1. Blending Behaviorists into the Patient
Centered Medical Home
Virginia Rural Health Association
Staunton, VA
December 8, 2011
© 2011 Cherokee Health Systems
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2. Primary Care and Behavioral Health Integration
An Imperative for Health Centers
• Widespread acceptance of the “concept” of integration
• Tantalizing outcome studies are beginning to appear
• Increased appreciation of behavioral factors in chronic disease
management
• Diminished scope of CMHC’s
• Concept of the Patient-Centered Healthcare Home
© 2011 Cherokee Health Systems
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3. Integrated Care Business
Development: Initial Considerations
• The Money
• The Manpower
• The Model
• The Mission
© 2011 Cherokee Health Systems
© 2011 Cherokee Health Systems All Rights Reserved

4. Our Mission…
To improve the quality of life
for our patients through the integration of
primary care, behavioral health and substance
abuse treatment and prevention programs.
Together…Enhancing Life
© 2011 Cherokee Health Systems
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5. Cherokee Health Systems
A Federally Qualified Health Center and
Community Mental Health Center
Corporate Profile
Founded: 1960
Services:
Primary Care - Community Mental Health - Dental - School-Based Health
Locations:
43 clinical locations in 12 Tennessee Counties
Behavioral health outreach at numerous other sites including primary care clinics, schools and Head Start Centers
Number of Clients: 60,896 unduplicated individuals served - 25,290 Medicaid (TennCare)
New Patients: 19,573 Patient Services: 475,628
Number of Employees: 567
Provider Staff:
Psychologists – 45 Master’s level Clinicians - 62 Case Managers - 31
Primary Care Physicians – 27 Psychiatrists - 11 Pharmacists - 8
NP/PA (Primary Care) - 23 NP (Psych) - 10 Dentists - 2
© 2011 Cherokee Health Systems
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6. CLAIBORNE HANCOCK
White Oak
Tazewell
New Tazewell
75
CAMPBELL
Bean Station
UNION GRAINGER
Washburn
Maynardville Rutledge
Morristown HAMBLEN
25E
Talbott
Blaine
Halls 81
Crossroads
KNOX Jefferson City
ANDERSON
JEFFERSON Newport
Knoxville
COCKE
40 40
SEVIER
Seymour
Lenoir City
LOUDON School Health Clinics
BLOUNT
Integrated Care
Services Health
Behavioral
75 Services Health Outreach
Behavioral
Dental Services
MONROE Transitional Living
Englewood
Facilities
MCMINN
© 2011 Cherokee Health Systems
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7. Key Values Compel Safety Net Providers to
Integrate Care
• Increase Access
• Eliminate Disparities
• Ensure Patient-Centered Culture
• Improve Population Health
• Reduce Healthcare Costs
© 2011 Cherokee Health Systems
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8. Primary Care in the United States:
The de facto Mental Healthcare System
• More mental health interventions occur in primary care than
in specialty mental health settings. (Wang, et. al., 2005)
• Primary care providers prescribe 70% of all psychotropic
medication, including 80% of anti-depressants. (Strosahl, 2001)
• Over one-third of the patients in most primary practices have
a psychiatric disorder. (Spitzer, et. al., 1994; Mauksch, et. al., 2001)
© 2011 Cherokee Health Systems
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9. Primary Care IS Behavioral Healthcare
• Psychological distress drives primary care utilization.
• A variety of studies have concluded that 70% of all
healthcare visits have primarily a psychosocial basis.
(Strosahl, 1998; Fries, et. al., 1993; Shapiro, et. al., 1985)
• Every primary care presentation has a behavioral
component.
• The highest utilizers of healthcare commonly have
untreated/unresolved behavioral health needs.
(Von Korff, et. al., 1992; Katon, et. al., 2003)
© 2011 Cherokee Health Systems
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10. A Few Nagging Questions About
Integration
• What is it?
• How do we do it?
• Who can do it?
• How do we pay for it?
• What are the results?
© 2011 Cherokee Health Systems
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11. © 2011 Cherokee Health Systems
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12. Primary and Behavioral Health Care Integration
Strategies in Search of a Model
• Preferential Referral Relationship
• Formalized Screening Procedures
• Circuit Riding
• Co-Location of Services
• Disease Management
• Behaviorist on Primary Care Team
© 2011 Cherokee Health Systems
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13. Integration vs. Co-Location
Integrated Care Co-Located Mental Health
• Embedded member of • Ancillary service provider
primary care team
• Patient contact via hand off • Patient contact via referral
• Verbal communication • Written communication
predominate predominate
• Brief, aperiodic interventions • Regular schedule of sessions
• Flexible schedule • Fixed schedule
• Generalist orientation • Specialty orientation
• Behavior medicine scope • Psychiatric disorders scope
© 2011 Cherokee Health Systems
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14. The Behavioral Health Consultant in Primary Care
Characteristics, Skills and Orientation to Practice
Characteristics
• Flexible, high energy level
• Team Player
• Interest in health and fitness
Skills
• Finely honed clinical assessment skills
• Behavioral medicine knowledge base
• Cognitive behavioral intervention skills
© 2011 Cherokee Health Systems
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15. The Behavioral Health Consultant in Primary Care
Characteristics, Skills and Orientation to Practice
Orientation to Practice
• Action-oriented, directive, focus on patient
functioning
• Emphasis on prevention and building resiliency
• Utilizes clinical protocols and pathways
• Invested in educating patients, health literacy
© 2011 Cherokee Health Systems
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16. Payment Disincentives for Behaviorists
Practicing in Healthcare Homes
• Mental health carve-outs
• Excessive documentation requirements
• Encounter-based reimbursement
• Same day billing prohibition
• Antiquated coding requirements
© 2011 Cherokee Health Systems
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17. Financing Structure for Integration of
BHCs into Healthcare Homes
• Health and Behavior Assessment/Intervention
CPT Codes 96150-55
• Same day billing by PCP and BHC
• Valuing consultation and case coordination
• Global funding streams
• Value-based contracting
© 2011 Cherokee Health Systems
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18. Integrated Care Standards
• Weekly multidisciplinary care team meeting
• Behavioral health provider embedded on primary care team
• Real-time psychiatric consultation available
• Behavioral health screening of primary care patient
• Integrated clinical record & treatment plan
• Teleconference capability to import providers, as needed
© 2011 Cherokee Health Systems
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19. Fostering the Informed and Activated Patient
• Assess readiness to change.
• Mutually establish behavioral goals and behavior change
strategies.
• Employ motivational interviewing and problem focused
interventions.
• Support patient self-management and self-regulation skills.
• Foster resiliency and personal responsibility for health.
© 2011 Cherokee Health Systems
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20. Cherokee’s Patient-Centered Healthcare Home
• Embedded Behavioral Health Consultant on the Primary Care Team
• Real time behavioral and psychiatric consultation available to PCP
• Focused behavioral intervention in primary care
• Behavioral medicine scope of practice
• Encourage patient responsibility for healthful living
• A behaviorally enhanced Healthcare Home
© 2011 Cherokee Health Systems
All Rights Reserved

21. Contact Information:
Bob Franko, MBA
VP, National Training Coordinator
Bob.Franko@Cherokeehealth.com
Cherokee Health Systems
2018 Western Avenue
Knoxville, Tennessee 37921
Phone: (865) 934-6725
© 2011 Cherokee Health Systems
All Rights Reserved