenges/Lessons Learned
4. Include key management/finance personnel in program development.
-Without funding/management support the best plans can get shut down.
5. Identify key primary care & behavioral health support that can lead their professions in
program development.
-Strong advocates, can inform key finance, personnel & management stakeholders
with expected ROI & scientific data supporting proposed effort.
-Providing real world stories of patient/provider satisfaction/change, can facilitate
movement of clinical/operational worlds in the same direction.
6. Timing is important. Determine when leadership may be receptive to a proposal for a
new service delivery model.
-Move forward when you can present a clear rationale & answer difficult
questions in thoughtful ways.
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Military Health System
2014 Annual Conference
Challenges/Lessons Learned
7. Develop an agreed upon set of clinical and administrative standards that are observable &
can be enforced.
-Develop methods to ensure workforce is trained to clinical & administrative standards.
-Fidelity to service delivery model for desired outcomes to have a chance to be realized.
8. Develop manuals addressing clinical, administrative, operational & financial components.
- Guide practitioners/administrators on what services will & will not do.
9. Develop a set of process and outcome metrics.
-An effective evaluation design to allow scientifically robust conclusions to be drawn.
-Demonstrating return on investment results to management, providers and patients
facilitates ongoing support & informs service delivery course changes if desired
outcomes are not reached.
Primary Care Behavioral Health Model
2014 Annual Conference
Questions?
Primary Care Behavioral Health Model
2014 Annual Conference
Implementing the PCBH Model in Diverse Settings
Large Public Health Department (SFDPH)
State Level Research (Texas Medicaid Children)
PCMH Initiatives (Oregon PCPCI)
Trillium CCO (Oregon)
Yakima Pediatrics (WA)
Patricia J. Robinson, Ph.D.
Director of Training and Program Evaluation
Mountainview Consulting Group (Mtnviewconsulting.com)
Primary Care Behavioral Health Model
2009-2012
San Francisco Department of Public Health
2014 Annual Conference
● Healthy San Francisco Plan, 2007
○ Universal coverage
○ September, 2010
○ Instantly, medical access problem, similar to that faced in
most communities now with ACA implementation
● RFP (did not specify PCBH model)
● Request for assistance with assessment of need for
integrated BH services; model development and
implementation in SF public health PC clinics and
other PC clinics (including SF General)
Primary Care Behavioral Health Model
Operations
Francisco Department of Public Health
2014 Annual Conference
● Ratification of PCBH model by senior leadership,
manual development
● Formal Readiness Reviews in 15 clinics (multiple-day
site visit evaluations)
○ Summary of findings (current services, population
demographics, staffing)
○ Clinic factors influencing integration (availability and training
background of BH staff, relationship with CMH, space,
language and culture of patients, age, most common patient
health problems, co-located resources)
○ Recommendations and development of implementation plan
Primary Care Behavioral Health Model
Policy / Standards / Training
San Francisco Department of Public Health
2014 Annual Conference
● Program Evaluation Matrix
● Go Live Training (series of 3: 2010; class size: 7-28)
○ 5-day intensive for 35 BH providers
○ Mastery of manual
○ Modeling, Guided rehearsal, Role-playing
● Core Competency Training On-site
○ Week 1 (5 days / 2 BHCs, BAs)
○ Week 2 (2/2 additional, mentor)
● Mentor support; on-going workshops, T cons
Primary Care Behavioral Health Model
Funding
San Francisco Public Health Department
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2014 Annual Conference
Built into clinic budgets
No increase in public health dollars
Overage covered by grants, local businesses
Avoided use of MH dollars if possible
More support available from state now with
implementation of ACA
Primary Care Behavioral Health Model
Challenges / Lessons Learned
San Francisco Public Health Department
2014 Annual Conference
● Challenges/Lessons Learned
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Challenge of starting model at same time in multiple clinics
BHCs placed rather than self-selected
Multi-cultural, multi-language clinics
Staffing ratios for street youth and homeless clinics
Assisting other area PC clinics with implementation with limited
funding
○ Implementation in large, hospital-based PC residence training clinics
Primary Care Behavioral Health Model
Challenges / Lessons Learned
Other Dissemination Venues
2014 Annual Conference
● State of Texas Medicaid Children (SUPPORT)
○ Adequacy of training: Manual, 1-day Go Live (recorded), phone
support
● State of Oregon (PCPCI)
○ The power of sponsors: Trained 40+ practices in 3 5-day trainings
(1 day: team; 4 days: BHCs) in 4 months
● Trillium CCO (Oregon)
○ Multiple clinics—urban, suburban, rural—implementing with
PCBH Tool Kit (Can one model fit all?)
