and Jeffrey T. Reiter2
(1)
Mountainview Consulting Group, Inc., Zillah, WA, USA
(2)
HealthPoint, Seattle, WA, USA
Electronic supplementary material:
The online version of this chapter (doi:10.1007/978-3-319-13954-8_4) contains supplementary material, which is available to authorized users.
Keywords
BHC servicesBHC locationBudgetPodWorkstationBHC officeBrief interventionsPathway servicesPCP prep visitsMedication assistance visitsClasses of psychotropic medicationPDR Drug Guide for Mental Health ProfessionalsCare augmentation visitsAppointment typesScheduled appointmentsWarm-handoff appointmentsSame-day appointmentsGroup appointmentsSchedule templateConsultant modelRequest for time offBillingCPT codesPhysician’s Current Procedural Terminology (CPT) systemHealth and Behavior (H&B) Assessment and Intervention codesCPT psychotherapy codesSBIRT codesMedicare reimbursement ratesInternational Classification of Diseases Tenth Revision Clinical ModificationAmerican Psychological AssociationDSM-VAPA Government Relations Department“The devil is in the details.”
Anonymous
Everyone knows the saying, “The devil is in the details,” and upon entering a new behavioral health consultant (BHC) position, the meaning of this becomes immediately clear. Questions will abound on any number of topics, such as where to see patients, how to bill, how to schedule patients, and other technical, but important issues. This is particularly true for those who are beginning a new BHC service. Earlier chapters have outlined the rationale for the Primary Care Behavioral Health (PCBH) model, oriented the reader to PC, outlined a BHC job description, and suggested a plan for BHC training, supervision, and evaluation. The next step is to begin answering the technical questions about how to effectively implement a new BHC service.
With this in mind, the current chapter begins with suggestions for finding the optimal location for the BHC in the clinic and how to budget for a new BHC service. We also discuss common administrative issues, such as how to structure the BHC’s schedule template and which diagnostic and billing codes to use. The chapter ends with a discussion of general issues regarding billing for BHC services.
Location, Location, Location
It can be a big surprise to enter a new clinic on the first day of work and discover that you have no place to sit. However, this is a fairly common experience for those starting up a new BHC service. Owing to the novelty of the service, clinic administrators are often unsure where to place a BHC and may simply decide to wait for input from the new hire. Believe it or not, this can actually be the best-case scenario. Work locations established by a manager who doesn’t understand the PCBH model will often be far from ideal. Having the opportunity to select one’s own work location offers the best possibility for getting a new service off to an excellent start. Make no mistake about it; the location of the BHC is an extremely important factor in the success of a BHC service.
Prime Real Estate in Primary Care
Before launching into a discussion about where to locate a new BHC, a few important points about space in PC need to be noted. First, space is often at a premium in PC. One of the most commonly perceived obstacles to bringing a new BHC team member into a clinic is a lack of space. Thus, a new BHC will not always have complete control over where he is located. Second, sharing is common in PC. Many Primary Care Providers (PCPs) share offices, exam rooms, and even equipment. Very commonly, one PCP will see a patient in an exam room typically used by a different PCP, or a float provider will use the computer of a PCP who is out for the day. As such, the BHC should not expect to be granted space that is solely her own.
Another important point is that the design of PC clinics varies. Some will have a single work area (called a pod) where all of the PCPs and NAs sit when not seeing patients, while others may have multiple pods, each with a smaller number of Patient Centered Medical Home (PCMH) team members. Still others may provide individual offices for each PCP. Regardless, most PCPs do not have a single location from which they work. Rather, most have a workstation usually consisting of a computer and phone, where they sit when not seeing patients (either in a pod or an individual office). Patient visits occur in the exam rooms. Commonly, each PCP will be allotted three exam rooms on a given day, which allows one room for the patient currently being seen by the PCP, a second for the next patient on the schedule (who perhaps is being checked in by the NA), and a third for overflow in case a given patient ends up occupying a room longer than planned.
The clinic layout and strategies for utilization of space all need to be considered when deciding on a BHC’s work location. The goals of PCBH care also need to be considered. New BHCs who trained in specialty environments run the risk of selecting a poor work location in PC if they fail to consider the unique goals of their new position. To help with the important decision of where to situate a BHC, we offer some general guidelines below.
No Office Space? No Problem!
