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
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Virna Little, PsyD, LCSW-r, SAP
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
Perinatal mood disorders
Persons with serious mental illness (SMI) are dying 25 years earlier than the general population
While suicide and injury account for about 30-40% 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)
Focus: Quadrants II and IV
Unützer et al, Med Care 2001; 39(8):785-99
50 % or greater improvement in depression at 12 months
The American Academy of Family Physicians, American Academy of Pediatrics,
American College of Physicians, and American Osteopathic Association
Unsafe sex practices
Ages and Stages, MCHAT, Developmental
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?
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
Discuss Treatment options with patient
Coordinate care with PCP
Referral to psychiatrist
Start Initial Treatment Plan
Arrange follow-up Contact
Referral to outside resources (if necessary)
Can help support integration work
Will vary by organization/setting/payor mix
Time spent with PCP
No show rates for PCP, specialty care
Emergency room visits/utilization
Productivity for behavioral health
908xx codes can
be used by
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 PA
CPT codes adopted in 2002 to address primary-care-based BH services delivered in coordination with PCP services.
Specific validated interventions for assessing readiness to change
Identification of barriers to change
Advising behavioral changes
Assisting by providing specific suggested actions
Arranging for follow-up services
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
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)
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.
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
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
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
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
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