- Jefferson Health implemented a system-wide integrated behavioral health (IBH) program that introduces behavioral health consultants (BHCs) into practices across Jefferson Health in an effort to improve behavioral healthcare for Medicare patients.
- Academic Hospital
- An estimated 26% of adults live with a behavioral health diagnosis, and many more go undiagnosed.
- According to the PHMC Household Health Survey for 2015, almost 20% of adults in Philadelphia have been diagnosed with a mental illness, a number that has doubled since 2000.
- Previous research has demonstrated that integrated behavioral health (IBH) interventions could provide improved outcomes and decreased cost to patients:
- The IMPACT program, a 2-year IBH intervention for patients with diabetes and depression, found 115 more depression-free days in the intervention group compared to the usual care group, as well as $3,363 less healthcare costs over 4 years in the intervention group vs. the usual care group.
- Jefferson Health has 60 primary care practices funded by the Center for Medicare and Medicaid’s (CMS) Comprehensive Primary Care Plus (CPC+) program.
- Prior to implementation of this program, one campus of Jefferson Health had recently adopted the Cherokee Health model, one of many national IBH models.
Patient Population Served and Payor Information
- Jefferson Health primary serves the residents of Philadelphia, Pennsylvania:
- The racial distribution of residents in Philadelphia is: 37% non-Hispanic white, 42% non-Hispanic African American, 13% Hispanic or Latino, and almost 7% non-Hispanic Asian
- According to the PHMC Household Health Survey for 2015, 46% of adults in Philadelphia are insured through employment or unions, 34% have Medicare, and 23% have Medicaid.
- A CPC+ leadership team, composed of primary care leaders and system administrators, and an IBH leadership team, composed of a Program Director, Primary Care Liaison, and Psychiatry Liaison, helped launch the program. The IBH leadership team provides leadership on an ongoing basis.
- The Center for Medicare and Medicaid’s (CMS) Comprehensive Primary Care Plus (CPC+) program provided funds necessary to hire behavioral health consultants.
Research + Planning
- Billing models were created to ensure that the IBH program would be financially sustainable prior to the end of the CPC+ funding period.
- In the 6 months leading up to implementation, an interdisciplinary group met to develop a IBH model. The group evaluated several national models and ultimately decided to adapt the Cherokee Health model to their local context.
Tools or Products Developed
- Behavioral health consultant (BHC) role: BHCs are licensed social workers who help patients manage disease within their specific psychosocial context and provide support for patients’ psychiatric needs. This intervention called for creation of 19 BHC positions across all Jefferson Health practices.
- Clinicians received an introduction to the model at primary care meetings. Leadership conducted follow-up site visits during routine population health management meetings.
- BHCs received both initial training and also ongoing support through meetings that provided updates and feedback. Difficult cases were addressed through group BHC supervision.
- Electronic medical record
Team Members Involved
- Primary Care Physicians
- Social Worker
- During a primary care visit, the primary care clinician determines that the patient could benefit from the support of a BHC. The PCP provides the patient with a warm handoff to the BHC.
- The BHC delivers a brief intervention, which may include addressing the psychosocial aspects of the patient’s disease(s) and providing mental health support.
- This workflow was adopted from The Cherokee Health Model:
- Primary care visits at Cherokee include check-in, rooming, preventive care screening, medical visit, patient education and care planning, and follow-up.
- Emphasis is placed on the ease with which behavioral health personnel are integrated into primary care visits and the flexibility of scheduling. BHCs can:
- See patients before or after a primary care visit
- Engage in collaborative visits with primary care physicians
- Bring in patients for independent visits such as a traditional 30-minute therapeutic appointment
- See patients for brief behavior change interventions in an exam room during a primary care visit
- Call a consulting psychiatrist for a 60- to 90-second conversation to get a recommendation for the patient
- Perform chart reviews and screenings, and consult with the primary care physician to integrate information from multiple sources of data
- Interrupt physician visits to make recommendations and “unify” the care plan
- Follow-up visits are planned according to clinical acuity and patients’ level of motivation and engagement.
- Cost of 19 full-time licensed clinical social workers: estimated to be $1,202,890 (average base salary of social worker in Pennsylvania is $63,310)
Where We Are
- The project is currently ongoing.
- An integrated behavioral health program allows for patients’ improved access to supportive resources that improve their health and wellbeing.
- Buy-in from organizational leadership, which can be difficult and take time, is essential to the success of this intervention.
- Successful implementation of this intervention required significant interdisciplinary planning and coordination with real-time iterative change. This type of work necessitates clear and frequent communication between many parties.
- Stoeckle J, Cunningham A, Arenson C. Scaling Integrated Behavioral Health Rapidly. Ann Fam Med. 2018 Sep;16(5):464. doi: 10.1370/afm.2297. PubMed PMID: 30201645; PubMed Central PMCID: PMC6130998.
- Stoeckle, MD, John J., “Integrated Behavioral Health” (2018). Department of Family & Community Medicine Presentations and Grand Rounds. Paper 265. https://jdc.jefferson.edu/fmlectures/265
- Jefferson Health Community Health Needs Assessment Report: 2016 https://hospitals.jefferson.edu/content/dam/health/PDFs/general/in-the-community/Community-Health-Needs-Assessment-Report.pdf
- CMS CPC+ Website https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus/
- Kessler RS, Auxier A, Hitt JR, et al. Development and validation of a measure of primary care behavioral health integration. Fam Syst Health. 2016 Dec;34(4):342-356. https://www.ncbi.nlm.nih.gov/pubmed/27736110
- Warm Handoff: Intervention. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/warmhandoff.html
- New Models of Primary Care Workforce and Financing Case Example #7: Cherokee Health Systems. AHRQ Publication No. 16(17)-0046-7-EF. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. https://www.ahrq.gov/professionals/systems/primary-care/workforce-financing/case-example7.html#model
- Christine Arenson, MD
- Amy Cunningham, PhD, MPH
- Johnny Stoeckle, MD
- Linda Xu, BA
Jefferson Health, Thomas Jefferson University Hospitals Inc.Talk to the Innovators