Implementation of the Psychiatric Collaborative Care Model in a Residency Clinic Memorial Family Medicine Residency Program
Speaker Disclosure Dr. Botsford has disclosed that she has no actual or potential conflict of interest in relation to this topic.
Objectives Learn how inter-professional team members can improve outcomes on chronic diseases impacted by behavioral health diagnoses. Understand the impact of an integrated behavioral health program on outcomes in a residency clinic population. Evaluate whether your practice could fulfill the requirements to bill the psychiatric collaborative care codes.
Effects of Depression on Chronic Illness Recent Heart Attack 2x risk of death 2X risk of repeat MI Diabetes 50% in death 30% in limb amputation glucose control
Barriers to Treatment of Depression Time to diagnose and address during office visit Comfort level to treat Lack of referral sources Stigma Lack of feedback from members of care team
The Solution: Integrated Behavioral Health Components include Ask everyone Confirm diagnosis Treat – medication and/or counseling Team-based care with ongoing feedback loop Universal Screening with the PHQ-2 Positive PHQ2 PHQ9 interview with DSM V criteria PHQ9 or GAD score >10 eligible for referral
Collaborative Care: “IMPACT Care” Trial 2002 JAMA Study showing improved outcomes Doubles effectiveness of usual care Less Pain Better physical functioning Greater patient and provider satisfaction More cost-effective ROI $6.50:1 80 RCTs for depression in primary care (US and Europe) Consistently more effective than usual care Emerging data for anxiety, PTSD, ADHD, alcohol use disorder Archer, J. et al., 2012
Collaborative Care Components
New patient or Collaborative Care Program at PSC wellness visit Administer No Rescreen PHQ-9 and Elevated? yearly GAD Yes PCP Eval Yes No Accepts Care Psychiatric CARE? Manager Consultation
Collaborative Care Program at PSC Demographics Outcomes Sex 50% Reduction in PHQ-9 Score at 3 Months: Male 22% 60% (constant over 5 years) Female 78% Usual care: 29% Age Decreased medical visits 17-34 28% 35-54 40% Improvement in (some) diseases 55-74 28% 75+ 4%
Primary Care Visits
TeamCare at PSC Monica Kalra, DO Liliana Hernandez, MPH Erica Gallardo, LPC Laura Boudreaux, RD, LD Sylvia Teeple, LCSW Julie Adkison, PharmD
Bimonthly Team Meeting Content Areas assessed Drug therapy recommendations given by PharmD Lapses in office visits identified Referrals made as needed
Getting Paid to Deliver Better Care Psychiatric Collaborative Care Codes Created in 2017 based on success of University of Washington program Valued for payment in 2018 Involves Physician, Behavioral Care Manager and Psychiatrist collaboration in primary care setting Covered under MEDICAL benefits, not behavioral health
Physician Workflow Physician evaluates patient’s mental health status Obtains patient consent using Consent form Informs patient that 20% co-pay applies to these services If resident makes referral, attending must see patient at initiation Inclusion Criteria Exclusion Criteria New or uncertain diagnosis Crisis management needed Requires counseling lasting 60+ min/mo Episode initiated within last 6 months Not responding to treatment Active substance misuse* Uncertain mental health diagnosis Complex mental health diagnosis* Physician needs med management assistance Patient condition beyond physician comfort * Relative exclusion criteria
Behavioral Care Manager • Individual with formal education or training in behavioral health • Social work, nursing, or psychology • Work under oversight and direction of the billing physician • Provides care management as well as needs assessment • Administration of validated rating scales • Development of a care plan • Provision of brief interventions • Ongoing collaboration with the treating physician, arrange follow-up visits • Maintenance of a registry • Services are provided both face-to-face and non-face-to-face • Psychiatric consultation is at least on weekly basis • Typically non face-to-face
Psychiatric Consultant • Medical professional trained in psychiatry or behavioral health • Qualified to prescribe the full range of medications • Advises and makes recommendations for psychiatric and other medical care and other differential diagnosis • Treatment strategies regarding appropriate therapies • Medication management • Medical management of complications associated with treatment • Referral for specialty services • Communicated through the behavioral health care manager • Does not typically see the patient nor prescribe medications
Documentation Requirements Care Manager Document intake visit Document Document care coordination activity with psychiatrist Time Spent! Update Care Management registry Inform PCP of progress PCP implements care plan, and documents implementation Billing occurs monthly, submitted by referring physician If resident physician, should be under initial precepting attending T emplates and auto texts are helpful for the documentation and notifying PCP of action items, billing codes
Billing and Payment CPT Description Time Payment* 99492 Initial 70 minutes 36-85 minutes $161.24 99493 Subs. Calendar month, 60 minutes 31-75 minutes $128.84 99494 Additional 30 minutes initial or subsequent >15 minutes $66.58 For Initial month, with 86-116 minutes, report both 99492 and 99494 • For subsequent month: 76-105 minutes, report both 99493 and 99494 • • PCP pays care manager and psychiatrist on a contract basis • $37/hr LPC • $435/hr Psychiatry Consultant • 43 patients in registry, ~30 active monthly *2018 Medicare payment allowances
Contact Information & Acknowledgments Lindsay.Botsford@ioraprimarycare.com David.Bauer@memorialhermann.org Matthew.Shields@memorialherman.org Special thanks to the following persons Liliana Hernandez, population health specialist Erica Gallardo, LPC Chips Adams, Michelle Brumley and Carol Paret for their historical support of the innovation
Resources CMS Fact Sheet: https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-Fact- Sheet.pdf CMS FAQ: https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-FAQs.pdf https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated- care/get-trained/about-collaborative-care https://aims.uw.edu/collaborative-care
References Johnson JA, Al Sayah F, Wozniak L, et al. Collaborative care versus screening and follow-up for patients with • diabetes and depressive symptoms. Diabetes Care. 2014 Dec;37(12):3220-6 Katon WJ, et al., Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010 Dec • 30;363(27):2611-20 McGregor M, et al.,TEAMcare: an integrated multicondition collaborative care program for chronic illnesses and • depression . J Ambul Care Manage. 2011 Apr-Jun;34(2):152-62. Von Korff M, et al., Functional outcomes of multi-condition collaborative care and successful aging: results of a • randomized trial . BMJ 2011 Nov 10:343 Lin EH, et al.,Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, • and depression: a randomized controlled trial. Ann Fam Med . 2012 Jan-Feb;10(1):6-14. Katon W et al., Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled • trial . Archives of General Psychiatry 2012; 69(5):506-14. Rosenberg D, et al., Integrated medical care management and behavioral risk factor reduction for multicondition • patients: behavioral outcomes of the TEAMcare trial . Gen Hosp Psychiatry 2013, Nov 4.
Lance Kelley, PhD Director of Human Behavior and Mental Health, Waco Family Medicine Residency Program; Director of Primary Care Behavioral Health, Waco Family Health Center
Heart of Texas Community Health Center Who We Are Key Partners Baylor University School of Social Work Waco, TX Massachusetts General Hospital Psychiatry FQHC serving 60,000 Academy 14 Clinical Sites Duke University School of Medicine, Dept. of Psychiatry and Behavioral Sciences Ethnically diverse Health Resources & Services Administration 12 / 12 / 12 Family Medicine Residency (HRSA) Episcopal Health Foundation High proportion of graduates serve in The Meadows Foundation health professional shortage areas Cooper Foundation
Primary Care Integrated • Accessible • Personal • Sustained • Comprehensive • Community-oriented
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