Providing Integrated Care helps patients and their providers. It blends the expertise of mental health, substance use, and primary care clinicians, with feedback from patients and their caregivers. This creates a team-based approach where mental health care and general medical care are offered in the same setting. Coordinating primary care and mental health care in this way can help address the physical health problems of people with serious mental illnesses. (https://www.nimh.nih.gov/health/topics/integrated-care/index.shtml)
LEVELS OF CARE FOR BHCM AS LABELED IN EPIC
After I met a patient and evaluated their level of need within IBH at CAFM I would label myself as one of the following assignments in Snapshot in Epic.
Case Manager -Mild level of care management needs (i.e. needs referral to outpatient care. No acute needs)
Care Manager- Moderate level of care management needs (i.e. needs referral to outpatient care with more moderate level of acute needs. May need some resources for mindfulness or know they can utilize BHCM for crisis needs if needed)
Care Coordinator- Intensive level of care management needed (i.e. needs a large amount of time to address various social determinants or emotional needs)
Assessment Coordinator- 1 IBH upcode/Tag Team session
Mental Health Therapists - 2+ upcodes or telecounseling (no bill dropped for tele-counseling)
Social Worker- MAT Injection pts &or Prior Auth patients.
BHCM CONSULTATIONS
Through Epic
I prefer referrals sent through Epic that are not time dependent. It gives the provider time to process what the the needs of the patient are and time for BHCM to research resources.
Phone Calls
This is definitely good for crisis related patients. BHCM should be kept in the loop some how of Suicidal Patients. I believe that staff should all know how to call Crisis or the safety steps but it's nice to have the BHCM on the other end of the phone to do an evaluation.
Curb Side Consult
This is when the BHCM is in the office and speak to Provider in between sessions to increase the providers awareness of the practices used to help the patient. Provider also can call/text BHCM before/during/after the session.
BHCM ROLES at CAFM
1. MAT CLINIC & COORDINATION
A. Tag Team Session with BHCM/PCP
B. NP Liaison that checks validity of new referrals & helps coordinate the process of referring. We take referrals from RASE, Retreat, & Blueprints.
Step 1, referral source sends fax cover sheet
Step 2, front desk creates chart
Step 3 patient is scheduled
C. MAT - Sublocade/Vivitrol**** Prior Auths, InSupport Co Pay Assistance, Specialty
Pharmacy identification/referral & scheduling of first two MAT Injections
i. Dotphrase .MAT & .INJ for Specialty Comments
D. Different levels of Care management
E. In person Counseling or TeleCounseling for MAT.
ii. Strongly recommended to refer to a MH or SUD therapist to handle their long
term counseling needs. Offered as interim services only for extreme cases or
patients that have a very high co pay.
2. MARCO PROJECTS/BUREAUCRATIC INTERVENTIONS
A. Created and updated a Community Resource Guide for Providers/Patients
i. Dotphrases per county covered by UPMC Pinnacle (LCR/Lanc County Resources;
DCR/Dauphin County Resources; LeCR/Lebanon County Resources).
iii. BHCM put Labels with dotphrase & BHMC contact info on each computer for
provider
iv. IBH Intranet Site started for Providers to use for psycho-education and
community resource management - http://phsintranet.pinnaclehealth.org
B. GENESIGHT COORDINATION
i. Portal to create a referral- https://www.mygenesight.com/Account
ii. Username: sugarmr@upmc.edu; password: Trekbike1!
iii. Tests can be sent directly to patients without the provider's signature.
iv. Tests can be administered in the office by MA. but the process for ordering
hasn’t been reviewed with them.
v. Reach out to rep on how to work portal if you have concerns.
Pamela Weaver
Molecular Sales Consultant
Myriad NS- GENESIGHT
Mobile- 717.283.7012
Customer Service Hours:Monday-Friday: 8am - 8pm Eastern Tel: 866.757.9204 Fax:888.894.4344 Email:support@genesight.com Medical Information Hours:Monday-Friday: 8am - 6pm Eastern Tel:855.891.9415 Email:medinfo@genesight.com
3. RESIDENCY CORE FACULTY
A. Weekly BH Rotation & shadowing [currently Wed 1pm-4pm]
B. BH Didactics/Lectures
C. Wellness/Balint Groups
D. QI Projects & Collaborations with various agencies to address providers in the
community.
References for Residency Core Faculty
PDF- ACGME REQUIREMENTS 2021- see II.B.3a) & II.B.3.c) for non physician core faculty requirements
PDF - ACGME REQUIREMENTS 2020 - (Notes from Residency Directory)
BURNOUT Topics- https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions/
WEBSITE- Physician Wellness - https://www.aafp.org/dam/AAFP/documents/medical_education_residency/program_directors/Physician_Well-being.pdf
MS WORD - BH Medicine Faculty job description
4. COUNSELING
A. In person Tag Team PCP/BHCM (upcode)
B. Face to Face Upcode- Counseling where PCP checks in during the session.
C. No bill
D. Over the phone/video visits
5. COLLABORATION CARE (To be started later)
B. A type of consultation Psychiatrist support for Providers
WHAT IS INTEGRATED CARE
IBH REFERENCES/RESOURCES
WEBSITE/ Collaborative Family Health Association - https://www.integratedcarenews.com/
Collaborative Family Health Association list of PPT's/Resources- https://www.integratedcareconference.com/2019-conference-resources/
WEBSITE/REFERENCE LIST - Behavioral Health and Primary Care Integration
VIDEO - What is Integrated Care?
MS WORD - FAMILY FIRST HEALTH BEHAVIORAL HEALTH CARE MANAGER’S ESSENTIAL DUTIES AND RESPONSIBILITIES
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