Making the Case for Behavioral Health

Integration into Primary Care: A Road Map to

Success and Sustainability

William J. Kuzbyt, Psy.D., JD, LHRM, CAP

Behavioral Health SolutionsBonita Springs, FL

www.bhsfl.com

Sponsored by:Gulf Region Health Outreach Program Gulf Coast Behavioral Health and Resiliency CenterMental & Behavioral Health Capacity ProjectUniversity of South Alabama

Objectives

I. Understand implications of integrating Behavioral Heath into Primary Care

II. Discuss conceptual and structural models of integration

III. Discuss privacy, billing, and documentation

IV. Develop a road map for a comprehensive and sustainable Behavioral Health integrated program

Who’s Attending Today?

Administrative

Financial

Medical Providers

Behavioral Health Providers

IT

Key Questions to be Answered

1. Are there different ways to integrate behavioral health into primary care?

2. Are there established models of integration?

3. Is it appropriate and legal to integrate behavioral health records with primary care records?

4. What is SBIRT and how does it work?

5. How does the PHQ-9 work?

6. What are the codes utilized in behavioral health billing?

7. What documentation is necessary to bill?

Types of Behavioral Health Services

Counseling

Education

Prevention

Case Management

Medication Management

Behavioral Health Continuum of Care

Screening Assessment Diagnosis Treatment

The Importance of Integration from 3 Points of ViewPhilosophical

Practical

Clinical

Philosophical It is the right thing to do to bridge the

gap between behavioral health and medical care

Helps minimize stigma and discrimination

Practical

HRSA told us to do it

Accreditation organizations require it (NCQA, TJC, AAHC)

Many current patients present with behavioral health issues

CHCs serve patients who need behavioral health care

It is a cost effective treatment approach

Practically Speaking…

Not a new concept. More than 15 years of research supports it: 1999 Surgeon General’s report on mental health

acknowledged the crucial role of primary care with that of mental health.

2003 President’s New Freedom Commission promotes integration.

2004 HRSA designated the integration of behavioral health as a required service to be provided by FQHC’s.

2005 Institute of Medicine (IOM) called for integration as a best practice.

2006 SAMHSA Transforming mental health care in America.

2011 Accreditation organizations include behavioral health in continuum of care.

Clinical

Mental health problems go untreated in primary care. This compromises the quality of overall treatment and outcomes for patients.

PCP typically under-identifies mental health problems in patients.

Mental health issues correlate higher with low-income patients and racial/ethnic minorities.

Clinical (continued)

People with mental health issues “over-use” primary care services 3:1 as compared to average patients

A significant part of disease management requires behavior change

Clinical protocols often specify BH components (e.g. depression)

Good clinical practice requires communication between clinicians

Croghan, T.W. & Brown, J.D. (2010). Integrating mental health treatment into the patient centered medical home, Agency for Healthcare Research and Quality. Rockville: MD.

Clinical (continued) Many primary care visits have psychosocial issues (20 -

45%)

More patients seek help through the primary care system (patient is already there)

Community mental health services cannot meet the demand for existing referrals

Most patients do not follow-up with referrals from primary care to CMHCs

Behavioral health IS a part of basic general health care (Bio-psychosocial model)

Paine, J. and Mabargto, M. 2012. Integrated behavioral health and primary care. Retrieved from: http://healthcarecommunities.org/workarea/download/asset.aspxid=1343.

Utilizing 2010 UDS data, looked at number of patients likely to need behavioral health

2.5 million patients have some level of mental illness

351,000 identified with substance abuse but not treated

For every 2,500 patients served, need: 0.9 Licensed Mental Health Provider 0.4 Mental health support staff 0.3 Substance Abuse Provider 0.1 Psychiatrist

90% of Community Health Centers stated that they are below these levels

Burke, B.T., Miller, B., Proser, M., Petterson, S. M., Bazemore, A. W., Goplerud, E., Phillips, R. L. (2013) A needs-based method for estimating the behavioral health staff needs of community health centers. BMC Health Services, 13, 245-262.

Do We Need Behavioral Health Providers?

So…

Why with all this history of research and policy support are there not more FQHCs with fully integrated systems of care?

3 Quick Reasons We Often Say “No” to Integration

Behavioral health and physical health typically operate in silos

Sharing of information can be difficult due to issues of confidentiality, HIPAA, and state laws

Payment and parity issues are restrictive

Practical, Financial, & Clinical BarriersAdministrative

Can’t handle new project now

Can’t hire new staff and supplies

Can’t risk losing money

Financial Can’t bill for that service

Can’t make money

Clinical Medical Director says “Can’t deal with the personalities and

power struggles of providers.”

