Innovative Program Provides MH Care to Thousands

As large health systems undergo broad-scale implementations of the Collaborative Care Model, innovations are cropping up in response to some of the challenges associated with integrating behavioral health care into primary care. In this month’s issue, learn how Penn Medicine’s Penn Integrated Care (PIC) initiative created a centralized Resource Center to assess and triage a large volume of patients—more than 11,000 people in six months—especially those who need more specialized services than can be provided in primary care. —Jürgen Unützer, M.D., M.P.H.

Mental health and substance use disorders are a leading cause of disease burden in the United States and a major driver of health care costs. Most people who get mental health care do so through primary care, and less than half of those referred to specialty psychiatric care follow through.

The Collaborative Care Model (CoCM) is recognized as the preeminent, evidence-based approach to integrating mental health care and primary care. CoCM improves clinical outcomes, increases provider satisfaction, and reduces health care costs. Primary care providers (PCPs) using CoCM can now be reimbursed through new CoCM billing codes, initially adopted by Medicare in 2017 and subsequently codified by CPT for other payers to adopt.

Penn Medicine, a large health system serving a diverse population, has succeeded in an innovative, broad-scale implementation of CoCM through an initiative called Penn Integrated Care (PIC). The program is financially sustainable through the new CoCM reimbursement codes.

How Does the Program Work?

PIC began in eight primary care practices in January 2018. Referrals are made to PIC in one of three ways: a warm handoff in the primary care practice to an embedded mental health provider (MHP), an electronic order to the PIC Resource Center, or proactive identification of those with high-risk comorbidities, such as uncontrolled diabetes and depression. In most cases, patients are referred to the telephonic Resource Center, staffed by trained intake coordinators who are supervised by a licensed clinical social worker.

A challenge common to many CoCM programs is the time commitment required to assess and triage patients, especially those who need more specialized services than can be provided in primary care. The Resource Center reduces this burden and allows the MHP to focus on delivering interventions that improve outcomes. The Resource Center leverages the principles of measurement-based care with tools such as the PHQ-9, GAD-7, PCL-5, AUDIT-C, and CSSRS. This information is fed into a decision-support algorithm, which helps the intake coordinators determine the appropriate setting and resources for each patient.

Patients who would benefit from collaborative care are scheduled with an MHP for brief interventions in the primary care practice. Each MHP receives face-to-face consultation with a psychiatrist and maintains a registry of patients. An e-consult is available between the PCP and psychiatrist for complex medication management cases.

PCPs have provided extremely positive feedback on the program. One PCP, Jeffrey Jaeger, M.D., said, “This is the single most impactful program I’ve seen in my 25 years at Penn.”

Innovations in Billing and Insurance

One of the most common obstacles to successfully implementing CoCM is financial viability. Initial billing for the CoCM codes was limited to Medicare, but now almost all commercial insurers and managed care organizations (MCOs), including Medicaid MCOs in Pennsylvania, are reimbursing through advocacy and innovative partnerships. Having multiple insurers cover the codes has allowed participating practices to offer the program across the full population of patients, which has increased access and satisfaction with the program.

Major Success and Plans for Future

When the program was first implemented, PIC expected 500 patients to participate in the first year. Instead, we received almost 6,000 referrals in 2018, and more than 11,000 by this past July. This large volume of referrals is due in part to the accessibility of the centralized Resource Center and the acceptance of all mental health concerns. The program has identified more than 1,000 patients at risk for suicide, as well as hundreds who were endorsing symptoms of mania and psychosis. This demonstrates how a short visit with a PCP may not always reveal the acuity of a patient’s situation, but PIC can help rapidly identify these patients and connect them to the care they need. Matthew Press, M.D., M.Sc., the associate medical director of primary care, noted, “Patients and their PCPs struggled for too long to access timely, high-quality mental health care. PIC is the answer to that struggle and is now foundational to the delivery of advanced primary care.”

Due to the immense success of the program so far, Penn Medicine will expand PIC to additional primary care practices and specialty care practices. PIC is still in its early stages, but its innovative and inclusive approach can help inform further adoption and evolution of CoCM. ■