Financing for Collaborative Care - A Narrative Review

Effect of Behavioral Health Disorders on Surgical Outcomes in Cancer Patients

BACKGROUND

Behavioral health disorders (BHDs) can often be exacerbated in the setting of cancer. We sought to define the prevalence of BHD among cancer patients and characterize the association of BHD with surgical outcomes.

STUDY DESIGN

Patients diagnosed with lung, esophageal, gastric, liver, pancreatic, and colorectal cancer between 2018 and 2021 were identified within Medicare Standard Analytic Files. Data on BHD defined as substance abuse, eating disorder, or sleep disorder were obtained. Postoperative textbook outcomes (ie no complications, prolonged length of stay, 90-day readmission, or 90-day mortality), as well as in-hospital expenditures and overall survival were assessed.

RESULTS

Among 694,836 cancer patients, 46,719 (6.7%) patients had at least 1 BHD. Patients with BHD were less likely to undergo resection (no BHD: 23.4% vs BHD: 20.3%; p < 0.001). Among surgical patients, individuals with BHD had higher odds of a complication (odds ratio [OR] 1.32 [1.26 to 1.39]), prolonged length of stay (OR 1.36 [1.29 to 1.43]), and 90-day readmission (OR 1.57 [1.50 to 1.65]) independent of social vulnerability or hospital-volume status resulting in lower odds to achieve a TO (OR 0.66 [0.63 to 0.69]). Surgical patients with BHD also had higher in-hospital expenditures (no BHD: $16,159 vs BHD: $17,432; p < 0.001). Of note, patients with BHD had worse long-term postoperative survival (median, no BHD: 46.6 [45.9 to 46.7] vs BHD: 37.1 [35.6 to 38.7] months) even after controlling for other clinical factors (hazard ratio 1.26 [1.22 to 1.31], p < 0.001).

CONCLUSIONS

BHD was associated with lower likelihood to achieve a postoperative textbook outcome, higher expenditures, as well as worse prognosis. Initiatives to target BHD are needed to improve outcomes of cancer patients undergoing surgery.

Core Components and Implementation Determinants of Multilevel Service Delivery Frameworks Across Child Mental Health Service Settings

Multilevel service delivery frameworks are approaches to structuring and organizing a spectrum of evidence-based services and supports, focused on assessment, prevention, and intervention designed for the local context. Exemplar frameworks in child mental health include positive behavioral interventions and supports in education, collaborative care in primary care, and systems of care in community mental health settings. Yet, their high-quality implementation has lagged. This work proposes a conceptual foundation for multilevel service delivery frameworks spanning diverse mental health service settings that can inform development of strategic implementation supports. We draw upon the existing literature for three exemplar multilevel service delivery frameworks in different child mental health service settings to (1) identify core components common to each framework, and (2) to highlight prominent implementation determinants that interface with each core component. Six interrelated components of multilevel service delivery frameworks were identified, including, (1) a systems-level approach, (2) data-driven problem solving and decision-making, (3) multiple levels of service intensity using evidence-based practices, (4) cross-linking service sectors, (5) multiple providers working together, including in teams, and (6) built-in implementation strategies that facilitate delivery of the overall model. Implementation determinants that interface with core components were identified at each contextual level. The conceptual foundation provided in this paper has the potential to facilitate cross-sector knowledge sharing, promote generalization across service settings, and provide direction for researchers, system leaders, and implementation intermediaries/practitioners working to strategically support the high-quality implementation of these frameworks.

Treating individuals with suicidal ideation in primary care: Patient-level characteristics associated with follow-up in the Collaborative Care Model

INTRODUCTION

The Collaborative Care Model (CoCM) is an evidence-based approach which embeds behavioral health providers (BHPs) into primary care. Whether patients with suicidal ideation (SI) are willing to engage in CoCM is unclear.

METHODS

Using Patient Health Questionnaire-9 (PHQ-9) administrative data from primary care practices within an urban academic health system, we identified patients with and without SI who were referred to a CoCM BHP. We compared engagement, defined as attendance at ≥1 CoCM visit, across groups.

RESULTS

Between 2018 and 2022, 7391 primary care patients were referred to a CoCM BHP. Eight hundred and ninety-two of these patients reported SI on the PHQ-9 (754 on "several days" during the previous 2 weeks and 138 on "more than half or most days"). Across groups, most patients engaged in CoCM. Patients reporting SI on several days engaged at a lower rate (61.4%) than those reporting SI on more than half or most days (65.9%). Both SI groups engaged at a lower rate than the 6499 patients who did not report SI (67.5%).

