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Affordable Care Act (ACA)

Implications for Clinical Mental Health Professionals

Behavioral Medicine for Mental Health Professionals

A Training Resource

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T

On April 8, 2016 in a FMHCA Webinar and on February 5, 2016 at the Florida Mental Health Counselors Association Annual Conference the following Presentation was presented to encourage the counselors in Florida to become more involved in advocating for CMHC's to become engaged as Behavioral Health Consultants in the PCMH's and ACO's in their State. You can watch this webinar on YouTube on the FMHCA Channel at:
On December 4, 2015 the following PowerPoint was presented to help the Michigan Mental Health Counselor to encourage counselors to get on board with the movement towards Integrated Medicine involving mental health counselors.
Three Programs Presented at The 2014 American Mental Health Counselors Association

What is the Official Name of the ObamaCare?

Official name for "ObamaCare" is the Patient Protection and Affordable Care Act (PPACA).

It is also commonly referred to as Obama care, health care reform, or the Affordable Care Act (ACA).

How many have signed up for ACA?


USA: 28,605,000

Florida: 2,545,000

Selected a Plan in Marketplace as of April 19, 2014

USA: 8,019,763   Percentage of Eligible: 28%

Florida: 983,775  Percentage of Eligible: 38.70%

Based on data from Health Insurance Marketplace: February Enrollment Report, October 1, 2013 - April 19, 2014. Office of the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS); February 12, 2014 and State-by-State Estimates of the Number of People Eligible for Premium Tax Credits Under the Affordable Care Act, Kaiser Family Foundation, November 5, 2013 You can get updated date on enrollments at:

So How Much Do American’s Know about the ACA?

In January 2014, the Kaiser Health Tracking Poll found that even after most of the ACA’s major provisions took effect on January 1, a large majority of the public (62 percent) continues to believe that only “some” provisions of the ACA have been put into place thus far. Only about one in five (19 percent) say “most” or “all” provisions have been implemented. To see this poll go to:

Majority are still negative about ACA but want it improved

Views of the law overall remained more negative than positive in January 2014, with 50 percent saying they have an unfavorable view & 34 percent favorable, almost identical to the split in opinion since November 2013. Still, more than half the public overall, including three in ten of those who view the law unfavorably, say opponents should accept that it’s the law of the land and work to improve it, while fewer than four in ten want opponents to keep up the repeal fight. 

When did the ACA become law?

The ACA was signed into law to reform the health care industry by President Barack Obama on March 23, 2010 & upheld by the Supreme Court on June 28, 2012

  • The ACA is "the law of the land“
  • Although many people would like to see it repealed
  • Many people had wanted it to be repealed but most are now willing to accept it & refine it

What is the Goal of the ACA?

ACA's goal is to 

  1. give more Americans access to affordable, quality health insurance
  2. to reduce the growth in health care spending in the U.S. 

What does the ACA do?

ACA expands the 

  • affordability
  • quality
  • availability of private & public health insurance 
  • consumer protections
  • regulations
  • subsidies
  • taxes
  • insurance exchanges
  • other reforms.
It does not 
  • replace private insurance, Medicare or Medicaid
  • regulate health care
It does
  • Regulate health insurance & some of the worst practices of the for-profit health care industry

What’s the Individual Mandate?

Most Americans will have to buy insurance by 2014 (or later based on new procedural delays put into place.

  • Exempted are those covered by: Medicaid, CHIP (Children’s Medicaid Program), Medicare, TRICARE & COBRA

The rest have the option to

  • buy private insurance
  • obtain insurance through the workplace
  • pay a small tax to not have health insurance (mandate)
  • buy private insurance through State Health Insurance Exchanges or National Health Exchange like in Florida

How are seniors affected by the ACA?

Seniors greatly benefit from the $716 billion of wasteful spending cut from Medicare & closing of the donut hole

Money saved is being reinvested in Medicare & ACA to improve coverage & insure tens of millions of more seniors. Medicare parts A, B, C and D have all been changed almost all for the better

What are the behavioral health requirements on hospitals?

  • ACA’s new Medicare Value-Based Purchasing Program means hospitals can lose or gain up to 1% of Medicare funding based on a quality vs. quantity system
  • Hospitals are graded on a number of quality measures related to treatment of patients with heart attacks, heart failures, pneumonia, certain surgical issues, re-admittance rate, as well as patient satisfaction

What are some rights and protections coming from the ACA?

  • Better access to preventive services
  • Expanded coverage to millions saving countless lives
  • Ensures people can't be denied for preexisting conditions
  • Stops insurance companies from dropping people when they are sick
  • Lets young adults stay on parents plans until 26
  • Regulates insurance premium hikes
  • Monitors & approves appeals process

What are some of the changes in the ACA regulations since its roll out in Fall 2013?

  • Deadline extended for individuals to March 31, 2014
  • Those who lost their insurance have until 2015 to get catastrophic coverage or keep sub-minimum plans if still offered by their insurance companites
  • Full-time workers who work for companies with 50-99 employees must be offered job based health coverage by 2016.
  • Large Businesses with 100 or more employees have until 2015 to have 70% of their employees covered instead of 95% covered

State Health Insurance Exchanges and the Federal Marketplaces

ACA exchanges are state or federal run (depends on the state) online marketplaces where health insurance companies compete to be people’s providers.

