Behavioral Health Integration in Private Practice
[Music] hello everyone and thank you for joining us today welcome to the American Medical association’s Private Practice Simple Solutions part of the steps forward innovation academy before we get started with the content a quick few housekeeping items the Private Practice Simple Solutions program is a series of Rapid learning Cycles designed to provide opportunities to implement actionable changes that can immediately increase efficiency please note that this presentation has been recorded and is for informational purposes only you should consult a professional adviser for specific medical Legal Financial or other advice please take a moment to carefully review this notice I’d like to now introduce today’s speakers Dr Yun Boon and Verna little Dr burlson take it away great thank you sble and I just want to thank the AMA for uh the honor of inviting me today and um any opportunity to collaborate with Verna who is a true thought leader in this space um I will take and so uh welcome and uh today we are talking about um integrated Behavioral Health uh in the private practice setting uh which is near and um dear to my heart and we’ll start off by um the broad-reaching goals like what are the goals of integrated Behavioral Health and the opportunities for your practice and hopefully this will really um hit true for many of the things that you’re trying to accomplish uh in your clinical care and running a a busy and hopefully thriving practice so the goals are are many uh including uh increasing patient access to care you know one of the pain points that that all Primary Care Providers have currently is there just aren’t enough uh specialists in um the psychiatric or psychological space to really refer all the um patients you have who really uh would benefit from this care and secondly to really improve patient experience and satisfaction you know we really um focus on making sure that um patients identify your clinic or your practice as their true medical home and uh where they can receive whole person care and so being able to offer bhi is such an integral part of the whole patient experience at your practice uh and um additionally we want to improve patient outcomes we want uh patients to um achieve successful management of their conditions to be able to reduce comorbidities or other complications that they have um that um stem from their behavioral health uh uh condition and so um certainly this is aligned uh with that effort uh and then aligning with clinical standard of care right um that has has more practices and uh um you know move towards um providing this uh this service in the primary care setting that it really is becoming the CL the the clinical standard of care to offer these services and then we really want to improve the provider and staff job satisfaction we know that it can be incredibly frustrating to see this need and not be capable of meeting this need for your patients and then lastly as with um you know all issues or topics in the private um practice setting it’s really gota um uh you know be directly related to achieving Financial stability and so we’ll address that as well and uh as you um can see here there are a lot of perceived barriers or maybe things that come to mind uh very quickly when we think about uh challenges in implementing Behavioral Health um integration at your practice and some of these may sound really familiar to you because they certainly do um to me and so really for a clinician the first question is how the heck am I supposed to do all this in 20 minutes right or I really want to treat mental health but I really dread my schedule blowing up and just having um having uh you know that happen in the afternoon and then you’re toast for the rest of the day um but the reality is that um establish bhi workflows within your practice um with the use of warm handoffs or having skilled staff who can also help support this work can actually uh facilitate workflows and create efficiencies um another perceived barrier is I can’t believe how long my patients are waiting for a Beal Health referral the reality is that with integrated Behavioral Health um Services you can actually address the majority of presentations of behavioral health conditions um and or be a um temporary Bridge until your patients can eventually access Specialty Care another perceived barrier I don’t feel comfortable managing behavioral health conditions and that was certainly true for um for my practice myself and my colleagues um and and really for um the resourceful minded practice there are many quality and often free resources that exists for clinicians um regardless of um what state you’re in um that really can help you develop the skill set needed um to be successful at be Health Management um another concern is I’m afraid to spend all this time doing all this work and not get paid for it and so this is where some of the back office and and being U more astute with understanding how billing and coding work for Behavioral Health um and as well as um work flows um within your clinic because these are uh the key to getting paid for the work that you are doing um another concern it’s frustrating not to be able to help patients um with what they need and we all know that when it comes to behavoral health moral injur is real um in the clinical setting where you see so much demand and you feel someone incapacitated to really help and um the effort that you put in to try to meet your patients where they are they will truly appreciate appreciate the care that you’re able to give um and then lastly uh you know the thought that my practice doesn’t have the resources or Staffing to do this um I argue that for private practice we do this best we are the ones who take nothing and make something um and so the key to behavoral health