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Collaborative Care: Part 2 A Deeper Dive into an Evidence-Based Model for Primary Care 1 Virna Little, PsyD, LCSW-R, SAP, CCM Laura Leone, MSSW, LMSW
Collaborative Care: Part 2
A Deeper Dive into an
Evidence-Based Model for
Primary Care
1
Virna Little, PsyD, LCSW-R, SAP, CCM
Laura Leone, MSSW, LMSW
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2
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Missed Collaborative
Care Part 1?
Visit the Montana
Health Care Foundation
to view Part 1 of this 2-
part webinar series!
Collaborative Care
Financial and Practice Improvement
Implications
Virna Little,PsyD, LCSW-r, SAP, CCM
Why this Webinar and Why Now?
Under billing
Under coding
Disconnect from financial team
Many senior leaders (CEO/CFO) don’t recognize revenue potential
Not just direct and case rate opportunity but impacts for quality dollars
Reimbursement Across the Board !
Commercial and Medicare reimburse case rates for collaborative care
Masters level licensed staff are able to provide care coordination
Third party payers are reimbursing Medicare
codes (let us know if you don’t get paid)
Payer SpreadsheetProvider Tit le CODES
All Professionals
ALL but
RN
BSW, Social Worker, Psychologist ,
Licensed Counselor ONLY
Psychiat rist , Psychiat ric NP, Psychiat ric
PA ONLY
96150 96151 99366 99367 99368 98967 98968 90853 90791 90832 90834 90837 90853 99211 99213 99214
BSW
• Medicaid
• Medicare
• Commercial
Social W orker
• Medicaid
• Medicare
• Commercial
Psychologist
• Medicaid
• Medicare
• CommercialLicensed
Counselo
r
• Medicaid
• Medicare
• Commercial
Psychiatrist
• Medicaid
• Medicare
• Commercial
Psychiatr ic NP
• Medicaid
• Medicare
• Commercial
Psychiatr ic PA
• Medicaid
• Medicare
• Commercial
RN
• Medicaid
• Medicare
• Commercial
Coding
Codes for depression screening are WAY underutilized
Optimize use of screening codes keeping in mind special populations ( prenatal)
Most practices are screening for depression few are optimizing for revenue –even for FQHC you have other payers
May be screening but not noting results
BHI Coding Summary non FQHC
BHI Code
Behavioral Health Care
Manager or Clinical Staff
Threshold Time
Activities Include:
CoCM First Month(G0502) (CPT 99492)
First 70 minutes per calendar
month
• Initial Assessment
• Outreach/engagement
• Entering patients in registry
• Psychiatric consultation
• Brief intervention
CoCM Subsequent
Months (GO503) (CPT
99493)
60 minutes per calendar
month
• Tracking + Follow-up
• Caseload Review
• Collaboration of care team
• Brief intervention
• Ongoing screening/monitoring
• Relapse Prevention Planning
Add-on CoCM (Any
month) (G0504) (CPT
99494)
Each additional 30 minutes
per calendar month
• Same as Above
General BHI (G0507)
(CPT 99484)
At least 20 minutes per
calendar month
• Assessment + Follow-up
• Treatment/care planning
• Facilitating and coordinating
treatment
• Continuity of care
10
BHI Coding Summary FQHC
BHI Code
Behavioral Health Care
Manager or Clinical Staff
Threshold Time
Activities Include:
CoCM First Month(G0512)
First 70 minutes per calendar
month
• Initial Assessment
• Outreach/engagement
• Entering patients in registry
• Psychiatric consultation
• Brief intervention
CoCM Subsequent
Months (GO511)
60 minutes per calendar
month
• Tracking + Follow-up
• Caseload Review
• Collaboration of care team
• Brief intervention
• Ongoing screening/monitoring
• Relapse Prevention Planning
11
99213 vs. 99214
Review of care plans, psychiatric consultation , phq9 review and education often meet higher time and complexity
Primary Care Coding
Depression Screening Simplified
Behavioral Health Screening Utilization: Depression
Code Description
1. G8431 (with HD modifier)
# of individuals screening for clinical depression is documented as being positive and a follow-
up plan is documented.
