Primary Care Practitioner Integrated Care (Model 1 ......PRIMARY & BEHAVIORAL HEALTH INTEGRATED CARE...

PRIMARY & BEHAVIORAL HEALTH INTEGRATED CARE PROGRAM | SCC PROJECT MANAGEMENT OFFICE Suffolk Care Collaborative │ www.suffolkcare.org │ 1383 Veterans Memorial Highway, Ste. 8, Hauppauge, NY 11788

Copyright © 2016 Suffolk Care Collaborative, All rights reserved

PROGRAM TOOL FOR PARTICIPANTS OF DSRIP PROJECTS 3ai

DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM

SUFFOLK CARE COLLABORATIVE

V.4

Primary Care Practitioner Integrated Care (Model 1) Implementation Manual

http://www.suffolkcare.org/



Primary & Behavioral Health Integrated Care Program

3rd Edition: 3/31/17

The Mind Matters



This material was created by, and is the proprietary work of the Suffolk Care Collaborative (SCC). It may not be copied,

transmitted, or reproduced in any manner without the express permission of the SCC.

For more information, please contact us at [email protected]

SUFFOLK CARE COLLABORATIVE 1383 Veterans Memorial Highway, Suite 8, Hauppauge, NY 11778

www.suffolkcare.org


mailto:[email protected]





4th Edition: 3/31/17

The Mind Matters



This material was created by, and is the proprietary work of the Suffolk Care Collaborative (SCC). It may not be copied,

transmitted, or reproduced in any manner without the express permission of the SCC.

For more information, please contact us at [email protected]

SUFFOLK CARE COLLABORATIVE 1383 Veterans Memorial Highway, Suite 8, Hauppauge, NY 11778

www.suffolkcare.org


mailto:[email protected]




Section 1:

Introduction

S.1




Acknowledgements We would like to acknowledge members of our program who support our ongoing efforts in health care

delivery system reform.

Primary & Behavioral Health Integrated Care Program Workgroup A composition of subject matter experts engaged to support the development, execution and

monitoring of project milestones.

Primary & Behavioral Health Integrated Care Program Committees A composition of key internal and external project stakeholders, including representation from key

community and public service and governmental agencies engaged to support the conclusions,

deliverables and monitor system impacts of the DSRIP Program.

Special thanks to our key contributors for their work on the 1st Edition Toolkit:

Primary & Behavioral Health Integrated Care Program Workgroup

Alyse Marotta , Project Manager, Suffolk Care Collaborative

Susan Jayson, Director of Behavioral Health Integration, Suffolk Care Collaborative

Kristie Golden, Project Lead, Suffolk Care Collaborative Associate Director of Operations, Neurosciences Neurology, Neurosurgery & Psychiatry, Stony Brook Medicine

Mary Emerton, DSRIP Project Manager, Behavioral Health, Catholic Health Systems

Andrew Tucci, DSRIP Project Manager, Northwell Health

Brian Bronson, Director, Division of Consultation and Liaison Psychiatry & Fellowship in Psychosomatic Medicine, Stony Brook Medicine

Gail Schonfeld, MD, East End Pediatrics

Jeffrey Steigman, Chief Administrative Officer, Family Service League

Linda Efferen, Medical Director, Suffolk Care Collaborative

Lorna Johnson, Vice President, Behavioral Health Services, Hudson River HealthCare

Harriett Hellman, NP, Hampton Community Healthcare

Maryann Braithwaite, Office of Mental Health

Matthew Grady, East Hampton Family Medicine

Rajvee Vora, Medical Director, Ambulatory Behavioral Health, Northwell Health

Richard Murdocco, Director of Social Work, Primary Care Initiative Grant Administrator, Clinical Assistant Professor, Stony Brook Medicine

Roberta Leiner, Chief Patient Engagement and Community Health Planning , Hudson River HealthCare

Recognition to the following organizations and coalitions for their collaboration and support:

Primary & Behavioral Health Integrated Care Committee

Stony Brook Medicine- Department of Psychiatry

Association for Mental Health and Wellness

Brookhaven Memorial Hospital Medical Center

Catholic Health Services of Long Island

Department of Family Medicine - Stony Brook Medicine

Developmental Disabilities Institute (DDI) NY




Division of Community Mental Hygiene - Suffolk County Government

East End Pediatrics

East Hampton Family Medicine

Family Service League of Long Island

Hampton Community Health Care

Hudson River HealthCare

Northwell Health

Office of Alcoholism and Substance Abuse Services (OASAS) Long Island Field Office

Stony Brook Medicine

Suffolk County Government




Table of Contents

Section 1: Introduction ................................................................................................................................. 1

Acknowledgements .................................................................................................................................. 1

Primary & Behavioral Health Integrated Care Program Workgroup .................................................... 1

Primary & Behavioral Health Integrated Care Program Committee .................................................... 1

Program Overview ................................................................................................................................... 1

Background ...................................................................................................................................... 1

State-wide Effort: Delivery System Incentive Payment Program .................................................... 1

Local Leadership: Suffolk Care Collaborative ................................................................................... 1

Primary & Behavioral Health Integrated Care Program .................................................................. 1

Primary & Behavioral Health Integrated Care Program Goals......................................................... 1

Purpose of the Implementation Toolkit........................................................................................... 1

Returning Required Documents ...................................................................................................... 1

PCMH Certification Program Alignment .......................................................................................... 1

Program Resources .......................................................................................................................... 1

Suffolk Care Collaborative Program Contacts ...................................................................................... 1

Section 2: Suffolk Care Collaborative Program Documents ....................................................................... 2

Clinical Guideline Summary (Model 1) ...................................................................................................... 2

Primary & Behavioral Health Integrated Care Program Flow Chart (Model 1) ........................................ 2

Section 3: Primary & Behavioral Health Integrated Care Program Implementation ................................. 3

Primary & Behavioral Health integrated Care Program protocols and Templates ................................... 3

Technical Assistance Plan .......................................................................................................................... 3

Protocol 3ai.01 Evidence Based Standards of Care, Medication Management ....................................... 3

Protocol 3ai.02 Evidence Based Guidelines .............................................................................................. 3

Protocol 3ai.03 Screening Procedure ........................................................................................................ 3

The Patient Health Questionare-2 (PHQ-2) ..................................................................................... 3

The Patient Health Questionare-9 (PHQ-9) ..................................................................................... 3

Alcohol Use Disorders Identification Test (AUDIT-C) ....................................................................... 3

Drug Abuse Screening Test (DAST-10) ............................................................................................. 3

CRAFFT ............................................................................................................................................. 3

Pediatric Screening Checklist (PSC) .................................................................................................. 3




Pediatric Screening Checklist (PSC) .................................................................................................. 3

Protocol 2ai.01 Warm Referral and Follow Up ......................................................................................... 3

Integrated Care Implementation Checklist ...................................................................................... 3

Maine Health Access Foundation (MeHAF) Site Self Assessment ................................................... 3

Section 4: Document Request ...................................................................................................................... 4

Protocol 3ai.11 Document Request .......................................................................................................... 4

Provider Directory Request Template ............................................................................................. 4

Integrated Care Practice Schedule ................................................................................................... 4

Integrated Care EHR Documentation Request Form ....................................................................... 4

Behavioral Health Warm Transfer EHR Document Request Form .................................................. 4

Patient Engagement Data Request .................................................................................................. 4

Section 5: Integrated Care Services Application Materials ......................................................................... 5

Protocol 3ai.05 Integrated Care Services .................................................................................................. 5

Application Materials ................................................................................................................................ 5

Thresholds and Licensure.......................................................................................................................... 5

New York State Department of Health FAQs ............................................................................................ 5

Approaches to Integrated Care ................................................................................................................. 5

Section 6: Billing for Integrated Care Services ............................................................................................ 6

SAMHSA Billing Guidelines ........................................................................................................................ 6

Section 7: Training ........................................................................................................................................ 7

Section 8: PCHM Certification Program Alignment Summary .................................................................... 8

Section 9: Resources..................................................................................................................................... 9

Program Resources ................................................................................................................................... 9




Overview

Background In response to rising healthcare costs, Medicaid spending and concerns of health care quality, Governor

Andrew M. Cuomo created the Medicaid Redesign Team (MRT). The MRT initiatives accounted for

approximately $17.1 billion in federal savings. On April 14, 2014, Governor Andrew M. Cuomo

announced New York finalized terms and conditions with the federal government for a groundbreaking

waiver that will allow the state to reinvest $8 billion of federal savings generated by the MRT reforms.

The MRT waiver amendment goal is to transform the state’s health care system, bend the Medicaid cost

curve, and ensure access to quality care for all Medicaid members. NYS Department of Health’s charter

under this waiver to fully implement an action plan to allow for comprehensive reform through a

Delivery System Reform Incentive Payment (DSRIP) Program.

State-wide Effort: Delivery System Reform Incentive Payment Program Through the Delivery System Reform Incentive Payment Program, a grant waiver administered by the

NYS Department of Health (NYS DOH), $6.42 billion Medicaid dollars were allocated to fundamentally

restructure the health care delivery system to transition care delivery from a largely inpatient-focused

system to a community-facing system that addresses both medical needs and social determinants of

health. DSRIP is a 5-year, performance payment-based program with primary goal of reducing avoidable

hospital use by 25% over 5 years. At the end of the program life, the aim is for the newly-transformed

system is to be sustainable. Project efforts are focused on achieving improved overall health through

integration of behavioral health and primary care, provision of appropriate levels of care management,

and care delivery models designed to improve chronic disease prevention and outcomes.

Local Leadership: Suffolk Care Collaborative New York State is broken into 25 regional organizations called Performing Provider Systems (PPS). Each

PPS is responsible for engaging providers, designing programs, coordinating collaboration, reporting

project outcomes and allocating funds to partners.

The Suffolk Care Collaborative (SCC) is the PPS for Suffolk County under the DSRIP Program. The goal of

SCC is to meet the requirements of the Triple Aim Initiative – improving patient experience, improving

health outcomes and reducing the per capita cost of healthcare. Our vision to become a highly effective,

accountable, integrated, patient-centric delivery system has positioned us well to make an important

contribution to the DSRIP program. Some of the many goals will include the capacity to make the most

of patients' self-care abilities, improve access to community-based resources, break down care silos, and

reduce avoidable hospital admissions and emergency room visits.

The SCC has operationalized all DSRIP requirements through a portfolio of programs.

Integration of Primary Care and Behavioral Health Program The purpose of this project improve identification and access to Behavioral Health Services in Suffolk

County while ensuring those residents who are enrolled in a behavioral health treatment program are

receiving primary care services. Over the five-year DSRIP program, the project seeks to implement one

of two models at primary care sites across Suffolk County. In addition, the project seeks to implement


https://www.health.ny.gov/health_care/medicaid/redesign/

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/

https://suffolkcare.org/aboutDSRIP/projects



primary care services at participating Behavioral Health sites including mental health and substance

abuse sites.

Click here to access the Primary & Behavioral Health Integrated Care Program webpage.

Program Goals Immediate Goal: Improve identification and access to behavioral health services in Suffolk

County o Model 1) Implement Integrated care by embedding behavioral health specialists into

primary care settings and supporting the PCMH model o Model 2) Implement Integrated care by embedding primary care services into

established behavioral health sites o Model 3) Integrate primary care and behavioral health using the IMPACT model, as

described in this toolkit o In all three models above, care should be as integrated as possible, offering warm

handoffs when providers are embedded and coordinated care performed by all members of care team.

Long Term Goal: Improve identification and access to behavioral health services in Suffolk County

Purpose of the Implementation Toolkit The purpose of this toolkit is to assist you and your team during the implementation phase and

throughout the life cycle of the project throughout the DSRIP years. It provides an overview of the DSRIP

project requirements, requirements for implementation, overview of the Primary & Behavioral Health

(PCBH) Integrated Program, instructions on how to submit documents and maintain your binder. It is

meant to act as a guide and information source in which you can refer to for all your DSRIP needs.

Please refer to the Unit Level Implementation Plan provided to you by the SCC which outlines deadlines

in which all project requirements must be met.

Returning Required Documents This toolkit includes several documents that will be needed to be completed and returned to the Suffolk

Care Collaborative by participating providers. Electronic copies of these documents can be accessed via

our Partner Portal or you can complete the hard copies provided here and return them to SCC. If you

complete a document in hardcopy form, please scan the completed document and email or fax it to

your Provider Relations Manager. We also recommend you keep a hardcopy of every document

submitted to Suffolk Care Collaborative.

PCMH Certification Program Alignment The SCC’s clinical improvement program’s implementation approach is closely aligned to our

participating primary care practices participation in our Patient Centered Medical Home (PCMH) Practice

Transformation Program.

Stakeholders have aligned all Domain 3 Clinical Improvement Program implementation protocols to

PCMH standards, as described herein. Implementing DSRIP’s primary care practice protocols throughout

the programs can help meet the requirements of many PCMH standards. An interactive crosswalk lists


https://suffolkcare.org/aboutDSRIP/projects/3ai

https://suffolkcare.org/aboutDSRIP/projects/2ai2

https://suffolkcare.org/aboutDSRIP/projects/2ai2



the DSRIP Domain 1 Project Requirements connected to primary care and aligns them with

requirements for the 2014 Patient-Centered Medical Home (PCMH) standards, Advanced Primary Care

(APC) model, and Transforming Clinical Practice Initiative (TCPI). Requirements for each model come

directly from their respective sources.

Click here to access our Program Goal Cross-walk to the PCMH Standards. This cross-walked was

leverage in the design of our SCC Clinical Improvement Program (Domain 3) Implementation Toolkits as

well as our implementation approach in working with our primary care practice sites.

Program Resources Appended to this Implementation Toolkit is a set of Program Resources designed for our network

participating providers. Click here to access. Program resources include the following:

Implementation Resources

Provider Resources

Additional Reading Materials


http://www.gnyha.org/whatwedo/finance-insurance-gme/nys-finance-issues/medicaid-waiver-dsrip/dsrip-crosswalk



Section 2:

Suffolk Care Collaborative

Program Documents

S.2


Suffolk CareCollaborative

Office of Population Health - 1383-8 Veterans Memorial Highway, Hauppauge NY 11788Tel: (631) 638-2227 | Fax: (631) 638-1009 | suffolkcare.org

Integration of Primary Care and Behavioral Health: Model 13.a.i

Project goal Immediate: Integrate Behavioral Health Services into primary care practices.

Long-term: Improve identification and access to Behavioral Health Services in Suffolk County.

Deliverables to include diabetes monitoring for people with diabetes and schizophrenia (HbA1c and LDL-C), diabetes screening for people using antipsychotic medication; cardiovascular monitoring for people with CVD and schizophrenia (LDL-C); antidepressant medication management - acute and continuous phase treatment; adherence to antipsychotic medications for people with schizophrenia; initiation of alcohol and other drug dependence treatment (1 visit within 14 days) and engagement (initiation and 2 visits within 44 days); follow up care for children prescribed ADHD medication – initiation and continuation phase; screening for clinical depression and follow up; follow up after hospitalization for mental illness within 7 and 30 days; decrease potentially avoidable ED visits.

Interventions Providers will be responsible for: 1) Collaborating with a behavioral health specialist/organization to integrate/co-locate in the primary care practice. 2) Screening all patients once per year (at a minimum), as part of their regular visit, for depression and substance use with evidence based screening tools. 3) Documenting scores for both clinical and reporting purposes in the EHR. 4) Connecting patients with the integrated/co-located professional to provide interventions for behavioral health concerns when the individual screens positive. 5) Arranging for shared documentation to ensure communication about the patient is easily accessible and readily available. 6) Carrying out “warm handoffs” and referrals to additional mental health and substance abuse resources/providers for more intensive treatment when indicated.

Providers will integrate the following behavioral health screening tools into the workflow:

• Depression Screening Tool: - PHQ2 (First two questions of PHQ9) followed by the PHQ9 when a patient scores positive on

the PHQ2 or PSC-Y/ PSC-17 for the pediatric population. PHQ2 positive result is defined as a score of 3 or higher. PHQ9 add score to determine severity.

• Substance Abuse Screening Tools: Adults age 18 or older - AUDIT C (First three questions of AUDIT) followed by the Full AUDIT when a patient scores positive on the AUDIT C. AUDIT-C positive score is 3 or higher for women and 4 or higher for men. A positive on the full AUDIT is greater than 7.

DAST pre-screen (question 1 of DAST) followed by the Full DAST when a patient screens positive (‘yes’ to question 1) on the pre-screen. Full DAST add score to determine severity.

• Substance Abuse Screening Tools: Age 13-17 - Pre-Screen CRAFFT: Provider asks first 3 questions. If “No” response to all three pre-screen questions, the provider needs to ask the fourth question - the CAR question. If the adolescent answers “Yes” to any one or more of the three opening questions, the provider asks all six CRAFFT questions. CRAFFT Scoring: Each “yes” response in Part B scores 1 point. A total score of 2 or higher is a positive screen, indicating a need for additional assessment.

Patient Engagement Metric The number of patients screened with PHQ2 or PHQ9 or or PSC-Y/ PSC-17 for the pediatric population; or number of patients screened using both Audit C and DAST; or number of patients (age 13-17) screened using the CRAFFT.

Clinical Metrics• Screening for Clinical Depression and Follow-up - People 18

and older with an outpatient visit who were screened for clinical depression using a standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the positive screen.

• Adherence to Antipsychotic Medications for People with Schizophrenia – People age 19 to 64 with schizophrenia dispensed at least 2 antipsychotic medications during the measurement year and remained on the antipsychotic

(continued on reverse)

Suffolk CareCollaborative

Office of Population Health - 1383-8 Veterans Memorial Highway, Hauppauge NY 11788Tel: (631) 638-2227 | Fax: (631) 638-1009 | suffolkcare.org

Integration of Primary Care and Behavioral Health: Model 13.a.i

medication for at least 80% of their treatment period.

Clinical Metrics (continued)

• Antidepressant Medication Management – Effective Acute Phase Treatment – People 18 and older diagnosed with depression and treated with an antidepressant medication who remained on antidepressant medication during the entire 12-week acute treatment phase.

• Antidepressant Medication Management – Effective Continuation Phase Treatment – People 18 and older diagnosed with depression and treated with an antidepressant medication who remained on antidepressant medication for at least six months.

• Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia – People age 18 to 64 with schizophrenia and cardiovascular disease who had an LDL-C test during the measurement year.

• Diabetes Monitoring for People with Diabetes and Schizophrenia People age 18 to 64 with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year.

• Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication – People age 18 to 64 with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication who had a diabetes screening test during the measurement year.

• Initiation of Alcohol and Other Drug Dependence Treatment (1 visit within 14 days) – People age 13 and older with a new episode of alcohol or other drug (AOD) dependence who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the index episode.

• Engagement of Alcohol and Other Drug Dependence Treatment (Initiation and 2 visits within 44 days) – People age 13 and older with a new episode of alcohol or other drug (AOD) dependence who initiated treatment and who had two or more additional services with a diagnosis of AOD dependence within 30 days of initiation visit.

• Follow-up after hospitalization for Mental Illness – within 7 days

• Follow-up after hospitalization for Mental Illness –within 30 days

• Follow-up care for Children Prescribed ADHD Medications - Initiation Phase – Children age 6 to 12 years, who were newly prescribed ADHD medication, who had one follow-up visit with a practitioner within 30 days after starting medication.

• Follow-up care for Children Prescribed ADHD Medications - Continuation Phase – Children age 6 to 12 years who were newly prescribed ADHD medication and remained on medication for 7 months who, in addition to the visit in the initiation phase,

had at least 2 follow-up visits in the 9-month period after the initiation phase ended.

• Potentially Preventable Emergency Department Visits (for persons with Behavioral Health Diagnosis)

Tools to be employed: PHQ2 / 9; AUDIT-C; AUDIT; DAST; CRAFFT

References/Guidelines1. http://www.integration.samhsa.gov/integrated-care-models/

Behavioral_Health_Integration_and_the_Patient_Centered_Medical_Home_FINAL.pdf

2. http://www.integration.samhsa.gov/integrated-care-models

3. http://www.integration.samhsa.gov/clinical-practice/screening-tools#drugs

4. http://www.guideline.gov/content.aspx?id=47315&search=adult+depression+in+primary+care

Prescreen for depression &

substance use*

Patients requiring intervention will receive a referral to co-

located BH provider for treatment via “warm handoff”

Member of health care

team to administer

applicable full screens

Were any pre-screen(s) positive?

Result(s) from full screen(s) documented

in EHR

A brief Intervention may occur at this junction & Primary care

provider alerted to assess needs†

Is a need Identified?

NO

Are any of the full-screens positive?

NO

Result of pre- screen(s)

documented in EHR

Patient seen at primary care for for acute visit or

check-up

Follow-up plan documented in EHR

Screening Process Complete

Primary & Behavioral Health Integrated Care Program (Model 1) Flow Chart

*For Depression: PHQ-2/9 and PSC-Y/17 For Substance Abuse >18 y.o.: AUDIT-C/DAST-1 13-17y.o.: CRAFFT

†Brief Interventions if performed following a substance

use screening may be billable if required criteria met

YES

NO

YES

YES



Section 3:

Primary & Behavioral Health

Integrated Care Program

Implementation

S.3





Protocols & Templates

Below are the listings of program protocols and program templates for the Primary & Behavioral Health

Integrated Care Program. The protocols were developed to help guide providers through the

implementation of DSRIP and correlate to specific DSRIP milestones. DSRIP partners are expected to

review each protocol and attest that they understand them.

Number Program Protocol Name Model Number

Model 1 Model 2 Model 3

3ai.01 Evidence Based Standards of Care, Medication Management

3ai.02 Evidence Based Guidelines

3ai.03 Screening Procedure 2ai.01 SCC Warm Referral & Follow Up 3ai.05 Integrated Care Services

3ai.06 IMPACT: Principles Summary & IMPACT Adoption 3ai.07 IMPACT: Designated Psychiatrist Scope of Practice Procedure 3ai.08 IMPACT: Depression Care Manager Scope of Work 3ai.09 IMPACT: Stepped Care Procedure 3ai.10 IMPACT: Relapse Prevention Plan

The template below provide supporting materials to help providers execute program expectations and

supply required feedback to SCC. DSRIP partners are expected to complete each document and return

them to SCC.



