#integratedprimarycare

Medicare and other federally funded healthcare programs are going away from fee-for-service to Alternative Payment Models as fast as legislatively possible. https://www.gao.gov/products/gao-22-104618 But are we ready?  If you were being paid for delivering the best care, rather than for the time of your licensed professionals, how would that impact your approaches to workforce, to clinical pathways, to whether care was delivered onsite or virtually?  With a lot of new options can come a lot of uncertainty. I find myself working on that issue with leaders on primary care services in several settings these days.

This is a question that is coming up, or should be, much more these days.  For a long time, primary care behavioral health clinicians (BHCs) and specialty mental health clinicians (MHCs) were likely to work in different organizations.  Different places pay differently, nothing to discuss.  In general, medical settings have more resources than mental health settings, so there was a general pattern of higher pay in primary care.  With the rise of ACOs and the growth of multi-state private health systems, it is becoming more common for both types of clinicians to be working in the same system and so be under one payment system.  Human Resources departments see workers with the same licensure, same degrees, same disciplinary designations, and put them on the same pay scales, what’s to discuss?

By BHC, I mean clinicians who work in primary care as part of the team.  They respond the day, often at the time, a patient with BH needs is identified. They tend to address immediate issues that are barriers to the patient’s functioning. They aim to return the patient to full management by the PCP in a few contacts, while standing ready for longitudinal relationships with patients when new needs arise. 

By MHC, I mean clinicians working in a specialty mental health model, no matter what the setting, that offer psychotherapy over longer periods of time targeting specific diagnoses. 

One of my current professional joys is teaching a course called Primary Care Behavioral Health Leadership, for the many BH clinicians who have been elevated to leadership positions as the number of BHCs in their organization grew big enough to need a manager.  In our regular discussions of the BHC/MHC workforce shortage, a new pattern has emerged: BH clinicians wanting to transfer out of primary care to specialty mental health work.  The most common reason is that primary care behavioral health is much harder.  It goes faster.  They have to see more different types of patient needs.  Working on a team, communicating with team members, and making care management calls are challenging and take time.   And they are always needing ongoing training in medical issues and approaches they didn’t learn in graduate school.  Specialty mental health is easier in that it is more predictable and often has lower productivity targets.  If the pay is the same, why go through the stress of learning a new approach?

The case for differential pay is captured in this one comparison: A mental health clinician generally is ready to do the basics of the job after the training they got in graduate school.  Successful functioning as a BH clinician in primary care takes additional training and a reorientation of perspective toward teamwork.

I’m not recommending differential pay just for a different title.  There are lots of programs where the "BHC"s function like MHCs (in a room most of the day, fully scheduled with patients, seeing mostly patients with MH issues).  These programs tend to have few warm handoffs and long waiting lists with lots of no-shows.  The job description should be for true BHC functioning, and include some sort of competency standard with internal training to keep everyone learning.  In that setting, I think the differential should be applied.

If you haven’t stopped reading yet and might want to look at job descriptions below.  These are descriptions of MHC and BHC positions, with the assumption that clinicians would use the MHC either as a professional landing place and/or as a stepping stone to the BHC position. The salary differential would determine whether the latter would become a common career pathway.

Behavioral Health Clinician 1 (BHC) – Licensed – Example of job description from FM Residency clinic in Oregon.  https://www.indeed.com/q-Behavioral-Health-Consultant-jobs.html?vjk=f689e6a2a317b4dc Job Specifics

Consult and collaborate on a multidisciplinary team to provide integrated on-site care, recommendations, and feedback to medical providers and allied staff

Have a clearly distinguished role from specialty mental health therapist practice model

Maintain a schedule and a presence in a clinic session that makes access by PCPs easy.  (One metric of the BH service will be visits with patients on the same day as their PCP visits.)

Practice in a population-based practice management strategy with flexibility to be interrupted to respond to urgent/emergency situations and “curb-side consults”

Utilize brief behavioral visits (20-30 minutes), most commonly in the range of 1-6 visits, which are provided in the primary care practice area and are seen as a routine primary care service.

