Integrating Behavioral Health into Wellness Visits in Pediatric Primary Care
Integrating Primary Care into Your Behavioral Health Practice
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Transcript of Integrating Primary Care into Your Behavioral Health Practice
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Integrating Primary Care into Your Behavioral Health
Practice
Dave Cook, LICSW, Chief Executive OfficerHeather Geerts, LICSW, Clinical Director
Scott Gerdes, Chief Financial OfficerCasey Langworthy, RN, Primary Care Nurse, Care
Coordinator
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Community Resource for Behavioral Health
• Providing behavioral health services to SE Minnesota since 1966– Therapy and
psychiatry– Regional detox unit– Residential/crisis
treatment facility– Community support
programs
• 150 total employees
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Community Resource for Behavioral Health
• Provide continuum of behavioral services to SE Minnesota and state-wide– Community mental
health center primarily for Olmsted, Fillmore county residents
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Unique Patient Demographics
Zumbro Valley Mental Health Center provides services to 5,000 people annually– 84% of these patients enrolled in publicly funded insurance
options– Medicaid expansion in 2014 will add 4,700 new enrollees in
Olmsted County Many of these patients have significant behavioral and
medical conditions– Over 70% of publicly funded patients diagnosed with serious
mental illness (SMI) or severe and persistent mental illness (SPMI)
– 1 of 3 patients utilize multiple services– More than 70% of patients seen in Psychiatry have a serious co-
morbid condition:• Morbid obesity
• Hypertension• Diabetes
• Asthma• Chronic pain• Heart disease
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Challenges
• Mental health centers across state facing variety of challenges – Low reimbursement rates for expanding
Medical Assistance and Medicare populations
– Growing need for treatment of people with dual diagnoses and co-morbid conditions
– Difficulty finding and retaining qualified behavioral health professionals
– Transforming care to meet rapidly changing demands of diverse populations
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Services Prior to Integrated Care Model
• Case management
• Adult Rehab Mental Health Services
• Homeless outreach
• Intensive Community Rehab Services
Community Support Programs
• Youth Behavioral Health
• Child Adult Relationship Enrichment
• Psychiatric services
Children's Services
• Psychiatry• Medication
management• Therapy -
individual and group
Outpatient Therapy
• Intensive Residential Treatment Services
• Crisis services
Residential
Services
• Detox• Recovery
programs• Choices
program (adults and adolescents)
Chemical Health
Services
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Adding to the Continuum of Care
April May June July August0
200
400
600
800
1000
QoL meds
Scripts
April May June July August0
50
100
150
200
250
Apple Tree Dental
Patients Visits
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Pre-Primary Care Model
•Case management
•Adult Rehab Mental Health Services
•Intensive Community Rehab Services
Community Support
Programs
•Youth Behavioral Health
•Day treatment•Psych services•Detox
Children's Services
•Psychiatry•Therapy - individual and group
Outpatient Therapy
•Intensive residential treatment
•Crisis services
Residential Services
•Detoxification•Recovery programs
•Choices program (adults and adolescents)
Chemical Health Services
Pharmacy
Dental Electronic M
edical
Record
Intake
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Co-morbidity is the Rule, Not the Exception
• Data-mining of Electronic Medical Record revealed 74% of psychiatric patients diagnosed with serious medical condition
• Research shows that people living with serious mental illness die an average of 25 years earlier than the general population1
– Lack of access to primary medical care
– Preventive health services
47.2%21.5%
16.4%
Likelihood to Use Zumbro Valley for Primary Care
Very Likely Likely Somewhat Likely1 Colton, CW, Manderscheid, RW. “Congruencies in Increased Mortality Rates, Years of Potential Life Lost and Causes of Death among Public Mental Health Clients in Eight States.” Preventing Chronic Disease, vol. 3, no. 2, 2006.
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Co-morbidity is the Rule, Not the Exception
• Integrated model of care incorporates mental health, chemical health, case management, housing, dental and pharmacy services with primary care
• Goal is to significantly improve clinical outcomes for area’s underserved populations
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Steps Toward Integration - Research
• Mental disorders and medical co-morbidity– The Synthesis Project.
Robert Wood Johnson Foundation. 2011.
– Basis for project rationale
• Correlation between childhood maltreatment and later-life health and well-being– Adverse Child Experiences
(ACE) Study. Centers for Disease Control and Prevention. 2010.
