Your Patients Are Waiting: Action steps to integrate behavioral health and primary care-Q&A + Resources

After a great discussion by our panelists, webinar guests had many questions. While we did not have time to answer all of them, our panelists were able to answer some additional questions after the webinar had ended. If you haven't yet watched the webinar, check out the recording and the slides.

Q: Many psychiatrists are uncomfortable working in PC environment for which they were not trained, and which is quite different from BH sector setting.  Could speakers respond to quickly integrate integrated care training in medical and nursing education;  and secondly, given not all clinical staff want to practice integrated care, should Q: We spend lot of time/expense "training" or move quickly to train integrated care clinicians care workers first, then direct them to work in integrated practice settings?

Tough problem and hugely pertinent question!  Like patient care, it depends on the particular situation.  There is a professional and policy imperative to stop training  health professionals for the old world and prepare them for the new world in which they will spend most of their professional lives.  It appears that the health professions are able in some places to ignore/bypass/finesse regulatory requirements to alter training now while awaiting “updated” regulations.  An example may be residency requirements in internal medicine:  I think they have no requirement for behavioral health training for internists, but some of their general IM residency programs are sliding it in, sometimes as part of the movement to interdisciplinary/interprofessional training intitiatives.   Messages from our ACT practices that are pertinent here:  Unite everyone you can with a shared vision that is a practice-wide change that matters to our patients—and if after awhile some just can’t make the shift, they may need to work elsewhere.  Some practices have trained their own pc and bh staff how to work together and are now training others for other practices, e.g. Salud Community Health Centers in Colorado.  

I think this is a "yes-and". We need better training on integrated care as part of standard education programs earlier, but this won't address the "re-training" needs of the workforce already out in practice. As one example of "re-training" opportunities, the University of Massachusetts Primary Care Behavioral Health program offers online courses for behavioral health clinicians on how to work in integrated settings. Integrated settings will also not be the right fit for everyone - it requires flexibility and a desire to work as a generalist that some will be uncomfortable with. 

Q: Do your integrated BH staff bill?

Yes - generally using traditional psychotherapy codes (e.g. 90832, 90834, 90846, 90847). As we mentioned in the webinar, there are also opportunities to bill using newer codes such as Health & Behavior codes (96000 series) and Collaborative Care (99492-99494) or general integration codes (99484). 

There are often perceived (and sometimes real) barriers to same-day billing for physical and behavioral health services under Medicaid; however, there is no federal-level barrier to this. In Colorado as well as in other states, it has been clarified that same-day billing is permitted and behavioral health clinicians bill for services on the same day as a general medical visit. 

Q: How are you defining remission, and when you use the PHQ-9 to assess for remission, do you complete the entire PHQ-9 even if the PHQ-2 is negative?

Remission is defined as a PHQ9 < 5.  Once a person is diagnosed with MDD or Dysthymia they should never receive the PHQ-2  which is a screening tool and not a measurement tool.  You  need to be able to identify not only remission but also when the PHQ9 score starts to rise again (depression is worsening) or they are not well (PHQ 2 does not detect PHQ9 scores below a certain point).  The  best approach in my opinion is to not sure the PHQ2 at all.  Especially if you want to  do suicide screening.  If you do not ask question 9 on the PHQ9 (even if PHQ2 is negative) then you did not do suicide screening.

Q: Wondering if you have tips for referring patients to clinic pharmacists for antidepressant optimization/titration? I can elaborate on my current practice model if needed.

An observation:  In many places there has emerged a critical mass of pharmacists, nurses, social workers, psychologists, psychiatrists, oral health professionals, community outreach workers, and primary care clinicians—who are thriving together in the same practice –generally feeling as if they are so much better together than apart, that they rather automatically exploit each other’s skills and talent.  This is not so much a referral as an assumed partnership.  This seems to be an expression of the aspiration of interprofessional collaboration that doesn’t so much answer important questions such as “how to refer to clinic pharmacists” –as it changes the question.

Q: What do you recommend about navigating provider resistance in spite of leadership support

One of our messages is that such resistance is “incomplete adaptation.”  If after adaptive leadership strategies and some patience fail, you have to get the right people in the practice.

One of the biggest motivators to providers can be showing them the data: where are their own patients not doing well? How are other patients in the practice improving with integrated care? 

Q: Who are you using as BHC's?  We're having trouble getting LCSW's to apply

The size of the available workforce is a big problem, with some counties having no or very few behavioral health and/or primary care clinicians.  It would be nice to have a decade of federal and state leadership to stimulate production of the new behavioral health workforce and incentives to redistribute what we have.   Our ACT practices and Sandy Blount emphasize that it is the skill set that matters to patients—not always predictable by our pedigrees.  It seems to me that there is sufficient clarity now of the skills needed in the pc setting to deliver integrated care that there could be additional certificate programs for some of them, deliverable by our country’s magnificent community college systems. 

This will range across practices from psychologists to LCSWs to addiction counselors to licensed marriage and family therapists to other master's level clinicians. The "personality fit" for integration and experience or training in integrated settings can generally predict success better than the degree itself.  Colorado developed core competencies for behavioral health clinicians working in integrated settings that may be a useful reference.

Q: What is a realistic timeframe from implementing transformation, from accepting the need to integrate and transform to planning and integrating and then actually showing results from those changes to your practice (including non-economic gains)?

Again, it depends, especially on where you start from, e.g. in terms of staff, local payment policy, EHR, burden of illness in your population.  The Westminster Clinic story shared by Scott Hammond and Caitlin Barba in Colorado=a 25 year journey.  They are confident that there is now a lot more knowledge and commitment to integrated care and their experience can dramatically shorten a journey to integration.  On the other hand, primary care practices are nothing if not pragmatic, and they will go as far as they can toward integrated care with what can be done now and in a matter of months have revised workflows that work and make a measurable improvement in their care of patients with mental, emotional and behavioral problems.  And then it not just an aphorism, integrated care is not actually a destination.  It is a way of life—a way of practice—that seems to always invite something further.

This will certainly vary across practices depending on where you start - for practices with a foundation in advanced primary care with strong team-based care and quality improvement efforts, it will likely go smoother and faster than others. Colorado was a site for the Centers for Medicaid and Medicare Innovation State Innovation Model demonstration project, with a focus on integrating behavioral health. Practices participated in 2-year cohorts and most successfully integrated care or demonstrated significant progress toward integration over that period of time (though notably with support from practice facilitators and some payer support). It's important to celebrate success early and often - this can include process improvements or patient stories that are evident even before integration is well established across the practice. 

Additional Resources:

Integrated Behavioral Health in Primary Care: Your Patients are Waiting 

From Our Practices to Yours: Key Messages for the Journey to Integrated Behavioral Health 

Additional articles from the Advancing Care Together project 

Core Competencies for Behavioral Health Providers Working in Primary Care