integration is to start with what you have and um we are truly the best at being resourceful next slide please and there is um a wealth of uh body of information that really show shows us that behavoral Health integration works this is not a new or novel concept it’s been studied um you know the the tires have been kicked for quite some time and there actually is a lot of um data that shows um benefits not just financially but also of clinical outcomes and so these are just a few of the uh of um the U some of the evidence that’s out there in terms of a decreasing total cost of care um provider um satisfaction as well as improved workflow efficiencies um and specifically within Integrated behavoral Health um uh models the collaborative care model has had lots of good studies that show um evidence um for um for targeted treatment and outcome based care next slide please and next I will turn it over to Verna thank you so much it’s a pleasure to be here um and I absolutely couldn’t agree more that the small practices are where you really find the creativity because I think necessity builds creativity and and builds what needs to happen so really excited to be able to give some information the good news is that there are more resources and options available now than there ever have been in the past and when I think about small practices trying to figure out how to build in and integrate Behavioral Health there’s a couple of ways to think about it so you can can hire um a full or part-time Behavioral Health provider or you can share uh one with other practices in the community so share in the the hiring and the salary Fringe and the overhead I think this has a lot of good opportunities especially now since there’s some changes in some of the codes that some of these providers can use it does mean that you have to credential them with your plans you’ll have to figure out how to build for them and do a bit of a proforma but certainly the opportunity even to share um is a little bit more viable now given some of the new codes also I think a lot of times people feel like their patients need someone in person the research doesn’t actually support that for Behavioral Health so it is possible to have someone work remotely and do uh some other kinds of visits to do T Health visits or video visits this can actually work really well particularly if you’re in a rural area or many of your your patients would have barriers in terms of needing offour care or just for accessibility and certainly it’s better than not having a behavioral health partner what I would say very clearly is really consider the type of lure before you do that the thing about Behavioral Health Providers and this is getting much better um but certain providers can build certain codes and others cannot uh until very recently counselors were not recognized by Medicare that’s actually changing now um but there are some commercial plans that aren’t um as generous with credentialing particularly in rural areas some different lure and so I would really think about the lure get some advice or information before you go forward and hire someone uh I would also think about the populations that you want to care for first if it’s not possible to care for your entire you know all of the patients that you see do you have a particular population that might be the most helpful so do you have someone U maybe a lots of pediatric population below the age of 10 and maybe you just try to figure out what you could do for that population or seniors or maybe people with depression and anxiety so maybe maybe think about what that might look like and do a full profor I get contacted by so many practices um that weren’t really expecting uh some of the problems they might have with billing or how long it might take to credential and so really would encourage you to do a pro full performer talk to your payers figure out what the reimbursement is going to be and then really be clear up front like you would with any other provider how many visits this person has to have in in order to be viable right now also more than ever before there is an opportunity to contract out for Behavioral Health and this looks really different now than it used to given some of the changes in the codes so certainly the tella health codes and you can contract with a tesy organization or a telebehavioral Health Organization to be able to provide provide Behavioral Health Services and there are some that will directly embed in your practice and others that you can contract with uh we’re going to talk about collaborative care and you can contract for collaborative care and some you know an organization can come in and provide the behavioral health that’s necessary to do collaborative care I would say really vet the vendor what’s really important to you um is you know right to quick turnaround in terms of referrals very important are you going to want data around outcomes for some of the other initiatives or quality measures that you might be participating in so really vet the vendor and really ask the kinds of questions what kind of data and how do you track data how do you care for patients and who’s going to be caring for my patients are they licensed are they not licensed what kinds of services are they going to be providing go ahead and so you could also do a hybrid you could build and maybe hire someone part-time and then contract out um for collaborative care or as an example so there’s a couple of things we know to really keep in mind when we think about optimizing integrated care and there’s a couple of things that we know really make that team successful and really make integration successful the first is really thinking about shared care plans so we’re not going to have a behavioral health treatment plan and we’re not going to have you know a primary care care plan