● Yakima Pediatric Associates
○ Funding, pushing on a string until you get a ball of yarn; the ongoing influence of intensive, well-timed, and on-going training
Primary Care Behavioral Health Model
2014 Annual Conference
Questions?
Primary Care Behavioral Health Model
2014 Annual Conference
Effectively Implementing the Model
Health Federation of Philadelphia
Neftali Serrano, PsyD
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Health Federation of Philadelphia
2014 Annual Conference
● Background/Context
○ A grantee organization with a focus on healthcare that
helps network varied Federally Qualified Health Centers
in the city of Philadelphia sought to help its member
FQHCs develop and sustain integrated care
○ Over a dozen members FQHCs with multiple sites each
(currently over 30 BHCs)
○ Most had no behavioral health prior to PCBH model
implementation
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Health Federation of Philadelphia
2014 Annual Conference
● Policy/Standards
○ The network helped to broker standards with the local
managed care organization, CBH, to adapt
documentation and billing standards from specialty care
to the PCBH model. This included a crossover document
so that CBH auditors could evaluate primary care
documentation.
○The network also helps each of the member clinics have
baseline standards for hiring and evaluating BHCs
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Health Federation of Philadelphia
2014 Annual Conference
● Funding
○ The clinics have varied funding strategies but most are
reimbursed through the FQHC Medicaid rate as managed
by CBH, the managed care organization
○CBH agreed to create a billing code exclusively for the
use of BHCs
○Adaptations of the specialty mental health processes
were negotiated with the network’s assistance such as
processes for “opening” cases and eliminating
“termination”
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Health Federation of Philadelphia
2014 Annual Conference
● Training/Program Fidelity
○ The network has monthly BHC meetings that include debriefing and
continuing education seminars; these follow a curriculum developed
around core competencies
○ There are formalized processes for integrating new BHC’s into the
network including shadowing/reverse shadowing, documentation
review, introductory curriculum
○ There is a separate meeting of BHC program directors where
strategy around program development and continuing education is
developed
○ The network has developed a patient simulation program to evaluate
BHC clinical performance
Primary Care Behavioral Health Model
Operations
Effectively Implementing the Model
Health Federation of Philadelphia
2014 Annual Conference
▪ Challenges/Lessons Learned
– The overall health of individual clinics and organizations is a key
predictor of success or failure of PCBH implementation
–The leverage created by a network of clinics can be an effective
strategy to negotiate changes in policy and funding mechanisms
–Training new behavioral health consultants in a scaled fashion
requires specific, formalized processes that are enacted even before
the hiring process to ensure “good fit” and model fidelity
–Collecting data across disparate organizations is a significant
challenge to be anticipated which can impact how well you can tell
the story of the model’s impact
– Talent, Talent, Talent: nothing replaces good talent which is why
good hiring is crucial
Primary Care Behavioral Health Model
2014 Annual Conference
Questions?