Getting insurance through the marketplace is done by applying for a plan, finding out if one qualifies for subsidies & then comparing competing health plans

A State's "Exchange" is commonly referred to as "Health Insurance Marketplace“

ACA offers New Benefits, Rights & Protections

  1. Provision that let young adults stay on their families’ plans until 26
  2. Stops insurance companies from dropping people when they are sick or if they make an honest mistake on their application
  3. Prevents against gender discrimination
  4. Stops insurance companies from making unjustified rate hikes
  5. Does away with life-time & annual limits
  6. Give people the right to a rapid appeal of insurance company decisions
  7. Expands coverage to tens of millions
  8. Subsidizes health insurance costs
  9. Requires all insurers to cover people with pre-existing conditions 

10 Essential Health Benefits Guaranteed by ACA

  1. Ambulatory Patient Care
  2. Emergency Care
  3. Hospitalization
  4. Prescription Drugs
  5. Maternity & Newborn Care
  6. Mental Health Services & Addiction Treatment
  7. Rehabilitative Services & Devices
  8. Laboratory Services
  9. Preventive services, wellness services & Chronic  Disease Treatment
  10. Pediatric Services

Essential Health Benefits Guaranteed by ACA & Behavioral Medicine will be on Parity with Physical Medicine

The 2008 Mental Health Parity and Addictions Equity Act applies to individual plans as well as small group plans 

This provision was inserted into the ACA law as an amendment by Senator Debbie Stabenow (D-MI) during the health reform debate and was implemented in Spring 2014

Adult Prevention Services Guaranteed by the ACA

  1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  2. *Alcohol Misuse screening and counseling
  3. Aspirin use to prevent cardiovascular disease for men and women of certain ages
  4. *Blood Pressure screening for all adults
  5. Cholesterol screening for adults of certain ages or at higher risk
  6. *Colorectal Cancer screening for adults over 50
  7. *Depression screening for adults
  8. *Diabetes (Type 2) screening for adults with high blood pressure
  9. *Diet counseling for adults at higher risk for chronic disease
  10. *HIV screening for everyone ages 15 to 65, and other ages at increased risk
  11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:Hepatitis A; Hepatitis B; Herpes Zoster; Human Papillomavirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diphtheria, Pertussis & Varicella
  12. *Obesity screening and counseling for all adults
  13. *Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  14. *Syphilis screening for all adults at higher risk
  15. *Tobacco Use screening for all adults and cessation interventions for tobacco users

*Opportunities for Mental Health Practitioners to provide behavioral medicine interventions

Women’s Preventative Services Guaranteed by the ACA

  1. Anemia screening on a routine basis for pregnant women
  2. *Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer
  3. *Breast Cancer Mammography screenings every 1 to 2 years for women over 40
  4. *Breast Cancer Chemoprevention counseling for women at higher risk
  5. *Breastfeeding comprehensive support and counseling from trained providers, and access to breast feeding supplies, for pregnant and nursing women
  6. *Cervical Cancer screening for sexually active women
  7. *Chlamydia Infection screening for younger women and other women at higher risk
  8. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs).
  9. This does not apply to health plans sponsored by certain exempt “religious employers.”
  10. *Domestic and interpersonal violence screening and counseling for all women
  11. Folic Acid supplements for women who may become pregnant
  12. *Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
  13. *Gonorrhea screening for all women at higher risk
  14. *Hepatitis B screening for pregnant women at their first prenatal visit
  15. *HIV screening and counseling for sexually active women
  16. *Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older
  17. Osteoporosis screening for women over age 60 depending on risk factors
  18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  19. *Sexually Transmitted Infections counseling for sexually active women
  20. Syphilis screening for all pregnant women or other women at increased risk
  21. *Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  22. Urinary tract or other infection screening for pregnant women
  23. Well-woman visits to get recommended services for women under 65

*Opportunities for Mental Health Practitioners to provide behavioral medicine interventions

Children’s Preventative Services Guaranteed by the ACA

  1. *Autism screening for children at 18 and 24 months
  2. *Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  3. Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years.
  4. Cervical Dysplasia screening for sexually active females
  5. *Depression screening for adolescents
  6. *Developmental screening for children under age 3
  7. Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  8. Fluoride Chemoprevention supplements for children without fluoride in their water source
  9. Gonorrhea preventive medication for the eyes of all newborns
  10. Hearing screening for all newborns
  11. *Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
  12. Hematocrit or Hemoglobin screening for children
  13. Hemoglobinopathies or sickle cell screening for newborns
  14. HIV screening for adolescents at higher risk **Hypothyroidism screening for newborns
  15. Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis; Haemophilus influenza type b; Hepatitis A; Hepatitis B; Human Papillomavirus; Inactivated Poliovirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal;
  16. Pneumococcal; Rotavirus; Varicella
  17. Iron supplements for children ages 6 to 12 months at risk for anemia
  18. Lead screening for children at risk of exposure
  19. Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years ,11 to 14 years , 15 to 17 years.
  20. *Obesity screening and counseling
  21. Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
  22. Phenylketonuria (PKU) screening for this genetic disorder in newborns
  23. *Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
  24. Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years,11 to 14 years, 15 to 17 years.
  25. Vision screening for all children.

*Opportunities for Mental Health Practitioners to provide behavioral medicine interventions

Implications of the ACA for Mental Health Practitioners

The emerging health needs of Americans is changing and as a result the roles and function of mental health practitioners will be changing as well due to the Affordable Care Act

The Implications of the Affordable Care Behavioral Medicine Interventions

1. ACA calls for the coordination and integration of medical services through the primary care provider for a “whole person orientation” to medical treatment - model currently implemented at some level in VA & Federally Qualified Health Centers (FQHC’s)

2. The ACA calls for creation of Affordable Care Organizations (ACO’s) to provide comprehensive services to Medicare recipients with a strong primary care basis

3. The ACA model includes integration of mental & behavioral health services into the Patient-centered medical home (PCMH) which can enhance patient outcomes

4. The ACA model integrates mental, behavioral and medical services under one roof with potential of controlling the costs for patients

5. The ACA integrated behavioral medical approach opens a massive opportunity for clinical mental health practitioners

6. To be prepared to fill this evolving behavioral medicine role, it is imperative that clinical mental health counseling training    programs establish training for future practitioners in these integrated medical settings.

