Behavioral Health, Patient Centered Medical Home: Embed or Not to Embed…?

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Lee Reichbaum copyBy Lee Reichbaum, Ph.D.

Don’t look now, but the pendulum has swung again. The federal government, insurers, and physician practices are considering the newest rendition of  what used to be known as preferred provider organizations, staff model HMO, and any number of other synonyms. The national push for new models of care are driven by the economics of medicine, the need to effectively manage healthcare by using evidenced-based protocols, and to establish coordinated quality of care based on establishing continuity in the doctor-patient relationship.

When reviewing  Patient Centered Medical Homes [PCMH] and Accountable Care Organizations [ACO] “white papers” the responsibility for managing all aspects of a patients’ care falls upon the primary care physician [PCP] selected by the patient or assigned by the insurer. This responsibility includes providing behavioral health services. Several approaches are being suggested to integrating behavioral health care: 1] embed care onsite with PCMH employed specialists [i.e. Psychiatrists, Psychologists, etc.]; 2] identify behavioral health specialists [BHS] in the community that provide excellence in both treatment and collaboration; and 3] a hybrid, with initial assessment onsite followed by referral to established resources in the community if needed.
Embedding provides outstanding opportunities: familiarity with the expertise of the BHS working side by side, facilitate “warm hand-offs” among colleagues, seamless scheduling among practitioners, sharing records, and close management of the provision and levels of care. Among the major drawbacks to the onsite format are the relative costs: salaries, employee benefits, difficulties in having an in-house staff with expertise diverse enough to address the range of complexities a practice may encounter, as well as the return on investment value assigned to real estate within the office.

The second option is often favored because of efficacy and fiscal considerations. Physicians can serve more patients in same time in the consolidated space of a typically configured office than a behavioral health specialist who typically spends 20-55 minutes/appointment and generally requires a space larger than the typical examination room. This model maximize office utilization, increasing the ability of a practice to meet benchmarks rewarding payment for performance schemas.

Option 3, allows for combining onsite efficiency as well as utilizing  broader expertise and resources in the community, with either an employee of practice or a consultant using space within the PCMH office.

In turn, PCPs/PCMHs/ACOs are urged to identify and affiliate with behavioral health specialists with demonstrated experience in evidenced-based treatment protocols. Physicians determine the breadth of behavioral care they personally feel competent to manage themselves and similarly identify markers requiring a higher level of expertise and referral. Close collaborative relationships between PCP and BHS help assure patients of coordinated continuity care, minimizes the sense of fragmentation or being abandon by the PCP referring to an estranged specialist. BHSs should be able to skillfully address the range of behavioral health problems by assessing patients’ needs, providing direct treatment, or knowing the community of resources so as to make well-planned referrals. Remembering in a Consultative Model, the consultant serves two masters, the patient and PCP. BHSs should be available to PCPs by telephone, secure emails, or teleconsultations to provide “arm chair consultations” assisting PCPs to manage patients who are not ready to be referred or to coordinate the care of mutual patients.

The scope of expertise a BHS will vary, but ideally ought to include areas such as: caring for adults, couples, children, family; Axis I/II diagnoses, substance abuse of drugs, tobacco, eating habits; adaptation to health problems like diabetes, strokes, heart disease, pain; capable of running psychoeducation groups for stress management, smoking cessation, weight management, etc.

Recently Medscape published succinct “20 Things Psychiatrists Think Hospitalists Should Know”, before requesting a behavioral health consultation.” Using such a template guides when and how to referral, by doing so the referring physician assists the specialist’s focus in consult, helps the specialist: prepare for the assessment, ultimately improving timeliness, efficacy of the evaluation; and leads the consultant to precisely respond to PCP/patient needs.

Bottom-line, identify a Behavioral Health Specialist who will provide expertise in helping care for your patients and with whom you develop a very collaborative trusted relationship.

Lee Reichbaum, Ph.D., Licensed Psychologist, is CEO, Allegheny Mental Health Associates. To learn more, visit http://amha4u.com/