THE ART OF THE BHC CONSULT BHC C Core C Competencies, U Utilizi - - PowerPoint PPT Presentation

THE ART OF THE BHC CONSULT

BHC C Core C Competencies, U Utilizi izing 1 15-30 M 0 Minutes Effectively ly, a and Co Common Ch Challe llenges

Hanna Kleiner, LPC-MHSP Director of Behavioral Health Services Connectus Health

LEARNING OBJECTIVES

■ UNDERSTAND:

• 1. Core competencies of a behavioral health consultant in primary care
• 2. How mastering core competencies can ensure efficacy of an integrated program
• 3. Methods for training new BHC’s to effectively utilize the 15-30 minute window

■ IDENTIFY:

• 1. Main components of a 15-30 minute brief consultation
• 2. Common challenges in adhering to the 15-30 minute brief consult
• 3. Common issues surrounding billing and reimbursement for BHC services

CORE COMPETENCIES OF THE BHC IN PRIMARY CARE

Impact of a competent BHC Core Competencies Role o

• f the

BHC HC

The Role of the BHC

Rationale for Integrating BH with PC

■ Flaws in the traditional medical model ■ Burden on primary care system ■ Primary care is a crucial point of access to mental health services – Primary care providers deliver at least half of all mental health care in the United States (Kessler et al., 2005). – 30-80% of primary care appointments are driven by problems stemming from psychosocial and BH issues (Gatchel & Oordt, 2003). – Half of all individuals with a psychiatric disorder seek NO specialty care, but 80% of them visit their PCP at least yearly (Narrow et al., 1993).

The Role of the BHC

Supporting the Medical Team

■ Management of acute behavioral health conditions ■ Engage in screening, assessment, and brief intervention for mild to moderate behavioral health conditions ■ Address lifestyle change issues for chronic medical conditions and high-risk patients ■ Collaborate on treatment plans to enhance patient engagement in care ■ Educate and provide plans for various behavioral health issues ■ Provide consultation to primary care team on behavioral and mental health components of care ■ Assist with community resources and referrals ■ Deliver brief, concise, and clear communication through documentation and curb-side consultation ■ Serve as liaison between patient and medical staff to support clinic flow, patient/provider satisfaction, and adherence to treatment goals

The Role of the BHC

The Ideal Candidate

■ Licensed master’s or doctoral level clinician with a background in social work, behavioral health counseling, health psychology, or marriage and family therapy ■ Experience with substance abuse treatment ■ Self-starter, curious, eager to learn, and flexible ■ General attitude of understanding and acceptance ■ Strong active listening skills ■ Focus on immediate goals ■ Generalist vs. specialist ■ Working knowledge of motivational interviewing, stages of change, CBT, and solution-focused approaches

CORE COMPETENCIES OF THE BHC IN PRIMARY CARE

Impact of a competent BHC Core e Competen encies es Role of the BHC

Core Competencies

■ Clinical Practice Skills ■ Practice Management Skills ■ Consultation Skills ■ Documentation Skills ■ Team Performance Skills ■ Administrative Skills

Core Competencies

Clinical Practice Skills

ELEMENT ATTRIBUTES Role D Definition Sets accurate expectations Proble lem I Identification Identifies referral problem within 1st consult Assessment Functional impact of current problem Problem F em Focus Hones in on problem without probing Population-Based Care Continuum of primary prevention to tertiary care Biopsychosocial Approach Medical and psychological connections Use of empirically-supported interventions Evidence based, suitable for primary care Interven ention Des Design Strategic, measurable functional outcomes Pharmacotherapy Basic understanding, remains within scope, effective collaboration

Core Competencies

Clinical Practice Skills (Role Definition)

SAMPL PLE I INTRODUCTORY S Y SCRIPT PT “Hello, my name is ____________ and I’m the behavioral health consultant for the clinic. I work as a part of the primary care team here. At our clinic, we pay attention to the whole person -- physical, mental, and social

