www.pspbc.ca adult mental health module an organized approach to mental health issues in realistic...
TRANSCRIPT
www.pspbc.ca
Adult Mental Health Module
An Organized Approach to Mental Health Issues in
Realistic TimeLearning Session 1
2015
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
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Psychiatrists and Mental Health Clinicians
Learn/understand module
Share resources
Comment/advise
Tell colleagues/Root for the PCPs
Support Team Advisor Roles
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Office Assistants:
Understand module
Take course on Mental Health First Aid
Organize office scheduling, materials Flag patient issues
›
Support Team Advisor Roles
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Nurses
Absorb these tools through your own lens.
Think about your own scope of practice . Present your ideas during the action
period planning and strategize with your doc how you will implement today’s training
Support Team Advisor Roles
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GP Champ, OA, nurse
Psychiatrist
Mental Health Clinicians
PSP Coordinators
Data Analyst
PSP Tech Group
Bounce Back Coaches
Adult Mental Health Module Team
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Anyone NOT wishing their name and EMR information shared with our PSP Technology Partners
please let ___ know.
Request your Permission
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Faculty’s Name
Relationship with Commercial Interest
Faculty’s Name
Relationship with Commercial Interest
Faculty/Presenter Disclosures
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Housekeeping
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Welcome1. Roles2. Survey feedback3. Funding, CME credits 4. What are we trying to accomplish
Context, aims, goals, module pathway, CBT, QI, Results5. Physician, patient advocate testimonial6. Break7. Algorithm scavenger hunt8. Tools intro, tips, PL, RL, PLAP Separate: MOAs billing and scheduling9. BB10. Billing11. Action planning, Evaluations
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Thank you for your responses to the following questions. 1. What are your challenges or frustrations supporting patients
with mental health concerns?
2. How do you currently support these patients & how is this working?
3. What are you hoping to get out of the PSP Mental Health module?
4. Are you familiar with the PHQ 9 screening tool
5. Are you paper based or do you have an EMR?
6. Are you with a group practice or alone?
Where You are Now Where You Would Like to Be
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Results of pre-course assessment survey N=36What are your challenges and frustrations?
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How do you currently support MH patients?
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What do you hope to get from PSP training?
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Familiarity with the PHQ9 screening tool?
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Paper or EMR?
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Want to provide the best care for your patients with MH problems
Concerned about time efficiency in your practices Doing a lot of MH care already Some don’t feel confident in MH care they provide and
some feel emotionally drained by it Would like clearer and more timely access to mental
health specialists for your patients Here to learn skills and tools to help with diagnosis and
in-office management as well as learn about helpful resources
What did we learn about you?
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Funding for Modules
3 x ½ day (max)GP Session x 3 $ 1, 235.64
MOA 12 hrs $ 240
1 ►Planning & initial implementation in practice►Report on experiences and successes at LS2►Billable at or after LS2
$ 823.76
2 ►Refine implementation, embed and sustain the change►Report on experiences and successes at LS3►Billable at or after LS3
$ 610.72
Action Periods
Learning Sessions
Potential Total: $ 2,910.12
Participant Funding GPs: Mental Health Module
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10.5 Mainpro M-1 credits based on Attendance hours at all learning sessions (LSs) Fewer if not all sessions attended
IN ADDITION
10.5 Mainpro C bonus credits based on Completion of all 3 LSs plus an Action Period and post reflective survey (we will contact DocBC 3 months after
LS3 and AP1 completion to request them to send your
Reflective Questionnaire)
Details are found on all PSP Sessional Forms in bottom right box
Mainpro Credits for Primary Care Physicians
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“This event is an Accredited Group Learning Activity eligible for up to 10.5 (3.5 per session) Section 1 credits as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada.
This program has been reviewed and approved by the UBC Division of Continuing Professional Development.”
MOC for Psychiatrists
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M 1 Credits for Residents
Residents can claim a maximum of 30 M-1 credits during their residency. Residents are eligible to receive M1 credits for attending learning sessions (up to and within their maximum allowance of 30 M1 credits).
To obtain M1 credits please contact: [email protected]
CME and Compensation: Who to Contact?
