Category: SOS Blog

Integrated Medical and Mental Health Care

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Almost every time I bring up the topic of behavioral healthcare being integrated with general healthcare delivery, a private mental health practitioner responds questioning how this could possibly work. In response to my June post on this issue, one of our customers shared his thoughts (see comments) about just how this might occur and the obstacles to making it happen in the private setting. I responded like this:

I think many private practitioners are in the same position you are. Unless they do a very health-oriented practice, they see themselves continuing to function quite separately from general healthcare.

The picture is not the same in the public arena. At this time, about 60% of the funding for all mental health and substance abuse services comes from public, not private, sources. Of the people receiving such services, a large percentage have serious physical illnesses as well.

SAMHSA and The National Council for Community Behavioral Healthcare are moving forward with pilot programs and research on the integration of general and behavioral healthcare since this makes lots of sense in the public sector for the seriously mentally ill. But it may also have implications in the private arena. In fact, the move to provide integrated healthcare services in the public sector, and wherever possible in the private sector (like in Accountable Care Organizations – ACOs) has many folks exploring obstacles that may exist to such integration and ways to overcome those obstacles.

Yesterday, I was reading a September SAMHSA-HRSA Center for Integrated Health Solutions newsletter that linked to an interesting article on the use and evaluation of Telephone Administered Cognitive Behavioral Therapy (CBT) for depression. The research started from the current reality that most treatment for depression is provided in primary care physician offices. Of course, this treatment usually consists of medication. While patients prefer psychotherapy to medication for treatment of depression, and both CBT and medication appear to be about equally effective, access to psychotherapy is limited for most people. Cost or convenient access to a psychotherapist covered by their health insurance or some other equally valid reason interferes with provision of psychotherapy.

The research demonstrated that telephone administered CBT was more effective in keeping the client participating in therapy. Both telephone administered CBT and face-to-face CBT were equally effective in diminishing symptoms of depression at time of termination. Face-to-face CBT seemed to maintain the effects better at a six-month measure.

At this point in reading the results, I was reminded of Dr. Suzanne Bennett Johnson’s initiative as President of American Psychological Association (APA) for 2012. She wanted to remind psychologists that they are part of a healthcare profession, and that most of us are well-trained in conducting research. We are ideally suited to design and conduct the studies that will demonstrate just where psychologists and other mental health professionals can best serve in integrated healthcare. I could instantly imagine the re-design of the study reported above to include Skype or other Internet service-based delivery of the CBT so that at least some of the elements of the face-to-face therapy would be present.

There is already lots of opinion about the potential benefits and detriments of remotely-administered behavioral health treatment. Psychologist David C. Mohr, Ph.D., Professor in Preventive Medicine, Medical Social Sciences, and Psychiatry and Behavioral Sciences at Northwestern University lists Internet Intervention and Telemental Health as significant aspects of his interests. Quoted in that 2008 Time Magazine article, Dr. Mohr sees distinct areas where teletherapy or other internet programming might be of use, especially CBT for depression.

Other cutting-edge practitioners have already added internet-based services including videotherapy into their retinue. Given a solid research foundation, video-based therapeutic services might well be a way for the private practitioner of behavioral healthcare to integrate their services with general healthcare.

We can sit back and watch as our healthcare system changes all around us, letting others dictate to us the role we will play. Alternatively, we can be active participants in designing the models for inclusion of behavioral healthcare in primary care. We can design the models, do the research, and market the methods to ACOs, health plans, and medical providers.

We would love to hear from any of you who already work in a setting where mental health services are integrated into primary healthcare. Please let us know your experience and what you think.

 

Psychiatry CPT Codes for 2013

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A few weeks ago I wrote about the upcoming changes in the CPT codes for psychiatric services. Lots of people have been looking for detail on those changes, but the American Medical Association has not yet released all of the specifics. They are planning major changes to the general illness codes as well.

