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Evaluation and Tracking
Summary of Models
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The inclusion of behavioral health in a primary care setting will create new challenges to work through with your team. The office manager, physician champion, and BHP will need to work together to address the operational components listed below.
- Space for added staff
BHPs need to be flexible since available space may be difficult to identify in primary care clinics. If the BHP is fully integrated and provides significant amounts of service in the exam room, then the amount of time that private office space is needed can be lessened significantly. A space issue for BHP services may be present if the exam room is needed for other patients. In some cases there are offices that can be shared when other providers are away. In either situation, it remains that the therapist will require some level of use of a private space, which can be a challenge in some clinics. The visibility of the BHP is important in a fast-paced medical setting, and other providers are less likely to engage the BHP for a consult if they have to walk to the other end of the clinic to find him/her. For this reason it is important for the BHP to consider using exam rooms when possible, spending time working out in the open near other staff, and encouraging PCPs to approach even when the BHP is busy (Robinson and Reiter, 2007).Resources:
- Integrated Behavioral Health Project: Scheduling and Space
- Scheduling options
Scheduling for behavioral health in integrated settings requires knowledge of how the service will be used within a particular practice. Planned sessions with the BHP are important for follow-up visits, however, the level of behavioral health integration may influence scheduling. A highly integrated practice may utilize the BHP’s services for multiple unplanned brief service encounters, requiring that the BHP has some unscheduled time. Some BHPs may find that they are available at the spontaneous request of their providers among their scheduled patients if they stagger their planned appointments. In lieu of patient care, there are typically administrative and follow-up functions that can fill any unplanned time for the BHP. BHPs working in brief intervention roles should adapt a primary care pace and schedule follow-up sessions for 15 – 30 minutes. Two of these appointments can be combined for assessments or other clinical patient needs (Gatchel & Oordt, 2003; Hunter, Goodie, Oordt, & Dobmeyer, 2009). If the BHP’s time is always accounted for by scheduled appointments, they will be less available and may miss opportunities to provide immediate service to patients being seen in physical health visits. Scheduling variables should be monitored over time and adjusted to reflect the goals of the program as well as the current needs and trends within the practice.Resources:
- Integrated Behavioral Health Project: Scheduling and Space
- Managing referrals communication/feedback
The BHP will need to develop a clear and easy way for PCPs to make referrals for behavioral health services. Organizational strategies will be required to manage communication and feedback to PCPs within the fast-paced culture of primary care, where a same-day response is normal. Robinson and Reiter (2002) provide a PCP survey that has referral barriers as a component to be evaluated.Resources:
- Managing medications
Patient medication adherence improvement is a common target for BHP interactions with patients. As discussed in greater detail in the section on “Medical literacy,” BHPs will need to have knowledge about basic medications for both physical and psychological conditions. BHPs may need to attend continuing education classes to supplement their knowledge.
- Patient-centered planning
The BHP’s service should be as convent as possible for the patient. This includes same-day scheduling options when PCP services are also involved. The location of the BHP’s office space should not be too far from the main exam area of the clinic and exam rooms should be used when possible. Practices will also have to work through billing issues and behavioral health insurance benefits so that patients are not faced with new financial hardships as a result of receiving BH services.
- Medical Records
Medical records and Electronic Medical Records (EMRs) will need arrangements to accommodate the BHP’s services. For example, paper charts, forms, and EMRs may need new areas for the BHP’s notes and assessments and EMRs will need to have new billing codes added for BH services.
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- Staffing model and start-up costs
In addition to the cost of the BHP’s salary and practice insurance, they will require many items common in the addition of adding any new provider to the practice. A computer, telephone line, and desk supplies are basic items to factor into expenses. Sometimes the addition of a new provider to an electronic medical record system incurs additional expenses. The practice manager should be able to quantify these expenses (Robinson & Reiter, 2007).
- Patient education materials
Patient education materials can be expensive to purchase in quantity; in some cases, creating materials from available resources can be more cost effective and allow for customization. For more information and examples of handouts, patient education materials, and brochures, see the topic called, “Patient Handouts, Education Materials, and Brochures,” below.Resource:
Information on readability and links to readability formulas
- Expected Revenues/ Billing options
Expected revenues may depend on the type of work the BHP has within the practice. Some BHP positions are not focused on earning salaries and may have a small or non-existent billing expectation. This type of position is either subsidized and/or is intended to be a cost-offset (Cummings, O’Donohue, Hayes, & Follette, 2001), by reducing utilization of more expensive services through the BHPs services. In either case, making high profits from the BHPs service is an unrealistic goal. BHPs may have limited billing options in certain environments which need to be considered when forming expectations for generated revenue.