CONCLUSION

Most patients referred to a CoCM BHP engaged in ≥1 visit. Rates were lower for patients with SI, with the lowest rate among those reporting SI on several days.

Lessons From Low- and Middle-Income Countries: Alleviating the Behavioral Health Workforce Shortage in the United States

The United States is facing a mental health workforce shortage, exacerbated by the COVID-19 pandemic. Low- and middle-income countries (LMICs) have historically grappled with even greater shortages. Therefore, LMICs have thought creatively about expanding the mental health workforce and the settings in which to deliver evidence-based and equitable mental health care. The authors introduce some mental health interventions in LMICs, describe evidence of the efficacy of these interventions gleaned from this context, and discuss the applicability of these interventions to the United States. The authors also reflect on the benefits and challenges of implementing these interventions in the U.S. mental health care system to alleviate its current workforce shortage.

Poor Access to Mental Healthcare is Associated with Worse Postoperative Outcomes Among Patients with Gastrointestinal Cancer

BACKGROUND

Mental health has an important role in the care of cancer patients, and access to mental health services may be associated with improved outcomes. Thus, poor access to psychiatric services may contribute to suboptimal cancer treatment. We conducted a geospatial analysis to characterize psychiatrist distribution and assess the impact of mental healthcare shortages with surgical outcomes among patients with gastrointestinal cancer.

METHODS

Medicare beneficiaries with mental illness diagnosed with complex gastrointestinal cancers between 2004 and 2016 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry. National Provider Identifier-registered psychiatrist locations were mapped and linked to SEER-Medicare records. Regional access to psychiatric services was assessed relative to textbook outcome, a composite assessment of postoperative complications, prolonged length of stay, 90-day readmission and mortality.

RESULTS

Among 15,714 patients with mental illness and gastrointestinal cancer, 3937 were classified as having high access to psychiatric services while 3910 had low access. On multivariable logistic regression, areas with low access had higher risk of worse postoperative outcomes. Specifically, individuals residing in areas with low access had increased odds of prolonged length of stay (OR 1.11, 95%CI 1.01-1.22; p = 0.028) and 90-day readmission (OR 1.19, 95%CI 1.08-1.31; p < 0.001), as well as decreased odds of textbook outcome (OR 0.85, 95%CI 0.77-0.93; p < 0.001) and discharge to home (OR 0.89, 95%CI 0.80-0.99; p = 0.028).

CONCLUSION

Patients with mental illness and lower access to psychiatric services had worse postoperative outcomes. Policymakers and providers should prioritize incorporating mental health screening and access to psychiatric services to address disparities among patients undergoing gastrointestinal surgery.

Financial Sustainability of Novel Delivery Models in Behavioral Health Treatment

BACKGROUND

In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through grants to develop and test the new interventions. The original grant funding is typically time-limited. This implies that eventually communities, clinicians, and others must find resources to replace the grant funding -otherwise the innovation will not be adopted. Diffusion is challenged by the continued dominance in the US of fee-for-service reimbursement, especially for behavioral health care.

AIMS

To understand the financial challenges to disseminating innovative behavioral health delivery models posed by fee-for-service reimbursement, and to explore alternative payment models that promise to accelerate adoption by better addressing need for flexibility and sustainability.

METHODS

We review US experience with three specific novel delivery models that emerged in recent years. The models are: collaborative care model for depression (CoCM), outpatient based opioid treatment (OBOT), and the certified community behavioral health clinic (CCBHC) model. These examples were selected as illustrating some common themes and some different issues affecting diffusion. For each model, we discuss its core components; evidence on its effectiveness and cost-effectiveness; how its dissemination was funded; how providers are paid; and what has been the uptake so far.

RESULTS

The collaborative care model has existed for longest, but has been slow to disseminate, due in part to a lack of billing codes for key components until recently. The OBOT model faced that problem, and also (until recently) a regulatory requirement requiring physicians to obtain federal waivers in order to prescribe buprenorphine. Similarly, the CCBHC model includes previously nonbillable services, but it appears to be diffusing more successfully than some other innovations, due in part to the approach taken by funders.

