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Should Primary Care Behavioral Health Clinicians and Specialty Mental Health Clinicians be Paid Differently?

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

Preferred but not required - experience in behavioral health in medical setting.

#patient-centered care #integratedprimarycare #behavioral health

Do you have a plan for when you get away from fee-for-service?

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.

On the question of whether integrated behavioral health is an asset or a liability in making things work financially in Alternative Payment Models, the initial evidence looks very good. Abstract The SHAPE program in Colorado matched 3 fee-for-service integrated practices with 3 equally integrated practices that switched to an alternative payment model. Over the course of 18 months, the alternative payment model practices saved over 1.08 million for their federal payers in total care costs over the f-f-s practices.

#patient-centered care #integratedprimarycare #alternative payment models #primary care

High Functioning Teams Can Mean Less Physician and Staff Burnout

The evidence related to high functioning teams reveals the benefits to everyone on the team when physicians take the facilitative rather than the directing approach. Rachael Willard-Grace and her colleagues (2014) looked at the relationship of team structure and culture to burnout or emotional exhaustion for both primary care clinicians and support staff. “Team structure” in their study indicated the consistency with which the same primary care clinicians and support staff worked together. They called a small group that worked together on a regular basis a “teamlet.” They used the term “team culture” to describe what might be called the cohesion of the team, built on elements such as: communication, participation, effort, social support, respect and shared objectives (essentially the IOM list of the elements of a good team in the “Quality Chasm” report). The study was done in 16 primary care practices, 10 serving primarily low income or uninsured patients and 6 serving more commercially insured and Medicare patients, in total encompassing 264,000 visits in the year before the study. They found that a strong team culture seemed to protect against emotional exhaustion for both clinicians and support staff. Tight team structure and consistency of working as a team helped to promote team culture, particularly for the physicians, and team culture lowered stress and increased work satisfaction for everyone.

Willard-Grace, R., Hessler, D., Rogers, E. Dube’, K., Bodenheimer, T., and Grumbach, K. (2014). Team structure and culture are associated with lower burnout in primary care. JABFM, 27:229-238.

#patient-centered care #team-based care #integrated primary care

Democratizing Healthcare

The Dept. of Health and Human Services is working to “democratize healthcare knowledge, capabilities and delivery” (https://bit.ly/43C9arI, slide 6). This is not about the movement to bypass professionals by using technology such as A.I. This is about bringing more members of underserved communities into the healthcare workforce and increasing access for members of their communities. Here is one way it can be done. (https://bit.ly/3obPpXI)

Where is the PCBH workforce?

Lack of fit between the training of most mental health professionals and the skills and mental models needed for successful functioning in a Primary Care Behavioral Health setting causes a great deal of frustration to new BH clinicians, their supervisors, administrators, and PCPs. Often expectations of BHCs, both for productivity and for breadth of problems then can address, are built on what BHCs in other sites routinely do. This is unreasonable and frustrates everyone. Bridget Beachy of CWHC says they don’t have any productivity goals for new BHCs for a year and don’t expect them to be fully functional in the model for three years. https://www.youtube.com/watch?v=0zVr_1w9oJU&list=PLvLh_YdubBs4VUmC8Lc4h6XUfVosdfFJm&index=2

But the vast majority of people who are hired for BHC positions did not receive practical training in primary care settings. What to do?

How about two levels of BHC. One fully functioning in PCBH, and another level who does some longer-term work, more manualized approaches, more focused on MH and SU work, and possibly work in the CoCM model. These roles fit more with common training, and with the mindset that problems are either biomedical or psychosocial. That is how a lot of our workforce is being trained. Asking them to think differently about their patients’ problems isn’t fair. People think how they think. Time working with a primary care population is what trained most of us to get beyond either/or conceptualizations. One crucial stipulation is that the senior position be paid more, to offer an incentive for the beginning BHC to acquire the competencies required for the more complex role.

Here are the two positions as defined in a primary care plan I am currently working on with an academic department of Family Medicine and an FQHC system. See what you think.

Behavioral Health Clinician 1 – 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.

· 2 to 3 years of experience in behavioral health

· Expertise in working with patients who have chronic health conditions

Behavioral Health Clinician 2 – 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. BHC 2 clinicians will be paid on the same salary scale as other mental health clinicians at in comparable specialty mental health settings.

BHC 1 clinicians will be paid at least 10% more than BHC 2s as fits the difficulty, increased competencies, and experience required for that position.

Advice for new leaders in primary care behavioral health

A common question: I work in a university health center that is creating a BH manager position for a relatively new, unestablished BH practice/transition, and agency leadership believes (a) this isn’t a leadership-level position (ie. it is not a directorship or department head but a team manager) and (2) the position should be exclusively clinical & supervisory, with very little admin, program development or professional development time/activity built in.

