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  • 1. Blending Behaviorists into the Patient Centered Medical Home Virginia Rural Health Association Staunton, VA December 8, 2011 © 2011 Cherokee Health Systems All Rights Reserved
  • 2. Primary Care and Behavioral Health Integration An Imperative for Health Centers • Widespread acceptance of the “concept” of integration • Tantalizing outcome studies are beginning to appear• Increased appreciation of behavioral factors in chronic disease management • Diminished scope of CMHC’s • Concept of the Patient-Centered Healthcare Home © 2011 Cherokee Health Systems All Rights Reserved
  • 3. Integrated Care BusinessDevelopment: Initial Considerations • The Money • The Manpower • The Model • The Mission © 2011 Cherokee Health Systems © 2011 Cherokee Health Systems All Rights Reserved
  • 4. Our Mission… To improve the quality of life for our patients through the integration ofprimary care, behavioral health and substance abuse treatment and prevention programs. Together…Enhancing Life © 2011 Cherokee Health Systems All Rights Reserved
  • 5. Cherokee Health Systems A Federally Qualified Health Center and Community Mental Health Center Corporate Profile Founded: 1960 Services: Primary Care - Community Mental Health - Dental - School-Based Health Locations: 43 clinical locations in 12 Tennessee CountiesBehavioral health outreach at numerous other sites including primary care clinics, schools and Head Start Centers Number of Clients: 60,896 unduplicated individuals served - 25,290 Medicaid (TennCare) New Patients: 19,573 Patient Services: 475,628 Number of Employees: 567 Provider Staff:Psychologists – 45 Master’s level Clinicians - 62 Case Managers - 31Primary Care Physicians – 27 Psychiatrists - 11 Pharmacists - 8NP/PA (Primary Care) - 23 NP (Psych) - 10 Dentists - 2 © 2011 Cherokee Health Systems All Rights Reserved
  • 6. CLAIBORNE HANCOCK White Oak Tazewell New Tazewell 75 CAMPBELL Bean Station UNION GRAINGER Washburn Maynardville Rutledge Morristown HAMBLEN 25E Talbott Blaine Halls 81 Crossroads KNOX Jefferson City ANDERSON JEFFERSON Newport Knoxville COCKE 40 40 SEVIER Seymour Lenoir City LOUDON School Health Clinics BLOUNT Integrated Care Services Health Behavioral 75 Services Health Outreach Behavioral Dental Services MONROE Transitional Living Englewood FacilitiesMCMINN © 2011 Cherokee Health Systems All Rights Reserved
  • 7. Key Values Compel Safety Net Providers to Integrate Care • Increase Access • Eliminate Disparities • Ensure Patient-Centered Culture • Improve Population Health • Reduce Healthcare Costs © 2011 Cherokee Health Systems All Rights Reserved
  • 8. Primary Care in the United States: The de facto Mental Healthcare System• More mental health interventions occur in primary care than in specialty mental health settings. (Wang, et. al., 2005)• Primary care providers prescribe 70% of all psychotropic medication, including 80% of anti-depressants. (Strosahl, 2001)• Over one-third of the patients in most primary practices have a psychiatric disorder. (Spitzer, et. al., 1994; Mauksch, et. al., 2001) © 2011 Cherokee Health Systems All Rights Reserved
  • 9. Primary Care IS Behavioral Healthcare• Psychological distress drives primary care utilization.• A variety of studies have concluded that 70% of all healthcare visits have primarily a psychosocial basis. (Strosahl, 1998; Fries, et. al., 1993; Shapiro, et. al., 1985)• Every primary care presentation has a behavioral component.• The highest utilizers of healthcare commonly have untreated/unresolved behavioral health needs. (Von Korff, et. al., 1992; Katon, et. al., 2003) © 2011 Cherokee Health Systems All Rights Reserved
  • 10. A Few Nagging Questions About Integration • What is it? • How do we do it? • Who can do it? • How do we pay for it? • What are the results? © 2011 Cherokee Health Systems All Rights Reserved
  • 11. © 2011 Cherokee Health Systems All Rights Reserved
  • 12. Primary and Behavioral Health Care Integration Strategies in Search of a Model • Preferential Referral Relationship • Formalized Screening Procedures • Circuit Riding • Co-Location of Services • Disease Management • Behaviorist on Primary Care Team © 2011 Cherokee Health Systems All Rights Reserved
  • 13. Integration vs. Co-LocationIntegrated Care Co-Located Mental Health• Embedded member of • Ancillary service provider primary care team• Patient contact via hand off • Patient contact via referral• Verbal communication • Written communication predominate predominate• Brief, aperiodic interventions • Regular schedule of sessions• Flexible schedule • Fixed schedule• Generalist orientation • Specialty orientation• Behavior medicine scope • Psychiatric disorders scope © 2011 Cherokee Health Systems All Rights Reserved
  • 14. The Behavioral Health Consultant in Primary CareCharacteristics, Skills and Orientation to Practice Characteristics • Flexible, high energy level • Team Player • Interest in health and fitness Skills • Finely honed clinical assessment skills • Behavioral medicine knowledge base • Cognitive behavioral intervention skills © 2011 Cherokee Health Systems All Rights Reserved
  • 15. The Behavioral Health Consultant in Primary CareCharacteristics, Skills and Orientation to Practice Orientation to Practice • Action-oriented, directive, focus on patient functioning • Emphasis on prevention and building resiliency • Utilizes clinical protocols and pathways • Invested in educating patients, health literacy © 2011 Cherokee Health Systems All Rights Reserved
  • 16. Payment Disincentives for Behaviorists Practicing in Healthcare Homes • Mental health carve-outs • Excessive documentation requirements • Encounter-based reimbursement • Same day billing prohibition • Antiquated coding requirements © 2011 Cherokee Health Systems All Rights Reserved
  • 17. Financing Structure for Integration of BHCs into Healthcare Homes• Health and Behavior Assessment/Intervention CPT Codes 96150-55 • Same day billing by PCP and BHC • Valuing consultation and case coordination • Global funding streams • Value-based contracting © 2011 Cherokee Health Systems All Rights Reserved
  • 18. Integrated Care Standards• Weekly multidisciplinary care team meeting• Behavioral health provider embedded on primary care team• Real-time psychiatric consultation available• Behavioral health screening of primary care patient• Integrated clinical record & treatment plan• Teleconference capability to import providers, as needed © 2011 Cherokee Health Systems All Rights Reserved
  • 19. Fostering the Informed and Activated Patient• Assess readiness to change.• Mutually establish behavioral goals and behavior change strategies.• Employ motivational interviewing and problem focused interventions.• Support patient self-management and self-regulation skills.• Foster resiliency and personal responsibility for health. © 2011 Cherokee Health Systems All Rights Reserved
  • 20. Cherokee’s Patient-Centered Healthcare Home• Embedded Behavioral Health Consultant on the Primary Care Team• Real time behavioral and psychiatric consultation available to PCP • Focused behavioral intervention in primary care • Behavioral medicine scope of practice • Encourage patient responsibility for healthful living • A behaviorally enhanced Healthcare Home © 2011 Cherokee Health Systems All Rights Reserved
  • 21. Contact Information: Bob Franko, MBAVP, National Training Coordinator Bob.Franko@Cherokeehealth.com Cherokee Health Systems 2018 Western Avenue Knoxville, Tennessee 37921 Phone: (865) 934-6725 © 2011 Cherokee Health Systems All Rights Reserved