PSP Modules• Mainpro C and M1 credits
• Fax all Learning Session and Action Period Invoices to Doctors of BC (604.638.2939)
• Contact:
Physician Forums• Mainpro M1 credits
• MUST sign in so we can send your name to VIHA Physician Compensation for both reimbursement and CME tracking
• Contact:
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Who sees MH patients in Canada?Pan Canadian Survey 2011
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Hypothesis
Family docs need:
time efficient skills to increase their comfort and confidence in treating their mental health patients
fee codes that fit this mental health work
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CBIS manual – cognitive behavioral interpersonal skills manual.
This formed the core of the BC provincial practice support program adult mental health module
Weinerman R et al, Improving Mental Healthcare by Primary Care physicians In British Columbia. Healthcare Quarterly, 2011. 14:1, 36-38
MacCarthy,D;Weinerman,R:Kallstrom,L;Kadlec,H;Hollander,M;Patten,S;Mental Health Practice and Attitudes Can be Changed. The Permanente Journal, 2013, Summe; 17(3);14-17.
Developed Training tools
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1. Screening scales: ie PHQ9
2. CBIS Screening Assessment tools: ie Diagnostic Assessment Interview (DAI)
3. Three Supported Self-Management Cognitive Behavioural Therapy (CBT) skills options
CBIS Manual Bounce Back Antidepressant Skills Workbook
Key Components of the Adult Mental Health (AMH) Module
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Results n=525 physicians
0
20
40
60
80
100
Further Results
Help pts retu
rn to
work
Help pts sta
y at w
ork
Increase
d pts se
nse of p
artnersh
ip
Reduced re
liance
on meds a
lone0
20406080
100
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Provide PCPs with effective tools to screen, diagnose, engage, partner with, manage their MH patients
Improve PCPs’ comfort, confidence and satisfaction
Improve patient experience and outcomes
Reduced healthcare provider stigma
Hope/Aim/Goals
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Depression used as Lens (Anxiety too) High prevalence in isolation/comorbid and comorbid with chronic diseaseLifetime prevalence of
Major Depressive Episode: 12.2%
Past-year episodes: 4.8%
Past-month episodes: 1.3% *
* Descriptive Epidemiology of Major Depression in Canada. Patten, SB; Wang, JL; Williams, JVA et al. Canadian Journal of Psychiatry; Feb 2006; 51, 2; 84.
** Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the US. Kessler, RC, Petukhova, M, Sampson, NA, Zalavsky, AM, Wittchen, H-U. Int J Methods Psychiatr Res. 2012 Sep:21(3) 169-184
Ranked by frequency **
Major depressive disorder
Specific Phobia
Social phobia
PTSD
GAD
Separation anxiety
Panic
Bipolar
Agoraphobia
OCD
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Focus of this modulePatients that present with:
1.fatigue, depression, anxiety, panic, insomnia,psychosomatic symptoms
2. chronic pain, headache, chronic illness,
3. depressed demeanor, worrier a thick chart
and trigger you to generate a mental health screening.
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Plan: Ride my bike to work
Bike ride Improvement Ramp
• I was late• I was
sweaty• Bike was
rusty• I was stiff
• Rain/wind• Forgot soap• Still late• Too many
hills
• On time!!• Felt good!!• I Can do
this!• Get up• Get ready• Get bike• Go
• Fix bike• Stretch• Leave early• Take clothes/shower at
work
Attempt #3
• Check google for bike time
• Got poncho/glasses• Brought shampoo• Find straighter route• Leave earlier
Done!!
