HMAHealthManagement.com

Denver, CO

Lori Raney, MD

Principal, Health Management Associates

Effective Design and ImplementationOf Integrated Care Programs

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Behavioral Health Presentations in PC

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Diabetes Uncontrolled

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Behavioral Health Presentations in PC

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Brief Intervention,Bill therapy code

Registry- PHQ-9

Registry –GAD7

MI – several sessions. Could Track total weekly drinks/max drinks/day

Diabetes Uncontrolled

Brief Intervention-Track HgA1c

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Blended Model - Best of Both

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• Team-driven collaboration that is patient-centered, immediate access in primary care for health behaviors, life stressors, crises, stress-related physical symptoms, ineffective patterns of health care utilization

• Evidence-based, practice-tested

– Mental health and substance use disorders

– Evidence-based behavioral interventions

• Measurement based care (MBC)

– Treat to defined targets

• Population- based

– Track a subgroup with registry as a standard practice

– Caseload review with psychiatric consultant to address patients who are not progressing

https://aims.uw.edu

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Recipe for

Success

Ingredients TEMPTeam that consists at a minimum of a PCP, BHP and psychiatric consultantEvidence-based behavioral and pharmacologic interventionsMeasuring care continuously to reach defined targetsPopulation is tracked in registry, reviewed, used for quality improvementAccountability for outcomes on individual and population level

Process of Care Tasks

• 2 or more contacts per month by BHP

• Track with registry• Measure response to treatment

and adjust• Caseload review with psychiatric

consultant

Secret Sauce Whitebird Brand• Strong leadership support• A strong PCP champion and PCP

buy-in• Well-defined and implemented

BHP/Care manager role• An engaged psychiatric provider• Operating costs are not a barrier

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Go Upstream:“Sweet” Spot in Primary Care

• Issues with depression and substance abuse can be pre-empted, rather than progressing to diagnosis

• Goal is to detect early and apply early interventions to prevent from getting more severe

None

Mild

ModerateSevere

Target Population

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Core Principles of Effective Integrated Care

• Operationalize the principles of the chronic care model to improve access to evidence based mental health treatments for primary care patients.

• Effective Care is: – Team-based effective collaboration and Patient-centered

– Evidence-based and practice-tested care

– Measurement-based care, treat to target

– Population-based care – registry, systematic screen

– Accountable care

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Care That Is Measured Gets Better

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Quo T, Correll, et al. American Journal of Psychiatry, 172 (10), Oct, 2015

• HAM-D 50% or <8

• Paroxetine and mirtazapine

• Greater response

• Shorter time to response

• More treatment adjustments (44 vs 23)

• Higher doses antidepressants

• Similar drop out, side effects

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MBC Concepts

Process:• Systematic administration of symptom rating scales – use huddle or

registry• NOT a substitute for clinical judgement• Use of the results to drive clinical decision making at the patient

level – overcome clinical inertia• Patient rated scales are equivalent to clinician rated scales• Aggregate data for

– Professional development at the provider level – MACRA– Quality improvement at the clinic level– Inform reimbursement at the payer level

Ineffective Approaches:• One-time screening• Assessing symptoms infrequently• Feeding back outcomes outside the context of the clinical encounter

10Fortney et al Psych Serv Sept 2016

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Collaborative Care

EffectiveCollaboration

PCP supported by Behavioral Health Care Manager

Informed, Activated Patient PRACTICE

SUPPORT

Measurement-basedTreat to Target

Caseload-focusedRegistry review

TrainingPsychiatricConsultation

Used with permission, AIMS Center

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Stepped Care

Approach

1o Care

Psychiatric consult(Face-to-face)

PsychiatricInpatient tx

Self-Management

1° Care + BHP

BH specialtyshort term tx

BH specialty long term tx

PsychiatricConsultation

• Uses limited resources to their greatest effect on a population basis

• Different people require different levels of care

• Finding the right level of care often depends on monitoring outcomes

• Increases effectiveness and lowers costs overall

Van Korff et al 2000

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Validated Tools

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MoodDisorders

PHQ-2, PHQ-9: Depression

MDQ: Bipolar disorder

CIDI 3.0: Bipolar

disorder

Anxiety and Trauma

Disorders

GAD- 7: Anxiety, GAD

PCL-C: PTSD

Substance Use

Disorders

DAST

AUDIT-C

CognitiveDisorders

Mini-Cog

Montreal Cognitive

Assessment

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PHQ - 2

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• Ultra brief screening • Commonly used in primary care• Scoring:

0-2: Negative 3 or Higher: Positive and patient needs further assessment

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Validated Screening and Measurement Tools

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PHQ 9 > 9 < 5 – remission 5 - mild 10 - moderate 15- moderate

severe 20 - severe

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GAD-7

✚ Bulleted List #1

✚ Bulleted List #2

✚ Bulleted List #3

✚ Bulleted List #4

✚ Bulleted List #5

Score ≥ 10 indicates possible diagnosis

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Caseload Overview

✚ FREE UW AIMS Excel® Registry (https://aims.uw.edu/resource-library/patient-tracking-spreadsheet-example-data)

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Measurement Based Treatment To Target

Used with permission UW AIMS Center

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BHPs/Care Managers

• Typically MSW, LCSW, MA, RN, PhD, PsyD, paraprofessionals

• Brief intervention skills, generalists

Who are the BHPs/CMs?

