15ol1jD4SGGz9BAtM0ya - Team Approaches in Psychiatric Disease Roles and Responsibilities - Ruegg

Spring 2021
Hilja Ruegg, MD
Medical Director of Integrated Mental Health Care
Departments of Psychiatry and Family Medicine
University of Cincinnati
Cincinnati, Ohio
Team Approaches in Psychiatric Disease:
Roles and Responsibilities
2
These materials are provided to you solely as an educational resource for your personal use. Any commercial use or distribution of these materials or any portion thereof is strictly prohibited.
Objectives
By the end of this session participants will be able to:

• Describe the rationale for team-based approaches to managing
psychiatric illness in the primary care setting
• Discuss key features of different models of team-based care
• Outline roles, strengths and weakness of different models
• Describe a framework for mental health integration in the
primary care setting
3
Defining a Team-Based Approach
Collaboration between a Integrated Primary Care is

variety of mental health “Collaborative,
and medical clinicians in Interdisciplinary and
the service of patient care population-based”
Shepardson RL, et al. J Anx Disord. 2018;54. 4

Why A Team-Based Approach?
Patient
Performance
Practice
5
Patient
• Average delay between onset mental illness symptoms and

treatment is 11 years
• Less than half of adults with mental illness get treatment in
a given year
• 21% of all adults in the United States are suffering from a
mental illness in any given 12-month period
National Alliance on Mental Illness. Mental health by the numbers. https://www.nami.org/mhstats. Updated 2021. Accessed May, 2021. 6
Patient
Medical and Mental Health Co-Morbidities

Are Common:
• Adults with depression are more likely to be obese than adults
without depression[a,c]
• People with cardiovascular disease have a higher prevalence of
mental illness AND people with mental illness have an increased risk
of heart disease[b]
• One-fifth of all patients with coronary heart disease suffer from
depression and depressed patients are at an increased risk for a
recurrent cardiovascular event[a]
• Rates of depression are doubled in patients with diabetes compared
to those without diabetes.[c]
• Depression may increase the risk of developing diabetes[b]
a. De Hert, et al. Dialog Clin Neurosci. 2018;20:31-40; b. Semenkovich K, et al. Drugs. 2015;75(6):577-587; c. Pratt LA, Brody DJ. NCHS data
brief. 2014(167):1-8. 7
Practice
Integrated Team Based Care:

• Can address mental health access barriers
• Helps realize the goals of the Quadruple Aim of health care:
Improved Patient
Experience
Improved
Lower
Clinical
Costs
Experience
Better Outcomes
Shepardson RL, et al. J Anx Disord. 2018;54:71-86. 8

Performance
Integrated models with multi-disciplinary teams improve outcomes:

