#behavioralhealthintegration

[hammidjohn]

Digital Way to Complete Health Problem

The remote patient monitoring collects the data from patients and securely transmits that information on industry-leading providing additional care to increase revenue by remote clinical monitoring.

[integratedprimarycare]

How do I start a B.H. clinical  conversation?

I am still unsure how to start my encounter with a patient. What do I say? How do I start the encounter? I have done a lot of searching online to find a list of questions to use when I first meet a patient but I don't think I have found the correct tool. Do you have a list of questions you would be willing to share?

  B. M.

Dear B.,

First, it is important to realize that any of the “correct tools” of today were “what works best in my experience” for some other clinician in the past.  If you didn’t find it on the web, that is probably because it has not been researched, and if it were researched, I wouldn’t trust the result because the situations in each case can be so different.  With a warm handoff, the best way to start is to have the doctor introduce you to the patient and say to you and the patient a bit about why she wanted to add you to the patient’s care.  If that happens, when the doctor leaves, you can ask the patient if there is anything else the doctor should have said, or if they would have described their situation any differently from the doctor.   Another question is “What else do I need to know before we start to talk.”  If the doctor is not part of helping with goals at the handoff, you can start by saying in a sentence or two what the patient’s doctor said about their situation and anything the doctor said about her (doctor’s) goals for your work together.  In some settings at this point, there are things that are required to be said: permission to treat, info about billing or co-pays, your discipline, limits of confidentiality, and so forth.  When required statements are out of he way and there is agreement on a very brief description of the situation, I would take a minute to set the goal for the interaction for that day. Don’t say “what are your goals for our work together today?” unless you have a fairly sophisticated patient.  I usually say, “Before we get started, I want to take a minute to ask you to imagine something.  Imagine that it is 20 minutes from now (or however much time you have) and you are walking back down the hall to go out, and you are saying to yourself, “That sure didn’t solve everything, but I think it was worth my time.  I am glad I had that conversation. What would have happened here that would make you say that?” (Unless you know a good reason to say it differently, say it just like I wrote it, like a script.). Whatever the patient answers is your goal for the meeting and you are in the middle of your clinical conversation.  If they say they can’t imagine what would make them say that, you can say, “So it we could come to any clarity on what would make our talking worth while to you, that might be a good place to start?”

Sandy

[dreddymd]

Tweeted

RT @allentien: in 2018, physicians and practices are still early in learning curve to provide coordinated care for patients with complex problems https://t.co/kzCYnC0GlJ#LivingSystems#FunctionalMedicine#SocialDeterminants#BehavioralHealthIntegration

— Eddy Bettermann 🇩🇪 (@DrEddyMD) April 13, 2018

[hammidjohn]

Understand the Patient Health Condition in Remote

Chronic care management achieves a best-in-class quality of life for your patients through expert oversight and continuous upkeep with vast welfare schemes.

[integratedprimarycare]

“Primary Care First”: CMS’s funding scheme for the most “complex” patients.

Primary Care First https://bit.ly/2P8lQlw is a new approach by CMS to paying for care for the most “complex” patients.  The new program is scheduled to launch 1/1/21.  It provides monthly payments and incentives for primary care practices that care for patients with multiple chronic illnesses.  This tends to be a group with high behavioral health needs in addition to physical illnesses.  In its present form, it does not incent Behavioral Health Integration for these patients, though the case for that change https://bit.ly/2SRCLJO is being made. There is a volume that focuses on this population with a patient-centered approach to both the physical and behavioral challenges they bring.  The approach is built on evidence about how to achieve lower costs, better outcomes and less stress for providers.  The book is Patient-Centered Primary Care: Getting from Good to Great. (www.pcpcg2g.com)

[integratedprimarycare]

Integrated Health Careers:  The Future of the Primary Care Behavioral Health Workforce

Finding the workforce of mental health professionals trained to function successfully as behavioral health clinicians in primary care and other health settings is getting harder and harder as integrated behavioral health is being implemented across the country.  Numerous folks-in-the-know are calling it a workforce crisis.  Mental health professionals just coming out of their graduate training, or those who have worked for a while in specialty mental health, struggle to adapt to the culture, pace, and routines of care in primary care.  At the same time, the need to specialty mental health professionals is also acute, so the idea that a large percentage of new mental health professionals will want to train to work in primary care so they can be assured of getting a job is not proving to be the case.  What’s a health system committed in integrated primary care to do?

