Bob Van Oosterhout

Plan for MMHP-HL Behavioral Health/Primary Care Integration
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1. Description of Proposed Behavioral Health Services Expansion
MHS has been developing plans to expand BH services into an integrative model for a number of years. BH services began to move from a referral to a collaborative model in 2001. For the past eight years; MHS BH staff have evaluated patients in primary care and urgent care suites when requested by PC providers; consulted and provided training for PC staff regarding BH concerns; provided PC staff with updated information regarding medical concerns of BH patients between PC visits; and worked collaboratively with PC staff to develop treatment plans for patients with BH related concerns. MHS staff have been developing systems for screening, evaluation, treatment, and follow-up of BH concerns to facilitate the transition to a fully Integrated Primary Behavioral Health Care model.

a) Process for identifying and communicating BH conditions and treatment needs:
MHS is committed to efficiently delivered, high quality, patient centered care. MHS believes that integrated treatment requires integrated information and emphasizes treating patients rather than diagnoses. Unfortunately, currently available screening/tracking tools and records/evaluation systems tend to provide fragmented and isolated bits of information that can be difficult to access and summarize. Currently available screening and tracking tools effectively identify specific diagnoses but do not adequately assess co-morbid conditions or clusters of BH symptoms that cross various diagnostic categories. In addition, recent research shows that patients who present symptoms during the PC visit that do not meet criteria for DSM diagnosis often do meet that threshold between visits. However, the identification of clusters of BH symptoms that do not meet diagnostic criteria are often missing from medical records and there are not systems to adequately tracked them.

Patients do not experience BH disorders such as anxiety and depression as separate entities. The frequency, severity and duration of their symptoms are not necessarily consistent over time. Yet currently available screening and diagnostic tools only provide a single snapshot of individual diagnostic categories without being able to identify the full scope of BH symptoms as patient's experience them. Differences in the frequency, severity and duration of symptoms that may affect individual patient's experience tend not to be accurately reflected in currently available screening instruments or tracking tools. Patients who present a wide range of variation in the frequency, severity and duration of symptoms are easily lumped into single diagnostic categories. In addition, progress in symptom resolution is documented in individual charts but information about the overall effectiveness of various treatment approaches for clusters of symptoms across diagnostic categories within a practice is difficult to obtain.

Quality improvement efforts traditionally involve a time-consuming review of a statistically selected sample of charts on a quarterly basis. Information about emerging trends or issues not evident from within the sample is not readily available.

A unique feature of this proposal is that MHS plans to implement a patient-centered, fully integrated BH/PC model that is built upon a screening, tracking and record keeping system that more accurately matches the patient's experience of their concerns. This grant will allow MHS to complete the development and testing of tools and systems that screen for BH and SA symptoms and evaluate the effectiveness of various interventions. Data from these tools as well as team discussions in Quality Improvement meetings will direct the ongoing development of these systems.

MHS BH staff is currently working with Dr. Michael Klinkman and Dr. Lee Green of the University of Michigan Department of Human Medicine to develop full spectrum BH screening and tracking tools. Dr. Green is also affiliated with Michigan Institute for Clinical and Health Research (MICHR) and Great Lakes Research into Practice Network (GRIN). The goal is to develop instruments that build on the clarity and simplicity of the PHQ-9 and REMIT (which only assess depression) to assesses the full range of common mental health symptoms and provide smaller increments of data on the frequency, severity and duration of symptoms in order to more accurately track the effect of interventions over time. These tools will be integrated into MHS Electronic Medical Records (EMR) system to provide data that generate reports that guide ongoing treatment planning for individual patients and provide feedback and direction for clinical supervision, staff training, quality improvement and program development. These tools will also allow MHS staff to identify patients who may be at risk for developing mental health disorders and track the effectiveness of early intervention approaches.

The BH Screening Form currently in development provides a checklist of most frequently reported BH symptoms and identifies the frequency, severity and duration ("How often, how bad, how long") of common mental health disorders on a ten-point scale similar to the screening form. It will be converted into a bubble sheet that can be easily completed by PC patients in the waiting room in a few minutes and scanned into the EMR by medical records staff prior to the patient's meeting with providers. A scoring system is being developed to develop a profile which will guide decisions regarding which patients can best be served by a BH assessment/intervention during the primary care visit and whether the BH or PC provider will see them first. Data from this form will be combined with the patient interview to provide direction in determining the most appropriate course of treatment (medication, referral for BH or SA counseling, and/or using patient education and self-management materials).

