Keywords: Behavioral Health, Mental Health, PCMH, Primary Care
Integration of behavioral health capabilities into primary care at a patient-centered medical home
South Huntington Primary Care Associates, Brigham Health, Boston, MA
South Huntington had already adopted the Collaborative Care Model, with multidisciplinary teams of doctors, physician assistants, nurses, social workers, and medical assistants providing team-based care to patients on a daily basis.
This created a more natural setting into which to bring a behavioral health focused multidisciplinary team consisting of a social worker, health support specialist, PCP, and consulting psychiatrist.
Project Research & Planning
Project Tools & Components
Daily Workflow Steps
2018 MIPS Quality Payment Program (QPP) Measures:
Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Providers may be able to improve their performance on a number of these metrics by integrating behavioral health programs into primary care. Sample metrics include:
More details about measures included in the QPP set can be found here.
Medicare Shared Savings Program (MSSP) ACOs:
Clinics associated with an MSSP ACO are required to report their performance on measures for Depression Remission at Twelve Months and Screening for Clinical Depression and Follow-Up Plan. More information about these measures and requirements can be found here.
Integrating a behavioral health program such as Collaborative Care for Depression into primary care may help practices meet a number of NCQA Patient Centered Medical Home 2017 Standards. Potential opportunities include:
HEDIS Depression-Related Measures:
Related HEDIS measures for 2018 include:
Providers may be able to directly bill for many of the services provided through Collaborative Care for Depression programs. For example, as of 2017, providers can bill CMS for counseling and care management services using BHI-specific codes (more information available here).
South Huntington’s Behavioral Health Workflow (Majzoub-Perez et al. Healthcare 2015)
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