Primary Care Mental Health. Primary Care Mental Health. Ms. Jones. Big picture: need, strategies Collaborative care model Implementing Barriers
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- Pauline Roberts
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1 Big picture: need, strategies Collaborative care model Implementing Barriers Ms. Jones New patient to you 45 year old with depression & anxiety Several prior antidepressant trials Primary Care Mental Health 60% of all mental health care 73% of depression care 77% of all psychotropic rx Primary Care Mental Health 60% of all mental health care 73% of depression care 77% of all psychotropic rx Kroenke and Unutzer. Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care. J Gen Intern Med, April 2017.
2 Too Few Psychiatrists Too Few Psychiatrists National: 6% shortfall 12% by 2025 Too Few Psychiatrists psychiatrist National: 6% shortfall 12% by 2025 Oregon: waiting lists of up to 12 months
3 (google that) /Washington (O K/Oregon, MCPAP/Mass)
4 University of Washington: BHC Sees/calls patients Maintains registry Standardized outcome measures Brief therapy Reviews with psychiatrist Conveys Impression/ Recommendations to PCP Collaborative Care 94 randomized trials Effect size of 0.3 ( ) Costs: Vary by group IMPACT ($/pt/year vs. usual care): $+300 at 2 years; $ 3000 at 4 years Collaborative Care Huffman JC, Niazi SK, Rundell JR, Sharpe M, Katon WJ. Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: a publication by the academy of psychosomatic medicine research and evidencebased practice committee. Psychosomatics Mar Apr;55(2):
5 Samaritan: Mental Health Specialists Structured interview, charted Zero therapy, zero dx Some case management Maintains registry/scales Face of psychiatry in clinic Psychiatrist charts Imp/Rec s MHS EMR EMR Ms. Jones New patient to you 45 year old with depression & anxiety Several prior antidepressant trials Warm hand off to MHS (PHQ 9, GAD 7, schedule app t) Structured interview Write up, send to psychiatrist Impression/Rec s to PCP PCP chooses what/when/how MHS f/u by phone in 2, 4, 6 weeks (talk, repeat scales) Write up, send to psychiatrist: new rec s to PCP Follow, until remission or okay plateau
6 psychiatrist Medicare Funding: Penciled MHS Cost Generate Psychiatrist $2000/month $8800/month $2400 / month Medicare Funding: minutes in 1 st month $ minutes following months $ min of general services/month $48 (>100 in 1 st mo or > 90 in f/u mos.) (add $66) Medicare Funding: Penciled MHS $25/hr (salary FTE = $25/hr *20hrs * 4wks = $2000/mo. Per hour: Two patients TC at 20 min / month; or 2 * 48 = $96 One patient TC 60 min/month 1 * 128 = $128 (New pts 90 minutes, $161, hourly equivalent $106) Average revenue per hour = ( )/3= $110 / hr Revenue per 0.5 FTE = $110/hr * 20 hrs/wk * 4 weeks /month = $8800/month $150/hr for 4 hrs / week = 150 * 4 * 4 = $2400 / month
7 Medicare Funding: Penciled MHS/BHC MHS Recruiting Cost Generate Training Time off Psychiatrist Management Space Computer/IT $2000/month $8800/month $2400 / month (FQHC or Rural Health Center) Different codes, same story, slightly better $ 20 min G0511 $62 60 min G0512 $145 Patients per MHS? 0.5 FTE MHS/BHC 1 clinic 3 4 full time PCPs 0.1 FTE Psychiatric Consultant Patients per MHS? MHS at 0.5 FTE can manage patients very rough estimate D/C follow up when improved ( treat to target ) 2 calls/hour * 4 hours * 5 days = 40 calls/week, 160 calls/month Some patients 1/month Some patients 1/week Unscheduled calls frequent Update on symptoms, medications, problems (chart 1 2 paragraphs) PHQ 9 and GAD 7: once a month
8 Google UW AIMS 1. Foundation: understand, ready, sustainable, champions 2. Plan: team, flow, funding, EHR/tracking 3. Training: MHS/BHC, PCP, psychiatric consultant 4. Launch: patients, problems Big picture: need, strategies Collaborative care model Implementing Barriers 5. Nurture
9 Resources 1. Background Kroenke and Unutzer. Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care. J Gen Intern Med, April (full text online) 2. Medicare Billing 3. University of Washington s Implementation Guide care/implementation guide psychologist psychiatrist Integrated Behavioral Health psychologist psychiatrist
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