• In one study, collaborative care (CoC), also called collaborative
care management (CCM), decreased time to depression
remission from over 600 days to under 90 days[a]
• When mental health disorders such as depression were
treated in a coordinated way along-side other chronic
conditions, such as diabetes and heart disease, outcomes for
all the conditions improved[b]
• Cancer patients with comorbid depression reported improved
depression symptoms and quality of life, pain, and fatigue[c-e]
a. Garrison GM, et al. J Am Board Fam Med. 2016;29:10-17; b. AIMS Center. Evidence base for COCM. 2021; c. Sharpe M, et al Lancet.
2014;384:1099-1108; d. Walker J, et al. Lancet Oncol. 2014;15:1168-1176; e. Wlaker J, et al. Lancet Psychiatry. 2014;1:343-350. 9
Levels of Integration
Coordinated Co-Located Integrated
Level 2 Level 4 Level 5 Level 6
Level 1 Level 3
Basic Collaboration Close Collaboration Onsite Close Collaboration Full Collaboration
Level of Integration Minimal Collaboration Basic Collaboration Onsite
Different Locations Some System Integration Approaching Integration Transformed/Merged Integrated Practice
• Same space, some shared
• Same facility, different • Same space
• Separate systems and facilities systems • Same space
• Separate systems and facilities space and system • Collaborative system
• Communicate about shared • Communicate in person as • Function as a single integrated system
• Rare communication driven by • Communicate regularly solutions and communication
Core Description patients and specific patient needed • Collaborative team care with formal and
clinician need, never in person about shared patients • Regular team meetings
issues • Collaboration driven by informal meetings
• Limited understanding of roles • Collaboration driven by • In-depth understanding of
• Appreciated each other’s roles need for consultation • Roles and culture is blended
need for reliable referral roles
•
• Screening agreed on based • Population-based standardized
• Some sharing of information, • Separate services with • Consistent shared screening
on ability to respond to screening
• Separate screening, treatment • Separate treatment plans shared information, across disciples
Clinical Delivery results • All patients with treatment plan
plans • Some shared knowledge of each agreed on referral • Collaborative treatment plans
• Collaborative treatment • Evidence based practices are shared
other’s evidence based practices criteria/screening • Joint monitoring
plans across disciplines
• Patient physical and behavioral • Health records shared but patient • Patients’ needs treated • Collaboration may include • Patient needs treated as a
• All patient needs treated by team
health treated separately health needs treated separately separately in same warm hand-off team
Patient Experience • Patients experience seamless response
• Patient has to negotiate • Patients referred between location • Internal referrals but still • Care responsive to patients
as needs arise in a unified practice
between separate practices clinicians • More successful referrals separate services needs by team of clinicians
• No coordination of • More systematic information • Leaders supportive but • Leaders problem solve • Leaders support integration as practice
• Leaders support integration
management sharing co-location seen as a system barriers for model
but no change to how
Practice/Organization • Minimal clinician buy-in for • Some clinician buy-into project integration • All components embraced by all
disciplines are practiced
collaboration collaboration and value on shared • Clinicians buy-in to • Inconsistent clinician buy- clinicians and involved in practice
• Consistent clinician buy-in
• information referrals and availability in change
• Separate funding and • Separate funding and
• Separate funding and billing • Blended funding, combined • Integrated funding on multiple sources
• Separate funding, resources billing practices billing
Business Model • May share some resources for billing • Resources shared and allocated
and billing practices • May share facility • May share grants, office
single projects • All expenses shared • Billing optimized for integration
expenses expenses, staffing
• Increased engagement,
• More interaction,
• Practices function adherence to treatment • Treat the whole person
communication and • Clinicians share patients
autonomously • Some coordination and plans and responsive to • All system barriers removed
Strengths relationships between • Systems promote
• Well understood by patients information-sharing patient care • Patient needs addressed as the occur
clinicians collaboration
and clinicians • Clinicians and patient • Shared knowledge increases
• More successful referrals
satisfaction increase
• Overlapping/duplicating • No systematic Information • Proximity may not lead to • System Issues may limit • Practice change may not fit
services sharing collaboration especially if collaboration some established clinicians • Reliable sustainability and outcome
Weakness
• Aspects of care may not be • Referrals fail due to barriers traditional roles • Conflicting agendas can • Time needs to be balanced expectations not well established
addressed or missed maintained create tension with practice productivity
Heath B, et al, eds. A standard framework for levels of integrated healthcare. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions; 2013. 10
Principles for Successful Team-Based Approach
•Patient needs met by a coordinated team[a,b]
•Low barrier access[a]
Patient- •Simplified system navigation[a]
Centered •Evidence and Outcome driven[b]
•EMR/Records for information sharing

•Shared Staffing
Structural •Leadership with vision
Support[a]
•Reliable
•Sustainable
Financial[a] •Competitive
Support
•Multi-disciplinary teams practicing at the top of training and expertise[b]

•Proximal in space and infrastructure to promote shared care[a]
Collaborating •Team-based decision making about quality and performance improvement[a,b]
Clinicians
a. Heath B, et al. A Standard Framework for Levels of Integrated Healthcare. Washington, DC: SAMHSA-HRSA Center for Integrated Health
Solutions, 2013; b. Kathol RG, Ann Fam Med. 2014;12:172-175. 11
A Case Study of Two Highly Integrated Models
12
Two Integrated Models: Shared Features
Embedded • Brief, problem-focused

Mental
Health
psychotherapy treatments
Clinicians[a]
• Use Screening tools to

Population- identify patients
Based[b]
• Panel turnover expected
• Primary Care Clinicians lead the team and

manage diagnosis and medications
Collaborative
[b]
• Team-based monitoring
a. Stepped model of integrated behavioral health care. https://aims.uw.edu/stepped-model-integrated-behavioral-health-care. Accessed May, 2021;
b. Daub S. "Primary Care Behavioral Health." 2014. 13
Key Features: Primary Care Behavioral Health
Focused on "just in Brief solution-
Accessible[b] time" care focused visits
Mental health Health behavior Response to

Generalist[a] disorders change
Self-management
physical illness
Consult about patient

