CalHIVE Behavioral Health Integration (BHI)

Access Integration Model resources below:

• The CIHS framework proposes six levels of collaboration/integration. While the overarching framework has
  three main categories — coordinated, co-located, and integrated care — there are two levels of degree within each
  category.
  • It is designed to help organizations implementing integration to evaluate their degree of integration across several levels and to determine what next steps they may want to take to enhance their integration initiatives.
• SAMHSA’s “Integrated Care Models: An Overview” provides an overview of different models of integrated care and their key components.​
• The “Collaborative Care Model” developed by the University of Washington’s Advancing Integrated Mental Health Solutions (AIMS) Center provides detailed information on how to implement this model, including care team composition, treatment protocols, and billing and reimbursement considerations.​
• The “Primary Care Behavioral Health (PCBH) Model” developed by the American Psychological Association (APA) provides guidance on how to integrate behavioral health services into primary care settings. The handout could include a summary of the key components of the model, such as the importance of communication and collaboration between primary care and behavioral health providers, use of brief interventions and assessment tools, and development of a stepped care approach.​​
• The “Behavioral Health Integration Toolkit” developed by the American Academy of Family Physicians (AAFP) provides a comprehensive toolkit for primary care providers looking to integrate behavioral health services into their practice. The toolkit includes assessment tools, treatment protocols, and resources for patient education and engagement.
• The Tools and Documents developed by the Michigan Institute for Care Management and Transformation provide a wide range of CoCM implementation resources.

Example Videos:

CoCM

The Collaborative Care Model(American Psychiatric Association) – 2:34

Collaborative Care Management for Behavioral Health(Ryan White HIV/AIDS Program TargetHIV) – 12:14

Collaborative Care Management at La Clinica del Pueblo D.C.(Ryan White HIV/AIDS Program TargetHIV) – 6:46

PCBH

PCBH Visit Demonstration with Dr. Bauman: Initial, Follow-up, and Debriefing(Beachy Bauman Consulting) – 1:07:25

Dr. Bauman PCBH patient introduction(Beachy Bauman Consulting) – 1:04

Focused Acceptance and Commitment Therapy(FACT): Engaged(Beachy Bauman Consulting) – 21:30

Compare and contrast the models

PCBH vs Collaborative Care(Primarycareshrink.com) – 19:25

These resources will support your teams to complete the Implementation Plan, Section 3 – Staffing.

General Resources

• Hiring and Onboarding Integrated Behavioral Health Providers in Primary Care (Rocky Mountain Health Plans) – general resources including interview questions, onboarding processes)

CoCM

• Job Descriptions
  • Behavioral Health Care Manager
    • Example 1 (AIMS Center)
    • Example 2, Page 149 -172 (Integrated Behavioral Health Project)
  • Psychiatric Consultant

PBCH

• Job Descriptions
  • Behavioral Health Clinician
    • Example 1 (CFHA)
• Job Posting
  • Example 1 (CFHA)
  • Example 2 (Cayuga Medical Associates)
  • Example 3 (Health Source of Ohio)
• PCBH Manual
  • Example 1 (Mountainview Consulting)

These resources will support your teams to complete the Implementation Plan, Section 4 – PHQ-9 Screening

• BHI Workflow Guide (American Medical Association) – actionable, evidence-based best practices on workflow design
• BHI Workflow Examples (American Medical Association) – examples of specific workflow diagrams
• BHI Workflow Plan (American Medical Association) – template to help organizations identify workflows already in place and improvements
• Creating A Workflow For Depression Screens & Follow Up Treatment (Colorado Access) -toolkit developed for primary care practices
• Crisis Text Line – 24/7 crisis line resource for patients in crisis
• Depression Coding Fact Sheet for Primary Care Clinicians (American Academy of Pediatrics) – coding information for depression coding
• NAMI: National Alliance on Mental Illness – external behavioral health resources
• Patient Health Questionnaire (PHQ) Screeners (Pfizer) – different versions of the PHQ in all translated languages
• Toolkit for Designing and Implementing Care Pathways (National Council for Mental Wellbeing)
• 988 Suicide and Crisis Lifeline – 24/7 lifeline resource for patients in crisis

These resources will support your teams to complete the Implementation Plan, section 5 – BHI Billing and Coding.

General Resources

• CA Billing and Payment Codes (CQC): (revised February 2024) codes to be used for each model (CoCM and PCBH)
• Behavioral Health Coding Resource (AMA) – outlines key CPT codes for behavioral health screening, treatment, and/or preventative services

• Behavioral Health Billing & Coding 101: How to Get Paid (AMA) – October 2020 webinar with information about how to get paid for BHI

• Decision Support Tool (National Council for Mental Wellbeing) – The DST empowers providers to estimate Medicare and Medicaid revenue across prominent integrated care services to finance these services more effectively
• Tips for Financial Sustainability in Integrated Behavioral Health – (Rocky Mountain Health Plans) – guide with a brief overview of key considerations for developing a business case for BHI
• Non-Specialty Mental Health Services: Psychiatric and Psychological Services – Medi-Cal guide for CPT codes
• Specialty Mental Health Services Medi-Cal Billing Manual – Medi-Cal guide for CPT codes
• Marriage and Family Therapists (MFT) and Mental Health Counselors (MHC) Provider Enrollment Frequently Asked Questions (FAQs) September 2023 – FAQ document from the Center for Medicare and Medicaid Services

Billing/Coding Tip Sheets

• The Practice and Billing Toolkit Tools for successful implementation of the Collaborative Care Mode – American Psychiatric Association

• Coding Tip Sheet Example

• Billing Tip Sheet Example

CoCM

• CoCM Practice and Billing Toolkit (APA) – Tools for successful implementation of CoCM