Integrated Health Careers (IHC) is an approach that allows a practice or a health system to “grow your own.”  IHC guides a practice so that it can develop the behavioral health skills needed by the whole healthcare team while it develops a BH clinician workforce that is already completely acculturated to primary care.  IHC removes the need to help most BH clinicians unlearn the culture in which they gained their skills so they can succeed in primary care.

The introduction of behavioral health functions to non-clincians on the healthcare team has created one of the problems and the opportunity that makes IHC so important for the future of behavioral health integration. Nurses, medical assistants, community health workers, medical translators and some staff with no disciplinary training are being used as care managers, care coordinators, navigators, health coaches, patient advocates, and cultural brokers, all in the service of expanding the monitoring and engagement provided to patients by the health team while taking some of the burden for these functions off of a very stressed PCP workforce.  For the sake of simplicity, I call these non-clinicians with behavioral aspects to their jobs “care enhancers.”

The behavioral health functions that are basic to many of these care enhancer roles (as delineated in the New Hampshire Primary Care Behavioral Health Workforce Assessment https://bit.ly/2LdzQqd), with a few possible additions, are:

·      Creating and maintaining patient engagement in care

·      Addressing health literacy, adherence and health barriers (i.e., the social determinants of health)

·      Keeping information about the patient’s health needs and health behavior flowing between the patient and the health team

Each of these care enhancer roles has some evidence of improving patient satisfaction, provider satisfaction or health outcomes when the behavioral aspects of their duties are broadened with appropriate training and a clear protocol for their contributions.

It is not uncommon for a practice or health system to make the mistake of assuming the evidence they see for one of these care enhancer roles means that the additon of that role will be adequate to achieve the benefits of integrated behavioral health.  Some of the patients identified for the protocol provided by the care enhancer will be helped, but the cost savings, broad health impacts, and transformation of a practice that can go with full behavioral health integration will not occur, and some patients with more serious conditions will be treated with an inapproprite protocol.

To achieve the benefits of IHC, a practice needs a hierachy of expertise in its behavioral services that is analogous to the hierarchy of expertise it maintains on the medical side.  The physican level of medical expertise needs to be paired with a professional with a similar level of behavioral expertise.  In some of the implementations of the Collaborative Care Model, this has been supplied by a psychiatrist.  More commonly, a psychiatrist supplies consultation on prescribing to the PCPs, while the broad range of behavioral health expertise, in mental health treatment, assessment, substance use disorders, parent guidance and behavioral approaches to chronic illness are provided by a clinical health psychologist or possibly an experienced masters trained clinician.  When a professional with a robust behavioral health expertise set is part of the healthcare team, it becomes possible for other team members to provide some defined behavioral health services in a way analogous to the way the presence of the physician makes it possble for non-physician team members to provide some defined medical services.  Even more important, the presence of a trained behavioral health professional makes it possible for the whole team to learn to relate more skillfully and smoothly to patients with behavioral issues and needs.

In a practice with one behaviorall health clinician, IHC can be a the way to develop a larger cadre of BHCs plus an array of other roles that can improve life for patients and team members.  This is done by developing a step-wise career ladder that can allow someone to enter the practice as a medical assistant, communty health worker or medical interpreter, and over time, without having to give up their job and their pay check, train to be a care manager, navigator, patient advocate or health coach.  There are programs online that can provide the necessary curriculum while supervision and possible additional training as the staff member broadens her/his duties provided by a BHC.  From the role of navigator, health coach, or care manager, a team member can take courses to become a licensed clinician either as a clinical social worker, marriage and family counselor or mental health counselor, again without having to leave their job and their check.  Not all training programs fit for this approach.  Some require a person to do a clinical placement experience in a site different from their employment.  But there are programs to do fit this need.  (See the lists on www.NHPCBHWorkforce.org)   This is an approach to career development that Nursing instituted long ago, but that has not previously been applied in the other roles in primary care because they are not all within one discipline.