Evaluation and Tracking
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- Pre & post Patient Satisfaction
Pre and post patient satisfaction survey results can be helpful in evaluating the new and existing integrated behavioral health programming by measuring different aspects of the received services. Based on these results, adjustments can be made to improve clinical, logistical, and administrative routines, to provide improved service. Some items frequently asked relate to the quality of the service, whether or not the patient felt their chief complaint was addressed, if they felt their PCP and BHP had communicated, if they were involved in making decisions about their treatment, and their overall impression of the service.
- Pre & post Primary Care Provider (PCP) satisfaction
Whether you choose to conduct a formal survey or an informal one, it is important to assess PCP satisfaction. Anonymous surveys may yield information that would otherwise not be shared freely. SurveyMonkey.com, an online resource, is a paperless way to reach your providers. A PCP satisfaction survey should evaluate how the integrated programming is affecting the PCPs satisfaction in the following areas: improved patient outcomes, an increase in availability of Behavioral Health (BH) services, collaboration, availability of BH information, efficiency, knowledge of BH conditions and treatment, the addition of BH services to their consumers, increase in access to community BH services via the BHP, and other items that are part of the specific BH programming.Resources:
- The Integrated Behavioral Health Project (IBHP) has information about provider and patient satisfaction measures and links to sample patient and provider satisfaction surveys.
- The Mountainview Consulting Group has a downloadable and customizable provider and patient satisfaction surveys on its website under “downloads.” Search for word “survey” to find: Sample Medical Provider Attitude and Satisfaction Survey & Sample Consumer Satisfaction Survey for Primary Behavioral Health Services
- Targeted outcomes measures, utilization, and tracking
IC practices will need to identify targeted patient and clinic outcome measures, ways to capture patient utilization numbers, and tracking tools to assess sustainability. The actual items identified should be realistic in terms of the amount of time and resources needed to capture them. Selected tools such as screening tools and assessments should be evaluated to ensure that they provide a true measurement for the targeted outcomes. Kirk Strosahl has designed a sample “Report Card” for integrated primary care behavioral health programs as described by Cummings, Cummings, & Johnson, 1997, table 3.1). These eight categories are rated in terms of receiving an inadequate grade, a passing grade, or a superior grade in relation to the design and functioning of the program. The categories are: program planning and approach, integration models employed, predicted population impact, service locations, service philosophy, service characteristics, service penetration, and referral and case finding impacts.The American Academy of Family Physician’s National Research Network has a subdivision devoted to collaborative care called The Collaborative Care Research Network. Their mission is as follows: “The objectives of the CCRN are to support, conduct, and disseminate practice-based primary care effectiveness research that examines the clinical, financial, and operational impact of behavioral health on primary care and health outcomes” (American Academy of Family Physicians, 2009, What is the CCRN section, para. 1). Interested clinicians and practices can enroll and participate in contributing to the larger pool of outcomes that will also assist in their own program development to generate the larger numbers needed for research and potential policy change.
- The Center for Quality Assessment and Improvement in Mental Health (CQAIMH) has a searchable database of quality measures and outcomes.
- IMPACT: Collaborative Care Model’s website has a host of patient tracking tools.
Identify & address potential referral barriers
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Increasing physician interaction and referral to the BHP and their services can be challenging. A BHP will often need to market their skills, availability, and understanding of how to address patient conditions that are most concerning to PCPs. BHPs should also be sure that the systems in place for making referrals are clear, available, and dependable, including timely follow-up back to the PCP. Robinson and Reiter provide a comprehensive selection of strategies to achieve this goal in the eighth chapter of their text, Behavioral consultation and primary care: A guide to integrating services.