The BH tracking form that is being developed tracks changes in common symptoms as well as the frequency and severity of incidents of anxiety, depression, impulse control and stress. Patients will complete a BH Symptom Tracking form prior to each follow-up BH visit and/or as indicated by symptoms and circumstances. This simple bubble sheet willbe scanned into the EMR prior to follow-up BH visits. Patients may be given these forms to complete between visits depending on the frequency of appointments. A patient compliance form will also be developed to track the extent to which patients have followed treatment recommendations. This will also be scanned into the EMR prior to BH follow-up visits.

Data from the screening, tracking and compliance forms will be entered into a data base to allow generation of a wide range of reports including population-based reporting. MHS staff have experience in generating registry reports from E-Clinical Works (MHS EMR program) and MHS has committed to implement report generating software, Cognos-EBO, that will facilitate the development of this project.


Difference Between MHS/UM Proposed Behavioral Health Screening, Tracking and Compliance Systems and Currently Available Instruments
Currently Available Instruments MHS/UM Proposed Tools
Focus on single diagnostic categories Provides documentation of most common BH symptoms seen in primary care practice
Broad indication of severity with little indication of frequency or duration Indicate frequency, severity and duration of depression, anxiety, impulse control disorders, and stress on a 10 point Lekert scale - allows identification of small changes and symptom clusters that do not meet threshold for DX
Generate single score that indicates presence or absence of single DX Generates profile of symptom clusters across diagnoses that also indicates frequency, severity and duration of BH concerns
Isolates one aspect of patient experience More closely describes actual patient experience of BH symptoms and concerns
Presents broad overview of changes in SX or DX Identifies small changes and improvements in SX and BH concerns at more frequent intervals
Paper based, hand scored Integrated into EMR and data base
Fixed Can be initially adapted during initial stages of implementation to more closely reflect patient concerns
No reporting capabilities built in Data base provides wide range of reporting capabilities and allows for generation of additional reporting as indicated
Have been standardized and validated Could be standardized and validated for wider use

MHS staff has identified sets of skills, capabilities and conditions that underlie DSM diagnoses and common clusters of BH symptoms. Patient reports and MHS staff observations indicate that effectively addressing specified skills, capabilities and conditions through BH intervention has consistently led to the elimination or effective management of symptoms within all BH diagnostic categories seen at MHS. MHS staff are developing an evaluation system where BH staff will assess the presence of skills, capabilities and conditions related to particular diagnoses or cluster of symptoms on a ten-point Lekert scale during regular behavioral health visits. This assessment process will be integrated into the EMR to provide data that will guide treatment and provide population-based data for program evaluation and development. Data collected over time will help to specify how limitations in capabilities and conditions affect treatment duration and provide justification to managed care providers for additional treatment when needed.

When fully developed and implemented, these tools will provide up-to-date data regarding patient reported symptom frequency, duration and severity as well as BH provider functional assessment of patient skills, capabilities and conditions related to symptoms and diagnoses. This system will guide treatment team decisions regarding appropriate services or referrals and track the effectiveness of treatment strategies for individual patients. It will also provide summary data that can be analyzed by diagnosis or symptom cluster, provider, treatment approach, patient compliance and other factors. This will facilitate quality improvement and continuing development of the system as well as guide training, supervision and resource development efforts. These efforts incorporate MHS's value of treating patients rather than diagnoses into the BH/PC assessment and treatment process.


BH staff will also use Alcohol Use Disorders Test (AUDIT) or the CAGE Questionnaire to screen for Alcohol abuse and the Drug Abuse Screening Test (DAST) to screen for drug abuse concerns as indicated. BH staff will determine the DSM diagnosis which the PC provider can use to access the online Psychopharmacology Algorithm Project developed by Harvard Medical School to determine the most appropriate medical approach as indicated.

Results of screening tools and the BH assessment interview will be entered into the EMR during the patient visit so all team members have updated information before seeing the patient. This will be supplemented by informal consultations between team members as needed.

b) Behavioral health services to be provided:
MHS plans to incorporate BH staff into the primary care suites to oversee the BH screening process, determine the DSM diagnosis, assess for and provide brief interventions for SA concerns using components of SBIRT including the WHO manual "Brief Intervention for Hazardous and Harmful Drinking" and the NIAAA document Helping Patients Who Drink Too Much: A Clinicians Guide." BH staff in PC suites will make appropriate referrals for onsite BH or SA counseling, provide information regarding community resources, offer patient education and self-management tools as appropriate, monitor patient compliance and the effectiveness of treatment strategies, and participate in team decisions.

