Transcript F) Implementing a Co-Located Behavioral Health Model in Primary

Implementing a
Co-Located
Behavioral
Health Model in
Primary Care
Benefits and Challenges
October 9, 2014
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Objectives
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Describe the process for obtaining a
collocated behavioral health practitioner
Describe the process for referring to
collocated behavioral health practitioner
Describe the process for coordinating care of
patient with behavioral health practitioner,
including having the behavioral health
practitioner in care team meetings on
patients
Describe how medical and behavioral health
records/notes are shared among providers
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FHSM Background
 PCMH-
3 physician practice
 Integrated
clinicians-NCM, Dietician,
Behavioral Health
 CSI
original pilot site
 2011
NCQA Level 3 recognized
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Gateway Background
 Non-profit
BH care organization
established in 1995
 Provides
a wide array of services to adults,
children, & families in RI
 Has
42 locations statewide, also offers free
care each year to those in needimproving access
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How it all began….
 The
relationship with Gateway was started
as part of contract with BCBSRI that we
negotiated 5 years ago
 BC was willing to support the concept of
a co-located BH provider
 BC provided funds for space in several
RIPCPC practices
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How it all began….
 The
concept was for the BHP to provide
BH to patients who have trouble stopping
bad habits, i.e., smoking, over-eating,
inability to follow a therapeutic diet, etc…
 BC allowed the practices to expand the
scope of the BHP to include all mental
health needs while continuing to
emphasize helping those requiring
behavior changes to improve their
physical health
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The original plan….
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What wasn’t working
 Timed
patient encounters
 Narrow
scope of intervention
 Focusing
only on habits, not getting to
root of the problem
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What was working…
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Increased access to BH provider
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Focus on identifying underlying issues
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Establishing in-roads to make real change
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As we see it in our practice, we see no flaws
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BC recognized the value of the co-located
BHP and agreed with broadening the scope
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Pros
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Increased patient
compliance with BH
counseling due to
the PCMH
relationships
Therapist seen as a
member of the
treatment team
Patients more
comfortable seeing
BH therapist in their
physicians office
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Decreased stigma
associated with BH
Convenience to
patients
Increased efficacy in
meeting patient needs
in a timely manner
Same message reiterated by all
members of the PCMH
team
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Cons
 Not
really any cons to this co-location of
BH within the PCMH practice
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What changes were made
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As a result, we now rely on our BHP to provide
treatment for all of our patient’s needs
Since BHP is employed by a larger
organization, she is able to refer patients to
Gateway specialists when she feels the
problem is beyond her scope of expertise
In this way it truly expands the reach of the
medical home to have access to treatment
for virtually all BH needs
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Co-located, Collaborative
Care Services
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Embedded behavioral health provider
This approach involves providing services to
primary care patients in a collaborative framework
within primary care teams.
Behavioral health visits are provided in the primary
care practice area, structured so that the patient
views meeting with the behavioral health provider
as a routine primary care service and medical
providers are supported across a broad scope of
behavioral health concerns
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Co-located, Collaborative
Care
 The
co-located, collaborative care model
involves the mental health professional as
an integral component of the primary
care team
 BPH
assists in managing the overall health
of their enrolled population
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A Different Approach
Mental Health
Specialty Care
Collaborative MH
Care/Co-Location
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Location-On site, embedded in the
primary care setting
Population -Most are healthy, mild to
moderate symptoms, behaviorally
influenced problems.
Provider CommunicationCollaborative & on-going consultations
via PCP’s method of choice (phone,
note, conversation). Focus within
PCMH.
Service Delivery Structure -Brief (20-40
min.)visits, limited number of
encounters(avg. 2-3), same-day as PC
visit.
Approach -Problem-focused, solution
oriented, functional assessment.
Focused on PCP question/concern
and enhancing PCP care plan.
Population health model.
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Location - A different floor, a different
building
Population -Most have mental health
diagnoses, including serious mental
illness
Provider Communication-Consult
requests, progress notes, Focus within
mental health treatment team.
Service Delivery StructureComprehensive evaluation and
treatment, 1 hour visits, scheduled in
advance.