Address Cultural Competencies
The culture of primary care practices is significantly different from that of specialty mental health and substance abuse clinics. The patients vary in their degree of need, ranging from healthy (i.e. appointments for a physical) to very ill (i.e. metabolic syndrome). Traditional BH environments serve a small portion of the population, who come for services when they are needing specialized care. Patient and PCP expectations are different in this fast-paced setting where many patient concerns are addressed in just one short encounter. BHPs will have to make adjustments to meet these expectations by modifying their approaches and interventions, response times, documentation, language, and specificity of feedback (Hunter, et.al., 2009)
- Informed Consent
Patients often sign a global consent for services when entering the practice as a new patient. This consent should describe the range of services provided within the practice. BH is not a widely known service to be routinely provided in these settings. Since the provision of BH services in primary care settings is not the norm, BH programming should account for this factor. Patients should be made aware of BH services provided to them in clinical and fiscal domains. Further, BH services and BHP roles should be explained and BH service charges addressed. Patients may have received physical health services at the clinic for a number of years before incurring new charges related to BH services. The idea of the informed consent is to avoid having these charges come as an unsuspected surprise to the patient. Some BHPs will also have patients sign an additional, more traditional BH consent, when rendering behavioral health services.
- Clinical Competency
BHPs must not practice outside of their clinical expertise and training. They should stay within the ethical boundaries of competence and roles, avoid giving medical advice (Gatchel & Oordt, 2003), and refer patients who need treatment that falls outside the scope of their training.
As discussed later in the section on “Medical records issues,” the confidentiality of the patient’s record is an ethical concern. Licensed BH professionals are most likely cognizant of these issues due to the culture of privacy surrounding mental health and substance abuse conditions in specialty settings. BHPs may find that the confidentiality in primary care does not hold prominence as it does in BH. The BHP may have to work to address these issues through well-planned educational opportunities. The BHPs clinical supervisor can be helpful in providing consultation on ways to approach the greater staff population.
- Practice Guidelines
BHPs should be proactive in identifying and addressing ethical issues before they arise. Once an ethical issue is identified, the BHP may have to evaluate whether the issue has arisen due to the addition of the new service, which may be less obvious to others. The ethical concern may lead to adjustments in some of the practice’s guidelines.Resource:
|Determining Your Readiness|
Identify key partners
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- Existing Organizational Mission/Values
Your organization’s mission in serving its patient population will help to guide your choices when exploring options for behavioral health integration. In many cases a medical practice will be interested in adding behavioral health services to improve delivery of overall care to its current patient population. Alternatively, some medical practices may be expanding their clinical focus or adding to their patient populations in such a way that the addition of behavioral health services will be the only way to meet their new goals for clinical service and/or the clinical needs of their new patient population. The Four Quadrant Clinical Integration Model can help to identify the location in which care should be delivered by organizing one’s thinking about the ways in which the practice site’s services relate to current services in the local community, the roles of individual providers, availability of system tools and clinical skills, and the needs of the entire population. This is a population-based system for planning; an individual patient’s services should be person-centered (Mauer & Druss, 2009).Resources:
- The Four Quadrant Clinical Integration Model developed by the National Council of Community Behavioral Health includes an environmental assessment tool to assist practices in evaluation and planning. Take note that the Four Quadrant model (page 3) in the document link here does not include some of the updated components mentioned in the description for the next resource, however, the environmental assessment tool is a valuable resource when beginning to explore IC. View PDF
- The Four Quadrant Clinical Integration Model with an update to include psychiatric consultation for services that are primarily focused on physical health and the addition of physical health services to support formats that primarily focus treatment on mental health and substance abuse treatment. View PDF
- How does behavioral health integration fit into current disease management approach?
The integration of behavioral health into primary care provides an enhanced approach to the treatment of many medical conditions, thereby complementing and improving medical treatment. Successful management of chronic medical conditions such as diabetes and asthma require patients to make significant changes in their lifestyle. A (BHP) can assist patients who have had difficulty making these lifestyle changes by helping increase attention to the behavioral health components that can increase the likelihood of success. Depression is the most common mental health condition presented by patients in primary care, and 80% of all antidepressants and 67% of all psychotropic agents are prescribed by Primary Care Providers (PCPs) (Strosahl, 1996). An estimated 10 to 30% of primary care patients suffer from significant depressive symptoms (McQuaid, Stein, Laffaye, & McCahill, 1999). Supporting the need for behavioral health services in the primary care setting is the following statistic: although rates of depression are high in the primary care patient population, it is estimated that only one third of depressed patients are properly diagnosed and many are inaccurately identified (O’Donohue, Byrd, Cummings, & Henderson, 2005). Moreover, it is estimated that 50 to 60% of patients do not adhere to psychotropic medications within the first 4 weeks (Strosahl, 1996). The circumstances and utilization statistics surrounding depression care are good examples of areas where assessment and interventions by an onsite BHP would be beneficial (O’Donohue, et al., 2005).Resources:
- MacArthur Foundation Initiative, Care Management Manual
- Community Care of North Carolina: Patient Management Tools
- What medical/ behavioral outcomes do you want to target?