7. Beginning 2014 ACA increased access to quality health care including coverage for mental health & substance use disorder services

8. All new small group & individual private market plans are required to cover mental health & substance use disorder services as part of the health care law's “Essential Health Benefits” categories

9. Behavioral health benefits are covered at parity with medical & surgical benefits

10. Insurers will no longer be able to deny anyone coverage because of a pre-existing medical or behavioral health condition

11. ACA ensures that new health plans cover recommended preventive benefits without cost sharing, including depression screening for adults & adolescents as well as behavioral assessments for children

Additional Results of the ACA

1. Primary care providers receive 10% Medicare bonus payment for primary care services

2. A new Medicaid state option was created to permit certain Medicaid enrollees to designate a provider as a health home & states taking up the option receive 90% federal matching payments for two years for health home-related services. [Unfortunately Florida did not accept this Medicaid State Option]

3. Small employers receive grants for up to five years to establish wellness programs

4. The Center for Medicare & Medicaid Innovation launches the Accountable Care Organization (ACO) Model & Advance Payment ACO Model, which offers shared savings & other payment incentives for selected organizations that provide efficient, coordinated, patient-centered care

5. Some States established American Health Benefit Exchanges & Small Business Health Options Program Exchanges to facilitate purchase of insurance by individuals & small employers

6. Teaching Health Centers are established to provide payments for primary care residency programs in community-based ambulatory patient care centers

Two Healthcare Organizational Models which are Driving Change

Two New Medicare/Medicaid models are driving a change in healthcare delivery:

  1. Patient Centered Medical Homes (PCMH)
  2. Accountable Care Organizations (ACO’s)

History of the Patient Centered Medical Home Model

The patient-centered medical home is not a new concept it has evolved to define a model of primary care excellence

1967: “Medical Home” first use in 1967 by the American Academy of Pediatrics

1978: The World Health Organization support principle of primary care

1996: The Institute of Medicine (IOM) redefined primary care close to PCMH model

2002: Family Medicine promotes Medical Homes

2005: Research on Primary Care promotes PCMH concepts

2006: (A) American College of Physicians adopts Patient Center Physician Guided model of health care (B) Patient Centered Primary Care Collaboration (PCPCC) is founded

2007: Major Primary Care Physician Associations endorse joint Principles of Patient-Centered Medical Home

2008: Medical Home accreditation began and 65 community health centers in five state transform into PCMH

2010: ACA includes numerous provisions for enhancing primary care and medical homes

2011: (A) Primary care providers receive a 10% Medicare bonus payment for primary care services. (B) new Medicaid state option is created to permit certain Medicaid enrollees to designate a provider as a health home (C) Small employers receive grants for up to five years to establish wellness programs. (D)The CMHO launches the Pioneer Accountable Care Organization (ACO) Model and Advance Payment ACO Model (E) States begin establishing of American Health Benefit Exchanges and Small Business Health Options Program Exchanges, which facilitate the purchase of insurance by individuals and small employers. (F) Teaching Health Centers are established to provide payments for primary care residency programs in community-based ambulatory patient care centers.

2012: 47 states had adopted policies and programs to advance the medical home

2013: Thanks to ACA (A) some states now operate their own health insurance marketplaces(B) Providers receive 1% point increase in federal matching payments for preventive services (C) Essential Health Benefits in health insurance marketplaces include prevention, wellness and chronic disease management

Patient Centered Medical Homes Objectives are

1. Patient Centered - Empowers patients with Information and Understanding

2. Comprehensive - Co-location of care providers in physical and behavioral health

3. Coordinated Care - Through Health Information Technology all providers are kept in touch

4. Accessible – same day appointment & 24/7 availability through technology online

5. Committed to Quality & Safety – Quality Improvement Goals which are tracked

Benefits of Patient Centered Medical Homes

1. Patients seek out the right care which is needed-which is often behavioral vs. physical

2. Less use of ER’s or delays in seeking care

3. Less duplication of tests, labs & procedures

4. Better control of chronic diseases & other illnesses improving health outcomes

5. Focus on wellness & prevention – reduce incidence & severity of chronic disease or illnesses

6. Cost savings less use of ER’s & Hospitals

What is moving the Patient Centered Home Health Model

In April 2013 the Patient-Centered Primary Care Collaborative Pointed out on it website these factors driving the Home Health Model

1. Unsustainable cost increases in health care delivery

2. Growing availability of data

3. Vast change in the way we communicate

Example: In Denmark, more than 80 percent of health-care encounters & transactions are electronically based & vastly different method of communicating is coming online and it is coming fast, driven by younger generations of patients and physicians.

Accountable Care Organizations

Have a look at the CMS video which overviews the ACO model at:

Goal of an ACO

The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

What are ACO’s

1. ACO assumes financial risk rather than 3rd party payers (government, business or insurance companies) for group of patients assigned to it

2. Consists of more than one hospital & number of primary care clinics with full array of medical & health specialists-who self-refer to their own specialists

3. Control costs by being responsible for full care of patients

4. Integration of mental & behavioral health services into Patient-centered medical homes

5. Enhance patient outcomes through emphasis on prevention, compliance, and immediate 24/7 attention

6. Utilize an integrated behavioral medical approach

Implications of ACA for Clinical Mental Health Counselors

Potential Roles for Mental Health Practitioners thanks to ACA

1. Conduct Depression, Anxiety & MH Assessments

2. Address the stressors which lead folks to seek out medical attention in the first place

3. Assist in increasing compliance of patients with the medical directives given them by primary care staff

4. Wellness educational programming to help ward off chronic or severe illnesses

5. Assisting clients to cope with the medical conditions for which they are receiving medical attention

AMHCA’s 2011 Expanded Clinical Standards for Training of CMHC’s include these ACA related Factors

