Implementing a Co-Located Behavioral Health Model in Primary Care Benefits and Challenges October 9,

Objectives  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 2

FHSM Background  PCMH- 3 physician practice  Integrated clinicians-NCM, Dietician, Behavioral Health  CSI original pilot site  2011 NCQA Level 3 recognized 3

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 need- improving access 4

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 5

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 6

The original plan…. 7

What wasn’t working  Timed patient encounters  Narrow scope of intervention  Focusing only on habits, not getting to root of the problem 8

What was working…  Increased access to BH provider  Focus on identifying underlying issues  Establishing in-roads to make real change  As we see it in our practice, we see no flaws  BC recognized the value of the co-located BHP and agreed with broadening the scope 9

Pros  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  Decreased stigma associated with BH  Convenience to patients  Increased efficacy in meeting patient needs in a timely manner  Same message re- iterated by all members of the PCMH team 10

Cons  Not really any cons to this co-location of BH within the PCMH practice 11

What changes were made  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 12

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Co-located, Collaborative Care Services  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 14

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 15

A Different Approach Collaborative MH Care/Co-Location  Location-On site, embedded in the primary care setting  Population -Most are healthy, mild to moderate symptoms, behaviorally influenced problems.  Provider Communication- Collaborative & 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. Mental Health Specialty Care  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 Structure- Comprehensive 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. 16

BHP Provider  BH provider provides assessment and psychosocial treatment for a variety of mental health problems, such as, but not limited to: depression and problem drinking  The BHP's goals are to help improve recognition, treatment, and management of psychosocial/behavioral problems and conditions in the enrolled population. 17

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:  Perhaps a service they would have not previously participated in 18

BH Provider Focus  General service delivery for a wide range of concerns.  Likely that the majority of presenting concerns addressed involve traditional mental health problems such as depression, anxiety, PTSD and substance misuse  The intended scope of these roles encompasses all behavioral issues that impact health  Such as pain management, insomnia, tobacco dependence, weight management etc. 19

Benefits of BH to the PCMH  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).  Demonstrates capacity to consistently use intermittent visit strategy-what is best for the patient  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) 20

BHP Introduction  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.  The initial introduction is usually unscheduled; staff or patient initiated contact with the BHP for an immediate problem-focused intervention. 21

BHP Initial Visit  Patient referred for a general BH evaluation or determination of level of care.  Focus on functional evaluation, recommendations for treatment and forming limited behavior change goals.  Involves assessing patients at risk because of some life stress event.  May include identifying if a patient could benefit from existing specialty care or community resources. 22

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 23

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. 24

BH Educational Group Visit  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… 25

Collaboration of the PCMH Team  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. 26

BHP Approach  Ability to apply the bio psychosocial model of assessment to the PCMH setting.  Ability to formulate diagnostic and treatment recommendations.  Present findings to treatment teams (i.e., physicians, nurse care manager, dietician, and supportive staff as appropriate).  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). 27

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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 29

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 30

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  The Change Process  Dealing with Stress 31

Referral Process  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 32

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 33

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 34

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 35

How patient info is shared, cont.  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 36

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 37

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 38

Communication with the PCMH Team  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  Imago couples therapy  Neuro-psych testing  Inpatient/Residential/Detox/Substance Abuse treatment  Psychiatry 39

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 40

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 41

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 42

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 43

Case Study  Patient Snapshots 44

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 45

Questions?  Thank You!  Albert J. Puerini, MD  Karen Bouchard, RN, NCM  Johnna Pratt, LICSW 46