Learning best practices from the three winners of TAFP’s Behavioral Health Integration Innovators Competition
By Jonathan Nelson
Family physicians know all too well how difficult depression can be for patients. According to the Centers for Disease Control, almost 8% of Americans ages 12 and older are estimated to suffer from depression for at least two weeks each year. Only a fraction of those receive any treatment and often the treatment is inadequate. For patients with one or more chronic conditions, depression just makes things worse.
Patients with diabetes and depression have a 50% higher mortality rate, a 30% higher likelihood of losing a limb, and significantly worse glucose control than patients with diabetes alone. Their medical costs are much higher, too. Medical expenditures for patients with diabetes and depression are more than 4 times higher than for patients with diabetes alone.
Behavioral health conditions like depression pose particularly frustrating problems for busy primary care physicians trying to provide the best care for their patients. David Bauer, MD, PhD, is the director of the Memorial Family Medicine Residency Program in Sugar Land, Texas, one of the winning clinics in TAFP’s Behavioral Health Integration Innovators Competition. He says behavioral health and physical health are inescapably intertwined, each affecting the other, yet medicine has traditionally separated the two.
“The question has always been, well, yeah, we know [depression] is there, but what do we do with it? Are we really trained to recognize it? Are we trained to manage it? Do we have the time to manage it?”
In the traditional model when a patient tells a family doctor they’re depressed, the physician either starts the patient on an antidepressant or refers the patient to a therapist, he says. “Then you never hear anything back and 50% of the time, they don’t even go.”
Lack of adherence to medication directions and the stigma patients may feel about seeing a therapist are major barriers to behavioral health treatment. In many communities, access to psychiatric services for referrals doesn’t even exist. Many primary care clinics around the country have found success by integrating behavioral health services into their practices and there are some excellent models and resources out there to help physicians who want to give it a try.
Basic components of a collaborative care model
Integrating behavioral health services into a primary care practice generally means bringing care managers or behavioral health consultants into the clinic to provide counseling and enhanced patient engagement. In 2017 the Centers for Medicare and Medicaid Services introduced a set of CPT codes to pay for behavioral health services in primary care through the Psychiatric Collaborative Care Model. The guidelines and requirements to use those codes constitute a good check list for integrating behavioral health.
The Psychiatric Collaborative Care Model includes a care team consisting of:
- a treating physician or other practitioner who will bill for services;
- a behavioral health care manager who has training in social work, nursing, or psychology; and
- a psychiatric consultant who is not required to be on site.
- The service components of the model include:
- an initial assessment by the physician and the health care manager complete with the administration of a validated rating scale, like the PHQ-9 (Patient Health Questionnaire) or GAD-7 (Generalized Anxiety Disorder);
- care planning by the care team and the patient, with revisions to the plan if the patient isn’t improving adequately;
- proactive and systematic follow-up by the behavioral health care manager with the patient using validated rating scales and a registry; and
- case reviews with the psychiatric consultant occurring at least weekly.
The process is more complex than this brief overview but these are the main components of the model. The Medicare Learning Network offers a booklet entitled “Behavioral Health Integration Services” that provides more detail on the roles of the care team members, the requirements of the services, and how to use the codes to bill for the monthly behavioral health fee.
Behavioral Health Integration Innovators Competition
Last year TAFP put out a call to Texas primary care practices asking them to submit their models of behavioral health integration for the chance to win $10,000. Entries were judged by the TAFP Behavioral Health Task Force, which was appointed after the Academy identified the need for greater integration of behavioral health services in primary care as a top priority in its strategic plan.
The task force members selected winners in each of three care settings: academic health centers, integrated health systems, and solo and small group practices. Thirty practices entered the contest. The winners were the Memorial Hermann Medical Group Physicians at Sugar Creek and Memorial Family Medicine Residency Program of Sugar Land in the academic setting category, the Heart of Texas Community Health Center of Waco in the integrated health systems category, and the Hope Clinic of McKinney in the small group and solo practice category.
The task force also developed TAFP’s new Behavioral Health Integration Toolkit to help members provide these services to their patients.
Winners of TAFP’s Behavioral Health Integration Innovators Competition
Winner in the Academic Setting Category:
Memorial Hermann Medical Group Physicians at Sugar Creek and Memorial Family Medicine Residency Program
The Memorial Hermann Medical Group Physicians at Sugar Creek has been providing integrated behavioral health services to their patients through a collaborative care model since 2009. Their collaborative care team includes more than 50 primary care physicians, a full-time psychologist, and a clinical care manager, along with support and administrative staff. The clinical care managers they’ve employed have been licensed clinical social workers and licensed professional counselors. They also retain a few hours each week with an off-site psychiatrist who consults with the care team about the registry of enrolled patients, with a special focus on challenging cases.