3ai.11 Document & Request

Blood Pressure Screenings and Tobacco Cessation and Control practices will be included as primary and

preventive care services to ensure that all participating providers and practices adopt strategies of the

Million Hearts Campaign. Practice sites to be referred to the following DSRIP Project 3bi protocols:

(3bi.01: Adopting Strategies of the Million Hearts Campaign, 3bi.06: Implementing the NY Smokers’

Quitline Protocol).



3bi.01 Implementing the Million Hearts® Campaign

3bi.06 Implementing the NY Smoker’s Quitline Protocol




Technical Assistance Plan: Project 3ai As we begin the process of implementing Primary Care Behavioral Health Integration across our

PPS, the Suffolk Care Collaborative will offer technical assistance to all of our partners.

As each partner is contracted a readiness/current state assessment will be scheduled in order

to best determine the individual needs and successes of each practice. SCC has chosen to use

the MeHAF Assessment with each of our partners. Once completed, each site will meet with

the North Carolina Center of Excellence and the Director of Behavioral Health Integration from

the SCC to review and discuss the findings. This information will become the basis for the plan

going forward as we determine what assistance may be required, how often and by whom.

Each site will also be assigned a Provider Relations Liaison with whom they will work. This

person will be responsible for working with the site as it relates to reporting timeframes and

requirements, helping to organize meetings/DSRIP requests with the site, assistance with

reporting as needed, as well as helping to identify and field any questions or concerns the site

may have.

After the evaluation process has been completed, support will be offered to our partners both

in person or remotely. This support will be tailored to fit the individual needs of each partner. In

order to help facilitate this process we have a developed a framework that defines various

levels of support. Partners may participate in any, and all, of these tiers of support as they feel

would best serve their needs.

Tier One: Sites in this tier will require the most extensive support. These sites will most likely

fall within a MeHAF score of 0-4. These sites have not begun integrating care and are just

beginning to identify the benefits of changing the culture in their practices to support

integrated care. These sites will not only require assistance in implementing the project, but in

developing buy-in and educating staff on the premise of integrated care and what the benefits

of such may be.

Tier Two: It is likely that sites in this tier will require less support than the tier one sites. These

sites will most likely fall within a MeHAF score of 4-7, as they will have already begun to change

their culture to one of integrated care, support from administration and staff, and may already

have begun co-location efforts. These sites may require some education about the various

models and creative ways to integrate as they begin to plan for integration and identify what

their needs may be.

Tier Three: Partners who fall into the third tier have already begun to fully integrate their care.

These sites will have scored between a 7-10 on the MeHAF and will already be practicing some

level of integrated care or co-location. These partners will already have a culture in place that

supports this kind of practice and is now finding ways to overcome the regulatory and

reimbursement barriers as they further develop their programs. These practices may require




support in finding ways to improve the sustainability of the program as they move forward into

value based payment.

All of the Suffolk Care Collaborative’s partners can expect technical support from the Director

of Behavioral Health Integration to include, at a minimum:

1. In person presentation and training on the toolkit for implementation – both at their

site as well as at the kick-off breakfast

2. Review of workflow

3. Needs assessment to determine number of hours of embedded resource

4. Identify source of embedded resource/obtain resource

5. On-site training for staff at office as well as embedded provider

6. Support in working through the barriers as they relate to billing and regulations

7. Learning Collaboratives will begin

8. Ongoing support and questions answered as the program is put into action throughout

the life of DSRIP




Primary & Behavioral Health Integrated Care Program Project Management Office │ Suffolk Care Collaborative (SCC)

Protocol Name: Evidence Based Standards of Care, Medication Management DSRIP Project Number: 3ai

Protocol Number: 3ai.01

Applicable Model Number: Model 1, Model 2, Model 3

Protocol Owner: Alyse Marotta, Project Manager, Behavioral Health

Approved By: 3ai Project Committee

Date Created: 1/29/2016

Effective Date: 6/8/2016

Last Revised Dates: 6/8/16; 2/7/2016; 3/31/2016

DSRIP Project Requirement & Performance Metric Reference

Project Requirement 2: Develop collaborative evidence-based standards of care including medication management and care engagement process. Metric: Coordinated evidence-based care protocols are in place, including medication management and care engagement process.

Narrative

Clinical Objective Statement/ Purpose Statement

The purpose of this protocol is to provide guidance to the general measurements and evidenced-based guidelines of care used to support meeting national benchmarks and improved health outcomes for medication management in integrated clinical settings. Behavioral health recipients cost, on average, 4.65 times more per recipient and represent 58%of total Medicaid spending, and drive 48% of all ED visits. Behavioral Health recipients also represent 58% of admissions to hospital and on average have a 1.65X longer length of stay in hospital than non-behavioral health recipients. Through the implementation of clinical policies, procedures, and guidelines upholding evidence-based medication management, it may be possible to reduce potentially preventable and costly ED visits.

Core Population All Medicaid patients

Protocol Narrative

Clinical Policies & Care Engagement Processes All 3ai clinical policies, procedures and guidelines should be followed to align in a manner that supports attaining clinical outcomes that meet or exceed federal health guidelines for evidenced-based medication management approaches and quality standards of care. Health care provider and practice involvement will be needed to achieve initial and ongoing expectations in these areas:

Document internal policies and procedures related to clinical quality measures - Review policies annually

Practice support and education on quality improvement measures

Medical record tracking methods to determine level of adherence for the individual patient as well as the group of patients who fall within each quality metric

Utilization of external reports and ability to compare these reports to internally generated reports

Patient visit strategies that will support the clinical and visit requirements to meet quality measures

Assessment of clinical, consultative, and general support needed to achieve quality measures, which may involve strong collaboration with other clinical entities

Use of baseline and longitudinal patient assessment tools

Medication Management Guidelines




Medication management guidelines will be adopted from the Greater New York Hospital Association (GNYHA). GNYHA has created a Collaborative Care Teaching Guide for Integrating Behavioral Health and Primary Care in Teaching Settings (referenced below) which lists medication tables that are applicable to this project. The following medication tables for anxiety and depression are abstracted from that document and will be adopted for this project.

Roles & Responsibilities for Team-based care

SCC Clinical Improvement Program Roles & Responsibilities Guide


http://scc.perflogic.com/document?s=PFN0cj4KMDExMC8xNjE3Mi80OC9wZGYKPC9TdHI%2bCg%3d%3d



Training Module & Curriculum Reference

Suffolk Care Collaborative Learning Center

Learning Module: Primary & Behavioral Health Integrated Care

This module provides a comprehensive look at the process of primary and behavioral health integration. The modules progress though understanding the core concepts related to integrating services, and the prevailing models on integration and their relation to population health, to preparing for integration, and finally to full implementation and documentation. Participants will gain a full understanding of the potential of this type of integration to improve the health outcomes of patients, and what the steps will be to work towards this integration. Training Topics: Basics of Integrated Care

https://suffolkcare.org/forpartners/learning-center#ChildVerticalTab_111

Basics of Bidirectional Integrated Care


SCC Documents

Clinical Guideline Summaries

Model 1 Clinical Guideline Summary Model 2 Clinical Guideline Summary

Model 3 Clinical Guideline Summary

Primary & Behavioral Health Integrated Care Program Toolkits

https://suffolkcare.org/forpartners/programs-initiatives-publications

References & Recommended Tools

AHRQ Guide to Clinical Preventative Services, Measures:

http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html AHRQ Guideline Clearinghouse:

http://www.guideline.gov/

Greater New York Hospital Association, Collaborative Care Teaching Guide – Integrated Behavioral Health and Primary Care in Teaching Settings

https://www.gnyha.org/PressRoom/Publication/680b5fd2-31eb-4eeb-9dec-ee0ceb1c42be/

NCQA HEDIS Measures:

http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality.aspx

NCQA HEDIS main page:

http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx

Million Hearts Treatment Protocols:

http://millionhearts.hhs.gov/tools-protocols/protocols.html PCMH Element Reference

Standard 2D (Must Pass)

Standard 3E

Standards 4A, 4C, 4E

Standard 6A

The featured protocols are examples of a wide variety of available evidence-based protocols that are within the SCC Program Requirements. Linking to Recommended Tools does not constitute an endorsement by the Suffolk Care




https://suffolkcare.org/forpartners/learning-center%23ChildVerticalTab_111

https://suffolkcare.org/pubfiles/Integration%20of%20Primary%20Care%20and%20Behavioral%20Health-%20Model%201%20v12.pdf

https://suffolkcare.org/sites/default/files/Integration%20of%20Primary%20Care%20and%20Behavioral%20Health-%20Model%202.pdf


http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html







http://millionhearts.hhs.gov/tools-protocols/protocols.html



Collaborative. Links to Recommended Tools containing protocols serve only as a source of guidance. Health care professionals should always consider the individual clinical circumstances of each person. Links to the protocols are not intended to be a substitute for professional medical advice; individuals should seek advice from their health care professionals.





Protocol Name: Evidence Based Guidelines DSRIP Project Number: 3ai









Project Requirement 2: Develop collaborative evidence-based standards of care including medication management and care engagement process. Metric: Coordinated evidence-based care protocols are in place, including medication management and care engagement process.

Narrative


The purpose of this protocol is to outline the Clinical Guidelines for Behavioral Health and Primary Care Integration. Clinical Summaries are designed to give our partners an overview of each clinical DSRIP project. Each 3ai Summary illustrates the project’s immediate and long-term goals, interventions, metrics, helpful tools and useful reference materials in order to successfully implement your projects. A Clinical Guideline summary has been written for each of the three Models in this program: Model 1, Model 2, and Model 3. Information found in the Clinical Guideline Summaries has been derived from the Substance Abuse and Mental Health Services Administration (SAMHSA) and U.S. Department of Health and Human Services (HRSA) Center for Integrated Health Solutions, and the Agency for Healthcare Research and Quality (AHRQ). Providers will be responsible for following the evidence based clinical guidelines as outlined in the Clinical Guideline Summaries.


Protocol Narrative

Staff will be responsible for implementing all interventions and completing all clinical metrics outlined in the Clinical Guideline Summary which corresponds with their selected model (1, 2, or IMPACT). Model 1 – Integration of Behavioral Health services into Primary Care practice sites Providers will be responsible for: 1) Collaborating with a behavioral health specialist/organization to integrate/co-locate in the primary care practice. 2) Screening all patients once per year (at a minimum), as part of their regular visit, for depression and substance use with evidence based screening tools. 3) Documenting scores for both clinical and reporting purposes in the EHR. 4) Connecting patients with the integrated/co-located professional to provide interventions for behavioral health concerns when the individual screens positive. 5) Arranging for shared documentation to ensure communication about the patient is easily accessible and readily available. 6) Carrying out “warm handoffs” and referrals to additional mental health and substance abuse resources/providers for more intensive treatment when indicated.




Model 2 – Integration of Primary Care services into Behavioral Health practice sites Providers will be responsible for: 1) Providing space and scheduling resources to the co-located PCP to ensure patients can be readily seen for physical health services. 2) Providing OMH/ OASAS patients with access to an annual physical/well visit (at a minimum) and address in a timely manner physical health concerns (i.e. sick visits) when indicated. 3) Screening all OMH/ OASAS clinic patients seen by the PCP for chronic conditions: i.e. hypertension/blood pressure, diabetes/A1c and height-weight/BMI. 4) Documenting all screening/lab results for both clinical and reporting purposes in the EHR. 5) Working collaboratively with the PCP to ensure referrals to external pre-identified specialists are made for laboratory tests/treatment when indicated. 6) Working with the PCP to ensure the full scope of primary care services is available to patients at the OMH/OASAS clinic site. 7) Arranging for shared documentation to ensure communication about the patient is easily accessible and documented for reporting purposes. Model 3 – IMPACT Providers will be responsible for: 1) Utilizing the IMPACT approach to depression care management in the PCMH with fidelity to the model. (See Reference). 2) Collaborating with a Depression Care Manager for patients. 3) Establishing a working partnership/ agreement with a psychiatrist or Psychiatric Nurse Practitioner, clinic that employs a psychiatrist or with the local OMH Project TEACH/CAP-PC initiative. 4) Screening all patients once per year (at a minimum) as part of their regular visit, for depression and substance use with evidence based screening tools. 5) Documenting scores for both clinical and reporting purposes in the EHR. 6) Connecting patients with the Depression Care Manager to address needed referrals and follow-up for behavioral health concerns when the individual screens positive. 7) Arranging for regular communication between the Depression Care Manager, Psychiatrist and PCMH personnel per the IMPACT model to review patient cases. 8) Arranging for shared documentation among all parties to ensure communication about the patient is easily accessible and included in the EMR. 9) Ensuring the Depression Care Manager carries out “warm handoffs” and referrals to appropriate mental health and substance abuse resources/ providers for treatment when indicated.



Training Module & Curriculum References



This module provides a comprehensive look at the process of primary and behavioral health integration. The modules progress though understanding the core concepts related to integrating services, and the prevailing models on integration and their relation to population health, to preparing for integration, and finally to full implementation and documentation. Participants will gain a full understanding of the potential of this type of integration to improve the health outcomes of patients, and what the steps will be to work towards this integration.






Training Topics: Primer on Evidence Based Models of Integrated Care


Primer on the PCBH Model


SCC Documents Clinical Guideline Summaries






SAMHSA – HRSA Center for Integrated Health Solutions, Behavioral Health and Patient-Centered Medical Homes http://www.integration.samhsa.gov/integrated-care-models/behavioral-health-in-primary-care#Behavioral Health and Patient Centered Medical Homes SAMHSA – HRSA Center for Integrated Health Solutions, Integrated Care Models http://www.integration.samhsa.gov/integrated-care-models SAMHSA – HRSA Center for Integrated Health Solutions, Screening Tools http://www.integration.samhsa.gov/clinical-practice/screening-tools#drugs Agency for Healthcare Research and Quality (AHRQ), Adult Depression in Primary Care https://www.guideline.gov/summaries/summary/47315/adult-depression-in-primary-care

PCMH Element Reference

2D (Must Pass)

3C9, 3E

4C, 4E

5B (Must Pass)

The featured protocols are examples of a wide variety of available evidence-based protocols that are within the SCC Program Requirements. Linking to Recommended Tools does not constitute an endorsement by the Suffolk Care Collaborative. Links to Recommended Tools containing protocols serve only as a source of guidance. Health care professionals should always consider the individual clinical circumstances of each person. Links to the protocols are not intended to be a substitute for professional medical advice; individuals should seek advice from their health care professionals.







http://www.integration.samhsa.gov/integrated-care-models/behavioral-health-in-primary-care%23Behavioral%20Health%20and%20Patient%20Centered%20Medical%20Homes


http://www.integration.samhsa.gov/integrated-care-models

http://www.integration.samhsa.gov/clinical-practice/screening-tools%23drugs

https://www.guideline.gov/summaries/summary/47315/adult-depression-in-primary-care





Protocol Name: Screening Procedure DSRIP Project Number: 3ai









Project Requirement 3: Conduct preventive care screenings, including behavioral health screenings (PHQ-2 or 9, and for those screening positive, SBIRT) implemented for all patients to identify unmet needs (Model 1 and 2) Metric: Policies and procedures are in place to facilitate and document completion of screening Metric: Screenings are conducted for all patients. Process workflows and operational protocols are in place to implement and document screenings Metric: Screenings are documented in Electronic Health Record Metric: At least 90% of patients receive screenings at the established project sites (screenings are defines as industry standard questionnaires such as PHQ-2 or 9 for those screening positive, SBIRT) Metric: Positive Screenings result in “warm transfer” to behavioral health provider as measured by documentation in Electronic Health Record

Narrative


Screening is an important component of all integrated care models. Approximately 23% of our PPS Medicaid members are defined as behavioral health recipients. Routine and systematic screening for depression and substance use can identify if a patient is in need of behavioral health services, allowing for early and appropriate intervention. This early identification and treatment can prevent avoidable and costly hospitalizations of this patient population. This policy provides guidance for sites to implement evidence based screening procedures.


Protocol Narrative

Screening for depression should occur in a systematic fashion that is sustainable. This will vary across sites based on factors such as patient population, patient flow and clinic resources. All patients are eligible for screening, including the pediatric population, and should be screened using the appropriate tools. In general the following should be considered:

1. Screening should occur with the use of the Patient Health Questionnaire (PHQ) set of tools (PHQ-2, PHQ-9) based on site needs.

2. Screening frequency should be at least annual.




3. Screenings are universal. Implementation may be targeted to particular visit categories (e.g. all physicals) or disease categories (e.g. all patients with diabetes or depression).

4. Screening processes should be sustainable and must be reviewed for quality control at least annually.

5. At least 90% of patients receive screenings at the established project sites. The denominator of this percentage is all patients seen by the provider, while the numerator is all patients receiving screenings. Periodic documentation of this percentage may be requested by the Suffolk Care Collaborative.

6. Positive screenings result in a “warm transfer” as detailed in Protocol 3ai.04, and documented in Electronic Health Record, as detailed in 3ai.11



Training Module & Curriculum References



This module provides a comprehensive look at the process of primary and behavioral health integration. The modules progress though understanding the core concepts related to integrating services, and the prevailing models on integration and their relation to population health, to preparing for integration, and finally to full implementation and documentation. Participants will gain a full understanding of the potential of this type of integration to improve the health outcomes of patients, and what the steps will be to work towards this integration. Training Topics: Primer on Screening for Integrated Care


Improving Screening and Identification in Pediatric Practices


Documentation for Primary Care


SCC Documents SCC Protocols

Protocol 3ai.04 Warm Handoff Procedure

Protocol 3ai.11 Document and Data Request Clinical Guideline Summaries



Project Workflow Diagrams:

Model 1 Project Workflow Diagram











https://suffolkcare.org/pubfiles/3ai%20Model%201%20FLOW%20CHART%20FINAL.pdf








Screening Tools:

1. Patient Health Questionnaire -2 (PHQ-2) 2. Patient Health Questionnaire -9 (PHQ-9) 3. Alcohol Use Disorders Identification Test (Audit C)

4. Drug Abuse Screening Test (DAST-10) 5. Car, Relax, Along, Forget, Friends, Trouble (CRAAFT) 6. Pediatric Symptom Checklist (PSC-Y) 7. Pediatric Symptom Checklist - Youth Self Report (PSC-17)


Standard 2D (Must Pass)

Standards 3C9, 3D (Must Pass)

Standard 4A1




http://www.cqaimh.org/pdf/tool_phq2.pdf


http://www.integration.samhsa.gov/images/res/tool_auditc.pdf

http://www.bu.edu/bniart/files/2012/04/DAST-10_Institute.pdf

http://www.ceasar-boston.org/CRAFFT/pdf/CRAFFT_English.pdf

http://www.massgeneral.org/psychiatry/assets/PSCY-35_English.PDF

http://www.prohealthmd.com/windhampediatrics-dev/wp-content/uploads/sites/25/2015/01/PSC-17.pdf

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)DATE:NAME:Over the last 2 weeks, how often have you beenbothered by any of the following problems? Not at all Severaldays More thanhalf thedays Nearlyevery day(use "ⁿ" to indicate your answer) 0 1 2 3Little interest or pleasure in doing things1. 0 1 2 3Feeling down, depressed, or hopeless2. 0 1 2 3Trouble falling or staying asleep, or sleeping too much3. 0 1 2 3Feeling tired or having little energy4. 0 1 2 3Poor appetite or overeating5. 0 1 2 3Feeling bad about yourself or that you are a failure orhave let yourself or your family down6. 0 1 2 3Trouble concentrating on things, such as reading thenewspaper or watching television7. 0 1 2 3Moving or speaking so slowly that other people couldhave noticed. Or the opposite being so figety orrestless that you have been moving around a lot morethan usual8. 0 1 2 3Thoughts that you would be better off dead, or ofhurting yourself9. add columns + +TOTAL:(Healthcare professional: For interpretation of TOTAL,please refer to accompanying scoring card). Not difficult at allIf you checked off any problems, how difficulthave these problems made it for you to doyour work, take care of things at home, or getalong with other people?10. Somewhat difficultVery difficultExtremely difficultCopyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD© is a trademark of Pfizer Inc.A2663B 10-04-2005

PHQ-9 Patient Depression Questionnaire For initial diagnosis:

1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4 s in the shaded section (including Questions #1 and #2), consider a depressive

disorder. Add score to determine severity.

Consider Major Depressive Disorder

- if there are at least 5 s in the shaded section (one of which corresponds to Question #1 or #2) Consider Other Depressive Disorder

- if there are 2-4 s in the shaded section (one of which corresponds to Question #1 or #2) Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms. To monitor severity over time for newly diagnosed patients or patients in current treatment for depression:

1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment.

2. Add up s by column. For every : Several days = 1 More than half the days = 2 Nearly every day = 3

3. Add together column scores to get a TOTAL score.

4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.

5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of response, as well as guiding treatment intervention.

Scoring: add up all checked boxes on PHQ-9 For every Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3 Interpretation of Total Score

Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression

10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression

PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc. A2662B 10-04-2005

Drug�Abuse�Screening�Test�(DASTͲ10)�Using�drugs�can�affect�your�health�and�may�interact�with�medications�you�take.�Please�help�us�provide�you�with�the�best�medical�care�by�answering�the�questions�below.��Which�recreational�drugs�have�you�used�in�the�past�year?�

__Methamphetamines�(speed,�crystal)� __ Cocaine�

__Cannabis�(marijuana,�pot)�� __Narcotics�(heroin,�oxycodone,�methadone)�

__Inhalants�(paint�thinner,�aerosol,�glue)�� __Hallucinogens�(LSD,�mushrooms)�

__Tranquilizers�(valium)� __Other�______________________________�

1.�Have�you�used�drugs�other�than�those�required�for�medical�reasons?� No� Yes�

2.�Do�you�abuse�more�than�one�drug�at�a�time?� No� Yes�

3.�Are�you�unable�to�stop�using�drugs�when�you�want�to?� No� Yes�

4.�Have�you�ever�had�blackouts�or�flashbacks�as�a�result�of�drug�use?� No� Yes�

5.�Do�you�ever�feel�bad�or�guilty�about�your�drug�use?� No� Yes�

6.�Does�your�spouse�(or�parents)�ever�complain�about�your�involvement�with�drugs?� No� Yes�

7.�Have�you�neglected�your�family�because�of�your�use�of�drugs?� No� Yes�

8.�Have�you�engaged�in�illegal�activities�in�order�to�obtain�drugs?� No� Yes�

9.�Have�you�ever�experienced�withdrawal�symptoms�(felt�sick)�when�you�stopped�taking�drugs?� No� Yes�

10.�Have�you�had�medical�problems�as�a�result�of�your�drug�use�(e.g.�memory�loss,�hepatitis,�convulsions,�bleeding)?� No� Yes�

� 0� 1�

I��Low�Risk/Abstain�DAST:�0�

II��RiskyDAST:�1Ͳ2�

III��HarmfulDAST:�3Ͳ5�

IV��DependentDAST:�6+�

For�Clinician:�Clinician�Name:____________________________��Date:�_______________��DAST�Zone:�___________�

Brief�intervention:� ��Raised�subject �� Not�done �� Referral�recommended� ��Provided�feedback��

� ��Enhanced�motivation� �� Negotiated�plan�

CONFIDENTIALITY NOTICE: The information on this page may be protected by special federal confidentiality rules (42 CFR Part 2), which prohibit disclosure of this information unless authorized by specific written consent. A general authorization for release of medical information is NOT sufficient.

