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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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the integration of behavioral health and primary care keys to success
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 settings- with focus on preventive care and integration.
unrecognized and untreated
Unrecognized and untreated

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

less stigma
Less Stigma

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

physical health is comorbid with mental health
Physical Health is comorbid with mental health

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
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 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)



usual care vs integrated care
Usual Care vs. Integrated Care
  • 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
why integrate mental health in primary care
Why Integrate Mental Health In Primary Care?
  • 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
why integrate mental health in primary care1
Why Integrate Mental Health In Primary Care?
  • 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
impact model www impact wu edu
  • 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

impact findings robust across diverse organizations
IMPACT Findings Robust Across Diverse Organizations

50 % or greater improvement in depression at 12 months


Participating Organizations

gad 7 tools
GAD 7 Tools
  • 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
The Patient-Centered Medical Home
  • Principles of the Patient-Centered Medical Home
    • Personal physician
    • Physician/Nurse Fractioned directed medical practice (team care that collectively takes responsibility for the ongoing care of patients)
    • Whole person orientation
    • Care that is coordinated and/or integrated
    • Quality and safety (including evidence based care, use of information technology and performance measurement/quality improvement)
    • Enhanced access to care
    • 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



suggested starts
Suggested Starts



Alcohol/Drug use

Unsafe sex practices

Frequent Utilizers


Ages and Stages, MCHAT, Developmental

Chronic illness


three care model 3cm
Three Care Model (3CM)
  • 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
outcome measures
Outcome Measures

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?

who to hire for integrated care
Who to hire for integrated care?

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)

barriers to integrated care
Barriers to Integrated Care
  • 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
barriers to integrated care1
Barriers to Integrated Care
  • 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
abstract dollars
Abstract Dollars

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

goldberg oxman 2004
Goldberg & Oxman, 2004



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


mauer nccbh 2006
Mauer, NCCBH; 2006

CPT codes adopted in 2002 to address primary-care-based BH services delivered in coordination with PCP services.

Adopted by


Adoption by

Medicaid and

private sector

plans is

occurring on



health and behavior assessment documentation guidelines
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 guidelines1
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
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
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
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
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
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
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


Clinical impressions

Treatment recommendations

documentation guidelines 90804 and 90806
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