• health. Your [primary care/women’s health] provider will ask me to assist whenever there is a concern about

any area of your health. My job as a consultant is to help you and your provider better target any problems that have come up for you at this point. To do this, I’m going to spend about 20 minutes with you to get a snap shot of your life—what’s working well and what’s not working so well. Then together we’ll come up with a plan that seems doable. The recommendations might be things you try on your own and you might never see me again. Or, we may decide to have you come back to see me a couple times, if we think that would be helpful. We might also decide that you’d benefit from going to a more intensive specialty service outside of the clinic. In that case, I’d talk with your primary provider and, if that was something they wanted for you, I’d help them arrange a referral. Your provider and I will work together with you on this plan, and my chart note will be integrated in your healthcare record. My limits of confidentiality are the same as other providers in this clinic, which includes a responsibility to report cases in which there is a disclosure of any plans to harm yourself or anyone else, or any type of child/elder abuse. Do you have any questions about any of this before we begin? *If ye yes: Spend time needed to make sure the patient understands the purposes of this service. *If n f no: “Your provider is concerned about (referral reason). Is that your sense of what is going on here as well,

• r do you have another take on this?”

Core Competencies

Clinical Practice Skills (Problem Identification)

■ STE TEP 1: A Adeq dequate Prep eparation – Communicate with your team! – Determine referral question, current medical plan, last contact with BHC, history of compliance/non-compliance, etc. ■ STEP P 2: R Review the Char art – Review the last 1 or 2 BHC notes – Review the most recent PCP note – Any pending patient messages? – Med list? ■ STE TEP 3: Se Set your me mental framework – What do you need to accomplish today?

Core Competencies

Clinical Practice Skills (Problem Focus)

■ STE TEP 1: E Explore Pres esenting g and d Addi dditional C Concerns – But WITHOUT excessive probing! – Hone in on REFERRAL QUESTION ■ STEP EP 2: Asse Assessment nt – Symptoms – Functioning – Risk ■ GO GOAL: T To Ge Get a a Working g Di Diagn gnosis and d Begi egin Trea eatment

Core Competencies

Clinical Practice Skills (Intervention Design)

■ Factors to Consider der: – Symptom Severity – Readiness to Change – Psychosocial Stressors – Co-morbid conditions – Patient preference – Cultural beliefs – Resources – Health beliefs

Core Competencies

Practice Management Skills

ELEMENT ATTRIBUTES Visit E Efficiency Works to avoid common pitfalls Time M Management Effective communication and boundaries Follow-Up Planning Strategic prescription of f/u based on severity, momentum, and patient engagement Intervention Efficiency Treatment episode completed in 4 or fewer consults Visit F Flexibili lity Scheduled, unscheduled, phone consult, secure messaging Triage Attempts to manage most problems in PC Case Management Internal and external care coordination Community Resource Referrals Strong knowledge of available resources

Core Competencies

Practice Management Skills (Visit Efficiency)

■ STEP P 1: S Stay Within 1 15-30 Minute e Timef meframe me ■ STEP P 2: S Stic ick to the Steps – Introduction – Assessment – Intervention – Plan/Follow Up ■ STEP P 3: A Avoid Common Pit Pitfal alls! – Focus on symptoms, diagnosis, treatment plan, and needed action steps

Core Competencies

Practice Management Skills (Time Management)

■ STEP P ON ONE: Utilize Your Resources – Communicate what you need and what you’re doing ■ STEP EP TWO: S Set Y t Your ur Bound undaries – With patients – With providers ■ STEP EP THREE EE: U Use se Downt ntime W Wise sely – Take advantage of free moments for charting, phone calls, research, etc. ■ STEP EP FOUR: Keep Your ur C Cons nsul ults on Track – Use The 3 R’s

Core Competencies

Practice Management Skills (Visit Flexibility)

■ STEP P ON ONE: Be Op Open to Mu Multip iple Me Methods o

• f Service Delivery

– 15-30 Minute Brief Consultation in Clinic – Phone Consultation – Secure Messaging ■ STEP P TWO: O: Lim imit Engag agement in in 40+ Min Minute C Consults – Some high needs appointments are inevitable **Focus on Red educing Hea ealthcare Burde den for Patien ent and d Workflow Burde den for Provider

Core Competencies

Consultation Skills

ELEMENT ATTRIBUTES Referral al C Clar arit ity Develop understanding of, focus on, and respond to referral question from providers Curbside Consultation Clear, direct, concise consults with providers on general issues or specific patients Assertive Follow-Up Understands when to use multitude of follow up methods (verbal, written, urgent interruptions) Provider Education Capitalizes on teachable moments and provides educational support on connection b/t physical and mental health Recommendation Efficacy and Value Tailor recommendations to pace of primary care and with intention of reducing PCP workload

