Integrated Behavioral Health and the Patient-Centered Medical Home

Principle 1: Personal Physician

Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care

Principle 2: Physician-Directed Medical Practice

The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

Principle 3: Whole-Person Orientation

The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life: acute care; chronic care

Principle 4: Care is Coordinated and/or Integrated

• Across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services)

• Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner

Principle 5: Quality and Safety

• Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family

• Evidence-based medicine and clinical decision-support tools guide decision-making

• Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement

• Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met

• Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

• Practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model

• Patients and families participate in quality improvement activities at the practice level

Principle 6: Enhanced Access

Available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff

Principle 7: Payment

• Should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits.)

• Should recognize case mix differences in the patient population being treated within the practice

• Should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting

• Should allow for additional payments for achieving measurable and continuous quality improvements

The Joint Principles of the PCMH are a natural extension of the foundational features of primary care: “Important functions of primary care include serving as the first point of contact for all new health needs and problems; delivering long-term, person-focused care; comprehensively meeting all health needs except those whose rarity renders it impossible for a generalist to maintain competence in them; and coordinating care that must be received elsewhere” (Blount, 1998). According to Blount, these functions parallel the original definition of the modern family physician: “The central elements of this definition were that a modern family physician would do the following: (1) serve as the patient’s personal physician and provide entry to the health care system, (2) provide a comprehensive set of evaluative, preventive, and general medical services, (3) maintain continuing responsibility for the patient, including necessary coordination of care and referral, (4) practice in a manner both sensitive and responsive to community concerns and needs, and (5) provide care appropriate to the patient’s physical, emotional, and social needs, in the context of family and community” ((Blount, 1998). In January 2011, the Joint Principles for the Medical Education of Physicians as Preparation for Practice in the Patient-Centered Medical Home were released. The principles will guide medical school curricula in ensuring that all physicians, regardless of their specialty choice, will have the expertise to practice in a “reformed health care delivery system based on the patient-centered medical home” (AAFP, 2007).

In 2010, the Patient Protection and Affordable Care Act (PPACA) further established the medical home as the model for primary care in health care reform, defining the medical home as one that includes:

Personal physicians or other primary care providers
Whole-person orientation
Coordinated and integrated care
Safe and high quality care through evidenced informed medicine, appropriate use of health information technology, and continuous quality improvements
Expanded access to care and
Payment that recognizes added value from additional components of patient-centered care (Goodson, 2010)

PPACA also established a number of initiatives aligned with the medical home concept: providing coverage through a qualified direct primary care medical home plan, ensuring quality of care, rewarding quality through market-based incentives, establishing community health teams, supporting primary care training, and establishing a primary care extension program. Moreover, it commented specifically on issues relevant to this book, supporting “patient-centered medical home, team management of chronic disease, and interprofessional integrated models of health care that incorporate transitions in health care settings and integration of physical and mental health provision” (Kessler, Demler et al., 2005). Integration of physical and behavioral health care in the medical home, as promoted in PPACA, is consistent with prior efforts to improve care for mental health problems, since only 28 % of individuals suffering from psychiatric disorders seek care from mental health specialists (Hoffman et al., 1996).

Accreditation

National Committee for Quality Assurance (NCQA)

In 2003, the NCQA initiated the Physician Practice Connections (PPC) Recognition Program with support from The Robert Wood Johnson Foundation, the Commonwealth Fund, and Bridges to Excellence. The purpose of the program was to use “systematic process and information technology to enhance the quality of patient care” (National Committee for Quality Assurance [NCQA], 2010). In 2008, the ACP, the AAFP, the AAP, and the AOA joined forces to inform the creation of the PPC-PCMH standards. The standards were based on the Joint Principles outlined earlier in this chapter, and delineated specific requirements for recognition. The standards were intended to operationalize the core values of the PCMH in a way that could be captured and demonstrated through IT-driven practice-management efforts. Financial incentives were offered through various health plans and employers, and pilot projects were sponsored at both federal and state levels. Sustainability for these projects would ultimately depend on the ability to measure and demonstrate cost and quality outcomes as well as patient and provider satisfaction through formal evaluation processes (Stanek & Takach, 2010).