Primary Care Behavioral Health Model
2014 Annual Conference
Hiring the Right Behavioral Health Consultant
Jeffrey T. Reiter, PhD, ABPP
Primary Care Behavioral Health Model
Hiring a Behavioral Health Consultant
2014 Annual Conference
● Qualities to look for
○ Clinical
■ Skills
■ Knowledge
■ Experience
○ Personality
○ Interests
○ Degree
Primary Care Behavioral Health Model
Interview Questions and
Desired Responses
2014 Annual Conference
Primary Care Behavioral Health Model
Training a New BHC
2014 Annual Conference
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Reading
Shadowing
Mentoring
Online Continuing Education
Conferences
Academic Training
Core Competency Tool
Primary Care Behavioral Health Model
Evaluating the BHC
2014 Annual Conference
● Supervisor
○ Lead BHC (existing service)
○ Lead Medical Provider (new service)
● Evaluation Tools
○ Core Competency Tool
○ Chart Review Tool
○ 360 Evaluation
● Key Performance Metrics
○ Productivity
○ Patient Satisfaction and/or Clinical Outcomes
Primary Care Behavioral Health Model
2014 Annual Conference
Questions?
Primary Care Behavioral Health Model
2014 Annual Conference
Ethical-Legal Practices in PCBH
Neftali Serrano, PsyD
Primary Care Behavioral Health Model
Overview
2014 Annual Conference
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Informed Consent Procedures
Documentation in the Medical Record
Access to EHR Data
Releasing Information
Exemplars
Primary Care Behavioral Health Model
Informed Consent Procedures
2014 Annual Conference
● Key ethical and legal mandate is to provide patients with information
regarding their care so that patients are empowered to make key healthcare
decisions
● The nuance in the PCBH model is that the patient’s relationship is to the
clinic (and PCP), not uniquely to the BHC
● Key for clinics to have “up front” information related to billing practices,
confidentiality, HIPAA rights
● Key for BHCs and PCPs to communicate the role of the BHC, limits of
confidentiality when applicable, documentation procedures, and explain
treatment options
Primary Care Behavioral Health Model
Example of Informed Consent
In A BHC Practice Style
2014 Annual Conference
BHC Introduction:
“Good afternoon, my name is Dr. Serrano and I’m a psychologist who works here as a
Behavioral Health Consultant. What that means is that I work with Dr. Tellez and her medical
team - I don’t have patients of my own - and she involves me in situations where she might
need support helping a patient struggling with a lifestyle change such as quitting smoking or
losing weight, or when a patient may need some ideas for how to cope with life stress. So,
what we will do today is spend about 15 minutes reviewing what you discussed with her,
hopefully come up with a good plan of action, and then I will communicate with her what we
discussed and also document it in the medical record so that we can make sure we keep track
of what we are working on. If we decide some follow-up is needed to continue to support you
you may end up seeing one of the other members of the Behavioral Health Consultant team
based on the day you come in, but rest assured we work very hard to communicate with each
other so that you don’t have to repeat a thing. With that in mind, today …”
In certain situations, using judgment, limits of confidentiality may need to be discussed further.
Primary Care Behavioral Health Model
Documentation of BHC Informed Consent
After A First Visit
2014 Annual Conference
Tagged onto the end of a SOAP Note via “dotphrase”:
The patient was informed of the following characteristics of their care within the
primary care medical home at Access Community Health Centers: a. Behavioral health
providers operate as consultants to the medical team and not as stand-alone providers of
care, b. All information discussed with team members as applicable/appropriate will be
documented in the shared medical record and visible by all members of the Access
medical team, c. Patients have a right to a confidential record and when requesting a
release of records to external agencies can restrict aspects of their record from being
released including but not limited to mental health data, d. The Behavioral Health Team
works as a group providing care to all Access patients and as such a patient is likely to
work with multiple Behavioral Health providers.