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Steps Toward Integration – Pre-Planning (Phase 1)
• A pre-planning group of community leaders, Zumbro Valley staff and board members was assembled to discuss the research and subsequent efforts to address the problem
• Zumbro Valley conducted an internal patient survey and review of records that determined approximately 85% of psychiatric clients have a serious co-morbid medical condition
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Steps Toward Integration – Pre-Planning (Phase 1)
• Conduct literature review on the service models for integrated care
• Evaluate how primary care services have successfully been integrated in community mental health centers within Minnesota and other parts of the country
• Determine the financial model required for operation
• Develop the space and specifications needed for on-site services
• Explore the need for other resources
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Steps Toward Integration – Planning (Phase 2)
• Developed on-going Community Advisory Committee to assist Zumbro Valley board and leadership team in the development and implementation of the Primary Care Clinic Mayo Clinic Olmsted Medical
Center Olmsted County Rochester Area
Foundation MN Dept. of Health Olmsted Public Health United Way of MN Dept. of Human
Olmsted County Services
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Steps Toward Integration – Planning (Phase 2)
• Committee agreed community required integrated care model and primary care services for area’s under-served populations Hired consultant to develop business plan
and assist with financial pro forma Developed guiding principles, goals,
performance outcomes, community benefits, etc.
Formalized clinical model of care, with clinical integration manager serving as hub
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Steps Toward Integration – Planning (Phase 2)
• Trust major issue for target population– People diagnosed with
a serious mental illness significantly less likely to trust others
– Lack of follow-through by these clients with community medical providers
– Survey found clients view Zumbro Valley MHC as their primary care provider
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Steps Toward Integration – Planning (Phase 2)
• Planning workgroup developed project goals to assess short- and long-term outcomes– Improve health outcomes by enhancing the diagnosis of
chronic health conditions and providing treatment of these conditions
– Improve quality of health by increasing focus on wellness and healthy lifestyles
– Provide person-centered care and whole-person-centered care approaches
– Contain health care costs– Improve care coordination between behavioral and
primary care services– Improve the patient experience
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Steps Toward Integration - Implementation
Clinical
Integration
Manager
Mental
Health
CD/
Detox
IRTS
ARMHSCase
Managem
ent
Children
Services
CSP
Referral Source
Call to Zumbro Valley
Hunt Line
Pharmacy
Denta
l
Primary Care
Clinic
Electronic M
edical
Record
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Steps Toward Integration - Implementation
• The Primary Care Clinic team consists of a primary care provider (nurse practitioner) and support staff (registered nurse) Perform ancillary services –
vital signs, measuring BMI, etc.
Process lab samples and send out for results
Provide medical exam and any ongoing care
Refer patients to community specialty care providers
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Steps Toward Integration - Implementation
Current Model• RN care coordinator performs both
clinical and care coordination duties• Primary responsibilities:– Performs triage of new and ongoing patients
to determine level of care needed– Coordinates care for clinic patients with
internal and external providers– Provides regular follow-up contact to affirm
adherence to treatment plan
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Steps Toward Integration - Implementation
Future Model• Primary care clinic also has an intake
worker (BA level social worker) to assist with care coordination
• Primary responsibilities:– Answer calls within 30 seconds– Triage level of care needed: crisis, urgent,
routine– Arrange for logistics: transportation,
community resources, insurance enrollment, etc.
– Make appointment reminder calls
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Steps Toward Integration - Implementation
• Each new patient is assigned a clinical integration manager (nurse practitioner or clinical social worker) for the course of treatment
• Primary responsibilities:– Conduct diagnostic assessment– Triage risk level: high, medium, low– Monitor and evaluate risk levels– Refer to appropriate behavioral/medical
provider– Lead weekly clinical care conferences– Track patient outcomes
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Steps Toward Integration - Benefits
• Improved quality of life for clients– Increased medical and
behavioral compliance– Wellness programs
that compliment medical and behavioral services
– Ability to share clinical information via EMR
– Improved overall health and well-being
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Steps Toward Integration - Benefits
• Appropriate Level of Care = Reduced Costs– Reduced ER visits and
inpatient hospital days– Decreased utilization of
after-hours crisis/ambulance services
– Visits can be routine (primary care) rather than acute (emergency department)
– Fewer psychiatric visits due to medical stability
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Steps Toward Integration - Benefits
• Enhanced Access to Care = Improved Outcomes Proper medical care contributes to overall housing
stability Improved medical health results in better overall
health of clients Ability to share clinical information with other
health care providers via electronic medical record
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Steps Toward Integration - Payment
• Developing a strong financial pro forma key to successful plan Where do we start? What pieces are
different than mental health?