Document and review
Team-Based[d] shared documentation
care, treatment Monitor for response
adjustments
Mirror expectations of BHC visit lengths

High Volume[b] Primary Care Clinic may vary
Educate patients and

Education[c] team members
Mental Health Care viewed as

Routine Care routine part of primary care
a. Daub S. "Primary Care Behavioral Health." 2014; b. Landoll R, et al. J Clin Psychol Med Settings. 2019;26:243-258; c. Reiter JT, et al. J Clin
Psychol Med Settings. 2018;25:109; d. Kathol RG, et al. Ann Fam Med. 2014;12:172-175. 14
Key Features: Primary Care Behavioral
Health Target Population
All Primary
Care Patients
Team Members
a. Daub S. "Primary Care Behavioral Health." 2014; b. Landoll R, et al. J Clin Psychol Med Settings. 2019;26:243-258; c. Reiter JT, et al. J Clin Psychol
Med Settings. 2018;25:109. 15
Key Features: Primary Care Behavioral
Health Clinician Roles
Primary Care Clinician[a]
•Team leader
•Screens for mental health disorders
•Responsible for medication prescribing and monitoring[b]
Behavioral Health Consultant[a]

•Typically either doctorate-level or masters-level clinician (PsyD, PhD or MA)
•Available for warm hand-off visits and focused brief psychotherapy interventions
•Extends primary care capacity to address biopsychosocial needs of the patient[c]
•May serve as consultant educator in settings where there are primary care clinician learners[c]
•Bills based on encounter - number of patients seen
Clinic Staff[a]
•May assist with screening patients
•Facilitate warm hand-offs
Psychol Med Settings. 2018;25:109. 16
Strengths and Challenges
Strengths Challenges
Wide range of patients' needs Not easily adaptable to

can be met[a] sub-specialty populations[c,d]
Requires behavioral and primary

High volume[b] care clinicians skilled in this
kind of collaboration[b]
Highly suited to primary care setting[c]

Reimbursement Challenges for brief
interventions and on same day as the
primary care clinicians[c]
Aligns with Patient-Centered

Care Principles[b]
Psychol Med Settings. 2018;25:109; d. Kathol RG, et al. Ann Fam Med. 2014;12:172-175. 17
Key Features: Collaborative Care
Primary care and Behavioral
Patient goals incorporated into
Patient-Centered[a,b] treatment plans
health clinicians collaborate
to ensure low barrier care
Team tracks defined group

Population-Based[b] of patients on a registry
Clinical out-comes tracked

Treatment plan includes using evidence-based scales
Measurement-Based[a,b] patient's goals and treatments are changed
if not improving
Patients offered psychotherapies and

Evidence-Based[b] medications that have evidence base
in treating the condition targeted
Clinicians are accountable and

Accountable Care[a] reimbursed for quality of care
and outcomes, not just volumes
a. Principles of collaborative care. https://aims.uw.edu/collaborative-care/principles-collaborative-care. Accessed May, 2021; b. Kathol RG, et

al. Ann Fam Med. 2014;12(2):172-175. 18
Key Features: Collaborative Care
Primary Care • Mental Health Diagnosis specific (depression,

anxiety, PTSD, Substance Use Disorders)
Populations • Chronic medical conditions with comorbid
mental health conditions
Subspecialty • Oncology Patients

Disease Populations • Cystic Fibrosis
Other Defined •
•
Perinatal Patients
Adolescents
Populations • Geriatric
19
Key Features: Collaborative Care Clinician
Roles
Primary Care Clinician[b] • Responsible for medication prescribing and
• Team leader monitoring
• Screens for mental health disorders • Is the billing provider for the time-based
incident to service codes
Behavioral Health Care Manager[b] • Manages Registry of patients

• Monitors screened population and assesses patients • Reviews panel with collaborating psychiatrist
who meet criteria • Communicates with Primary Care Clinician
• May be masters-level clinician such as an independently • Tracks non-face to face care-coordination service time
licensed social worker, Registered Nurse, for billing
Collaborating Psychiatrist[b]
• Reviews panel with Care Manager
• Makes Treatment recommendations to Primary Care Clinician
• May see patient for diagnostic consultation
Clinic Staff[c]
•May assist with screen patients
•Facilitate warm hand-offs
a. Principles of collaborative care. https://aims.uw.edu/collaborative-care/principles-collaborative-care. Accessed May, 2021; b. Collaborative care

team structure. https://aims.uw.edu/collaborative-care/team-structure; c. Stepped model of integrated behavioral health
care. https://aims.uw.edu/stepped-model-integrated-behavioral-health-care. Accessed May, 2021. 20
Strengths and Challenges
Strengths Challenges
All members of the team need to