Primary Care Behavioral Health Model
Documentation In The Medical Record
2014 Annual Conference
● The only barriers to the full integration of mental health
data in the medical record exist in state-specific or
organization-specific instances based on state law or
organizational policy
● HIPAA does not treat mental health data in EHRs
differently than other data other than providing patient’s
rights to release aspects of their record
● There is no ethical mandate, such as in the APA Ethics
Code, which prohibits integration of records
Primary Care Behavioral Health Model
Documentation In The Medical Record
2014 Annual Conference
● Key is to train clinical staff to write appropriately for the
medical record, understanding the kinds of data that are
relevant for the medical team (process vs. progress notes)
● Key is to train non-clinical staff to respect all aspects of the
record, understand patient HIPAA protections and as
HIPAA requires have a mechanism to track abuses by
individuals of a patient record
Primary Care Behavioral Health Model
Access To EHR Data
2014 Annual Conference
● “Break the glass” impediments are largely considered to be a stopgap method by litigation-fearing institutions until state-based laws
are “harmonized” with HIPAA
● Consistency in policy is key across an organization
○In other words, if personnel have access to sensitive data, then
protections within protections don’t make sense unless you can
defend why those “extra” protections do not exist for the other
kinds of data (e.g. think STDs or sexual orientation)
●Key is having solid, ethical documentation standards, tracking
mechanisms and good general boundaries for the ways in which all
medical data is shared or seen
Primary Care Behavioral Health Model
Releasing Information
2014 Annual Conference
● HIPAA provides protections for the release of certain types
of data including mental health data, dictated by patient
consent
● Key is to have a medical records department that can
provide up-to-date HIPAA compliant releases and a
function within that department for sifting records when
releases are requested
Primary Care Behavioral Health Model
Exemplars
2014 Annual Conference
● A Community Health Center
○Transparent BHC notes, sharing an EHR with a larger
system
○Negotiation with larger system to maintain autonomy
in practice
●A Large University Medical System
○MH & BHC (new) notes “behind the glass”
○Lawyers took a conservative approach but did allow for
increased transparency and are revisiting this process
Primary Care Behavioral Health Model
Take Home Themes
2014 Annual Conference
● There are no compelling reasons to...
○ separate aspects of the medical record or create barriers to access
beyond what is required for the protection of the whole record
○ create cumbersome informed consent procedures
●There are compelling reasons to…
○train clinical staff in effective and ethical documentation
○train non-clinical staff in patient HIPAA rights
○ensure that state laws do not contradict or supercede HIPAA
protections or create special categories for AODA or mental health
documentation for certain organizations or licenses
Primary Care Behavioral Health Model
Key References
2014 Annual Conference
Hudgins, C., Rose, S., & Fifield, P. Y. (2013). Navigating the legal and
ethical foundations of informed consent and confidentiality in integrated
primary care. Families, Systems & Health. 31: 9-19.
Reiter, J., & Runyan, C. (2013). The ethics of complex relationships in
primary care behavioral health. Families, Systems & Health. 31: 20-27.
Your state mental health code.
HIPAA Federal Law:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html
Primary Care Behavioral Health Model
2014 Annual Conference
Questions?
Primary Care Behavioral Health Model
2014 Annual Conference
Research and Program Evaluation
Conducting Research on the PCBH Model
Kent A. Corso, PsyD, BCBA-D
National Capital Region Behavioral Health, LLC
Primary Care Behavioral Health Model
Examples of Improved PCP
and Clinic Efficiency
2014 Annual Conference
● PCP Satisfaction
○ 100% refer again (Corso & Corso, 2009)
● Effectiveness
○ PCP time saved/pt = 56.92 min on avg
○ Clinic time saved/pt = 18.59 min on avg
○ PCPs’ rated impact of integrated care on patients’ health = 2.07
(1-4 scale with 1 being resolved and 4 being no help)
(Corso & Corso, 2009)
Primary Care Behavioral Health Model
Strong Therapeutic Alliance with a BHC
2014 Annual Conference
● Patients rated their therapeutic alliance following a first
appointment with an BHC as statistically stronger than alliance
ratings from a previously reported sample of outpatient
psychotherapy patients
● Therapeutic alliance assessed after the first BHC appointment was
not associated with eventual clinical change in mental health
symptoms and functioning
Corso, K.A. Bryan, C.J., Corso, M.L, Kanzler, K.E., Houghton, D.C., Morrow, C.E. & Ray-Sannerud, B.