What CPT codes do we need to include?
How is productivity different?
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Steps Toward Integration - Payment
• Developing a financial pro forma – where to start?– Examination of payer mix– Research Evaluation and Management (E/M)
codes to identify appropriate types and levels– Review Medicare and Medicaid
reimbursement rates for selected services– Determine billing rates for medical services
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Steps Toward Integration - Payment
• Developing a financial pro forma – start-up costs?– Building space– Supplies– Equipment– Furniture
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Steps Toward Integration - Payment
E/M Codes
ZVMHCCoding
Distribution
Medicaid Fee
Schedule
Volume Year 1 (85%)
Year 2 (100%)
Year 3 (100%)
Year 4 (100%)
99201 0% $49.25 0 $0 $0 $0 $0
99202 3% $61.61 15 $2,379 $2,828 $2,870 $2,971
99203 29% $88.28 145 $30,996 $37,644 $38,209 39,552
99204 64% $134.43 320 $104,448 $126,594 $128,493 $133,009
99205 4% $166.53 20 $8,075 $9,767 $9,934 $10,283
New Patient Codes
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Steps Toward Integration - Payment
E/M Codes
ZVMHCCoding
Distribution
Medicaid Fee
Schedule
Volume Year 1 (85%)
Year 2 (100%)
Year 3 (100%)
Year 4 (100%)
99211 0% $29.25 0 $0 $0 $0 $0
99212 7% $36.11 140 $12,257 $14,636 $14,856 $15,079
99213 32% $59.62 640 $92,480 $110,432 $112,088 $113,770
99214 54% $87.99 1,080 $228,582 $272,954 $277,048 $281,204
99215 7% $117.80 140 $39,627 $47,319 $48,029 $48,750
Established Patient Codes
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Steps Toward Integration - Payment
Zumbro Valley MHC – Primary Care Financial Pro Forma (Revenue)
Year 1 Year 2 Year 3 Year 4
Primary Care Services $518,844 $619,581 $628,875 $638,308
Lab Services $0 $0 $0 $0
Gross Revenue $518,844 $619,581 $628,875 $638,308
Collection Ratio 41.1% 41.1% 41.1% 41.1%
Net Revenues $213,036 $254,399 $258,315 $262,088
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Steps Toward Integration - Payment
Zumbro Valley MHC – Primary Care Financial Pro Forma (Expenses)
Year 1 Year 2 Year 3 Year 4
Salaries $288,100 $296,743 $305,645 $314,815
Benefits $87,150 $98,667 $110,796 $114,120
Locum Coverage $30,000 $30,000 $30,000 $30,000
Supplies (1% gross revenue) $5,188 $6,196 $6,289 $6,383
Other Lab Expense $0 $0 $0 $0
MNCare Tax $5,166 $6,169 $6,262 $6,356
Malpractice Ins $800 $1,200 $1,200 $1,200
Interest $10,139 $8,860 $7,511 $6,086
Depreciation $11,000 $11,000 $11,000 $11,000
Admin $55,414 $58,272 $60,795 $62,225
Total $492,957 $517,107 $539,498 $552,184
Net Revenues $213,036 $254,399 $258,215 $262,088
Net Profit/(Loss) ($279,921) ($262,708) ($281,283) ($290,096)
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Steps Toward Integration - Payment
• Developing a financial pro forma – other costs?– Services and coding– Fee matrixes for primary care – Lab service integration
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Steps Toward Integration - Payment
• Model for financing publically funded primary care clinic has many financial challenges Low reimbursement
rates from Medicare, Medicaid do not support expenses
Low reimbursement levels = requires higher volume of clients
Tax status change (MNCare)
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Steps Toward Integration - Payment
• Zumbro Valley utilized variety of sources to pay for clinic– Obtained funding from Minnesota State
Legislature to pilot integrated care model– Applied for and received multiple grants from
local, state and national sources to help offset operational expenses
– Explored opportunities to obtain FQBHC, health home and behavioral health home status for higher reimbursement of services
– Received equipment donations from community sources such as Mayo Clinic
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Steps Toward Integration - Challenges
• Project – and Qualifacts system – are using a variety of measurements to determine outcomes– Meaningful Use– Physician Quality Reporting System (PQRS)– E-Prescribing (DrFirst)– DSM-5/ICD-10 cm enhancements– Minnesota 10x10 Initiative (Minnesota MHIS)– Minnesota Depression Care and Diabetes
management
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Steps Toward Integration - Challenges
• Other Challenges – Electronic Medical Record– Configuring Carelogic to bill primary care services
required close working relationship with QSI– Key tasks included
Creating new EDI file to accommodate Minnesota Administrative Uniformity Committee
Setting up overlapping E/M codes for primary care services Organizing CPT codes and other activities Creating pricing structure based upon market data Modifying program history for admitting diagnosis Mapping new National Provider Identifier number to all
services
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Steps Toward Integration - Challenges
• Other Challenges – Laboratory services– Identify lab provider (Quest
Labs) who can interface with system
– Utilize web portal to transact information on patient lab results, submit orders, review results, etc.