Provide assessments, screening, or intervention services for about 5 patients per ½ day clinic with the primary goal of assisting the primary care providers with identification, treatment, and management of mental and behavioral health concerns.

Consult on psychological distress, behavioral problems/conditions, exacerbating chronic medical conditions including chronic pain. 

Offer targeted behavioral health and patient engagement skills training to members of other disciplines and trainees.

Job Requirements            

Doctoral Level Degree (Ph.D. or Psy.D.) in clinical psychology from an APA accredited institution – Health Psychology emphasis preferred; OR LCSW training (or other master’s level license) and significant primary care BH experience.  After 1/1/24, includes LMHC and LMFT

2 to 3 years of experience in behavioral health

Expertise in working with patients who have chronic health conditions

Behavioral Health Clinician 2 (MHC) – Licensed – This role is envisioned as a transition role for clinicians who have been trained in specialty mental health work and have their only experience in specialty settings.   There would be no timetable for their advancement to BHC 1.  Some may choose to remain in a BHC 2 position while others would want to take on additional functions and demonstrate competencies for the BHC 1 role.  They would see patients who are designated for and willing to accept a therapeutic protocol for anxiety, depression, substance use, or other specified disorders.  They could function in the therapist/care manager role for the Collaborative Care Model.  BHC 2 clinicians will be expected to see 3 patients in a ½ day clinic and will be scheduled with 45 min. appointment times. 

Job Requirements            

Doctoral Level Degree (Ph.D. or Psy.D.) in clinical psychology from an APA accredited institution; OR LCSW training (or other master’s level license).  After 1/1/24, includes LMHC and LMFT

Governor Charlie Baker signed a new law on Friday designed to improve healthcare access in Massachusetts for the time of COVID and after.   This law and other requirements implemented in the 2021 budget that was supported by the administration constitute important steps toward better equity in access for low income and underserved people in the state.  These are part of what seems to be a cooperative effort with the administration and the legislature to make stepwise improvements in healthcare funding and regulation in the direction of access and quality of care.

A partial list of these improvements includes:  

Insurance companies are required to cover telehealth visits the same way they cover in person care.  This is a step that improves both access and provides a foundation for improvement in equity.

Community hospitals get enhanced payments for the services they give to Medicaid patients.  These are often the hospitals that serve a high number of low-income patients.

In addition to previous laws requiring raising insurance payment rates for behavioral health and addiction services, the current budget addresses two of the chronic barriers to providing behavioral health and addiction services in primary care.  The process of getting a psychologist or clinical social worker credentialled by the many insurance companies that cover the patients in any given primary care practice has been a deterrent for years.  All insurers will be required to use a single credentialling form.  

Insurance companies will only be able to charge one co-pay for a primary care visit that involves medical and behavior health services.  The “two co-pays for two services” that many companies have been charging effectively eliminates the ability of many patients to access behavioral health services.    Improving the addition of behavioral health services adds to clinical effectiveness and reduces overall health costs. www.integratedprimarycare.com.  In addition, it is a step in the direction of improving social justice through healthcare.

Consider the following statements:

·      Burdens of illness, for both chronic illnesses and behavioral health conditions, correlate with income.  

·      African American and Latinx populations, on average, have significantly lower incomes than whites.  This is a legacy of structural racism.

·      Equity in healthcare would require that the complexity of services offered be appropriate to the burden of illness of each patient.

·      Successful care for people with complex illness burdens requires behavioral healthcare as well as medical care.

·      Behavioral healthcare in the specialty mental health and substance abuse systems is not available to, or acceptable to, most minority patients (and others as well).  For them, it is behavioral health care in primary care or no care at all.

Many health professionals have been surprised at how their patients have taken to telemedicine. The loss of the physical presence of the doctor, at least for many, has been more than made up for by the convenience and autonomy that telemedicine offers. The challenge for the future of medical care for a large portion of the medical services that will be provided is not how to get back to face-to-face medicine, but how to utilize a broader array of our tools for caring for people through the new medium.  There are tons of start-ups trying to make cheap and convenient ways to reporting bodily functions at a distance.  Yet the most widely used form of exchanging medical information is through talking, and the most important medical channel is the relationship between the patient and the health professional.