According to their contest entry form: “The broad goals of the program are to more effectively meet the mental health needs of patients, improve the physical health and overall functioning of patients with co-morbid physical and mental health problems, and improve the efficiency of the clinic by more accurately targeting services.”
The program focuses on depression and anxiety, and it is based on the IMPACT model, or Improving Mood: Providing Access to Collaborative Treatment. The AIMS Center at the University of Washington Department of Psychiatry and Behavioral Sciences developed the model during the IMPACT study, which was the “first large randomized controlled trial of treatment of depression,” according to the center’s website. It took place from 1998 to 2002 with results published in JAMA in December 2002. Patients who received the IMPACT collaborative care were twice as likely to show improvement in their depression and total health care costs were lower for them. The AIMS Center says it has trained more than 6,000 clinicians around the world to implement collaborative care.
The model involves:
- care coordination using a behavioral health coordinator who is embedded in the practice;
- monitoring patients to make sure they are meeting goals;
- treating patients to target; and
- sharing progress and information regularly with the care team.
When new patients come to the clinic or each time they come in for a wellness visit, they complete a PHQ-2. If they screen positive, they proceed to screen with the PHQ-9 and GAD-7 assessments. Once the care team identifies someone as having depression or anxiety, the physician invites the patient to participate in what they call the Care Program. If the patient agrees, they are introduced to the therapist and scheduled for an intake visit.
After the initial consultation, the clinical care manager generates a summary of the visit that includes PHQ-9 and GAD-7 scores along with suggestions for interventions. The referring physician receives the report in their EHR. Patients can be treated with medication, therapy or both. A psychiatrist provides consultation to the care manager and primary care physicians, especially focusing on cases in which patients aren’t responding as hoped. Patients receive follow-up visits in person or by phone from the care manager and the care team tracks patients using a data registry system.
Back in 2008, Bauer says the clinic saw many patients with chronic diseases compounded by depression and anxiety, and the usual practice of prescribing and referring them out for treatment of those behavioral health disorders wasn’t working sufficiently. “It had been such a huge problem. Terrible outcomes for patients and very unsatisfying.”
Then they learned about IMPACT and secured a grant to bring a representative from the University of Washington to demonstrate the model. “Once we knew the process, we had to make sure we were getting patients identified,” Bauer says. That’s when they began universal screening of patients for depression and anxiety, embedded a behavioral health specialist, and launched the program.
From 2009 to 2017, grant funding covered the cost of the program. The end of the grant coincided with the introduction of the CMS psychiatric collaborative care codes so they can now bill monthly for services in the program.
For more than 10 years, the Memorial Hermann Medical Group Physicians at Sugar Creek has maintained an excellent and consistent record of success in improving their patients’ health through the Care Program. Before its implementation, they report patients achieved a 29% reduction in PHQ-9 scores, whereas with the program, patients’ scores go down by 50% after three months. Patients in the program have significantly fewer primary care visits than they did before enrollment, going from 1.8 visits per month to 0.5 visits per month after being enrolled for three to six months. The clinic reports that after six months in the program, 67% of patients are at goal for LDL cholesterol, up from 50% at intake. They report similar results in diabetes control, with the percentage of their patient population having HbA1c levels of less than 9% improving from 59% to 80% after 6 months.
One question from the contest application asked how integrating behavioral health services had changed their practice, and the response from the Physicians at Sugar Creek reveals another reason to implement such a program. “Our integrated behavioral health program has given us the opportunity to work side by side with a variety of behavioral health providers. In addition to the improved outcomes, it has made our physicians more comfortable handling the treatment of mood disorders as part of routine primary care. Given that we are a residency training site, having integrated behavioral health has exposed hundreds of trainees to the model. We hope this will normalize working with behavioral health providers as well as increase our residents’ confidence in handling patients with mood disorders as they go out into practice.”
Every year, 14 new residents gather for orientation at the Memorial Family Medicine Residency Program and they are told about the Care Program, “along with about 6,000 other things,” Bauer says. “So, of course, they’re shell shocked. The first time we precept with them when there’s a patient they’ve identified as depressed, one of the things we’ll say is, ‘Have you thought about the Care Program?’ and their eyes just light up. It really is so well accepted now and the residents are grateful for it, to have that resource for their patients.”