– Billing for laboratory services
– Determine how payers reimburse for lab services
– Discuss use of new e-Labs program with Qualifacts
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Steps Toward Integration - Challenges
• Other Challenges – Third party contracting– Negotiate agreements
with payers to reimburse for medical codes
Medicaid Medicare Others – Blue Cross
Blue Shield, Optum, MMSI (Mayo), UCare Minnesota, South Country
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Steps Toward Integration - Challenges
• Other Challenges - Clinical Found there were numerous cultural
differences between medical and mental health settings
Success of integrated model dependent upon availability and willingness for cross-consultation
Need for seamless connection with external specialty care providers for complex care needs
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Steps Toward Integration - Challenges
• Other Challenges – Staff and training– Staffing
Identify right number of people and appropriate positions
Budget for productivity Determine type of clinicians/licenses to properly bill
for services
Training Prepare appropriate documentation Have provider choose the right codes Conduct ongoing training and note review
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Steps Toward Integration - Challenges
• Other Challenges – Care coordination and patient registry– Coordinate with area health care providers to
transition care back and forth– Use of weekly clinical conference to discuss
highest-need patients with all applicable personnel
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Steps Toward Integration - Outcomes
• Clinic staff has seen nearly 100 people since opening in December 2013
• Expanding services at 7th Street office– RN to be available
8 hours per week
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Steps Toward Integration - Outcomes
• Development of patient registry critical element to gauge success Track patients with
specific chronic conditions
Allow for appropriate patient staffing
Determine who, if anyone, is “falling through the cracks”
• “Jane’s Story”
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Steps Toward Integration - Outcomes
• Measurement of clinic outcomes was core principle from project initiation– Contracted with third party – Wilder Research
– to measure outcomes– Wilder staff will present results of 2-year study
to Minnesota Legislature in 2015
• Collaborative effort to gather data Minnesota Department of Human Services Wilder Research Team Rochester Epidemiology Project
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Steps Toward Integration – Lessons
• Important lesson learned throughout process has been having the right partners– Company with a vision– Roadmap for the future– Knowledgeable program
staff– Supportive agency
environment• Key to success of project
has been willingness of QSI and its staff to provide assistance
• Be flexible about model and funding
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Steps Toward Integration - Milestones
• 2011– January: added pharmacy and dental services– July: began research of Robert Woods Johnson
Synthesis Project and Adverse Childhood Experience (ACE) studies
– September: implemented Community Advisory Committee
• 2012– January: formalized internal integration activities– June: submitted grant request to SAMHSA– July: began meetings with state leaders– July: entered Phase 2 of project and hired consultant
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Steps Toward Integration - Milestones
• 2012 (continued)– October: received financial support from Community
Advisory Committee members– January – December: presented to local and regional
organizations
• 2013– January: completed business plan and Olmsted County
designated our project as a key initiative for legislative session
– July: received appropriation from State of Minnesota– August: combined internal integration activities
• 2014– January - September: received grants from Mayo
Foundation, Merchants Bank, Schmidt Foundation, Medica Foundation
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Questions?
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For More Information…
• David Cook, LICSWChief Executive Officer507.535.5718 or [email protected]
• Heather Geerts, LICSWClinical Director507.535.5745 or [email protected]
• Scott GerdesChief Financial Officer507.535.5717 or [email protected]
• Casey Langworthy, RNPrimary Care Nurse/Care Coordinator507.535.5616 or [email protected]