The AMA invites the health care community to learn more about the significant changes to the 2013 CPT codes and descriptors by attending the CPT/RBRVS Symposium in Chicago from Nov. 14-16, 2012. For additional information, please visit the AMA website at:http://www.ama-assn.org/go/symposium

If you are not going to be in Chicago in November for the symposium, there will likely be some other venues through which you can obtain more detail. The American Psychiatric Association (aPa) has created some documents that should be helpful, but they too cannot release the codes to the general public until the AMA gives them the go ahead. aPa members can obtain more specific information at their website.

The National Council announced their own upcoming workshop in today’s Public Policy Update. The challenge is that the codes are changing for everyone who provides mental health services. While some changes happen every year, this is a pretty involved set requiring the use of evaluation and management codes. The Council has already put together a fact sheet that you might find helpful. You might consider attending the webinar they are planning in November.

This is a topic for all of us to get informed about and stay on top of. Please share any information or links that you become aware of. Just enter them in the Comments below.

Energy at Work: What recharges you?

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Last night I saw a great horned owl sitting at the top of a tall pine tree silhouetted against the sky.

We had been hearing the hoots of the owls for the past several weeks. Sometimes we would hear him near bedtime when we walked outside briefly to say good night to departing guests or to pet our front porch cat. A few times I heard him calling early in the morning.

I had looked for him before, but seeing a bird in the dark is a real challenge, especially not really knowing where to look. It can be a challenge to localize the source of a bird call, especially one as loud and deep as that of an owl. The sound bounces off nearby houses and trees.

Last night, I walked out into an open part of my front yard and looked up toward the tops of very tall pine trees a couple of properties away from mine. I saw movement at the top of a tree, then saw a very large bird fly off. As I kept watching, I saw a second bird fly from the same location to the top of a nearby pine tree. It sat on the very top of the tree so I could see its 2+ foot height dark against the lighter sky. I ran inside to get my binoculars and he waited in the same spot. I had no camera with the power to photograph it, so my brain will need to store the image. And it will!

I am not a serious birder. I do not have a life list that I seek to fill. I do get significant pleasure from sighting birds that share my locale. It is a major recharge event for me.

You see, I have long found that I require a great deal of self-care and stress management to function well. When I worked as a psychologist, I used a variety of methods, mostly focused on professional involvement and time spent with other people. After 15 years of practice, I had burned out. I had not done enough to take care of myself.

I believe this is a major problem among behavioral healthcare workers. The job of assisting other people in being mentally healthy is a very difficult one. The chronically and seriously mentally ill can be a very satisfying but very draining population with which to work. Finding ways to recharge and re-energize is crucial to doing this work well.

Now that I work with providers of behavioral healthcare services instead of with patients themselves, I still need to do lots of self-care. Bicycling, gardening, watching the birds in my garden and near my home . . . these have become the ways I energize myself.

How do you take care of yourself? What recharges your batteries? Does your practice or organization have tools to help you with your self-care? When did you last see a great horned owl?

Please share your thoughts and experiences. When you offer your insights, you give other readers additional ideas to explore. Please do so!

New IOM Report: Best care at lower cost

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In early September, the Institute of Medicine published its most recent report on the state of healthcare in the U.S. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, identifies three major “imperatives for change: the rising complexity of modern health care, unsustainable cost increases, and outcomes below the system’s potential. You can download a free, prepublication .pdf version of this 450 page report before it is out in print.

The committee explored in detail some of the pressing needs of the system. They are convinced that we must move toward a healthcare system that learns from itself as rapidly as possible or the system is likely to self-destruct. We must learn how to incorporate research results more quickly, we must learn to change delivery systems that cost too much, we must move the system closer to its highest potential. In short, we must develop a culture of “continuous improvement to produce the best care at lower cost.”