Even though MHMG Physicians at Sugar Creek is a large practice with more than 50,000 patient visits a year, Bauer believes integrating a similar collaborative care model in small and even rural practices can be achieved. A few practices could share the services of a behavioral health care manager and a psychiatric consultant, and employing telemedicine for the therapy sessions and behavioral interventions is an option for remote areas.
In the closing statement of their contest application, the MHMG Physicians at Sugar Creek expressed the same sentiment that led TAFP to host the innovators competition. “We have seen the effect collaborative care has had on patients’ health, physicians’ comfort treating behavioral health conditions, and on tightening the connection between mental and physical health. We hope our experience can convince our family physician colleagues that a collaborative care model is effective, feasible, and financially viable for a variety of practice settings and patient populations so that we can increase access to behavioral health services and effective treatment of depression throughout the state of Texas.”
Winner in the Integrated System Category:
Heart of Texas Community Health Center
Heart of Texas Community Health Center has developed a behavioral health program they call Integrated Health Management, which they employ to care for their 59,000 active patients in Central Texas. Headquartered in Waco, HOTCHC is a federally qualified health center with 14 clinical sites and a family medicine residency program that trains 36 residents. The health center has a longstanding commitment to providing comprehensive care to a socioeconomically vulnerable population.
Lance Kelley, PhD, is a clinical psychologist and the Human Behavior Mental Health Director for HOTCHC. He says seven years ago, he and his colleagues became concerned about the high prevalence of mental health conditions they were seeing among their patients and the relationship between those conditions and the physical health problems patients experienced. Patients were reluctant to seek specialty mental health outside of the primary care setting, and there was a growing lack of access to those services.
In 2014, Kelley and some of his colleagues put together a behavioral health leadership team to plan and implement a behavioral health integration program. They developed a blended model, merging the roles of behavioral health provider and care manager into a single professional position they call the integrated health manager. This person is a licensed clinical social worker who has been trained to perform integrated behavioral health and chronic care management in the primary care setting.
“IHMs are core members of the primary care team, working alongside physicians, nurse practitioners, and physician assistants in a shared-care model to enhance primary care and improve population and behavioral health outcomes,” Kelley wrote in the award application.
Each day, physicians, nursing staff, and the IHM huddle and identify patients on the schedule who would benefit from behavioral health treatment. Then the IHM joins the physician when seeing those patients. The IHM engages the patients in brief psychological interventions, health behavior counseling, chronic disease care planning, and a host of other activities to address their mental health and chronic care needs. The IHM also follows up with patients over the phone or through secure electronic messaging to check on them and make sure they are adhering to their treatment plans.
HOTCHC employs 10 full-time IHMs plus an IHM trainer. “The trainer is key in all of this,” Kelley says. “We spent almost an entire year with our trainer before we went live with our system.” All new IHMs spend eight weeks in a personalized training program, including four weeks working as an apprentice with the trainer in the residency training clinic. For the last month, IHMs train with their intended clinic team while the trainer helps customize the clinic workflow and coaches the team on how to maximize the model.
“We quip around here that we want [IHMs] to be really bright and wear running shoes,” Kelley says. “The work is really fast-paced and you have to have someone who is both going to always have the drive to learn more and know more, but not be so paralyzed by the generalist nature of primary care that they can’t act. They need a tolerance for uncertainty.”
HOTCHC also has developed psychopharmacology decision support tools to ensure their providers can access clinically proven treatment regimens that are consistent with general family medicine practice and vetted by content experts in psychiatry. The academic faculty at HOTCHC collaborated with a team from the Harvard Medical School Department of Psychiatry to develop the treatment algorithms. Kelley says HOTCHC is currently in the process of making these tools available to physicians outside their system. They are even developing an app, so stay tuned.
They have also designed stepped care intervention programs to respond to patients with more complex mental health disorders, including a co-located specialty behavioral health clinic staffed by a physician and a clinical psychologist. “Primary care physicians can refer patients for short-term diagnostic clarification and treatment planning. This consultation clinic does not retain patients long-term, but refers patients back to their family doctor for ongoing management, usually after fewer than four mental health visits,” Kelley wrote in the award application.
Having such a robust integrated behavioral health program greatly enhances the residency experience for family medicine residents in training. “Here we say the clinic is the curriculum,” Kelley says. Since its founding, the Waco Family Medicine Residency Program has instilled a culture of service dedicated to recruiting and training physicians to care for underserved and vulnerable populations. “Having master experiences while you’re in residency is really empowering for you,” he says. “It gives you the confidence to detect things you might not detect otherwise. We are less likely to look for something if we don’t feel we can offer much if we find it.”