Approach- Diagnostic assessment,
psychotherapy and psych
pharmacotherapy, individual and
group, recovery- oriented care. Broad
scope that varies by diagnosis.
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BHP Provider
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BH provider provides assessment and
psychosocial treatment for a variety of
mental health problems, such as, but not
limited to: depression and problem drinking
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The BHP's goals are to help improve
recognition, treatment, and management of
psychosocial/behavioral problems and
conditions in the enrolled population.
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Co-located BHP Role
 The
BHP’s role is to provide support and
assistance to both PCMH team and their
patients from a different perspective
 Engaging
the patient in behavioral
health care:
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Perhaps a service they would have not
previously participated in
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BH Provider Focus
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General service delivery for a wide range of
concerns.
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Likely that the majority of presenting concerns
addressed involve traditional mental health
problems such as depression, anxiety, PTSD and
substance misuse
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The intended scope of these roles encompasses
all behavioral issues that impact health
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Such as pain management, insomnia, tobacco
dependence, weight management etc.
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Benefits of BH to the PCMH
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Using appointments efficiently (e.g., identify
problem, recognizing how functionally impaired is
the patient, noting their symptoms, summarize to
patient understanding of problem, use some time to
develop and start a behavioral change plan).
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Demonstrates capacity to consistently use
intermittent visit strategy-what is best for the patient
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Appropriately suggests the patient seek specialty
behavioral health care when the intensity of service
needed to adequately address the patient’s
problem is beyond what the BHP scope of practice
(e.g., PTSD, OCD, Marital Counseling, ETOH)
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BHP Introduction
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Initial patient/provider introduction helps to
make the patient more comfortable seeking
BH treatment and is especially helpful within
the comfort of their PCP practice.
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The initial introduction is usually unscheduled;
staff or patient initiated contact with the BHP
for an immediate problem-focused
intervention.
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BHP Initial Visit
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Patient referred for a general BH evaluation or
determination of level of care.
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Focus on functional evaluation, recommendations
for treatment and forming limited behavior change
goals.
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Involves assessing patients at risk because of some
life stress event.
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May include identifying if a patient could benefit
from existing specialty care or community resources.
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BHP Follow-Up Visits
 Arranged
to support a behavior change
plan or treatment target identified by the
PCP on the basis of earlier consultation;
often in tandem with planned PCP visits
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BH Treatment Adherence
 Visit
designed to help patient adhere with
intervention initiated by PCP.
 Focus on education, motivational
interviewing, addressing negative beliefs,
or strategies for coping with side effects.
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BH Educational Group Visit
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Brief group interventions that supplement
individual consultative treatment, designed to
promote education and skill
building/effective problem-solving.
Support of their peers who have similar health
challenges addressed in this type of group
treatment has been beneficial
Topics discussed -the change process, coping
with stress and chronic illness, etc…
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Collaboration of the PCMH
Team
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An on-going dialogue between the provider, nurse care manager, and
behavioral health.
This communication should not only include consultations about direct
patient care, but should also include discussions about role expectations
and the unique contributions that each position brings to the PCMH
team.
When each provider type is functioning well within their roles, all three
positions compliment each and blend to provide exceptional patient
care.
It is recommended that initially formal meetings are scheduled, until
collaborative roles, expectations, and processes for informal
consultations are well established.
For example, within this framework the behavioral health coordinator
can serve as an expert consultant on health behavior change to both
the Physician and the NCM. Further, NCMs and Physicians can
mutually refer to each other, depending on the needs of any given
patient.
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BHP Approach
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Ability to apply the bio psychosocial model of assessment to
the PCMH setting.
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Ability to formulate diagnostic and treatment
recommendations.
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Present findings to treatment teams (i.e., physicians, nurse care
manager, dietician, and supportive staff as appropriate).
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Use their specialized knowledge of evidence-based treatment
for general behavioral health problems (e.g., depression and
anxiety) and areas of behavioral medicine (e.g., chronic pain,
obesity and sleep problems).
