The Solution: An Integrated Model

To improve the ability of community health centers to provide behavioral health services, HFP addressed the issue of access from both a systematic and cultural perspective, looking at issues of capacity and the stigma attached to receiving treatment. The behavioral health integrated model brings the work of the behavioral health specialist into the primary care setting of health centers by making specialists a part of the primary care team and allowing them to see more patients with shorter, more problem-focused visits. The behavioral health integrated model “fits” with the way that primary care is practiced — it is fast-paced, population-based care that is both preventive and therapeutic. Behavioral health specialists document their care in the medical record, alongside the primary care notes, using a notation format familiar to PCPs.

When the PCP notices a behavioral health issue affecting a patient during the course of an examination, the provider calls in the team’s behavioral health specialist for a consultation. The specialist can provide the following services (HFP 2009b):

• Assessment and diagnosis
• Psychoeducation for the patient and the patient’s support network
• Development of a short-term behavioral plan
• Referrals or suggested prescriptions as necessary
• Patient education
• Behavioral activation
• Relaxation/stress reduction
• General coping strategies
• Pain management
• Supportive listening
• Cognitive techniques
• Problem solving/Goal setting
• Consultation to the PCP regarding the diagnosis, the recommended treatment and follow-up and, in some cases, the medication

This model increases system capacity by allowing behavioral health specialists to see up to 12 patients a day versus the traditional four to five patients. The cultural stigma and physical challenges of seeking behavioral health treatment are lessened because a separate visit is not required. In the second year of the model, over 2,000 patients received behavioral health care as part of their primary care visit. By 2009, that number had jumped to more than 3,600 patients (HFP 2009b).

In its role as the model champion, HFP has played an instrumental part in ensuring the success of the behavioral health integrated model. HFP and Levkovich were able to mobilize resources among the key players, provide training to new participants, and create a community to share lessons learned. Dr. Serrano has observed that “what has held this [model] together is the Health Federation continuing to advocate for policy and training and the clinicians to do the work,” and says the success of the program is rooted in “the ability of the Health Federation to make this a priority for the clinics and the clinicians.” Successful implementation of the integrated model was also due to the essential leadership and contribution of the behavioral health specialists and the commitment and vision of their executive leaders. Dr. Serrano also attributes the success of the model to the behavioral health specialist and PCP staff on the ground; they were “willing to be flexible and trainable and take the model to heart.”

Implementing the integrated model within the existing healthcare system was extremely difficult because so many elements of the status quo needed to be addressed. The key in the early stages of the program was to implement a successful pilot without disrupting the usual operations of health centers, thereby demonstrating the effectiveness of the model and serving as an example to other health clinics. HFP started by focusing on two main areas: altering the behavior of the behavioral health specialist and the PCP through skill building, and streamlining the reimbursement process of behavioral health treatment with Community Behavioral Health (the HMO) to encourage adoption.

To encourage behavioral health specialists and PCPs to accept the integrated model, HFP brought in nationally known integrated care experts, including Dr. Kirk Strosahl, to introduce the concept and initiate dialogue between PCPs and behavioral health specialists. PCPs are not used to having these specialists on-site and do not automatically think to call in the specialist for a consultation. Behavioral health specialists are used to sessions with patients that involve a prolonged diagnostic and therapeutic period, and they needed to learn new skills and methods to implement the “brief, problem focused consultation model” (HFP 2009b).

After convincing the providers to give the model a try, HFP provided more detailed training to providers at the pilot site, Delaware Valley Community Health, and sought to identify “early adopters” of the model to implement it. Early adopters included 11th Street Health Center, a partnership between Family Practice and Counseling Network and Drexel University, and Esperanza Health Center, a faith-based community health center. Experiencing firsthand the success of an integrated model was crucial to converting the providers. The behavioral health specialist realized that the consultations were still extremely meaningful to the patient and often more effective than the traditional referral model. One specialist stated that “it is so gratifying to work in a way that our patients really respond to.” At the same time, the PCP realized that having a behavioral health specialist did not disrupt normal operations and helped the patient to recover faster; says one PCP of the model: “In the past we didn’t want to go there [assessing behavioral health issues] because it would open a can of worms. Now I can’t imagine working without a behavioral health consultant.”

On the administrative front, HFP worked closely with Community Behavioral Health to change and streamline the reimbursement policies. In the Medicaid managed care environment of Southeastern Pennsylvania, the PCP is reimbursed through a physical health HMO and the behavioral health specialist through a behavioral health HMO. In order to qualify for reimbursement, behavioral health treatment had to include a long and exhaustive assessment. Through an iterative process, HFP and Community Behavioral Health were able to arrive at a documentation standard that fits the model, meets Community Behavioral Health’s standards of clinical accountability, and qualifies for reimbursement. Community Behavioral Health developed credentialing standards, and identified a billing code and a billing rate to apply to the integrated behavioral health consultation model. “It’s really unique to engage an insurer in that way,” says Dr. Serrano. “That is to the credit of Community Behavioral Health and to what Natalie and the Health Federation have been able to do.”

Today, the primary care visit is still covered by a Medicaid HMO, and the behavioral healthcare portion is now covered by Community Behavioral Health. This was a huge systems change instigated by HF and brought about through dialogue and collaboration. Also, in accordance with policies for Medicaid reimbursement of FQHC services, both the primary care and the behavioral health visits are eligible for additional cost-based reimbursement directly from the State Medicaid program. HF was able to advocate successfully that both visits occurring on the same day are eligible for payment.

HFP continues to provide considerable support for the implementation of the behavioral health integrated model, through training, community building, and advocacy. Ongoing training for the providers and sites that are implementing the model includes access to external experts such as Dr. Serrano as well as internal expertise that HFP has developed through its implementation experience. HFP also hosts monthly meetings where practitioners of the model can gather to continue their professional development, share lessons learned, ask questions, and provide encouragement.