MHS BH staff have developed patient education and self-management tools that have been effective over a number of years in helping patients in various settings understand and resolve symptoms for a wide range of disorders including anxiety, depression, stress, relationship issues, chronic pain, impulse control problems, PTSD, ADHD, fibromyalgia, diabetes, grief, and heart disease. These tools provide a simple, clear explanation of how mental, physical and emotional factors contribute concerns or condition along with a set of physical and mental exercises that are easy to learn and practice and facilitate recovery and/or effective management of symptoms. These will be summarized in written and electronic format for distribution to patients by BH staff in primary care suites as appropriate. They will be revised and updated based on team input and data from symptom tracking and patient compliance forms.


MHS BH staff currently provide individualized treatment plans that are entered into the computer with printouts given to patients during BH visits. Templates will be created to facilitate this process so it can also be used during brief BH interventions in primary care suites. MHS BH and trained medical records staff will make follow-up telephone calls to patients as appropriate to determine if there are questions about the treatment plan and to track compliance with treatment recommendations.

BH counseling services provide solution-focused/strength-based, cognitive behavior therapy and relationship counseling for adults and limited play and activity therapy for children and adolescents. They also provide training in a simple problem-solving approach that has consistently helped patients (and students in another setting) prevent and resolve stressful situations. The emphasis is on brief therapy (less than 5 visits) but long-term treatment is provided when necessary. BH staff provide counseling and training in stress management, pain management, grief issues, problems related to impulse control, management of health problems and limitations, as well assistance in dealing with BH components of specific disorders including diabetes, heart disease, fibromyalgia, closed head injuries and physical limitations, disabilities and terminal diagnoses.

The patient education and self-management approaches currently in use at MHS have been observed to be effective when used in PC and UC settings. MHS BH staff working in PC suites will also incorporate evidence-based practices including protocols based on the Strosahl model of Acceptance and Commitment Therapy (ACT) as appropriate. Data from patient and provider assessments will be used to determine which tools are most likely to be effective in specific circumstances.

This grant will fund the hiring of a fully licensed Psychologist with a Doctorate in Health Psychology. She will complete a Post doctorate Masters in Psychopharmacology in December of 2009. She will oversee the proposed expansion to fully integrated BH/PC services and will develop and provide training and materials to patients and community groups on a wide range of health and medication concerns as needed.

BH staff also provide counseling to children and adolescents and this grant will allow the development of a play therapy room to be used for young children. This grant will fund the expansion of these services from .6FTE to 2 FTE in the first year. This meets a gap in services available to patients in the MHS service area.

MHS has installed equipment and reached tentative agreement with MSU Department of Psychiatry to provide telepsychiatry services onsite on a regular basis. This system could also be used for telepsychology appointments with staff who are unable to come into the clinic. This meets a gap in services available in the MHS service area.

MHS contracts with Catholic Human Services to provide on-site individual and group substance abuse counseling and assessment. This grant will expand those services to five days per week. This meets a gap in services available in the MHS service area.

Summary of BH Services to be Provided
Service Tools and Resources
Screening and tracking of BH concerns MHS/UM developed tools
Screening for Substance Abuse (SA) CAGE, AUDIT
Brief intervention for Alcohol Abuse Babor and Higgins, Brief Intervention for Hazardous and Harmful Drinking, World Health Organization, Dept. of Mental Health and Substance Dependence, 2001

NIAAA document: Helping Patients Who Drink Too Much: A Clinicians Guide
Brief intervention for BH concerns in primary care suites Tools currently in use at MHS

Cognitive Behavioral Therapy

Acceptance and Commitment Therapy

Community Referrals Community Resource Directory
Referral for SA counseling Catholic Human Services - on site
Referral for BH counseling On-site with MHS BH staff using
Patient education and self-management tools; Solution Focused / Strength Based Therapy; Cognitive Behavioral Therapy
Psychopharmacology Harvard Psychopharmacology Algorithm Project
Psychiatric Consultation Telepsychiatry with MSU Dept of Psychiatry
Treatment for young children On-site Play Therapy with BH staff


2. Proposed Behavioral Health Service Delivery Model
a) Description of model
The proposed MHS BH service delivery model is an outcome-based system designed to facilitate communication and information sharing among all primary care team members through EMR and personal communication. This model incorporates many aspects of the Strosahl model for integrated PC/BH care but will be enhanced with the additional of screening, tracking, and evaluation components that are being developed to provide flexible system that can adapt to changing patient needs and medical provider preferences. In the MHS model, BH staff may see the patient before the PCP and will provide a BH diagnosis as indicated. PC providers will be trained to provide the same services as BH staff during PC visits.