© Children’s Hospital Boston, 2009. Reproduced with permission from the Center for Adolescent Substance Abuse Research, CeASAR, Children’s Hospital Boston.

CRAFFT Reproduction produced with support from the Massachusetts Behavioral Health Partnership.

The CRAFFT Screening Questions Please answer all questions honestly; your answers will be kept confidential.

Part A During the PAST 12 MONTHS, did you: No Yes

1. Drink any alcohol (more than a few sips)?

2. Smoke any marijuana or hashish?

3. Use anything else to get high?

“anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”

Part B No Yes

1. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?

4. Do you ever FORGET things you did while using alcohol or drugs?

5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?

If you answered

YES to ANY

(A1 to A3), answer

B1 to B6 below.

If you answered NO to ALL

(A1, A2, A3) answer only B1

below, then STOP.



Building a Suffolk County Integrated Delivery System Project Management Office │ Suffolk Care Collaborative (SCC)

Protocol Name: Warm Referral & Follow up Protocol DSRIP Project Number: 2ai, 2biv, 2bix, 2bvii, 3ai, 3bi, 3ci, 3dii


Protocol Owner: Project Manager, Integrated Care Sr. Director Care Coordination & Care Management

Approved By: Clinical Governance Committee

Date Created: September 12, 2016

Effective Date: September 30, 2016

DSRIP Project Requirement

DSRIP Project Requirement: PPS has developed referral and follow-up process and adheres to process. Follow up with referrals to community based programs to document participation and behavioral and health status changes.

Narrative

Clinical Objective Statement

Clinical protocol 2ai.01 is designed to provide a universal definition of warm patient handoffs, (including transfers and referrals) and follow up process with the goal of adhering to the process. This includes warm transfer protocols and is intended to provide standardization to the term “warm handoff” and guide implementation efforts for sites participating in care coordination across their care teams.

Core Population Any Medicaid patient 13 years and older who meets the targeted patient populations of DSRIP Project 2ai, 2biv, 2bix, 2bvii, 3ai, 3bi, 3ci or 3dii.

Protocol Narrative 1. Warm Referral Definition a. A warm referral is an introduction by phone call or visit, where the

individual making the referral makes first contact on behalf of the patient, and explains to the referral organization/provider the circumstances and the reason they believe the patient would benefit from the referral. This occurs particularly when a patient has a high level of vulnerability.

b. Under the context of Behavioral Health (DSRIP project 3ai/Behavioral Health Status changes), a warm handoff is defined as the process by which a primary care provider (PCP) consults with an embedded behavioral health provider in a face-to-face manner for the purpose of collaboratively involving the behavioral health provider in the care of a patient on a given day. To meet this definition the patient must be seen at a time reasonably close to their original appointment with the primary care provider. Other “referrals” for scheduled appointments are not considered warm handoffs.

c. Whenever possible, provider introductions will be completed face-to-face or telephonically with the patient or their caregiver(s) either present or otherwise engaged.

d. All information sharing will be done in compliance with Health Insurance Portability and Accountability Act (HIPAA) law and any other applicable state or federal laws.

2. Process Components for Behavioral Health Integrated Care: a. Introduction of the concept of integrated care to the patient to seek

verbal assent to involvement of Behavioral Health Counselor (BHC).




b. Curbside Consultation (can occur in the room with the patient or outside of the room between PCP and BHC) to inform the BHC of relevant case details and determine patient flow.

c. “Closing the loop” consultation (can occur in a variety of ways including written formats) to ensure that treatment planning is collaboratively planned between BHC and PCP after the PCP and BHC have met with the patient. PCP and BHC discuss in either written or face-to-face format to determine course of care for patient. This should include a collaborative approach with patient involvement as well.

d. Providers will communicate to one another when discussing the patient’s care.

e. Patient hand-off will include the sharing of current patient specific information relevant to their medical diagnosis, medical history, and the reason for hand-off. The SBAR method (situation, background, assessment, recommendation) is recommended to communicate patient information. Available training curricula includes available tools such as SBAR as well as reviewing processes, located on the SCC Learning Center.

3. Community Based Referrals a. Practices participating will follow up with all referrals to community

based programs to document participation and behavioral health status changes within 3 months.

b. Practices participating will leverage community-based resource directories provided by the Suffolk Care Collaborative to support knowledge of CBO’s.

4. Community-based Referrals Training a. Participating practices will provide periodic training to staff on warm

referral and follow up-processes. Reference: SCC Core Curriculum Guidelines for Participating Practice Sites


Clinical Improvement Program Roles & Responsibilities Guide

Training Module & Curriculum

SCC Core Curriculum Guidelines for Participating Practice Sites Module Name: Care Coordination Methodology, Protocol & Treatment Plans

SCC Documents SCC Clinical Improvement Program Implementation Toolkit SCC Core Curriculum Guidelines for Participating Practice Sites Clinical Improvement Program Roles & Responsibilities Guide CWSP Workflow diagram (3bi) DWSP Workflow Diagram (3ci) PCBH Workflow Diagram (3ai) PASP Workflow Diagram (3dii)


1. Robinson, P., Reiter, J. (2015). Behavioral Consultation and Primary Care. A Guide To Implementing Services. Springer: New York.

2. American Medical Association, Resources for Improving Patient Handoffs;

http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/resident-fellow-section/rfs-resources/patient-handoffs.page

3. Do’s & Don’ts of Patient Handoff’s Video, Dr. Vineet Arora, University of Chicago, https://www.youtube.com/watch?v=dOm7SxFZCG8

4. Handoff Communication, Mark R Chassin, MD, President, The Joint Commission: https://www.youtube.com/watch?v=aTQq_EcvkCE






https://www.youtube.com/watch?v=dOm7SxFZCG8

https://www.youtube.com/watch?v=aTQq_EcvkCE



5. Making the Most of Patient Handoffs: Critical for Patient Safety & Learning, Handoff Workshop, The George Washington University Medical Center; http://www.slideshare.net/MergeLab/gw-uhandoffs

6. Integrated Behavioral Health Partners, Referrals, Handoffs and Good-byes http://www.ibhpartners.org/get-started/client-experience-toolkit/referrals-handoffs-and-good-byes/

Community-based Referrals for Suffolk County Providers’ 7. Suffolk Care Collaborative, www.suffolkcare.org 8. HITE Online Community Resource Directory http://www.hitesite.org/ 9. 211 Long Island Community Resource Directory http://211longisland.org/cms/

PCMH Element 1. The Practice Team (2D) (Must Pass) 2. Support Self-Care and Shared Decision Making (4E) 3. Comprehensive Health Assessment (3C): The practice collects and regularly

updates a comprehensive health assessment that includes depression screening for adults and adolescents using a standardized tool

4. Care Management & Support (4A.1): The practice establishes a systematic process and criteria for identifying patients who may benefit from care management, including behavioral health conditions



http://www.slideshare.net/MergeLab/gw-uhandoffs

http://www.ibhpartners.org/get-started/client-experience-toolkit/referrals-handoffs-and-good-byes/



http://www.hitesite.org/

http://211longisland.org/cms/



Integrated Care Implementation Checklist Project Management Office Suffolk Care Collaborative (SCC)

Checklist Narrative This checklist provides the activities and steps integrated programs typically need to follow in order to achieve

maximal integration of physical and behavioral health services. This procedure should be revisited periodically

by the site implementation team to track progress.

The checklist serves as a general guide for sites to track progress towards integration efforts. The intention is

not for sites to check all items off the list but that sites are mindful of the core tasks necessary for success.

Checklist items: *As each task is completed, check the box and list the date on the line next to the check list.

☐ Design the initial project concept

☐ Draft a mission statement

☐ Identify service line goals based on population demographics and health outcomes

☐ Set initial desired provider competencies/roles (may need to be revisited)

☐ Assess the need for additional staff

☐ Create a job description and advertise

☐ Hire provider(s)

☐ Initiate rapport building with entire health care team

☐ Identify and convene an implementation team

☐ Identify members, including admin, medical, behavioral health, nursing staff (others?)

☐ Schedule regular meetings

☐ Establish a communication plan between:

☐ Clinical team and the other clinic staff (huddles, EHR, flags, etc.)

☐ The Clinical team and the Implementation Team

☐ Site staff with the treatment teams for practice flow efficiencies

☐ Review credentials of current staff for additional credentialing

☐ Identify service line and specific disease states or populations to be served

☐ Review patient information/consent information and revise to reflect the new services

☐ Establish agreements between providers when appropriate to the model and the types of services provided

☐ Establish basic services and patient base

☐ Review current staff credentials for billing

☐ Consult with billing expert

☐ Identify target population and comorbidities to guide screening and intervention protocols

☐ Identify behavioral health/mental health issues/substance use disorders to be identified and treated

☐ Establish protocols and work flow related to each service in the plan

☐ Screening instruments and protocols

☐ Documentation guidelines

☐ Shared treatment planning

☐ Acuity/duration thresholds

☐ Outcome measures

☐ Referral protocols




☐ Care management and external tracking

☐ Define the roles of all behavioral health providers associated with the practice (across the continuum)

☐ Identify provider billing/encounter coding that will reflect time and services even when service may not be billable

☐ Identify outcome measures, including how and when to track and report the data

☐ Patient registries

☐ Dashboards and other types of reporting mechanisms

☐ Begin shadowing the existing providers to develop relationships and practice flow

☐ Provide basic consultation to the existing providers to gain trust

☐ Schedule an “all staff” meeting for the kick off to

☐ Gain buy-in from all site staff

☐ Identify and establish everyone’s role in the IC project

☐ Connect to external referral sources and inform them on the new IC services

☐ Create a QI process that will include regular PDSA cycles and benchmarking


Adapted from the PCRS – Developed by the Robert Wood Johnson Foundation Diabetes Initiative, www.diabetesintiative.org; Also adapted from the ACIC survey developed by the MacColl Institute for Healthcare Innovation, Group Health Cooperative.

1

Instructions for Completing the MeHAF Site Self Assessment (SSA) Survey

The purpose of this assessment is to show your current status along several dimensions of integrated care and to stimulate conversations among your integrated care team members about where you would like to be along the continuum of integrated care. Please focus on your site’s current extent of integration for patient and family-centered primary care, behavioral and mental health care. Future repeated administrations of the SSA form will help to show changes your site is making over time. Organizations working with more than one site should ask each site to complete the SSA.

Please respond in terms of your site’s current status on each dimension. Please rate your patient care teams on the extent to which they currently do each activity for the patients/clients in the integrated site. The patient care team includes staff members who work together to manage integrated care for patients. This often, but not always, involves health care providers, behavioral health specialists, specialty care providers, case managers or health educators and front office staff.

Using the 1-10 scale in each row, circle (or mark in a color or bold, if completing electronically) one numeric rating for each of the 18 characteristics. If you are unsure or do not know, please give your best guess, and indicate to the side any comments or feedback you would like to give regarding that item. NOTE: There are no right or wrong answers. If some of this wording does not seem appropriate for your project, please suggest alternative wording that would be more applicable, on the form itself or in a separate email. This form was adapted from similar formats used to assess primary care for chronic diseases.

Identifying Information: Name of your site: Date:

Name of person completing the SSA form: Your job role:

Did you discuss these ratings with other members of your team? YES NO

Grantee Organization:

September 29, 2014 MeHAF – Site Self Assessment


2

I. Integrated Services and Patient and Family-Centeredness (Circle one NUMBER for each characteristic) Characteristic Levels 1. Level of integration: primary care and mental/behavioral health care

. . . none; consumers go to separate sites for services

1

. . . are coordinated; separate sites and systems, with some communication among different types of providers; active referral linkages exist

2 3 4

. . are co-located; both are available at the same site; separate systems, regular communication among different types of providers; some coordination of appointments and services

5 6 7

. . . are integrated, with one reception area; appointments jointly scheduled; shared site and systems, including electronic health record and shared treatment plans. Warm hand-offs occur regularly; regular team meetings.

8 9 10

2. Screening and assessment for emotional/behavioral health needs (e.g., stress, depression, anxiety, substance abuse) 2. (ALTERNATE: If you are a behavioral or mental health site, screening and assessment for medical care needs)

. . . are not done (in this site)

1

. . .are occasionally done; screening/assessment protocols are not standardized or are nonexistent

2 3 4

. . .are integrated into care on a pilot basis; assessment results are documented prior to treatment

5 6 7

. . . tools are integrated into practice pathways to routinely assess MH/BH/PC needs of all patients; standardized screening/ assessment protocols are used and documented.

8 9 10

3. Treatment plan(s) for primary care and behavioral/mental health care

. . . do not exist

1

. . . exist, but are separate and uncoordinated among providers; occasional sharing of information occurs

2 3 4

. . .Providers have separate plans, but work in consultation; needs for specialty care are served separately

5 6 7

. . . are integrated and accessible to all providers and care managers; patients with high behavioral health needs have specialty services that are coordinated with primary care

8 9 10

4. Patient care that is based on (or informed by) best practice evidence for BH/MH and primary care

. . . does not exist in a systematic way

1

. . . depends on each provider’s own use of the evidence; some shared evidence-based approaches occur in individual cases

2 3 4

. . .evidence-based guidelines available, but not systematically integrated into care delivery; use of evidence-based treatment depends on preferences of individual providers

5 6 7

. . . follow evidence-based guidelines for treatment and practices; is supported through provider education and reminders; is applied appropriately and consistently

8 9 10



3

5. Patient/family involvement in care plan

. . . does not occur

1

. . . is passive; clinician or educator directs care with occasional patient/family input

2 3 4

. . . is sometimes included in decisions about integrated care; decisions about treatment are done collaboratively with some patients/families and their provider(s)

5 6 7

. . . is an integral part of the system of care; collaboration occurs among patient/family and team members and takes into account family, work or community barriers and resources

8 9 10

6. Communication with patients about integrated care


1

. . . occurs sporadically, or only by use of printed material; no tailoring to patient’s needs, culture, language, or learning style

2 3 4

. . . occurs as a part of patient visits; team members communicate with patients about integrated care; encourage patients to become active participants in care and decision making; tailoring to patient/family cultures and learning styles is frequent

5 6 7

. . .is a systematic part of site’s integration plans; is an integral part of interactions with all patients; team members trained in how to communicate with patients about integrated care

8 9 10

7. Follow-up of assessments, tests, treatment, referrals and other services

. . . is done at the initiative of the patient/family members

1

. . . is done sporadically or only at the initiative of individual providers; no system for monitoring extent of follow-up

2 3 4

. . . is monitored by the practice team as a normal part of care delivery; interpretation of assessments and lab tests usually done in response to patient inquiries; minimal outreach to patients who miss appointments

5 6 7

. . . is done by a systematic process that includes monitoring patient utilization; includes interpretation of assessments/lab tests for all patients; is customized to patients’ needs, using varied methods; is proactive in outreach to patients who miss appointments

8 9 10

8. Social support (for patients to implement recommended treatment)

. . . is not addressed

1

. . . is discussed in general terms, not based on an assessment of patient’s individual needs or resources

2 3 4

. . . is encouraged through collaborative exploration of resources available (e.g., significant others, education groups, support groups) to meet individual needs

5 6 7

. . . is part of standard practice, to assess needs, link patients with services and follow up on social support plans using household, community or other resources

8 9 10

9. Linking to Community Resources


1

. . . is limited to a list or pamphlet of contact information for relevant resources

2 3 4

. . . occurs through a referral system; staff member discusses patient needs, barriers, and appropriate resources before making referral

5 6 7

. . . is based on an in-place system for coordinated referrals, referral follow-up and communication among sites, community resource organizations, and patients

8 9 10



4

MeHAF Plus Items 10. Patient care that is based on (or informed by) best practice evidence for prescribing of psychotropic medications

… does not exist in a systematic way

1

. . . depends on each provider’s own use of the evidence; some shared evidence-based approaches occur in individual cases

2 3 4

. . .evidence-based guidelines available, but not systematically integrated into care delivery; use of evidence-based treatment depends on preferences of individual providers

5 6 7

. . . follow evidence-based guidelines for treatment and practices; is supported through provider education and reminders; is applied appropriately and consistently; support provided by consulting psychiatrist or comparable expert

8 9 10

11. Tracking of vulnerable patient groups that require additional monitoring and intervention

… does not occur

1

… is passive; clinician may track individual patients based on circumstances

2 3 4

… patient lists exist and individual clinicians/care managers have varying approaches to outreach with no guiding protocols or systematic tracking

5 6 7

… patient lists (registries) with specified criteria and outreach protocols are monitored on a regular basis and outreach is performed consistently with information flowing back to the care team

8 9 10

12. Accessibility and efficiency of behavioral health practitioners

… behavioral health practitioner(s) are not readily available

1

… is minimal; access may occur at times but is not defined by protocol or formal agreement; unclear how much population penetration behavioral health has into primary care population

2 3 4

… is partially present; behavioral health practitioners may be available for warm handoffs for some of the open clinic hours and may average less than 6 patients per clinic day per clinician (or comparable number based on clinic volume)

5 6 7

… is fully present; behavioral health practitioners are available for warm handoffs at all open clinic hours and average over 6 patients per clinic day per clinician (or comparable number based on clinic volume)

8 9 10



5

II. Practice/Organization (Circle one NUMBER for each characteristic)

Characteristic Levels 1. Organizational leadership for integrated care

. . . does not exist or shows little interest

1

. . . is supportive in a general way, but views this initiative as a “special project” rather than a change in usual care

2 3 4

. . . is provided by senior administrators, as one of a number of ongoing quality improvement initiatives; few internal resources supplied (such as staff time for team meetings)

5 6 7

. . . strongly supports care integration as a part of the site’s expected change in delivery strategy; provides support and/or resources for team time, staff education, information systems, etc.; integration project leaders viewed as organizational role models

8 9 10

2. Patient care team for implementing integrated care

. . . does not exist

1

. . . exists but has little cohesiveness among team members; not central to care delivery

2 3 4

. . . is well defined, each member has defined roles/responsibilities; good communication and cohesiveness among members; members are cross-trained, have complementary skills

5 6 7

. . . is a concept embraced, supported and rewarded by the senior leadership; “teamness” is part of the system culture; case conferences and team meetings are regularly scheduled

8 9 10

3. Providers’ engagement with integrated care (“buy-in”)

. . . is minimal

1

. . . engaged some of the time, but some providers not enthusiastic about integrated care

2 3 4

. . . is moderately consistent, but with some concerns; some providers not fully implementing intended integration components

5 6 7

. . . all or nearly all providers are enthusiastically implementing all components of your site’s integrated care

8 9 10

4. Continuity of care between primary care and behavioral/mental health


1

. . . is not always assured; patients with multiple needs are responsible for their own coordination and follow- up

2 3 4

. . is achieved for some patients through the use of a care manager or other strategy for coordinating needed care; perhaps for a pilot group of patients only

5 6 7

. . . systems are in place to support continuity of care, to assure all patients are screened, assessed for treatment as needed, treatment scheduled, and follow-up maintained

8 9 10



6

5. Coordination of referrals and specialists


1

. . . is sporadic, lacking systematic follow-up, review or incorporation into the patient’s plan of care; little specialist contact with primary care team

2 3 4

. . . occurs through teamwork & care management to recommend referrals appropriately; report on referrals sent to primary site; coordination with specialists in adjusting patients’ care plans; specialists contribute to planning for integrated care

5 6 7

. . . is accomplished by having systems in place to refer, track incomplete referrals and follow-up with patient and/or specialist to integrate referral into care plan; includes specialists’ involvement in primary care team training and quality improvement

8 9 10

6. Data systems/patient records . . . are based on paper records only; separate records used by each provider

1

. . . are shared among providers on an ad hoc basis; multiple records exist for each patient; no aggregate data used to identify trends or gaps

2 3 4

. . . use a data system (paper or EMR) shared among the patient care team, who all have access to the shared medical record, treatment plan and lab/test results; team uses aggregated data to identify trends and launches QI projects to achieve measurable goals

5 6 7

. . . has a full EMR accessible to all providers; team uses a registry or EMR to routinely track key indicators of patient outcomes and integration outcomes; indicators reported regularly to management; team uses data to support a continuous QI process

8 9 10

7. Patient/family input to integration management


1

. . . occurs on an ad hoc basis; not promoted systematically; patients must take initiative to make suggestions

2 3 4

. . . is solicited through advisory groups, membership on the team, focus groups, surveys, suggestion boxes, etc. for both current services and delivery improvements under consideration; patients/families are made aware of mechanism for input and encouraged to participate

5 6 7

. . . is considered an essential part of management’s decision-making process; systems are in place to ensure consumer input regarding practice policies and service delivery; evidence shows that management acts on the information

8 9 10

8. Physician, team and staff education and training for integrated care


1

. . . occurs on a limited basis without routine follow-up or monitoring; methods mostly didactic

2 3 4

. . . is provided for some (e.g. pilot) team members using established and standardized materials, protocols or curricula; includes behavioral change methods such as modeling and practice for role changes; training monitored for staff participation

5 6 7

. . . is supported and incentivized by the site for all providers; continuing education about integration and evidence-based practice is routinely provided to maintain knowledge and skills; job descriptions reflect skills and orientation to care integration

8 9 10



7

9. Funding sources/resources

. . . a single grant or funding source; no shared resource streams

1

. . . separate PC/MH/BH funding streams, but all contribute to costs of integrated care; few resources from participating organizations/agencies

2 3 4

. . . separate funding streams, but some sharing of on-site expenses, e.g., for some staffing or infrastructure; available billing codes used for new services; agencies contribute some resources to support change to integration, such as in-kind staff or expenses of provider training

5 6 7

. . . fully integrated funding, with resources shared across providers; maximization of billing for all types of treatment; resources and staffing used flexibly

8 9 10



Section 4:

Documentation and Data

Request

S.4





Protocol Name: Document and Data Request DSRIP Project Number: 3ai









Metric: Behavioral health services are co-located within PCMH/APC practice sites and are available

List of practitioners and licensure performing services at PCHM and/or APCM sites

Behavioral Health Practice Schedules Metric: Primary Care services are co-located within behavioral health practices and are available

List of practitioners and licensure performing services at behavioral health site

Behavioral Health Practice Schedules Metric: Screenings are documented in Electronic Health Record

Screenshots or other evidence of notifications of patient identification and screening alerts

Metric: Positive screening s result in “warn transfer” to behavioral health provider as measured by documentation in Electronic Health Record

Sample HER demonstrating warm transfers have occurred Metric: EHR demonstrates integration of medical and behavioral health record within individual patient records

Sample EHR demonstrating both medical and behavioral health Project Requirements

Metric: PPS identifies qualified Depression Care Manager (can be a nurse, social worker, or psychologist) as identified in electronic Health Record

Screenshot from HER identifying Depression Care Manager Metric: All Impact participants in PPS have a designated psychiatrist.

