Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Psychiatric and mental health nursing wikipedia , lookup
History of mental disorders wikipedia , lookup
History of psychiatry wikipedia , lookup
Abnormal psychology wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Deinstitutionalisation wikipedia , lookup
Community mental health service wikipedia , lookup
The Integration of Behavioral Health and Primary Care: Keys to Success ! Virna Little, PsyD, LCSW-r, SAP Treat mental health disorders where the patient feels most comfortable receiving care Better coordination of care Mind and body connection More likely to keep appointments where multiple issues are being addressed The majority of mental health treatment will occur in community health settingswith focus on preventive care and integration. Mental health diagnosis often go unrecognized in primary care Primary care providers often under treat mental health diagnosis Screening alone does not improve outcomes for primary care nor is it considered integrated care Comfortability in discussing mental health issues Established relationship with primary care provider “I am not crazy” Less stigma walking into primary care setting then mental health setting Depression and anxiety are adverse outcomes of diabetes, heart disease and asthma and/or vice versa Bipolar Disorder Anxiety Disorder Perinatal mood disorders Morbidity and Mortality in People with Serious Mental Illness Persons with serious mental illness (SMI) are dying 25 years earlier than the general population While suicide and injury account for about 3040% of excess mortality, 60% of premature deaths in persons with schizophrenia are due to medical conditions such as cardiovascular, pulmonary and infectious diseases (NASMHPD, 2006) 7 Usual Care Rarely treated effectively Only 1 in 5 receive treatment Rarely treated by MH professionals Fewer than 10 report see a MH worker Increasing use of antidepressants in PC but treatment often not effective Integrated Care Most effective approach to treat mental health in PC settings Comprehensive Multidisciplinary approach Fully integrated with information available to all practitioners Cost-effective People seek mental health care in primary care settings Many completed suicides were seen by PCP 20% on the same day 40% within 1 week 70% within 1 month White men ages 85 and older highest risk PCP referrals to mental health providers may be necessary but not sufficient to improve outcomes Strong evidence has emerged for collaborative/integrated care for treatment of common mental disorders The IMPACT (Improving Mood Promoting Access to Collaborative Treatment) Model The Three Component Model (3CM) Insurance does not provide adequate coverage for mental health services The Four Quadrant Clinical Integration Model Quadrant II BH PH High Behavioral Health (MH/SA) Risk/Complexity PCP (with standard screening tools and guidelines) Outstationed medical nurse practitioner/physician at behavioral health site Nurse care manager at behavioral health site Behavioral health clinician/case manager External care manager Specialty medical/surgical Specialty behavioral health Residential behavioral health Crisis/ ED Behavioral health and medical/surgical inpatient Other community supports Persons with serious mental illnesses could be served in all settings. Plan for and deliver services based upon the needs of the individual, personal choice and the specifics of the community and collaboration. Quadrant I BH PH Low Behavioral health clinician/case manager w/ responsibility for coordination w/ PCP PCP (with standard screening tools and guidelines) Outstationed medical nurse practitioner/physician at behavioral health site Specialty behavioral health Residential behavioral health Crisis/ED Behavioral health inpatient Other community supports Quadrant IV BH PH PCP (with standard screening tools and behavioral health practice guidelines) PCP-based behavioral health consultant/care manager Psychiatric consultation Quadrant III BH PH PCP (with standard screening tools and behavioral health practice guidelines) PCP-based behavioral health consultant/care manager (or in specific specialties) Specialty medical/surgical Psychiatric consultation ED Medical/surgical inpatient Nursing home/home based care Other community supports Physical Health Risk/Complexity Low High Focus: Quadrants II and IV 12 Design 1,801 depressed older adults with major depression and / or dysthymia (chronic depression) randomly assigned to IMPACT or to Care as Usual Usual Care Primary care or referral to specialty mental health IMPACT Care Collaborative / stepped care disease management program for depression in primary care offered for up to 12 months Analyses Independent assessments of health outcomes and costs for 24 months. Intent to treat analyses Unützer et al, Med Care 2001; 39(8):785-99 50 % or greater improvement in depression at 12 months Usual Care 70 IMPACT 60 50 % 40 30 20 10 0 1 2 3 4 5 6 7 Participating Organizations 8 Generalized Anxiety Disorder 7 Tool simplified questionnaire developed to help in the diagnosis of Generalized Anxiety Disorder, or GAD. 7 item questionnaire a score of 10 or more on the GAD-7 represented a reasonable cut point for identifying cases of GAD Cut points of 5, 10, and 15 may be interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7. The Patient-Centered Medical Home Principles of the Patient-Centered Medical Home 