we’re going to come together and we’re going to have a shared care plan and this is something I would almost insist on right from the beginning and shared care plans meet the requirements for a treatment plan for Behavioral Health so you can come together I would also think about some shared accountability what quality measures are really important to your practice maybe that have dollars attached to them or that you’ve been working on that are important to you or important for other initiatives and then everybody’s accountable so that when if I come in and I’m a behavioral health provider in your practice I also am very invested in trying to help you with the number of patients who get a flu shot or have a mamogram or any of the other quality measures and that you may also work on some Behavioral Health measures that you really have shared records it’s very hard I talked to um a vendor yesterday and they were working with the practice and it was so difficult because they were sending records they were sending consult notes and the practice couldn’t find them they were trying to find them and scan them in and attach to the visit and it was just a really difficult process and the providers weren’t able to see the notes so I would say really encourage you to share access to your electronic health record and that way often times it’s equivalent of like a medical assistant somebody often won’t be prescribing or or placing orders and so it really is something that I would strongly consider so that you have your documentation in one place and that person feels like a team and they can see your notes and you can see their notes and that you really have some real understanding of what that person is going to do how do they care for patients what does that look like and also that they have an understanding of what chronic illnesses you take care of and the patients that you see um so that they’re can really be a team and you can care for your patients and sort of optimize bringing someone in uh to do the Behavioral Health Services whether they’re contracted or whether you hire someone um or it’s some version of a hybrid and so when we think about some of the options for integration certainly you can collocate someone in I would say for the most part that unless you’re really thoughtful um about this person being collocated and they’re going to share your records you’re going to have some kind of shared accountability that often times this has someone come in I’ve heard from so many practices and they bring a behavioral health provider in and before you know it that provider is full and then they’re kind of back where they started with their being a weightless and so to really be thoughtful about what that looks like how we’re going to know people are getting better what the case load is going to look like and how we’re going to care for people and really making sure that they’re a transdisciplinary team member that all those pieces are in place we talked about whether they’re employed or contracted so I would strongly um consider you to think about all of the options that you have and the kinds of integration so one of them is the collaborative care model which we’ll talk about an evidence-based model that Dr Boston mentioned uh has lots of uh studies and evidence to support it also thinking about uh Primary Care behavioral health or the pcbh model and now one of the things that’s changing is the health and behavior codes can be provided by a variety of behavioral health professionals this was not the case in the past the the regulations are likely changing in January and so that means that for a lot of your anticipatory guidance obesity smoking um a lot of the any behavioral health provider that you could bring in can now help you with those patients as well um as well as take warm handoffs for some of the populations that you have also maybe thinking about options for referrals so there are a lot of organizations now that do a really nice job with specialty populations remotely that serve all of the states or most of the states um as an example Charlie health does adolescent up to age 33 like intensive day treatment Mental Health Services take patients the same day really nice strong referral option or equip for um Eating Disorders so that for some of your patients who might need specialty mental Heth there’s some additional options now um or with a local provider if you have someone that specializes or make a a a um make an arrangement with you I worked one time with a practice and the local Community Mental Health Center and people that called the Community Mental Health Center that were either patients of the practice or who didn’t have a primary care provider that were calling for care for depression and anxiety actually went to the primary care provider um and if patients then needed specialty mental health in the primary care practice had more access in the Community Mental Health Center so really coming together and thinking about Arrangements like that are helpful and then really thinking about your population so that you can really try to say how many health and behavior needs do I have do I have patients that need specialty mental health what what about my broad Primary Care population maybe think about where do I want to try to solve the problem first and then go from there with what some of your options are go ahead great and next we’ll talk about the potential revenue and value to your practice and recognizing that um that the value certainly includes the financial um value but also the intangible value as well and so um some of the ways that integrated Beal Health um Services can increase uh your revenue is um to really provide a consistently increased visit volume you know Primary Care is very seasonal we rely on um flu season acute illnesses um but for Behavioral