1. Behavioral Medicine in Primary Care: Putting the “Psychosocial” in the “Biomedical” Home
Mary Lynn Barrett, LCSW, MPH
Melissa Hicks, MD
Tonya Warren, PsyD
MAHEC Family Health Center
Asheville, NC

2. Objectives
Learn about the Integrated Primary Care model at MAHEC Family Health Center
Understand the benefits of the model for patients, residents, physicians, and behavioral health providers
Discuss how this model enhances the concept of the medical home

3. Integrated Primary Care
Medical and Behavioral health care are integrated in a primary care setting
The Behavioral Health Provider is considered part of the primary care team
There are a wide range of models with varying levels of integration

4. Advantages of Integrated Care
Increases patient and provider satisfaction
Improves access to mental health services
Improves quality of care
Lowers cost of service, especially for highest utilizing patients
In most settings is cost-saving or cost-neutral
Reduces stigma
Mutual learning for the behavioral health and medical provider
Treats the WHOLE patient

5. MAHEC FHC

6. MAHEC Family Health Center Model
During clinic hours, a BHP is scheduled to consult with physicians and residents
Patient care is not scheduled during the BHP’s consultation time
BHP is centrally located and visible; with the physician consultants

7. Integrated Primary Care Patient Flow
Physician recognizes possible psychosocial or mental health issue requiring treatment
Physician consults with Behavioral Health Provider (BHP) via:
Face to face consult
Electronic consult if BHP is not immediately available
BHP assesses patient
BHP reviews consult and follows up with patient with either:
1.Phone contact
2.Scheduled appointment
3.Community referral or
4.Psychiatric consult
BHP will either:
1.Provide brief treatment at time of contact
2.Schedule future appointment for continued treatment
3.Make community referral or
4.Make psychiatric consultation
Treatment plan is developed
This is our current flow at the MAHEC Family Health Center in Asheville, NC.-
Feedback is provided to the physician
Treatment continues with collaboration between BHP & physician
Ongoing psychiatric evaluations as needed

8. Consultation Video

9. Benefits for Patients
Prevention/early intervention/subclinical symptoms are treated
Easy access to services
Increased trust in the BHP because she is a member of the team
Acknowledges how patient’s physical health is effected by their mental health (and vice versa) and ensures coordinated treatment of both

10. Benefits for Residents
Increases residents ability to recognize behavioral health issues
Increases residents ability to recognize subtle/subclinical symptoms/psychosocial issues and to be proactive
Understanding of the impact of psychosocial issues on physical health and adherence to treatment plan
Longitudinal learning
Immediate application and feedback

11. Benefits for MD
Increased confidence in their ability to treat behavioral health issues
Ability to receive immediate feedback and avoid the “black hole” of outside referrals
Fewer “frequent flyers” backing up schedule
Satisfaction of “team approach,” reaching beyond ruling out disease

12. Benefits for BHP
Increased knowledge of medical issues and their interplay with emotional health
Immediate access to physicians for medication changes
Satisfaction in being part of a team
Diversity of patient population and presenting problems
Physician buy-in of important role on team

13. Primary Care Medical Home
A patient-centered medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience, and optimal health throughout their lifetimes. (AAFP 2008)

14. Integrated Primary Care Enhances the Medical Home
Continuity of care within an ever-changing residency environment
Promotes PCMH concept of “whole person care”
Reduces overall health care costs
When patient’s mental health concerns are addressed and managed, they are better able to take care of themselves and participate as part of their “team”
Providers are part of team, not separate entities

15. PCMH Over time will decrease the STIGMA of mental health care
Providers are more likely to ask for Behavioral Medicine intervention early and decrease crisis episodes

16. Financial Issues
It will take several months before BHP case load is established
Grant money may be available for start up

17. BHP PROFORMA Preferred Primary Care, Inc.
EXPENSES
DESCRIPTION
COST
1 FTE- LCSW
$45,000.00
Benefits- 23%
$10,350.00
Administrative overhead 20%
$11,070.00
Total
$66,420.00
REVENUES
1 intake/day ( Medicaid code $100.19) x 5 days X 50 weeks
$25,047.50
minutes sessions/day (Medicaid code $62.20) X 5 days X 50 weeks
$46,650.00
minute sessions/day( Medicaid code $42.64) X 5 days X 50 weeks
$21,320.00
$93,017.50
Minus 20% no shows and cancellations
-$18,603.05
Grand total
$74,414.45
Net Profit $
BHP PROFORMA
Preferred Primary Care, Inc.
BHP with masters level licensure
(LCSW, LPC, & LMFT)
NC Medicaid
DMA Rate Setting Date: July 1, 2007