1. G8510 (with HD modifier, replaces
99420)
# of individuals screening for clinical depression is documented as negative, a follow-up plan is
not required
1. CPT code 96127
# of individuals screened with a brief emotional/behavioral assessment with scoring and
documentation, per standardized instrument
1. G0444# individuals receiving annual depression screening, 15 minutes
1. CPT 96161
Administration of caregiver-focused health risk assessment instrument (e.g., health hazard
appraisal) with scoring and documentation, per standardized instrument
- Maternal depression screening during well-child visit, billed using child’s ID number.
Service Optimization
Opportunity for Medicare optimization-overlap with CCM and transitions
Depression care visits create opportunity to review primary care access
Behavioral health schedule optimization is often greatest opportunity for revenue and access
Centralizing phone based services
Review of quality dollar opportunities
Patients you are already caring for ( medications)
Staffing for individual visits and case rate
Supporting other initiatives- pcmh , joint commission, HRSA
Input
Calculation
Benchmark
Workbook Template Updated 05/02/2017 Linked Information
= User-entered value
= Calculated field (not editable)
= Suggested benchmark (editable)
= Information copied from another cell
Team Member FTE
Total Hours
per Week
Suggested
Hours per Week
(Based on 40:3 ratio)
Care Management Service Category
Percentage (%)
of Total Hours
per Week Hours per Week
Service Units
Generated
Hours per Service
Unit
Avg. length of warm connection
Avg. length of phone calls
Staffing and Service Delivery
STAFFING
Hours per week per 1.0 FTE at your organization
WEEKLY TIME AND EFFORT ALLOCATION AND SERVICE UNIT GENERATION: CARE MANAGER
Total Care Manager Hours per Week
Indirect Care Coordination and Administrative Tasks
Charting
Registry Management
Psychiatric Consultation
Team Communication
Other (Clinical Supervision, Staff Meetings, Training, etc.)
Subtotal: Indirect Care Coordination and Administrative Tasks
Unassigned Time [Target = 0%] 100.0% (Green checkmark indicates value is at target)
WEEKLY TIME AND EFFORT ALLOCATION AND SERVICE UNIT GENERATION: PSYCHIATRIC CONSULTANT
Reimbursable Direct Care Services
Avg. length of assessment visit
Avg. length of ongoing visits
Avg. length of group visit divided by
Avg. # of participants
Non-Reimbursable Direct Care Services
Care Manager 0.0
Psychiatric Consultant 0.0
Direct Treatment: Assessment Visit 0.75
Direct Treatment: Ongoing Visits 0.50
Group Treatment 0.25
Subtotal: Reimbursable Direct Care Services
Warm Connection (Non-Billable) 0.25
Care Management Telephonic Services 0.25
Subtotal: Non-Reimbursable Direct Care Services
Problem Solving Treatment:
A Brief Overview
Laura Leone, MSSW, LMSW
Poll
Got milk problems?
THE TENANTS OF
PROBLEM SOLVING TREATMENT
▪ A problem is any situation in which an immediate and easily
recognizable solution is not apparent
▪ Problems and minor life events are strongly associated with
psychological symptoms
▪ Weak problem solving capability is linked to the creation and
maintenance of psychological disorders
▪ Regaining a sense of control over one’s life problems is the
most important factor for resolving depressive symptoms
THE TENANTS OF
PROBLEM SOLVING TREATMENT
▪ The goal of PST is to teach the patient the problem solving skills
so that they can use them in the future to avoid depression
▪ The purpose of psychoeducation is to increase the patients
understanding of how and why PST will help them
▪ Once learned, problem solving skills can help prevent relapse
The Effects of Depression
Unresolved problems create a feeling of overwhelm that is usually met with
avoidance and feelings of powerlessness
▪ Life problems can be precipitants of depression
▪ Once depressed, problems become more difficult to solve
▪ Weak problem solving skills make a person vulnerable to depression
RATIONALE FOR PST
As a patient begins to use PST they :
▪ Begin addressing their problems
▪ Decrease avoidance and experience a feeling of control over their life
▪ Problem solving helps patients exert control over problems
▪ Fewer problems increase self-efficacy and hope, and improve mood
SHIFT IN ROLE: THERAPIST TO TEACHER
▪ You are in the role of teacher when doing PST, not in
the role of a traditional psychotherapist
▪ Teach the steps of PST and then practice the steps
learned in every session with real-life problems
▪ This is a much more directive role – you are directive in
guiding the patient through the process and keeping
them on task but not in telling them what to do!