(2012). Therapeutic alliance and treatment outcome in integrated primary care. Families, Systems, &
Health, 30 (2), 87-100
Primary Care Behavioral Health Model
Measuring Clinical Outcomes
2014 Annual Conference
● The Behavioral Measure 20 normed on a sample of military service
members, veterans, and family members in three primary care samples (N=
3072)
○ Scores on each of the BHM’s four scales satisfied the criterion for internal consistency
reliability
○ Across all three samples, internal consistency estimates were stable and ranged from
adequate to excellent (> .82)
○ The Well Being subscale resulted in the relative lowest reliability estimate (.74), likely
due in part to it having the relative fewest number of items.
○ All other scales showed good to excellent internal consistency
○ Use of the unidimensional Global Mental Health score is superior to using multiple
subscales (Well-Being, Symptoms, and Life Functioning) as indicated by the high
intercorrelations among the BHM’s multiple scales (r’s > .69) -- suggests they have
considerable overlap and are measuring interrelated constructs
Bryan CJ, Blount TH, Kanzler KE, Morrow CE, Corso KA, Corso ML, Ray-Sannerud B. Reliability and normative data for the
Behavioral Health Measure (BHM) in primary care behavioral health settings. Families, Systems, & Health. 2014; 32(1): 1-11.
Primary Care Behavioral Health Model
Symptom Reduction
2014 Annual Conference
● BHC patients (N=495) demonstrated significant improvements in
clinical status (as assessed by BHM-20).
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72% of pts improved across appointments
57% of pts demonstrated clinically meaningful & reliable improvement
Improvements also seen in those with most severe levels of distress at baseline
Bryan, C.J., Corso, M.L., Corso, K.A., Morrow, C.E., Kanzler, K.E., & Ray-Sannerud, B. (2012). Severity of mental health
impairment and trajectories of improvement in an integrated primary care clinic. Journal of Consulting & Clinical
Psychology. 80 (3), 396-403
Primary Care Behavioral Health Model
Decreased Psychological Distress
2014 Annual Conference
● Patients (N=234) demonstrated statistically significant decrease in
psychological distress over from first to last BHC appointment
○ Measure: Outcomes Questionnaire-45 (OQ-45)
○ Most common diagnoses: depression, anxiety, marital problems, chronic pain
○ 51% had 1 appt; 25% had 2 appts, 12% had 3 appts, 7% had 4 appts, 5% had > 4 appts
Cigrang, J. A., Dobmeyer, A. C., Becknell, M. E., Roa-Navarette, R. A., & Yerian, S. R. (2006). Evaluation of a
collaborative mental health program in primary care: effects on patient distress and healthcare utilization. Primary
Care and Community Psychiatry, 11, 121-127
Primary Care Behavioral Health Model
Insomnia
2014 Annual Conference
● Brief behavioral intervention with BHC associated with decreased severity of
insomnia
Goodie, J., Isler, W., Hunter, C., & Peterson, A. (2009). Using behavioral health consultants to treat insomnia in primary
care: A clinical case series. Journal of Clinical Psychology, 65, 294-304
Primary Care Behavioral Health Model
Routine Screening for Suicide
2014 Annual Conference
● 338 patients referred to BHCs by their PCPs in the course of routine
treatment
○ Suicidal ideation reported to BHC by 12.4% (N=42) via routine screening with BHM20
○ Only 2.1% (N=7) actually reported suicidal ideation to their PCP
○ Applicability for PCBH: routine screening via written methods yields higher
identification of suicidal patients in PCBH
○ The “as indicated” approach is less effective as a population health screening method
Bryan CJ, Corso KA, Rudd MD, Cordero L. Improving identification of suicidal patients in primary care
through routine screening. Primary Care and Community Psychiatry. 2008; 13(4): 143-147.