1. Evidenced-Based Practices

Diagnosis and Treatment Planning using EBP’s

Diagnosis of Co-Occurring Disorders & Trauma

2. Biological Basis of Behaviors

Knowledge of Central Nervous System

Lifespan Plasticity of the Brain

3. Psychopharmacology

4. Behavioral Medicine

Neurobiology of Thinking, Emotion & Memory

Neurobiology of mental health disorders (mood, anxiety, psychosis) over life span

Promotion of optimal mental health over the lifespan

Potential Clinical Setting Openings for CMHC’s with full ACA Implementation

Clinical Mental Health Counselors will be ideally situated to provide Behavioral Medical Interventions based on their expanded training and implementation of AMHCA’s Clinical Standards. They will then need to promote themselves in the following settings:

  • PCMH’s and ACO’s
  • General Practice: Family Practice & Internal Medicine Clinics
  • Rehabilitation In-patient and out-patient Centers
  • General and Specialized Hospitals
  • Senior Citizen’s Independent housing, Assisted Living & Nursing Homes

What Competencies Do Mental Health Professionals Need to Become Members of Integrated Medical Teams under the Affordable Care Act (ACA) Guidelines?

What is needed to improve an integrated Primary Care Model with Behavioral Care?

The American Hospital Association (AHA) recommendations for Workforce Roles in a Redesigned Primary Care Model in 2013 on their website.

Their overall recommendations for all health care professional workforce is:

       They need to be educated within the context of inter-disciplinary clinical learning teams.

Their overall recommendation a Primary Care Delivery Model is:

  1. Primary health care should be centered around the patient and family in a user-driven design, in all aspects of practice.
  2. Hospitals should evolve from traditional “hospitals” to “health systems,” partnering with community organizations and patients in order to advance the community’s wellness and health needs.
  3. Hospitals, or health systems, can serve as catalysts for linking and integrating the various components of health and wellness together for patients in a way that provides a sustainable infrastructure of health care for patients and the community.
  4. In order to mitigate rising health care costs, a fundamental shift in reimbursement will need to occur


You can read their entire report at:


Need to integrate Behavioral Care into Primary Health Care

In 2012, the American Hospital Association (AHA) in its TrendWatch posted this article: Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes. In this article they pointed out that many providers already are working with private payers to meet the goals of integration of behavioral health care services into the broader health care continuum to obtain a positive impact on quality, costs and outcomes. These initiatives span value-based purchasing, accountable care organizations, patient-centered medical homes, and efforts to reduce readmissions.

These initiatives the ACH believes will have important implications for the delivery of behavioral health care. They state that as the demand for behavioral health services is likely to continue to outstrip capacity, improving care integration can help to better manage this need.


You can read this entire article on the AHA website at:


What is the Federal Standard for Integrated Medical Care?

SAMHSA put out these guideline for integrated medical care: A Standard Framework for Levels of Integrated Healthcare in April 2013.

They point out that there are three distinct levels of integrated care:


Coordinated Care

Level 1 – Minimal Collaboration

Behavioral health and primary care providers work at separate facilities and have separate systems. Providers communicate rarely about cases. When communication occurs, it is usually based on a particular provider’s need for specific information about a mutual patient.

Level 2- Basic Collaboration at a Distance

Behavioral health and primary care providers maintain separate facilities and separate systems. Providers view each other as resources and communicate periodically about shared patients. These communications are typically driven by specific issues. For example, a primary care physician may request copy of a psychiatric evaluation to know if there is a confirmed psychiatric diagnosis. Behavioral health is most often viewed as specialty care.


Co-Located Care

Level 3 – Basic Collaboration Onsite

Behavioral health and primary care providers co-located in the same facility, but may or may not share the same practice space. Providers still use separate systems, but communication becomes more regular due to close proximity, especially by phone or email, with an occasional meeting to discuss shared patients. Movement of patients between practices ismost often through a referral process that has a higher likelihood of success because the practices are in the same location. Providers may feel like they are part of a larger team, but the team and how it operates are not clearly defined, leaving most decisions about patient care to be done independently by individual providers.

Level 4 — Close Collaboration with Some System Integration

There is closer collaboration among primary care and behavioral healthcare providers due to colocation in the same practice space, and there is the beginning of integration in care through some shared systems. A typical model may involve a primary care setting embedding a behavioral health provider. In an embedded practice, the primary care front desk schedules all appointments and the behavioral health provider has access and enters notes in the medical record. Often, complex patients with multiple healthcare issues drive the need for consultation, which is done through personal communication. As professionals have more opportunity to share patients, they have a better basic understanding of each other’s roles.


Integrated Care

Level 5 — Close Collaboration Approaching an Integrated Practice

There are high levels of collaboration and integration between behavioral and primary care providers. The providers begin to function as a true team, with frequent personal communication. The team actively seeks system solutions as they recognize barriers to care integration for a broader range of patients. However, some issues, like the availability of an integrated medical record, may not be readily resolved. Providers understand the different roles team members need to play and they have started to change their practice and the structure of care to better achieve patient goals.

Level 6 — Full Collaboration in a Transformed/Merged Practice

The highest level of integration involves the greatest amount of practice change. Fuller collaboration between providers has allowed antecedent system cultures (whether from two separate systems or from one evolving system) to blur into a single transformed or merged practice. Providers and patients view the operation as a single health system treating the whole person. The principle of treating the whole person is applied to all patients, not just targeted groups.


SAMHSA implies that the level 6 model is the ultimate goal of the ACA and other reforms in the Medicare-Medicaid Health Delivery Systems. However they stated: Even if health outcomes improve as levels of integration increase, it is not practical to believe that every healthcare setting will be able, at least in the near term, to implement increasing levels of integration. Many integrated implementations will be constrained by community politics, trust between organizational systems, financing, and/or differing service values.