Electronic Health Record identifying Psychiatrist for eligible patients

Narrative


This protocol provides instructions for the return of the Directory Request template, Schedule Request template, and EHR Documentation Request forms that will satisfy the above metrics.


Protocol Narrative To fulfill the documentation and data reporting requirements, there are several forms and templates that need to be submitted to the Suffolk Care Collaborative.




One-Time Submissions In this section you will find four (4) types of forms that need to be completed by your facility and returned to SCC: directory requests, schedule requests, and EHR documentation requests. These three documents types only need to be submitted once. These forms are:

Name of Document Type of

Request Form* Model 1 Model 2 Model 3

Provider Directory Request Template

Directory Request

Integrated Care Practice Schedule

Schedule Request

Integrated Care EHR Documentation Request Form

EHR Request

Behavioral Health Screening EHR

Documentation Request Form

EHR Request

Primary Care Screening EHR

Documentation Request Form

EHR Request

Warm Transfer to Behavioral Health

Provider EHR Document Request

Form

EHR Request

Warm Transfer to Primary Care Provider

EHR Document Request Form

EHR Request

IMPACT Staff Request Form

EHR Request

Depression Care Manager Identified in

EHR Request Form

Patient Education Materials Provided by

Depression Care Manager

Document Request

*Please do NOT include any Protected Health Information (PHI)

All completed forms and supporting documentation listed above can be returned your Provider Relations Manager during a site visit or via the methods below: Via Mail: Suffolk Care Collaborative ATTN: [Name of your Provider Relation Manager’s]




1383 Veterans Memorial Highway, Suite 8 Hauppauge, NY 11788 Via Email: To your Provider Relations Manager Quarterly Submission On a quarterly basis, patient engagement information from the primary care and behavioral health sites need to information needs to be submitted to the Suffolk Care Collaborative. Patient engagement refers to how many patients are being impacted by Primary & Behavioral Health Integrated Care project. The specific patient engagement parameters are defined on the Domain 1 Patient Engagement Data Request document for this project.



SCC Documents Provider Directory Request Template



Behavioral Health Screening EHR Documentation Request Form

Primary Care Screening EHR Documentation Request Form

Warm Transfer to Behavioral Health Provider EHR Document Request Form

Warm Transfer to Primary Care Provider EHR Document Request Form

IMPACT Staff Request Form

Domain 1 Patient Engagement document

Primary Care and Behavioral Health (Model 1 & 3) Patient Engagement Template

Project 3.a.i Primary Care and Behavioral Health (Model 2) Patient Engagement Template


PCMH Element Reference Standard 3C




https://suffolkcare.org/forpartners/datarequest





•%09https:/suffolkcare.org/forpartners/programs-initiatives-publications



Provider Directory Request Template

Facility Name: __________________________ Facility Address:___________________________________________________

Instructions: Please complete the fields below and return to your Provider Relations Manager.

Practioner Name Licensure License Number Provider Type (BH or PC)* Site Address

*Include Integrated Care Service Providers at site

Signature_______________________________________Date:________________________________


36:




Facility Name:________________________________________________________

Facility Address:______________________________________________________

Days of Operation:_______________________________________

Total Hours of Operation/Day:

Days of Operation Hours/ Day

(00:00AM – 00:00PM)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Hours/Availability of BH/PC Services:

Days of Operation BH Hours

(00:00AM – 00:00PM) PC Hours

(00:00AM – 00:00PM)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Signature: _______________________________ Date:___________________________


37:



Behavioral Health Screening EHR Documentation Request Form

Project Requirement:

Conduct preventive care screenings, including behavioral health, implemented for all patients to identify

unmet needs.

Request:

Screenings are documented in EHR. Please provide a screenshot of:

1. Documentation of screening

Screenshots should include but are not limited to: evidence of appointments and services received by

patient.

Date: ________

Practice Site: ________________________________________________________

Practice Address: ____________________________________________________

Please insert and label screenshots in the box below:

Signature: __________________________________________ Date: __________


38:





Use EHR to track all patients engaged in project. Use of EHR demonstrates integration of medical and

behavioral health record within individual patient record.

Request:

EHR screenshots demonstrating both medical and behavioral health providers’ treatment by notes.

Date: __________ Practice Name: _____________________________________ Practice Address:_____________________________________________ Provider Name (Medical): _____________________________________________ Provider Name: (Behavioral Health): _____________________________________


Signature: ___________________________________ Date: __________


39:



Warm Transfer to Behavioral Health Provider EHR Document Request Form


Positive screenings results in “warm transfer” to behavioral health providers as measured by

documentation in EHR.

Request:

Sample EHR screenshot demonstrating documentation that warm transfer has occurred.

Date: ________

Practice Site: ________________________________________________________

Practice Address: ____________________________________________________


Signature: __________________________________________ Date: __________


40:



Section 5:

Integrated Care Services

Application Materials

S.6

S.5


41:




Protocol Name: Integrated Care Services DSRIP Project Number: 3ai


Applicable Model Number: Model 1, Model 2







Project Requirement 1 (Model 1): Co-locate behavioral health services at primary care practice sites. All participating primary care sites must meet 2014 NCQA level 3 PCMH or Advance Primary Care Model standards by DY3. Project Requirement 1 (Model 2): Co-locate primary care services at behavioral health sites.

Narrative


The purpose of this protocol is to outline the integrated care services scope of work, and define the parameters for integrated licensure. The scope of work is specific to the 3ai Model selected. In Model 1, primary care sites are charged with integrating behavioral health services. In Model 2, behavioral health sites are charged with integrating primary care services. Within this framework, specific actions will be performed to provide patients with integrated care services.


Protocol Narrative

Integrated Care Services Scope of work - Primary Care Practice

o Conduct behavioral health screenings as outlined and documented in Protocol 3ai.03

o Document screenings in Electronic Health Record as specified in Protocol 3ai.11

o Behavioral health providers that may be utilized to provide behavioral health services in the primary care setting include LMSWs, LCSWs, Psychologists, and Psych NPs

o Provide on-site behavioral health services through embedded behavioral health provider as outlined in Protocol 3ai.02

o Provide warm handoffs to behavioral health provider as outlined in Protocol 2ai.01

- Behavioral Health Setting o Conduct primary care screenings as outlined in Protocol 3ai.03 o Document primary care screening in Electronic Health Record as specified in

Protocol 3ai.11 o Provide on-site primary care services through embedded primary care provider

for a minimum of 16 hours/week as outlined in Protocol 3ai.02


42:



o Primary Care services are defined through patient engagement metrics. A list of eligible CPT codes can be found on Project 3ai Primary Care and Behavioral Health (Model 2) Patient Engagement Template

o Primary care providers that may be utilized to provide primary care services in the behavioral health setting include only PCPs, NPs, and PAs

o Provide warm handoffs to primary care provider as outlined in Protocol 2ai.01 o Complete Tobacco requirements outlined in Cardiovascular Wellness & Self-

Management Program (CWSP) Protocols 3bi.05 and 3bi.06 Completing an Integrated Care License For the purposes of DSRIP, integrated care applications are applicable to Behavioral Health settings. Please see the NYS DOH FAQ document below for details and DSRIP thresholds.

A provider licensed by DOH to provide primary care services that wishes to add behavioral health services can do so as long as under 49% of their visits are dedicated to those services. If a primary care provider will exceed that DSRIP threshold, they must submit a CON application or an LRA through NYSE-CON –one separate application must be submitted for each site

A provider licensed by OMH or OASAS that wishes to add primary care or the other behavioral health service must submit the DSRIP Project 3.a.i Integrated Services Application –multiples sites may be included on one application

A clinic site licensed by DOH pursuant to PHL Article 28 seeking to add behavioral health services must submit a CON application or LRA through NYSE-CON if they exceed the 49% threshold of these services.

A clinic site licensed by OMH pursuant to MHL Article 31 or certified by OASAS pursuant to MHL Article 32 seeking to add primary care or behavioral health services must submit the application available on the OMH and OASAS websites

Upon the conclusion of DSRIP, the waiver providing higher thresholds will no longer be applicable, thus an integrated license would be of greater utility. Please refer to the Primary & Behavioral Health Integrated Care Program Toolkit for more information regarding the Integrated Care License

Section 5: Integrated Care Services Application Materials



Training Module & Curriculum Reference



This module provides a comprehensive look at the process of primary and behavioral health integration. The modules progress though understanding the core concepts related to integrating services, and the prevailing models on integration and their relation to population health, to preparing for integration, and finally to full implementation and




43:



documentation. Participants will gain a full understanding of the potential of this type of integration to improve the health outcomes of patients, and what the steps will be to work towards this integration. Training Topics: Primer on the Primary Care Consult


Primer on Pediatric Consults for Primary Care




Registry Basics



DOH Certificate of Need (CON) Application or Limited Review Application (LRA)

https://www.health.ny.gov/facilities/cons Application Instructions

https://www.health.ny.gov/facilities/cons/limited_review_application/lra_instructions_outpatient.htm

OMH Prior Approval Review (PAR) or EZ PAR Application

http://www.omh.ny.gov/omhweb/par

OASAS Certification Application

http://oasas.ny.gov/legal/CertApp/capphome.cfm NYS OMH & OASAS Integration of Primary Care and Behavioral Health Services

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2016-01-26_integrate_serv_webinar.pdf

NYS Office of Mental Health, Integrated Services

https://www.omh.ny.gov/omhweb/clinic_restructuring/integrated-services.html NYS Department of Health, DSRIP Frequently Asked Questions

http://www.health.ny.gov/health_care/medicaid/redesign/docs/dsrip_faq.pdf

SCC Documents Protocols

Protocol 3ai.02 – Evidence Based Guidelines

Protocol 3ai.03 – Screening Procedure

Protocol 2ai.01 – Warm Referral & Follow up Protocol

Protocol 3bi.05 – Implementing the 5A’s of Tobacco Control Protocol

Protocol 3bi.06 - Implementing the NY Smoker’s Quit line Protocol






https://www.health.ny.gov/facilities/cons



http://www.omh.ny.gov/omhweb/par

http://oasas.ny.gov/legal/CertApp/capphome.cfm



https://www.omh.ny.gov/omhweb/clinic_restructuring/integrated-services.html



44:



Protocol 3ai.11 – Documents and Data Request

Project 3ai Primary Care and Behavioral Health Data Request


o Project 3ai Primary Care and Behavioral Health Data Request o Project 3ai Primary Care and Behavioral Health (Model 1 & 3) Patient

Engagement Template o Project 3ai primary Care and Behavioral Health (Model 3) Patient

Engagement Template - use this excel workbook to access CPT codes for primary care services that may be provided in an integrated behavioral health setting




2D (Must Pass)

3B, 3C9, 3D (Must Pass)

4A, 4E

5B (Must Pass) The featured protocols are examples of a wide variety of available evidence-based protocols that are within the SCC Program Requirements. Linking to Recommended Tools does not constitute an endorsement by the Suffolk Care Collaborative. Links to Recommended Tools containing protocols serve only as a source of guidance. Health care professionals should always consider the individual clinical circumstances of each person. Links to the protocols are not intended to be a substitute for professional medical advice; individuals should seek advice from their health care professionals.




45:



Applications

The applications applicable to this project have been included in this toolkit. For electronic copies of

these toolkits, please the links below to access.

Application Materials

1. LRA application:

http://www.health.ny.gov/facilities/cons/limitedreviewapplication/consolidatedlimitedr

eviewapplication.htm

2. Integrated license application:

http://www.oasas.ny.gov/mis/forms/ppd/documents/PPD-12.pdf

3. Licensure/Waiver Thresholds

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/do

cs/licensure_threshold_guidance.pdf


http://www.health.ny.gov/facilities/cons/limitedreviewapplication/consolidatedlimitedreviewapplication.htm

http://www.health.ny.gov/facilities/cons/limitedreviewapplication/consolidatedlimitedreviewapplication.htm

http://www.oasas.ny.gov/mis/forms/ppd/documents/PPD-12.pdf

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/docs/licensure_threshold_guidance.pdf

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/docs/licensure_threshold_guidance.pdf

March 18, 2016

Licensure Thresholds1

DSRIP Licensure Thresholds2

Integrated Outpatient Services Regulations3

Multiple License/ Certification 4

PHL Article 28 Licensed Provider

• Currently, a provider licensed under PHL Article 28 and offering mental health services –meaning a general hospital outpatient department or a diagnostic and treatment center (primary care provider) – and which has more than 2,000 total visits per year must be licensed under Article 31 of the Mental Hygiene Law (MHL) by OMH if it has more than 10,000 annual visits for mental health services or more than 30 percent of its total annual visits are for mental health services.

• A primary care provider may not provide substance use disorder services without being certified by OASAS pursuant to MHL Article 32.

• Consistent with section 2807(2-a)(f)(ii)(c) of the Public Health Law (PHL), Medicaid reimbursement is available for individual mental health counseling services provided by a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW) under the

• A practitioner providing mental health and/or substance use disorder services in a DOH licensed clinic must be a licensed psychiatrist, psychologist, psychiatric nurse practitioner, or an LCSW.

• Licensed mental health counselors, licensed marriage and family therapists, and PhD staff are not recognized providers in the PHL Article 28 licensed setting.

• Providers integrating services under the DSRIP 3.a.i Licensure Threshold should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment.

• Consistent with section 2807(2-a)(f)(ii)(c) of the Public Health Law (PHL), Medicaid reimbursement is available for

• When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.

• A licensed or certified provider approved under the integrated outpatient services regulations to provide integrated care services will be issued an integrated services rate code that will reimbursed through the APGs

• Medicaid is always the payer of last resort. Providers must bill all commercial insurance prior to billing Medicaid. Medicaid will pay the lower of the third party patient responsibility or the difference between the third

• When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.

• Population limits placed on Medicaid reimbursement for mental health counseling provided by LCSWs or LMSWs are not applicable to dually licensed clinics.

1 A licensed or certified provider may add primary care, mental health and/or substance use disorder services under a single license or certification as long as the service to be added does not exceed

the applicable Licensure Threshold. 2 A licensed or certified provider may add primary care, mental health and/or substance use disorder services under a single license or certification, as long as the service to be added is not more than

49 percent of the provider’s total annual visits (“DSRIP Project 3.a.i Licensure Threshold”) and the patient initially presents to the provider for a service authorized by such provider's license or certification. 3 A provider that is licensed or certified by more than one agency to may add services at one of its sites without having to obtain an additional license or certification, as long as it is licensed or certified

to provide such services. 4 A provider may integrate services by obtaining a license or certificate from each licensing agency (DOH, OMH or OASAS), as appropriate.

1

March 18, 2016





supervision of a LCSW, psychologist or psychiatrist in PHL Article 28 licensed outpatient hospital clinics (OPDs) and freestanding diagnostic and treatment centers (D&TCs), including school based health centers (SBHCs). Such services, however, are reimbursable only when provided to enrollees under the age of 21 and to pregnant women up to 60 days postpartum (based on the date of delivery or end of pregnancy). In order to qualify as a billable Medicaid service, claims for services rendered to pregnant women are required to have a primary or secondary diagnosis of pregnancy and claims for services rendered to women post-pregnancy are required to have a primary or secondary diagnosis of postpartum depression.

individual mental health counseling services provided by a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW) under the supervision of a LCSW, psychologist or psychiatrist in PHL Article 28 licensed outpatient hospital clinics (OPDs) and freestanding diagnostic and treatment centers (D&TCs), including school based health centers (SBHCs). Such services, however, are reimbursable only when provided to enrollees under the age of 21 and to pregnant women up to 60 days postpartum (based on the date of delivery or end of pregnancy). In order to qualify as a billable Medicaid service, claims for services rendered to pregnant women are required to have a primary or secondary diagnosis of pregnancy and claims for services rendered to women post-pregnancy are required to have a primary or secondary diagnosis of postpartum depression.

party paid amount and the integrated services APG rate.

• Approved integrated services providers are assigned APG Medicaid billing rate codes which are to be used by the integrated services provider at the host site.

• A primary care host model provider approved to provide integrated care services may bill for behavioral health services provided by a nurse practitioner. Note: Nurse Practitioner may not bill Medicaid for professional services provided in an Article 28.

• A primary care host model provider approved to deliver mental health services is reimbursed through APGs. The APG grouper reimburses for individual and group psychotherapy.

• Consistent with section 2807(2-a)(f)(ii)(c) of the Public Health Law (PHL), Medicaid reimbursement is available for individual mental health counseling services provided by a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW) under the supervision of a LCSW, psychologist or psychiatrist in PHL Article 28 licensed outpatient hospital clinics (OPDs) and freestanding diagnostic and treatment centers (D&TCs), including school based health centers (SBHCs). Such services, however, are reimbursable only when provided to enrollees under the age of 21 and to pregnant

2

March 18, 2016





women up to 60 days postpartum (based on the date of delivery or end of pregnancy). In order to qualify as a billable Medicaid service, claims for services rendered to pregnant women are required to have a primary or secondary diagnosis of pregnancy and claims for services rendered to women post-pregnancy are required to have a primary or secondary diagnosis of postpartum depression.

PHL Article 28 Licensed Provider (FQHC)

• Population limits placed on Medicaid reimbursement for mental health counseling provided by LCSWs or LMSWs are not applicable to federally designated health clinics (Federally Qualified Health Center (FQHC), FQHC “look-alike”, or Rural Health Clinic (RHC)).

• FQHCs that have not opted into APGs operate under the PPS (Prospective Payment System) rate. Federally designated health clinics must bill their all-inclusive PPS rate for individual therapy and a lesser rate per recipient for group therapy.

• No regulatory waiver of 10 NYCRR § 86-4.9 will be provided to allow for reimbursement of two visits on one day.

• DOH sets the PPS rate using the methodology established under federal law. The PPS methodology, including the “per visit basis,” is established under federal law and DOH does not have the authority to waive federal rules.

MHL Article 31 Licensed Provider

• Currently, a provider licensed by OMH under MHL Article 31 to provide outpatient mental health services must obtain PHL Article 28 licensure by DOH if more than 5 percent of total annual visits are for primary care services or if any visits are for dental services.

• New rate codes are being established to allow an MHL Article 31 licensed provider to bill for the provision of primary care services under the DSRIP Project 3.a.i. Licensure Threshold construct.

• When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not

• When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not

3

March 18, 2016





• Providers integrating services under the DSRIP 3.a.i Licensure Threshold should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment. (see Integrated Services FAQ, question #69, for specific codes)

bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.

• A licensed or certified provider approved under the integrated outpatient services regulations to provide integrated care services will be issued an integrated services rate code that will be reimbursed through APGs.

• Providers integrating services under the integrated outpatient services regulations should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment. (see Integrated Services FAQ, question #69, for specific codes)

• Medicaid is always the payer of last resort. Providers must bill all commercial insurance prior to billing Medicaid. Medicaid will pay the lower of the third party patient responsibility or the difference between the third party paid amount and the integrated services APG rate.

bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.

MHL Article 32 Certified Provider

• Currently, a provider certified by OASAS under MHL Article 32 to provide outpatient substance use disorder services must obtain PHL Article 28 licensure by DOH

Providers integrating services under the DSRIP 3.a.i Licensure Threshold should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g.,

• When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a

• When a provider believes its volume of services will approach the threshold limits, a provider has the option of integrating services by either seeking a

4

March 18, 2016





if more than 5 percent of total annual visits are for primary care services or if any visits are for dental services.

behavioral health services and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment.

second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.

• A licensed or certified provider approved under the integrated outpatient services regulations to provide integrated care services will be issued an integrated services rate code that will reimbursed through the APGs.

• Providers integrating services under the integrated outpatient services regulations should submit one claim for each visit with all the procedures/services rendered on the date of service (e.g., behavioral health services

and primary care services). The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment. (see Integrated Services FAQ, question #69, for specific codes)

• Medicaid is always the payer of last resort. Providers must bill all commercial insurance prior to billing Medicaid. Medicaid will pay the lower of the third party patient responsibility or the difference between the third party paid amount and the integrated services APG rate.

second license for a particular site or integrating services under the integrated outpatient services regulations. Providers may not bill Medicaid for any service rendered above the licensure threshold amount unless the appropriate licensure or certification is in place at the time the service was rendered.

5

I. Identification of Applicant

Provider Name

Executive Director

Telephone Number of Applicant Medicaid Provider Number (if any)

Fax Number of Applicant E-Mail Address of Applicant

Contact Name Contact Title

Contact Telephone Number(s) Contact E-Mail Address

Alternate Contact Name Alternate Contact Title

Alternate Contact Telephone Number(s) Alternate Contact E-Mail Address

Type of Application Requested

Article 28 Services (DOH) Article 31 Services (OMH) Article 32 Services (OASAS)

Site Address

Current License/Certificate at Site

Article 28 Services (DOH) Article 31 Services (OMH) Article 32 Services (OASAS)

Current Health Home Affiliation

Name Address Phone Number

II. Project Narrative

Service #1 OASAS OMH DOH

Provide rationale; specify services to be added and describe plan for implementation


Provide rationale; specify services to be added and describe plan for implementation

PPD-12 (Rev. 12/14)

III. Staffing


List staff by title based on FTE allocation assigned to the new service; identify if the titles will be shared between services at the site.