1. Personal physician 2. Physician/Nurse Fractioned directed medical practice (team care that collectively takes responsibility for the ongoing care of patients) 3. Whole person orientation 4. Care that is coordinated and/or integrated 5. Quality and safety (including evidence based care, use of information technology and performance measurement/quality improvement) 6. Enhanced access to care 7. Payment structure that reflects these characteristics beyond the current encounter-based reimbursement mechanisms The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association http://www.pcpcc.net/ 18 Suggested Starts Smoking Depression Alcohol/Drug use Unsafe sex practices Frequent Utilizers Obesity Ages and Stages, MCHAT, Developmental Chronic illness 19 Initial PHQ9 Depression Scores (Mean Score of 14.03) Number of Patients 152 62.6% 153 68 27.9% 68 23 9.5% 23 0 Under 10: Mild Depression 10-14: Moderate Depression 15-19: Moderately Severe Depression PHQ9 Score 20+: Severe Depression Number of Patients 6 Month PHQ9 Depression Scores (Mean Score of 7.91) 84 65.6% 84 31 24.2% 31 6 4.7% 6 Under 10: Mild Depression 10-14: Moderate Depression 15-19: Moderately Severe Depression PHQ9 Score 7 5.5% 7 20+: Severe Depression systematic approach that includes certain tools, routines, and a team approach to patient care 3 Components of 3CM prepared primary care clinician and practice, care management, a collaborating mental health specialist What do you want to achieve? Are there diagnosis or measures your organization/department is already tracking/monitoring? Are there measures that will help us subsidize the integration work? Can this be a CQI or research project? What is realistic? Are there outcome measures that will increase organization buy-in for integration work? Integrated Care Co-location Collaborative Care - Systematically combining physical and mental health services - Most common model of integrated care - Integrated health care model - Term care approach to mental health based in community health primary care setting - PCPs develop agreement with mental health providers to whom they refer their patients with mental health needs to onsite mental health services -Partnership between the physical health and mental health providers to manage the treatment of mild to moderate and stable severe psychiatric disorders in primary care settings - Integration of mental health treatment in primary care - PCPs typically do not follow up on their referral once it has been made - May include brief psychotherapy or simply medication management and patient education Function Minimal Collaboration Basic Collaboration from a Distance Basic Collaboration onSite Close Fully CollaboIntegrated ration Partly Integrated Doherty, McDaniel & Baird (1995) Separate Systems Separate facilities Periodic focused communication ; mostly written View each other as outside resources Little understanding of each other’s culture or influence Separate systems Same facilities Regular communication; occasionally face-to-face Some appreciation of each others role & general sense of large picture Mental health usually has more influence Some shared systems Same facilities Face-to-face consultation; coordinated tx plans Basic appreciation of each others role and cultures Collaborative routines difficult; time & operation barriers Influence Separate Systems Separate facilities Communicatio n is rare Little Appreciation Shared systems & facilities in seamless biopsychosocial web Consumers & providers have same expectations of system(s) In-depth appreciation of roles & culture Collaborative routines are regular & smooth Model 1: Mental health staff colocated in FQHC Community Health Centers Model 2: Article 31 Mental Health Center co-located in FQHC Community Health Center Model 3: Cooperative Agreement with County Mental Health Service Model 4: Part-time Primary Care Services in Mental Health Day Treatment Program - A full-time Licensed Social Worker Family Practice Psychiatry - Staff includes primary care providers, adult and child psychiatrists and licensed mental health clinicians - FQHC Community Health Center partnered with County Mental Health provider to provide comprehensive specialized care - Primary care provider in day treatment program approximately 6 hours per week - Model improved with EHR facilitates special populations receiving care at multiple Institute locations. - Provides excellent ability to care for most populations with coordinated, comprehensive care - Utilizes existing services to expand access, continuity and comprehensive care, and ensure all have access to appropriate level of service - Primary care provider ongoing primary care as well as urgent care to patients who attend day treatment program - Encourages - Both services - All patients will be Able to use behavioral activation techniques with patients as an adjunct to other treatments Able to provide optional evidence-based, brief structured psychotherapy Able to establish quick rapports to a wide range of individuals Ability to make patients feel that they are being listened to and supported Screening Referral Assessment Education Discuss Treatment options with patient Coordinate care with PCP Referral to psychiatrist Start Initial Treatment Plan Arrange follow-up Contact Documentation Referral to outside resources (if necessary) Clinical Barriers Traditional separation of mental health issues from general medical issues Lack