In 2011, the PPC-PCMH standards were revised to align with other health care developments evolving simultaneously (NCQA, 2011). The first of these was Meaningful Use (MU), a movement that grew out of the National Quality Forum’s (NQF) 2008 report that identified a set of national priorities focused on performance improvement in health care (National Quality Forum [NQF], 2011). The priorities identified were: patient engagement, reduction of racial disparities, improved safety, increased efficiency, coordination of care, and improved population health. In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act highlighted the centrality of using electronic health record (EHR) data and functionality to track and report data elements considered to be demonstrative of these principles for the purposes of continuous quality improvement and improved patient health (Health Information Technology for Economic and Clinical Health Act, 2011). This initiative became known as “meaningful use (MU).” Also in 2009, the Centers for Medicare and Medicaid Services (CMS) implemented the American Recovery and Reinvestment Act (ARRA, 2011). The act provided incentive payments to eligible providers for adopting and demonstrating meaningful use of EHR technology certified through the Certification Commission for Health Information Technology (CCHIT, 2011). In mid-2010, CMS released a Final Rule detailing MU requirements that reward clinicians for using Health Information Technology (HIT) to improve quality (Centers for Medicare and Medicaid Services [CMS], 2011). Table 3.2 summarizes the timeline for these developments.

Table 3.2

Timeline of key events leading up to PCMH 2011 standards

2003: PPC Recognition Program

NCQA program to identify practices that use systematic processes and information technology to enhance the quality of patient care

2005: AAFP creates TransforMED

Creates funding opportunities for primary care centers to develop PCMH practices

2008: PPC-PCMH Standards

A standardized way to categorize primary care practices and how closely they align with the PCMH

2008: NQF Report

25 % of 514 endorsed standards apply to primary care. NCQA PCMH recognition requires reporting on at least 10 of these measures

2009: ARRA

Included $20 billion for health care information technology

2009: HITECH Act

Signed into law to promote adoption and meaningful use of health information technology

2010: CMS Final Rule

Outlined meaningful use requirements that reward clinicians for using HIT to improve health care quality

2011: PCMH 2011 Standards (New Draft Standards)

Updated PCMH standards better reflecting aspects of health care delivery other than HIT

The 2011 original nine standards have been reduced to six and differ from the pre-2011 standards in significant ways. In addition to aligning with CMS and MU requirements, they emphasize integrating behavioral health care and care management, include patient surveys, and emphasize the involvement of patients and families in quality improvement. The clause, “to integrate behaviors affecting health, mental health and substance abuse” has been added to the goals and specified through PCMH Standard 1 (depression screening for adolescents and adults), PCMH Standard 3 (one of three clinically important conditions identified by the practice must be a condition related to unhealthy behaviors or a mental health or substance abuse condition), and PCMH Standard 5 (track referrals and coordinate care with mental health and substance abuse services) (NCQA, 2011). Table 3.3 lists both the 2008 and 2011 standards.

Table 3.3

2011 and 2008 PCMH standards

Standard	2011 PCMH standards	2008 standards (PPC-PCMH)
1	Enhance Access & Continuity	Access & Communication
2	Identify & Manage Patient Populations	Patient Tracking & Registry Function
3	Plan and Manage Care	Care Management
4	Provide Self-Care Support & Community Resources	Patient Self-Management Support
5	Track and Coordinate Care	Electronic Prescribing
6	Measure and Improve Performance	Test Tracking
7		Referral Tracking
8		Performance Reporting Improvement
9		Advanced Electronic Communications

Practices must provide defined standards or policies and demonstrate performance monitoring against the standards they have defined. Each of the six standards contains a Must-Pass Element, defined earning a score of 50 % or higher on each element and passing all six elements, to achieve NCQA recognition. Some of the elements contain critical factors, identified as those that are “central to the concept being assessed within a particular element” (NCQA, 2011). Critical factors must be met in order for practices to receive any score on the element.