Position by Title # FTEs Schedule

Shared (Yes/No)

Service Days Hours

Describe supervisory arrangements and/or provision for Medical Director.

PPD-12 (Rev. 12/14) 2

III. Staffing (Continued)


List staff by title, based on FTE allocation, assigned to the new service; identify if the titles will be shared between services at the site and with which agency.

Position by Title # FTEs Schedule Shared

(Yes/No) Service

Days Hours

Describe supervisory arrangements and/or provision for Medical Director.

PPD-12 (Rev. 12/14) 3

IV. Budget

First Year (Projected)

Operating Expenses (Incremental) OASAS OMH DOH

Staffing Salaries

Employee Benefits

Property (Rent/Utilities, etc.)

Other Non-Personal Services Expenses

Administrative and Overhead

Total Expenses

Revenue (Incremental)

Medicaid

Medicare

Insurance

Fees

Other (Identify)

Total Revenue

Total Expenses less Total Revenue

V. Utilization of Additional Service(s) First Year (Projected)

Number of Individuals (OASAS) Annual Units of Services (OASAS)

Number of Individuals (OMH) Annual Units of Services (OMH)

Number of Individuals (DOH) Annual Units of Services (DOH)

VI. Physical Plant(Attach a labeled floor plan for the site and schedule for use of any shared space by service.)

Minor Construction/Renovation Involved? Yes No Total Cost of Construction $

If yes, provide a description of the work to be completed, including change of use for existing spaces.

PPD-12 (Rev. 12/14) 4

VII. OASAS and OMH Host or Integrated Service Addition

Local Governmental Unit (LGU) Notification

Does this proposal have the support of the LGU? Yes No

LGU Contact Telephone Number of LGU Contact Date of LGU Contact

Field Office Approval

Does this proposal have the support of the Field Office? Yes No

Field Office Contact Telephone Number of Field Office Contact Date of FO Contact

VIII. Attestation

Signature required by CEO/CFO, I hereby give the following assurances:

Applicant is aware of, and agrees to comply with the licensing standards, including DOH, OMH or OASASsupplemental standards which apply to the provision of the requested additional services at the identified site.

Name (Please Print) Signature

Title Date

For submission of this application electronically, I understand that by typing my name above, I am attesting that I am authorized to represent the applicant and hereby give my assurance of all applicable standards required for the proposed service.

PPD-12 (Rev. 12/14) 5

46:



Guidance for DSRIP Performing Provider Systems

Integrating Primary Care and Behavioral Health

(Mental Health and/or Substance Use Disorder)

Services under Project 3.a.i

See “Attachment A” on the NYS Department of Health website for information and guidance


https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/licensure_thresholds.htm

Integrated Care Approaches FAQs - January 2016

Updated: March 18, 2016

Frequently Asked Questions (FAQs) Approaches to Integrated Care

health.ny.gov

Contents

Frequently Asked Questions (FAQs) – Approaches to Integrated Care ............................................... 1 Integrated Care ......................................................................................................................................... 1 Licensure Threshold ................................................................................................................................. 2 DSRIP Project 3.a.i Licensure Threshold ................................................................................................. 3 Integrated Outpatient Services Regulations ............................................................................................. 6 Collaborative Care .................................................................................................................................. 10 Multiple Licenses .................................................................................................................................... 12 Telehealth ............................................................................................................................................... 13 Other ....................................................................................................................................................... 15 Billing – DSRIP Project 3.a.i Licensure Threshold ................................................................................. 16 Billing – Integrated Outpatient Services Regulations ............................................................................. 17 Billing – Other ......................................................................................................................................... 20

Frequently Asked Questions (FAQs) – Approaches to Integrated Care These Frequently Asked Questions (FAQs) issued by the New York State Department of Health (DOH), the New York State Office of Mental Health (OMH) and the New York State Office of Alcoholism and Substance Abuse Services (OASAS) will provide guidance to providers that wish to integrate primary care and mental health and/or substance use disorder (behavioral health) services. The FAQs cover the following approaches:

• Licensure Thresholds

• DSRIP Project 3.a.i Licensure Threshold

• Integrated Outpatient Services Regulations

• Collaborative Care

• Multiple Licenses

New questions added to this FAQ and updated answers (released March 18, 2016) are highlighted in red. All questions included relate specifically to Article 28, 31, and 32 and does not reflect questions regarding private practices.

Integrated Care

1. Q: How does the Waiver Amendment relate to the Medicaid Redesign Team? Why is integration of primary care and behavioral health (mental health and/or substance use disorder) services important?

A. Health care providers have long recognized that many patients have multiple physical and behavioral health care needs, yet services have traditionally been provided separately. The integration of primary care mental health and/or substance use disorder services can help improve the overall quality of care for individuals with multiple health conditions by treating the whole person in a more comprehensive manner.

1

2. Q. Within New York State, an 822 clinic has restrictions in terms of sharing patient information at the State level. Will state agencies look into the obstacles regarding improving communication between health organizations?

A. All involved agencies continue to explore strategies to assist providers in implementing "true" integration while maintaining compliance with federal law and regulations. However, Federal confidentiality requirements contained in 42 CFR Part 2 continue to apply to SUD treatment records and information unless exception provided under the federal law/regulations are met.

Licensure Threshold

3. Q. What are Licensure Thresholds?

A. A licensed or certified outpatient provider may add primary care, mental health services under a single license or certification without any additional licenses or certifications, as long as the service to be added does not exceed the applicable Licensure Threshold. Licensure Thresholds are not currently applicable for substance use disorder services; OASAS certification is required if a clinic licensed by DOH or OMH wishes to provide any substance use disorder services.

• A clinic site licensed by DOH pursuant to PHL Article 28 must also be licensed by OMH if it provides more than 10,000 annual mental health visits, or if more than 30 percent of its annual visits are for mental health services. The policy is the lowest of 30%/10,000 visits.

• A clinic site licensed by OMH pursuant to MHL Article 31 or certified pursuant to MHL Article 32 must also be licensed by DOH if more than 5 percent of its visits are for medical services or any visits are for dental services.

The provider that integrates services under the applicable Licensure Threshold must follow the programmatic standards of its licensing agency. More information can be found here: http://www.health.ny.gov/press/releases/2008/2008-03-04_con_reform_ambulatory_care_services.htm.

4. Q. Under the current Licensure Threshold, can a primary care provider offer substance used disorder services?

A. Under the current Licensure Threshold regulations a primary care provider may not provide substance use disorder (SUD) services without being certified by OASAS pursuant to MHL Article 32. Under DSRIP Project 3.a.i Licensure Threshold, OASAS will implement a Licensure Threshold for DSRIP providers participating in project 3.a.i so that primary care providers may provide up to 49% of its total annual visits for substance use disorder services without MHL Article 32 certification.

5. Q. What is the application process to integrate services under the current Licensure Thresholds?

A. The provider does not need to submit an application to add services as long as the number of visits does not exceed the applicable Licensure Thresholds (non-DSRIP).

2

http://www.health.ny.gov/press/releases/2008/2008-03-04_con_reform_ambulatory_care_services.htm

http://www.health.ny.gov/press/releases/2008/2008-03-04_con_reform_ambulatory_care_services.htm

6. Q. Which state agency is responsible for oversight of the provider that integrates services under the Licensure Thresholds?

A. The state agency that licensed or certified the provider is responsible for regulatory oversight of the provider.

DSRIP Project 3.a.i Licensure Threshold

7. Q. What is the DSRIP Project 3.a.i Licensure Threshold?

A. A licensed or certified provider that is part of DSRIP Project 3.a.i may integrate primary care, mental health and/or substance use disorder services under a single license or certification as long as the service to be added is not more than 49 percent of the provider’s total annual visits (“DSRIP Project 3.a.i Licensure Threshold”) and the patient initially presents to the provider for a service authorized by such provider's license or certification. A licensed or certified provider is part of DSRIP Project 3.a.i if it is responsible for implementing one of the Project’s models as identified in the PPS’s implementation plan (i.e., Model 1 (PCMH), Model 2 (BH), Model 3 (IMPACT)). The provider that integrates services under the DSRIP Project 3.a.i Licensure Threshold must follow the programmatic standards of its licensing agency and the supplemental requirements for added service(s) as outlined in the DSRIP Licensure Threshold Guidance, which can be found here:

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/licensure_threshold_guidance.htm.

8. Q. What is the application process if a provider wishes to integrate services under the DSRIP Project 3.a.i Licensure Threshold?

A. The provider must submit an application to and receive approval from the agency that licensed or certified the provider site.

• A provider licensed by DOH pursuant to PHL Article 28 seeking to add behavioral health services must submit a Certificate of Need (CON) application or a Limited Review Application (LRA) through NYSE-CON. A separate application is required for each site.

• A provider licensed by OMH pursuant to MHL Article 31 seeking to add primary care or substance use disorder services or certified by OASAS pursuant to MHL Article 32 seeking to add primary care or mental health services must submit the “DSRIP Project 3.a.i Licensure Threshold Application.” The provider can include all the sites that wish to integrate services on a single application.

The application documents and instructions can be found here: http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/draft_appl_instructions.htm

9. Q. If a licensed or certified provider wishes to integrate services and is a PPS provider partner as identified on the PPS Performance Network List but is not involved in Project 3.a.i, can the provider use this approach?

A. No. This approach exists specifically to advance the integration of primary care and behavioral health services as part of DSRIP Project 3.a.i. The PPS Lead is responsible for identifying which provider partners in its network (including their sites) will be pursuing which DSRIP Project 3.a.i model(s), as identified in its implementation plan (i.e., Model 1 (PCMH), Model 2 (BH) or Model 3

3

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/licensure_threshold_guidance.htm



http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/draft_appl_instructions.htm

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/draft_appl_instructions.htm

(IMPACT)). These providers may submit an application for the participating sites as described in FAQ #8.

10. Q. Is a PHL Article 28 licensed provider licensed in a category other than primary care, able to add behavioral health services under the DSRIP Project 3.a.i Licensure Threshold?

A. No. This approach exists specifically to advance the integration of primary care and behavioral health services as part of DSRIP Project 3.a.i and only a provider that is part of Project 3.a.i as explained in FAQ #9 and is licensed by DOH pursuant to PHL Article 28 in primary care (i.e., operating certificate should list “medical services – primary care”) may apply.

11. Q. If a licensed or certified provider that is part of DSRIP Project 3.a.i receives approval to integrate services under the DSRIP Project 3.a.i Licensure Threshold, will the added service be reflected on the provider’s operating certificate?

A. If a provider licensed by DOH is approved to add mental health and/or substance use disorder services, the added service(s) will appear on the provider’s operating certificate as follows: DSRIP Integrated Outpatient Services (MH) and/or DSRIP Integrated Outpatient Services (SUD). If a provider licensed by OMH or certified by OASAS is approved to add primary care and/or the other behavioral health services, the provider will receive an approval letter from its licensing or certifying agency.

12. Q. Does a PPS provider partner that wishes to integrate services under the DSRIP Project 3.a.i Licensure Threshold need to be affiliated with a health home?

A. A licensed or certified outpatient provider that wishes to integrate services under the DSRIP Project 3.a.i Licensure Threshold does not need to be affiliated with a health home in order to apply, as it would for participation under the integrated outpatient services regulations. However, PPSs, as well as their network partners participating in Project 3.a.i, should keep in mind that a requirement of DSRIP is to have Health Homes participating in the network. Health Homes include former targeted case management (TCM) providers who specialized in behavioral health populations. Health Homes should be a resource for care management in any project involving behavioral health services.

13. Q. If a licensed or certified provider is part of DSRIP Project 3.a.i and wishes to integrate services but does not anticipate exceeding the applicable non-DSRIP “Licensure Threshold,” does the provider still need to submit an application?

A. No. However, a provider may not provide services or bill Medicaid for any service rendered above the applicable Licensure Threshold unless the appropriate approval is in place. Therefore, when a provider approaches the Licensure Threshold, the provider should consider seeking approval from the relevant state agency to add services above the Licensure Thresholds up to the DSRIP Project 3.a.i Licensure Threshold, if applicable. As always, the provider also would have the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations, if applicable (see 10 NYCRR Part 404, 14 NYCRR Part 598 and 14 NYCRR Part 825).

4

14. Q. If a PPS provider is approved to integrate services under the DSRIP Project 3.a.i Licensure Threshold, does the provider need to meet all the requirements of the integrated outpatient services regulations as well?

A. In addition to following the programmatic standards of its licensing agency, the provider needs to meet the prescribed requirements of the integrated outpatient services regulations as outlined in the DSRIP Licensure Threshold Guidance, which can be found here: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/licensure_threshold_guidance.htm

15. Q. How is a provider supposed to define a visit for purposes of calculating the DSRIP Licensure Threshold?

A. The DSRIP Licensure Threshold Calculation Methodology will be available soon. Please continue to watch the webpage, which can be found here: https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/draft_appl_instructions.htm

16. Q. What happens when a provider approaches the 49 percent threshold for the added service?

A. The provider has the option of integrating services by either seeking a second license for a particular site or integrating services under the integrated outpatient services regulations (see 10 NYCRR Part 404, 14 NYCRR Part 598 and 14 NYCRR Part 825), if applicable. A provider that elects to integrate services under the integrated outpatient services regulations will need to comply with all applicable provisions under the regulations.

17. Q. Which state agency is responsible for oversight of a provider that integrates services under the DSRIP Project 3.a.i Licensure Threshold?

A. The state agency that licensed or certified the provider is responsible for regulatory oversight of the provider.

18. Q. What happens to a provider that integrates services under the DSRIP Project 3.a.i Licensure Threshold at the end of the DSRIP program?

A. This approach is limited to the life of the DSRIP program. As eligible providers take advantage of this approach, the state agencies will be able to assess the effectiveness of this approach is effective and decide whether to pursue its continuation, with any appropriate adjustments.

19. How is 42 CFR Part 2 applicable to providers in DSRIP projects that seek to offer substance use disorder treatment services?

A. The federal confidentiality law, 42 CFR Part 2, controls the privacy of, access to and maintenance of patient records of federally funded alcohol and drug abuse providers. This would include any provider under DSRIP that seeks to add substance use disorder treatment services. A provider who provides substance use disorder treatment under any of the integrated services models, including DSRIP thresholds, must comply with these rules. Accordingly, a provider licensed by DOH pursuant to PHL Article 28 or by OMH pursuant to MHL Article 31 that delivers substance use disorder services must comply with 42 CFR Part 2.

5



https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/draft_appl_instructions.htm

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/regulatory_waivers/draft_appl_instructions.htm

Integrated Outpatient Services Regulations

20. What is the definition of Primary Care?

A. DOH defines “primary care services” as “services provided by a physician, nurse practitioner, or midwife acting within his or her lawful scope of practice under Title VIII of the Education Law and who is practicing primary care.” The OMH and OASAS regulations include the same language. https://www.health.ny.gov/regulations/recently_adopted/docs/2015-01-

01_integrated_outpatient_services.pdf.

21. Q. How does a provider add services under the integrated outpatient services regulations?

A. An outpatient provider that is licensed or certified by more than one agency may add primary care, mental health and/or substance use disorder services at one of its sites without having to obtain an additional license or certification, as long as it is licensed or certified to provide such services at another location. There are three models:

• Primary Care Host Model

• Mental Health Behavioral Care Host Model

• Substance Use Disorder Behavioral Care Host Model

The “host site” is the single outpatient site at which a provider who is licensed or certified by DOH, OMH or OASAS is approved to provide integrated services as prescribed under the regulations. The provider that integrates services under the integrated outpatient services regulations must follow the programmatic standards of the licensing agency that licensed the “host site” and follow supplemental requirements for added service(s) as outlined in the regulations.

• DOH licensed providers (10 NYCRR Part 404);

• OMH licensed providers (14 NYCRR Part 598); and

• OASAS certified providers (14 NYCRR Part 825).

Guidance regarding the integrated outpatient services regulations is available at: http://www.oasas.ny.gov/legal/CertApp/documents/IOSGuid.pdf

22. Q. Are the integrated outpatient services regulations limited to DSRIP providers?

A. No. The regulations are applicable to any eligible licensed or certified provider. However, a provider in a PPS network that is part of Project 3.a.i may opt to proceed under the integrated outpatient services regulations if otherwise eligible and may wish to do so, for example, if it wishes to offer an additional type of services above the 49 percent DSRIP Project 3.a.i Licensure Threshold.

23. Q. Is the Health Care Coordinator role (as previously required by OASAS) still applicable under the integrated license?

A. Yes, for those programs that operate as an OASAS host site.

6

https://www.health.ny.gov/regulations/recently_adopted/docs/2015-01-01_integrated_outpatient_services.pdf

https://www.health.ny.gov/regulations/recently_adopted/docs/2015-01-01_integrated_outpatient_services.pdf

http://www.oasas.ny.gov/legal/CertApp/documents/IOSGuid.pdf

24. Can an agency that is an OMH host site that has added OASAS services (with integrated licensing) co- treat with another OASAS agency?

A. Yes, an OMH Host integrated outpatient services provider could refer a patient to a separate SUD provider to the extent that the host site is unable to provide services or a patient desires to us another SUD provider. Provider would continue to bill for the mental health services delivered using the integrated rate code.

Approval to provide “integrated outpatient services” is site specific; however providers can have multiple sites approved. There is no limit on the number of sites for which a provider can seek approval.

25. Q. Is a specialty care provider, e.g., a provider licensed by DOH pursuant to PHL Article 28 in a category other than primary care, able to add mental health and/or substance use disorder services under the integrated outpatient services regulations?

A. No. This approach exists specifically to advance the integration of primary care, mental health and substance use disorder services and only a provider licensed by DOH pursuant to PHL Article 28 in primary care (i.e., operating certificate that lists “medical services – primary care”) may apply.

26. Q. The integrated outpatient services regulations require the applicant to be a member of a health home designated by the Commissioner of Health. What information is required?

A. The applicant must indicate the Health Home Lead for which the applicant is a network partner as identified on the Network Health Home Partner List (https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/contact_information/county_list.htm). If an applicant is not on the list, the applicant may provide other documentation of its affiliation with a health home (e.g., copy of contract, MOU, etc. between applicant and the Health Home Lead).

27. Q. What is the application process under the integrated outpatient services regulations?

A. The provider must submit an application to and obtain approval from the state agency that licensed the “host site.”

A provider licensed by DOH pursuant to PHL Article 28 seeking to add mental health and/or substance use disorder services must submit a CON application or LRA through NYSE-CON. A separate application is required for each site.

• A provider licensed pursuant to MHL Article 31 seeking to add primary care or substance use

disorder services or a provider certified pursuant to MHL Article 32 seeking to add primary care or mental health services must submit the “Integrated Services Application” available on the OMH and OASAS websites. A separate application is required for each site.

The application instructions and documents can be found here:

• DOH Application Instructions (Primary Care Host Model): https://www.health.ny.gov/facilities/cons/limited_review_application/lra_instructions_outpatient.htm

• OMH Application Instructions (Mental Health Behavioral Care Host Model): https://www.omh.ny.gov/omhweb/clinic_restructuring/integrated-services.html

• OASAS Application Instructions (Substance Use Disorder Behavioral Care Host Model): https://www.oasas.ny.gov/legal/CertApp/capphome.cfm

7

https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/contact_information/county_list.htm

https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/contact_information/county_list.htm



https://www.omh.ny.gov/omhweb/clinic_restructuring/integrated-services.html

https://www.oasas.ny.gov/legal/CertApp/capphome.cfm

28. Q. When will the integrated services provider application approvals be released?

A. The process is currently up and running and applications are being accepted and reviewed on a rolling basis. Providers should contact their appropriate agencies for additional clarification and follow-up.

29. Q. Which state agency is responsible for regulatory oversight of the licensed or certified provider that integrates services under the integrated outpatient services regulations?

A. The state agency responsible for regulatory oversight of the provider at a host site is the agency that initially licensed or certified the host site:

• Primary Care Host Model – DOH

• Mental Health Behavioral Care Host Model – OMH

• Substance Use Disorder Behavioral Care Host Model – OASAS

30. Q. Under the Mental Health Behavioral Care Host Model, is the host provider limited in the range of primary care services that may be provided by the APG rate codes (i.e., health assessments and health monitoring)?

A. No. Any provider licensed by OMH pursuant to MHL Article 31 may offer health physicals and health monitoring as optional services, which do not count towards the 5% threshold. For more information about services that can be billed under the mental health behavioral care host model, please see the Integrated Outpatient Services – Implementation Guidance, which can be found here: http://www.oasas.ny.gov/legal/CertApp/documents/IOSGuid.pdf

31. Q. How is 42 CFR Part 2 applicable to primary care host and mental health behavioral care host providers that offer substance use disorder treatment services?

A. The federal confidentiality law, 42 CFR Part 2, controls the privacy of, access to and maintenance of patient records of federally funded alcohol and drug abuse providers. This would include primary care host and mental health behavioral care host providers of substance use disorder treatment services. A provider who provides substance use disorder treatment under any of the integrated services models, including the integrated outpatient services regulations, must comply with these rules. Accordingly, a PHL Article 28 or MHL Article 31 licensed provider that adds substance use disorder services must comply with 42 CFR Part 2.

32. Q. Can a provider certified by OASAS pursuant to MHL Article 32 be approved to add primary care services pursuant to the integrated outpatient regulations provide primary care services to other Opioid Treatment Programs (OTP a/k/a MMTP) within the same organization?

A. Under the substance use disorder behavioral care host model, the OASAS certified provider is only allowed to provide primary care services at the approved host site and may not provide primary care services at an OTP program operated by the same provider at another site without approval. A separate application must be submitted for each OASAS certified site so that it may be separately considered for approval as a host site before it is able to add primary care services.

8

http://www.oasas.ny.gov/legal/CertApp/documents/IOSGuid.pdf

33. Q. If a Diagnostic and Treatment Center receives approval to operate an Article 31 Mental Health Clinic, can the operation of the mental health services be conducted under the administration, management and support (clerical and others) staff of the D&TC?

A. Yes, but only if the D&TC is correspondingly approved for “Certified Mental Health O/P” on its Article 28 operating certificate or is approved for “integration” under the Integrated Outpatient Services regulation. Otherwise, what is described would still require “separation” under existing constructs.