FierceHealthFinance focused on the reported waste of $750 Billion a year (about 30% of the cost of healthcare in the U.S.) as one of the most important things to change. While that number is appalling, the fact that the figure reported was from 2009 is the most striking thing about it to me. Our system has become so complex that it takes three years before we know what it costs. We are constantly behind the curve, and must find ways to speed up the process of information assessment, dissemination, and implementation for change.

The behavioral healthcare system is often far behind the curve in implementing change that might be more productive. The public health and public behavioral health systems are deep in conversation and pilot programs related to integrating physical and behavioral healthcare. Suzanne Bennett Johnson, Ph.D., current President of the American Psychological Association (APA) identified the need to increase psychology’s role in integrated care as a primary thrust of her presidency; her presidential address also focused on this issue. I wonder how many mental health providers in the private sector are even willing to consider what changes to their work such an integrated system might bring.

Take a look at the very brief summary of the IOM report to see if you would like to read the whole thing. What do you think we need to do in behavioral healthcare to begin to address some of these issues?

Where is the Consumer in Health IT?

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On Monday, September 10, 2012, I listened in on the first few hours of the 2012 Consumer Health IT Summit: Expanding Access to Health Information. The program was streamed live on the HHS website. The information presented was pretty fascinating, but what impressed me most was the passion of the presenters. They were really excited about what they call the Blue Button.

Most of Monday’s session focused on increasing patient involvement in their health care through access to their health information, mostly by way of Blue Button technology. While there are many reasons for our healthcare system to move toward our medical records being entirely electronic and interoperable, one of the most important of those reasons is patient access. It is widely believed that engaging consumers in the process of their healthcare is essential to effective prevention and management of chronic health conditions. Unless we get chronic illnesses well-managed, we will never get control of healthcare costs.

This is an important arena for Behavioral Health. I went to the website of The National Council for Community Behavioral Health and did a quick search on “chronic illness and mental health” and came up with 762 documents that contained reference to those terms. Obviously, this is an area that has been written about a great deal. Approximately 78 percent of all health care spending is for individuals with chronic conditions.  There is a high co-occurrence of mental illness and substance use disorders and chronic physical health conditions.

Involving the consumer of healthcare services and their families in their treatment may go a long way toward controlling some of the costs involved. Having access to our medical records is just one way to assist in this process. Hence, the focus on the Blue Button.

The Office of the National Coordinator for Health Information Technology has made patient access to their health data a priority. They have created a Pledge program whereby corporations and individuals can pledge to work to make patient health information available to them.

There are Two Types of Pledges. Data Holders, those who manage or maintain individually identifiable health data such as providers, hospitals, payers and pharmacies) would take this pledge:

 

We pledge to make it easier for individuals and their caregivers to have secure, timely, and electronic access to their health information. We further encourage individuals to use this information to improve their health and their care.

 

Non-Data Holders, that is folks

 who do not manage or maintain consumer health data, but have the ability to educate consumers about the importance of getting access to and using their health information (e.g., employers, consumer and disease-based organizations, health care associations, product developers) . . .

 

would pledge the following:

We pledge to engage and empower individuals to be partners in their health through information technology.

This is an interesting approach to involve as many people as possible in a process that is huge and will undoubtedly take many years to complete. In the spirit of sharing as much information as possible so we can all learn about our own healthcare information and find ways to gain access to it, I thought I would at least share some links with you.

The Office of the National Coordinator (ONC) maintains a website that contains a wealth of information about healthcare technology and events related to it. The goal of consumer involvement or putting the “I” in healthcare IT is the current focus at this site. If you would like to see the progress physicians and hospitals are making toward adopting electronic medical records, take a look at this dashboard. I am sure there are many other useful sites. I will do my best to share them as we all move forward with this process. Please share the ones you know about as well.

If your doctor had a patient portal for you to visit and have access to your health record, would you use it? Is this something that is important to you? Do you use a Personal Health Record now? Please let us know what you think about this whole move toward patient involvement in and responsibility for their healthcare and using Electronic Medical Records to help it happen.