Medical records staff will identify primary care patients who will be asked to complete the behavior health-screening tool. (All primary care patients will be asked to complete the form annually and the treatment team may designate others in the EMR to complete it more frequently.) The form, which can be easily completed in 3 to 4 minutes, will be scanned into the EMR or given to the BH provider. Data accumulated over time from completed forms and outcomes will help in developing an automated scoring system that will generate a symptom profile that will guide in prioritizing which patients will most likely benefit BH staff intervention in the primary care treatment room.
If the primary reason for a visit involves behavioral health concerns, the PCP could introduce BH staff to the patient after the MA/nurse assessment before assessing medical concerns. BH staff may also be asked to meet with patients in response to requests by other team members at any point during a PC visit.

BH staff will determine if SA screening is needed, identify the DSM IV diagnosis, and assess if referral to SA or BH counseling or patient education and self-management is appropriate. If referral is needed, appointments will be scheduled at that time on the BH staff's laptop computer. When appropriate, BH staff will cover relevant patient education and self-management components during the visit and/or provide written or electronic (DVD/CD) materials that the patient can take with them. BH staff will also provide information regarding community resources as appropriate. BH staff will record the DSM IV diagnosis along with treatment recommendations in the EMR on the laptop computer. When appropriate, BH staff will, with patient input, write a brief treatment plan that will be printed out and given to the patient before they leave the office. When indicated, BH staff will provide compliance tracking forms that can be scanned in the EMR during the patients next visit.

BH staff may make suggestions to the PCP regarding a possible need for medication. (MHS has recruited a fully licensed Psychologist who will soon complete a Post Doctorate Masters degree in Psychopharmacology). BH staff will also provide the PCP with a DSM diagnosis.

The PC provider will meet with the patient to provide medical treatment. If medication is indicated for BH concerns, providers will have access to the evidence-based Harvard Medical School Psychopharmacology Algorithm Project on their laptop computer to assist in determining the most appropriate course of treatment. Telepsychiatric consultations can be schedule as needed at that time.

Patients with BH concerns will leave the primary care visit with a list of appointments for follow-up and referral, a printed treatment plan and educational and self-management materials along with compliance tracking forms as appropriate.

On follow-up visits for BH concerns whether for counseling or to meet with a BH and medical provider in the PC suite, the patient will complete the behavioral health symptom tracking form. Medical records staff will identify these patients, provide the forms and scan them into the EMR, or give them to providers prior to the visit.

Data regarding the effect of treatment on symptom change and the development of patient skills, capabilities and conditions will allow BH staff to confirm the effectiveness of these approaches and identify areas where additional counseling, training and/or resources may be needed.


3. How Behavioral Health Will Be Integrated with Other Health Care Services:

a) Current integration of BH with other services:
MHS has demonstrated a high degree of integration of BH services with other services as part of the culture of the facility for a number of years. BH staff have evaluated patients in primary care and urgent care suites when requested by PC providers, consulted and provided training for PC staff regarding BH concerns, provided PC staff with updated information regarding medical concerns of BH patients between PC visits, and worked collaboratively with PC staff to develop treatment plans for patients with BH related concerns. BH staff regularly consult by phone or in person with PC providers regarding medical concerns that arise during BH sessions and PC providers have evaluated patients during BH sessions when needed. BH and PC staff also consult with the MHS staff dietician/diabetes educator when patients present concerns regarding weight or diet, diabetes, or eating disorders. BH staff, the dietician and PC providers have worked together to co-manage patients with eating disorders and health problems that span all three disciplines. BH staff also provide consultation by phone to both PC and UC staff in crisis situations. There has been a similar cooperative relationship with Physical Therapy staff who are located on site. There is also a staff person from the American Cancer Society on the grounds who has co-facilitated cancer support groups with current BH staff and MHS patients. All primary care suites as well as urgent care have access to BH scheduling and schedule appointments with patients during PC visits so that patients have an appointment date in hand before leaving the building. The MHS EMR system also facilitates integration and collaboration between providers from various disciplines by providing a quick means of communication and shared access to all relevant patient information.