My answer: I teach the PCBH Leadership course through CFHA. https://www.cfha.net/events/EventDetails.aspx?id=1446239&group= We’re about to start our 6th cohort of the class, 52 people in leadership positions in integrated care settings. The universal experience of these new leaders is some degree of underestimating of them, both the challenge they face and the contribution of behavioral health integration, by medical or administrative leaders who have not had experience in integrated settings before.

One way you can tell how far the administration above the BH leader has come in their understanding is by how much time they allow the BH leader for administrative functions. Less that 10% is not uncommon (nor nearly enough, especially when you are building the program). On the other hand, you don’t want to be perceived as never satisfied, always wanting something more. It is a tough spot.

A few general ideas that might help:

You are not just changing a few clinic routines by the presence of an integrated behavioral health service, you are changing the culture of the organization. Take the long view.

Don’t let the descriptions of practices in places that have been at it for many years make you feel like you are not moving along well. The “model” can be both a North Star and an albatross around your neck.

You will have to get good at teaching people above you as well as below you. You know things they don’t know, and they will naturally be slow at supporting your requests before the understand what you are contributing. For each step forward, give away the credit with those above as well as those below.

New people, like new attendings, new administrators, trainees, can be great allies. Don’t skimp on onboarding, orientations, teaching, building relationships, even though the clinical pressures are great. Most new behavioral health clinicians need just as much teaching about the role as medical folks.

Never argue for integration, always argue for better patient care. Integration is just a way to get there.

To the degree that you make the lives of your medical colleagues easier, and you document and share that data, you gain influence. (use a physician satisfaction survey at least annually https://bit.ly/3xj9lKN)

Find a medical champion, the one who understands best what you can contribute and uses you most, and encourage them to take a role in the development of your service, to represent you to some degree when you are not there, and give them credit for their role in your success.

Go to all the previously “medical” meetings you can. You are part of healthcare, and what you treat impacts a great deal of what medical folks want to do in their work.

Make friends with and explain the importance of your service to people in roles like billing people, IT/EMR people, MAs, registration people . . . Each can make your program work better or (usually unwittingly) stand in the way.

You can do that in 10% time, right?

Sandy

#integratedbehavioralhealth primarycare leadership

Preparing for the Cares Act and Open Notes

With few exceptions, all healthcare records of each patient will have to be easily accessible to the patient very shortly. I have been active in making Behavioral Health and Medical records of patients available to them since 1983, but the Cares Act is a watershed moment in the development of patient-centered care. As clinicians learn to write notes that patients can read, they tend to become more patient-centered in their clinical work as well as in their documentation. It is much easier to make a patient a partner in their care when they are a partner in the informational record of their care. Clinicians need to adjust notes a bit, not to change facts, but to change some terminology. Few clinicians are aware that terms that they use that are designed to be neutral scientific descriptions are taken by patients as descriptions about the doctor/patient relationship. To respond to the concerns about the coming transparency of notes, I have developed an overview for professionals in the issues and in some steps that can be taken to make the transition go more easily. I have also been delivering longer workshops that include practice in writing notes and let clinicians work together to learn to use a different set of terms for the elements that they find hardest to transform for patients to read. ABlountEdD at gmail.com

#patient-centered care #Cares Act integratedprimarycare

Massachusetts Takes Some Important Steps in Healthcare Policy

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.

The next legislation should require insurance companies who credential the medical providers in a primary care practice to credential properly licensed behavioral health providers employed in the practice. Historically, some companies have failed to credential new behavioral health clinicians in primary care, saying that the company already had plenty of providers in their specialty mental health and addiction networks. That meant that 60-70% of the patients with behavioral health needs in the practice, who would accept services within the practices, but would not go to a mental health specialty service like a community mental health center, got only the care their PCP could offer.

#health equity #integratedprimarycare #massachusetts

IPC Cost Savings: Small Studies, Big Results

The Cost Effectiveness of Embedding a Behavioral Health Clinician into an Existing Primary Care Practice to Facilitate the Integration of Care: A Prospective, Case–Control Program Evaluation

Abstract

This project evaluated the cost effectiveness of integrating behavioral health services into a primary care practice using a prospective, case–control design. New Directions Behavioral Health collaborated with a large Kansas City primary care practice to integrate a licensed psychologist (i.e., behavioral health clinician) into the practice. Patient claims data were examined 21 months prior to and 14 months after the psychologist began providing full-time behavioral health services within the practice. Claims data from patients with Blue Cross Blue Shield of Kansas City insurance (BCBSKC) who had at least one encounter with the psychologist (N = 239) were compared to control patients (BCBSKC fully insured patients at large) to calculate cost savings. The results demonstrated that integrating behavioral health services into the practice was associated with $860.16 per member per year savings or 10.8% savings in costs for BCBSKC patients. Integrating behavioral health services into primary care may lead to reductions in health care costs.

