Download Scope of Primary Care - Partnership HealthPlan of California

PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: MPCP2017 (previously MPQP1024,
MPQG1024, QG100124)
Policy/Procedure Title: Scope of Primary Care – Behavioral Health
and Indications for Referral Guidelines
Original Date: 02/18/2004 – Medi-Cal
Next Review Date:
(QG100124)
Last Review Date:
04/18/2007 – Healthy Kids (MPQG1024)
Applies to:
☒ Medi-Cal
☒ Healthy Kids
Reviewing
Entities:
Approving
Entities:
Lead Department: Health Services
☒External Policy
☐ Internal Policy
04/20/2017
04/20/2016
☐ Employees
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☒ FINANCE
☒ PAC
☐ CEO
☐ COO
☐ CREDENTIALING
Approval Signature: Robert Moore, MD, MPH
☒ DEPT. DIRECTOR/OFFICER
Approval Date: 04/20/2016
I.
RELATED POLICIES:
A. MCUP3101 Alcohol and Substance Abuse Screening and Treatment (Including SBIRT)
B. MCQG1005 Adult Preventative Health Guidelines
C. MCUP3028 Mental Health Services
D. HKUP3075 Mental Health Services (Healthy Kids)
E. County specific Mental Health Plan MOUs
F. MPUP3126 Autism Spectrum Disorder (ASD) Behavioral Health Treatment (BHT)
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS:
A. N/A
IV.
ATTACHMENTS:
A. Beacon Adult Behavioral Health Screening Tool
B. Beacon Child 0-5 Behavioral Health Screening Tool
C. Beacon Child 6-17 Behavioral Health Screening Tool
D. Beacon Instructions for Behavioral Health Screening Tool & Referrals
E. Beacon Primary Care Provider (PCP) Referral Form
F. Beacon Health Strategies, Policy # QM 15.17 Exchange of Information between Behavioral Health,
Primary Care Providers and Behavioral Health Practitioners
V.
PURPOSE:
The purpose of this guideline is to define the scope of primary care practice and appropriate situations for
referral to Beacon Health Strategies, Kaiser Permanente, OPTUM, or County Mental Health Specialty
Services or Substance Abuse Services for behavioral health conditions. The guideline will help facilitate
communication between primary care practitioners and behavioral health specialists and help identify
educational opportunities for the Partnership HealthPlan of California (PHC) provider network.
Page 1 of 5
Policy/Procedure Number: MPCP2017 (previously
Lead Department: Health Services
MPQP1024, MPQG1024, QG100124)
☒External Policy
Policy/Procedure Title: Scope of Primary Care – Behavioral
Health and Indications for Referral Guidelines
☐Internal Policy
Original Date: 02/18/2004 – Medi-Cal
Next Review Date: 04/20/2017
(QG100124)
Last Review Date: 04/20/2016
04/18/2007 – Healthy Kids (MPQG1024)
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
VI.
POLICY / PROCEDURE:
PHC utilizes this guideline to generally define the services and responsibilities of Primary Care Providers
(PCPs) and behavioral health providers. It states that a PCP is responsible for all services within the scope of
primary care required by the patient except when precipitous circumstances preclude the PCP role. The
PCP’s services are personal, and his/her responsibility is continuous. The scope of the responsibility is
comprehensive, (i.e. all required services including preventive services). The PCP should provide those
services which can be provided within his/her competence and should obtain consultation when additional
knowledge or skills are required. PHC recognizes that differences in skill level exist among PCPs and that
this document serves as a general guideline to define the scope of services and the indications for specialty
referral. PCPs should continue to use their sound clinical judgment when considering the need for specialty
evaluation. Consultation includes advice received from a telephone discussion with a specialist and the
referral of a patient to a specialist for services. When care by specialists is required, it is the responsibility of
the PCP and the specialist to coordinate all services.
A. The primary care physician should be responsible for providing the following in regards to basic
behavioral health conditions:
1. Obtain developmental and psychosocial histories and perform mental status examinations when
indicated by psychiatric or somatic presentations.
2. Routinely screening for common behavioral health and substance abuse conditions. The plan has
adopted and PHC contracted providers are expected to follow the USPSTF Guide to Clinical
Preventive Services. Routine screening for depression is recommended by the USPSTF. Please
refer to the Adult Preventative Policy - MPQG1005 for further details. Screening for alcohol misuse
is also recommended. Please refer to Alcohol and Substance Abuse Screening and Treatment policy
(Including SBIRT) – MCUP3101 for details.
3. Determine whether high risk factors such as suicidal or homicidal ideation with active planning,
threats of physical harm, or psychomotor agitation, or active substance abuse exist, and/or whether
the member can be considered to be gravely disabled.