Attempt # 1
Attempt # 2
Always go back to why is this important! Get exercise Save on gas & wear/tear on car Contribute to carbon footprint Promote exercise/wellness in
community Lessen traffic flow by one
car………
• Confirm patient population• Locate tools on algorithm• Begin trying out tools• Review use of MH Log Sheet• Confirm MOA role• Billing questions/tech assistance
• Review Log Sheet progress• Use of DAI• Use of other resources• Discuss optimal office flow
(include MOA)
• Overview of aims, CBIS, ASWBounceback and practice finding the tools (Scavenger Hunt)• Log sheet/AP requirements• Billing and EMR
optimization• Develop an action plan
• Share experiences (good & bad) w peers
• Use of tools• DAI role play• Log sheet/AP requirements• Update action plan
• Share experiences• Community Resource Cafe• Troubleshoot issues
for sustainability & improvement
• Sustainability Plan
AP1 AP2Pre-visit
Month 0 Month 7-8
Sustain
• Survey-barriers, desires• Orientation to Algorithm,• Review use of MH Log Sheet• Location of tools on
algorithm• Confirm use of EMR
• Ongoing Support• CME• Post Module Reflective
Questionnaire (mid-March)
Module Pathway
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Cognitive Behavioural Therapy (CBT): Setting the Stage
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Level 1 Evidence based. CBT prevention endures beyond tx cessation. If both CBT and meds stopped after successful acute treatment, patients who received CBT have lower rates of relapse **
Behavior/Activation oriented
Helps patients learn to change thought patterns/behaviors that negatively affect mood
Gives patients a sense of power and control
Retrains the brain!
You are the coach not the therapist
**CANMAT Clinical Guidleines for the management of major depressive disorder in adults: Kennedy SH, Lam RW, Prikh SV, Patten SB, Ravindran AV
What is a Cognitive Behavioral Approach?
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How does CBT and CBT skills work?Use this to introduce CBT skills
Situation Situation
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SITUATIONS
• Loss• Conflict• Isolation
SITUATIONS
• Loss• Conflict• Isolation
THOUGHTS • Harsh self-
criticism• Over-
pessimistic• Catastrophic
about future
THOUGHTS • Harsh self-
criticism• Over-
pessimistic• Catastrophic
about futurePHYSIOLOG
Y · Altered sleep· Low energy· Δ brain
chemistry
PHYSIOLOGY
· Altered sleep· Low energy· Δ brain
chemistry
ACTIONS · Withdrawal· Reduced
activity· Poor self-care
ACTIONS · Withdrawal· Reduced
activity· Poor self-care
EMOTIONS
· Sadness· Despair· Numbness
EMOTIONS
· Sadness· Despair· Numbness
Problem SolvingProblem Solving
Behavioural ActivationBehavioural Activation
Realistic ThinkingRealistic Thinking
How does CBT and CBT skills work?Use this to introduce CBT skills
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Helps on its own
Mild or moderate depression, mild and moderate anxiety disorders such as GAD, social anxiety, panic, stress, anger, self esteem, some personality disorders
As an adjunct with medications in primary care or collaborating with secondary care
Severe depression, anxiety disorders, obsessive compulsive disorder, bulimia, post-traumatic stress disorder, personality disorders, stable bipolar disorder and stable psychosis
Engages, empowers patients to work towards their recovery
Provides patients with coping skills & a sense of control
A non-pharmaceutical option/adjunct for treatment that is enduring and prevents relapse
The benefits of using CBT skills?
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“Before just jumping into pharmaceuticals you can start with other things like re-training your brain, I have some
strategies involving some homework to help you, what do you think about trying this?”
Dr. Howard Bright, Chilliwack
An alternate approach….consider saying to your patient….
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
Results n=525 physicians
0
20
40
60
80
100
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Giving practitioners and patients more coping tools reduced healthcare provider stigma against AIDS **
Family docs feel unequipped to deal with mental health issues ***
Novel hypothesisProviding tools for practitioners, patients to use will reduce healthcare provider stigma against mental health issues** Brown, L. Trujillo, L., Macintyre, K.; (2001)Interventions to Reducde HIV/AID Stigma: What have we learned?, Horizons Program/Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, *** Clatney, L., MacDonald, H., & Shah, S.M. (2008). Mental health care in the primary care setting: Family physicians’ perspectives. Canadian Family Physician, 54,
New Hypothesis
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OMS-HC Total average scores: Both groups
4343
*Wilcoxen rank sum test was used to measure between group change from pre-test to follow-up, p<.001 **Wilcoxen sign rank test was used to measure within group change. Intervention group pre-test to post-test change, p=.002; post-test to follow-up change, p=.017. Control group, not significant.
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Why this module will change everything!
Dr. Fiza video
Perspective
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Break
www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
Let’s Do it!