The advantages of IHC are many.  It allows a practice to maintain staff, with their longitudinal relationships with patients, while they grow in skill and responsibility.  It makes the achievement of diversity of staff, especially in ways that match the diversity of the patients being served, much more possible than hoping that a licensed professional of the group or with the language skills needed will walk in the door.  It creates an environment of learning and sharing of skills that is a routine part of the work experience for everyone.  And it greatly enhances the array of behavioral interventions and services that can be provided to patients, which tends to make the lives of PCPs significantly easier.

There will be challenges in some health systems with no flexibilty in job descriptions and pay scales, but if there is a commitment to integrated care at the top of the organization, the advantages of IHC should be apparent.

For more information about Integrated Health Careers, you can get in touch with me at ablountedd (at) gmail.com or watch the development of the New Hampshire Primary Care Behavioral Health Workforce Initiative web page (www.NHPCBHWorkforce.org) and the graphical representation of the IHC career ladder as it goes up over the next 6 months.

[integratedprimarycare]

Thinking about competencies for behavioral health clinicians in primary care.

Last week I was in Charlotte, NC, for the Collaborative Family Healthcare Association conference. (Every year the best conference on integrated primary care in the nation). I presented with my colleague, C.J. Peek who is Professor of Family Medicine at the University of Minnesota Medical School.  We introduced the audience to the process and the product of the Colorado Consensus Conference, establishing core competencies for behavioral health providers working in primary care. 

Lists of core competencies for behavioral health clinicians in primary care are not new and this conference made use of all the ones we could find at the time we met.  What was new was that the list was not established by a small group of experts and then promulgated.  It was established through an iterative, many stepped email process, culminating in an all day face to face meeting, with still more refining and reviewing after the meeting.  C J and I were consultants to the group.  C J was the one who designed the process and I was an external content expert. 

The idea of competencies is a slippery concept.  It is great in that it is not dependent on specific disciplinary training.  In that sense it offers some parity.  Supposedly if you can do the job, we can tell.  If you have a fancy degree and can’t do the job, we can tell.  The problem comes when you try to get the right “altitude” to describe.  If the altitude is high, statements are general, not descriptive of behavior, and it is hard to say what each competency would look like in behavior.  If the competency is granular, very behavioral, the list of what competencies one needs to do a whole job gets very long.  Each one becomes a-contextual.  Knowing when to do what is an important skill and it is hard to show. The Colorado Competencies are 8 high altitude skills, each one consisting of several sub-areas with behavioral examples of what those areas look like behaviorally.  Have a look.

For the slides in our presentation, go to http://www.cfha.net/page/2016Resources and click on the slides for G6.  You can find the (currently) final document at http://farleyhealthpolicycenter.org/wp-content/uploads/2016/02/Core-Competencies-for-Behavioral-Health-Providers-Working-in-Primary-Care.pdf

[integratedprimarycare]

Integrated Primary Care becomes law in Oregon

The following was copied from the APA Division 38 listserve on 7/30/15:

On July 28, 2015, Governor Kate Brown signed Senate Bill 832 into law, which takes effect immediately. This paves the way for Oregon’s communities to integrate mental health and physical health services where the patient presents for service—fulfilling the promise of real time care in patient centered primary care homes and behavioral health homes. In short, the bill:

