1 Boring Old Man

The Medicaid Health Home State Plan Option, authorized under the Affordable Care Act [Section 2703], allows states to design health homes to provide comprehensive care coordination for Medicaid beneficiaries with chronic conditions. States will receive enhanced federal funding during the first eight quarters of implementation to support the roll out of this new integrated model of care.

^{[participating states so far]}

…"only around 40 percent of Americans with a diagnosable mental illness received any specific mental health treatment in the prior year, and only around one-third of those – therefore, approximately one in seven overall – received treatment that could be characterized as minimally adequate based on practice guidelines."

"… and many of these patients do not receive these medications in sufficient doses or for a sufficient duration; while others continue to use medications even if they are not effective for them, rather than having their treatment adjusted, due to lack of regular monitoring and clinical inertia. As a result, as few as 20 percent of patients started on antidepressant medications in usual primary care show substantial clinical improvements. Many patients referred to psychotherapy receive an insufficient number of visits and/or ineffective forms of psychotherapy, so that treatment response for this type of treatment is also as low as 20 percent under usual care. Finally, poor quality of medical care in patients with mental illness may explain a significant portion of their excess mortality."

The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes

By Jürgen Unützer, Henry Harbin, Michael Schoenbaum, and Benjamin Druss.

EXECUTIVE SUMMARY

• Depression and other common mental disorders are common, disabling, and associated with high health care costs and substantial losses in productivity. Yet only about 25 percent of patients with these disorders receive effective care.
• Only 20 percent of adult patients with mental health disorders are seen by mental health specialists and many prefer and receive treatment in primary care settines.
• Individuals with serious and persistent mental illnesses are more likely to be seen by specialty mental health providers, but they have limited access to effective medical care and high mortality rates.underscoring the need for better connections across primary care and mental health.
• The collaborative care model is an evidence-based approach for integrating physical and behavioral health services that can be implemented within a primary care-based Medicaid health home model, among other settings.
• Collaborative care includes:
  1. care coordination and care management;
  2. regular/proactive monitoring and treatment to target using validated clinical rating scales; and
  3. regular, systematic psychiatric caseload reviews and consultation for patients who do not show clinical improvement.
• More than 70 randomized controlled trials have shown collaborative care for common mental disorders such as depression to be more effective and cost-effective than usual care, across diverse practice settings and patient populations. Collaborative care programs have been implemented by large health care organizations and health plans in both commercially insured and low income/safety-net populations.Traditional fee-for-service reimbursement programs have been a barrier to widespread implementation of collaborative care, but new* reimbursement models using capitated, case-rate payments, or pay-for-performance mechanisms may provide opportunities to expand its use.
• Implementation of evidence-based collaborative care in Medicaid – and in integrated care programs for individuals dually eligible for Medicare and Medicaid- could substantially improve medical and mental health outcomes and functionins. as well as reduce health care costs.

This brief was developed for the Centers for Medicare & Medicaid Services by the Center for Health Care Strategies and Mathematica Policy Research. For more information or technical assistance in developing health homes, visit http://www.medicaid.gov.

Job Description: Psychiatric Consultant

JOB SUMMARY

The consulting psychiatrist is responsible for supporting behavioral health care provided in primary care settings by a team comprised of primary care and behavioral health providers.