Brief BH interventions in PC have focused on providing the patient with a clear, simple explanation of how physical, mental, and emotional factors contribute to their concerns and providing a set of mental and physical exercises that can be quickly learned and practiced. Patients leave the session with a clear understanding of what is happening to them, reasons for hope, and specific steps they can take to improve their situation. This process has been applied to a wide range of disorders including anxiety, depression, stress, relationship issues, chronic pain, impulse control problems, PTSD, ADHD, fibromyalgia, diabetes, grief, and heart disease. These approaches will be summarized in written and electronic format for training and distribution to patients by BH staff in primary care suites as appropriate. They will be revised and updated based on team input and data from symptom tracking and patient compliance forms. MHS staff recently provided training in these approaches to the Michigan Primary Care Association Behavioral Integration Workgroup on "Brief Interventions that Work in a Primary Care Setting."

b) Expansion to fully integrated model
The transition to a fully integrated model will enhance systems currently in practice while facilitating consultation and co-management of complex patient problems. All BH staff will be available for both traditional counseling and brief interventions in the primary care suites. There are six treatment rooms in each suite with one or two providers. It is expected that most brief patient centered consultations will take place in the primary care suites but also may occur in the counseling offices (just down the hall) when space limitations or scheduling dictate. BH staff will also incorporate brief interventions and workbooks from evidence based practices such as Strosahl's Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT) as appropriate. The screening and tracking systems being developed will provide ongoing feedback on the effectiveness of different approaches in given situations and identify potential needs for additional training or resources.

c. Delivery of brief, patient-centered behavioral health consultations:
The screening and tracking tools that are being developed for BH expansion support the MHS philosophy of treating patients rather than diagnoses. These tools will generate reports and profiles, which will assist staff in obtaining an overall picture of patient concerns. Patient education and self-management tools that have been in use will be formalized and all appropriate primary care team members will be trained in their use. Brief BH consultations will primarily be carried out by BH staff in primary care suites but PCP's and other appropriately trained staff could implement and distribute them as well.

d. System for supporting co-management of patients:
MHS has had an informal system for co-managing complex concerns for a number of years. This expansion will significantly enhance that process by insuring that BH staff is always available in primary care suites. When indicated, BH staff will develop a treatment plan in consultation with patients and provide compliance tracking forms. Both of these systems will facilitate co-management of patients and PC providers can update and modify these forms before they are printed and given to the patient.

Scheduling of BH staff in primary care suites will be worked out over time to insure maximum responsiveness, efficiency of services, and minimal waiting time. BH staff who have unfilled, canceled, or missed appointments will continue to be available for consultations in primary care suites if the staff assigned to the suite at that time is occupied with another patient.

4. How the Proposed Services will be Provided

a) Description of service delivery process
The following description of how BH services will be provided in primary care represents current thinking regarding the process that BH and medical staff believe will be most effective and efficient. Treatment teams within each primary care suite will meet on a regular basis to assess the effectiveness of this process and adapt it to fit the needs of their patients as appropriate. It is possible that there may be different versions of the BH integration model used in various settings, which will reflect differing needs and preferences among patients and staff.


b. Insuring optimum accessibility
Placing BH providers in PC suites for brief interventions will significantly improve patient access to BH services. The screening and tracking tools currently in development by MHS will assist team members in determining which patients might benefit most from BH services. These tools will also identify patients who may hesitate to discuss BH concerns to their provider or do not meet the criteria for DSM diagnosis but still present symptoms that limit their health and functional capacity.

Cost of services is a significant obstacle to BH service delivery in this area because of a predominance of low-income and elderly people. MHS has developed a "Special Circumstances" program for BH services where BH staff negotiate a fee or co-pay (when appropriate) that is affordable without creating additional financial stress.

Having a fully licensed Psychologist to supervise BH staff will allow LLP, LMSW, and LPC licensed staff to bill Blue Cross for BH interventions. This will allow MHS to increase staffing to be able to respond to the pressing BH needs in the service area.

All BH staff will provide both traditional counseling and primary care brief consultations. Schedules will be adapted over time as indicated by patient need and reports from BH tracking system on the effectiveness of various treatment approaches. BH staff will have designated times when they will be assigned to PC care. They will also be available for PC consultations during a crisis situation or whenever cancelled or missed BH appointments cannot be filled. MHS plans to have at least two BH staff available for consultation in primary care at all times when the project is fully implemented and will add additional staff as indicated.