Core Competencies

Consultation Skills (Referral Clarity)

■ STEP EP ONE: E: Ask Ask S Str trategic Que uestions ns – Based on what the provider needs from the patient – In consideration of what you already know – What do you need to accomplish what you need to today? ■ STEP P TWO: O: Qu Quic ickly D Determine Y Your Tar arget – By gathering information from:

■ Patient ■ Provider ■ Support staff

Core Competencies

Documentation Skills

ELEMENT ATTRIBUTES Conc ncise C Charting ng Concise, includes only pertinent info in PC setting, and written from the lens of BHC vs. traditional therapist Prompt Feedback Documentation and feedback completed/delivered on same day basis Appropriate Format SOAP, consistent with curbside consultation recommendations

Core Competencies

Documentation Skills (Concise Charting)

■ STE TEP ONE: Do Document for P Prima mary Care – Documentation is NOT primary mode of communication – Timely and concise – Medical vernacular – Include observed and reported symptoms, functioning, intervention, and plan ■ STEP TWO: Include Only y Pertinent H Historic ical al/Contextual Informatio ion

Core Competencies

Team Performance Skills

ELEMENT ATTRIBUTES Fit with primary care culture Operates comfortably within fast-paced, action

• riented, team-based culture

Knows team members Awareness of multidisciplinary team member’s roles Responsiveness Effectively communicate availability and deliver unscheduled services as needed Availability and approachability Approachable demeanor, ensures staff are aware of whereabouts at all times, available for

• n-demand consultation prn

Core Competencies

Administrative Skills

ELEMENT ATTRIBUTES IBH program policies and procedures Understands clinic scheduling, templates, privacy, informed consent policies, etc. Billing/CPT Coding Routinely completes all billing and coding activities Quality measures and data tracking Completes all data tracking procedures and assists with quality metrics Clinic materials Maintains exam room posters/fliers regarding BHC services Program support and development Assists with program development tasks when requested

CORE COMPETENCIES OF THE BHC IN PRIMARY CARE

Impac act of a com competent BHC HC Core Competencies Role of the BHC

Impact of a Competent BHC

Positive Patient Outcomes

■ Decrease patient symptoms and increase functioning/quality of life (Balestrieri, Williams, and Wilkinson, 1988; Moore, Von Korff, Cherkin, Saunder, & Lorig, 2000) ■ Greater improvement in anxiety, depression, and quality of care (Roy-Byrne, et al., 2010; Lang, 2003) ■ Reduction of panic attacks in COPD patients (Livermore, Sharpe, & McKenzie, 2010) ■ Increased self-management skills (Battersby, et al., 2010; Damush et al., 2008; Kroenke et al., 2009) ■ Improved quality of life for patients with chronic cardiopulmonary conditions (Cully, et al., 2010) ■ Reduction of substance abuse (Whitlock, et al., 2004) ■ Reduction of somatization (Escobar, et al., 2007; Kronke & Swindle, 2000)

Impact of a Competent BHC

Positive Provider/Clinic Outcomes

■ Improve medical provider satisfaction (Katon, et al. 1995; Corney, 1986) ■ Reduce healthcare costs (Blount, 1998; Chiles, Lambert & Hatch, 1999) ■ Improving treatment adherence for patients with comorbid diabetes and depression (Lamers, Jonkers, Bosma, Knottnerus, & Van Eijk, 2011; Osborn, et al., 2010) ■ Increase patient likelihood of attending behavioral health appointments, as opposed to being referred to off-site providers (90% vs 15%) (Strosahl, 1998)

THE 15-30 MINUTE CONSULT

Common Challenges Training Considerations Compo mpone nent nts o

• f

an e effective consu sult Making it work

Components of an Effective Consult

• 1. Introduction
• 2. Assessment
• 3. Intervention
• 4. Plan

Components of an Effective Consult

Introduction Phase (2-3 Minutes)

MAIN ELEMENTS: ■ Introduction and disclosure statement ■ Setting expectations ■ Defining role and time frame ■ Refining “referral question” from provider COMMON PITFALLS: ■ Failure to completely and clearly define role ■ Failure to hone in on referral question