Primary Care Behavioral Health Model
Decreased Suicidal Ideation
2014 Annual Conference
● Suicidal ideation generally improved over the course of several BHC appointments
○ 497 primary care patients who kept 2 to 8 appointments with BHC
○ Therapeutic alliance was rated very high by patients
○ Alliance was not related to positive clinical outcomes
Bryan, C.J., Corso, K.A., Corso, M.L., Kanzler, K.E, Ray-Sannerud, B., & Morrow, C.E. (2012). Therapeutic alliance and
change in suicidal ideation during treatment in integrated primary care settings. Archives of Suicide Research, 16, 316323.
Corso, K.A., Pino, J., Clancy, J.P., Corso, M.L., Kanzler, K.A., Ray-Sannerud, B., Morrow, C.E., & Bryan, C.J.
Clinical improvement and worsening in suicidal ideation across behavioral health appointments in two patient-centered
medical homes. Manuscript submitted to Annals of Family Medicine.
Primary Care Behavioral Health Model
Decreased PTSD Symptoms
2014 Annual Conference
● In a pilot study of 19 active duty airmen, combat writing (i.e., impact statement
from CPT), and imaginal exposure yielded positive outcomes
○ Patients receiving TAU showed no clinical improvement
○ Exposure patients became slightly worse
Corso KA, Bryan CJ, Morrow CE, Appolonio KK, Dodendorf DM, Baker MT. Managing post traumatic stress disorder
(PTSD) symptoms in active duty military personnel in primary care settings. Journal of Mental Health Counseling. 2009;
31(2): 119-137.
Primary Care Behavioral Health Model
Complex Patients
2014 Annual Conference
● Among patients with suicidal symptoms, depression, and PTSD
BHCs provided treatment
○ No direct relationship found between PTSD and suicide
○ Suicidal symptoms explained exclusively by depression
○ Applicability for PCBH: if patients with trauma, depression, and suicide present in
primary care, do NOT begin treating PTSD – depression symptoms should be treated
first providing suicide risk has already been assessed and addressed
Bryan CJ, Corso KA. Depression, PTSD, and suicidal ideation among active duty veterans in an integrated primary care
clinic. Psychological Services. 2011; 8(2): 94-103.
Primary Care Behavioral Health Model
BH Symptom Improvements Maintained
2014 Annual Conference
● Patients improved from their first to last BHC appointment, with
gains being maintained an average of 2 years after intervention
○ Measure: Behavioral Health Measure (BHM) – 20
○ N = 70
Ray-Sannerud, B., Dolan, D., Morrow, C.E., Corso, K.A., Kanzler, K.E., Corso, M.L., & Bryan, C.J. (2012). Longitudinal
outcomes after brief behavioral health intervention in an integrated primary care clinic. Families, Systems & Health, 30,
60-71.
Primary Care Behavioral Health Model
Positive Impact on the Medical System
2014 Annual Conference
● Impact of PCBH Model on Access to Specialty MH Care (St.