DISCUSSION

A common challenge for all three models has been their inclusion of services that were not (initially) reimbursable in a fee-for-service system. However, even establishing new procedure codes may not be enough to give providers the flexibility needed to implement these models, unless payers also implement alternative payment models.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

For providers who receive time-limited grant funding to implement these novel delivery models, one key lesson is the need to start early on planning how services will be sustained after the grant ends.

IMPLICATIONS FOR HEALTH POLICY

For research funders (e.g., federal agencies), it is clearly important to speed up the process of obtaining coverage for each novel delivery model, including the development of new billable service codes, and to plan for this as early as possible. Funders also need to collaborate with providers early in the grant period on sustainability planning for the post-grant environment. For payers, a key lesson is the need to fold novel models into stable existing funding streams such as Medicaid and commercial insurance coverage, rather than leaving them at the mercy of revolving time-limited grants, and to provide pathways for contracting for innovations under new payment models.

IMPLICATIONS FOR FURTHER RESEARCH

For researchers, a key recommendation would be to pay greater attention to the payment environment when designing new delivery models and interventions.

Medicaid Costs and Utilization of Collaborative Versus Colocation Care for Patients With Depression

OBJECTIVE

The authors examined cost and utilization metrics for racially diverse Medicaid primary care patients with depression receiving care through either a collaborative care model (CoCM) of integration or the standard colocation model.

METHODS

Data from a retrospective cohort of Medicaid patients screening positive for clinically significant depression during January 2016-December 2017 were analyzed to assess health care costs and selected utilization measures. Seven primary care clinics providing CoCM were compared with 16 clinics providing colocated behavioral health care. Data for the first year and second year after a patient received an initial Patient Health Questionnaire-9 score ≥10 were analyzed.

RESULTS

In the first year, compared with patients receiving colocated care (N=3,061), CoCM patients (N=4,315) had significantly lower odds of emergency department (ED) visits (OR=0.95) and medical specialty office visits (OR=0.92), with slightly higher odds of primary care provider (PCP) visits (OR=1.03) and behavioral health office visits (OR=1.03). In year 2, CoCM patients (N=2,623) had significantly lower odds of inpatient medical admissions (OR=0.87), ED visits (OR=0.84), medical specialty office visits (OR=0.89), and PCP visits (OR=0.94) than the colocated care patients (N=1,838). The two groups did not significantly differ in total cost in both years.

CONCLUSIONS

Access to CoCM treatment in primary care for racially diverse Medicaid patients with depression was associated with more positive health care utilization outcomes than for those accessing colocated treatment. As organizations continue to seek opportunities to integrate behavioral health care into primary care, consideration of health care costs and utilization may be helpful in the selection and implementation of integration models.

Making It to Sustainability: Evaluating Billing Strategies for Collaborative Care

The collaborative care model (CoCM) is an effective strategy to manage common mental disorders in primary care. Despite the growing adoption of newer CoCM billing codes to support these programs, few studies have investigated the use of these codes. This column evaluated the implementation of CoCM billing codes by comparing clinics using different billing strategies and assessed the impact of CoCM code implementation on revenue and on clinical and process-of-care outcomes. Qualitative data were obtained to understand provider perspectives. The results indicate that CoCM billing code implementation is operationally feasible, does not adversely affect the delivery of patient care or revenue, and is acceptable to providers.

Clinical Psychologists as T-Shaped Professionals

The modern world is becoming increasingly integrated, and disciplines are frequently collaborating with each other. Following this trend, clinical psychologists are also often working within multidisciplinary teams and in settings outside of traditional mental health. To be competent and effective in these contexts, clinical psychologists could benefit from skills outside of psychology. The current psychology training model provides depth of training in psychology but could be improved by providing the breadth of training required of modern clinical psychologists working in these contexts. Other disciplines, such as engineering, business, and social work, have improved their breadth of training through the adoption of the T-shaped model. This model of training allows individuals to simultaneously acquire the depth of knowledge required for their discipline and the breadth required to work effectively in multidisciplinary contexts. This article discusses areas in which clinical psychologists could benefit from broad training and recommendations to implement the T-shaped model.