There is one population of patients that will require us to be particularly innovative in how we use the medium of telemedicine.  It is the population of “multiply-disadvantaged” patients.[1] These are patients who, in other literatures, are called “complex” patients because of their burdens of multiple chronic illnesses and behavioral health problems.  They tend to use a disproportionate number of medical services, though in many cases those services still don’t address their needs adequately.  These patients have very high rates of trauma as children or adults.  They are likely to be “dually disadvantaged” because of their low incomes and because of the racism or bias they face as members of minorities. 

This population of people is likely to be suspicious of medical providers and to resent what they have experienced as disrespectful care.  Paradoxically, they are much more likely to follow suggestions for taking care of their health when they have developed a trusting relationship with a medical or behavioral health provider.  Evidence produced by programs that have had good outcomes serving multiply-disadvantaged patients shows that they need “high touch” care (see “High-Touch Telemedicine”) provided by high-functioning primary care teams that include a medical provider, a behavioral health clinician, and a care manager or health coach. The health coach keeps the relationship between the patient and team current, while monitoring the patient’s condition and progress.  For these patients, “patient-centered care” has been shown to be most effective when it is transparent (patients have access to all their medical information and notes) and empowering (the care focuses of the strengths of the patient) so that the patient can be a partner in developing their own care plan.  The challenge in serving this population through telemedicine is how to enact this patient-centered approach to team-based care within the limits of the medium. 

I am currently working on a project funded by the HRSA Graduate Psychology Education program through Antioch University in New England to create a video example of one patient visit that enacts team-based patient-centered care.  The product the project will be the video of the visit and an accompanying webinar that describes the ideas and principles that the video will exemplify. 

I would be interested in hearing from primary care professionals, both medical and behavioral, who feel that their setting has developed innovative ways of giving patients the experience of patient-centered care by high-functioning teams using telemedicine as the central (but not necessarily the only) means of contact between the team and each patient.  I can be contacted at ablountedd(at)gmail.com.  Also see: www.IntegratgedPrimaryCare.com

Last week I was in Charlotte, NC, for the Collaborative Family Healthcare Association conference. (Every year the best conference on integrated primary care in the nation). I presented with my colleague, C.J. Peek who is Professor of Family Medicine at the University of Minnesota Medical School.  We introduced the audience to the process and the product of the Colorado Consensus Conference, establishing core competencies for behavioral health providers working in primary care. 

Lists of core competencies for behavioral health clinicians in primary care are not new and this conference made use of all the ones we could find at the time we met.  What was new was that the list was not established by a small group of experts and then promulgated.  It was established through an iterative, many stepped email process, culminating in an all day face to face meeting, with still more refining and reviewing after the meeting.  C J and I were consultants to the group.  C J was the one who designed the process and I was an external content expert. 

The idea of competencies is a slippery concept.  It is great in that it is not dependent on specific disciplinary training.  In that sense it offers some parity.  Supposedly if you can do the job, we can tell.  If you have a fancy degree and can’t do the job, we can tell.  The problem comes when you try to get the right “altitude” to describe.  If the altitude is high, statements are general, not descriptive of behavior, and it is hard to say what each competency would look like in behavior.  If the competency is granular, very behavioral, the list of what competencies one needs to do a whole job gets very long.  Each one becomes a-contextual.  Knowing when to do what is an important skill and it is hard to show. The Colorado Competencies are 8 high altitude skills, each one consisting of several sub-areas with behavioral examples of what those areas look like behaviorally.  Have a look.