Significant evidence base in wide
be skilled in the unique tasks of
range of populations[a-d]
team-based approach[d]
Financial sustainability due

CPT Codes to Support Team-Based
to inconsistent payor coverage
approach[b]
of codes[e]
Time-Based Coding task require

Versatile application work-flow and infrastructure
investment[b]
a. Financing strategies for behavioral health integration and collaborative care. https://aims.uw.edu/collaborative-care/financing-strategies-
behavioral-health-integration-and-collaborative-care. Accessed May, 2021; b. Bachman J, et al. Gen Hosp Psychiatry. 2006;28:278-288;
c. Bao Y, et al. Am J Manag Care. 2017;23:48; d. Carlo AD, et al. Psychiatric Services. 2020;71:972-974; e. Miller BF, et al. Am Psychologist.
2017;72:55-68 21
Lessons in Integration and Teams Based
Care and the COVID-19 Pandemic
• United States Government Accountability Office Report on
Behavioral Health and the effects of COVID found:
Increase in anxiety and depression report
Increase in Emergency Department reports of overdose and
suicide attempts
Decrease in access as many service organizations were

forced to down-size staffing
U.S. Government Accountability Office, ed. Behavioral health: Patient access, provider claims payment, and the effects of the COVID-19
pandemic. Washington DC: GAO; 2021. 22
Lessons in Integration and Team-Based Care
and the COVID-19 Pandemic
• Tele/video visit expansion did increase access for some
patients[a]
• The increased demand for mental health care is far outpacing
the supply of traditional outpatient mental health services[a]
• Integrated team-based models can be used efficiently to expand
access to patients, particularly when paired with telehealth
modalities[b]
a. Kannarkat JT, et al. Adm Policy Ment Health. 2020;47:489-491; b. Carlo AD, et al. JAMA Psychiatry. 2020;78:355-356. 23
Integration into the Future: A Blended Collaborative
Care/Primary Care Behavioral Health Model :
Stepped Care
Referral to mental
health specialty
Collaborative Care care
team implements
On-site Behavioral registry based
Health Consultant systematic
provides brief treatment to target
Primary Care
Clinician intervention
Primary Care asynchronous

Clinician provides consultation of
initial treatment mental health
specialist
Stepped model of integrated behavioral health care. https://aims.uw.edu/stepped-model-integrated-behavioral-health-care. Accessed May, 2021. 24
Integration into the Future
Coming Together is a Beginning,

Staying Together is a Process,
And Working Together is Success.
-Henry Ford
25
Thank you for
participating in this
activity.

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Spring 2021

By the end of this session participants will be able to:

Collaboration between a Integrated Primary Care is

Shepardson RL, et al. J Anx Disord. 2018;54. 4

• Average delay between onset mental illness symptoms and

Medical and Mental Health Co-Morbidities

Integrated Team Based Care:

Shepardson RL, et al. J Anx Disord. 2018;54:71-86. 8

Integrated models with multi-disciplinary teams improve outcomes:

•EMR/Records for information sharing

•Multi-disciplinary teams practicing at the top of training and expertise[b]

Embedded • Brief, problem-focused

• Use Screening tools to

• Primary Care Clinicians lead the team and

Mental health Health behavior Response to

Consult about patient

Mirror expectations of BHC visit lengths

Educate patients and

Mental Health Care viewed as

Behavioral Health Consultant[a]

Wide range of patients' needs Not easily adaptable to

Requires behavioral and primary

Highly suited to primary care setting[c]

Aligns with Patient-Centered

Team tracks defined group

Clinical out-comes tracked

Patients offered psychotherapies and

Clinicians are accountable and

a. Principles of collaborative care. https://aims.uw.edu/collaborative-care/principles-collaborative-care. Accessed May, 2021; b. Kathol RG, et

Primary Care • Mental Health Diagnosis specific (depression,

Subspecialty • Oncology Patients

Behavioral Health Care Manager[b] • Manages Registry of patients

a. Principles of collaborative care. https://aims.uw.edu/collaborative-care/principles-collaborative-care. Accessed May, 2021; b. Collaborative care

All members of the team need to

Financial sustainability due

Time-Based Coding task require

Decrease in access as many service organizations were

Primary Care asynchronous

Coming Together is a Beginning,

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