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

• utcomes 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

Administer PHQ-9 and GAD New patient or wellness visit Elevated? No Rescreen yearly Yes Accepts CARE? PCP Eval No Yes Care Manager Psychiatric Consultation

Collaborative Care Program at PSC

Collaborative Care Program at PSC

Demographics Outcomes

 Sex

 Male

22%

 Female

78%

 Age

 17-34

28%

 35-54

40%

 55-74

28%

 75+

4%

 50% Reduction in PHQ-9 Score at

3 Months:

 60% (constant over 5 years)  Usual care: 29%

 Decreased medical visits  Improvement in (some) diseases

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

Lapses in office visits identified

Drug therapy recommendations given by PharmD Referrals made as needed

Bimonthly Team Meeting Content

Areas assessed

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 care coordination activity with psychiatrist  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

Document Time Spent!

Billing and Payment

• 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

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

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

• f Primary Care Behavioral Health, Waco Family Health Center

Heart of Texas Community Health Center

Who We Are

• Waco, TX
• FQHC serving 60,000
• 14 Clinical Sites
• Ethnically diverse
• 12 / 12 / 12 Family Medicine Residency
• High proportion of graduates serve in

health professional shortage areas Key Partners

• Baylor University School of Social Work
• Massachusetts General Hospital Psychiatry

Academy

• Duke University School of Medicine,
• Dept. of Psychiatry and Behavioral Sciences
• Health Resources & Services Administration

(HRSA)

• Episcopal Health Foundation
• The Meadows Foundation
• Cooper Foundation

Primary Care

Integrated • Accessible • Personal • Sustained • Comprehensive • Community-oriented

Integrated Health Manager (IHM)

Core primary care healthcare team member who serves as integrated behavioral health (IBH) provider and chronic care manager (CCM)

• Licensed Clinical Social Workers (LCSWs) ideal professional for

the role

• Generalist training in mental health and advanced case

management

• Social workers equipped to pay attention to macro and mezzo

considerations that impact the delivery of micro services

• LCSW is trained and supported to work at the top of their

license

Shared Care

• Moves well beyond consultation and collaboration
• IHM assumes care for panel of patients
• Providing IBH (i.e. brief psychological interventions) and Care

Management (for physical and behavioral health) services when appropriate

• Bidirectional Warm Handoffs and Co-visits
• The Team determines who is seen

Shared Care – Outcomes

• 9/14 clinics at shared care level
• ~2500 patient behavioral health encounters per IHM per year
• 85% result in a full behavioral health visit
• 75% are reimbursable
• 250% increase in behavioral health screening
• Physicians report the IHM is a vital team member
• Physicians report greater ability to address the gamut of patient

needs

• Clinics without an IHM repeatedly request to add one to the team

Quality Assurance and Training

• First, Train the Trainer
• Train the IHM
• 4 weeks of individualized training in apprenticeship model
• Standard syllabus: Integrated care models; Screening and brief intervention for most

common medical and mental health diagnosis in primary care; maximizing team-based care

• Training occurs in FM residency clinics
• Most IHMs have completed 64-hour certificate program through Baylor University

School of Social Work

• Train the Clinic Team
• IHM receives 4 additional weeks of training with new clinic team with IHM trainer
• nsite
• IHM trainer coaches other team members on maximizing the model and troubleshooting

barriers

Ongoing Support, Internal Stepped Care, and Retention

• Real-time consultation with behavioral health leadership team
• Human Behavior and Mental Health Consultation Clinic
• Staffed by clinical psychologist and family medicine resident and faculty
• Stepped Care Pathways
• e.g., Integrated Child-Adult Relationship Enhancement (iCARE)
• Intervention for disruptive behavior disorders delivered by IHM
• Developed in partnership with faculty at Duke Medical School
• Reduction in overall problem behaviors
• Clinical Decision Support Tools

Psychopharmacology Decision Support

• Waco Physicians

– Family Medicine Faculty – Psychiatry – Maternal-Fetal Medicine

• Developed in close consultation

with faculty of the Massachusetts General Hospital Psychiatry Academy

• Adult, Pediatric, Maternal tools
• 3-year project with continuous

support and generous funding from Episcopal Health Foundation

Decision Support Tool Examples

Psychopharmacology Decision Support Tools

Ongoing Support, Internal Stepped Care, and Retention

• Bimonthly IHM meetings include ongoing training and case-

consultation

• Stipend for trainings and certification in areas identified by physicians

and IHMs (Diabetes, CBT-Insomnia, CBT-chronic pain, postpartum mental disorders)