The following was copied from the APA Division 38 listserve on 7/30/15:

On July 28, 2015, Governor Kate Brown signed Senate Bill 832 into law, which takes effect immediately. This paves the way for Oregon’s communities to integrate mental health and physical health services where the patient presents for service—fulfilling the promise of real time care in patient centered primary care homes and behavioral health homes. In short, the bill:

Defines the “Behavioral Health Clinicians” that can independently provide care within these settings to include: Licensed psychologists, social workers, professional counselors and others who are able to treat mental illness within their scope of practice Interns and residents who are practicing under supervision through a Board contract working their way to licensure ·         Allows providers to use the appropriate physical, mental health or health and behavior code as the situation warrants, regardless of setting ·         Allows patient-centered primary care homes (as defined by the OHA) to bill for mental health services provided in primary care and urgent care settings, and allows behavioral health homes to bill for primary care services Defines “Integrated Care” as “care provided to individuals and their families in a patient centered primary care home or behavioral health home by licensed primary care clinicians, behavioral health clinicians and other care team members, working together to address one or more of the following: Mental illness Substance use disorders Health behaviors that contribute to chronic illness Life stressors and crises Developmental risks and conditions Stress-related physical symptoms Preventive care Ineffective patterns of health care utilization” Defines a “Behavioral Health Home” as “a mental health disorder or substance use disorder treatment organization, as defined by the Oregon Health Authority by rule, that provides integrated health care to individuals whose primary diagnoses are mental health disorders or substance use disorders.” Directs the Oregon Health Authority to prescribe by rule standards for achieving the integration of behavioral health services and physical health services in patient centered primary care homes and behavioral health homes

SB 832 is the beginning of bidirectional integration across the health system, increasing access to behavioral health care at the point where the patient presents. The full text of the new law can be found at https://olis.leg.state.or.us/liz/2015R1/Downloads/MeasureDocument/SB832/Enrolled. The Oregon Psychological Association wishes to thank chief sponsor, Senator Laurie Monnes-Anderson, for her tireless support of this bill. Without her efforts and the dedication of her staff, this new law would be just an idea.

The following was copied from the APA Division 38 listserve 7/30/15:

On July 28, 2015, Governor Kate Brown signed Senate Bill 832 into law, which takes effect immediately. This paves the way for Oregon’s communities to integrate mental health and physical health services where the patient presents for service—fulfilling the promise of real time care in patient centered primary care homes and behavioral health homes. In short, the bill:

Defines the “Behavioral Health Clinicians” that can independently provide care within these settings to include: Licensed psychologists, social workers, professional counselors and others who are able to treat mental illness within their scope of practice Interns and residents who are practicing under supervision through a Board contract working their way to licensure ·         Allows providers to use the appropriate physical, mental health or health and behavior code as the situation warrants, regardless of setting ·         Allows patient-centered primary care homes (as defined by the OHA) to bill for mental health services provided in primary care and urgent care settings, and allows behavioral health homes to bill for primary care services Defines “Integrated Care” as “care provided to individuals and their families in a patient centered primary care home or behavioral health home by licensed primary care clinicians, behavioral health clinicians and other care team members, working together to address one or more of the following: Mental illness Substance use disorders Health behaviors that contribute to chronic illness Life stressors and crises Developmental risks and conditions Stress-related physical symptoms Preventive care Ineffective patterns of health care utilization” Defines a “Behavioral Health Home” as “a mental health disorder or substance use disorder treatment organization, as defined by the Oregon Health Authority by rule, that provides integrated health care to individuals whose primary diagnoses are mental health disorders or substance use disorders.” Directs the Oregon Health Authority to prescribe by rule standards for achieving the integration of behavioral health services and physical health services in patient centered primary care homes and behavioral health homes

SB 832 is the beginning of bidirectional integration across the health system, increasing access to behavioral health care at the point where the patient presents. The full text of the new law can be found at https://olis.leg.state.or.us/liz/2015R1/Downloads/MeasureDocument/SB832/Enrolled. The Oregon Psychological Association wishes to thank chief sponsor, Senator Laurie Monnes-Anderson, for her tireless support of this bill. Without her efforts and the dedication of her staff, this new law would be just an idea.

Pretty cool, eh?