Practices receive a final ranging from 0 to100, with Levels of recognitions based on those scores as follows:

Level 1	35–59 points and all six must-pass elements
Level 2	60–84 points and all six must-pass elements
Level 3	85–100 points and all six must-pass elements

However, simply passing the Must-Pass Elements only adds up to 29 points, so practices must also pass other elements in order to qualify for recognition. Once granted, recognition is valid for three years.

As stated earlier, the 2011 standards of PCMH align with CMS MU specifications. These contain a core set of 15 requirements and five of 10 menu requirements that must include the capability to submit electronic data to immunization registries/information systems or the capability to submit electronic surveillance data to public health agencies. Although NCQA added the integration of behaviors affecting health, mental health, and substance abuse to its stated goals in the 2011 standards, it is worth noting that none of the must-pass elements focus on behavioral health. Behavioral health is addressed in some of the non-must-pass elements, however, as detailed in Table 3.4.

Table 3.4

PCMH 2011 elements targeting behavioral health

PCMH 2: Identify and Manage Patient Populations

Examples of Behavioral Health and PCMH 2011 Principles

PCMH 3: Plan and Manage Care

Element A: Implement Evidence-Based Guidelines through point of care reminders for patients with:

3. The third condition, related to unhealthy behaviors or mental health or substance abuse

To receive a 50 % or 100 % score, at least one identified condition must be related to #3 (obesity, smoking, drug addiction, alcoholism, depression, anxiety, ADHD)

PCMH 4: Provide Self-Care Support and Community Resources

Element B: Provide Referrals to Community Resources

3. Arranges or provides treatment for mental health and substance abuse disorders

It is Mrs. P’s fourth visit in the month. Complaints include insomnia, fatigue, and vague chest pain. As part of her routine care, Mrs. P has also been screened for depression, with negative results. This time, in addition to inquiring about her physical symptoms, Dr. M requests an intervention from the behavioral health provider (BHP). The BHP administers a screening for posttraumatic stress disorder, which is positive. The BHP encourages Mrs. P to follow up for continued treatment. At the end of the visit, Mrs. P suddenly reveals that she is currently in an abusive relationship. After taking reasonable steps to ensure Mrs. P is in no imminent danger, the BHP refers her to the Domestic Violence Crisis Center for housing assistance and legal services. In addition, he schedules an appointment for the following week for further assessment of Mrs. P’s trauma symptoms.

Of the 152 possible factors listed, only 6 specifically target behavioral health (Element 2C, Factors 6–9; Element 3A, Factor 3; and Element 4B, Factor 3). Of these, Element 3A, Factor 3 is arguably the most significant since it requires practices to: (a) identify a behavioral health, substance abuse, or an unhealthy behavior condition as its “third important condition” and (b) design care management services targeting that condition. In other words, if a practice chooses depression as its behavioral health condition, it would also have to comply with Element 3C (Care Management), a Must-Pass Element that calls for practice to demonstrate management of at least 75 % of the patients identified in Element 3A (third important condition) as well as 3B (high-risk patients). As a Must-Pass Element, at least three of the seven factors must be present to achieve PCMH status. While behavioral health can theoretically satisfy the requirements of other elements and factors such as Element 3B or Element 1E, Factor 1 (coordinating patient care across multiple settings), a behavioral health emphasis, is not necessary. (For more detailed information on the operational requirements for the third most important condition and high-risk/complex patient groups, please see Appendix A.)

Application fees to become a PCMH are determined by the number of providers in a practice. Survey Tool Licenses include an $80 flat fee and Application Fees range from $450 for a solo practice to $2,700 + $10/number>100 for practices with more than 100 providers. A 20 % discount is offered to applicants sponsored by health plans, employers, and other programs. The discount applies when practices have fewer than 15 physicians and the sponsor has 10 or more applications in a market area within a 12-month period. Practices with a Level 1 or Level 2 designation can apply for an add-on survey discounted at the 50 % level of the standard application fees. Multi-site group survey pricing is also available for qualifying practices.

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