Implementation of the Psychiatric Collaborative Care Model in a - PowerPoint PPT Presentation

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