Louis VA)
○ Resulted in a 48% decrease in direct consultation to specialty mental health
services by PCPs
○ With a concurrent increase in access to mental health services (including via
“warm handoffs” to PC Psychologists) of 170%
Martielli, Brawer, Metzger, & Gaioni
Primary Care Behavioral Health Model
Conducting Research in PCBH
2014 Annual Conference
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Benefits
Challenges
Importance
Tips
Future Directions
Primary Care Behavioral Health Model
Questions
2014 Annual Conference
kent@ncrbehavioralhealth.com
Primary Care Behavioral Health Model
2014 Annual Conference
Reimbursement and Fiscal Support
of the Primary Care Behavioral Health Model
Bill Rosenfeld, MC, LPC
Primary Care Behavioral Health Model
Overview
2014 Annual Conference
● History of Billing PCBH
● FQHC Point of View
● Care Strategy and the Financial Wheel
● Necessary Considerations
● Alternative funding potentials
Primary Care Behavioral Health Model
Funding Strategies for
Primary Care Behavioral Health
2014 Annual Conference
Historical View of Program Growth
● 2003 single BHC program infancy
○ 2,000 encounters
● 2014 robust Integrated Health Service Department
○ 27,000 encounters
● 2015 Projections
○ 40,000 encounters
Primary Care Behavioral Health Model
Fiscal Sense of BHC Encounter Growth
2014 Annual Conference
HRSA Program Information Notice 2004-05
Document Date: October 31, 2003
Document #: 2004-05
Document Name: Medicaid Reimbursement for
Behavioral Health Services
Each State Medicaid Plan made interpretations of this PIN that
had Primary Care Behavioral Health Billing Implications
Primary Care Behavioral Health Model
Care Strategy and the Financial Wheel
2014 Annual Conference
Find the Win-Win Scenarios for greatest financial impact to be realized
● Match the culture of your care arena
○ Physical Health Problems
○ Biopsychosocial factors important to physical health problems
and treatments
● Focus on Low Lying fruit
○ Prevalent chronic illness
○ Bane of the Medical Provider Existence
Primary Care Behavioral Health Model
CPT Coding
2014 Annual Conference
Codes Accepted : Health and Behavior Assessment/Intervention (96150-96155)
Health and Behavior Assessment procedures are used to identify the psychological,
behavioral, emotional, cognitive and social factors important to the prevention,
treatment or management of physical health problems.
Primary Care Behavioral Health Model
CPT Coding
2014 Annual Conference
96150 –Initial Health and Behavior Assessment –each 15 minutes face-to-face with patient
96151 –Re-assessment –15 minutes
96152 –Health and Behavior Intervention –each 15 minutes face-to-face with patient
96153 –Group (2 or more patients)
96154 –Family (with patient present)
96155 –Family (without patient present)
Primary Care Behavioral Health Model
FQHC Financial Model
2014 Annual Conference
COST BASED REIMBURSEMENT
Prospective Payment System (PPS)
Example:
If it costs 40 million dollars to complete 200,000 encounters, the
cost of each encounter is $200.00
40,000,000/200,000 = 200
Primary Care Behavioral Health Model
Necessary Billing and
Reimbursement Considerations
● Point of Service
● Funding Source
● Diagnostics
● CPT Code
● Provider Type
Primary Care Behavioral Health Model
Alternative Funding Potential
2014 Annual Conference
PCBH Attractive Lure for the Philanthropic or Grant Funded
Pond?
● Mayo Clinic
● Az. Department of Health Services
● Komen Race for the Cure
● Arizona Cancer Center at the University of Arizona
Primary Care Behavioral Health Model
State by State PCBH Financing Information
2014 Annual Conference
Go to
www.integration.samhsa.gov/financing/billing-tools
Primary Care Behavioral Health Model
2014 Annual Conference
Questions?
Primary Care Behavioral Health Model
Bibliography / Reference
1. Hunter, C. L., Goodie, J. L., Dobmeyer A. C., & Dorrance, K. A. (2014). Tipping points in
the Department of Defense’s experience with psychologists in primary care. American
Psychologist, 69, 388-398.
2. Hudgins, C., Rose, S., & Fifield, P. Y. (2013). Navigating the legal and ethical foundations of
informed consent and confidentiality in integrated primary care. Families, Systems &
Health. 31: 9-19.
3. Reiter, J., & Runyan, C. (2013). The ethics of complex relationships in primary care
behavioral health. Families, Systems & Health. 31: 20-27.
4. Bryan CJ, Blount TH, Kanzler KE, Morrow CE, Corso KA, Corso ML, Ray-Sannerud B.
Reliability and normative data for the Behavioral Health Measure (BHM) in primary
care behavioral health settings. Families, Systems, & Health. 2014; 32(1): 1-11.
5. Ray-Sannerud, B., Dolan, D., Morrow, C.E., Corso, K.A., Kanzler, K.E., Corso, M.L., &
Bryan, C.J. (2012). Longitudinal outcomes after brief behavioral health intervention in
an integrated primary care clinic. Families, Systems & Health, 30, 60-71.
Primary Care Behavioral Health Model
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!