Provider says “I can’t treat those diagnoses, not my training.”

Provider says “I don’t have time to deal with more patient issues during the office visit. I barely have time to do referrals.”

New Motivating Factors…

Many grants (HRSA 330, HRSA HIT) and accreditation organizations (NCQA, TJC, AAAHC) are requiring integrated health care

Patient-Centered Medical Homes (PCMH)

PCMH Defined Care Delivery Model where the patient’s treatment is

coordinated through the Primary Care Provider to ensure they receive the necessary care when and where it is needed.

The goal is a centralized setting that facilitates partnerships between the patient, PCP and potentially, as needed and appropriate, the patient’s family.

Key focus is on information technology, health information exchange, and other means to assure that the patient gets the needed care. Care is to be culturally and linguistically appropriate to the patient.

PCMH Defined (continued) Quality of care is improved and enhanced through

access, planning, management, and monitoring of care.

Better coordinated care, treating the many needs of the patient at once, and empowering the patient to be a partner in their care are basic tenets.

The Joint Commission

New standard implemented January 1, 2014

Designed to further promote the integration of behavioral and physical health within healthcare homes

www.apapracticecentral.org/update/2013/11-21/accreditation-standards.aspx

Recap: Integrating Behavioral Health FQHCs provide a significant amount of primary care in the

United States

Primary Care is the “defacto” behavioral health “starting point”

Primary care settings are appropriate locations in which to provide behavioral health services

The “gold standard” is to provide fully integrated care

There are various ways to provide behavioral health services and different models available to achieve this goal

Models of Integration

Conceptual vs. Structural

Conceptual: A theoretical approach or framework to describe the model

Structural: The actual step by step guide to the procedures of the model

Continuum of Service Delivery

Isolated/Silo

Collaborative Co-Location Integrated

Conceptual Models of Integration

Isolated/Silo

Collaborative

Co-Location

Integrated

Isolated/Silo

No commitment between medical and behavioral health providers to work together

Patient provides only source of history

No referral network

Collaborative

A partnership under which a provider agrees to furnish services to those patients who are referred to it by another provider

Referral relationships may serve as a useful precursor to a more collaborative model, providing both parties with the opportunity to evaluate the partnership prior to implementing a co-location or purchase of services arrangement

Co-Location

A partnership arrangement under which a provider agrees to treat patients who are referred by another provider, but maintains autonomy of the practice and control over the provision of the referral, and is legally and financially responsible for the patient within the practice.

However, unlike the Silo and/or Collaborative Model, the provider furnishing the clinical services is physically located at the referring entity’s site.

Integrated Behavioral and medical providers are

physically located at the same site

In-depth appreciation of roles and cultures of providers

Team approach to treatment for the patient which increases treatment outcomes

Shared systems and facilities in seamless bio-psychosocial framework

Integrated vs. Co-Located

Integrated Care• Embedded member of primary care team

• Patient contact via hand off

• Verbal communication predominate

• Brief interventions

• Flexible schedule

• Generalist orientation

• Behavioral medicine scope

Co-Located • Ancillary service provider

• Patient contact via referral

• Written communication predominate

• Regular schedule of sessions

• Fixed schedule

• Specialty orientation

• Psychiatric disorders scope

Cherokee Health Systems, Blending Behaviorists into the Patient Centered Medical Home, Michigan Primary Care Association Webinar January 11, 2012

Collaborative Care Categorizations At a Glance

Collins, C., Hewson, D.L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. New York: Milbank Memorial Fund.

Collaborative Care Categorizations (continued)

Collins, C., Hewson, D.L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care. New York: Milbank Memorial Fund.

Structural Models of Integration Impact

Chronic Care Model

Primary Mental Health Care

4 Quadrant Clinical Integration Model

Impact Model Patient’s primary care physician works with care manager to

develop patient treatment plan

Care manager educates the patient or “coaches”; offers brief (8 session) consults

Psychiatric Support

Outcome

“Stepped Care” 50% reduction in symptoms within 10-12 weeks

Unutzer, J., www.Impact-UW.org Professor, University of Washington

Wagner, E. (2002). The Chronic Care Model

Primary Mental Health CareKirk Strosahl

Mental Health Provider (“Behaviorist”) functions as a member of primary care team

Provides consultation to Medical providers

Brief “targeted” interventions

Co-located close to exam room

15-30 minute sessions

Focus is specific “behavior” changeStrosahl, K. (2002). Primary Mental Health Care, Mountainview Consulting Group, Yakima, WA.

National Association of State Mental Health Program Directors (NASMHPD). 2005. Integrating Behavioral Health and Primary Care Service: Opportunities and Challenges for State Mental Health Authorities.

