Improving Quality and Access in Specialty Mental Health By Applying the Principles of Integrated Care- We’ll Even Show You The Money Caroline Fisher MD PhD Please note that the views expressed are those of the conference speakers and do not necessarily reflect the views of the IPS and no commercial interest in this presentation
Source: Thomas, K. C., Ellis, A. R., Konrad, T. R., Holzer, C. E., & Morrissey, J. P. (2009). County-level estimates of mental health professional shortage in the United States. Psychiatric Services .
Initial evaluation and diagnosis – 90 min Therapy – 60 min/week, 10-15 weeks Medication management visit 30 min/month Very stable patients 30 min/ 3 months 36 hours/week, 46 weeks a year 276 patients total 528 patients at 15 min med management visits
Specialty Mental Health medical assistant ◦ Screen and triage calls from existing patients ◦ Get basic intake information ◦ Keep track of referrals, requests for info ◦ Take vitals ◦ Deal with prescriptions, pharmacy prior auths, etc
Simultaneously Running Psychiatry Integration project in Pediatrics Using U of W IMPACT model ◦ “Behavioral Health Consultant” stationed in Pediatrics ◦ ½ day a week of child psychiatry Consulting on anybody who can be stabilized in 4 sessions – 78% improvement BUT Increases complexity of Specialty Mental Health
BHC: Masters level ◦ Sees/calls patients ◦ Maintains registry ◦ Standardized outcome measures ◦ Brief therapy MHS: Bachelors + experience ◦ Unlicensed MA ◦ Zero therapy, zero dx ◦ some case management ◦ Maintains registry ◦ Warm handoffs ◦ “face” of psychiatry in Primary Care
Set up a system where: ◦ Urgent appointments available ◦ Phone calls instead of follow up visits Would I feel confident? Would families feel cared for? Would I burn out? ◦ New evaluations streamlined by having MHS do it ◦ Capacity expands
1 visit q 3 months + 2-6 phone calls ◦ Triple capacity? ◦ Double capacity? Ideal schedule
Interview for “psychological mindedness” Use same process as training early residents ◦ Interviewing SCID CSV Epic template ◦ Boundaries ◦ Risk assessment ◦ Vitals ◦ Case management ◦ customer service ◦ Self care ◦ Not to overstep role CMA does prescriptions/orders, not MHS
Source: http://smartcatalog.co/Catalogs/Linn-Benton-Community-College/2016- 2017/Catalog/Degrees-and-Certificates/Associate-of-Applied-Science-Degrees- and-Certificates/Medical-Assistant/Medical-Assistant-Associate-of-Applied- Science
How good of a data gatherer your MHS is while doing evaluations. As in primary care, patients bond do MHS Doesn’t increase burn out for me ◦ Need support for MHS Between the two projects, no waiting in the county Much more flexibility for intensity of follow up
Varies over time Too many of them Parents don’t want to treat that aggressively
Psychiatrist CPT Codes: Initial evaluations (90791-90792) Follow up 99212-15 + 90833 (E/M plus add- on therapy codes ) January- GPPP1, GPPP2 and GPPP3
Fee for service ◦ Psychiatrist bills each session via CPT reimbursement Update Contracts to include chart reviews And MH specialist screenings Pediatric Department still reimbursed on a Fee-For-Service basis
Evaluations Already charging them 99213 +90833 What can we do with that rate? ◦ Psychiatrist face to face ◦ MH specialist phone screening ◦ Paid per month rather if both or one of these services happens
It is New- upcoming Provider buy in EMR security/access (new role) Data from EMR to help with Dashboard
Credentialing CMS/State laws Commercial insurance: move away from fee for service based to capitation
Feb 2015 1 MH Specialist for Specialty Mental Health Clinic July 2016 2 MH specialist for Specialty Mental Health Clinic ◦ *total of 9 MH combined across our System for Primary Care with covering 13 primary cares and two specialty mental health clinics Increased patient satisfaction scores Contracting with our local ACO to capitation model in both adult and child specialty Mental Health Clinics
Front line for specialty mental health
Confirm appointments Triage emergent needs of patient while the Psychiatrist is unavailable. Conduct outcome measures and report progress to Attending Psychiatrist. Track patient load progress and assure timely follow up. Conduct Psychiatric History Questionnaire session. Currently scheduled for 90 minutes a piece. Complete full history on patient and family, screen for areas of concern in behaviors and family history (i.e. genetic predispositions, social histories, confirm former treatment. ) Report initial data to Psychiatrist who can then proceeded based on information already gathered.
Between February 2015 and March 2016, The Psychiatrist and Mental Health Specialist have had 180 Patient contacts The data shows a 3-to-1 contact ratio between the Mental Health Specialist and the Psychiatrist. Patients surveyed report a XX% favorable view of the Mental Health Specialist position and felt it was helpful for their maintained mental health.
Follow up calls are scheduled as 30 minute appointments, with confirmation calls going out before hand The MH Specialist checks on the patents mood, social HX since last visit, and other concerning factors (over time, the MH specialist gets to know these families, and knows their specific qualities and traits) The MH Specialist addresses any specific concerns the Psychiatrist may have (i.e. Sleep, appetite, etc.) and may impart information on their behalf (need for blood draw, lab results, etc.) The MH Specialist conducts formal outcome measures based on the patients diagnosis “(SNAP IV, GAD-7, PHQ-9 etc.) Often, the MH Specialist will use this time to listen to the patients concerns, and assure them that the Specialist will get the information to the doctor. Working with the Psychiatrist, the MH Specialist is trained to listen critically for worrisome factors, and use interview techniques to obtain the most pertinent information for their care.
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The Psychiatric History Questionnaire sessions are scheduled for 90 minutes, with confirmation calls going out to families before hand. In this time, the MH Specialist asks about family/patient concerns, social history, treatment history, symptoms review, current and past medications, allergies, Developmental Milestones in children, Substance history and Family history Once compiled, the MH Specialist will brief the Psychiatrist on endorsed factors, areas of concern brought up in interview and presentation of patient in session The Psychiatrist will then meet with the patient for 20-30 minutes, referring to history obtained by MH Specialist, and bill out an evaluation code once completed Afterwards, a follow up schedule with the MH specialist is planned and scheduled based on the patients needs (Daily check-ins for suicidal tendencies, weekly, semi weekly, monthly, etc.)
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In a recent patient survey, XX % of patients felt comfortable speaking with the MH Specialist versus coming in more often XX % said that they felt their concerns were addressed promptly by the MH Specialist when things were not going well Surveyed patients felt that due to proximity, it was easier to speak on the phone with an MH Specialist than to come in for an appointment
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Appropriate links to SHS clinic site.
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