Use of North Carolina Medicaid Collaborative Care Billing Codes After Statewide Approval for Reimbursement

Effective October 2018, North Carolina Medicaid approved reimbursement for collaborative care model (CoCM) billing codes. From October 2018 through December 2019, only 915 of the estimated two million eligible Medicaid beneficiaries had at least one CoCM claim, and the median number of claims per patient was two. Availability of reimbursement for CoCM Medicaid billing codes in North Carolina did not immediately result in robust utilization of CoCM. Furthermore, the low median number of claims per patient suggests lack of fidelity to CoCM. A better understanding of barriers to CoCM implementation is necessary to expand utilization of this evidence-based model.

Clinician Experiences With Telepsychiatry Collaborative Care for Posttraumatic Stress Disorder and Bipolar Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) and bipolar disorder are common in primary care. Evidence supports collaborative care in primary care settings to treat depression and anxiety, and recent studies have evaluated its effectiveness in treating complex conditions such as PTSD and bipolar disorder. This study aimed to examine how primary care clinicians experience collaborative care for patients with these more complex psychiatric disorders.

METHODS

The authors conducted semistructured interviews with 22 primary care clinicians participating in a pragmatic trial that included telepsychiatry collaborative care (TCC) to treat patients with PTSD or bipolar disorder in rural or underserved areas. Analysis utilized a constant comparative method to identify recurring themes.

RESULTS

Clinicians reported that TCC improved their confidence in managing medications for patients with PTSD or bipolar disorder and supported their ongoing learning and skill development. Clinicians also reported improvements in patient engagement in care. Care managers were crucial to realizing these benefits by fostering communication within the clinical team while engaging patients through regular outreach. Clinicians valued TCC because it included and supported them in improving the care of patients' mental health conditions, which opened opportunities for clinicians to enhance care and address co-occurring general medical conditions. Overall, benefits of the TCC model outweighed its minimal burdens.

CONCLUSIONS

Clinicians found that TCC supported their care of patients with PTSD or bipolar disorder. This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.

Primary Care Behavioral Health Integration and Care Utilization: Implications for Patient Outcome and Healthcare Resource Use

BACKGROUND

Behavioral health (BH) integration in primary care (PC) can potentially improve outcomes and reduce cost of care. While different models of integration exist, evidence from real-world examples is needed to demonstrate the effectiveness and value of integration. This study aimed to evaluate the outcomes of six PC practice sites located in Western New York that implemented a primary care behavioral health (PCBH) integration model.

OBJECTIVE

To assess the impact of PCBH on all-cause healthcare utilization rates.

DESIGN

A retrospective observational study based on historical multi-payer health insurance claims data. Claims data were aggregated on a per-member-per-month basis to compare utilization rates among the patients in the PC practice sites that had implemented PCBH to those in the sites that had not yet done so.

PARTICIPANTS

The sample included 6768 unique adult health plan members between October 2015 and June 2017 with at least one BH diagnosis code who were attributed to one of the six newly integrated PC practice sites.

INTERVENTIONS

Under the PCBH integration model, BH specialists were embedded in PC practice sites to treat a wide range of BH conditions.

MAIN MEASURES

Rates of all-cause ED visits and hospital admissions, along with rates of PC provider and BH provider visits.

KEY RESULTS

PCBH implementation was associated with reductions in the rates of outpatient ED visits (14.2%; p < 0.001) and PC provider visits (12.0%; p < 0.001), as well as with an increased rate of BH provider visits (7.5%; p = 0.018).

CONCLUSIONS

PCBH integration appears to alter the treatment patterns among patients with BH conditions by shifting patient visits away from ED and PC providers toward BH providers who specialize in treatment of such patients.

Improving Suicide Prevention in Primary Care for Differing Levels of Behavioral Health Integration: A Review

Importance

Suicide prevention implementation in primary care is needed due to the increasing rate of suicide in the past few decades, particularly for young and marginalized people. Primary care is the most likely point of contact for suicidal patients in the healthcare system. Attention to the level of medical integration with behavioral health is vital to suicide prevention and is applied throughout this review.

Methods

A narrative review was performed.

Observations

Many interventions help improve suicide prevention care. PCP education, screening, safety planning/lethal means reduction, care transitions, psychotherapy, and medication management are all evidence-based strategies. Additionally, the pragmatic topics of financing suicide prevention, supporting providers, enacting suicide postvention, and preparing for future directions in the field at each level of primary care/behavioral health integration are discussed.