Recap: Models of Integration

Behavioral Health service delivery is on a continuum

Move from Silos to Integration

A variety of ways or “models” to achieve integration

Understanding HIPAA Acronyms:

HIPAA — Health Insurance Portability and Accountability Act of 1996

HHS — US Department of Health and Human Services

OCR — Office for Civil Rights

Definitions: Protected Health Information (PHI)—

Covered Entities — every health care provider, regardless of size, who electronically transmits health information

Business Associate — person or organization that you work with which involves the use or disclosure of individually identified protected health information (PHI).

Privacy Rule—

Business Associate Agreement—defines the relationship between you and the business associate specifically regarding PHI

HIPAA—3 Rules Privacy

Security

Enforcement

HIPAA Privacy:

HIPAAPrivacy:

Major goal of the Privacy Rule is to ensure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public health and well-being.

The rule strikes a balance that permits important uses of information while protecting the privacy of people who seek care. The rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed.

Permitted Uses

A covered entity is permitted, but not required, to use and disclose protected health information WITHOUT an individual’s authorization, for the following purposes or situations:

1. To the individual

2. Treatment, payment, and health care operations

3. Opportunity to agree or object

4. Incident to an otherwise permitted use and disclosure

5. Public Interest and Benefit Activities

6. Limited Data Set for research, public health, or health care operations

Treatment, Payment, and Health Care Operations

Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.

Treatment, Payment, and Health Care Operations (continued)

Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits, and furnish or obtain reimbursement for health care delivered to an individual and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual.

Treatment, Payment, and Health Care Operations (continued) Health care operations are any of the following activities:

1. Quality assessment and improvement activities, including case management and care coordination

2. Competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation

3. Conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs

4. Specified insurance functions, such as underwriting, risk rating, and reinsuring risk

5. Business planning, development, management, and administration

6. Business management and general administrative activities of the entity, including but not limited to: de-identifying protected health information, creating a limited data set, and certain fundraising for the benefit of the covered entity

Authorized Uses and Disclosures

An authorization must be written in specific terms.

It may allow use and disclosure of protected health information by the covered entity seeking the authorization, or by a third party.

Examples of disclosures requiring an individual’s authorization: Disclosures to a life insurer for coverage purposes

Disclosures to an employer for the results of a pre-employment physical or lab test

Disclosures to a pharmaceutical firm for their own marketing purposes

All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data.

The Privacy Rule contains transition provisions applicable to authorizations and other express legal permissions obtained prior to April 14, 2003.

Authorized Uses and Disclosures: Psychotherapy Notes A covered entity must obtain an individual’s authorization to use or

disclose psychotherapy notes with the following exceptions:

The covered entity who originated the notes may use them for treatment

A covered entity may use or disclose, without an individual’s authorization, the psychotherapy notes,

for its own training, and to defend itself in legal proceedings brought by the individual

for HHS to investigate or determine the covered entity’s compliance with the Privacy Rules

to avert a serious and imminent threat to public health or safety

to a health oversight agency for lawful oversight of the originator of the psychotherapy notes

for the lawful activities of a coroner or medical examiner or as required by law

Acknowledgement of Notice Receipt A covered health care provider with a direct treatment relationship

with individuals must make a good faith effort to obtain written acknowledgment from patients of receipt of the privacy practices notice.

The Privacy Rule does not prescribe any particular content for the acknowledgment.

The provider must document the reason for any failure and obtain the patient’s written acknowledgment.

The provider is relieved of the need to request acknowledgment in an emergency treatment situation.

Notice and Other Individual Rights Privacy Practices Notice: Each covered entity, with certain

exceptions, must provide a notice of its privacy practices.

The Privacy Rule requires that the notice contain certain elements. The notice must:

Describe the ways in which the covered entity may use and disclose protected health information.

State the covered entity’s duties to protect privacy, provide a notice of privacy practices, and abide by the terms of the current notice.

Describe individuals’ rights, including the right to complain to HHS and to the covered entity if they believe their privacy rights have been violated.

Include a point of contact for further information and for making complaints to the covered entity.

Covered entities must act in accordance with their notices.

The Rule also contains specific distribution requirements for direct treatment providers, all other health care providers, and health plans.