34. Q. Is methadone maintenance one of the OASAS services that can be integrated into a primary care host site?

A. Providers interested in integrating methadone maintenance services into their program should reach out to the appropriate OASAS Field Office.

35. Q. Since nurse practitioners are recognized as independent practitioners in New York State, can they be licensed to prescribe buprenorphine?

A. No. Under the federal Drug Addiction Treatment Act (DATA) of 2000, only qualifying physicians who receive a waiver from the special registration requirements in the Controlled Substances Act are able to practice medication-assisted opioid addiction therapy with Schedule III, IV, or V narcotic medications specifically approved by the Food and Drug Administration (FDA). The term "qualifying physician" is specifically defined in DATA 2000 as a provider meeting all of the following conditions: a physician who is licensed under State law, has a DEA registration number to dispense controlled substances, has the capacity to refer patients for counseling and ancillary services, will treat no more than 30 such patients at any one time for the first year, then no more than 100 patients at any one time thereafter provided the physician has received approval to increase capacity from the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment, and is qualified by certification, training, and/or experience to treat opioid addiction.

36. Q. How often is utilization review (UR) of services needed as required under 14 NYCRR 598.11(a)(2)(iii)(e) and 14 NYCRR 825.(a)(2)(iii)(e) of the integrated outpatient services regulations?

A. The integrated outpatient services regulations state that utilization reviews must be conducted for all active cases within the twelfth month after admission and every 90 days thereafter. This is an increase from the utilization review requirements under OMH’s Clinic Treatment Programs regulation (14 NYCRR Section 599.6(l)(2)), which allows for a review of the need for continued treatment in a clinic treatment program within seven months after admission and every six months thereafter. For MHL Article 31 licensed providers operating under the mental health behavioral care host model, OMH will consider a regulatory waiver request pursuant to 14 NYCRR Part 501 to allow flexibility with respect to the frequency of the performance of utilization reviews. OMH is willing to consider a six-month review, consistent with 14 NYCRR Part 599, as the standard in certain cases, if the clinic provider adheres to the requirements of such Part with respect to utilization review, as well as all other pertinent regulatory provisions found in 14 NYCRR Parts 598 and 599. For MHL Article 32 licensed providers operating under the substance use disorder behavioral care host model, the MHL Article 32 certified provider only needs to follow the utilization review requirements under 14 NYCRR Part 822. However, the provider must submit a request pursuant to Mental Hygiene Law using the OASAS PAS-10 form to waive 14 NYCRR § 825(a)(2)(iii)(e). The PAS-10 form can be found here: http://oasas.ny.gov/mis/forms/pas/documents/pas-10.pdf.

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http://oasas.ny.gov/mis/forms/pas/documents/pas-10.pdf

Under the primary care host model, utilization review must be conducted for all active cases within the twelfth month after admission and every 90 days thereafter.

37. Q. Do DOH/OMH/OASAS hosted program requirements change under the integrated outpatient services regulations?

A. Absent other regulations, the host rules continue to apply.

38. Q. How does the new deeming law in effect in outpatient mental health and substance use disorder settings interact with the survey process for integrated services providers?

A. Via the new deeming law, with respect to OMH services, the Joint Commission (TJC) will add a surveyor with knowledge and experience in behavioral health to the hospital survey team to conduct the survey of the outpatient program. OASAS is likewise working on a plan to allow deeming in hospital-based certified outpatient clinics. Once the joint- agency “Integrated Services Surveillance Tool” is finalized, it will be shared with the TJC to be incorporated within their outpatient surveillance functions.

39. Q. What will the fiscal viability review for integrated services clinics involve?

A. Fiscal viability reviews will be conducted for mental health and substance use disorder behavioral care host sites. The review will include the host site’s most recent financial statements and an assessment of whether assets are sufficient relative to liabilities. The outcome of the review will be a determination as to whether the provider’s current fiscal health precludes the clinic from sustaining the provision of integrated outpatient services pursuant to the integrated outpatient services regulations.

Collaborative Care

40. What is Collaborative Care?

A. Collaborative Care is an evidence-based model of behavioral health integration for detecting and treating common mental health conditions such as depression and anxiety in primary care settings. Collaborative Care focuses on defined patient populations tracked in a registry, measurement-based treatment to target. Trained primary care providers and embedded behavioral health professionals provide evidence-based medication and/or psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for patients who are not improving as expected.

41. Q. What is the New York State Medicaid Collaborative Care program?

A. The New York State Medicaid Collaborative Care Program was set up to sustain the work of practices that had implemented Collaborative Care as a part of the DOH Hospital Medical Home Demonstration project which ended in 2014. The Medicaid program provides a monthly case rate payment per patient to practices that are enrolled in this program, as well as ongoing technical assistance and training to the sites.

42. Q. Who are the participants in the Medicaid Collaborative Care Program?

A. Participants in the New York State Medicaid Collaborative Care Program are primarily those that had participated in the Medical Home Demonstration Project and are Article 28 academic medical

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center- affiliated primary care practices. The program also includes some federally qualified health centers (FQHCs).

43. Q. What is the application process for participating in the Collaborative Care initiative?

A. Currently, the New York State Medicaid Collaborative Care Program is not accepting new practices.

44. Q. Who is responsible for oversight under the Collaborative Care initiative?

A. OMH oversees sites participating in the New York State Medicaid Collaborative Care Program. They are required to report data to OMH and meet certain quality outcome standards.

45. Q. What is the difference between Collaborative Care and the IMPACT model?

A. IMPACT is a brand name for the Collaborative Care model. It was called IMPACT in the initial study done on the model which was limited to depression in older adults aged 55 and over, but has since been shown to be effective in treating other conditions, such as anxiety, and in populations other than the Medicare population. OMH uses the broader term “Collaborative Care” to describe the model, which is not limited to a particularly study, but it is still commonly known as IMPACT as reflected in the DSRIP project.

46. Q. How can a provider implement the IMPACT model as part of DSRIP Project 3.a.i?

A. A PPS must have initially selected the IMPACT model as part of its 3.a.i project selection to obtain the project achievement value. For providers, there are many resources available to sites implementing Collaborative Care as a part of DSRIP. DSRIP funding can be used to support education and training from consultants and other technical assistance providers in order to build the team and implement the model. It has been shown to be cost effective by saving money from emergency room usage and hospital readmissions and admissions, and also by improving efficiencies within the practice. The DSRIP program has many resources available including the MAX series on Behavioral Health integration. OMH also encourages sites to partner with other sites in the PPS that are implementing Collaborative Care to learn from their experiences. A PPS and/or its network providers which are not implementing the IMPACT model may want to consider it as part of a future strategy in the context of Value Based Payment given its evidence of improving outcomes and overall impact on medical utilization. The University of Washington AIMS Center is an excellent source for information on the principles of Collaborative Care and provides a guide to implementation. Information is available at: http://aims.uw.edu/collaborative-care

47. Q. Are there plans to grow/expand the Collaborative Care program?

A. At this time, the New York State Medicaid Collaborative Care Program is not accepting new practices. The goal of the program is to gain support for the model in New York State and demonstrate the efficacy of this funding mechanism. A robust evaluation of this program will serve to inform the next iteration of Collaborative Care financing in NYS, as payers transition to Value Based Payment arrangements in the next few years. In addition to the Medicaid Collaborative Care program, efforts are ongoing to enlist commercial payer support of behavioral health integration and Collaborative Care are integral parts of the Advanced Primary Care (APC) standards that practices will begin to implement in 2016. Practice transformation funding and support is available for practices carrying out APC.

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http://aims.uw.edu/collaborative-care

48. Q. If a Psychiatrist wants to see a particular patient due to either non-response or diagnostic question, can that evaluation be billed through the Collaborative Care Model?

A. In the Collaborative Care model, the Psychiatrist does not routinely see patients face to face. In the event that they do, this is separate from Collaborative Care and would be billed the same as any encounter with the Psychiatrist would normally.

49. Q. What are the criteria for admission to the depression monthly case rate model and what are the outcome measures?

A. Any site can implement the Collaborative Care model, but only sites that are part of the New York State Medicaid Collaborative Care program can receive the monthly case rate reimbursement. These sites that are part of this program have been actively providing Collaborative Care for depression in their practice for several years. Participating sites report 11 measures to the NYS OMH on a quarterly basis.

Multiple Licenses

50. Q. How can a provider integrate services using multiple licenses?

A. A provider may opt to pursue the integration of primary care, mental health and/or substance use disorder services by obtaining a license or certificate from each licensing agency (DOH, OMH or OASAS), as appropriate. This is an option, for example, if the provider wishes to exceed the Licensure Thresholds but is not eligible under the integrated outpatient services regulations or does not qualify to use the DSRIP Project 3.a.i Licensure Threshold approach, or wishes to exceed the 49 percent DSRIP Project 3.a.i Licensure Threshold. If two or more licenses/certifications are obtained, the provider must follow the programmatic standards of each licensing agency, as appropriate.

• DOH regulations, including 10 NYCRR Parts 401 and 751, can be found here: https://www.health.ny.gov/regulations/

• OMH regulations can be found here: https://www.omh.ny.gov/omhweb/clinic_restructuring/part599/599.tex t.full.1.9.13.pdf

• OASAS regulations can be found here: https://www.oasas.ny.gov/regs/index.cfm

51. Q. What is the application process for a provider that wishes to integrate services using multiple licenses?

A. The provider must submit an application to and obtain approval from each licensing agency, as appropriate.

• DOH: Certificate of Need (CON) Application or Limited Review Application. More information can be found here: https://www.health.ny.gov/facilities/cons.

• OMH: Prior Approval Review (PAR) or EZ PAR Application. More information can be found here: http://www.omh.ny.gov/omhweb/par/.

• OASAS: Certification Application. More information can be found here: http://oasas.ny.gov/legal/CertApp/capphome.cfm.

52. Q. When a provider has multiple licenses, which state agency is responsible for oversight?

A. Each state agency that licenses or certifies the provider is responsible for oversight of its agency’s regulatory standards.

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https://www.health.ny.gov/regulations/

https://www.omh.ny.gov/omhweb/clinic_restructuring/part599/599.text.full.1.9.13.pdf



https://www.oasas.ny.gov/regs/index.cfm

https://www.health.ny.gov/facilities/cons

http://www.omh.ny.gov/omhweb/par/

http://oasas.ny.gov/legal/CertApp/capphome.cfm

Telehealth

53. Q. Do the integrated outpatient services regulations cover services provided through telemedicine?

A. A provider licensed by OMH pursuant to MHL Article 31 under the mental health behavioral care host model has the ability to utilize telepsychiatry for assessment and treatment services under existing OMH regulations. OMH has issued regulations, effective February 11, 2015, establishing the basic standards and parameters for use of “telepsychiatry” in OMH- licensed clinic programs (14 NYCRR § 599.17). This regulation allows telepsychiatry to be utilized for assessment and treatment services provided by physicians or psychiatric nurse practitioners, from a site distant from the location of a recipient, where both the patient and the physician or nurse practitioner are physically located at clinic sites licensed by OMH (i.e., MHL Article 31 licensed clinic to MHL Article 31 licensed clinic). “Telepsychiatry” is defined as the use of two-way real time-interactive audio and video equipment to provide and support clinical psychiatric care at a distance. Such services do not include a telephone conversation, electronic mail message or facsimile transmission between a clinic and a recipient, or a consultation between two professional or clinical staff.

OASAS is developing guidelines and protocols to support the use of telemedicine in OASAS certified programs, including substance use disorder behavioral care host models. More information will be available in the future.

54. Q. Can a provider licensed by OMH pursuant to MHL Article 31 provide telepsychiatry services in conjunction with a provider licensed by DOH pursuant to PHL Article 28 that adds mental health services under the primary care host model or to a clinic certified by OASAS pursuant to MHL Article 32 that adds mental health services under the substance use disorder behavioral care host model?

A. OMH is continually exploring options to expand the use of telepsychiatry. However, the agency seeks to do so in a manner that utilizes the technology to supplement, not supplant, the need for psychiatric services in areas where there is not only need but a shortage of psychiatry personnel. In short, when contemplating whether telepsychiatry can be used in an “integrated” setting, the answer is dependent upon exactly how the technology is being proposed to be used in such a setting. What OMH is most concerned with is that, since telepsychiatry can be cost-effective, providers may choose to employ this technology as a cost-saving measure before the behavioral health field knows if it is equivalent to in-person psychiatry in terms of its effectiveness. The factors for consideration by OMH would, therefore, include intent of use consistent with the delineated program standards, the need in the setting, and the status of psychiatry recruitment.

55. Q. Is there a billing mechanism for tele-services provided by a clinic licensed by OMH?

A. Once a provider licensed by OMH pursuant to MHL Article 31 has requested and received approval from OMH to provide telepsychiatry, pursuant to 14 NYCRR § 599.17, claims may be submitted for Medicaid fee-for-service and Medicaid managed care reimbursement if the clinic meets the requirements outlined in the “Telepsychiatry Standards Guidance” found here: http://www.omh.ny.gov/omhweb/guidance/telepsychiatry-guidance.pdf Medicaid Managed Care plans are currently required to reimburse clinics at the fee-for-service rates. This requirement will continue through at least the first two years of implementation of Health and

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http://www.omh.ny.gov/omhweb/guidance/telepsychiatry-guidance.pdf

Recovery Plans (HARPs) and the “carve-in” of all behavioral health services into mainstream Medicaid Managed Care plans. The services eligible for Medicaid and Medicaid managed care reimbursement when provided using telepsychiatry are: Initial Assessment, Psychiatric Assessment, Psychiatric Consultation, Crisis Intervention, Psychotropic Medication Treatment, Psychotherapy (Individual, Family, Group, and Family Group), Developmental Testing, Psychological Testing and Complex Care Management. Only physicians, psychiatrists and psychiatric nurse practitioners may deliver Medicaid fee- for-service and Medicaid managed care reimbursable telepsychiatric services. Federal terms relevant for purposes of telepsychiatry reimbursement are “spoke” and “hub.” The term “spoke” refers to the physical location of the patient during a telepsychiatric service. The term “hub” means the physical location of the practitioner during a telepsychiatry service. To constitute a reimbursable service, the patient must be physically present at the clinic in which he/she is already enrolled or is presenting for assessment (i.e., the “spoke”). Medicaid payment policy for telehealth services can be found in the March 2015 Medicaid Update. The Department is in the process of drafting regulations to implement the recently enacted telehealth parity law. OMH has issued regulations on telepsychiatry. Guidance is available here: http://www.omh.ny.gov/omhweb/clinic_restructuring/telepsychiatry.html March 2015 Medicaid Update: http://www.health.ny.gov/health_care/medicaid/program/update/2015/2015-03.htm

56. Q. Do providers licensed by DOH pursuant to PHL Article 28 need approval from DOH to use telehealth modalities?

A. No. A PHL Article 28 licensed provider does not need to apply for permission from DOH to utilize telehealth. Telehealth modalities are viewed as another tool that providers can use to provide services under the existing category on their operating certificate. The New York State Medicaid Program provides coverage for services delivered via telehealth in some settings and by some provider types as described in FAQ #57 and FAQ #58. To obtain Medicaid reimbursement for services delivered via telehealth, an Article 28 provider must comply with Medicaid policy and billing guidance.

57. Q. Is telehealth covered by New York State commercial insurers and the Medicaid Program?

A. Yes, in 2015, telehealth parity legislation was passed that requires commercial insurers and the Medicaid program to provide reimbursement for services delivered via telehealth to the same extent that services would be covered if provided in person. The legislation, which amended Public Health Law, Social Services Law, and Insurance Law, went into effect on January 1, 2016. As defined in PHL Article 29-g, telehealth is the use of electronic information and communication technologies to deliver health care to patients at a distance, which includes the assessment, diagnosis, consultation, treatment, education, care management and/or self- management of a patient. Telehealth is limited to telemedicine (which includes telepsychiatry), store-and-forward, and remote patient monitoring. Telemedicine allows a telehealth provider at a “distant site” to use synchronous, two-way electronic audio visual communications to deliver clinical health care services to a patient at an “originating site.”

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Store and forward technology is the asynchronous, secure electronic transmission of a patient’s health information in the form of patient-specific digital images and/or pre-recorded videos from a telehealth provider at an originating site to a telehealth provider at a distant site. Remote patient monitoring uses synchronous or asynchronous electronic information and communication technologies to collect personal health information and medical data from a patient at an “originating site”; this information is then transmitted to a provider at a “distant site” for use in treatment and management of unstable/uncontrolled medical conditions that require frequent monitoring. Such conditions shall include, but are not limited to, congestive heart failure, diabetes, chronic obstructive pulmonary disease, wound care, polypharmacy, mental or behavioral problems, and technology-dependent care such as continuous oxygen, ventilator care, total parenteral nutrition or enteral feeding. Remote patient monitoring must be ordered and provided by a physician, a nurse practitioner or a midwife, who has examined the patient and with whom the patient has a substantial and ongoing relationship. Patient specific health information and/or medical data may be received at a distant site by means of remote patient monitoring by a registered nurse, licensed pursuant to Education Law. Providers eligible for reimbursement include physicians, physician assistants, dentists, nurse practitioners, podiatrists, optometrists, psychologists, social workers, speech pathologists, physical therapists, occupational therapists, audiologists, midwives, certified diabetes educators, certified asthma educators, genetic counselors, hospitals, home care, and hospices. In addition, a registered nurse may be reimbursed when receiving patient data by means of Remote Patient Monitoring (RPM). Regulations related to Medicaid reimbursement under the telehealth reimbursement law are currently under development.

58. Q. What telehealth services does Medicaid currently cover?

A. Telemedicine (defined as the use of interactive audio and video technology to support real-time patient care) has been covered by Fee for Service Medicaid in specific settings and by specific provider types since September 2006. Coverage was expanded in February 2010, October 2011 and March 2015 to enable greater access to specific provider types in short supply across New York State. http://www.health.ny.gov/health_care/medicaid/program/update/2015/mar15_mu.pdf Regulations pertaining to Medicaid coverage of telehealth services are under development.

Other

59. Q. Are there any other alternatives to support the integration of care?

A. Yes. Staff leasing agreements may be used to help facilitate the provision of integrated care. For example, a clinic licensed by DOH pursuant to PHL Article 28 that would like to provide mental health services could contract with a provider licensed by OMH pursuant to MHL Article 31 for clinical staff to furnish such services on its behalf. The DOH licensed clinic would reimburse the OMH licensed provider for services rendered. The DOH licensed clinic would be financially and legally responsible for the services provided by the OMH licensed provider staff. The DOH licensed clinic also would be the provider of record and responsible for submitting any claims for services rendered.

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http://www.health.ny.gov/health_care/medicaid/program/update/2015/mar15_mu.pdf

In addition, the agencies are working on guidance to be issued shortly for multiple providers that are interested in sharing licensed clinical space and carrying out programmatic activities for purposes of offering integrated services.

Billing – DSRIP Project 3.a.i Licensure Threshold

60. Q. If a provider licensed by DOH pursuant to PHL Article 28 utilizes the DSRIP Project 3.a.i Licensure Threshold in development of a DSRIP project, can such provider provide the mental health and/or substance use disorder services (and bill) with a LMHC, LMFT, etc. as opposed to LCSW-R or PhD staff?

A. A practitioner providing mental health and/or substance use disorder services in a DOH licensed clinic must be a licensed psychiatrist, psychologist, psychiatric nurse practitioner, or an LCSW. Services provided by an LCSW in a DOH licensed clinic are limited to patients who are under age 21 or pregnant women up to 60 days postpartum (based on the date of delivery or end of pregnancy). Licensed mental health counselors, licensed marriage and family therapists, and PhD staff are not recognized providers in the PHL Article 28 licensed setting.

61. Q. Under DSRIP, can a provider request a waiver of 10 NYCRR § 86-4.9 to allow for reimbursement of two visits on one day?

A. No regulatory waiver will be provided. FQHCs that have not opted into APGs operate under the PPS rate. DOH sets the PPS rate using the methodology established under federal law. The PPS methodology, including the “per visit basis,” is established under federal law and DOH does not have the authority to waive federal rules.

62. Under DSRIP Project 3.a.i, Model 1, does the PCP have to submit the claim for a medical service provided by a Behavioral Health provider under their Article 31 or 32? Can Behavioral Health providers bill separately for services within a PC provider site as one of their billing locations?

A. As an Article 28 integrated service provider relative to Model 1 of DSRIP Project 3.a.i, a single APG claim is submitted to Medicaid and all the services provided are reported on the APG claim. The Behavioral Health provider cannot bill separately for services within a Primary Care provider site as one of its billing locations. If a host Article 28 provider is not an integrated services provider AND is contracting with a Behavioral Health provider, the host Article 28 provider would bill for services rendered by the contracted BH provider.

63. Q. Under DSRIP Project 3.a.i, Model 2, does the Behavioral Health provider have to submit the claim for a medical service provided by a PCP under their Article 31 or 32? Can PCPs bill separately for medical services that are provided within a Behavioral Health provider site especially if they add the BH site as one of their billing locations?

A. DSRIP Project 3.a.i Model 2 is an integrated service provider; one APG claim is submitted to Medicaid and all the services provided are reported on the APG claim. The Primary Care Physician cannot bill Medicaid separately.

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64. Q. How should an MHL Article 31 licensed provider bill for the provision of primary care services under the DSRIP Project 3.a.i. Licensure Threshold construct?

A. New rate codes are being established for this purpose. This will involve changing the definition of the hospital-based rate codes 1110 and 1112 to say OMH – HOSP, rather than OMH – OPD to avoid confusion.

Billing – Integrated Outpatient Services Regulations

65. Q. Under the integrated outpatient services regulations, may a provider bill the current mental health patients with the OASAS rates as with the incoming patients seeking mental health services?

A. A licensed or certified provider approved under the integrated outpatient services regulations to provide integrated care services will be issued an integrated services rate code that will be reimbursed through the APGs. All services should be billed under the integrated services rate code.

66. Q. Would an Article 28 facility be eligible for the additional payment for E&M if they are integrating behavioral health?

A. For Article 28 clinics, all services provided should be billed on one claim. The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment.

67. Q. Why do the two E&Ms not apply to a DOH licensed host clinic?

A. NCCI edits apply to hospitals only and not to other providers. However, the Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment.