DUTIES AND RESPONSIBILITIES

1. Provide regularly scheduled [usually weekly] caseload consultation to behavioral health care managers [CMs]. These consultations are typically conducted by telephone and focus primarily on patients who are new to treatment or who are not improving as expected.
2. Provide occasional telephonic consultation to primary care providers [PCPs] as needed, focusing on patients in the CMs caseload.
3. Work with assigned CMs to track and oversee their patient panels and clinical outcomes using an electronic registry or other type of system capable of tracking clinical processes and patient outcomes.
4. Suggest treatment plan changes, including medication recommendations for patients who are not improving as expected.
5. Discuss patients who need referral for additional specialty mental health care [e.g., to a community mental health center] and advise on treatment plans until patients are engaged in such care.
6. Use a population-focused registry to document recommendations for treatment and/or referrals within 24 hours of consulting with a CM so that they can be easily shared with PCPs and other treating providers.
7. Clearly communicate to CMs and PCPs the limitations of the consultation and treatment recommendations if you did not evaluate the client in person. Include the following disclaimer statement acknowledging these limitations in all consult notes:
   The above treatment considerations and suggestions are based on consultation with the patient’s care manager and a review of information available in registry. I have not personally examined the patient. All recommendations should be implemented with consideration of the patient’s relevant prior history and current clinical status. Please feel free to call me with any questions about the care of this patient.
8. Maintain professional cell phone and Email accounts for contact during usual business hours.
9. Respond to telephone calls from primary care providers and CMs within one business day. Respond to urgent telephone calls within one hour, if available.
10. Check professional Email account daily. Respond to Email questions/consultations within two business days, sooner if urgent.
11. Coordinate with other consulting psychiatrists for vacation coverage.
12. When possible, visit each participating clinic at least once when initiating a new consulting relationship and then at least once per year to meet clinic providers and discuss ongoing collaboration.

OPTIONAL ACTIVITIES

1. Direct evaluation of patients
   Direct evaluation of patients, focusing on clients with diagnostic or therapeutic challenges who are identified in discussion with the patient’s CM and/or PCP. Such consultation may be provided in person or via telemedicine .
2. Training
   This may involve development and delivery of in-service training for primary care-based providers and staff regarding current understanding of best practices for the recognition and treatment of behavioral health conditions in primary care.

Job Description: Care Manager

JOB SUMMARY

The care manager functions as a core member of a collaborative care team that involves the patient’s primary care provider, a consulting psychiatrist and, when available, other mental health providers in the primary care clinic. The care manager is responsible for coordinating and supporting mental health care provided in the primary care clinic. He/she is also responsible for coordinating referrals to clinically indicated services outside the primary care clinic [e.g., social services, mental health specialty care, substance abuse treatment]. The care manager may provide evidence ? based treatments or work with other mental health providers when such treatment is indicated.

"Care management staff, such as a nurse, clinical social worker, or psychologist, who is based in primary care and trained to provide evidence-based care coordination, brief behavioral interventions, and to support the treatments such as medications initiated by the PCP. In some implementations of collaborative care, this staff also provides evidence-based, brief/structured psychotherapy, such as cognitive behavioral therapy."

DUTIES AND RESPONSIBILITIES

1. Support and closely coordinate mental health care with the patient’s primary care provider and, when appropriate, other treating mental health providers.
2. Screen and assess patients for common mental health and substance abuse disorders.
3. Provide patient education about common mental health and substance abuse disorders and available treatment options.
4. Monitor patients [in person or by telephone] for changes in clinical symptoms and treatment side effects or complications.
5. Support psychotropic medication management prescribed by PCPs, focusing on treatment adherence, side effects and other complications, and effectiveness of treatment.
6. Provide brief interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, motivational interviewing, or other treatments appropriate for primary care settings.
7. Provide or facilitate in-clinic or outside referrals to evidence?based psychosocial treatments [e.g, CBT, IPT] as clinically indicated.
8. Participate in regularly scheduled [usually weekly] caseload consultation with the consulting team psychiatrist and communicate resulting treatment recommendations to the patient’s PCP. These consultations will primarily focus on patients who are new to treatment or who are not improving as expected.
9. Facilitate patient engagement and follow-up in care.
10. Track patient follow-up and clinical outcomes using a registry. Document in person and telephone encounters in the registry and use the system to identify and reengage patients who may be lost to follow ? up.
11. Document patient progress and treatment recommendations in the registry so that they can be easily shared with PCPs, the consulting psychiatrist, and other treating providers.
12. Facilitate treatment plan changes for patients who are not improving as expected in consultation with the PCP and the team psychiatrist. These may include changes in medications or psychosocial treatments or appropriate referrals for additional services.
13. Facilitate referrals for clinically indicated services outside the primary care clinic [e.g., social services such as housing assistance, vocational rehabilitation, mental health specialty care, substance abuse treatment].
14. Complete relapse prevention plan with patients who are in remission.