SIM small grants fuel practice transformation

By Meg Quiat, JD, SIM grants project manager


During a two-year period, 47 SIM cohort-1 practices will receive up to $40,000 each to support practice integration plan goals, such as:

  • Integrating licensed behavioral health providers into daily workflows.
  • Conducting digital behavioral health screenings on tablets
  • Renovations to make space for behavioral healthcare in practices
  • Training staff
  • Investing in technological solutions for reporting and analyzing data
  • Creating programs to foster patient and family engagement
  • Seeking methods to foster better coordination and referral to specialty mental health setting

The SIM office will feature one of these categories regularly to explore successes and challenges practices encounter as they incorporate these changes. The first piece, below, focuses on integrating behavioral health providers (BHPs).

HIRING/CONTRACTING FOR A BHP

Since October 2016, 13 SIM practices that received small grants through the Colorado Health Foundation funding stream have been experimenting with different models of adding licensed BHPs to their practices. This process is not a “one size fits all” endeavor and each practice must determine what approach works best for them. Grant recipients range from small practices to large, complex practices. Some are independent while other practices are part of larger healthcare systems. Practice locations dot the map of Colorado in rural and urban areas, metro Denver and mountain towns.

These practices experimented with hiring:

  1. Full time psychiatrist-supervised behavioral health interns
  2. Private licensed psychologists contracting some of their time to the practice
  3. Full or part-time time licensed practitioners

Overall, providers report that it is useful to have BHPs in the heart of their practices and ready to provide:

  1. Warm hand-offs with providers
  2. Short-term solution focused therapy
  3. Co-consults and expert behavioral health advice
  4. Brief interventions

Challenges

  1. Finding Qualified BHPs: While several SIM practice representatives have commented on the challenge of finding these professionals regardless of location, one grantee summed it up well with this comment: “Our practice has become aware that there is a significant shortage in qualified applicants for BHP positions.” It can be especially challenging to find licensed BHPs who are interested in or qualified for a position with an integrated primary care practice. Tested solutions cited by SIM practices:
    1. One SIM practice hired two full-time master’s degree-level behavioral health interns who are supervised by a psychiatrist. The interns were involved in the care of 814 patients from January to April, and are in high demand by other providers in the practice as well as patients.
    2. One SIM practice is contracting with a hospital to provide tele-psychiatric services to patients in the practice’s office.
    3. A practice organization has made plans to support a pipeline for training competent BHPs. The organization is collaborating with local schools that offer social work degrees to implement an internship site where students who are pursuing master’s degrees in social work can train in an integrated care setting.

In general, practices agree that it took longer than anticipated to hire qualified BHPs.

  1. Billing for BHPs: Many practices have had trouble billing for BHP services and getting these BHPs credentialed through insurance companies. Tested solutions:
  1. Paying BHP salaries through operational budgets
  2. Negotiating with payers to designate billing codes for specific behavioral health services provided by BHPs with specific education and/or licensing
  1. Collecting data/tracking in EHRs: Many practices have had trouble incorporating behavioral health screening results into electronic health records (EHRs) and generating reports related to the delivery of BHP services. Practices are struggling with tracking statistics for BHP patients due to deficiencies in their EHRs and are tracking them manually or with a combination of electronic data entry and paper documentation. Proposed solution: Continue to work with clinical health information technology advisors, report issues to SIM and talk with EHR vendors to find a solution.

Benefits

Provider supported: Providers are enthusiastic about the value of BHPs in their practices. Feedback:

  1. Nurses in one practice said that having a BHP on staff freed some of their time to work with other patients as appropriate referrals were made to the BHP.
  2. Physicians appreciated the ability to work with a therapist and patient to achieve care goals.
  3. Providers reported regularly using BHPs for co-consults, warm hand-offs, and follow up sessions for a multitude of diagnoses.
  4. Providers said they were very pleased with the additional support for their patients and their practice demands.
  5. A practice administrator recognized how vulnerable and frustrated providers and staff were by not having BH resources for patients.

Appropriate care: Many practices informally tracked the number of emergency room visits made by specific patients before and after adding BHP services to their primary care settings in various forms. These professionals documented significant decreases in emergency room (ER) visits by these patients after working with BHPs as part of their overall healthcare.

Willingness to see BHP: Multiple practice professionals observed an increase in the willingness of patients diagnosed with depression to try therapy when a warm handoff was offered or a practice can schedule in-office appointments. “We have been surprised by the number of males, who access this resource when [it is] available without barriers in their primary care offices,” wrote one SIM practice representative. “We do not use the term counseling but ‘tools’ to help support and that is widely accepted.”

Improvement in PHQ Scores. Some practices are tracking patient health questionnaires (PHQ) scores before and after visits with BHPs or incorporation of BHP input in care plans. These practices reported significantly lower points for moderately depressed patients and even more significantly reduced points for severely depressed patients after BHP interventions, visits and input in care plans.