68. Q. Can you clarify how to bill for a medical service and a BH service on the same day using two separate E&M codes and the 27 modifier? There is a comment that this does not apply to DOH licensed host clinics. What does that mean?

A. Article 28 clinics should bill all services provided on one claim. The Department intends to reimburse for all services submitted on the claim, and is currently working on methodologies to effectuate that payment.

69. Q. What are the behavioral health integrated rate codes? How and when will an agency know what the new integrated APG is their designation?

A. The Department is presently working on activating the DSRIP rate codes. The codes will be assigned to providers as appropriate. Providers will be notified by the department when the codes have been activated. Please see below for DSRIP and Integrated Services rate codes:

• DSRIP rate codes:

• 1102-DOH DTC APG ART 28 INTEGRATED SVC (SINGLE LIC),

• 1104- DOH OPD APG ART 28 INTEGRATED SVC (SINGLE LIC),

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• 1106-OMH DTC APG ART 31 INTEGRATED SVC (SINGLE LIC),

• 1108- OMH DTC APG ART 31 INTEGRATED SVC-SED (SINGLE LIC),

• 1110- OMH OPD APG ART 31 INTEGRATED SVC (SINGLE LIC),

• 1112- OMH OPD APG ART 31 INTEGRATED SVC-SED (SINGLE LIC),

• 1114- OASAS DTC APG ART 32 INTEGRATED SVC (SINGLE LIC),

• 1116-OASAS DTC APG MMTP INTEGRATED SVC (SINGLE LIC),

• 1118- OASAS OPD APG ART 32 INTEGRATED SVC (SINGLE LIC),

• 1120- OASAS OPD APG MMTP INTEGRATED SVC (SINGLE LIC)

• Integrated Services rate codes:

• 1480 - OMH DTC APG ART 31 INTEGRATED SVC (DUAL LIC)

• 1483 - OMH DTC APG ART 31 INTEGRATED SVC-SED (DUAL LIC)

• 1486 - OASAS DTC APG ART 32 INTEGRATED SVC (DUAL LIC)

• 1594 - DOH OPD APG ART 28 INTEGRATED SVC (DUAL LIC)

• 1597 - DOH DTC APG ART 28 INTEGRATED SVC (DUAL LIC)

• 1122 - OMH OPD APG ART 31 INTEGRATED SVC (DUAL LIC)

• 1124 - OMH OPD APG ART 31 INTEGRATED SVC-SED (DUAL LIC)

• 1130 - OASAS DTC APG MMTP INTEGRATED SVC (DUAL LIC)

• 1132 - OASAS OPD APG ART 32 INTEGRATED SVC (DUAL LIC)

• 1134 - OASAS OPD APG MMTP INTEGRATED SVC (DUAL LIC)

70. Q. What are the differences between integrated billing codes 1480 and 1122 “OMH APG Article 31 Integrated Service”?

A. The difference between the two codes (1122 and 1480) is the setting in which the service took place. 1122 is for a hospital outpatient department setting, while 1480 is for D&TC setting.

71. Q. Under the integrated outpatient services regulations, will the mental health services be billable to Medicare under the OASAS billing guidelines?

A. The integrated outpatient services regulations (10 NYCRR Part 404, 14 NYCRR Part 598 and 14 NYCRR 825) apply to Medicaid-only patients. When services are provided to a Medicare/Medicaid dually eligible patient, Medicaid is the secondary payor and defers to the Medicare coverage and payment policy. If the host site is a PHL Article 28 clinic, Medicaid will reimburse providers the lower of the difference between the Medicare paid amount and the Medicaid rate or the Medicare Part B coinsurance amount for integrated care services. If the host site is a MHL Article 31 or MHL Article 32 clinic, Medicaid will pay the difference between the Medicare payment and the Medicaid rate.

72. Q. Under the integrated outpatient services regulations, should all mental health services be billed with all payer sources under the OASAS rates; i.e., Medicaid managed care, insurance, etc.?

A. Medicaid is always the payor of last resort. Providers must bill all commercial insurance prior to billing Medicaid. Medicaid will pay the lower of the third party patient responsibility or the difference between the third party paid amount and the integrated services APG rate.

73. Q. Are OMH behavioral health billing codes used in clinics licensed by DOH pursuant to PHL Article 28 the same as those used in the clinics licensed by OMH pursuant to MHL Article 31?

A. As stated in the response to FAQ #65, approved integrated services providers are assigned APG Medicaid billing rate codes which are to be used by the integrated services provider at the host site.

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74. Q. If a provider licensed by DOH pursuant to PHL Article 28 has been approved to provide integrated services under 10 NYCRR Part 404, can such provider bill for behavioral health services provided by a nurse practitioner?

A. A primary care host model provider approved to provide integrated care services may bill for behavioral health services provided by a nurse practitioner.

75. Q. If a provider licensed pursuant to PHL Article 28 has been approved to add mental health services under 10 NYCRR Part 404, can such provider bill for group psychotherapy services?

A. A primary care host model provider approved to deliver mental health services is reimbursed through APGs. The APG grouper reimburses for individual and group psychotherapy.

76. Q. Under the integrated outpatient services regulations, does a provider licensed by DOH pursuant to PHL Article 28 need to be licensed by OMH in order to bill for mental health services?

A. Upon DOH and OMH approval as an integrated services provider, the primary care host site can bill for mental health services. In the absence of approval to provide integrated care services, the provider licensed by DOH pursuant to PHL Article 28 is limited to the Licensure Thresholds described in FAQ #3.

77. Q. Can a provider certified by OASAS pursuant to MHL Article 32 that has been approved to add mental health services under 14 NYCRR 825 bill for substance use disorder services provided by a licensed social worker?

A. An OASAS certified provider that has been approved to add mental health services under 14 NYCRR 825 can bill for substance use disorder services provided by a licensed clinical social worker or licensed master social worker.

78. Q. Do managed care contracts have to be individually negotiated with each company or are these requirements mandated?

A. Providers treating patients who are in a managed care plan are subject to the contract terms and conditions that have been negotiated with the plan. Some plan contract terms are mandated terms that are the result of requirements in the contract between the state and MCOs (e.g. MCOs must pay OMH licensed and OASAS certified providers at the State rate.)

79. Q. Are managed care plans required to follow both the clinical and billing regulations? If they don’t, then what recourse do facilities have to remedy the situation?

A. Managed care plans are bound by the terms contained in the contract they have with the state. If plans do not follow these requirements, providers and plan members should file all necessary appeals with the managed care plan.

80. Q. If group psychotherapy services can be billed by MHL Article 31 licensed providers, does that mean only an MD can provide these services?

A. Group psychotherapy services billed by a provider licensed by OMH pursuant to MHL Article 31 can be provided by any practitioner recognized under OMH regulations, e.g., licensed psychologist, licensed clinical social worker, licensed master social worker, licensed mental health counselor, etc.

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81. Q. Per Medicare regulations, is a provider licensed by DOH pursuant to PHL Article 28 able to bill for mental health services provided by a licensed clinical social worker?

A. Medicaid will reimburse a provider licensed by DOH pursuant to PHL Article 28 for mental health services provided by a licensed clinical social worker provided to a Medicare/Medicaid dually eligible recipient to the extent permitted by cost sharing statute, i.e., Medicaid will pay full annual Medicare Part B deductible amounts and Medicare Part B coinsurance amounts up to the Medicaid rate.

Billing – Other

82. Q. To what extent can a clinic licensed by DOH pursuant to PHL Article 28 bill for mental health services provided by licensed social workers?

A. Consistent with section 2807(2-a)(f)(ii)(c) of the Public Health Law (PHL), Medicaid reimbursement is available for individual mental health counseling services provided by a licensed clinical social worker (LCSW) or a licensed master social worker (LMSW) under the supervision of a LCSW, psychologist or psychiatrist in PHL Article 28 licensed outpatient hospital clinics (OPDs) and freestanding diagnostic and treatment centers (D&TCs), including school based health centers (SBHCs). Such services, however, are reimbursable only when provided to enrollees under the age of 21 and to pregnant women up to 60 days postpartum (based on the date of delivery or end of pregnancy). In order to qualify as a billable Medicaid service, claims for services rendered to pregnant women are required to have a primary or secondary diagnosis of pregnancy and claims for services rendered to women post-pregnancy are required to have a primary or secondary diagnosis of postpartum depression. LCSW/LMSW Mental Health Counseling Medicaid Rate Codes

Individual mental health counseling services provided by a LCSW or LMSW to enrollees under the age of 21 and to pregnant women up to 60 days postpartum (based on the date of delivery or end of pregnancy) should be billed under the following rate codes (not APGs):

• 4257 (SBHCs 3257) Individual Brief Counseling (psychotherapy which is insight oriented,

behavior modifying and/or supportive, approximately 20-30 minutes face-to-face with the patient).

• 4258 (SBHCs 3258) Individual Comprehensive Counseling (psychotherapy which is insight oriented, behavior modifying and/or supportive, approximately 45-50 minutes face-to-face with patient).

• 4259 (SBHCs 3259) Family Counseling (psychotherapy with or without patient).

Applicability

This policy applies to PHL Article 28 licensed outpatient providers that integrate services under the Licensure Thresholds, DSRIP Project 3.1.i Licensure Threshold or the integrated outpatient services regulations.

Exceptions

Population limits placed on Medicaid reimbursement for mental health counseling provided by LCSWs or LMSWs are not applicable to:

• Dually Licensed Clinics: A dually licensed PHL Article 28 licensed clinic is a clinic that also

possesses a MHL Article 31 license and has the appropriate certification listed on its

20

operating certificate (i.e., “Certified Mental Health O/P”). This certification means that the operator also possesses an MHL Article 31 operating certificate from OMH for the site and is permitted to render any service and/or serve any population authorized under its MHL Article 31 license. A dually licensed provider should bill APGs utilizing Current Procedure Terminology (CPT) codes instead of LCSW/LMSW mental health counseling Medicaid rate codes.

• Federally Designated Health Clinics: A federally designated health clinic means a Federally Qualified Health Center (FQHC), a FQHC “look-alike” (a clinic that meet FQHC requirements but is not receiving a grant under Section 330 of the Public Health Service Act) or a Rural Health Clinic (RHC) that is certified by the Centers for Medicare and Medicaid Services (CMS). Mental health counseling services provided by a LCSW or a LMSW are not subject to population limits (e.g. age) placed on Medicaid reimbursement since such services are covered under the all- inclusive Prospective Payment System (PPS) rate. Federally designated health clinics must bill their all-inclusive PPS rate for individual therapy and a lesser rate per recipient for group therapy. FQHCs can bill one PPS rate for all services on the same day. The FQHC rate codes, which are used by all federally designated health clinics, are:

• 4011 FQHC Group Psychotherapy, or

• 4013 FQHC Individual Threshold Visit

Billing for services rendered at part-time clinics will not be allowed.

• Collaborative Care Program: Collaborative Care is an evidence- based model of behavioral health integration to detecting and treating common mental health conditions such as depression and anxiety in primary care settings. Collaborative Care focuses on defined patient populations tracked in a registry, measurement-based treatment to target. Trained primary care providers and embedded behavioral health professionals provide evidence-based medication and/or psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for patients who are not improving as expected.

As part of the NYS Medicaid Collaborative Care program, participating academic medical center-affiliated primary care practices offer care management services provided by psychiatrists, nurse practitioners, psychologists, LCSWs or LMSWs to patients diagnosed with depression (patients must have a minimal score on an approved psychometric measure). These patients are monitored on a monthly basis for up to 12 months. Care management services provided by a psychiatrist, a nurse practitioner or a psychologist are billable under the APG rates. However, care management services provided by a LCSW or a LMSW are not billable under the APG rates, nor are they billable under the LCSW/LMSW mental health counseling Medicaid rate codes. The services are billable as an indirect part of the collaborative care rate, which is only provided to the academic medical centers that are participating in the collaborative care program. Furthermore, care management services provided by a LCSW or a LMSW may be provided to eligible patients regardless of their age or whether they are pregnant.

83. Q. If a clinic is dually licensed as Article 28 D&TC and Article 31, can the patient receive billable services from the D&TC and the Mental Health Clinic on the same day?

A. If a patient was seen in an Article 28 and Article 31 on the same day, both clinics can bill Medicaid.

21

47:



Section 6:

Billing for Integrated Care

Services

S.6


Paid? Credentials Paid? Code Credentials

Physician, NP, PA,

CNS, Clinical

Psychologist,

Clinical Social

Worker

Yes90791 GT Psych eval

w/o medical services Psychiatrist,

Clinical

Psychologist

No

State: New York, July 2014

CPT CodeDiagnostic

Code

Community Health Center

Medicare State Medicaid

Comments

99201-99205

New Pt MD, PA, ANP

99211 - 99215

Est. Pt.

99211 - 99215

Est. Pt.

Yes

Health and

Behavior

(HABI)

96150

Assessment

Services are

secondary to

a physical

health

diagnosis

Yes

PhD

Psychologist at

this time;

excludes

LMSW

E & M

Codes

99201-99205

New Pt May be used

for behavioral

health or

physical health

services

Yes MD, PA, ANP

96154 Family TX

w/ PTYes

96155 Family TX

w/o PTNo

96151

ReassessmentYes

96152 Individual

TXYes

96153

Group TXYes

Yes

96150 Assessment

96151

Reassessment

96152 Individual

TX

96153

Group TX

96154 Family TX

w/ PT

96155 Family TX

w/o PT

90792 Psych eval w/

medical services

90832-38 GT

Therapy Services

Psychiatrist, CNP,

Clinical

Psychologist,

Clinical Social

Worker

Yes90832-38 GT

Therapy Services

Physician, NP, PA,

Nurse-Midwife, CNS,

Psychologist, Clinical

Social Worker

Tele-

medicine

90791 GT Psych eval

w/o medical

services

Psychiatric

diagnosisYes

90792 Psych eval w/

medical services

Physician, NP,

PA, CNS

99201-99215 Office

or other OP services

Both MH & PH

diagnosisYes

Physician, NP,

PA, CNS

Alcohol &

Substance

Services

G0442 GT Annual

Alcohol Misuse

Screen

1 per year

Yes

Physician,

Clinical Nurse

Specialist,

Certified Nurse-

Wife, NP, PA

Yes

99201-99215 GT

Office or other OP

services Physician,

96150-54 HABI

Codes

Physical health

diagnosis

NoPhysician,

Clinical Nurse

Specialist,

Certified Nurse-

Wife, NP, PA

No

G0459 GT

Pharmacological

Management No

NoG0443 GT Brief Face

to Face Counseling

for alcohol misuse

4- 15 minute

interventions

within the 11

G0406-G0408 GT

Inpatient

Consultation

Yes

G0444 Annual

Depression

Screening

Use GT for

Telemedicine;

See Behavioral

Health section

Physician, Nurse,

PA

No

Non-physician

mental Health

practitioners

Hub and Spoke Eligible sites:

Article 28 hospitals, Diagnostic &

Treatment Centers, FQHC's that

have opted into APG's. The

patient must be physically

present at the originating

"spoke" site; the physician

specialist and/or CDE/CAE is

located at the "hub" site. The

physician specialist at the "hub"

site, who is performing the

consult, must be licensed in New

York State, enrolled in New York

State Medicaid and be

credentialed and privileged at

both the "hub" and "spoke" site

hospital and/or D&TC.

Psychiatrist

Substance Use

Codes / SBIRT

G0442 Annual

Alcohol Misuse

Screen

1 per year H0001 - AOD

Assessment

Yes H0002 BH Screen

H0004 BH

Counseling H0005

AOD Group

Yes

SBIRT

Yes -with Medicare and specific providers w/ grants

Paid? Credentials Paid? Code Credentials

G0446 Behavioral

Counseling for

cardiovascular

Physician, Clinical

Nurse Specialist,

Certified Nurse-

Physician or

certified

provider

G0444 Annual

Depression

Screening

Use GT for

Telemedicine;

See Behavioral

Health section

Physician, Nurse,

PA

NoG0447 Behavioral

Counseling for

Obesity

Physician, NP,

PA

G0436-37, 99406-

07 Smoking

Cessation

Health, Obesity

and Tobacco

Counseling (Face

to Face &

Telemedicine

G0108, G0109 Ind-

Group Diabetes

Tx

Two services in one day billable at FQHC?

90792 Psych eval w/

medical services

90832-38 Therapy

Services

Physician, NP,

PA

90832-38 Therapy

Services

Psychiatrist, PA,

APRN, Clinical

Psychologist, LCSW

Physician,

Clinical Nurse

Specialist,

Certified Nurse-

Wife, NP, PA

YesG0443 Brief Face to

Face Counseling for

alcohol misuse

4- 15 minute

interventions

within the 11

months after a

positive

screening

90791 Psych eval

w/o medical services

Psychiatrist, PA,

APRN, Clinical

Psychologist, LCSW

90792 Psych eval w/

medical services

Psychiatrist, PA,

APRN, Clinical

Psychologist

there can be 2 encounters for different types of visits on the same day (ex: physician and social worker)

CPT CodeDiagnostic

Code

Community Mental Health Centers (CMH)

Medicare State Medicaid

Comments

H0031 Mental

Health Assessment

No90863 Group

Therapy

H2011 Crisis

Intervention

T1017 Case

ManagementNo

Physician, NP,

PA, CNS,

Psychologist,

LCSW

Mental

Health

90791 Psych eval

w/o medical

services

Use with BH

diagnosis

codes

Billable in and

by primary

care clinics -

check your

state's FQHC

manual for

billability in

your state.

Physician, NP,

PA, CNSYes

99201-99205

New Pt MD, PA, Certified

NP

99211 - 99215

Est. Pt.

99211 - 99215

Est. Pt.

E & M

Codes

99201-99205

New Pt May be used

for behavioral

health or

physical health

services

Yes MD, PA, ANP Yes

Hub and Spoke Eligible sites:

Article 28 hospitals, Diagnostic &

Treatment Centers, FQHC's that

have opted into APG's. The

patient must be physically

present at the originating

"spoke" site; the physician

specialist and/or CDE/CAE is

located at the "hub" site. The

physician specialist at the "hub"

site, who is performing the

consult, must be licensed in New

York State, enrolled in New York

State Medicaid and be

credentialed and privileged at

both the "hub" and "spoke" site

hospital and/or D&TC.

G0444 Annual

Depression

Screening

H0004 AOD Ind Tx

H0005 AOD Group

Health and

Behavior

(HABI)

96150

Assessment

Services are

secondary to

a physical

health

diagnosis

Yes

PhD

Psychologist at

this time;

excludes

LMSW

No

Tele-

medicine

90791 GT Psych eval

w/o medical

services

Psychiatric

diagnosisYes

90832-38 GT

Therapy Services

No

96151

ReassessmentYes

96152 Individual

TXYes

96153

Group TXYes

96154 Family TX

w/ PTYes

Psychiatrist, CNP,

Clinical

Psychologist,

Yes

90791 GT Psych eval

w/o medical services Psychiatrist

90792 GT Psych eval

w/ medical services

Psychiatrist,

CNP, CNS90792 GT Psych eval

w/ medical services

Psychiatrist

96155 Family TX

w/o PT

Psychiatrist, NP, PA

96150-54 GT HABI

Codes

Physical health

diagnosis

NoNoG0459 GT

Pharmacological

ManagementG0406-G0408 GT

Inpatient

Consultation

Yes

Psychiatrist, CNP,

Clinical

Psychologist,

Clinical Social

Worker

Yes90832-38 GT

Therapy Services

Physician, NP, PA,

Nurse-Midwife, CNS,

Psychologist, Clinical

Social Worker

99201-99215 GT

Office or other OP

services

Both MH & PH

diagnosisYes

Physician, NP,

PA, CNS

Yes99201-99215 GT

Office or other OP

services

Alcohol &

Substance

Services

G0442 GT Annual

Alcohol Misuse

Screen

1 per year

Yes

Physician,

Clinical Nurse

Specialist,

Certified Nurse-

Wife, NP, PA

NoHealth, Obesity

and Tobacco

Counseling

(Telemedicine

and Face to

Face)

Codes are

reimbursed by

Medicare and

other insurances

in a primary

clinic. Use GT

for telemedicine

Yes

Physician,

Clinical Nurse

Specialist,

Certified Nurse-

Wife, NP, PA,

LMSW, LP

G0436-37, 99406-

07 Smoking

Cessation

G0443 GT Brief Face

to Face Counseling

for alcohol misuse

4- 15 minute

interventions

within the 11

G0446 Behavioral

Counseling for

cardiovascular disease

G0442 Annual

Alcohol Misuse

Screen

1 per year in a

primary care

clinic

Yes

Physician,

Clinical Nurse

Specialist,

Certified Nurse-

Wife, NP, PA

G0108, G0109 Ind-

Group Diabetes Tx

Yes

Physicians, NP, LP,

LLP, CSWSubstance Use

Codes / SBIRT

H0001 AOD Assessment

H0002 BH Screening

H0038 Peer

Support Group

Services

References:

FQHC Information: https://www.emedny.org/meipass/webinar/EPFQHCMEIPASSWalkthrough.pdf

Mental Health Psychiatry / E&M https://www.emedny.org/providermanuals/physician/PDFS/Physician_Procedure_Codes_Sect2.pdf

Mental Health SW: https://www.emedny.org/ProviderManuals/ClinicalSocWork/PDFS/ClinicalSocialWorker_Fee_Schedule.pdf

Mental Health Pscyhologist:https://www.emedny.org/ProviderManuals/CMCM/PDFS/CMCM_Billing_Guidelines_UB04.pdf

No

Yes

Physician,

Clinical Nurse

Specialist,

Certified Nurse-

Wife, NP, PA

Yes

Physicians, NP, LP,

LLP, CSW

G0443 Brief Face to

Face Counseling for

alcohol misuse

4- 15 minute

interventions in a

primary care clinic

within the 11

months after a

positive screening

Yes

Physician, NP,

PA, CNS

Clinical Social

Worker, NP Clinical Social Worker can only

use 90834 and 90837 90785 -

Interactive complexity can be

added on

H0031 Mental

Health Assessment

90863 Group

TherapyYes

90791 Psych eval

w/o medical services Psychiatrist, NP

90792 Psych eval w/

medical services

90792 Psych eval w/

medical services Psychiatrist

90832-38 Therapy

Services

Physician, NP,

PA, CNS,

Psychologist,

LCSW

90832-36, 90853

5250-5259 CSM

Case Manager

Qualifications -

Master's or

Bachelor's degree in

health, human or

education services,

and one

year of qualifying

experience; or

Associate's degree in

health or human

services or

certification as an

Substance Use

Codes / SBIRT

Medicare Billing Information www.cms.gov

Medicare Telemedicine: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Telemedicine: https://www.emedny.org/providermanuals/physician/PDFS/Physician_Procedure_Codes_Sect2.pdf

Mental Health CSM: https://www.emedny.org/ProviderManuals/CMCM/PDFS/CMCM_Billing_Guidelines_UB04.pdf

Must be pre-approved for

varying levels of case

management

Peer

Support

H0038 Peer

SupportNo

H0038 Peer Services,

Ind & Group (HQ),

Whole Health &

Wellness Coach

H2011 Crisis

Intervention

T1017 Case

Management

NoT1016 Supports

Coordination

Mental

Health

90791 Psych eval

w/o medical

services

Use with BH

diagnosis

codes

48:



Section 7:

Training

S.7


49:



DSRIP Project 3ai – Primary and Behavioral Health Integration Module Overview: This module provides a comprehensive look at the process of primary and behavioral health integration. The modules

progress though understanding the core concepts related to integrating services, and the prevailing models on integration and their relation to

population health, to preparing for integration, and finally to full implementation and documentation. Participants will gain a full understanding

of the potential of this type of integration to improve the health outcomes of patients, and what the steps will be to work towards this

integration.

