Integrating Primary Care and Behavioral Health Services
Monday, July 18, 2016
Joel Hornberger, MHS, Chief Strategy Officer, Cherokee Health Systems
A. Integrated Care: What is it?
When implementing integrated care in their organizations, providers often face a variety of challenges, not the least of which is often the lack of a common definition for what integrated care actually is.
This lack of a common definition of integrated primary and behavioral care has often hampered provider initiatives, resulting in missed opportunities. As integrated care becomes more recognized as an important model of care, many definitions of “integrated care” have crept into the healthcare lexicon. As a result of this confusion, the Agency for Healthcare Research and Quality (AHRQ) in 2013 commissioned a group of thought leaders to define integrated care. They developed the following definition:
“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress related physical symptoms, and ineffective patterns of health care utilization (Peek, 2013).” (author’s underlines for emphasis)
B. Core components of integrated care
Several core components of integrated care that providers need to execute effectively during practice transformation are outlined below:
· Primary care visits -- Evaluation and Management Service CPT Codes (99212, 99313, 99214, etc.) are utilized when the patient is seen by a primary care provider (PCPs usually physicians and advanced nurse practitioners). Associated lab and x-ray codes are included.
· Behavioral Health Consultant visits – Health and Behavior Assessment and Intervention CPT codes (96150 – 96155) are used by a Behavioral Health Consultant (BHCs are often clinical psychologists or licensed clinical social workers, or their equivalents in particular states). These codes are used when the BHC sees a patient at the request of a PCP to address specific concerns or questions prompted by the patient’s medical diagnosis. If the focus of the BHC’s attention is the psychiatric condition of the patient the customary psychiatry CPT codes (90791, 80832, etc.) are utilized.
· Hallway consultations – Outside-the-exam room consultations between BHCs and PCPs are commonplace in the integrated care model. There are no CPT codes nor generally any direct reimbursement for the time spent by either provider in these consultations.
· BHC follow-up visits – Frequently, BHCs will provide ongoing short term follow-up care to patients within the primary care setting. This care may be provided to address patient’s behavioral health and/or medical needs. These visits are typically 15-30 minutes in length and the appropriate CPT is used.
· Treatment team meetings -- The multidisciplinary team of providers meets to develop treatment plans for complex patients. This provider time is generally not reimbursed in a fee for service funding environment.
The shift from fee-for-service reimbursement to other value-based arrangements are rapidly escalating. Value-based contracts can be built on a fee-for-service base using the codes above, with additional incentives for improved quality and controlled costs (value), but increasing they are built on a reimbursement platform using global non-encounter-based reimbursement methodologies, such as blended per-member-per-month capitation rates, episodes of care rates, and case rates. As managed care risk arrangements shift from payers to providers, providers are often using the following risk management tools to manage and assigned populations of integrated care patients:
· Clinical pharmacists -- Complex patients frequently have multiple prescriptions. Clinical pharmacists consult with other members of the treatment team and provide one-on-one counseling to patients about medication compliance and adverse medication interactions.
· Care coordination -- Care coordination is frequently performed by nursing staff within the PCP office. These staff work with patients using various databases and patient registries, contacting patients to close gaps in care, arrange follow-up appointments and schedule visits for prevention services.
· Community outreach and patient engagement -- As contracts shift to value-based arrangements and primary care teams are assigned patient panels to manage, there is a greater emphasis outreach, patient engagement and community support. Community health workers help patients negotiate social determinants of heath.
· Psychiatric consultation and management – Psychiatric consultation may be available when PCPs or BHCs have questions about medication management of a patient. In circumstances where the PCP determines that psychiatric management of the patient requires direct care from a psychiatrist, the psychiatrist may see the patient until they are psychiatrically stable and then return the patient to the primary care provider to manage on an ongoing basis.
· Data analytics and complexity of care measures – Increasingly, providers are obtaining claims data “dumps” and other payer reports that identify high-utilizing patients, quality outcome targets versus actual results, and detailed actuarial cost reports. Additionally, providers are developing or purchasing analytics tools to help identify and predict high-utilizing patient. Finally, providers are connecting electronically with payers and other providers, including inpatient and ER providers, to receive real-time alerts when assigned patients are admitted to the hospital or the ER.
Each of these components can be found in mature models of integrated care and assist practices in achieving desired outcomes and cost targets.
In summary, provider organizations experience greater success in implementing an integrated care model when a common, team-based definition of integrated care is used and understood throughout the organization. It is imperative that all staff – medical providers, behavioral providers, nursing staff, front desk staff, IT staff, administration, leadership and others – are all on the same page and understand the details of the model and how to transform a practice to implement it effectively. As financial models shift from fee-for-service to value-based contracts, more sophisticated population management tools and skills need to be employed in order to effectively manage risk, improve outcomes and control costs.
For questions, contact Joel at Joel.firstname.lastname@example.org or 865-202-9969
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