Behavioral Health

Project ID: 3.a.i

Project Name:

Behavioral Health

Project Description:

Integration of primary care and behavioral health services

Project Chairs:

Celeste Johns, MD, Bassett Medical Center

Marietta Taylor, Bassett Medical Center

Objective:

Integration of mental health and substance abuse with primary care services to ensure coordination of care for both services.

Rationale and Relationship to Other Projects:

Integration of behavioral health and primary care services can serve

  1. to identify behavioral health diagnoses early, allowing rapid treatment,
  2. to ensure treatments for medical and behavioral health conditions are compatible and do not cause adverse effects, and
  3. to de-stigmatize treatment for behavioral health diagnoses. Care for all conditions is delivered under one roof by known health care providers.

This may be achieved by

  1. integration of behavioral health specialists into primary care clinics using the collaborative care model and supporting the PCMH model, or
  2. integration of primary care services into established behavioral health sites such as clinics and Crisis Centers.

When onsite coordination is not possible, then in model 3) behavioral health specialists can be incorporated into primary care coordination teams (see project IMPACT described below).

These three projects are outlined in this section. Performing Provider System (PPS) should identify which one of these is most impactful on their population based upon the community assessment data.

Any PPS undertaking one of these projects is recommended to review the resources available from the Substance Abuse and Mental Health Services Administration (SAMHSA)’s website.

Core Components:

  1. PCMH Service Site: Performing provider systems undertaking this project will develop behavioral health services onsite at their 2014 NCQA level 3 PCMH or Advance Primary Care Model practices. Practices that are not at this level should anticipate meeting it by the beginning of Year 3 of DSRIP. This level of integrated and collaborative care will be required to successfully implement this project. The following components must be met:
    • Provider will work with community, facility and Local Governmental Unit (LGU) Single Point of Access (SPOA) resources to identify behavioral health providers in the community with an interest in developing the collaborative care model with PCMH. This will include a community assessment of most efficient care delivery plan.
    • With interested community and facility providers, provider will develop structure for integration including governance, MOUs, financial feasibility, and meeting regulatory requirements.
    • PCHM and behavioral health providers will collaborate on evidence based standards of care including medication management and care engagement process.
    • Preventive care screenings including behavioral health screenings (PHQ-9, SBIRT) will be implemented for all patients to identify unmet needs. When screenings are positive, providers will take immediate steps to ensure access for further evaluation and treatment when necessary. Preferably, this should include a warm transfer to the appropriate provider if the screening provider is unable to provide the service.
    • A shared EHR/clinical record must be implemented to ensure coordination of care planning.and appropriate outcome metrics are met.
  2. Behavioral Health Service Site: It is anticipated that the components of this project will mirror those of “1” above with the exception that primary care services will be placed within behavioral health clinics. There are additional specific aspects in the first bullet point that need to be addressed:
    • Performing provider systems will identify appropriate behavioral health sites where there can be an efficient integration of primary care services. Provider will work with community, facility and LGU (SPOA) resources to identify behavioral health providers in the community and interest in developing collaborative care model at that behavioral health site. This will include a community assessment of most efficient care delivery plan. Licensure issues for co-located clinics must be addressed.
    • With interested community and facility providers, provider will develop structure for integration including governance, MOUs, and financial feasibility.
    • PCHM and behavioral health providers will collaborate on evidence based standards of care including medication management and care engagement process.
    • Preventive care screenings including behavioral health screenings (PHQ-9, SBIRT) will be implemented for all patients to identify unmet needs. When screenings are positive, providers will take immediate steps to ensure access for further evaluation and treatment when necessary. Preferably, this should include a warm transfer to the appropriate provider if the screening provider is unable to provide the service.
    • A shared EHR/clinical record should be implemented to ensure coordination of care planning.
    • A quality process and outcome program will be implemented to ensure integration is efficient and appropriate outcome metrics are met.
  3. IMPACT: This is an integration project based on the Improving Mood – Providing Access to Collaborative Treatment (IMPACT) model. The IMPACT model, which originates from the University of Washington in Seattle, integrates depression treatment into primary care and improves physical and social functioning, while cutting the overall cost of providing care. Several community-based primary care providers in New York have experience implementing the IMPACT model. In this model, the behavioral health providers do not necessarily physically integrate into the primary care site. From http://impact-uw.org, the following are the key components of the program that will be expected to be present in this project:
    1. Collaborative care is the cornerstone of the IMPACT model and functions in two main ways:
      • The patient’s primary care physician works with a care manager to develop and implement a treatment plan (medications and/or brief, evidence-based psychotherapy)
      • Care manager and primary care provider consult with psychiatrist to change treatment plans if patients do not improve
    2. Depression Care Manager: This may be a nurse, social worker or psychologist and may be supported by a medical assistant or other paraprofessional. The care manager:
      • Educates the patient about depression
      • Supports antidepressant therapy prescribed by the patient’s primary care provider if appropriate
      • Coaches patients in behavioral activation and pleasant events scheduling
      • Offer a brief (six-eight session) course of counseling, such as Problem-Solving Treatment in Primary Care
      • Monitors depression symptoms for treatment response
      • Completes a relapse prevention plan with each patient who has improved
    3. Designated Psychiatrist:
      • Consults to the care manager and primary care physician on the care of patients who do not respond to treatments as expected
    4. Outcome measurement:
      • IMPACT care managers measure depressive symptoms at the start of a patient’s treatment and regularly thereafter. We recommend the PHQ-9 as an effective measurement tool, however, there are other effective tools.
    5. Stepped care:
      • Treatment is adjusted based on clinical outcomes and according to an evidence-based algorithm
      • The aim is for a 50 percent reduction in symptoms within 10-12 weeks
      • If patient is not significantly improved at 10-12 weeks after the start of a treatment plan, the treatment plan is modified. The change can be an increase in medication dosage, a change to a different medication, addition of psychotherapy, a combination of medication and psychotherapy, or other treatments suggested by the team psychiatrist.

A quality process and outcome program will be implemented to ensure integration is efficient and appropriate outcome metrics are met.