To access the trainings, please click on the links below and enter the following username and password when prompted:

Password: coe2016

Topic Description Learning Objectives Audience Core Curriculum

Basics of Integrated Care

This module prepares the audience to understand the core concepts related to integrating behavioral health services into a primary care setting

Describe the population based goals of integrated care

Describe the continuum of integrated care

Name the core competencies for providers in an integrated care approach

All (includes any clinical and/or

administrative personnel)

https://suffolkcare.org/forpartners/learning-center

Basics of Bidirectional Integrated Care

This module prepares the audience to understand the core concepts related to integrating primary care services into a behavioral health setting

Describe the basic parameters of bidirectional programs

Identify the common goals of bidirectional interventions

Identify the core factors that make bidirectional programs effective

All



http://integratedcare.talentlms.com/






50:



Primer on Evidence Based Models of Integrated Care

This module prepares the audience to understand the current prevailing models of integrated care and their relationship to constructs such as “level of integrated care” and “population penetration.”

Name and describe the three prevailing models of integrated care

Describe the meaning behind the constructs of levels of integration and population penetration

Describe the difference between models and programs

All


Rating Your Level of Integrated Care Using the MeHAF

This module prepares the audience to learn how to self administer the MeHAF tool which is used to rate a site’s level of integration.

Describe the team members required for self-administering the MeHAF

Describe the core competencies of the MeHAF

Self-administer the MeHAF rating scale

Site-specific personnel

who will participate in self-rating


Primer on Screening for Integrated Care

This module provides an introduction to the concept of screening as it pertains to integrated care efforts including the different uses of screening tools and key implementation concerns.

Identify the typical tools used in primary care

Describe the concepts of screening, assessment and tracking

Describe implementation considerations for establishing screening pathways

Clinical staff












51:



Working with BHCs: The Warm Hand-Off

This module provides primary care providers with basic language and understanding of how to effectively provide a warm handoff of a patient to a behavioral health consultant.

Describe the function of a warm handoff

Describe the strategies often used to manage flow in a primary care setting

Describe a sample introduction that a primary care provider can use to introduce services to a patient

Clinical staff


Documentation for Primary Care

This module provides an exemplar of effective standard practices for documenting for the primary care record. Although North Carolina standards are referenced the core concepts are applicable across different state settings.

Describe the components of a primary care specific SOAP note

Describe elements that do not belong in a primary care record

Describe regulatory parameters that may influence the content of a SOAP note

Behavioral health staff


Primer on the Primary Care Consult

This module provides behavioral health consultants with a framework for how to structure consults with patients in primary care in a 15 to 30 minute modality.

Describe the core components of a typical consult

Describe the content of an effective introduction

Describe the content of an effective functional analysis

Behavioral health staff












52:




This module provides an overview of one of the three prevailing models of integrated care, the primary care behavioral health model.

Describe the core attributes of the PCBH model

Describe the goals and core metrics of a PCBH service

Describe the core competencies of a BHC in this model

All


Registry Basics This module provides the audience an overview of the use of and rationale for registries in managing patient populations.

Describe the difference between a spreadsheet and a database

Describe the way in which registries are used to manage care

Describe considerations for implementing a registry based care pathway

Clinical staff


Improving Screening and Identification in Pediatric Practices

This module provides the audience with a strategy for identifying pediatric patients who are at risk of behavioral health issues.

Name the percentage of children who have identifiable behavioral health conditions

Describe the components of the AAP Mental Health Toolkit

Describe the elements to consider when implementing screening

Clinical staff












53:



Primer on Pediatric Consults for Primary Care

This module provides the audience with basic strategies for structuring a pediatric primary care behavioral health consult.

Describe the areas where primary care consultation can be effective

Describe the strategies for engaging pediatric patients

Describe the core competencies of a pediatric behavioral health consultant

Clinical staff






54:



Section 8:

PCHM Certification Program

Alignment Summary

S.8


55:



DSRIP Projects – PCMH Standard Overlap Guide: Behavioral Health Integration

DSRIP Protocols PCMH Standards

Medication Management (01)

2D (Must Pass) ) (Team-based Care) 3E (Population Health, Evidence-Based Decision Support) 4A; 4C; 4E (Care Management & Support) 6A (Performance Measurement & QI)

Screening (03)

PHQ-2, PHQ-9, Audit C, DAST-10, CRAAFT

2D (Must Pass) ) (Team-based Care) 3C9; 3D (Must Pass) (Population Health, Depression tool) 4A1 (Care Management & Support)

Warm Handoff (04)

Embedded behavioral health professional

2D (Must Pass) ) (Team-based Care) 4E (Care Management & Support –Self Care & Shared Decision Making) ) 5B (Must Pass) (Care Coordination & Care Transitions – Referral Tracking & F/U)

5 Components of IMPACT(06)

Collaborative care

Depression Care Manager

Designated Psychiatrist

Outcome Measurement

Stepped care

22D (Must Pass) ) (Team-based Care) 3C; 3E (Population Health – Comprehensive Assessment, Evidence-Based) 4A; 4B (Must Pass); 4C; 4E (Care Management & Support) 5B (Must Pass) (Care Coordination & Care Transitions – Referral Tracking & F/U) 6A (Performance Measurement & QI)

Psychiatrist SOW (07)

2D (Must Pass) ) (Team-based Care) 4A (Care Management & Support, Identify Patient for Care Management) 5B (Must Pass) (Care Coordination & Care Transitions – Referral Tracking & F/U)

Depression Care Manager SOW (08)

2D (Must Pass) (Team-based Care) 3D (Must Pass) Factor 5 (Medication monitoring/alert)

Stepped Care Algorithm (09)

3 Steps

2D (Must Pass) (Team-based Care) 3E (Population Health, Evidence-Based Decision Support) 4A; 4C (Care Management & Support - Identify Patient for Care Management; Medication Management) 5B (Must Pass) (Care Coordination & Care Transitions – Referral Tracking & F/U)

Relapse Prevention (10)

Depression Care Manager oversight

4E (Care Management & Support – Self Care & Shared Decision Making)


56:



Primary & Behavioral Health Integrated Care Program Patient Centered Medical Homes (PCMH)

Alignment Summary

Project Requirement

Metric/Deliverables PCMH Standard

Co-locate behavioral health services at primary care practice sites (Model 1) Co-locate primary care services at behavioral health sites (Model 2)

Behavioral health services are co-located within the PCMH/APC practices and are available (Model 1) Primary care services are co-located within behavioral health practices and are available (Model 2)

Standard 5B - Referral Tracking and Follow-Up 5.B.4. The practice integrates behavioral health care providers within the practice site

Develop collaborative evidence-based standards of care, including medication management and care engagement processes (Models 1 and 2)

Coordinated evidence-based care protocols are in place, including medication management and care engagement processes

Standard 4C - Medication Management Standard 4E - Support Self-Care and Shared Decision Making

Conduct preventive care screenings, including behavioral health screenings (PHQ-2 or 9, and for those screening positive, SBIRT) implemented for all patients to identify unmet needs (Models 1 and 2)

Policies and procedures are in place to facilitate and document completion of screenings

Standard 3C - Comprehensive Health Assessment 3.C.9. The practice collects and regularly updates a comprehensive health assessment that includes depression screening for adults and adolescents using a standardized tool Standard 4A - Care Management and Support 4.A.1. The practice establishes a systematic process and criteria for identifying patients who may benefit from care management, including behavioral health conditions


57:




At least 90% of patients receive screenings at the established project sites



Positive screenings result in "warm transfer" to behavioral health provider as measured by documentation in EHR



58:



Use EHRs and other technical platforms to track all patients engaged in the project (All Models)

PPS identifies target patients and is able to track actively engaged patients for project milestone reporting [ACTIVELY ENGAGED DEFINITION: Model 1 - The total number of patients receiving appropriate preventive care screenings that include mental health/substance abuse; Model 2 - The total number of patients receiving primary care services at a participating mental health or substance abuse site; Model 3 - The total number of patients screened using the PHQ-2 or 9 / SBIRT]

Standard 3D - Use Data for Population Health Management At least annually the practice proactively identifies populations of patients and reminds them of needed care, including for: 3.D.1. Two different preventive care services 3.D.3. Three different chronic disease or acute care services 3.D.4. Patients not recently seen by the practice 3.D.5. Medication monitoring or alert

Implement IMPACT model at primary care sites (Model 3)

PPS has implemented IMPACT model at primary care sites

The IMPACT model helps satisfy PCMH factors under the following Standards: Standard 2D - The Practice Team Standard 3C - Comprehensive Health Assessment Standard 3E - Implement Evidence-based Decision Support Standard 4A - Identify Patients for Care Management Standard 4B - Care Planning and Self-Care Support Standard 4C: Medication Management Standard 4E - Support Self-Care and Shared Decision Making Standard 5B - Referral Tracking and Follow-up Standard 6 - Performance Measurement and Quality Improvement


59:



Utilize IMPACT model collaborative care standards, including developing coordinated evidence-based care standards and policies and procedures for care management (Model 3)

Coordinated evidence-based care protocols are in place, including medication management and care engagement process to facilitate collaboration between primary care physician and care manager

Standard 3E - Implement Evidence-Based Decision Support 3.E.1. The practice implements clinical decision support following evidence-based guidelines for a mental health or substance abuse disorder Standard 4C - Medication Management 4.C.1. Reviews and reconciles medications for more than 50% of patients received from care transitions 4.C.3. Provides information about new prescriptions to more than 80% of patients 4.C.4. Assesses understanding of medications for more than 50% of patients 4.C.5. Assesses responses to medications for more than 50% of patients, and dates the assessment 4.C.5. Assesses responses to medications and barriers to adherence for more than 50% of patients, and dates the assessment


60:



Utilize IMPACT model collaborative care standards, including developing coordinated evidence-based care standards and policies and procedures for care management (Model 3)

Policies and procedures include process for consulting with Psychiatrists

Standard 3E - Implement Evidence-Based Decision Support 3.E.1. The practice implements clinical decision support following evidence-based guidelines for a mental health or substance abuse disorder Standard 4C - Medication Management 4.C.1. Reviews and reconciles medications for more than 50% of patients received from care transitions 4.C.3. Provides information about new prescriptions to more than 80% of patients 4.C.4. Assesses understanding of medications for more than 50% of patients 4.C.5. Assesses responses to medications for more than 50% of patients, and dates the assessment 4.C.5. Assesses responses to medications and barriers to adherence for more than 50% of patients, and dates the assessment

Employ a trained Depression Care Manager meeting requirements of IMPACT model (Model 3)

PPS identifies qualified Depression Care Manager (nurse, social worker or psychologist) as identified in EHR

Standard 2D - The Practice Team 2.D.5. Training and assigning members of the care team to coordinate care for individual patients 2.D.6. Training and assigning members of the care team to support patients in self-management, self-efficacy, and behavior change


61:



Employ a trained Depression Care Manager meeting requirements of IMPACT model (Model 3)

Depression care manager meets requirements of IMPACT model, including coaching patients in behavioral activation, offering courses in counseling, monitoring depression symptoms for treatment response, and completing a relapse prevention plan

Standard 2D - The Practice Team 2.D.5. Training and assigning members of the care team to coordinate care for individual patients 2.D.6. Training and assigning members of the care team to support patients in self-management, self-efficacy, and behavior change

Designate a Psychiatrist meeting the requirements of the IMPACT model (Model 3)

All IMPACT participants in PPS have a designated Psychiatrist

Element 5B - Referral Tracking and Follow-up 5.B.2. Maintains formal and informal agreements with a subset of specialists based on established criteria 5.B.3. Maintains agreements with behavioral health care providers 5.B.4. Integrates behavioral health providers within the practice site 5.B.9. Documents co-management arrangements in the patient's medical record

Measure outcomes as required in the IMPACT model

At least 90% of patients receive screenings at the established project sites

Standard 3C - Comprehensive Health Assessment To get credit for documenting behaviors affecting health under Standard 3.C.6., practices must indicate that data was entered for more than 50% of the time

Provide "stepped care" as required by the IMPACT model (Model 3)

In alignment with IMPACT model, treatment is adjusted based on evidence-based algorithm that includes evaluation of patient 10-12 weeks after the start of treatment plan.

Standard 3E - Implement Evidence-Based Decision Support 3.E.1. The practice implements clinical decision support following evidence-based guidelines for a mental health or substance abuse disorder


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Section 9:

Resources

S.9


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Additional Resources Please find additional program resources to answer further questions that you may have:

Agency for Healthcare Research and Quality (AHRQ) AHRQ Guide to Clinical Preventative Services, Measures: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html AHRQ Guideline Clearinghouse: http://www.guideline.gov/ Adult Depression in Primary Care https://www.guideline.gov/summaries/summary/47315/adult-depression-in-primary-care Playbook https://integrationacademy.ahrq.gov/playbook/about-playbook Creating Patient-centered Team-based Primary Care https://pcmh.ahrq.gov/sites/default/files/attachments/creating-patient-centered-team-based-primary-care-white-paper.pdf

Advancing Integrated Mental Health Solutions (AIMS) Center Resource Library https://aims.uw.edu/resource-library Commonly Prescribed Psychotropic Medications https://aims.uw.edu/resource-library/commonly-prescribed-psychotropic-medications Supporting Antidepressant Medication Therapy https://aims.uw.edu/resource-library/supporting-antidepressant-medication-therapy

Center for Integrated Healthcare Primary Care-Mental Health Integration Co-Located, Collaborative Care: An Operations Manual http://www.mentalhealth.va.gov/coe/cih-visn2/Documents/Clinical/Operations_Policies_Procedures/MH-IPC_CCC_Operations_Manual_Version_2_1.pdf

Greater New York Hospital Association (GYNA) Collaborative Care Teaching Guide http://files.ctctcdn.com/b450ac0d401/8d432195-db5b-4bda-a866-cec98736d738.pdf?ver=1459273593000





https://integrationacademy.ahrq.gov/playbook/about-playbook

https://pcmh.ahrq.gov/sites/default/files/attachments/creating-patient-centered-team-based-primary-care-white-paper.pdf

https://pcmh.ahrq.gov/sites/default/files/attachments/creating-patient-centered-team-based-primary-care-white-paper.pdf

https://aims.uw.edu/resource-library

https://aims.uw.edu/resource-library/commonly-prescribed-psychotropic-medications

https://aims.uw.edu/resource-library/supporting-antidepressant-medication-therapy

http://www.mentalhealth.va.gov/coe/cih-visn2/Documents/Clinical/Operations_Policies_Procedures/MH-IPC_CCC_Operations_Manual_Version_2_1.pdf



http://files.ctctcdn.com/b450ac0d401/8d432195-db5b-4bda-a866-cec98736d738.pdf?ver=1459273593000

http://files.ctctcdn.com/b450ac0d401/8d432195-db5b-4bda-a866-cec98736d738.pdf?ver=1459273593000

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IMPACT (Model 3) IMPACT main page: http://impact-uw.org/ IMPACT manual: http://impact-uw.org/files/IMPACT_Intervention_Manual.pdf Implementation guide: https://aims.washington.edu/sites/default/files/CollaborativeCareImplementationGuide.pdf AIMS Center https://aims.uw.edu/ Aims Center – Collaborative Care https://aims.uw.edu/collaborative-care

Million Hearts Campaign Million Hearts Treatment Protocols: http://millionhearts.hhs.gov/tools-protocols/protocols.html

Monroe County Medical Society Community-wide Guidelines, Major Depressive Disorder http://www.mcms.org/community-guidelines

National Council for Behavioral Health Educational Video Series on Integrated Care Motivational Interviewing – March 25, 2016 (5:17)

Warm Handoff – Anxiety – March 25, 2016 (5:58)

Morning Huddle – March 25, 2016 (4:07)

Brief Intervention – March 25, 2016 (5:50)

NCQA NCQA HEDIS Measures http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality.aspx NCQA HEDIS main page: http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx

New York State Department of Health

Frequently Asked Questions (FAQs) Approaches to Integrated Care - Clean - Updated August 12, 2016

Frequently Asked Questions (FAQs) Approaches to Integrated Care - Redline - August 12, 2016 (PDF, 243KB)

Integrated Services Overview Webinar - July 14, 2016 (youtube.com)


http://impact-uw.org/

http://impact-uw.org/files/IMPACT_Intervention_Manual.pdf

https://aims.washington.edu/sites/default/files/CollaborativeCareImplementationGuide.pdf

https://aims.uw.edu/

https://aims.uw.edu/collaborative-care

http://millionhearts.hhs.gov/tools-protocols/protocols.html

http://www.mcms.org/community-guidelines

https://www.youtube.com/watch?v=GpSU7zMZ6xA

https://www.youtube.com/watch?v=pkKZ4e0iUqg

https://www.youtube.com/watch?v=-8lDsdru0Hs

https://www.youtube.com/watch?v=T4EFmjw7Epc



http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2016/2016-01_integrated_care_faqs.htm

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2016-08-12_integrated_care_faqs_redln.pdf

https://youtu.be/csOomn43oWI

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Integrated Services Overview Webinar - July 14, 2016 (PDF, 722KB) Integrated Services Webinar - January 26, 2016 (youtube.com) Integration of Primary Care and Behavioral Health Services - January 26, 2016 (PDF) Billing Matrix - March 18, 2016 (PDF)

Shared Space Guidance https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/reg_flex_guide_res_prog_stat_waiver_resp_approvals.htm

Screening Tools

Patient Health Questionnaire -2 (PHQ-2)

Patient Health Questionnaire -9 (PHQ-9)

Alcohol Use Disorders Identification Test (Audit C)

Drug Abuse Screening Test (DAST-10)

Car, Relax, Along, Forget, Friends, Trouble (CRAAFT)

Pediatric Symptom Checklist (PSC-Y)

Pediatric Symptom Checklist - Youth Self Report (PSC-17)

New York State Department of Health Administering the Patient Health Questionnaires 2 and 9 (PHQ 2 and 9) in Integrated Care Settings (clean) – July 1, 2016 (PDF)

Substance Abuse and Mental Health Services Administration (SAMSHA) SAMHSA Website https://www.samhsa.gov/ National Directory of Mental Health Treatment Facilities (2016) https://www.samhsa.gov/data/sites/default/files/2016%20National%20Directory%20of%20Mental%20Health%20Treatment%20Facilities.pdf HRSA Center for Integrated Health Solutions, Behavioral Health and Patient-Centered Medical Homes http://www.integration.samhsa.gov/integrated-care-models/behavioral-health-in-primary-care#Behavioral Health and Patient Centered Medical Homes HRSA Center for Integrated Health Solutions, Integrated Care Models http://www.integration.samhsa.gov/integrated-care-models HRSA Center for Integrated Health Solutions, Screening Tools http://www.integration.samhsa.gov/clinical-practice/screening-tools#drugs


http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2016-07-14_integrate_serv_webinar.pdf

https://youtu.be/jOanGi7Lyjk

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2016-01-26_integrate_serv_webinar.pdf

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2016-03-18_billing_matrix.pdf

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/reg_flex_guide_res_prog_stat_waiver_resp_approvals.htm

https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/reg_flex_guide_res_prog_stat_waiver_resp_approvals.htm



http://www.integration.samhsa.gov/images/res/tool_auditc.pdf

http://www.bu.edu/bniart/files/2012/04/DAST-10_Institute.pdf

http://www.ceasar-boston.org/CRAFFT/pdf/CRAFFT_English.pdf

http://www.massgeneral.org/psychiatry/assets/PSCY-35_English.PDF

http://www.prohealthmd.com/windhampediatrics-dev/wp-content/uploads/sites/25/2015/01/PSC-17.pdf

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2016-07-01_phq_2_and_9_clean.pdf

http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/docs/2016-07-01_phq_2_and_9_clean.pdf

https://www.samhsa.gov/

https://www.samhsa.gov/data/sites/default/files/2016%20National%20Directory%20of%20Mental%20Health%20Treatment%20Facilities.pdf

https://www.samhsa.gov/data/sites/default/files/2016%20National%20Directory%20of%20Mental%20Health%20Treatment%20Facilities.pdf



http://www.integration.samhsa.gov/integrated-care-models

http://www.integration.samhsa.gov/clinical-practice/screening-tools%23drugs

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2016 National Directory of Mental Health Treatment Facilities http://www.samhsa.gov/data/sites/default/files/2016%20National%20Directory%20of%20Mental%20Health%20Treatment%20Facilities.pdf The Integration Edge https://integrationedge.readz.com/home

Training Module & Curriculum References Integrated Behavioral Health Partners, Referrals, Handoffs, and Good-bys http://www.ibhpartners.org/get-started/client-experience-toolkit/referrals-handoffs-and-good-byes/


http://www.samhsa.gov/data/sites/default/files/2016%20National%20Directory%20of%20Mental%20Health%20Treatment%20Facilities.pdf

http://www.samhsa.gov/data/sites/default/files/2016%20National%20Directory%20of%20Mental%20Health%20Treatment%20Facilities.pdf

https://integrationedge.readz.com/home


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