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Background
 Co-Located
BH has been located at
FHSM, a PCMH physician office, for the
past 3 years
 Patients come in for appointments with
the BH therapist at the physician office
 The therapist has her own comfortable
private office located near the practice
NCM and physician offices
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Background
 The
BH therapist sees patients for
individual psychotherapy
 The therapist works closely with PCP’s and
NCM to coordinate treatment efforts
 The therapist is available to the PCMH
practice to assist with staff training and
education, having provided in-service
education on Cultural Diversity and
Conflict Management
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Background
 This
past year the BH therapist has assisted
with group patient education classes held
at the practice for our chronic disease
patients,
 The therapist provided educational topics
on the behavioral health component
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The Change Process
Dealing with Stress
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Referral Process
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Referrals are made directly from the PCP,
NCM, or the integrated Dietician
The patient appointments are scheduled
through a Gateway scheduler.
Also, referrals can be made through EMR
Introduction to the BH therapist is done along
with the PCP or staff member who works with
the patient to arrange BH counseling
Meeting the therapist within the comfort of
their physician office eases the acceptance
of participating in behavioral health services
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Referral Process, cont.
 The
Gateway case manager takes the
basic demographic patient data and
reason for therapy via phone intake
process
 The patient appointment with BH therapist
is arranged
 Patients eligibility and co-pay is validated
at this time
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Types of patient information
needed for referral
 Basic
demographic
info
 Insurance and
billing info
 Medical issues
 Medications
 Diagnoses
 PCP/NCM
recommended
treatment plan
 Pertinent info
related to reason
for behavioral
health referral
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How patient information is
shared
 When
there is a particularly sensitive or
pressing referral the PCMH staff will consult
with BH therapist in person to make aware
of the presenting issues
 Helps to ensure that the patients gets an
appointment booked with me in a timely
manner
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How patient info is shared,
cont.
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When the therapist meets the patient for the
first time, a discussion takes place with the
patient that the therapist is part of the PCMH
team
The therapist has access to patient medical
record at the practice
The therapist visit notes become part of the
medical record
Info is shared through therapy notes, phone
messages in the EMR, and by in person
consultation
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Types of therapy offered
 Primarily
cognitive and dialectical
behavior therapy
 Motivational interviewing to help gauge
where the patient is in the change
process
 Motivation in working toward increasing
confidence in their ability to make positive
change
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Types of therapy, cont.
 Some
elements of a psychodynamic
insight oriented approach to help
patient’s understand how dysfunctional
behaviors have been developed and
maintained
 Utilization of CBT/DBT techniques to
establish healthier, more functional
behavior patterns
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Communication with the
PCMH Team
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Treatment is provided generally individual,
sometimes couples or family therapy
Referrals will be made as are clinically
appropriate which will include inpatient, PHP,
and more specialized interventions
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Imago couples therapy
Neuro-psych testing
Inpatient/Residential/Detox/Substance Abuse
treatment
Psychiatry
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Communication with PCMH
Team
 PCPs/NCM
are kept updated by
treatment notes
 However, when patients present with
these greater needs these are the
patients that the BHP and the PCPs/NCM
are touching base on with brief
consultations on a regular basis to ensure
we are on the same page with regard to
what will best meet the patient’s needs
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How BH provider collaborates
with Physicians and NCM
 We
work together collaboratively as part
of the patient’s treatment team
 We provide different interventions but
communicate to ensure we are all saying
the same thing to the patient
 Thus, we are reinforcing the work the
patient is doing in all areas of their
treatment
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How f/u appointments are
coordinated
 Follow
up appointments are generally
scheduled by BHP at the end of the initial
appointment
 Patients can also either call the BHP or the
Gateway case manager directly to
schedule a follow up appointment
 The PCPs/NCM can request that a patient
be contracted for a follow up
appointment
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Costs for BH Therapy
 The
charge for therapy is determined by
the patient’s insurance company
 The patient is responsible for whatever
their specialist co-pay or deductible
mandates
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Case Study
 Patient
Snapshots
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Conclusion
 Co-location
provides a Holistic approach
to our PCMH practice
 Extends the access to behavioral health
services
 Allows for prompt feedback
 Promotes a care team effort
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Questions?
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Thank You!
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Albert J. Puerini, MD
Karen Bouchard, RN, NCM
Johnna Pratt, LICSW
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