You might have noticed that up until now we have avoided using the term “office” when discussing where to locate a BHC. This is because in many clinics the BHC does not have a designated BHC office, and in many cases this is actually the preferred situation. Success of a BHC service has a great deal to do with accessibility, and segregating oneself off in an office can run contrary to that goal. The pace in PC is fast, and PCPs often do not have time to walk down long hallways, let alone a flight of stairs, to talk with the BHC.
If the clinic utilizes pods for the PCPs, having a designated workstation in a pod can be the ideal location for the BHC. The pod is where a great deal of formal and informal collaboration, consultation, and learning occurs, not to mention socializing. Very commonly, sitting in the pod results in referrals from the PCP on the same day of the patient’s medical visit. These referrals are less likely if the BHC is sitting in a separate office. For example, seeing the BHC might remind the PCP of an upcoming patient she wants to refer, or the BHC might overhear discussion of a patient with a behavioral issue and offer to help. Important opportunities for interacting socially with the team, which can help tremendously with breaking down stereotypes and furthering PCP understanding of the BHC’s role, also abound in the pod.
If stationed in the pod, the BHC will typically see patients in an exam room. Sometimes clinics will have an exam room consistently available for the BHC to use throughout the day (though which room it is might vary from day to day). Other times, the BHC will use different exam rooms throughout the day. Either setup is acceptable, though having a consistent room throughout the day usually works best because otherwise staff might encounter problems finding the BHC. Working out of a different exam room each day, however, can be advantageous, in that it may expose the BHC to different parts of the clinic and hence different PCPs. If there is more than one pod in the clinic, the best strategy is often for the BHC to have a workstation in one pod and also spend part of each day (or certain days each week) using the workstation of an absent PCP in other pod(s). This will help the BHC develop relationships with all of the PCPs.
Seeing patients in an exam room can have subtle, positive effects on how the BHC is perceived by patients and staff. Instead of being the specialty provider in the quiet wing of the clinic that the “psych” patients are sent to, the BHC in the exam room may be more likely to be viewed as a regular part of the PC team. Yet, as a general rule, PCPs are always reluctant to offer up exam rooms; sometimes this is truly the result of an inadequate number of rooms, but more often it results from merely a fear of inadequate space. If seeing patients in an exam room is not an option, office space will be needed.
Be in the Chaos
Regardless of the office versus exam room issue, a guiding theme for selecting a work location is to be in the middle of the action. This might run contrary to one’s instincts. Most PC clinics can be quite loud at times, with overhead pages, crying babies, and staff and patients in discussion moving here and there. At times it can seem like barely controlled chaos. A new BHC might be tempted to assume that being in the middle of all of this is exactly the wrong place to be and that what is needed is instead a quieter, more controlled section of the clinic. But actually, being in the chaos is the perfect location; it allows PCPs the easiest access to the BHC, and just as importantly it signals that the BHC is not a typical MH provider, but rather a regular part of the team who wants to be involved.
Thus, when touring the clinic on the first day, try to locate the clinic’s epicenter. What area do providers pass by most often? Are there some hallways or areas that get more use than others? Does the clinic have provider pods, and if so which is the biggest and busiest? These questions help find the epicenter, and it is as close to this area as possible that the new BHC should try to set up shop. If scouting out an office location, sacrifice space for accessibility, as being seen is more important than having legroom. Above all, avoid locating oneself in an administrative wing, as that will erect numerous barriers to referrals and runs contrary to the whole concept of the PCBH model.
Please DO Disturb!
We really cannot stress enough how important accessibility is to the success of a BHC, so if working solely out of an office (i.e., no workstation elsewhere), be sure to keep the door open when not seeing patients. If a PCP or other team member needs something, give him immediate attention. Accessibility is also a mindset as much as a physical quality, meaning one should also welcome interruptions during patient visits, assuming it is for a referral or other immediate need. In provider meetings, emails, and newsletters, tell PCPs that the door is always, at least figuratively, open for them. This message will need to be repeated, as PCPs have often been trained in residency by MH providers who practice more like specialty therapists and probably taught them to avoid interrupting therapy visits.
New BHCs are themselves sometimes squeamish about being interrupted during visits, until they have experienced it several times. The reality is that in PC, patients almost expect interruptions; it is a normal part of team-based care. Sometimes interruptions even help the BHC develop a fresh focus upon returning to the patient. Providers will be brief when interrupting a visit; indeed, they interrupt because they do not have time to wait. The worst-case scenario is for a PCP to walk away frustrated because the BHC is unavailable. Accepting interruptions takes some getting used to, but most new BHCs come to prefer it in time because of positive feedback from PCPs (and patients) who marvel at their accessibility. We talk more in various parts of the book about how to handle interruptions and also have a video demonstration of an interrupted visit on the book website http://www.behavioralconsultationandprimarycare.com.