SEVEN STEPS OF PST
▪ Step 1 Clarifying and defining the problem
▪ Step 2 Establishing achievable goal
▪ Step 3 Generating multiple solution alternative: Brainstorming
▪ Step 4 Implementing decision making guidelines: Pros & Cons
▪ Step 5 Choosing the preferred solution(s)
▪ Step 6 Implementing the preferred solution(s): Action Planning
▪ Step 7 Evaluation of the outcome
INTRODUCING PST TO THE PATIENT
(INTRO SESSION)
Tasks for this session include:
▪ Give an overview of length & frequency of PST treatment
▪ Review the use of PHQ-9 & clarify patient’s understanding
of their symptoms
▪ Discuss patient’s problem solving orientation & provide
information about effective problem solving
▪ Challenge distortions in thinking regarding problems as needed
INTRODUCING PST TO THE PATIENT
(INTRO SESSION)▪ Describe the 7 steps of Problem Solving
▪ Review activity scheduling
▪ Create a problem list with the patient
Intro to PST can be done in either one 60 minute session or two 30
minute sessions
STRATEGIES FOR EXPLAINING AND
CREATING THE PROBLEM LIST▪ Create a comprehensive list of problems at the beginning of the
treatment process and use throughout to identify problems to
work on
▪ Allow patient to spontaneously report problems before cueing
with Problem List Worksheet
▪ Focus on current problems – if patient reports past problems ask
how this is affecting the patient NOW
▪ Don’t be afraid to be directive – keep the patient on task with
the steps when they digress
▪ New problems can be added if they arise
CLARIFYING AND DEFINING THE
PROBLEM▪ The task for this step is to define the problem in “I” language and in
behavioral terms – we can change behavior, when we change
behavior emotions can change.
▪ The problem statement must be “objective” and therefore
amenable to change: Think Behavior vs. Emotion
▪ I am sad (emotion) all the time – ask: what do you do
(behavior) or stop doing when you’re sad?
▪ By asking yourself if you can picture the problem you will be
able to gauge whether or not it’s behavioral
▪ “I stay home alone” is objective – this can be changed and is
therefore measurable – doesn’t have to be a number!
CLARIFYING AND DEFINING THE
PROBLEM CONTINUED
▪ Explore and Clarify: Don’t take the problem from the problem list
and use it directly. Think of it as the general topic – you are looking
for the specific behavior that accompanies the problem
▪ Explore the Who, What, Where, When, Why of the problem
▪ Break down complex problems into manageable pieces with
feasible solutions
▪ Housing is a BIG problem – what are the components that
make up the problem?
▪ Think about the time frame of this visit to the next – what
can be achieved in that time?
▪ Must be feasible – can the patient accomplish it between sessions?
▪ The Patient must have some degree of control over the problem – if
the problem lies with someone else it’s not feasible! We can’t
change anyone else – an important psychoeducation piece of work
can be done here
▪ Life problems are potentially controllable – I don’t have enough
food to get me through the week
▪ Symptoms are not directly controllable – I am in pain
REMINDER: TAKE TIME ON STEP 1 – IT WILL HELP BUILD THE
FOUNDATION FOR THE REST OF THE PROCESS!
CLARIFYING AND DEFINING THE
PROBLEM
IDENTIFYING THE GOAL
Follows directly from the Problem definition
Ask:
▪“What do you want to change about…”
▪“How would you like things to be different?”
The goal must be objective (ie: measurable):
▪ Either it happened or it did not happen – this is how we can measure
it – does not have to be a number
▪Improving self-esteem is not objective whereas getting my hair and
nails done is
IDENTIFYING THE GOAL
Must be stated in Behavioral Terms:
▪Weight loss is objective, but it is not behavioral
▪Changing eating habits is both objective and behavioral
▪Goal must be Achievable: Can it be accomplished prior to next visit?