You can read the entire manual on the SAMHSA website at: 

which is located on their webpage on integrated health care models at::



Self-Assessment of Your Personal Competencies to Function in an Integrated Medicine Setting


BI-CAT (Robinson, 2013) Downloadable at:

This self-assessment helps you to determine your functioning in the following areas:

1. Practice Context

2. Intervention Design

3. Intervention Delivery

4. Outcome-Based Practice


Primary Care Behavioral Health Toolkit (Mountainview Consulting Group, 2013)

This manual provides both institutional and individual practitioner self-assesments as to their readiness for integrated primary care behavioral health. You can download this kit at:


What is the Role of a Behavioral Health Care Provider?

You will learn about what competencies are needed by Behavioral Care Professionals within an Integrated Primary Care Program by use of the Primary Care Behavioral Health Toolkit available at:  This is a must document for those who intend on working within an integrated health system.

This manual presents the keep Principles of an Integrated Model

Principle #1:

The Behavioral Health Consultant’s role is to identify, treat, triage, and manage primary care patients with medical and/or behavioral health problems.

Principle #2:

The Behavioral Health Consultant functions as a core member of the primary care team, providing consultative services.

Principle #3:

The Primary Care Behavioral Health Model is grounded in a population-based care philosophy.

Principle #4:

The Behavioral Health Consultant seeks to enhance delivery of behavioral health services at the primary care level and works to support a smooth interface between primary care and specialty services (Mental Health and Substance Abuse Treatment).


Responsibilities of Behavioral Health Consultants

The Behavioral Health Consultant in the Primary Care Behavioral Health (PCBH) has the following role. The BHC role is a behavioral health provider who:

1) Operates in a consultative role within a primary care team utilizing the PCBH Model

2) Provides recommendations regarding behavioral interventions to the referring Primary Care Clinician (PCC)

3) Conducts brief interventions with referred patients on behalf of the referring Primary Care Clinician PCC.

The Toolkit identifies the responsibilities of Behavioral Health Consultants as:

The BHC responsibilities include the following:

1. Maintains a visible presence to the PCCs during clinic operating hours.

2. Is available for “curbside” consultation (a brief interaction between the PCB

and a PCC) by being in the clinic or available by phone or pager.

3. Is available for same day and scheduled initial consultations with patients referred by PCCs.

4. Performs brief, limited follow-up visits for selected patients

5. Provides a range of services including screening for common conditions, assessments, and interventions related to chronic disease management programs.

6. Conducts risk assessments, as indicated.

7. Provides psycho-education for patients during individual and group visits.

8. Assists in the development of clinical pathway programs, group medical appointments, classes, and behavior focused practice protocols.

9. Maintains an up-to-date library of patient education materials for commonly seen problems.

10. Identifies, reviews, and modifies educational materials for literacy level and cultural appropriateness under the supervision of the PCBH Supervisor.

11. Provides brief behavioral and cognitive behavioral interventions for patients

12. Triages patients with severe or high-risk behavioral problems to CBHS or other community resources for specialty MH services consistent with Step-up/Step-down criteria.

13. Provides PCCs with same-day verbal feedback on client encounters either in person or by phone.

14. Facilitates and oversees referrals to specialty MH / SA services, and when appropriate, support a smooth transition from specialty MH / SA services to primary care.

15. Presents the PCBH model to private and public programs and agencies, in order to establish effective linkages and resources.

16. Prepares brief consultant notes for the medical chart that explain assessment findings, interventions delivered, and recommendations made to the PCC.

17. Maintains clinical records and other necessary paperwork in a timely manner to comply with all administrative regulations.

18. Educates PCCs in the basic principles of brief behavioral and cognitive behavioral interventions and reinforce their use in the medical visit.

19. Supports collaboration of PCCs and psychiatrists concerning medication protocols.

20. Provides assistance in capturing program evaluation and fidelity measures.

21. Attends clinic meetings, including all staff, PCC, Clinic Leadership, and Clinic

PCBH Committee meetings as requested by Clinic Site Director and or PCBH

Program Supervisor.

22. In primary care clinics with two or more BHCs, one BHC may be designated as the BHC Lead. The Clinic Site Director may appoint the lead; otherwise it will be based on seniority. A small amount of the BHC Lead’s time may be shifted from clinical activities to administrative activities and attending meetings.

Read more about within the Primary Care Behavioral Health Toolkit available at:

Importance of Behavioral Medicine Under the ACA


An Integrated Behavioral Medicine Specialty Focus is in the new DSM-5

The DSM-5 identified a number of medical conditions which co-occur with mental health disorders. Some of examples of them are:

  • Neurocognitive Disorders
  • Hormonal Imbalances
  • Cardiovascular Health Conditions
  • Respiratory Difficulties
  • Chronic Health Conditions
  • Cancers: Bladder, Breast, Colon, Rectal, Uterine-Ovarian, Kidney, Leukemia, Lung, Melanoma, Non-Hodgkin Lymphoma, Pancreatic, Prostate, Thyroid


Rule of Thumb in Diagnosing a Mental Health Disorder due to a Medical Condition

First: Put in the ICD code for the Medical Condition

Second: Put in the mental health disorder related to the Medical Condition


Co-Occurring Mental Health Disorders with Medical Conditions

Schizophrenia & Psychotic Disorder Co-occurring with Medical Condition

293.81 (F06.2) Psychotic Disorder due to Another Medical Condition with delusions

293.82 (F06.0) Psychotic Disorder due to Another Medical Condition with hallucinations

293.89 (F06.1) Catatonic Disorder Associated with Another Medical Condition

293.89 (F06.1) Catatonic Disorder Due to Another Medical Condition


Bipolar Disorder Co-occurring with Medical Condition

293.83 (F06.33) Bipolar and Related Disorder due to Another Medical Condition with manic features

293.83 (F06.33) Bipolar and Related Disorder due to Another Medical Condition with manic-or hypomanic-like episode