Components of an Effective Consult

Assessment (7-10 Minutes)

MAIN ELEMENTS: ■ Assessment of symptoms based on the referral question ■ Assess for daily functioning, safety, risk, need, symptom severity ■ Determine actions already taken to improve ■ Assess for strengths and stage of change ■ Use of screening tools COMMON PITFALLS: ■ Tendency to “go fishing” for additional problems ■ Moving too fast towards intervention

Components of an Effective Consult

Intervention (5-7 Minutes)

MAIN ELEMENTS: ■ Concrete, practical, patient-centered interventions ■ Focus on symptom reduction and improvement in functioning ■ Acquire patient buy-in through behavioral activation ■ Elicit patient engagement and empowerment through use of a “menu of options” and handouts COMMON PITFALLS: ■ Failure to provide adequate direction to begin self-management skills ■ Tendency to limit interventions ■ Lack of awareness of BHC’s role in continuity of care

Components of an Effective Consult

Plan/Follow Up (3-5 Minutes)

MAIN ELEMENTS: ■ Scheduling is done in collaboration with patient and provider ■ Follow up is based on clinical necessity ■ Identify when bridging/staggering appointments can be helpful COMMON PITFALLS: ■ Scheduling too brief of an interval between appointments ■ Scheduling unnecessary appointments ■ Failure to recommend follow up

THE 15-30 MINUTE CONSULT

Common Challenges Training Considerations Components of an effective consult Maki king it it work

Making 15-30 Minutes Work

■ Communication ■ Setting Realistic Expectations ■ Graceful Interruption ■ Connecting supportive therapy with direction and purpose ■ Thinking algorithmically early ■ Adequate prep

THE 15-30 MINUTE CONSULT

Common Challenges Train inin ing Consid ideratio ions Components of an effective consult Making it work

Training Considerations for New BHC’s

■ Shadowing ■ Peer Review ■ Documentation Evaluations ■ Ongoing training topics

THE 15-30 MINUTE CONSULT

Commo mon n Challe lleng nges Training Considerations Components of an effective consult Making it work

Common Challenges

■ The Talker ■ The Unclear Presenting Issue ■ The “Where Do I Even Begin” Dilemma ■ Determining which hat to wear ■ The Paradigm Shift

ADDITIONAL TOPIC:

ISSUES SURROUNDING BHC BILLING AND REIMBURSEMENT

■ Revenue Producers vs. Enhancing Team and System Functioning ■ Grant Funding ■ CPT Codes ■ Getting Paid

RESOURCES

■ Balestrieri M, Williams P, Wilkinson G. Specialist mental health treatment in general practice: a meta-analysis. Psychol Med 1988;18:711-7 ■ Battersby, M., Von Korff, M., Schaefer, J., Davis, C., Ludman, E., Greene, S. M., … Wagner, E. H. (2010). Twelve evidenced- based principles for implementing selfmanagement support in primary care. Joint Commission Journal on Quality and Patient Safety, 36(12), 561-570. ■ Blount, A. (1998). An introduction to integrated primary care. In Blount, A. (Ed.). Integrated Primary Care: The Future of Medical and Mental Health Collaboration. New York: W. W. Norton. ■ Chiles, J. A., Lambert, M. J., & Hatch, A. L. (1999). The impact of psychological interventions on medical cost offset: A meta-analytic review. Clinical Psychology: Science and Practice, 6(2), 204-220. http://dx.doi.org/10.1093/clipsy/6.2.204 ■ Corney, R. H. (1986). Marriage guidance counseling in general practice. The Journal of the Royal College of General Practitioners, 36(290), 424–426. ■ Cully, J. A., Stanley, M. A., Deswal, A., Hanania, N. A., Phillips, L. L., & Kunik, M. E. (2010). Cognitive –behavioral therapy for chronic pulmonary conditions: Preliminary outcomes from an open trial. Primary Care Companion Journal of Cli i l P hi t 12 Clinical Psychiatry, 12(4), pii. ■ Damush, T.M., Wu, J., Bair, M.J. et al. J Behav Med (2008) 31: 301. https://doi.org/10.1007/s10865-008-9156-5 ■ Escobar, J. I., Gara, M. A., Diaz-Martinez, A. M., Interian, A., Warman, M., Allen, L. A Rodgers D (2007) Effectiveness of a time A., … Rodgers, D. (2007). Effectiveness of a time-limited cognitive behavior limited cognitive behavior therapy intervention among primary care patients with medically unexplained symptoms. Annals of Family Medicine, 5(4), 328- 335.

