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:
- Primary health care should be centered around the patient and family in a user-driven design, in all aspects of practice.
- 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.
- 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.
- In order to mitigate rising health care costs, a fundamental shift in reimbursement will need to occur
You can read their entire report at: http://www.aha.org/content/13/13-0110-wf-primary-care.pdf
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: http://www.aha.org/research/reports/tw/12jan-tw-behavhealth.pdf
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: http://www.integration.samhsa.gov/integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare.pdf
which is located on their webpage on integrated health care models at:: http://www.integration.samhsa.gov/integrated-care-models
Self-Assessment of Your Personal Competencies to Function in an Integrated Medicine Setting
BI-CAT (Robinson, 2013) Downloadable at: http://cabhp.asu.edu/presentations/other-center-hosted-presentations/media-and-pdfs/robinson-handouts
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: http://www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf
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: http://www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf 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: http://www.pcpci.org/sites/default/files/resources/PCBH%20Implementation%20Kit_FINAL.pdf