293.83 (F06.34) Bipolar and Related Disorder due to Another Medical Condition with mixed features


Depressive Disorder Co-occurring with Medical Condition

293.83 (F06.31) Depressive Disorder Due to Another Medical Condition with depressive features

293.83 (F06.32) Depressive Disorder Due to Another Medical Condition with major depressive-like episodes

293.83 (F06.34) Depressive Disorder Due to Another Medical Condition with mixed features


Anxiety Disorder Co-occurring with Medical Condition

293.84 (F06.4) Anxiety Disorder Due to Another Medical Condition


Obsessive-Compulsive Disorder Co-occurring with Medical Condition

294.8 (F06.8) Obsessive-Compulsive and Related Disorder Due to Another Medical Condition

Specify if with obsessive-compulsive-disorder-like symptoms or with appearance preoccupation or with hoarding symptoms or with hair-pulling symptoms or with skin picking symptoms


Somatic Symptom & Related Disorders

300.82 (F45.1) Somatic Symptom Disorder

300.7 (F45.21) Illness Anxiety Disorder Conversion Disorders (Functional Neurological Symptoms Disorder)

300.11 (F44.4) Conversion Disorder with weakness or paralysis

300.11 (F44.4) Conversion Disorder with abnormal movement

300.11 (F44.4) Conversion Disorder with swallowing symptoms

300.11 (F44.4) Conversion Disorder with speech symptoms

300.11 (F44.5) Conversion Disorder with attacks or seizures

300.11 (F44.6) Conversion Disorder with anesthesia or sensory loss

300.11 (F44.6) Conversion Disorder with special sensory symptom

300.11 (F44.7) Conversion Disorder with mixed symptoms

316 (F54) Psychological Factors Affecting Medical Condition

300.19 (F68.10) Factitious Disorder (includes Factitious Disorder Imposed on Self, Factitious Disorder imposed on Another)

300.89 (F45.8) Other Specified Somatic Symptom and Related Disorder

300.82 (F45.9) Unspecified Somatic Symptom and Related Disorder


Feeding and Eating Disorders

307.52 (F98.3) Pica in Children

307.52 (F50.8) Pica in Adults

307.53 (98.21) Rumination Disorder

307.59 (50.8) Avoidant/Restrictive Food Intake Disorder

307.1 (F50.01) Anorexia Nervosa Restricting type

307.1 (F50.02) Anorexia Nervosa Binge-eating/purging type

307.51 (F50.2) Bulimia Nervosa

307.59 (F50.8) Other Specified Feeding or Eating Disorder

307.50 (F50.9) Unspecified Feeding or Eating Disorder


Elimination Disorders

307.6 (F98.0) Enuresis

307.7 (F98.1) Encopresis

788.39 (N39.498) Other Specified Elimination Disorder with urinary symptoms

787.60 (R15.9) Other Specified Elimination Disorder with fecal symptoms

788.30 (R32) Unspecified Elimination Disorder with urinary symptoms

787.60 (R15.9) Unspecified Elimination Disorder with fecal symptoms


Sleep Wake Disorders

780.52 (G47.00) Insomnia Disorder

780.54 (G47.10) Hypersomnolence Disorder

347.00 (G47.419) Narcolepsy without Cataplexy but with hypocretin deficiency

347.01 (G47.411) Narcolepsy with Cataplexy but without hypocretin deficiency

347.00 (G47.419) Autosomal dominant cerebellar ataxia, deafness, and narcolepsy

347.00 (G47.419) Autosomal dominant narcolepsy, obesity and type 2 diabetes

347.10 (47.429) Narcolepsy secondary to another medical condition

Breathing-Related Sleep Disorders

327.23 (G47.33) Obstructive Sleep Apnea Hypopnea

Central Sleep Apnea

327.21 (G47.31) Idiopathic Sleep Apnea

786.04 (R06.3) Cheyne-Stokes Breathing

780.57 (G47.37) Central Sleep Apnea comorbid with opioid use (first code opioid use disorder if present.)

Sleep-Related Hyperventilation

327.24 (G47.34) Idiopathic hypoventilation

327.25 (G47.35) Congenital central aveolar hypoventilation

327.26 (G47.36) Comorbid sleep-related hypoventilation

Circadian Rhythm Sleep-Wake Disorders

307.45 (G47.21) Circadian Rhythm Sleep-Wake Disorder Delayed sleep phase type

307.45 (G47.22) Circadian Rhythm Sleep-Wake Disorder Advanced sleep phase type

307.45 (G47.23) Circadian Rhythm Sleep-Wake Disorder Irregular sleep-wake type

307.45 (G47.24) Circadian Rhythm Sleep-Wake Disorder Non-24 hour sleep-wake type

307.45 (G47.26) Circadian Rhythm Sleep-Wake Disorder Shift Work type


307.46 (F51.3) Non-Rapid Eye Movement Sleep Arousal Disorder Sleepwalking Type Specify if: With sleep-related eating; With sleep-related sexual behavior (Sexsomnia)

307.46 (F51.4) Non-Rapid Eye Movement Sleep Arousal Disorder Sleep terror type

307.47 (F51.5) Nightmare Disorder Specify if: during sleep onset. Specify if: With associated non-sleep disorder; With associated other medical condition; With associated other sleep disorder

327.42 (G47.52) Rapid Eye Movement Sleep Behavior Disorder

333.94 (G25.81) Restless Legs Syndrome


Sexual Dysfunctions

302.74 (F52.32) Delayed Ejaculation

302.72 (F52.21) Erectile Disorder

302.73 (F52.31) Female Orgasmic Disorder Specify if: Never experienced an orgasm under any situation

302.72 (F52.22) Female Sexual Interest/Arousal Disorder

302.76 (F52.6) Genito-Pelvic Pain/Penetration Disorder

302.71 (F52.0) Male Hypoactive Sexual Desire Disorder

302.75 (F52.4) Premature (Early) Ejaculation

Definition of Behavioral Medicine

Behavioral Medicine is the interdisciplinary field concerned with the development and the integration of behavioral, psychosocial, and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation.