https://link.springer.com/article/10.1007/s10880-018-9564-9

Cost savings associated with an alternative payment model for integrating behavioral health in primary care

Abstract

Financially supporting and sustaining behavioral health services integrated into primary care settings remains a major barrier to widespread implementation. Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) was a demonstration project designed to prospectively examine the cost savings associated with utilizing an alternative payment methodology to support behavioral health services in primary care practices with integrated behavioral health services. Six primary care practices in Colorado participated in this project. Each practice had at least one on-site behavioral health clinician providing integrated behavioral health services. Three practices received non-fee-for-service payments (i.e., SHAPE payment) to support provision of behavioral health services for 18 months. Three practices did not receive the SHAPE payment and served as control practices for comparison purposes. Assignment to condition was nonrandom. Patient claims data were collected for 9 months before the start of the SHAPE demonstration project (pre-period) and for 18 months during the SHAPE project (post-period) to evaluate cost savings. During the 18-month post-period, analysis of the practices’ claims data demonstrated that practices receiving the SHAPE payment generated approximately $1.08 million in net cost savings for their public payer population (i.e., Medicare, Medicaid, and Dual Eligible; N = 9,042). The cost savings were primarily achieved through reduction in downstream utilization (e.g., hospitalizations). The SHAPE demonstration project found that non-fee-for-service payments for behavioral health integrated into primary care may be associated with significant cost savings for public payers, which could have implications on future delivery and payment work in public programs (e.g., Medicaid).

https://academic.oup.com/tbm/article-abstract/9/2/274/5001714?redirectedFrom=fulltext

Integrated behavioral health in primary care is a foundational element of social justice.

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.

· Integrating behavioral health into primary care is a foundational element for health access and health equity for people who are disadvantaged by a history of structural racism and burdened with the highest levels of illness. This is basic to social justice.

#integratedprimarycare #Primary Care Behavioral health #social justice

Can Telemedicine Deliver Patient-Centered Care?

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

[1] Blount, A. (2019). “When the doctor-patient divide is a chasm,” Patient-Centered Primary Care: Getting from Good to Great, Springer, 77-92.

#integratedprimarycare #patientcenteredcare #team-based care

Setting the goal for a BHC visit

I got this question in my email today:

Sandy, What has your experience shown to be a good goal for BHC visits in an integrated FQHC setting per session and/or per day? Thank you. Do you know of any research or "standard" out there?

That is a question that is too broad for me to answer because of the variety of patients, situations, and requests. I know that if the goal is not at least largely the patient’s goal, then my goal would be to try to help the patient to get to being able to be clear about a goal. But even that is an inadequate statement because if you are rigidly asking patients what their goals are, very many have no idea how to define a solvable problem and what the choices of types of goals can be. I try to be flexible between using the concept of goal and the concept of indicator. Instead of saying “What are you goals?” many patients do a lot better if you ask “If things were getting better, how would you know it? What would indicate that things had improved enough to make you feel there had been real progress?”

My favorite question in a first visit, or in any visit where the goal for the visit is very unclear is to ask the following. It is long winded, but it really works if you say it this way: “Before we start, I want to ask you a quick question. I want you to imagine that it is half an hour from now and you are walking back to your car. You are saying to yourself ‘Well, that certainly didn’t solve everything, but I’m glad I came. It was definitely worth my time and effort.’ What would have happened in our meeting that would make you say that?” Whatever they say is your goal for the meeting. If they say they have no idea, you can say, “ So I guess helping you have some idea of what could be helpful might be our goal, does that make sense?”

Sandy

Keeping the Sense of Team in a Busy Practice

Dr. Blount,

When the PCP gets bypassed because MA staff refers patient directly to the BHCs, or the patient self-refers directly to us, it starts to feel like a co-located model. That drift has a force of its own, like a current pulling things back to the old ways of care (you take this part, I’ll take that part, the box is checked) and I’m holding the patient on my own without the team, which is my favorite part of this work.

Though now you have me thinking of some other ways to possibly interact with this issue, such as reaching out to the PCP letting them know that we’ve heard from their patient and engaging them in the care while we also keep access for patients. Any quick thoughts on how this conversation would look, if you have time, would be helpful.

My response:

I have a couple of thoughts. One, just as you suggested, make reaching out to the doc an essential part of the process. I would drop the word “referral”. Instead I would use, “involved in the care of.”

E.g., To Bob Smith MD: “Bob, Maryellen (MA) has asked us on your behalf to be involved in the care of Joe Jones. She reports he is coping with depression. We are happy to meet with him and assess his situation and report back to you with an update. CC. Maryellen.”