18. Financial Issues
“Incident to” billing – Services rendered by BHP as a physician extender. MD’s NPI number is utilized. See link for requirements:
Traditional therapy billing codes by BHP using their National Provider Number (NPI)

19. Financial Issues
Education and Medication Management – Can be used by MD when BHP assists in session and 50% or more of the time is spent counseling the patient. MD’s NPI number is utilized
Health and behavioral codes – potential to bill for medical diagnoses

20. Financial Issues
Billing for a BHP’s time is different from typical medical billing, therefore staff may need training
BHP should have the ability for independent reimbursement across all payer mixes = maximizes flexibility and increase return

21. Case 1 22 yr-old female in for f/u CP, SOB, dizziness
“pt. reports intermittent episodes of nausea, palpitations, tachyarrhythmia, chest pressure, ‘like someone is either stepping on me, or squeezing me real hard,’ light-headedness, hot flashes/sweats w/cold hands”
Biomedical differential:
Dizziness: postural hypotension, benign postural vertigo,
Chest pain: rule out MI, arrhythmia, chest wall pain, reflux

22. Case 1 BHP suggests resident evaluate for anxiety as well
Although patient denies any increased stress, anxiety or depression, resident makes following behavioral medicine referral, and BHP did “meet and greet” with patient at that visit

23. Behavioral Medicine Referral
“22 yo woman with baby has multiple physical complaints.. Abdominal pain, HA, nausea, dizziness, chest pain w/SOB that have no clear medical explanation so far. I am still waiting for the results of cardiac event monitor which she has been wearing, but I think the patient has an anxiety component to her symptoms. Pt. reports after delivering her daughter, she did have some baby blues which seemed to have resolved, but over the past couple of weeks, her irritability and teariness have returned.”

24. BHP Assessment
Pt. not on-board with possible mh diagnosis and so is not entirely truthful about symptoms at first visit, wants to wait and see
As symptoms persist, patient decides to give Beh. Med another try, schedules appt. and is truthful
Started SSRI and cognitive therapy

25. Outcome Drastic decrease in MD visits from MH diagnosis and treatment:
2/28 MD intake appt.
7 biomedical appts
4/08 8th biomed appt. – BHP involved meets patient
4/30 BHP assessment- no pt. buy-in
7 more biomed visits
7/16 Pt. requests f/u with BHP –diagnosis and treatment with meds
1 f/u meds visit
2 BHP visits
9/4 1 biomed visit for migraines

26. Case # 2
54 yo female, RH, widowed x 4 months with a personal hx of Coronary artery disease. Raising 2 adopted sons.
Multiple ER visits and office visits for CP, and Shortness of breath. Complaining of ongoing fatigue.
tearful at every visit
Referrals for Beh Med evaluations done after each of 2 visits. Pt did not follow through.

27. Case #2 Both primary care and Cardiology felt sx were Not cardiac.
After several ER and office visits, pt was in the office when ML was present- a brief meeting at the time of the office visit occurred, Pt agreed to return for further sessions,
Sessions scheduled around medical provider office visit (as pt lived 30 miles away)

28. After multiple sessions with Beh. Med and a Beh Med Intern (great asset!) pt began showing interest in outside actiivties.
Was able to seek help when oldest son began acting out, also.
Seen weekly for months, now seen q month or as needed.
NO ER visits for MONTHS

29. Case 3
4 year old boy in for a well child visit accompanied by father and grandmother
Father and GM complain patient has many temper tantrums and note that his mother has Bipolar Disorder
Resident gives handout on strategies for dealing with tantrums and makes a referral to Behavioral Health

30. BHP Assessment
Interviews are done with patient, father, and grandmother
Grandmother feels strongly that patient has Bipolar Disorder and refers to patient’s behavior as “manic”
Patient is having severe tantrums that include physical harm to family members and destruction of property
Patient has witnessed family violence and has not had contact with his mother in over a year

31. Introduction of Psychiatrist
Dual session with Dr. McKay, child psychiatrist, to assist with diagnosis

32. Ongoing course of treatment
Continued diagnostic assessment with r/o high functioning Asperger’s, ADHD, Bipolar, Anxiety Disorder
Play therapy
Caregiver education and support

33. Audience Case 86 year old female cared for by daughter in law (DIL)
Received a letter from DIL earlier in the week where she notes
Patient is exhibiting signs of agitation, memory loss, hallucinations, confusion
She is giving patient extra doses of Remeron to deal with this behavior

34. Audience Case Pt diagnoses Medications Hypertension Allergic Rhinitis
Esophageal Reflux
Venous Insufficiency
Debility
Medications
Lotensin 40mg
Norvasc 5mg
Inderide 80-25mg
K-Dur Oral CR 20meq
Remeron 30mg
Vitamin D