4. Evaluate and provide ongoing management for the following:
a. Psychological factors affecting a medical condition and psychological symptoms precipitated by
medications being used to treat medical conditions
b. Psychological issues or problems which are conditions such as anxiety, depression and conduct
problems that do not meet the criteria for a DSM diagnosable disorder
c. Medical assessments of members to evaluate and treat general medical conditions causing or
exacerbating psychiatric symptoms.
d. Initial diagnosis and treatment of dementia. Differentiate delirium and depression from
dementia. Manage general medical factors that improve or worsen dementia.
B. The primary care provider should be responsible for the initial evaluation and referral for behavioral
health services as follows:
1. Members with Healthy Kids Health Plan in Solano, Sonoma, Yolo, and Marin counties: All levels of
mental health services and substance abuse disorder services are covered by PHC through a
contractor: OPTUM. For information on accessing this behavioral health plan contact: 800-7188430.
2. Members assigned to Kaiser Permanente: Kaiser will provide Mental Health Services in Solano,
Sonoma, Napa, Yolo, and Marin counties for mild-to-moderate conditions.
3. Medi-Cal only Members (with no Medicare and not assigned to Kaiser Permanente nor to Healthy
Kids Health Plan): All behavioral health services for these members are provided either by Beacon
Health Strategies’ network of providers for mild to moderate behavioral health conditions or by
Page 2 of 5
Policy/Procedure Number: MPCP2017 (previously
Lead Department: Health Services
MPQP1024, MPQG1024, QG100124)
☒External Policy
Policy/Procedure Title: Scope of Primary Care – Behavioral
Health and Indications for Referral Guidelines
☐Internal Policy
Original Date: 02/18/2004 – Medi-Cal
Next Review Date: 04/20/2017
(QG100124)
Last Review Date: 04/20/2016
04/18/2007 – Healthy Kids (MPQG1024)
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
4.
5.
6.
7.
County Mental Health Specialty Services or Substance Abuse Services for moderate to severe
behavioral health conditions or substance abuse.
PCP should determine a provisional diagnosis for the following behavioral health conditions:
schizophrenia/psychotic disorder, bipolar depression, depression, anxiety disorder, impulse control
disorder, adjustment disorder, personality disorder (except anti-social), eating disorder, pervasive
developmental disorder, disruptive behavior/attention deficit disorder, feeding and
eating/elimination disorders, other disorders of infancy, childhood, or adolescence, somatoform
disorders, factitious disorders, dissociative disorders, paraphilias, gender dysphoria.
PCP should determine the level of functional impairment in the following life domains resulting
from the behavioral health condition:
a. Independent living skills
b. Social relations
c. Physical condition (chronic medical condition)
d. Vocational/Employment
e. Sexuality
f. Self-care
g. Decision making
h. Legal
i. Residential instability
PCP should determine the probability of deterioration/risk factors linked to the behavioral health
condition such as:
a. Psychiatric hospitalization
b. Criminal behavior
c. Suicidal/homicidal behavior
d. Transitional age youth with acute psychotic episode
e. Self-injurious behavior that required medical attention
f. Sexual aggression with acute risk of re-offending
PCP should refer Medi-Cal only members to Beacon Health Strategies when a provisional diagnosis
(from VI.B.4) is present or the diagnosis is uncertain, where functional impairment is considered to
be in mild to moderate range (from VI.B.5), and where there are no deterioration/risk factors (from
VI.B.6)
a. PCP may refer for Outpatient Behavioral Health Services for therapy or medication
management via Beacon’s network of providers by calling (855)765-9703 or providing the
member with this referral number. PCP can also fax a Beacon PCP Referral Form to Beacon at
866-422-3413 or use secure email: [email protected], Licensed Mental Health
Providers at Beacon will screen the patient and determine the appropriate level of care needed
and make the actual referrals.
b. PCP may request decision support related to member diagnostic and medication clarification;
the PCP may request a telephone consultation with a Beacon psychiatrist at (855)765-9703.
Before phone consult with Beacon, fax medication list and last 2 PCP progress notes for
Psychiatrist review. Fax: (866) 422-3413 or secure email: [email protected]
c. PCP may refer for Beacon Care Management: local behavioral health care coordination services
to help link members to mental health providers, support their transition between levels of care,
or engage members with history of non-compliance and link them to community services.
Fax: (855) 371-2279 or email: [email protected]
d. Primary care sites with integrated behavioral health, whose mental health professionals are
credentialed with Beacon, may co-manage patients who would qualify for the “mild -moderate”
mental health benefit.