Defines the “Behavioral Health Clinicians” that can independently provide care within these settings to include: Licensed psychologists, social workers, professional counselors and others who are able to treat mental illness within their scope of practice Interns and residents who are practicing under supervision through a Board contract working their way to licensure ·         Allows providers to use the appropriate physical, mental health or health and behavior code as the situation warrants, regardless of setting ·         Allows patient-centered primary care homes (as defined by the OHA) to bill for mental health services provided in primary care and urgent care settings, and allows behavioral health homes to bill for primary care services Defines “Integrated Care” as “care provided to individuals and their families in a patient centered primary care home or behavioral health home by licensed primary care clinicians, behavioral health clinicians and other care team members, working together to address one or more of the following: Mental illness Substance use disorders Health behaviors that contribute to chronic illness Life stressors and crises Developmental risks and conditions Stress-related physical symptoms Preventive care Ineffective patterns of health care utilization” Defines a “Behavioral Health Home” as “a mental health disorder or substance use disorder treatment organization, as defined by the Oregon Health Authority by rule, that provides integrated health care to individuals whose primary diagnoses are mental health disorders or substance use disorders.” Directs the Oregon Health Authority to prescribe by rule standards for achieving the integration of behavioral health services and physical health services in patient centered primary care homes and behavioral health homes

SB 832 is the beginning of bidirectional integration across the health system, increasing access to behavioral health care at the point where the patient presents. The full text of the new law can be found at https://olis.leg.state.or.us/liz/2015R1/Downloads/MeasureDocument/SB832/Enrolled. The Oregon Psychological Association wishes to thank chief sponsor, Senator Laurie Monnes-Anderson, for her tireless support of this bill. Without her efforts and the dedication of her staff, this new law would be just an idea.

Robin Henderson, PsyD Chief Behavioral Health Officer and Vice President of Strategic Integration St Charles Health System

[integratedprimarycare]

Integrated Primary Care is the law in Oregon

The following was copied from the APA Division 38 listserve 7/30/15:

On July 28, 2015, Governor Kate Brown signed Senate Bill 832 into law, which takes effect immediately. This paves the way for Oregon’s communities to integrate mental health and physical health services where the patient presents for service—fulfilling the promise of real time care in patient centered primary care homes and behavioral health homes. In short, the bill:

Defines the “Behavioral Health Clinicians” that can independently provide care within these settings to include: Licensed psychologists, social workers, professional counselors and others who are able to treat mental illness within their scope of practice Interns and residents who are practicing under supervision through a Board contract working their way to licensure ·         Allows providers to use the appropriate physical, mental health or health and behavior code as the situation warrants, regardless of setting ·         Allows patient-centered primary care homes (as defined by the OHA) to bill for mental health services provided in primary care and urgent care settings, and allows behavioral health homes to bill for primary care services Defines “Integrated Care” as “care provided to individuals and their families in a patient centered primary care home or behavioral health home by licensed primary care clinicians, behavioral health clinicians and other care team members, working together to address one or more of the following: Mental illness Substance use disorders Health behaviors that contribute to chronic illness Life stressors and crises Developmental risks and conditions Stress-related physical symptoms Preventive care Ineffective patterns of health care utilization” Defines a “Behavioral Health Home” as “a mental health disorder or substance use disorder treatment organization, as defined by the Oregon Health Authority by rule, that provides integrated health care to individuals whose primary diagnoses are mental health disorders or substance use disorders.” Directs the Oregon Health Authority to prescribe by rule standards for achieving the integration of behavioral health services and physical health services in patient centered primary care homes and behavioral health homes

SB 832 is the beginning of bidirectional integration across the health system, increasing access to behavioral health care at the point where the patient presents. The full text of the new law can be found at https://olis.leg.state.or.us/liz/2015R1/Downloads/MeasureDocument/SB832/Enrolled. The Oregon Psychological Association wishes to thank chief sponsor, Senator Laurie Monnes-Anderson, for her tireless support of this bill. Without her efforts and the dedication of her staff, this new law would be just an idea.

Pretty cool, eh?

Robin Henderson, PsyD Chief Behavioral Health Officer and Vice President of Strategic Integration St Charles Health System

[integratedprimarycare]

Metrics for Assessing Integration

Sandy,

Our team is wondering whether there are national metrics used to demonstrate the effects of behavioral health in the primary care setting.  Anything you guys are using or see other groups using successfully?