Conclusions and Relevance

The findings are clinically relevant for practices interested in implementing evidence-based suicide prevention strategies by attending to the behavioral health/medical interface. Leveraging the patient/provider relationship to allow for optimal suicide prevention care requires clinics to structure provider time to allow for emotionally present care. Defining clear roles for staff and giving attention to provider well being are also critical factors to supporting primary care-based suicide prevention efforts.

Structural Components of Integrated Behavioral Health Care: A Comparison of National Programs

Initiatives that support and incentivize the integration of behavioral health and general medical care have become a focus of government strategies to achieve the triple aim of improved health, better patient experience, and reduced costs. The authors describe the components of four large-scale national initiatives aimed at integrating care for a wide range of behavioral health needs. Commonalities across these national initiatives highlight health care and social services needs that must be addressed to improve care for people with co-occurring behavioral health and general medical conditions. These findings can inform how to design, test, select, and align the most promising strategies for integrated care in a variety of settings.

Health Plans Struggle to Report on Depression Quality Measures That Require Clinical Data

OBJECTIVE

Depression quality measures aligned with evidence-based practices require that health care organizations use standardized tools for tracking and monitoring patient-reported symptoms and functioning over time. This study describes challenges and opportunities for reporting 5 HEDIS measures which use electronic clinical data to assess adolescent and perinatal depression care quality.

METHODS

Two learning collaboratives were convened with 10 health plans from 5 states to support reporting of the depression measures. We conducted content analysis of notes from collaborative meetings and individual calls with health plans to identify key challenges and strategies for reporting.

RESULTS

Health plans used various strategies to collect the clinical data needed to report the measures, including setting up direct data exchange with providers and data aggregators and leveraging data captured in health information exchanges and case management records. Health plans noted several challenges to reporting and performance improvement: 1) lack of access to clinical data sources where the results of patient-reported tools were documented; 2) unavailability of the results of patient-reported tools in usable data fields; 3) lack of routine depression screening and ongoing assessment occurring in provider practices.

CONCLUSIONS

Our findings demonstrate ongoing challenges in collecting and using patient-reported clinical data for health plan quality measurement. Systems to track and improve outcomes for individuals with depression will require significant investments and policy support at the point of care and across the healthcare system.

Remote care management for older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness: A systematic review

BACKGROUND

Comorbidity of psychiatric and medical illnesses among older adult populations is highly prevalent and associated with adverse outcomes. Care management is a common form of outpatient support for both psychiatric and medical conditions in which assessment, care planning, and care coordination are provided. Although care management is often remote and delivered by telephone, the evidence supporting this model of care is uncertain.

OBJECTIVE

To perform a systematic review of the literature on remote care management programs for older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness.

METHODS

A systematic review was performed in accordance with PRISMA guidelines. A multi-database search was performed. Articles were included for review if they studied fully remote care management for older adult populations with elevated prevalence of depression or anxiety and chronic medical illness or poor physical health. A narrative synthesis was performed.

RESULTS

A total of 6 articles representing 6 unique studies met inclusion criteria. The 6 studies included 4 randomized controlled trials, 1 case-matched retrospective cohort study, and 1 pre-post analysis. Two studies focused on specific medical conditions. All interventions were entirely telephonic. Five of 6 studies involved an intervention that was 3 to 6 months in duration. Across the 6 studies, care management demonstrated mixed results in terms of impact on psychiatric outcomes and limited impact on medical outcomes. No studies demonstrated a statistically significant impact on health care utilization or cost.

CONCLUSION

Among older adult populations with elevated prevalence of depression or anxiety and comorbid chronic medical illness, remote care management may have favorable impact on psychiatric symptoms, but impact on physical health and health care utilization is uncertain. Future research should focus on identifying effective models and elements of remote care management for this population, with a particular focus on optimizing medical outcomes.

Digital and Mobile Health Technology in Collaborative Behavioral Health Care: Scoping Review

BACKGROUND

The collaborative care model (CoCM) is a well-established system of behavioral health care in primary care settings. There is potential for digital and mobile technology to augment the CoCM to improve access, scalability, efficiency, and clinical outcomes.

OBJECTIVE

This study aims to conduct a scoping review to synthesize the evidence available on digital and mobile health technology in collaborative care settings.