Today: Start with Algorithm and 4 Basic tools
CBIS Manual
Bounce Back
Coaching/DVD
Anti-Depressant
Skills Workbook
PHQ9/GAD7
Updated Algorithm Available
‘Google’ this:
www.gpscbc.ca
Click PSP
Scroll to this:
• Scroll down• Click Adult Mental Health • Select • Algorithm for Mental Health (pdf) • Right click select "Save target" to
download to your desktop
Algorithm Scavenger Hunt
(locating the tools quickly)
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MH Tools Scavenger Hunt
Form groups of 2-3, each with at least one laptop with downloaded MH Algorithm
OR Google www.gpscbc.ca click PSP, scroll down click Adult Mental Health Module, select Algorithm, right click save target
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FormatEach Pair:
Will review 2 Case Studies (Anxiety, Depression) Must complete each task to receive next task One person to bring completed task to Coordinator
Each Group Member: Will receive an Action Period log to fill in (keep at your
table until the end of the Scavenger Hunt)
Bonus Tasks = Prizes
Coordinators will be circulating to provide assistance
Algorithm Scavenger Hunt
Discussion and “Treasures”
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MOA Tasks to discuss Reschedule MH patients
in blocks Organize relevant
resources – forms, booklets, other materials
Provide patient follow-up calls
Identify how Action Period logs will be completed and faxed
Complete the CMHA Mental Health First Aid course
Contact the Practice Support Team for support
Ensure Algorithm is loaded on each computer
Today: Start with 4 Basic tools
CBIS Manual
Bounce Back
Coaching/DVD
Anti-Depressant
Skills Workbook
PHQ9/GAD7
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PHQ-2 & PHQ-9
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Need one or both questions endorsed as “2” or “3”(“More than half the days” or “Nearly every day”)
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PHQ-9 Scoring
Major Depressive Disorder: Need 5 or more questions endorsed as “More than half the days” or “Nearly every day” (i.e. in shaded areas)
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8 91
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PHQ-9 Scoring
Is functional impairment endorsed as “Somewhat difficult” or greater?
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8 91
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DSM 5 Confirming Diagnosis of Major Depressive Episode
Criteria A: reflected in PHQ9 nine questions1 symptom is either
depressed mood or loss of interest or pleasure
(PHQ9 1st 2 questions) 5/more symptoms
present in same 2 week
period/change of function
Criteria B: Reflected in PHQ9
function question
Criteria C: episode is not due
to a substance or other medical condition
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Bereavement
May resemble a major depressive episode Use your clinical judgment depending on
your knowledge of the individual and their cultural norms
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Manual Overview
Assessment FlowDAIProblem ListAction PlanResource ListSAQAnxiety Dx
SkillsActivationCognitionRelaxationLifestyleAnxiety
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WHAT & HOWFour Ways To Flow
1. Problem list action plan2. Symptoms
3. SAQs 4. Specific anxiety diagnosis
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Tools – use according to your needs
Be selective
Use all, some, now, later
Be strategic
Flexibility of Use - Key Strategy
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Shift in How we Work
Shift to shared patient responsibility
Chronic problemsNo quick fixAll tools to engageBuild partnership
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General
Breathe, relaxNo right or wrongPDSACan’t hurtNegotiate,
demonstrate and soft sell
Validate, encourage and praise
Skills
• Activation - first• Cognition – prepare• Relaxation/Anxiety –
demonstrate• Lifestyle – always good• Anxiety disorders -
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Organizing Tips
Handouts availableOne at a timeSmall goals Chart homework
givenRegular follow-upPractice
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Problem List
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Resource List (Reslience)
About the patientShift to strengthChallengingHelp Internal and
externalWellspring
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Problem List Action Plan
All knownPatterns, not
solutionsChaos organizedBeing heardValidatedPrepares for action
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Ask patient:
What action do you think would be helpful for this problem….? Activation? Relaxation? Thought changing? lifestyle changes? medications ? referrals to other resources
Small Group Activity – Problem List Action Plan 10 min
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WHAT & HOWFour Ways To Flow
1. Problem list action plan2. Symptoms
3. SAQs 4. Specific anxiety diagnosis
Summary• Just do it!• Jump in!• Use favorites!• Own it!