REMINDER: BOTH THE PROBLEM STATEMENT AND THE GOAL
STATEMENT MUST BE WORDED IN “I” LANGUAGE
BRAINSTORMINGProvide psycho education re: how cognitive function gets dulled when
we’re depressed and Brainstorming is a way of waking up the brain
▪Throw caution to the wind – just throw out ideas even if they seem wild
or out of reach
▪Solutions come from the patient - encourage the patient to think for
themselves vs. relying on you for the answers
▪You want to get quantity over quality
▪Provide solutions without judgment or explanation
BRAINSTORMING
▪At end you can review in order to combine and modify ideas if
appropriate
▪Prompt the patient to think outside the box by asking: “What else?”
(then be quiet)
▪Write down what ever the patient states no matter how
unreasonable it might sound
▪ There is no exploration here – just generating ideas and supporting
the patient in their process
REMINDER: AVOID INSERTING ANY QUALIFYING STATEMENTS SUCH
AS “GOOD” OR “GREAT IDEA” FOR IDEAS THAT ARE GENERATED.
WEIGHING THE PROS AND CONS
The task of this step is to explore and process all the possibilities of
each solution so that the patient has a clear understanding of
each and can easily choose the best one at the end of the
exploration.
Simply ask:
▪ Pros: What makes this a good solution?
▪ Cons: What makes this not such a good solution
▪ What are the barriers and obstacles?
WEIGHING THE PROS AND CONS
Review themes as needed:
▪ Time, Effort, Money etc.
Only ask about themes that fit with the solution – ask about a theme
if you recognize it as a potential problem but the patient hasn’t
brought it up
CHOOSING THE PREFERRED SOLUTION
The task of this step is to support the patient’s choice of solution
Simply ask: Which solution seems like the
best one?
Explore by asking:
▪Does the solution satisfy the goal?
▪Is the negative impact limited?
▪Does it make sense to the patient?
▪Does it empower the patient?
If you can identify a valid reason for the patient not to pick the solution it’s
good to explore this and discuss your concerns
CREATING AN ACTION PLANThis is the reason for all the previous steps – creating a plan that is
detailed and specific will enhance the possibility of the patient following through
DON’T RUSH THIS STEP! ▪ Specific steps: who, what, when, where, etc.▪ Identify and work through potential obstacles and barriers▪ Ensure that it is realistic for the patient to follow through with
within the timeframe▪ Engage in role play if needed▪ If you feel you don’t have the time to create a comprehensive plan
then you can assign it as homework to complete ▪ Inform patient that it’s ok whatever the outcome – you’re looking
forward to seeing them again and reviewing how it went
ACTIVITY SCHEDULING
▪ Lack of pleasurable activities can contribute to a depressed mood
▪ Rationale: Feeling bad causes you to do less
▪ Goal: Encourage patients to increase level of engaging in
pleasurable activities
▪ Work with patients to schedule regular enjoyable events if
possible within 24-48 hours
▪ Should be small, feasible activities.
▪ Focus on activities that individual previously enjoyed
▪ Trouble shoot possible barriers to activation
TASKS FOR THE 7 STEPS OF PROBLEM SOLVING
Step 7: Evaluating the outcome
The 7th step is done in the next session – assess what worked and what didn’t.