METHODS

This review included cohort and experimental studies of digital and mobile technologies used to augment the CoCM. Studies examining primary care without collaborative care were excluded. A literature search was conducted using 4 electronic databases (MEDLINE, Embase, Web of Science, and Google Scholar). The search results were screened in 2 stages (title and abstract screening, followed by full-text review) by 2 reviewers.

RESULTS

A total of 3982 nonduplicate reports were identified, of which 20 (0.5%) were included in the analysis. Most studies used a combination of novel technologies. The range of digital and mobile health technologies used included mobile apps, websites, web-based platforms, telephone-based interactive voice recordings, and mobile sensor data. None of the identified studies used social media or wearable devices. Studies that measured patient and provider satisfaction reported positive results, although some types of interventions increased provider workload, and engagement was variable. In studies where clinical outcomes were measured (7/20, 35%), there were no differences between groups, or the differences were modest.

CONCLUSIONS

The use of digital and mobile health technologies in CoCM is still limited. This study found that technology was most successful when it was integrated into the existing workflow without relying on patient or provider initiative. However, the effect of digital and mobile health on clinical outcomes in CoCM remains unclear and requires additional clinical trials.

Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector

People with serious mental illness die 10-20 years earlier, compared with the overall population, and the excess mortality is driven by undertreated physical health conditions. In the United States, there is growing interest in models integrating physical health care delivery, management, or coordination into specialty mental health programs, sometimes called "reverse integration." In November 2019, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness convened a forum of 25 experts to discuss the current state of the evidence on integrated care models based in the specialty mental health system and to identify priorities for future research, policy, and practice. This article summarizes the group's conclusions. Key research priorities include identifying the active ingredients in multicomponent integrated care models and developing and validating integration performance metrics. Key policy and practice recommendations include developing new financing mechanisms and implementing strategies to build workforce and data capacity. Forum participants also highlighted an overarching need to address socioeconomic risks contributing to excess mortality among adults with serious mental illness.

Integrated behavioral health treatments: innovations to achieve population impact

Translational Behavioral Medicine is a journal that brings together relevant scholars and practitioners to produce articles of scientific and practical significance in a variety of fields. Here, we published a call for manuscripts detailing the study of innovations in the field of implementation of integrated care in the USA. We present 13 articles, all peer reviewed and all targeting some aspect of integrated care implementation. These articles include medical and community-based settings, as well as interventions that effectively engage peers, family members, and other social systems to support and extend care. The behavioral health conditions of interest include but were not limited to those that carry the greatest population disease burdens: depression, posttraumatic stress disorder, bipolar disorder, anxiety disorders, and substance abuse disorders. Examples of cross-cutting issues of high interest include research focused on provider and system barriers to integrated care implementation, interventions to improve the use of innovative treatments, disparities in access to care and quality of treatment, the intersection of behavioral health disorders and complex chronic conditions as it affects regimen adherence, health services organization and quality of care, policy effects, innovative methods using health information and mHealth technologies, and personalized/precision medicine. This introduction briefly summarizes some of the relevant topics and background literature. We close with an eye toward future research activities that will continue to advance the field and offer directions to stimulate new research questions in the area.

Implementation of collaborative care for depressive disorder treatment among accountable care organizations

Collaborative care - primary care models combining care management, consulting behavioral health clinicians, and registries to target mental health treatment - is a cost-effective depression treatment model, but little is known about uptake of collaborative care in a national setting. Alternative payment models such as accountable care organizations (ACOs), in which ACOs are responsible for quality and cost for defined patient populations, may encourage collaborative care use.Determine prevalence of collaborative care implementation among ACOs and whether ACO structure or contract characteristics are associated with implementation.Cross-sectional analysis of 2017-2018 National Survey of ACOs (NSACO). Overall, 55% of ACOs returned a survey (69% of Medicare, 36% of non-Medicare ACOs); 48% completed at least half of core survey questions. We used logistic regression to examine the association between implementation of core collaborative care components - care management, a consulting mental health clinician, and a patient registry to track mental health symptoms - and ACO characteristics.Four hundred five National Survey of ACOs respondents answering questions on collaborative care implementation.Only 17% of ACOs reported implementing all collaborative care components. Most reported using care managers (71%) and consulting mental health clinicians (58%), =just 26% reported using patient registries. After adjusting for multiple ACO characteristics, ACOs responsible for mental health care quality measures were 15 percentage points (95% CI 5-23) more likely to implement collaborative care.Most ACOs are not utilizing behavioral health collaborative care. Including mental health care quality measures in payment contracts may facilitate implementation of this cost-effective model. Improving provider capacity to track and target depression treatment with patient registries is warranted as payment contracts focus on treatment outcomes.

