PhD/PsyD Integrated Behavioral Health Settings

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

OneNeuroDoctor

Clinical Neuropsychologist
10+ Year Member
Joined
Nov 1, 2013
Messages
697
Reaction score
122
I currently moved into a new position with a large rural Federally Qualified Health Center. Most of the Federally Qualified Health Centers recently received funding to integrate Behavioral Health into their programs and administrators received training on implementing Behavioral Health into their Medical Health settings.

We are having a number of glitches with different expectations and some issues related to differences in training. The physicians and nurse practitioners are set up on a schedule of seeing patients every 20 minutes or roughly three patients per hour. When behavioral health issue are an area of focus, the Behavioral Health Team see the patient for a ten-minute screening that is non billable, but paid through the grant. We do a brief Mental Status and interview and then we either set them up for a diagnostic interview either the same day or when convenient for the patient.

Since I am the only Psychologist at my facility with psychological and neuropsychological testing approval, I am asked to rule out or rule in ADHD by the medical staff and it seems that they would like for me to do this when I do the BH Consults for ten-minutes. Rather than just do a brief consult for ADHD, I prefer to do a comprehensive evaluation and schedule it later on. However, the medical trained prescribers are wanting quicker information, so they will start the patient on a trial of stimulant-based medications pending evaluation by psychologist for ADHD.

We have had difficulty related to expectations of length of sessions. Coming from a mental health setting, we normally had one-hour sessions and three to four-hours for psychological and neuropsychological evaluations. Here they are wanting me to have 20-minute to 30-minute sessions, as we are reimbursed a set rate not based on length of time we see patients, since many are uninsured or have Medicaid-Medicare. We have agreed for psychological and neuropsychological evaluations that I have 30 to 60-minutes for the diagnostic interview and 120-minutes for psychological or neuropsychological testing.

Since this agency has traditionally provided only medical care, we seem to have problems associated with expectations. Apparently the medical providers see three-patient per hour and they may see up to 20-24 patient per day. In some of our staff meetings, it has been expressed by the medical providers that behavioral health in an integrated setting should be able to see at least two patients per hour, given they are booked solid throughout the day seeing 20 or more patients per day.

Per the training the administrators received, we are supposed to work as a team and meet briefly when needed in "huddling" about specific patient having behavioral health concerns. We are suppose to communicate back and forth electronically and in person about patients having behavioral health concerns. Anyway, to some extent medical providers have not been completely on board related to having behavioral health providers as it seems that expectations differ and the whole medical scheduling systems seems to endorse quantity of patients seen rather than quality of services provided.

I gather some on this board have worked in Integrated Behavioral Health Care longer than I have and I was curious if you have had similar issues, and if so, how these were resolved? We are having multidisciplinary meetings weekly and the first two went well, but now medical providers seem to express some hostilities related to wanting to have these brief BH consults to determine ADHD or other diagnosis quickly so they may make medication decisions quickly before the patient leaves from the appointment.

Apparently this agency being a FQHC has it mission to treat the whole person with emphasis on education, prevention, and intervention per the Health Home model where the patient can receive all of the treatment at one facility rather than go to multiple facilities. The local CMHC recently discontinued having medical providers and medications implementation for their patients and all of their patients are now referred to where I work for medication follow-up. The medical providers have been overloaded since this happened as has our whole system due to the influx of mental health patients we now serve. Being a FQHC we have to accept all patient regardless of ability to pay. So part of the issue could be that we are now expected to provide all of these services within the community whereas before it was primarily medical services with well child checkup and patient only having minor mental health concerns.

Members don't see this ad.
 
Last edited:
If the docs want to start a trial of stimulants right away without waiting for more extensive testing, that is their call. We are the specialists in this area and we can advise them of any potential issues. I imagine I could make a preliminary call on an ADHD case pretty quickly and advise doc on need for further testing or therapy before medication. Oppositional behavior or anxiety or significant family problems are typically readily apparent. Learning disability can be tested for later and if the doc wants to start them on a medication prior to testing and parents agree, then that is again their call. I would tend to wait for clearer testing but I'm not going to buck the whole system and piss everyone off needlessly.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
2 hours for such evaluations is either not enough time, or too much. One, there is no neuropsychological profile for ADHD, so if it is uncomplicated and straightforward, doing testing is pretty meaningless. Two, if there is concern for a rule out (i.e., low IQ, LD, etc) then 2 hours is laughable in relation to getting any kind of meaningful information to explore anything outside of IQ. If this place is dead set on doing shi tty clinical work, just throw a Wender Utah at that and have the Prescribers go with that.
 
  • Like
Reactions: 1 user
Agreed with above posters and I also find that educating the docs on a case by case basis is more effective. They don't really know what we do and how we do it much more than the average public and it is difficult to explain in the abstract.
 
I would find it unethical to practice in an area in which I have no training or supervision.
 
  • Like
Reactions: 1 user
="WisNeuro, post: 19064383, member: 248083" Two, if there is concern for a rule out (i.e., low IQ, LD, etc) then 2 hours is laughable in relation to getting any kind of meaningful information to explore anything outside of IQ. If this place is dead set on doing shi tty clinical work, just throw a Wender Utah at that and have the Prescribers go with that.
7-8 hours minimum.
 
Some suggestions:

1. Read Integrated Behavioral Health in Primary Care by Hunter et al. (1st or 2nd ed.) cover to cover. Then read Behavioral Consultation and Primary Care: A Guide to Integrating Services by Robinson & Reiter.
2. Join the Collaborative Family Healthcare Association (CFHA.net) and network with people who have been doing this for years.
3. Get a solid grasp of what you can and cannot do in your allotted time slots. 30-min new patient and 15-min follow up appointments are not unusual in integrated primary care (though I prefer a 1 hr/30 min model). Yes you can be helpful in this time frame, but you have to be efficient and very targeted.
4. Don't cave to pressure to provide useless services. Educate your colleagues. If they want you to be a gatekeeper, be an effective one. Instead of going along with your medical colleagues' half-baked ideas on express neuropsych, improve the model of care. A care pathway for suspected ADHD could be clinical interview --> first-line behavior mod/parent training --> check adherence, repeat/reinforce as needed --> consider stimulants only after implementing behavioral recommendations. There is evidence to support this pathway, as opposed to the one being suggested to you.
5. Give some thought to how much testing you really need to do in this setting. If you are offering testing for routine and relatively uncomplicated cases you're probably doing something wrong. Learn when and how to refer out. The behavioral health consultant is primarily an interventionist.
 
Last edited by a moderator:
  • Like
Reactions: 4 users
MamaPhD provided the well-thought out response. I was shooting off the cuff a bit this a.m. ;) Nevertheless, I do have quite extensive experience working with physicians and know that they don't respond well to hard lines drawn by other providers that are not well-reasoned, logical, and concise in their clinical rationales. Also, keep in mind that in this situation we are typically the consultant and they are primarily responsible for making the decision. The medical docs rarely go head to head with each other the way they do on tv, there is a much more subtle interplay of roles and responsibilities. The better one is at meshing with that system, the more effective one will be.
 
Is there a reason those appointment aren't billable using the health and behavior CPT codes? I.E. 9615x? They can be billed as 15 minute increments.
 
Is there a reason those appointment aren't billable using the health and behavior CPT codes? I.E. 9615x? They can be billed as 15 minute increments.

Definitely. These codes are rounded to the nearest 15-min increment, so the service only needs to be longer than 8 minutes to count as one unit. The problem is that Medicaid doesn't cover these services in some states.
 
Last edited by a moderator:
Top