Dr. J.

 Dear Dr. J,

The issue of metrics is the hottest thing going now.  We are each of us working on it and inching toward something that is workable, though not necessarily toward consensus.  I would say that there are metrics that look at implementation and metrics that look at outcomes.  Outcome metrics can be divided into metrics for those that receive BH services and metrics for some larger population of which they are a part.  I am assuming that your pre-post PHQ-9 scores are for the patients who get behavioral health service.  That is a good start.  On a population basis while it helps to get outcome metrics in place early on in your implementation, it is likely that there will be movement in the implementation metrics well before there is movement in outcome metrics.  

You should also be clear about for whom and to what end these data are being gathered.  If it is because they might be useful some day, you may have a hard time getting people in the practice to buy in.  Ditto if it is for research for the benefit of the field or for the career of the researcher.  The more your data informs the practice of people on the team, that means regular meetings to look at it together and to design improvements based on what you see, the more the buy in from people will be durable.  If you are keeping some data element that you never use to see how your site is functioning and to design improvements, unless it is required by someone outside of you (payer, funder, regulator) or you collect it inevitably as part of clinical work, stop collecting it.  

When data is specified by a funder, then that may be what you have to do.  Your clinical people will do it, but they won't like it.  Better to be going with your own data collection program that you use to inform your and improve your practice.  That will in all likelihood be enough get you credibility in the other places that you want to show how well you are doing.  

So what do you want to know to improve the practice?  How well do we identify people who need our extra care?  What percentage of those identified are offered the care?  Are we engaging the ones we offer care to?  Do they stay engaged to get the dose we think they should get?  Do those who get the dose we think they should get do better, same or worse than those who get a lower dose or no dose?  If we refer out, what are the results in terms of the engagement and getting better?  

For implementation metrics, you can look at one of the tools that assesses integrated functioning.  There are a couple in the Atlas of Measures of Integration on the Integration Academy site. http://integrationacademy.ahrq.gov  Look at the Antioch or the Maine forms.  When new ones are out, they will appear there.

Also for a thoughtful take on clinical and implementation metrics, see the work of Ben Miller, Rodger Kessler, C.J. Peek and Rusty Kallenberg below.

http://archive.ahrq.gov/research/findings/final-reports/collaborativecare/index.html

In planning for the cost of the implementations you are considering, you might also be interested in the cost calculator that the Department of Family Medicine at the Medical School of the University of Colorado Denver has developed.

http://emrpl.us/CoachCostTool/Welcome.html

[integratedprimarycare]

The American College of Physicians calls for BH Integration

The American College of Physicians (ACP) in the June 30 issue of the Annals of Internal Medicine calls for “The Integration of Care for Mental Health, Substance Abuse, and Other Behavioral Health Conditions into Primary Care.”  The paper authored by Ryan Crowley and Neal Kirschner was accepted as expressing the position of the ACP by its Board of Governors on April 28, 2015.  The distinctions of types of relationship between medical and behavioral clinicians, (coordinated,  co-located, integrated) first offered in my paper, Blount, A. (2003). Integrated primary care: Organizing the evidence.  Families, Systems & Health: 21, 121-134, figure prominently in their discussion.

They also cite the training programs of Center for Integrated Primary Care.  “Some medical schools have developed programs to teach existing and future health care professionals to work effectively in an integrated practice. The University of Massachusetts Medical School Center for Integrated Primary Care offers a certificate program to prepare behavioral health providers to work in the primary care setting. A care management certificate program is offered to nurses and mental health professionals to provide training in such activities as assessment, care planning, and quality evaluation in the PCMH setting (124).“  124. University of Massachusetts Medical School. Workforce Training for the Whole Team. Accessed at www.umassmed.edu/cipc on 4 June 2015

Link to Annals of I.M.: http://annals.org/article.aspx?articleid=2362310