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BOUNCE BACK: SELF-HELP DVD & TELEPHONE‐COACHING FOR LOW MOOD, STRESS, & WORRY
Supported Self Management Cognitive Behavioral Skill Building Mood Improvement
Program
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Brief ‘Little Booklet’ format with less text
Accessibility Alternatives
Cantonese versions + Coaching also available
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To learn more about Bounce Back in general: Visit our Website: www.bouncebackbc.ca
Bounce Back toll-free #s:Phone: 1-866-639-0522Facsimile: 1-877-688-3270
Additional Information
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Advocate Perspective
Importance of
being heard
being asked the questions
Short term more time, long term less time/gain
Stigma experience
Other experience
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Discussion
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Funding for Modules
3 x ½ day (max)GP Session x 3 $ 1, 235.64
MOA 12 hrs $ 240
1 ►Planning & initial implementation in practice►Report on experiences and successes at LS2►Billable at or after LS2
$ 823.76
2 ►Refine implementation, embed and sustain the change►Report on experiences and successes at LS3►Billable at or after LS3
$ 610.72
Action Periods
Learning Sessions
Potential Total: $ 2,910.12
Participant Funding GPs: Mental Health Module
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CBIS tools
• DAI 2 counseling visits 00120 x 2 1 counseling visit finish with MH planning fee 00120, 14043
• Problem List Action Plan Counseling visit 00120
• Skills Office Visit 00100 Tel Fup 14079
MSP Compensation
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Impact of using the tools: Dr. Egan’s Renewed Practice
Visit 1 PHQ9/GAD & PL/RLBill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times
a year
Visit 2 Review PL/RL & create Action Plan, choose Skill sheet
Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year
Visit 3 Review and add ASW (pt may choose Bounce Back too)
Bill 0010 or if >20 minutes, bill 00120 worth 1.5 of a 00100 up to 4 times a year
Visit 4 May need more in depth Diagnostic Assessment Interview
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Visit 4 May need more in depth Diagnostic Assessment Interview
Bill 14043 MH planning fee, and after this is billed, this generates 4 more counseling visits giving access to 8 prolonged visits in one calendar year in addition to the planning visit 14043 worth $100 once a year. Plan must include a screening assessment and a planning document to keep on chart. If you take 2 sessions to do this bill 00120 for first and 14043 for second giving you the time to discuss with patient easily.
More about Visit 4
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Action Period Planning
• Confirm patient population• Locate tools on algorithm• Begin trying out tools• Review use of MH Log Sheet• Confirm MOA role• Billing questions/tech assistance
• Review Log Sheet progress• Use of DAI• Use of other resources• Discuss optimal office flow
(include MOA)
• Overview of aims, CBIS, ASWBounceback and practice finding the tools (Scavenger Hunt)• Log sheet/AP requirements• Billing and EMR
optimization• Develop an action plan
• Share experiences (good & bad) w peers
• Use of tools• DAI role play• Log sheet/AP requirements• Update action plan
• Share experiences• Community Resource Cafe• Troubleshoot issues
for sustainability & improvement
• Sustainability Plan
AP1 AP2Pre-visit
Month 0 Month 7-8
Sustain
• Survey-barriers, desires• Orientation to Algorithm,• Review use of MH Log Sheet• Location of tools on
algorithm• Confirm use of EMR
• Ongoing Support• CME• Post Module Reflective
Questionnaire (mid-March)
Plan Your Pathway
PSP Mental Health Log
Successful planning
for achieving Action Period
activities
To complete Action Period 1Replace this box: With your practice ideas
• Scheduling options• Create/Review patient registry• Select specific patient criteria…
complex care, migraine, others?• Organize relevant resources –
forms, booklets, other materials• Follow up with patients (MOA can
follow up with patients on homework and goals agreed to in action plans)
• Identify changes to work processes and office re-design
• Record overall progress on log sheets
Paperwork
• Learning Session Evaluation
• KEEP Invoices to FAX to Doctors of BC (FAX # at lower R side)
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What is your proof that this stuff works???
How will you know that what you are doing is an improvement???
My appointments will be faster
Some of my patients may not need to see psychiatry
My patients will progress and respond to my approach
My appointments will be proactive
My income will increase
My MOA will have an
enhanced role and a workflow
in place
My communications with Mental Health and Addictions will improve
Thanks for Attending
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Lunch Info
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