(Definition is provided by Society of Behavioral Medicine on their website at: )


What is the focus of Behavioral Medicine?

Life-span approach to health & health care for:

  • Children
  • Teens
  • Adults
  • Seniors

In racially and ethnically diverse communities


Desired Impact of Behavioral Medicine

Changes in behavior and lifestyle can

  • Improve health
  • Prevent illness
  • Reduce symptoms of illness

Behavioral changes can help people:

  • Feel better physically and emotionally
  • Improve their health status
  • Increase their self-care skills
  • Improve their ability to live with chronic illness.

Behavioral interventions can:

  • Improve effectiveness of medical interventions
  • Help reduce overutilization of the health care system
  • Reduce the overall costs of care


Key Strategies of Behavioral Medicine

  • Lifestyle Change
  • Training
  • Social Support


Examples of Goals of Lifestyle Change

  • Improve nutrition
  • Increase physical activity
  • Stop smoking
  • Use medications appropriately
  • Practice safer sex
  • Prevent and reduce alcohol and drug abuse


Examples of Training in Behavioral Medicine

  • Coping skills training
  • Relaxation training
  • Self-monitoring personal health
  • Stress management
  • Time management
  • Pain management
  • Problem-solving
  • Communication skills
  • Priority-setting


Examples of Social Support

  • Group education
  • Caretaker support and training
  • Health counseling
  • Community-based sports events


Age Related Behavioral Medicine Focus

  • Children’s Health
  • Adolescent Health
  • Women’s Health
  • Men’s Health
  • Aging
  • Brain’s Neuroplasticity


Special Focus on the Baby Boomers

  • The increase in Boomers aging and their impact on the medical and mental health field cannot be ignored or underestimated
  • It is imperative that CMHC’s be armed with Behavioral Medicine techniques to address the needs of this geriatric population to address their chronic health issues, disabilities and cognitive decline needs


Weight Management Focus

  • Obesity
  • Exercise
  • Diet
  • Nutrition
  • Cognitive Approach to Approaching Weight
  • Body Image
  • Eating Disorders


Emotions Related

  • Coping with Depression
  • Coping with Bipolar Disorder
  • Coping with Anxiety
  • Coping with Obsessive Compulsive disorder
  • Coping with PTSD
  • Coping with Panic Disorder


Muscular/Skeletal Related Focus

  • Arthritis
  • Chronic Pain
  • Disease-Related Pain
  • Low Back Pain
  • Myofascial Pain
  • Fibromyalgia
  • Accident related Pain
  • Multiple Sclerosis
  • Lupus
  • Parkinson’s Disease
  • ALS


Rehabilitation Focus

  • Developmental Disability
  • Accident Related
  • Neurological Condition Related
  • Aging Related


Pulmonary Related Focus

  • Asthma
  • Allergy
  • Cystic Fibrosis
  • Pulmonary Disease


Allergy Related Focus

  • Seasonal allergies
  • Food allergies
  • Environmental allergies


Cardiovascular Related Focus

  • Type A vs Type B Personality Style
  • Chronic hostility vs lowered hostility
  • Heart Disease
  • Hypertension
  • Stroke


Gastrointestinal Related Focus

  • Diabetes
  • Incontinence
  • Irritable Bowel Syndrome IBS
  • Ulcers


Renal Disease Related Focus

  • Dialysis
  • Kidney Transplant Process


Neurological Related Focus

  • Neurodevelopmental Disorders (ADHD and Autism)
  • Headaches
  • Epilepsy
  • TBI
  • Stroke
  • Tics
  • Brain Plasticity


Cancer Related Focus

  • Early identification of symptoms
  • Getting routine testing for Cancer related symptoms
  • Coping with Diagnosis
  • Coping with Treatments
  • Coping with physical health during treatment process


Sexually Transmitted Diseases Related

  • Information on STD’s
  • Education on Steps to Take to prevent STD’s
  • Information on HIV/AIDS
  • Surviving getting HIV/AIDS through lifestyle change


Addiction Related Focus

  • Substance Abuse
  • Alcohol
  • Illegal Drugs
  • Prescription Drugs
  • Tobacco-Nicotine
  • Caffine
  • Other compulsive addictions: gambling, sex, computer


Focus on Connectedness with others

  • Social Relationships
  • Isolation
  • Loneliness
  • Avoidance of Contact with Others
  • Sense of Community


Spirituality Focus

  • Internal vs External Locus of Control issues
  • Spiritual Practices which encourage healing and good health
  • Maintaining a Positive Outlook on Life which encourages physical healing and good health


Death and Dying Focus

  • Coping with a Terminal Diagnosis
  • Making sense of Life from a new perspective
  • Maintaining one’s composure facing the end of life


Examples of Behavioral Medicine Interventions

  • Biofeedback
  • Cognitive Behavioral Therapy (CBT)
  • Neurofeedback
  • Meditation
  • Guide Imagery
  • Mindfulness
  • Clinical Self-Hypnosis
  • Relaxation Training
  • Progressive Muscle Relaxation
  • Yoga
  • Tai Chi
  • Transcendental Meditation
  • Self-Regulation Skills-learn to put control of health under one’s own personal locus of control


Examples of Outcome Goals of Behavioral Medicine Interventions

  • Prevent disease onset
  • Lower blood pressure
  • Lower serum cholesterol
  • Reduce body fat
  • Reverse atherosclerosis
  • Decrease pain
  • Reduce surgical complications
  • Decrease complications of pregnancy
  • Enhance immune response
  • Increase compliance with treatment – medication plans
  • Increase relaxation
  • Increase functional capacity
  • Improve sleep
  • Improve productivity at work & school
  • Improve strength, endurance, and mobility
  • Improve quality of life