The Integrated Health Management program at HOTCHC hasn’t just been a success for the people of Central Texas. It’s been great for the health care providers, too.
“We have found that implementing this model has increased joy and satisfaction in practice because I think it allows for our family medicine doctors to get closer to providing the kind of care they really want to provide.”
Winner in the Small Group and Solo Practice Category:
Hope Clinic of McKinney
Almost four years ago, a pastor in McKinney, Texas, came upon a man lying in a ditch. The man was experiencing homelessness and had mental health problems, along with other chronic health conditions. The pastor wanted to help but, in that moment, he couldn’t find any health resources aside from an emergency room, which the man initially refused, afraid they might amputate his gangrenous legs.
After this encounter, the pastor approached a member of his church, Stephen Twyman, MD, MPH, and said, “Let’s open a clinic and let’s not charge anything.”
That’s how Twyman told the story when he described his award-winning integrated behavioral health program to attendees of TAFP’s 2019 Annual Session and Primary Care Summit.
In 2017, Hope Clinic of McKinney opened its doors to serve uninsured patients who are at or below 200% of the federal poverty level. They provide a medical home to more than 400 patients and are expanding quickly, according to Twyman. They have three full-time staff, two part-time staff, and more than 90 active volunteers, including physicians, nurse practitioners, nurses, social workers, and more. Hope Clinic is a faith-based organization and it is funded entirely through grants and donations.
To assess which patients could benefit from behavioral health services, the clinic has a strategic partnership with UT Southwestern Center for Depression Research and Clinical Care to implement VitalSign6, a comprehensive program the school designed to help identify and treat depression and anxiety in the primary care setting. “The cool thing about VitalSign6 is it really gave us a turnkey solution,” Twyman says. “All the things we needed were already there.”
The platform comes complete with validated assessments, iPads for data entry, measurement-based care tools to track patient progress, and clinical decision support. Plus, Hope Clinic providers can access psychiatric consultation through the partnership.
According to the UTSW website, patients using the VitalSign6 platform complete the PHQ and other systematic assessments “on an iPad during the triage process, thus making screening for depression the sixth vital sign after body temperature, pulse rate, respiration rate, blood pressure, and pain.”
The data is immediately accessible to the clinic’s providers and the VitalSign6 team at UTSW, and the program provides clinical support to the providers as they treat patients with depression, anxiety, and other behavioral and mental health conditions. “What that does is it helps us standardize the care we’re providing and make sure we’re actually following the best evidence for our treatment,” Twyman says.
The clinic employs a bilingual licensed professional counselor who sees patients often in back-to-back visits with their primary care provider. The LPC and provider both have access to the electronic health record, so they can share notes and track progress toward treatment goals. The LPC touches base frequently with patients to encourage medication and treatment adherence, to remind them of upcoming counseling sessions, and just to check in.
Patients can use a patient portal in the EMR to directly contact their providers and clinic staff with concerns, questions, refill requests, and other issues, but many patients of Hope Clinic have limited or sporadic access to the Internet. In January 2019, the clinic introduced a secure messaging platform, Care Message, which lets patients access their providers via text message.
Twyman says implementing an integrated behavioral health program at the heart of a free clinic has helped remove the stigma associated with mental health among patients and providers alike. “I’m a big believer in being as comprehensive of a doctor as I can be. I think there’s good data to suggest that the more comprehensive family doctors can be, the better outcomes their patients have and the lower costs their patients have. Behavioral health interacts with every other aspect of a patient’s life.”
He knows the patients at Hope Clinic are getting better. His data shows that “44% of patients who initially screened positive for and were subsequently diagnosed with major depressive disorder or other mental health disorders have since achieved remission.” That compares to a national rate of about 25%. “Our patients are getting better and we are excited to share what we’ve learned,” Twyman wrote in the contest application.
One such patient in his early 30s came to the clinic with anxiety, depression, high blood pressure, and obesity. Twyman told attendees at TAFP’s 2019 Annual Session and Primary Care Summit: “He came to us and he said, ‘I don’t know what to do. I can’t keep a job. I’m so anxious I can’t do my normal activities. I find myself worrying myself to death and I just can’t work.’”
It took five visits, Twyman says, but through counseling and treatment, he now has had a steady job for almost a year. His blood pressure is under control and he’s lost 30 pounds. His depression and anxiety are much better. “You know, that’s the reason we do this. He is one example of why we cared to integrate behavioral health into our clinic, why we care to try to do wrap-around services. … This has been a really rewarding part of our practice and it’s really enhanced the level of care we can offer to our patients.”