In this way the other team members are reminded each time that you are helping the doctor care for his/her patient and not starting a new treatment. Second, send back a summary of that meeting with a biopsychosocial assessment and a recommendation. In practice, that would mean that you would have asked how the symptoms of depression have impacted or been impacted by Joe’s chronic illness or his health behavior. This report is short, possibly in bullets. (In my shop, it would also be the note). Don’t let the term “biopsychosocial” set off the creation of a lot of text by your BHCs. Again, copy Maryellen as another team member in Joe’s care, the one who identified the need. If your folks always do it “as if” we are a team supporting the PCP, you gradually move people’s consciousnesses without telling them that they should do things differently. I think you will find people gradually doing things differently.

“Primary Care First”: CMS’s funding scheme for the most “complex” patients.

Primary Care First https://bit.ly/2P8lQlw is a new approach by CMS to paying for care for the most “complex” patients. The new program is scheduled to launch 1/1/21. It provides monthly payments and incentives for primary care practices that care for patients with multiple chronic illnesses. This tends to be a group with high behavioral health needs in addition to physical illnesses. In its present form, it does not incent Behavioral Health Integration for these patients, though the case for that change https://bit.ly/2SRCLJO is being made. There is a volume that focuses on this population with a patient-centered approach to both the physical and behavioral challenges they bring. The approach is built on evidence about how to achieve lower costs, better outcomes and less stress for providers. The book is Patient-Centered Primary Care: Getting from Good to Great. (www.pcpcg2g.com)

#primarycare behavioralhealthintegration patientcenteredcare CMS healthcare

Is the “Hotspotters” Program Ineffective?

On January 9, the New England Journal of Medicine published an article with the results of a large randomized controlled trial of a program implemented by the Camden Coalition to serve patients with complex physical and behavioral health needs, the “super utilizers” of the system. The program is designed to engage patients using multi-disciplinary outreach teams of nurses, social workers, community health workers and health coaches (a dream team of resources in many people’s minds.). The team members accompany patients to primary care and specialty medical appointments and try to link them to existing services in the community. The rigorous study found that the program was not more effective than “usual care” for the same population. The authors concluded that “It is possible that approaches to care management that are designed to connect patients with existing resources are insufficient for these complex cases.” (p.158)

Compare this finding to the program assessment of The Health Resilience Program done by CareOregon (Oregon’s Medicaid). The program serves essentially the same population as the Camden Coalition program, though in its design, it focuses much more on the likely trauma histories of its patients that does the Camden program as described in the NEJM article. Its results seem better. (To say they are better would take several pages and would require a lot of comparing of methodologies and outcome measures.) If you choose to look up both, notice that the Camden program focuses on the disciplines of its teams and on adding existing services. The Oregon program focuses on specialized expertise of their Health Resiliency Specialists who are embedded in the 16 primary care sites of the program. The emphasis is on training to fit the exact job and the population. This is very different from the common assumption that the necessary expertise will be available if there are multiple disciplines on the team. The second important difference is that the Camden program focuses on adding services, while the Oregon program focuses on building partnerships with patients. Its use of trauma-informed care requires an more humble, listening rather than teaching approach to building these partnerships. I suspect there is an important finding in the comparison for anyone who wants to work with this group of patients. (See my chapter, Getting from “Delivering Care to Patients” to “Partnership with Patients,”).

#patient-centered care #complex patients #high utilizers integratedprimarycare

Patient-Centered Primary Care: Getting from Good to Great Chapter Abstracts

In the posts below are all of the abstracts of the chapters of my book. Every so often I throw in the link to where they can be accessed: https://link.springer.com/book/10.1007/978-3-030-17645-7

That site gives access to all of the chapters.

The whole book is available on Amazon: https://amzn.to/2KQDKWE

Until September 22, a certificate for 20% off is available on www.PCPCG2G.com along with a number of comments about the book from leaders in the field.

#patient-centered care #primary care #behavioral health integration

Abstract for Chapter 1: Getting to Patient-Centered Care

https://link.springer.com/book/10.1007/978-3-030-17645-7

Primary care is the foundation of an effective and efficient health system. The more robust a nation’s primary care service, the better are the health markers seen in the population and the lower the comparative cost of healthcare. In the US, primary care has been under stress for some time, under-supported financially with too small a physician workforce and over-taxed by demands to impact the population as a whole. The Institute of Medicine (IOM) and other health policy leaders have attempted to remedy the quality problems of the healthcare system by calling for a reorganization of primary care into a medical home that is patient-centered, evidence-based, offering improved access, better ongoing contact, and coordination of care. The IOM’s ten rules for the redesign of healthcare include some that are focused on systems change in the delivery of care and others that are focused on relationship change of doctors and their patients. The systems change rules have been easier to implement. The improvements associated with the change of the relationship of the physician and healthcare team to the patient have not been nearly as impressive. Therefore, it is in this area that the next steps to a more equitable delivery of health care must take place.

#patient-centered care #primary care #healthcare

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