RESOURCES

■ Gatchel, R. J. & Oordt, M.S. Clinical Health Psychology and Primary Care: Practical Advice and Clinical Guidance for Successful Collaboration, Washington, D.C. American Psychological Association, 2003. ■ James, L.C., & O’Donohue, W.T. (2009). The Primary Care Toolkit: Pratical Resources for the Integrated Behavioral Care

• Provider. NY: Springer.

■ Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G.E., Bush, T., … Russo, J. (1995). Collaborative management to achieve treatment guidelines: Impact on depression in primary care. Journal of the American Medical Association, 273(13): 1026-1031. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/7897786. ■ Kessler RC, Demler O, Frank RG, et al. Prevalence and Treatment of Mental Disorders, 1990 to 2003. N Engl J Med. June 16, 2005 2005;352(24):2515-2523. ■ Kroenke K, Bair MJ, Damush TM, et al. Optimized Antidepressant Therapy and Pain Self-management in Primary Care Patients With Depression and Musculoskeletal PainA Randomized Controlled Trial. JAMA.2009;301(20):2099–2110. doi:10.1001/jama.2009.723 ■ Kronke, K., & Swindle, R. (2000). Cognitive behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychotherapy and Psychosomatics, 69, 205-215. ■ Lamers, F., Jonkers, C. C., Bosma, H., Knottnerus, J. A., & van Eijk, J. T. (20110. Treating depression in diabetes patients: Does a nurse-administered minimal psychological intervention affect diabetes-specific quality of life and glycemic

• control. Journal of Advanced Nursing, 67( ) 4 , 788-799.

■ Lang, A. J. (2003). Brief intervention for co-occurring anxiety and depression in primary care: A pilot study. International Journal of Psychiatry in Medicine, 33(2), 141-154. ■ Livermore, N., Sharpe, L., & McKenzie, D. (2010). Prevention of panic attacks and panic disorder in COPD European Respiratory Journal panic disorder in COPD. European Respiratory Journal, 35(3) 557 (3), 557-563.

RESOURCES

■ Moore, J. E., Von Korff, M., Cherkin, D., Saunder, K., & Lorig, K. (2000). A randomized trial of a cognitive-behavioral program for enhancing back pain self care in a primary care setting. Pain, 88(2): 145-153. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11050369. ■ Mountainview Consulting Group. (2013). Primary Care Behavioral Health Toolkit. Retrieved from http://www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf ■ Narrow, W., Reiger, D., Rae, D., Manderscheid, R., & Locke, B. (1993). Use of services by persons with mental and addictive disorders: Findings from the National Institute of Mental Health Epidemological Catchment Area Program. Archives of General Psychiatry, 50, 95- 107 ■ Osborn C, Trott H, Buchowski M, et al. Racial disparities in the treatment of depression in low-income persons with

• diabetes. Diabetes Care. 2010;33:1050–4.

■ Robinson, P.J. & Reiter, J.T. (2015). Behavioral Health Consultation and Primary Care: A Guide to Integrating Services. NY: Springer. ■ Roy-Byrne, P., Craske, M. G., Sullivan, G., Rose, R.D., Edlund, M. J., Lang, A. J., … Stein M B (2010) Delivery of evidenced based treatment for multiple anxiety Stein, M. B. (2010). Delivery of evidenced based treatment for multiple anxiety disorder in primary care: A randomized controlled trial. JAMA, 303(19), 1921-1928. ■ Strosahl, K. (1998). Integrating behavioral health and primary care services: The primary mental health care model. In A. Blount (Ed.), Integrated primary care: The future of medical and mental health collaboration (pp. 139-166). New York, NY, US: W W Norton & Co. ■ Whitlock, E.P., Polen, M.R., Green, C.A., Orleans, T., & Klein, J. (2004). Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. Preventative Services Task Force, Annals of Internal Medicine 140(7):557–568.