Provision of Collaborative Care Model and General Behavioral Health Integration Services in Medicare

OBJECTIVE

The authors sought to describe the early use of collaborative care model (CoCM) and general behavioral health integration (BHI) billing codes among clinicians.

METHODS

Counts and payments were calculated for accepted and denied claims for CoCM and general BHI services delivered to Medicare beneficiaries nationwide in 2017-2018. Payment and utilization data were stratified by clinical specialty and site of service.

RESULTS

Overall, 10,294 CoCM and general BHI services were delivered in 2017, totaling $626,292 in payments, and 81,433 CoCM and general BHI services were delivered in 2018, totaling $7,442,985 in payments. Medicare denied 5% of services in 2017 and 32% in 2018. Most CoCM and general BHI services were delivered by primary care physicians in office-based settings.

CONCLUSIONS

This study of codes designed to promote BHI revealed an eightfold increase in CoCM and general BHI use between 2017 and 2018. However, denied services represent a barrier, and use among eligible beneficiaries remains low.

Using Latent Class Analysis to Understand Social Worker Roles in Integrated Health Care

Purpose: Social work (SW) is a profession that fulfills important roles on integrated health teams, yet there remains a lack of clarity on SW's functions. The current study sought to identify typologies of SW's roles on integrated care teams using latent class analysis (LCA).Method: An electronic survey was developed, piloted, and administered to Masters level SW students and practitioners in integrated health care settings (N = 395) regarding weekly use of interventions. LCA was conducted to estimate latent sub-groups of respondents.Results: Respondents reported an average of 14.6 (SD = 4.7) interventions. Five classes of SW roles were identified and varied by setting and focus. One class (13%) completed a hybrid function providing behavioral health and social care interventions.Conclusions: Classes of SW roles on teams may reflect varying models of integrated care. A flexible SW on the team may adapt to patient and clinic needs, but increases the opportunity for role confusion.

Improving Payment for Collaborative Mental Health Care in Primary Care

BACKGROUND

There is strong evidence supporting implementation of the Collaborative Care Model within primary care. Fee-for-service payment codes, published by Current Procedural Terminology in 2018, have made collaborative care separately reimbursable for the first time. These codes (ie, 99492-99494) reimburse for time spent per month by any member of the care team engaged in Collaborative Care, including behavioral care managers, primary care providers, and consulting psychiatrists. Time-based billing for these codes presents challenges for providers delivering Collaborative Care services.

OBJECTIVES

Based on experience from multiple health care organizations, we reflect on these challenges and provide suggestions for implementation and future refinement of the codes.

CONCLUSIONS

Further refinements to the codes are encouraged, including moving from a calendar month to a 30-day reimbursement cycle. In addition, we recommend payers adopt the new code proposed by the Centers for Medicare and Medicaid Services to account for smaller increments of time.

Adapting the Comprehensive Unit Safety Program (CUSP) implementation strategy to increase delivery of evidence-based cardiovascular risk factor care in community mental health organizations: protocol for a pilot study

BACKGROUND

People with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder experience excess mortality driven in large part by high rates of poorly controlled and under-treated cardiovascular risk factors. In the USA, integrated "behavioral health home" models in which specialty mental health organizations coordinate and manage physical health care for people with SMI are designed to improve guideline-concordant cardiovascular care for this group. Such models have been shown to improve cardiovascular care for clients with SMI in randomized clinical trials, but real-world implementation has fallen short. Key implementation barriers include lack of alignment of specialty mental health program culture and physical health care coordination and management for clients with SMI and lack of structured protocols for conducting effective physical health care coordination and management in the specialty mental health program context. This protocol describes a pilot study of an implementation intervention designed to overcome these barriers.

METHODS

This pilot study uses a single-group, pre/post-study design to examine the effects of an adapted Comprehensive Unit Safety Program (CUSP) implementation strategy designed to support behavioral health home programs in conducting effective cardiovascular care coordination and management for clients with SMI. The CUSP strategy, which was originally designed to improve inpatient safety, includes provider training, expert facilitation, and implementation of a five-step quality improvement process. We will examine the acceptability, appropriateness, and feasibility of the implementation strategy and how this strategy influences mental health organization culture; specialty mental health providers' self-efficacy to conduct evidence-based cardiovascular care coordination and management; and receipt of guideline-concordant care for hypertension, dyslipidemia, and diabetes mellitus among people with SMI.