Health uh you know especially for management of chronic conditions um there is greater predictability um in in um scheduling these types of visits than relying on sick Urgent Care visits um secondly there’s payment for higher complexity of visit so as we know you know if you have um evaluation and management codes uh Behavioral Health um in uh by its very nature puts you into like the established 99 um 214 99215 categories it um certainly isn’t just like a very focused um you know um diagnosis of otitis media uh and uh another um potential Revenue uh you know capture opportunity is the optimized staff deployment with behavoral health integration um uh in the context of teleah Health visits so for our Clinic one of the ways that we promote efficiency especially when we’re under staff with nursing is um we tend to put in additional Beal health teleah health um visit blocks recognizing that the provider is essentially a little bit on autopilot because it kind of removes the need for a very Hands-On nurse during those visits and they can be deployed um to other um to other um uh needs you know within the practice there’s also a fair bit of um ancillary income now no one is is uh you know going to achieve ridiculous profitability off of surveys but the time to administer and review and um discuss surveys these would be things like the phq9 Gad 7 certainly uh many others um that um cumulative uh cumulatively you might be really um surprised by what that Revenue stream means to to your practice um and and finally the additional revenue streams with um collaborative care model codes uh the distinction with these codes you know conventionally in Primary Care the um the the physician or the um AP um they are the um you know the the revenue centers right and so it’s very much I provide a visit um and this is my uh you know this is the what I bill but the beauty of collaborative care is you have your Bure real healthare man managers who basically bill on behalf of the provider and so it’s um essentially a a novel Revenue stream for your practice that you know that you probably haven’t um had the opportunity to tap into uh and then we move into kind of the intangibles that are so important for your practice um and ultimately they do uh inform the bottom line which we’ll talk about um so it increases patient satisfaction and loyalty you know with primary care that’s the the value proposition for Primary Care you come to me for whole person care um and I will continue to see you we have a relationship which is fundamentally different from an Urgent Care setting or more the consumer type of um you know Urgent Care models out there um that that we you know the reality is we compete with now right uh and um and as a part of that it really improves the Fidelity of your patients um you know to your practice that they will continue to stay with you they will have longevity with you um and that’s deeply gratifying not just for um the the relationship and the trust between patient and provider um but also in continuing to build a healthy patient panel for your practice um for me and certainly for others um you’ll find that you know improved provider satisfaction and retention you know we’ve all seen um the the AMA Publications now um talking about how many Primary Care Providers uh you know many fields um including Pediatrics is greater than 50% burnout we all believe it because we live it um and so really being Adept at delivering in a great Bal Health uh for me has been uh you know a tremendous source of just really improving my connection to my patient feeling empowered like I can do something to help uh and I I think ultimately it’s really good for longevity uh for all of our clinicians out there uh it certainly improves on quality of care um as well as outcomes if we’ll go back to the um the last slide please uh and and that’s really important for all of us who increasingly are in value-based care payment models we might be a part of acos and so these are all the metrics um that that um are being looked at at a higher level you know for our practices um and then lastly the potential to decrease total cost of care while increasing um uh or improving outcomes is certainly the gold standard for all of us um so the next slide um I will turn it over to Verna we’ve talked a little bit about collaborative care and I think it’s helpful uh to just do a little bit of a deep dive so collaborative care is an evidence-based model that was was dedicated in 2017 with some CPT codes uh specific to the model and essentially collaboratives care is evidence-based for depression and anxiety and Health Care settings it is very different uh as we sort of alluded to it is a monthly case rate so that means the total number of minutes spent caring for a patient or in patient related activities every month is billable they are technically referred to as incident 2 codes because they can only be build by Primary Care Providers but actually they kind of fall out of some of the incident 2 requirements like the provider has to be on site and and some of the others um so they are adding two people to that Primary Care team the first is a behavioral health care manager CMS says that this person does not have to be licensed but they do have to provide all of the treatment choices in collaborative care one of which is talk treatment so the nice thing um is that it is very measurement based using the phq9 for depression the gad7 for anxiety and really looking for that 10 point or 50% reduction in the first couple of months the average amount of time in collaborative care is about six to eight months and that Behavioral Health Care manager really manages patients with the Primary Care Pediatric Women’s Health provider really helping to reduce those scores sometimes talking to them every day or every other day setting goals following up and if someone isn’t getting better they meet with the second person that gets added to the team the psychiatric consultant and in collaborative care the psychiatric consultant doesn’t see patients or prescribe meds they meet with that care manager weekly talk about those patients that aren’t improving or having side effects and then make recommendations in the electronic health record to that healthc care provider and so it really allows for access to service because it can be same day next day it is by nature a remote option uh telephonic actually works best for those frequent hight touch uh patients and also it becomes very affordable because it is a monthly case rate and because it falls under primary care so the idea is that my um co-pay for going to see the provider might be $20 and then I’m paying $20 for a month of collaborative care so it becomes accessible and affordable particularly for your commercial and your Medicare patients so this is a little bit about what it looks like in practice um this is from my organization concert uh we do contract out and so but this is a really nice example this is what the primary care is responsible for they’re still captain of the ship I like to say they really establish the diagnosis they might do the screening and I think it is important to add the screening to your practice that 96127 code you know it adds up over time um the G-Code for Medicare but it adds up over time and some payers will pay it multiple times a month so really good and then you also can track how many how many screenings you’ve done they do a warm hand off often time this person is telephonic or remote and that’s really helpful because it can be hey I work with Verna she helps me care for my patients who are sad I’m going to have her give you a call later today and that makes a big difference because then I’m doing this warm handoff to the Behavioral Health Care manager to that clinician who’s going to manage me and then talk to the psychiatric consultant if I’m not getting better and that psychiatric consultant is going to help with any diagnostic questions any patients with comorbidities there it might be um difficult and make recommendations for labs for medications um whatever is most appropriate for that patient in collaborative care so collaborative care now is on the Medicaid fee schedule in about half of the states we still have half to go so it provides a really nice option whether you build it or contract it to be able to have a behavioral health provider access to a behavioral health provider that might be able to help you care for a pretty broad swath of your your patients and again more than half of the states Medicare Advantage so certainly Medicare Advantage Medicare and all of the commercial plans we have actually not had a commercial plan um that is not reimbursing for collaborative care so when we talk oh go ahead Dr BR go for it oh thank you Vera and and so uh you know ierna provided um just a really helpful snapshot of one archetype of integrated Behavioral Health um and so this is another um case um just to highlight Primary Care Beal Health um model and just so you know you know this is um a Choose Your Own Adventure when it comes to particularly private practices um that that your model what works for you may actually be a hybrid of maybe the collaborative care and the pcbh model you may decide to take um initial steps to work towards maybe one of these uh but there are certainly other models and we just wanted to highlight maybe two of the more commonly used ones and so for pcbh um uh it also follows the same tenants of Integrated baval Health that Verna so nicely outlined for collaborative care I just love that she um used the term um you know um the uh Beal Health um provider is such an integral part of the team the primary care team and that is really um the foundation for a successful integrated Beal Health um uh model and so this is very much um again like um collaborative care pcbh is um it’s a team-based approach to supporting Beal Health Care in the primary care setting um and P the pcbh model um includes a Beal Health consultant um commonly this might be a master’s level psychologist or a PhD um and they are commonly um uh a part of you know team huddles warm handoffs with the um with the um primary care team and really part of the um the daily workflow and so the distinction is they’re not a specialist that you um you know call or selectively use um this is a service and a team member who really is available um to the majority of your um primary care patient panel uh this individual can be virtual or in person I think Verna really um captured that well that in this day and age with all the digital advancements you know there are so many things that you can bring into your office um and it helps us overcome some of those Geographic constraints and the key here with pcbh is focused intervention um because one Pitfall is uh you don’t want the um Behavioral Health consultant to be consumed and bogged down with just 5% of your patient panel um who are highly complex this is truly for um the individuals who um just need focused um support behavioral activation or like a defined series of um sessions where after which they’re um moved on and and transition to a community um therapist or other Behavioral Health um provider available in the community um and again they’re broadly available to the majority of the practices patient panel um a key distinction and actually and this is true for collaborative um care as well but um the uh for both of these models um the behavioral health expert um who is embedded in your in your team really uh strives to educate the team as a whole whether it’s your staff other clinicians the primary care providers to upskill all members to be knowledgeable to be comfortable and having