Notice and Other Individual Rights

Notice Distribution: A covered health care provider with a direct treatment relationship with individuals must have delivered a privacy practices notice to patients starting April 14, 2003 as follows:

Not later than the first service encounter by personal delivery (for patient visits), by automatic and contemporaneous electronic response (for electronic service delivery), and by prompt mailing (for telephonic service delivery)

By posting the notice at each service delivery site in a clear and prominent place where people seeking service may reasonably be expected to be able to read the notice

In emergency treatment situations, the provider must furnish its notice as soon as practicable after the emergency abates

HIPAA Privacy Authorization Form

HIPAA Privacy Authorization Form (continued)

HIPAASecurity: Specifically electronic transmission

3 Areas of Safeguards

1. Administrative

Policies and Procedures

2. Physical

Hardware

Software

Who has access?

Access of workstations

3. Technical

Housing of data

Authentication of entities

With which communication occurs

Documentation requests

Risk Analysis

HIPAAEnforcement: In 2006, set civil money penalties for violating HIPAA rules and established procedures for investigations and hearings.

As of a year ago:

Total investigations 72,570

Corrective Actions 19,306

100% Compliance 9,146

Eligible cause for enforcement 44,118

Health Information Technology for Economic and Clinical Health (HITECH) Act

The HITECH Act was enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009 and became law on February 7, 2009

It’s purpose is to promote the adoption and meaningful use of health information technology

The goal was to “create a nationwide network of electronic health records”

The Road to Success and Sustainability of Behavioral Health in Primary Care

According to HRSA (2012), utilizing UDS data, the average percentage of Medicaid patients in Alabama is approximately 50%

Generally, if you successfully bill Medicaid, Behavioral Health programs can be sustained

Alabama Medicaid

On May 13, Act 2013-261 Alabama Code §§ 22-6-150

Changes from fee-for-service to managed care

Creates Regional Care Organizations (RCO)

5 RCOs (§§ 560-X-37-.07)

RCO Governing Body consists of Board of Directors of 23 people

12 represent risk-bearing members

8 represent non-risk-bearing members

1 is physician from an FQHC, appointed by Alabama Primary Care Association and Alabama Chapter of the National Medical Association

RCO must establish a network of care. Psychologists, therapists, and social workers are clearly spelled out as providers in the legislation.

Alabama Medicaid Manual

Relevant Chapters:

16—FQHC

23—Licensed Social Workers

34—Psychologists

Documentation Required for Medicaid BillingReference: Alabama Medicaid Provider’s Manual

Chapter 34: Psychologists pp. 34-7 to 34-9

Client Intake

An intake evaluation must be performed for each client considered for initial entry into any course of covered services.

The intake evaluation process shall result in a determination of the client’s need for psychological services based upon an assessment that must include relevant information from among the following areas:

Family history Educational history Medical history Educational/vocational history Psychiatric treatment history Legal history Substance abuse history Mental status exam Summary of the significant problems the client is experiencing

January 2014 Medicaid Manual, Chapter 34--Psychologists, p.34-7

Treatment Planning

The intake evaluation process shall result in the development of a written treatment plan completed by the fifth client visit.

The treatment plan shall:

Identify the clinical issues that will be the focus of treatment

Specify those services necessary to meet the client’s needs

Include referrals as appropriate for needed services

Identify expected outcomes toward which the client and therapist will work to have an effect on the specific clinical issues

Be approved in writing by a psychologist licensed in the state of Alabama

The (initial) Treatment Plan is valid when the recipient/legally responsible person and the person who developed the plan sign and date it. Unless clinically contraindicated, the recipient will sign or mark the treatment plan to document the recipients participation in developing /revising the plan. If the recipient is under the age of 14 or adjudicated incompetent, the parent, foster parent or legal guardian must sign the treatment plan.

Treatment Planning (continued)

The Treatment Plan should not be signed or dated prior to the plan meeting date.

The Treatment Plan is valid when the recipient/legally responsible person and the person who developed the plan sign and date it.

Service Documentation

Documentation in the client’s record for each session, service, or activity for which Medicaid reimbursement is requested shall include, at a minimum, the following:

The identification of the specific services rendered

The date and the amount of time (time started and time ended--- excluding time spent for interpretation of tests) that the services were rendered

The signature of the staff person who rendered the services

The identification of the setting in which the services were rendered

A written assessment of the client’s progress, or lack thereof, related to each of the identified clinical issues discussed

All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. The author of each entry must be identified and must authenticate his or her entry. Authentication may include handwritten signatures, written initials (for treatment plan reviews), or computer entry (associated with electronic records—not a typed signature). A stamped signature is not acceptable.

Additional Information

Documentation should not be repetitive (examples include, but are not limited to the following scenarios):

Progress Notes that look the same for other recipients.

Progress notes that state the same words day after day with no evidence of progression, maintenance or regression.

Treatment Plans that look the same for other recipients.

Treatment Plans with goals and interventions that stay the same and have no progression.