• Shared clinical toolboxes via cloud service storage

Financial Sustainability

• Reimbursement structure covers most salary expenses
• Use grant funding as seed money to establish reimbursable

service expansion and some of the training expense

• Funding from:

– Episcopal Health Foundation – Health Resources and Services Administration (HRSA) – The Meadows Foundation – Cooper Foundation

Contact

Lance Kelley, PhD Clinical Psychologist Waco Family Medicine Residency Program 1600 Providence Drive Waco, TX 76707 (254) 313-4213 (Office) lkelley@wacofhc.org

Better Together – Providing Integrative Care

Objectives

• Review one model of behavioral health integration in a primary care

solo or small group setting.

• Understand the basic components necessary to implement this

particular model for behavioral health integration in individual practice contexts.

Our Story

• It started with one man lying in a ditch…
• ER…but then what?
• Our resources
• Hospital cot
• One naïve young doctor
• No money

Collin County

2018 Collin county homeless census1

Today

• Primary medical home for ~300 uninsured, low‐income individuals and

their families

• 3 full‐time and 2 part‐time staff
• 95 active volunteers
• New location

Services

• Primary care
• Family Medicine
• Pediatrics
• Specialty care
• Cardiology
• Gynecology
• Pulmonology
• Dermatology
• Neurology
• Asthma/allergy
• Allied health
• Counseling
• Physical therapy
• Occupational therapy
• Optometry

Other services

Prescription assistance Care messaging Community events Social work

• An estimated 50% of all Americans are diagnosed with a mental illness
• r disorder at some point in their lifetime.
• Mental illnesses, such as depression, are the third most common cause
• f hospitalization in the United States for those aged 18‐44 years
• ld22,3
• Adults living with serious mental illness die on average 25 years earlier

than others.

Why should we care?

Despite these facts, there is a national and local shortage of mental health resources resulting in critical lack of access and disparities in care.

Location Number of Uninsured Texas 4,500,000 Collin County 104,000 Hope Clinic of McKinney Every patient Prevalence of depression 8% 11.6% 33.6%

A Widening Gap…

Integrated

Care

Provider Collaboration Universal screening Shared EMR/location Individualized care Streamlined referral scheduling Measurement‐ based care

We believe an innovative and multi‐ faceted approach to treatment is essential

Universal Depression Screening

Positive Screens

VitalSign6

• Collaboration with UTSW Center for Depression

Research and Clinical Care:

• Universal screening at a minimum of every 6

months

• The use of research‐driven and evidenced‐based

measurement‐based care algorithms and guidelines

• Expert psychiatry back‐up for difficult cases or

recalcitrant patients

Provider Collaboration

• Co‐location and EMR provide for:
• Streamlined referrals and scheduling for

behavioral health counseling

• Regular collaboration of care for individual

patients between medical provider and licensed professional counselor

Individualized Care

• All patients are offered spiritual and social

support at every visit

• CareMessage text messaging or phone call

follow‐up for high risk patients

It is this multi‐faceted approach to mental health (and patient care in general) that we believe has led to excellent outcomes.

Outcomes

Remission Rates after treatment National average 25% Hope Clinic of McKinney 44%

Outcomes

Can I do this?

• Cost‐effective
• CareMessage ‐ $250/yr
• VS6 – free
• Counseling – no added cost
• Fixed costs likely already present in your office
• EMR
• Physical space
• Support staff

Can I do this?

• Provider time
• 2 min/pt
• Patient time
• 15 min first visit
• ~5 min thereafter
• Management

concerns

• Clinical decision

making

• Suicidality

Challenges

REFUSAL OF TREATMENT SEPARATE SYSTEM LANGUAGE OR LITERACY BARRIERS SOME TRAINING REQUIREMENT

ONE PATIENT’S STORY

References

• 1. 2018 Collin County Homeless Census.

https://friscotexas.gov/DocumentCenter/View/15110/Collin‐County‐ 2018‐Homeless‐Census‐Report

• 2. Parks J. et al. Morbidity and Mortality in People with Serious Mental

IllnessCdc‐pdfExternal. National Association of State Mental Health Program Directors Medical Directors Council. Alexandria, VA; 2006.

• 3. Kessler RC, et al. Lifetime prevalence and age‐of‐onset distributions
• f mental disorders in the World Health Organization’s World Mental

Health Survey Initiative. World Psychiatry. 2007;6(3):168‐176.