DISCUSSION

While we apply CUSP to the implementation of evidence-based hypertension, dyslipidemia, and diabetes care, this implementation strategy could be used in the future to support the delivery of other types of evidence-based care, such as smoking cessation treatment, in behavioral health home programs. CUSP is designed to be fully integrated into organizations, sustained indefinitely, and used to continually improve evidence-based practice delivery.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04696653 . Registered on January 6, 2021.

Eliminating Defects in Behavioral Health Treatment

To improve care, clinicians should seek to eliminate defects in behavioral health systems. The proposed framework to eliminate defects has three parts: designing a vision for defect-free care, designing analytics to guide care delivery, and identifying and alleviating defects that impede expected outcomes. To shepherd this process, psychiatrists need to embrace the role of systems engineer. An ideal system should work to not only help people recover (get better) from acute illness, but also manage chronic disease effectively (get well) and establish preventive care whenever possible (stay well).

Models of Mental Health Consultation and Collaboration in Primary Care Pediatrics

Pediatricians are increasingly asked to address the mental health care needs of their patients, despite lack of formal mental health training. Pediatricians who wish to expand their scope of practice to include mental health care may benefit from didactic training as well as ongoing consultative or collaborative relationships with mental health specialists. Consultative and collaborative relationships between mental health and primary care have evolved in various models across the country. We outline models of mental health consultation and collaboration, address some considerations for pediatricians prior to adopting a model, and list key collaborative care resources. [Pediatr Ann. 2020;49(10):e416-e420.].

Achieving Mental Health Equity: Collaborative Care

The literature supports the effectiveness of systems-based integrated care models, particularly collaborative care, to improve access, quality of care, and health outcomes for behavioral health conditions. There is growing evidence for the promise of collaborative care to reduce behavioral health disparities for racial and ethnic, low-income, and other at-risk populations. Using rapid literature review, this article highlights what is known about how collaborative care may promote health equity for behavioral health conditions, by reducing disparities in access, quality, and outcomes of care. Further, it explores innovative intervention and engagement strategies to promote behavioral health equity for at-risk groups.

Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff

BACKGROUND

Although collaborative care (CoCM) is an evidence-based and widely adopted model, reimbursement challenges have limited implementation efforts nationwide. In recent years, Medicare and other payers have activated CoCM-specific codes with the primary aim of facilitating financial sustainability.

OBJECTIVE

To investigate and describe the experiences of early adopters and explorers of Medicare's CoCM codes.

DESIGN AND PARTICIPANTS

Fifteen interviews were conducted between October 2017 and May 2018 with 25 respondents representing 12 health care organizations and 2 payers. Respondents included dually boarded medicine/psychiatry physicians, psychiatrists, primary care physicians (PCPs), psychologists, a registered nurse, administrative staff, and billing staff.

APPROACH

A semi-structured interview guide was used to address health care organization characteristics, CoCM services, patient consent, CoCM operational components, and CoCM billing processes. All interviews were recorded, transcribed, coded, and analyzed using a content analysis approach conducted jointly by the research team.

KEY RESULTS

Successful billing required buy-in from key, interdisciplinary stakeholders. In planning for CoCM billing implementation, several organizations hired licensed clinical social workers (LICSWs) as behavioral health care managers to maximize billing flexibility. Respondents reported a number of consent-related difficulties, but these were not primary barriers. Workflow changes required for billing the CoCM codes (e.g., tracking cumulative treatment minutes, once-monthly code entry) were described as arduous, but also stimulated creative solutions. Since CoCM codes incorporate the work of the psychiatric consultant into one payment to primary care, organizations employed strategies such as inter-departmental ledger transfers. When challenges arose from variations in the local payer mix, some organizations billed CoCM codes exclusively, while others elected to use a mixture of CoCM and traditional fee-for-service (FFS) codes. For most organizations, it was important to demonstrate financial sustainability from the CoCM codes.

CONCLUSIONS

With deliberate planning, persistence, and widespread organizational buy-in, successful utilization of newly available FFS CoCM billing codes is achievable.