A final suggestion about the office is to use the door for providing information about the BHC service. For example, one might post brief summaries of important research studies on PC treatment of behavioral health issues, copies of recent BHC newsletters (see example on book website), handouts advertising parenting classes and other resources in the community, and, of course, the BHC schedule.
When in Rome, Do as the Romans Do
If not seeing patients in an exam room, think carefully about how the BHC office is decorated. Most PCPs do not have fancy offices with couches and comfortable armchairs, and thus the BHC shouldn’t either. Remember that one goal of integrating behavioral health into PC is to break down the stigma of the former, and this task is made more difficult if the BHC office looks different than other patient care rooms. A good practice is to recreate as much of the content of exam rooms as possible. If, for example, each exam room has brochures offering information on various health conditions or community resources, consider having the same in the BHC office. If each exam room has a bulletin board with information about clinic events and resources, try to also procure a bulletin board to post the same information. Also note what items are not present in exam rooms. If, for example, exam rooms do not contain plants or family photos, then try to avoid putting such items in the BHC office.
Maintaining the same sparse, pragmatic décor that typifies exam rooms is not only about influencing how the BHC is perceived. A less cozy office also likely discourages the BHC from settling in and thereby missing opportunities to grow the service and build team relationships. All too often, BHCs who work solely out of an office experience “therapist creep,” meaning they spend more and more of their time in the office doing administrative tasks and less and less of their time with other staff seeking out new clinical opportunities or drumming up new patients during slow periods.
Common Expenses to Include in the Budget
The good news about a BHC’s budget needs is that they are usually quite modest. Unless hiring a BHA (see Chapter 3), no new staff members are needed beyond the BHC herself. The BHC utilizes the same receptionists, the same technology department, and the same administrative staff as the other providers. The most expensive item in the BHC budget (other than salary) is usually the computer. If a BHC has both a BHC office and a workstation in the pod, then two computers will be needed (this is another argument for working out of an exam room rather than a separate BHC office).
If an office has been allocated, it will need three or four small office chairs. A folding chair can be hung on a coat rack behind the door for use when seeing a family. A separate printer is not necessarily needed, as the computer can probably map to a printer very close by. A basket full of toys, a good selection of children’s books, and a robust collection of fun stickers is a good idea, as there are many children to see in PC. (Be sure to select toys that can stand up to frequent bleach wipes and will not pose a choking hazard for small children.) Bulletin boards are great for displaying information about community and clinic resources or BHC classes. The BHC should also have easy access to a phone wherever he sees patients, as well as at his workstation (if applicable). A cell phone is typically not necessary.
Other miscellaneous small budget items include: printer cartridges and paper (if applicable), business cards, pens equipped with highlighters (for reviewing patient education materials with patients), and possibly a pager (though usually this is not necessary). A whiteboard may be useful for providing patient education and a small whiteboard on the door provides a handy way for the BHC to indicate her whereabouts if leaving the office for more than a few minutes. A small file cabinet is helpful for keeping paper copies of assessment tools or patient handouts, though mostly these can be maintained on the computer. Appendix A (Chapter 16) provides a list of books that can be helpful to keep in the BHC office. Most BHCs have favorite self-help books that they also keep on hand to show to patients who might benefit from them. We list some of our favorites in Appendix B (Chapter 17).
BHC Services
At the most basic level, BHCs provide two services: brief consultative interventions and pathway-related services. Brief interventions serve at least one of three purposes: (1) preparation for a PCP visit (PCP-prep), (2) medication assistance, and (3) care augmentation. We explain each of these in the paragraphs below. Pathway services also utilize brief interventions but do so with a focus on patients who share a similar challenge or problem. The shared challenge might be broadly defined and focused on prevention (e.g., families seeking to live healthy lifestyles) or more specifically defined and focused on disease management (e.g., patients with three or more chronic conditions). Specific outcomes are targeted, such as clinical outcomes, cost, or satisfaction level. Pathways are different from clinical guidelines. They are developed at the clinical level and are the result of a process where providers and patients have input on the selection of evidence-based interventions that are feasible, from a cost and workflow standpoint. We provide guidance on design and evaluation of pathway services in Chapter 12.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