of awareness of mental health screening tools in the primary care setting Physicians' limited training in psychiatric disorders and their treatment Financial Barriers Lack of insurance parity for psychiatric disorders Medicaid's low payment rates Billing restrictions Policy Barriers Physical health and Mental health funding streams Difficulty of sharing information due to HIPAA regulations (progress notes) Organizational Barriers Shortage of mental health professionals Limited communication between medical and mental health providers Lack of agreement between medical and mental health providers Can help support integration work Will vary by organization/setting/payor mix Time spent with PCP No show rates for PCP, specialty care Medication adherence Emergency room visits/utilization Productivity for behavioral health HRSA Medicaid Guide, 2003 E&M Psychotherapy New 99201 thru 99205 Where? Medical Office or other O/P Facility Behavior Health Office or other O/P Facility Behavior Health Office or other O/P Facility Behavior Health Office or other O/P Facility Medical Visit that can include Counseling 10 10 Psychiatric Diagnostic Interview Individual Psychoth. Insight Oriented Face-to-Face W/patient Identify and address psychological, behavioral, emotional cognitive and social factors important to physical health. Patients not diagnosed with mental illness. 60 Min. Who? Service Emphasis 90801 40 Min. Physician, NP, PA Other Medical Clinicians Psychiatrist, LCSW, Clinical Psychologist, Psych ARNP, Other (Payer criteria) Medical Behavioral Health Initial Assessment 90804 90806 90808 20 90805 90807 90809 80 Min. Behavioral Assessment Codes? What? Est’d 99211 thru 99215 Initial Assessment Individual Psychoth. w/ medical mgmt. All On-going Individual Psychotherapy 96150 thru 96155 Clinical Psychologist, ARNP, Other for Medicare Biopsychosocial factors important to Physical Health problems and treatments Goldberg & Oxman, 2004 Medicare Reimbursement: 908xx codes can be used by non-mental health professionals Commercial Payers: Sometimes do not allow use of 908xx by PCPs (usually because of ‘carve-out’ to third party) Medicaid: Psychiatry codes must be billed by licensed MH provider in 34 PA Mauer, NCCBH; 2006 CPT codes adopted in 2002 to address primary-carebased BH services delivered in coordination with PCP services. Adopted by Medicare Adoption by Medicaid and private sector plans is occurring on state-by-state basis Health and Behavior Assessment Documentation Guidelines Specific validated interventions for assessing readiness to change Identification of barriers to change Advising behavioral changes Assisting by providing specific suggested actions Motivational counseling Behavioral Activation Arranging for follow-up services Health and Behavior Assessment Documentation Guidelines Behavior change services are performed as part of treatment of condition related to or exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in illness Health and Behavior Assessments Focus is NOT on mental health but bio-psychosocial factors relating physical health Focus is on improving patients health and well being Focus on utilizing evidence strategies, behavioral observations, health oriented questionnaires Focus on reduction of disease related problems Focus on treatment adherence These are NOT preventative medicine counseling codes( 99401-99412) CPT Codes for Medical Case Conferences 99366-Medical team conference with interdisciplinary team of health care professionals, face to face with patient and/or family, 30 minutes or more, participation by non-physician qualified health care professional. 99367-Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more participation by physician. 99368-Participation by non-physician qualified health care professional. Documentation Guidelines A complete patient history with a focus on current problems and symptoms An exam focusing on presenting problems Medical review , impression and decision Counseling and/or coordination with care team, may include patients family 15 minute visit Documentation for Case Conferences Each participant should document participation in team conference Documentation should include contributed treatment recommendations Documentation should include role of individual in patients care Documentation should include subsequent treatment recommendations Telephone Consultation Not traditionally covered by payors Can be completed by physicians and qualified non physician providers Must be established patient or collateral Cant be within 7 days following an appointment or prior to next appointment 98967- 11-20 minutes of medical discussion 98968- 21-30 minutes of medical discussion 98966- 5-10 minutes of medical discussion Documentation Guidelines 90801 Document reason for visit and describe presenting problem, current symptoms Obtain psychosocial history including supports, substance abuse, legal, family, trauma Obtain psychiatric history including medication, treatment Mental Status Multi-axial Clinical impressions Treatment recommendations Documentation Guidelines 90804 and 90806 Include reason for visit diagnosis (most payors do not reimburse for “v”codes) Include previous symptoms and current symptom assessment (quantify if possible) Utilize tools and report results ( GAD 7, Phq9) Describe clinical interventions provided in session Discuss progress towards treatment goals and discharge from treatment Questions ???