• Organization

• Persistence- tenacity

• Creativity and flexibility

• Enthusiasm for learning

• Strong patient advocate

• Willingness to be interrupted

• Ability to work in a team

What makes a good BHP/CM?

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CAUTION:Traditional Approach to therapyNot willing to be interruptedTimid, insecure about skills

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Evidence-based Brief Interventions

Motivational Interviewing

Distress Tolerance Skills

Behavioral Activation

Problem Solving Therapy

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Frequent, Persistent Follow-up

Bao et al: Psych Serv 2015

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Task Sharing - Behavioral Health Provider

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Registries to Track Progress, Change Treatment

AIMS Center: http://aims.uw.edu

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Psychiatric Consultant

Caseload Reviews

• Scheduled (ideally weekly)

• Prioritize patients that are not improving – extends psychiatric expertise to more people in need

• Make recommendations –PCP may or may not implement

• NO RX

Availability to Consult Promptly

• Diagnostic dilemmas

• Education about diagnosis or medications

• Complex patients, such as pregnant or medical complicated

• Pattern recognition**

• Education**

• Build confidence and competence**

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Psychiatric Providers Supporting Teams

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Care Manager/BHP 1

Care Manager/BHP 2Care Manager/BHP 3

Care Manager/BHP 4

50-80 patients/caseload2-4 hrs psych/week/ care coordinator= a lot of patients getting care

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Roles of Primary CareProvider

• IDENTIFY individuals who need BH support and

• ENGAGE them in the treatment model

• Utilize screening tools to track progress (e.g., PHQ-9)

• Sufficient knowledge of psychopharmacology

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PCP “Buy-In”

Before Implementation After Implementation

• This is going to slow me down

• I don’t have time to address one more problem

• I have liability concerns

• I already do a good job of treating mental illness

• This takes a load off my plate

• This speeds me up• I always want to

practice like this• I am giving better

care to my patients• This gives me time to

finish my note

“If you aren’t uncomfortable with your practice you aren’t practicing integrated care.”

PCP - Colorado

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Effective Implementation: 9 Factors

Whitebird, Jaeckels Kamp et al. Am J Manag Care. 2014;20(9):699-707

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Performance Measures: Accountability

• Process Metrics:

– Percent of patients screened for depression

– Percent with follow-up with behavioral care manager within 2 weeks

– Percent not improving that received case review and psychiatric recommendations

– Percent treatment plan changed based on advice

– Percent not improving referred to specialty BH

• Outcome Metrics

– Percent with 50% reduction PHQ-9 – Clinical Response

– Percent reaching remission (PHQ-9 < 5 ) NQF 710 and 711

• Satisfaction – patient and provider

• Functional –work, school, homelessness

• Utilization/Cost

– ED visits, 30 day readmits, med/surg/ICU, overall cost

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July 1st – 6 Visits in Primary Care

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Documentation Requirements

• The requirements for this type of note have four parts/requirements that we use to make documentation simple and compliant

• First visit

Diagnosis -patient referred by primary care provider for depression follow-up

Assessment of symptoms-patient scored a 14 on the PHQ9, reports difficulty sleeping and concentrating as most prominent symptoms

Clinical Intervention- utilized behavioral activation to establish short term goal of XX to begin care and engage patient into treatment

Plan-patient provided with follow up phone appointment ( 1-2 days) on XX and follow up visit on XXX (within the week) to begin care for depression and PHQ9 reduction ……..

• This documentation can be short and often done concurrently with the patient and during a warm hand off and can be done to help keep up with the volume

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CPT Codes for CoCM

99492 - $162

99493 - $130 Billed once a month by the PCP99494 - $6699484 - $48G0512 -$134 (FQHCs only)

• Outreach and engagement by BHP• Initial assessment of the patient, including administration of

validated rating scales• Entering patient data in a registry and tracking patient follow-up

and progress • Participation in weekly caseload review with the psychiatric

consultant• Provision of brief interventions using evidence-based techniques

such as behavioral activation, motivational interviewing, and other focused treatment strategies.

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Recipe for

Success

Ingredients TEMPTeam that consists at a minimum of a PCP, BHP and psychiatric consultantEvidence-based behavioral and pharmacologic interventionsMeasuring care continuously to reach defined targetsPopulation is tracked in registry, reviewed, used for quality improvementAccountability for outcomes on individual and population level

Process of Care Tasks

• 2 or more contacts per month by BHP

• Track with registry• Measure response to treatment

and adjust• Caseload review with psychiatric

consultant

Secret Sauce Whitebird Brand• Strong leadership support• A strong PCP champion and PCP

buy-in• Well-defined and implemented

BHP/Care manager role• An engaged psychiatric provider• Operating costs are not a barrier

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Resources

University of WA AIMS Center http://aims.uw.edu

Center for Integrated Health Solutions https://www.integration.samhsa.gov

www.seattlechildrens.org/pdf/PAL/WA/WA-care-guide.pdf

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Lori Raney, MDlraney@healthmanagement.org

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