issues in implementation ointegrationof …the center for integrated primary care university of...
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The Center for Integrated Primary Care
University of Massachusetts Medical School
Alexander Blount, EdDDirector, Center for Integrated Primary Care
Professor of Family Medicine and Psychiatry
University of Massachusetts Medical School
ISSUES IN IMPLEMENTATION OINTEGRATION OF BEHAVIORAL
HEALTH AND PRIMARY CARE
The Center for Integrated Primary Care
University of Massachusetts Medical School
Considerations in Addinga Behavioral Health Provider
Committed leadership and medical champion
Provider skill set and fit
Financial sustainability, but not “pay for itself”
Information exchange between providers
Charting
Scheduling – flexible schedule for BHC allows
access
Space – Close to exam rooms or in the exam
rooms
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University of Massachusetts Medical School 3
Leadership buy-in and energy are crucial.
• Integrated care takes innovation and collaboration at every level
• -Defining program scope and vision
• - Being realistic about implementation planning and timeline
• - building the integrated care team
Almost all of the transformation for PCMH goes better when BHI is part of the process.
Administrative Considerations in Integration
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University of Massachusetts Medical School 4
• Billing and reimbursement planning and discovery
• Beginning targeted advocacy for the long run
• Training for medical providers, consulting psychiatrists, behavioral health providers, clinic managers and administrators
• Making a plan for reporting and future QI
• Restructuring cost centers to treat BH as a crucial service that brings in some money (like nursing visits).
Administrative Considerations in
Integration
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University of Massachusetts Medical School 5
• Where the “rubber meets the road” or “the pretty words are enacted.”
• Huddles are basic. You can’t skip them.
• Clear roles, flexible tasks
• Continuity of care counts for team members as much as the patient.
• Continuity breeds expertise transfer.
• BH is a second expertise set that makes it easy to add the third, the patients’ expertise.
• Foundational practices of patient centered care are often new to everyone.
The Integrated Care Team
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University of Massachusetts Medical School 6
Passing the relationship
Speaking in front of the patient
Basics of positive attribution
Basics of solution talk
Patient centered care plan for most complex patients who can participate
Learning to do goal setting
Shared decision making
Systemic view – dangers of change
Foundational Practices of Patient
Centered Care
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University of Massachusetts Medical School 7
Integrated Care and
Payment Models• Integrated primary care does not flourish
in fee-for-service environments.
• The billing and documentation
requirements of two systems (MH and
medical) are too different to work easily as
one service.
• The evidence for its effectiveness and
cost savings comes from sites with some
form of capitated or bundled payment for
total (not just MH) care.
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University of Massachusetts Medical School 8
It is a different set of services
that are often hard to code.
“It appears that the better targeted the behavioral health
intervention is to the needs of patients with specific medical
conditions . . . the more medical cost savings are realized. The
more generic the behavioral health intervention (outpatient
psychotherapy) is, the less medical cost savings are realized. . .
Behavioral health intervention included crisis intervention,
psychiatric consultation, brief psychotherapy, relaxation training,
biofeedback, and education about emotions and symptoms.”Blount, Shoenbaum, Kathol, et al, Professional Psychology: Research and
Practice 2007, Vol. 38, No. 3, 290–297
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University of Massachusetts Medical School 9
• Mental Health billing- FFS
• Bill for small bits of time
• If panels are a problem, primary care docs may help
• Get regulations about billing Tx w/o full eval.
• For medical people, Behavioral Health billing is a nightmare. This is why administrative staff need to feel some buy-in to integrated care.
• Expect to pay something for better care and for the increase in medical providers enjoyment of the practice.
FinancialYour administrators make the program.
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University of Massachusetts Medical School 10
Financial
• Medical billing:
• Increase number of patients seen by physicians. (1/sess.)
• Up-code a visit: Level 3 to Level 4 or 5
• SBIRT funds can support a lot of care in the flow of PC visits
• Health and Behavior codes: 96150-96155
• Medicare, many Blues, some Medicaid, some privates
The Center for Integrated Primary Care
University of Massachusetts Medical School
Payment Models for Behavioral Health Integration
Fee for Service, + Health Behavior Codes
Bundled payments
Case rates
Supplemental payments, eg, care management
Pay for Performance
Shared Savings
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University of Massachusetts Medical School 12
Mass Medicaid Primary Care
Payment Reform Initiative In process right now. Full roll out – 3/1/14.
Capping 4 years of developing programming.
First – “PCMH lite” – Chronic illness colaboratives
Second – PCMH pilot
48 practices, small financial incentives, care management only addition, training in
integrated behavioral health
Third and currently – PCPR
Small payments for quality
Some payments for savings (ACO model, shared risk)
Main Per Member Per Month decided by level of behavioral health offered
Tier 1 – BH screening, care management, and good linkages
Tier 2 – Tier 1 plus primary care BH, screening, brief intervention, referral to
specialty care if necessary. BHC in the practice 40 hours a week.
Tier 3 – Tiers 1 & 2 plus specialty mental health, longer term tx and psychiatry
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University of Massachusetts Medical School 13
Start with a program for a population.
What groups are most frustrating to PCPs?
What fits the NCQA requirements?
IMPACT is as good a model as is out there for a targeted population.
- Advantages of a program.
Clear guidelines
Evidence support for gaining acceptance
Easier to predict workforce needs because population is defined.
Be ready to expand toward practice-wide Behavioral Health. After you get going.
Limiting access goes against providers’ values
As they get used to collaborating, they want to expand
Starting from scratch.
What model shall we use?
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University of Massachusetts Medical School 14
Provider Skill Set and Fit
• Someone who has taken our course should have the orientation necessary to learn on the job.
• Good at making relationships with all of the roles in primary care
• They must do well in ambiguous situations, dive in rather than wait for an invitation.
• Handle new situations with assurance and confidence without misrepresentation knowledge.
The Center for Integrated Primary Care
University of Massachusetts Medical School
Information Exchange Between Providers
Medical and mental health cultures have very different approaches to confidentiality. The mental health approach is usually that the unit of confidentiality is the therapist/patient while the medical approach is that the unit of confidentiality is the team/patient.
MH culture developed in a day when confidentiality was the only thing that made revelations possible.
We are now in a day in which the patient can be at risk from failure to share information (eg., changes in medication in one site unknown to the other)
Reasonable sharing is possible if it is a goal.
http://www.integration.samhsa.gov/operations-administration/confidentiality
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University of Massachusetts Medical School 16
Information Exchange
Between Providers
• Everyone is sure and many are quoting culture, not law. We will not settle it for you today. http://www.integration.samhsa.gov/operations-administration/confidentiality
• Lawyers often deliver different opinions
• States are different
• Care coordination info is different than therapy info.
• And progress notes different from psychotherapy notes
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University of Massachusetts Medical School 17
Charting
• Patient must give permission for unified charting
• “Our behavioral health program” handout
• Unified charting means social hx and previous medical hxalready done for MH rules.
• Unified charting may not need to be undifferentiated charting
• Coming of EHR will make much of this moot once the implementation issues are solved.
• Health and Behavior codes charted in medical record as medical services.
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University of Massachusetts Medical School 18
Scheduling
• Medical scheduler keeps BHP’s book
• Shorter time periods, 30, 20, 15 min.
• Consider an Open Clinic as a way of learning to work differently
• Schedule some free time for introductions and curbside consultations
• Schedule time for conjoint interviews
• On/off scheduling.
• Huddle instead of scheduling.
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University of Massachusetts Medical School 19
What doesn’t work?Bill Rosenfeld, Mountain Park HC, Phoenix
- Part time presence of a BH provider failed in multiple trials. It is nearly impossible to request a medical provider to practice differently one or two days a week. No-shows were rampant, and warm handoffs seldom.
- Placing a BH provider outside of clinic areas that the medical providers use was also a failure. It seems like many practices commit to integrating services, but place the Behaviorist in the furthest broom closet from clinical traffic areas….they almost all fail.
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University of Massachusetts Medical School 20
- Success of the BH providers is largely personality driven. It takes a person with a strong constitution and excellent communication skills to be accepted as part of the primary care team.
- Setting up shop and waiting for referrals in one’s office has failed in multiple trials. The Behaviorist that has a strong sense of self marketing and the boldest open door policy seems to fare much better.
- Lack of executive level support would have been tragic, and would have led to failure. Luckily, we were strongly supported. We have seen many other health centers fail because of poor support from their leaders.
What doesn’t work?Bill Rosenfeld, Mountain Park HC, Phoenix
The Center for Integrated Primary Care
University of Massachusetts Medical School
Center for Integrated Primary Care
UMass Medical School21
Workforce Crisis Alleviation
Retrain the current BH workforce - examples
Certificate Program in Primary Care Behavioral Health – UMass Medical School Behavioral Health Clinicians
Certificate Program in Integrated Care Management –UMass Medical School Care Managers
Certificate of Intensive Training in Motivational Interviewing – UMass Medical School Any member of the care team
Support BH internships and residencies in primary care – at the level of primary care physician residencies
Stipulate that BH trainees in approved training settings can be service providers in all future payment models.
The Center for Integrated Primary Care
University of Massachusetts Medical School
Questions?
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Contact Info:
The Center for Integrated Primary Care
University of Massachusetts Medical School
Online Certificate Programs for Behavioral Health Professionals
www.umassmed.edu/cipc/
Primary Care Behavioral Health
Integrated Care Management
Intensive Training in Motivational Interviewing