The tasks of this step are to provide support and encouragement for the patient’s
efforts, explore what might have gotten in the way if not followed through on and
to withhold judgment
Ensure that it’s ok re: what ever outcome occurs – best to do this at the end of the
previous session and reinforce at beginning of current session
Praise success and rate patient’s sense of accomplishment and mood
Explore barriers to patient follow through and create a plan to address barrier if
feasible – this may be a plan “B” for what’s already occurred or a new plan
RELAPSE PREVENTION PLANNING
▪ This is an important part of the treatment process
▪ Review with the patient the reasons it is important
▪ Discuss the warning signs of relapse
▪ Review what strategies have worked previously with the pt
▪ It should be completed when:
▪The Patient completes PST treatment
▪The Patient wishes to end treatment
PST RESOURCES
Some helpful resources for enhancing your understanding of PST:
Impact Website: http://impact-uw.org/
Impact training manual▪ On line training and videos
LA County Mental Health Dept. Website: uwaims.org/lacounty/index.html▪ Impact program model▪ Videos on Behavioral Activation
PST Following Self Harm Study
Review of 7 Steps of PST:
http://www.problemsolvingtherapy.ac.nz/3_1.html
Questions or
Comments
Behavioral Activation (BA)
Laura Leone, MSSW, LMSW
Depression Cycle
Lack of active
engagement in
environment
Depressive
Symptoms
Core Principles of Behavioral Activation (BA)
• BA helps depressed people improve their mood by engaging in pleasurable activities or activities of mastery.
• BA targets patterns of avoidance, withdrawal, and inactivity in order to decrease their depression.
• BA is a brief intervention and easy to use
• Behavior vs. Motivation
• BA focuses on creating structure and scheduling activities that follow a plan.
• BA supports idea that change is easier when you start small
• The practitioner acts as a coach and helps trouble shoot possible barriers to activation
The EVIDENCE BASE for BA
Robust effects have been found in reviews of behavioral activation for depression
Large-scale treatment studies with younger persons found BA to be more effective than Cognitive therapy and equivalent to medication for treating depression.
Research with older adults found similar results, indication that older individuals respond well to BA.
Behavioral Activation Goals
Re-establish routines that have been dropped due to depression
Increase positive experiences to break depression cycle
Be able to apply skills learned in the future to decrease recurrence of depression
Treatment Rationale
Increased healthy behavior
Positive Experiences Improved Thoughts & Mood
Decrease depressed behavior
4 Steps in the Behavioral Activation Process
1. Activity Monitoring
▪ How is the patient spending their time now?
2. Activity Scheduling
▪ Focus on identifying what the patient used to like to do
that they are not doing now
▪ What positive activities could be added into their day to
boost mood?
3. Creating Activity Plans
▪ Be as specific as possible re: activity, day, time etc.
4. Reviewing Progress and Modify
▪ At each visit review log, check mood and identify new
activity
Step 1 in the Behavioral Activation Process
Step 1 - Activity Monitoring
• How is the patient spending their time now?
• Review both positive and negative
• Explore ways to minimize negative behavior by decreasing it
• Explore ways to increase positive behaviors
Activity Monitoring
Self-reports are not as accurate as a log of activities kept between meetings. Depressed people tend to under report positive experiences, emphasize negative perceptions, and focus more on failures than on successes
The Activity Log form can be used in many settings
Activity Monitoring
Have the client fill in his/her activities for each time block before the meeting.
Encourage the client to write in activities that actually occurred, no matter how mundane. E.g. bathing, dressing, eating, traveling, talking with others, watching TV and sleeping.
Ask them to rate (simple 1-10 scale) the degree of enjoyment experienced for each, or the sense of mastery or accomplishment that was associated with the activity.
Activity Monitoring
Simple tasks might receive high ratings
Clients should try to give themselves credit for small accomplishments, because progress is generally made in small, incremental steps.
Low rating of pleasure should be expected for two reasons
▪ If there is little involvement in activities that most people would consider highly pleasurable and
▪ If the capacity for experience joy or pleasure is blunted
Questions to Stimulate Thinking
Are there periods of time you experience enjoyment or pleasure?
What kinds of activities seem to give you pleasure or sense of accomplishment?
Are there certain times of day when you feel less pleasure?
What activities did you do in the past that have been stopped or reduced?
Are there activities you have thought about doing but believe that you cant?
Take the patient down memory lane by asking them to recall memories of past pleasant activities or events or things that they used to do but stopped doing.
Step 2 in the Behavioral Activation Process
Step 2 - Activity Scheduling
▪ Get positive activities scheduled in
▪ Track progress (Tracking Form)
Social / physical activities tend to be most potent mood boosters
Treatment will also focus on increasing daily pleasant events
Activity Scheduling
Once the patient sees relationships between activity and mood, the goal is to increase those activities likely to have the most positive impact on their mood.