Assessments for Behavioral Medical use by Mental Health Practitioners


Patient Health Care Questionnaires Screeners

They screen for most common types of mental disorders presenting in medical populations:





Eating disorders

Concise, self-administered screening, Quick & user-friendly. PHCQ forms are available at:

PHQ Assessments

1. PHQ: assesses Depression, Anxiety, Eating Disorders and Alcohol Abuse Click here for form

2. PHQ-9: Depressive Scale from PHQ Click here for form

3. GAD-7: Anxiety Screener from PHQ Click here for form

4. PHQ-15:  Somatic Symptom Scale from PHQ Click here for form

5. PHQ-SADS: Includes PHQ-9, GAD-7, PHQ-15 plus panic measure Click here for form

6. Brief PHQ: PHQ-9 and panic measures plus items on stressors & women’s health Click here for form

Manual Instructions on use of the PHQ Assessment Click her for form

DSM-5 Assessments

Available at:

1. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult, 11-17, Parent Report for Children

2. Level 2: Adult Scale by PROMIS: anger, depression, mania, repetitive thoughts, sleep disturbance, substance use

3. Level 2: Children Scale by PROMIS (Parent Report) & 11-17: anger, anxiety, depression, inattention, irritability, mania, sleep disturbance, substance use

4. Disorder-Specific Severity Measures (Agoraphobia, Generalized Anxiety, Panic Disorder, Separation Anxiety, Specific Phobia, Acute Stress, PTSD)

5. Disability Measures (World Health Organization Disability Assessment Schedule)

6. Personality Inventories (The Personality Inventory for DSM-5 - Adult & Children)

7. Early Development and Home Background (Clinician and Parent/Guardian)

8. Cultural Formulation Interviews 

To Address ACA Changes: What Skills Do Mental Health Counselors Need?

  • Ability to understand dynamics of Human Development to capture good psychosocial history of clients
  • Diagnosis of and treatment for behavioral pathology
  • Evidenced based practices in psychotherapy to provide credible treatment to clients
  • Understanding of basic neuroscience of  brain and nervous system to understand roots of emotional responses to life’s stressors
  • Understanding of psychopharmacological treatment of psychopathology


Evidence Based or Evidence-Informed Treatment

1. The treatment regimen shall be individualized based on the Client’s age, diagnosis & circumstances. This includes, but is not limited to, addressing grief, loss, trauma, and criminogenic factors affecting Client.

2. Maintain fidelity of the approved evidence-based or evidence informed treatment program through monitoring effectiveness of program.

3. Maintain documentation of staff training received and/or skills in t evidence based treatment for which Client will be engaged to restore the highest possible level of function.


Tools on to build skills needed in ACA related work

Evidenced Based Practices with Apps that work



Behavioral Medicine


Evidenced-Base Practices

  • Overview of Evidenced Based Practices
  • Anxiety Disorder
  • Obsessive-Compulsive Disorder (OCD)
  • PTSD
  • Phobias
  • Depressive Disorders
  • Bipolar Disorder
  • Alcohol Dependence
  • Substance Abuse
  • Anorexia
  • Bulimia
  • Autism
  • ADHD
  • Guidebooks for EBPs
  • Resources on Evidenced Based Practices


Apps that work:

  • For Clients
  • For Practitioners
  • Moving the concept of Telehealth to new levels



  • Basics of Neuroscience
  • Stress Response of Humans
  • Lectures on Neuroscience
  • Traumatic Brain Injury


Psychopharmacology at:

Psychopharmacology Chart

  • Drug Classifications to treat the following conditions:
  • ADHD
  • Alcohol Disorder
  • Schizophrenia and other Psychotic Disorders
  • Depressive Disorders
  • Bipolar Disorder
  • Anxiety Disorders
  • Eating Disorders
  • Dementia
  • Generic names of each drug
  • Commercial names of each drug
  • Time to reach clinical level for each drug
  • Benefits of each drug
  • Side effects of each drug


Behavioral Medicine:

  • Background on Behavioral Medicine
  • Lectures on Behavioral Medicine
  • Behavioral Medicine Introductory Bibliography
  • Internet Resources on Behavioral Medicine
  • Impact of ACA on work of CMHC


Evidenced Based Tools on

Tools for Coping: CBT based Client Workbooks

  1. SEA’s: 12 Step Program in Self-Esteem Recovery
  2. Laying the Foundation: Tools for overcoming Patterns of Low Self-Esteem
  3. Tools for Handling Loss and Grief
  4. Tools for Personal Growth
  5. Tools for Relationships
  6. Tools for Communications
  7. Tools for Anger Work-Out
  8. Tools for Handling Control Issues
  9. Growing Down: Tools for Healing the Inner Child
  10. Tools for a Balanced Lifestyle: weight management program


How can CMHC use the Tools for Coping on

Clinical mental health counselors can utilize these workbooks with their clients to:

  • Expedite their treatment
  • Encourage their recovery
  • Sustain their well-being
  • Identify triggers for & steps to prevent relapse


The free online Tools for Coping Handbooks enable CMHC’s to challenge clients to:

Maintain personal growth in between sessions by use of:

  • Exercises
  • Tools for changing behaviors
  • Journal writing


These free online workbooks are cost effective interventions based in clinically sound principles which have an evidenced based support in Cognitive Behavior Therapy for their efficacy & positive results

Internet Resources Related to the ACA

Healthcare Marketplace:

Obamacare Facts:

Centers for Medicare & Medicaid Services Information on ACO:

Patient-Centered Primary Care Collaborative:

Patient Health Questionnaire (PHQ) Screeners: 

Society of Behavioral Medicine:

National Council for Behavioral Health:

The Kaiser Family Foundation:

Stories on Why Health Care Reform Matters: