UPlift Collaborative Care

Need

The integration of mental/behavioral health services with primary care (behavioral health integration or BHI) is widely considered to be an effective strategy for improving outcomes for patients with mental health or behavioral health conditions. Research indicates that BHI reduces self-reported levels of depression and medical visits for behavioral health symptoms[1], that collaborative chronic care models can improve mental and physical health outcomes[2]^,[3], and that collaborative treatment models decrease the total health care cost of patients with behavioral health symptoms. [4]

The need for better access to behavioral health care is especially acute in the rural counties of Michigan’s Upper Peninsula (UP). 14 out of 15 UP counties are designated as mental health – Health Professional Shortage Areas (HPSAs) by the Health Resources and Services Administration (HRSA). Luce and Schoolcraft counties are designated “high needs” (i.e. meets one of HRSA’s criteria demonstrating higher than normal need).[5] According to the 2018 Upper Peninsula Community Health Needs Assessment, 8 full-time psychiatrists serve the population of 311,000 and nearly all primary care providers surveyed indicated that their patients encounter long waitlists when attempting to access external behavioral health resources.[6]

Approach

To alleviate the problem of mental health provider shortages, Upper Peninsula Health Care Solutions, Inc. (UPHCS) proposes utilization of the Agency for Healthcare Research and Quality: Integrating Behavioral Health and Primary Care Playbook to pilot BHI in two UP rural primary care settings. The project will initially focus on the introduction of specialized behavioral health care management into project participating clinics by establishing behavioral health integrated care teams (BH Care Teams), providing trainings on reimbursable BHI services and evidence-based quality improvement models (including LEAN and Model for Improvement), and establishing a replicable set of policies and procedures to support BHI workflows and billing.

Ultimately, UPHCS will encourage participating clinics to use the, CMS approved, Psychiatric Collaborative Care Model (CoCM) to provide additional care management services and capture additional BHI revenue. CoCM is a billable model of BHI that enhances primary care by including regular psychiatric inter-specialty consultation in addition to specialized behavioral health care management, especially for those patients for whom symptoms are not improving.

UPHCS will ask participating clinics to commit at least one treating (billing) physician or non-physician practitioner (PA, NP, CNS, CNM) and at least one mid-level provider or MSW as behavioral health care manager (BH Care Manager) to be a part of the BH Care Team. BH Care Teams will take part in five one-hour, continuing medical education credit eligible, team-based learning, online modules. BH Care Managers will also obtain a University of Michigan School of Social Work – Integrated Behavioral Health and Primary Care Certificate (consisting of 15, 2-hour, live online sessions and 20 hours of self-paced content that is eligible for 50 CME credits) and The Association for Rural and Community Health Professional Coding Webinar on documenting and coding for behavioral health services. UPHCS will work closely with BH Care Managers to document BHI processes and workflows and to develop a BHI patient panel.

In addition to online training, UPHCS will include case-based learning via the Extension for Community Health Outcomes (ECHO) model. These one-hour, CME eligible sessions will connect BH Care teams with peers and with specialists in BHI via teleconferencing technology to address topics that the teams select and develop. Sessions will be organized into multiple four-part series and BH Care teams will present de-identified cases for discussion.

Launched in 2003, the ECHO model offers a way for primary care providers in underserved areas to develop expertise in addressing the behavioral health issues of primary care patients by building capacity to treat common, complex conditions via mentorship and case-based learning. Participants in a psychiatry ECHO program reported that feedback was highly valuable and led them to make improvements to their care plans more than 75% of the time and that the model may be more effective than traditional CME approaches.[7] ECHO-supported programs have been able to provide and bill for higher levels of care, to retain patients they otherwise would have referred elsewhere, and to receive reimbursement for collaborative care. UPHCS is in talks with University of Michigan to establish an ECHO team of psychiatrists and BHI experts.

Pending grant funding, UPHCS will provide resources to train the BH Care Manager (including partial employee compensation and benefits), for contracted telepsychiatry, and for any necessary video conferencing hardware and software. In order to assess project progress and impact UPHCS will collect de-identified data on the BHI patient panel at each participating clinic. BH Care Teams will be asked to participate in regular surveys and focus groups.

For more information on integrating behavioral health services into your clinic, CLICK HERE contact Kristie Hechtman or call (906) 225-7166.

Timeline

Year 1

Establish and train at least two BH Care Teams that each include at least one treating physician or non-physician practitioner AND at least one BH care manager.
Identify behavioral health integration patient panel and establish benchmark outcome objective data.
Document clinical protocols and workflows regarding behavioral health integration.

Year 2

Complete three ECHO series on topics chosen by the behavioral health integration teams.
ECHO series will be four 1-hour sessions and at least one case presentation by each BH Care Team.
Make improvements to clinical protocols and workflows regarding behavioral health integration.
Extract and analyze outcome objective data.

Year 3

Establish and train at least one additional behavioral health integrated care team at an additional clinic.
Consider long-term integration of telepsychiatry including provider consultation and direct psychiatric provider to patient interactions.

Footnotes

[1] https://www.integration.samhsa.gov/Primary_Care_Behavioral_Health_Consultation_Reduces_Depression.pdf

[2] https://doi.org/10.1176/appi.ajp.2012.11111616

[3] http://www.cochrane.org/CD006525/DEPRESSN_collaborative-care-for-people-with-depression-and-anxiety

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3810022/

[5] https://data.hrsa.gov/tools/shortage-area/hpsa-find

[6] http://www.wupdhd.org/wp-content/uploads/2018/08/Upper-Peninsula-Community-Health-Needs-Assessment-2018-Second-Edition-1.pdf

[7] https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600471