Medical practices can explore the identified needs that led them to the decision to integrating behavioral health (BH) into their service continuum. PCPs who are interested in the inclusion of the new service will most likely have ideas about the patent populations, chronic diseases, conditions, treatment adherence issues, and other items they would like to target, such as reducing utilization of medical visits for particular conditions. Consultations with other staff for their input, including nurses and medical assistants, may be helpful as well. Utilization data is useful to quantify the prevalence of the proposed target treatment conditions and circumstances.
Summary of Models
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- 5 levels of Collaboration
Choosing the appropriate model of collaboration/integration is dependent on several factors, some of which are listed: clinical intention(s), interest by medical providers in mental health and behavioral health treatments, fiscal realities, the possibility of clinical limitations due to behavioral health services provided through contracted BHPs, billing and licensing constraints, communication, logistical issues such as available clinic space, and how medical records are managed. There is no particular level of integration/collaboration that will fit all settings. Also, the specifics within levels need not be rigid, in that there are many hybrid configurations that combine functions and services from different levels (Peek, 2007). For example, in some cases providers may collaborate closely, bill, and treat as a team for some clinical conditions but not with others. Additionally, some models evolve due to interest in providing higher levels of service in certain conditions, additional training, or a new condition that is identified for collaboration. One caution to consider in model development over a period of time is that all provider-types can become complacent in the way they use the behavioral health services at their site, possibly making future changes to the level of collaboration more difficult. It may be helpful to view the behavioral health program’s services at the outset as an evolving program that will benefit from the continual input of all providers. These providers can help with further refinement, the addition of behavioral health service functions, and ways to increase and improve collaboration. There is much to be gained in integration and collaboration over time while enthusiastic providers are working together and sharing strengths that benefit their common patient.The chart adapted by Peek (2007) from Doherty, McDaniel, & Baird shows how providers can interact with each other, outside providers, systems, records, resources, shared patients, with patients in session and in routines, and how expectations and the degree of collaboration changes among levels. Practices can also adjust the focus of their integration from medical, mental health, and substance abuse services to meet the needs of their patients and service intentions. Much of this curriculum discusses Primary Care Behavioral Health Integration, where primary care patients with mild to moderate mental health, behavioral health, and substance abuse concerns are serviced by their PCP and BHP within a primary care scope of practice. In this type of integration, PCPs and BHPs are working in shorter time frames and offering concrete interventions focused on increasing patient functionality (O’Donohue et al., 2005). Those with more serious mental health or substance abuse conditions are often referred out to specialty providers. A Co-location Model is followed when a mental health “specialist” provides a separate service. The specialist is convenient to consumers because it is located in the same building. Over time, a practice with a co-located therapist may decide to adjust its level of collaboration and integration of services. Some practices may collaborate in a Chronic Care or Disease Management Model approach, which was discussed earlier in this document. BHPs in this configuration will focus their attention on a few target conditions such as depression, anxiety, or perhaps ADHD in a pediatric practice. The Federally Qualified Health Centers, or FQHCs, and some VA programs use a model approach called a Unified or Partnership Model (The National Council for Community Behavioral Healthcare, 2009). In these models, medical, mental health, and substance abuse care are provided by robust services capable of managing mild to severe conditions. Reverse Co-location Models are designed to provide medical care to patients with Severe and Persistent Mental Illness (SPMI) within specialty mental health and substance abuse services. It has been shown that SPMI patients have increased morbidity rates and are dying at an alarming rate of 25 years earlier than that of the general population. Cardiovascular disease and pulmonary disease make up 60% of these mortality rates. PCPs in these settings can integrate health status assessments and planning into the patient’s plan of care (Moran, 2007).
- The National Council for Community Behavioral Healthcare describes some of these models in more detail in their report: Behavioral Health / Primary Care Integration and the Person-Centered Healthcare Home (April 2009).
- Hogg Foundation for Mental Health: Connecting Body: A Resource Guide to Integrated Health Care in Texas and the United States (printed 2008; online version updated regularly)