Page 3 of 5
Policy/Procedure Number: MPCP2017 (previously
Lead Department: Health Services
MPQP1024, MPQG1024, QG100124)
☒External Policy
Policy/Procedure Title: Scope of Primary Care – Behavioral
Health and Indications for Referral Guidelines
☐Internal Policy
Original Date: 02/18/2004 – Medi-Cal
Next Review Date: 04/20/2017
(QG100124)
Last Review Date: 04/20/2016
04/18/2007 – Healthy Kids (MPQG1024)
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
e.
8.
9.
10.
11.
12.
After initial evaluation and/or referral, the PCP may continue to follow and treat a PHC member
based on his/her current clinical competence and in collaboration with the behavioral health
specialist as appropriate.
PCP should refer members (primarily Medi-Cal only) to County Mental Health Specialty Services
when a provisional diagnosis (from VI.B.4) is present and when functional impairment is considered
to be in the moderate to severe range (from VI.B.5), and/or when any risk factor (from VI.B.6) is
present.
a. The process of accessing mental health services in each county may be different. PCPs should
consult the PHC website for county-specific details.
b. Patients with emergency psychiatric conditions should be referred for emergency evaluation,
calling the county-designated crisis phone number to arrange for services.
c. After initial evaluation and/or referral, the PCP may continue to follow and treat a PHC member
based on his/her current clinical competence and in collaboration with the behavioral health
specialist as appropriate.
d. Federally qualified health centers with integrated mental health may provide outpatient services
for patients who would otherwise qualify for County Specialty Mental Health Services. These
services are billed directly to the state.
PCP should screen and refer Medi-Cal only Members with Substance Abuse problems as follows:
a. Screening and Brief Intervention for Alcohol misuse should be performed by PCP.
b. The process of accessing substance abuse services in each county may be different. First point
of contact for substance abuse referrals for each county is found on the PHC website at:
http://www.partnershiphp.org/Members/Medi-Cal/Pages/Benefits.aspx#phpFaqItem16
towards the bottom of the page under the heading “Substance Abuse Services.”
c. For details on substance abuse screening and referral, see MCUP3101 – Alcohol and Substance
Abuse Screening and Treatment (Including SBIRT).
d. Provide ongoing follow-up as jointly determined by the PCP and County Substance Abuse
provider for members whose substance abuse conditions have reached a high degree of stability.
Psychiatric manifestations of neurologic disorders, developmental neurologic disorders, traumatic
brain injury, and encephalopathy. A specialist in neuropsychiatry is ideally suited to assist with
these cases.
Behavioral Health Treatment (BHT) for Medi-Cal only Members: BHT is covered by PHC for
Members between the ages of 0-21 years old who have Autism Spectrum Disorder (ASD), including
Asperger’s and pervasive developmental disorders. Contact PHC’s Member Services Department
for further information.
School aged children may also have some assessment and treatment covered through their schools.
School-based mental health services include a broad range of services, settings, and strategies.
These services may include academic counseling, brief interventions to address behavior problems,
family counseling, suicide prevention, and assessment and referral to other systems. Further
information is available through your County mental health department.
VII.
REFERENCES:
A. Latest USPSTF Guide to Clinical Preventive Services
VIII.
DISTRIBUTION:
A. PHC Provider Manual
B. PHC Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
Page 4 of 5
Policy/Procedure Number: MPCP2017 (previously
Lead Department: Health Services
MPQP1024, MPQG1024, QG100124)
☒External Policy
Policy/Procedure Title: Scope of Primary Care – Behavioral
Health and Indications for Referral Guidelines
☐Internal Policy
Original Date: 02/18/2004 – Medi-Cal
Next Review Date: 04/20/2017
(QG100124)
Last Review Date: 04/20/2016
04/18/2007 – Healthy Kids (MPQG1024)
☒ Healthy Kids
☐ Employees
Applies to: ☒ Medi-Cal
X.
REVISION DATES:
PREVIOUSLY APPLIED TO:
Medi-Cal
Original Date: 02/18/2004
Revision dates: 05/18/05; 04/19/06; 04/18/07; 04/16/08; 03/18/09 11/17/10; 01/16/13; 02/19/14; 05/20/15
Healthy Kids
Original Date: 04/18/2007
Revision dates: 04/16/08; 03/18/09 11/17/10; 01/16/13; 02/19/14; 05/20/15
PartnershipAdvantage:
MPQG1024 – 04/18/2007 to 11/17/2010
MPQP1024 – 11/17/2010 to 01/01/2015
Healthy Families:
MPQP1024 - 11/17/10 to 03/01/2013
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