Progress Notes

Progress Notes should not be preprinted or predated.

The progress note should match the goals on the plan and the plan should match the needs of the recipient. The interventions should be appropriate to meet the goals. There should be clear continuity between the documentation.

Progress Notes must provide enough detail and explanation to justify the amount of billing.

Authentication

Authors must always compose and sign their own entries (whether handwritten or electronic). An author should never create an entry or sign an entry for someone else or have someone else formulate or sign an entry for them. If utilizing a computer entry system, the program must contain an attestation signature line and time & date entry stamp. A stamped signature is not acceptable.

If utilizing a computer entry system, the program must contain an attestation signature line and time & date entry stamp. There must also be a written policy for documentation method in case of computer failure/power outage.

Billing Requirements Diagnosis—DSM-IV/DSM-5

CPT Codes

Encounter Form

Billing Form—HCFA 1500

DSM IV to DSM-5: Summary of ChangesThree Major Sections of the DSM-5

I. Introduction and clear information on how to use the DSM.

II. Provides information and categorical diagnoses.

III. Provides self-assessment tools, as well as categories that require more research.

DSM IV to DSM-5: Summary of Changes Section II—Disorders

Organization of chapters is designed to demonstrate how disorders are related to one another.

Throughout the entire manual, disorders are framed in age, gender, developmental characteristics.

Multi-axial system has been eliminated. “Removes artificial distinctions” between medical and mental disorders.

DSM-5 has approximately the same number of conditions as DSM-IV.

CPT Codes

SBIRT Screening

Initial screening is brief (5-10 minutes)

Universal

1 or more targeted behaviors (depression, anxiety, alcohol abuse, tobacco)

Brief Intervention Defined as 1-5 sessions

Goals

Educate patient about health risk

Motivate patient to reduce risky behavior

Referral to Treatment Can be complex based upon the information _____ in the Brief Intervention

Requires strong linkages to specialty treatment

Can be incorporated into an integrated model of care

SBIRT Screening Examples

PHQ-9

GAD-7

MAST

DSM-5 Online Measures

PHQ-9

PHQ-9 (continued)

PHQ-9 (continued)

GAD-7

MAST

MAST (continued)

92

Online Assessment Measures

SBIRT Documentation Documentation for billing purposes

Name, DOB, record number

Start/stop time of face-to-face

Assessment, clinical impression, and diagnosis

Plan of care (goals)

Patient progress, responses to treatment, revision of diagnosis

ICD-9, DSM-IV, DSM-5 diagnosis

Sign, title, and date the record

Key Questions to be Answered

1. Are there different ways to integrate behavioral health into primary care?

2. Are there established models of integration?

3. Is it appropriate and legal to integrate behavioral health records with primary care records?

4. What is SBIRT and how does it work?

5. How does the PHQ-9 work?

6. What are the codes utilized in behavioral health billing?

7. What documentation is necessary to bill?

Roadmap for Implementation

Acknowledgment of the Transition New processes

New procedures

Disruptive workflow

Modification of workflow

Present a plan with a “staged” approach Can’t do it all at once

Emphasize Continuous Quality Improvement (PDSA)

Roadmap (continued) Involve Leadership at every stage

Key stakeholders need to know of successes/needs for modification

Include “Technical Assistance” at all stages

Include a specific timetable for implementation at each stage

Include Performance Measures for goals

Include “Staff Training” as an “item” in the plan

Develop the “Tool Kit” for success

Premise; All FQHCs are Not Alike

“One size does not fit all.”

All FQHC sites within the same FQHC are not alike.

Just like we develop individual treatment plans for patients, we must develop individual behavioral health integration models for each FQHC, and possibly, each FQHC site.

Factors/Steps to Consider BEFORE Integration Conduct a needs assessment

Determine which approach works best for your agency/patients (coordinating care, co-locating, integrated)

Use data as the basis for decisions

Address the barriers, they will not leave by themselves!

“Buy-in” needs to be top-down and “inclusive”

Select the “right” providers; establish “champions”

Use a continuance performance measure (PDSA; PDCA)

Develop BOTH a good business AND professional relationship

Flexibility! **Change of Scope

Normalize BH in PC PracticeConceptually, management of mental health issues are similar to other common medical conditions

Recognition (Clinical/Screening Tools)

Initial Diagnosis/Assessment

Treatment Plan

Monitoring

Adjustments

Follow-Up Care

For more severe cases, refer to specialist

PCP Stressors

Lack of training to diagnose mental health patient

Time concerns for screening and treatment

Concern about effectively monitoring efficacy of treatment

Lack of access to mental healthCollaborationCoordinationCo-change