these discussions as well as you know tips on management and so I think that’s how we really share best practices and lift up the whole team um to do this work and uh keeping in mind that um with the pcbh model because these are Beal health consultants often times in the like psychology um expertise realm um that there are specific CPT codes that um that Primary Care um you know typically does not use and so if you are interested in pursuing this model then you really want to make sure that these CPT codes um are included and um and you understand the rates um in your current insurance contracts uh and it’s really promising um uh that that Verna mentioned you know uh because of the need for um for this Behavioral Health report that a lot of the restrictions on these codes are um being liberalized and so the key takeaways today you know because this is all about fast action see what we can do today within um you know within the constraints um and the resources um that you currently have and so the first would be um assess where your practice is now you know can you find ways to measure the current unmet demand for behavoral health integration services at your practice you know you may want want to track um you know a a length of time between referral to eventual first appointment um for your patients that might be really eye openening to really U make the argument to the stakeholders within your practice about maybe um your need and your patient specific needs um in approaching um your your work on Behavioral Health secondly um brainstorm how to build on what you’re already doing odds are really good that either functionally or just in a practical sense um we know that you’re already doing a lot of this work and so um you know you can find ways that well what do we do well currently and how do we increase capacity um to better meet demand as well as to increase revenue and then um another good um assessment tool is quantify your current behavoral health um uh Revenue so what is your current revenue from um Beal Health this might be doing report from uh you know your EHR or your Billing System about you know um visits um with primary um diagnosis of be health conditions like anxiety or depression you know there are different ways you can go about that but I think um you might be surprised that it really does uh constitute a significant part of your current um Revenue stream uh and then you know certainly survey your providers to assess their comfort level in managing baral health conditions so your primary care team you know collectively between your clinicians um whether they be Physicians or APS uh you know certainly for our practice we recognize and uh and honor that everyone is on um a Continuum of comfort and so it’s really about helping to support everybody uh not developing oh these are the people who do behavoral Health at our practice ideally uh that um that you provide a fairly consistent standard of care uh for your patients regardless of who may who they may see um in in your setting and then lastly examine your current um Beal Health workflows you know what changes could be implemented to improve screening rates um increase your appointment availability for behavoral health visit and to raise revenue so some of this might be you know at one uh you know working on the workflow for surveys right so um if you don’t currently have Universal surveys for phq9 or um Gad sevs to um evaluate for anxiety you know what are some ways that we could um change the workflow or at what point um during the appointment experience do the patients receive this information so that they can be um evaluated or um you know reviewed during the time of visit and so those are all things that are going to require multiple stakeholders and all members of your team whether it be and certainly actually these are the most important people you know everyone from um the receptionist who greets the patients to the people scheduling the appointments to your clinical team and certainly to your provider team all right and thank you so much um gosh I guess uh you know time flies when we’re having fun and certainly that was the case today Verna it was such a pleasure to be here with you and um suble and AMA uh thank you again for the opportunity uh to share in this discussion and we look forward to seeing everyone during our office hours where we can continue the discussion and we look forward to engaging with you absolutely I’m really um excited to see all questions in the chat and be able to follow up with everyone so I look forward to seeing you there and thank you Dr Boon it’s always a pleasure all right that concludes our presentation for today thank you to both our speakers for sharing their time as they mentioned please go ahead and check out that attendee chat it’ll be on the leth hand side of this webinar and we encourage you to check out additional resources on the steps forward website thank you everyone have a great day
This session of Private Practice Simple Solutions, part of the AMA STEPS Forward®️ Innovation Academy, is a four-week learning session that is focused on behavioral health integration in private practices. Topics addressed will include how to approach the work, needs of private practices, constructive tools & resources, and practical suggestions for integrating into your workflows.
Learn more: https://bit.ly/3RTh8cv
About Private Practice Simple Solutions 00:00:00
Goals of BHI and the Opportunity for your Practice 00:00:55
Perceived Barriers in Implementing BHI – 00:03:32
Evidence that BHI Works – 00:06:23
Considerations for Integrating BHI – 00:07:23
Optimizing Integrated Care – 00:11:57
Options for Integration – 00:14:39
Potential Revenue & Value – 00:18:06
Case #1 – 00:23:16
Case #2 – 00:28:26
Key Takeaways – 00:32:34
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