How do we do this?
Generate a list of pleasurable activities. Include ones from the monitoring exercise (Activity Log) that had the highest ratings for pleasure
Brainstorm with the patient to list some new ideas that may be worth trying (Tracking Form).
The Patient determines which activities to add to their daily routine.
Select specific times and write them on the schedule as a plan (Activity Schedule Log)
Activity Log 1 Write in each box: 1:Activity 2: Mood Rating (1-10)
Time M T Wed Th F Sat Sun
6-7am
7-8am
8-9am
9-10am
10-11am
Tracking Form-Pleasant Events and
Monitoring Your Mood
Pleasant
Events
1 2 3 4 5 6 7
1
2
3
4
5
Total
Mood
Score
Very sad 1 2 3 4 5 6 7 8 9 10 very happy
Responding to ResistanceStatements Responses
I don’t have any money! Are there things you enjoy that don’t
cost money?
I am in a wheel chair, so there is
nothing I can do !
Is it true that people in wheel chairs
don’t participate in activities?
I don’t like to do anything! What would your family/friends say
you like to do?
I’ll never be able to do it! Is there another way of looking at
this situation?
It is just too hard! What is the best thing that could
happen?
Step 3 in the Behavioral Activation Process
Step 3 - Making the Specific Activity Plan
The more detailed the plan the more likely it is to be
followed
In the plan consider:
Date or days of the week
What time of day
How long
With whom
Other aspects that need to be planned
Back up plan
Step 4 in the Behavioral Activation Process
Step 4 - Review Progress
•Identify successes
▪ Modify the list of activities based on feedback
▪ Schedule new activities. (Activity Schedule Log)
•Review all tasks
•Praise success - ask about how the activity effects their mood
•Discuss things that didn’t work
•What obstacles got in the way?
•Maybe we picked the wrong activity?
•What might work better?
•Set new goals and continue successful ones
Step 4 continued - Modify
Modify scheduling based on feedback, barriers, cultural considerations, and what was successful for the person
What activities actually improved their mood is the key question – to ask and observe as patient retells their experience
Useful Questions to Facilitate Review of BA Plan
• How did the client feel when engaging in in identified activity? (Use rating scale)
• Has there been a disruption in the client’s routine (review monitoring sheets, you may have to break down the pleasurable event?
• What is getting in the way of the client’s completing the pleasurable event?
Helpful Tips for Clients
A – assess what is making me depressed
C – choose to self-activate
T – try the new behavior
I – integrate new behavior into routine
O – observe the results
N – Never give up
Summary of Behavioral Activation
1. Activity Monitoring –(Step 1)
▪ How is client spending their time now? (Activity Log)
▪ What positive activities could be ADDED IN to their days, to boost
mood?
2. Activity Scheduling –(Step 2)
▪ Get positive activities scheduled in.
3. Create Activity Plan-(Step 3)
▪ Track progress. (Tracking Form)
4. Review Progress and Modify–(Step 4)
▪ Modify the list based on feedback,
▪ barriers, and culture. (Activity Schedule Form)
Take Away Message
Four Pleasant Activities a Day, Keeps the Blues Away
They don’t have to be huge - just consciously chosen, and deliberately done to experience control.
1. Events and activities impact mood.
2. To some extent you can control activities & events.
3. Therefore, to some extent, you can control (influence) your mood.
4. By increasing this sense of control, you increase your sense of efficacy or mastery for reducing depression and improving your quality of life.
Questions from the
chat box?
REMINDER
Trauma Informed Care with Youth
Monday July 9th 12-1pm MST
Register:
https://attendee.gotowebinar.com/re
gister/4373922515134638338
Suicide Safer Care
Tuesday July 17th 1:30-3pm MST
Register:
https://attendee.gotowebinar.com/re
gister/7704538950196726273
Reducing Recidivism Among Justice
Involved Youth
Friday August 24th 11-12pm MST
Register:
https://attendee.gotowebinar.com/re
gister/1328002629902583041