These resources will support your teams to complete the Implementation Plan, section 6 – Pilot Site Evaluation & Engagement

Evaluation

• Patient Experience

  • Patient Satisfaction Questionnaire (PSQ-III) – 50 item survey

• Workforce
  • Provider Integration Profile

  • Provider Satisfaction Survey (example from external organization)

• Financial
  • Collaborative Care Implementation: Costs Across 10 United States Health Care Systems (Meadows Mental Health Policy Institute)

Engagement

• Stakeholder Communication Plan

• Building a Collaborative Team Environment

• Team Building and Workflow Guide (Aims Center)

• Integration Academy Interdisciplinary Communication (AHRQ)

• Making the Case for Change and Overcoming Resistance (Safety Net Medical Home)

Warm Handoff

• American Psychological Association, “The impact of warm handoffs on patient engagement”
• The National Council, Optimizing Handoffs for In-person and Virtual services
• Beachy Bauman Consulting, The Warm Handoff Trophy; video
• Primarycareshrink.com, Air Traffic Control: Handling Multiple Consults in PCBH; video 
• Agency for Healthcare Research and Quality, Warm Handoff: Intervention

Huddles

• Matthew Martin, Team huddle between medical and behavioral health providers; video
• The National Council, 10 Ways Behavioral Health Staff Can Positively Influence Team Huddles in Primary Care
• Primarycareshrink.com, How to Get PCPs to Use You Effectively; video

Workflows

• AMA, BHI Workflow Guide
• AMA, BHI Workflow Example
• AMA, BHI Workflow Plan Resource
• CQC, BHI Workflow Checklist
• Maryland Department of Health, Maryland Primary Care Program: Behavioral Health Integration
• University of Wisconsin Workflows, Primary Care Behavioral Health: Pediatric Collaborative Care Family Medicine Workflows

Other Resources

• AIMS Center, Administrative Readiness Checklist

These resources will support your teams to complete the Implementation Plan Section 8 – Reflect and Adjust.

Staff Perception Surveys

• IBHP, Satisfaction Measures

Change Management

• Team Discussion Guide

Huddles

• Esperanza Health Center, 10 Ways Behavioral Health Staff can Positively Influence Team Huddles in Primary Care

Implementation Considerations

• AHRQ, A Guidebook of Professional Practices for Behavioral Health and Primary Care Integration Observations From Exemplary Sites

• Access Community Health Centers, Integrated Primary Care Consulting Psychiatry Toolkit

Data Exchange Framework

Rapid data exchange within the health care delivery system is integral to achieving equitable, patient-centered care for all Californians. The California Quality Collaborative (CQC) supports the California Health and Human Services Agency’s Data Exchange Framework (DxF), the first-ever statewide data sharing agreement, because it will accelerate and expand the exchange of health information among health care entities, government agencies and social service programs.

DxF Resources:

• CQC DxF Resource Guide
• DxF Overview Video #1
• DxF Overview Video #2

DxF Signatory Grants Application Resources:

• DSA Signatory Grant Guidance Document 
• DSA Signatory Application Template
• Application Portal “Getting Started” video 

Find the most up-to-date resources and events on the Connecting For Better Health Hub.

Other Learning Opportunities

• Tuesday, December 5 – Privacy Explained for CBOs host by BluePath Health
  • Slide deck; Webinar recording

CFHA supports healthcare professionals in integrating physical and behavioral health. It is our hope that the organization can be a professional home where you can network with colleagues, nurture new professional relationships, exchange information relevant to integration and collaboration, and most of all, provide an avenue where you can make meaningful contributions to the field and your community.

As part of your membership and participation in the CalHIVE BHI Collaborative, you gain access to an array of resources provided by CFHA. These include their esteemed journal, ‘Families, Systems & Health’, and their educational platform, ‘CFHA Learns and Shares’. These resources are specifically designed to assist in the successful implementation of behavioral health services and are now at your disposal.

CFHA Member Resources

Ask your CalHIVE BHI Team lead about how to access your free 1 year  CFHA Membership.

Materials

• SMARTIE Aim Statement Template

Webinars

3/26/24 Model for Improvement Fundamentals – Setting Aims Slide deck; Audio Recording

4/30/24 Model for Improvement Fundamentals

Find full course details here.

Participant Agenda

Attendee List

Workbook

Day 1 Slide Deck

Day 2 Slide Deck

PO Posters

BHI Workflow Handouts:

• Primary Care Behavioral Health: Pediatric Collaborative Care Family Medicine Workflows (Wisconsin Family Medicine)
• PCBH Initial BHC Visit Workflow (HMA Integrated Care DC)
• CoCM Workflow (MCCIST)
• Warm Handoff Script (AMA)
• Warm Handoff Script for PCP
• Ideal Warm Handoff (CQC)
• BHI Workflow Checklist (CQC)

Other Resources:

• “I like, I wish, I wonder” (Global Learning Partners)
• Day in The Life of a Behavioral Health Consultant in Primary Care: PCBH Workflow (HMA Integrated Care DC)
• Warm Handoff: Intervention (Agency for Healthcare Research and Quality)
• “See one, do one, teach one” (Journal of Global Health)
• Change Management (Prosci)
• The Piker Principles of Person Centered care (Picker)
• A Toolkit to Advance Racial Health Equity in Primary Care Improvement (California Improvement Network)
• Healthy People 2030 ( Office of Disease Prevention and Health Promotion)
• Social Determinants of Health in Community Health Assessment and Improvement Planning (NACCHO)

Day 1 Takeaways

Day 2 Takeaways

What makes BHI stick?

Provider Organization Videos – Why BHI?

• Chinese Hospital
• Perlman Clinic
• Sharp Rees-Stealy

Access conference materials for the September 2023 CalHIVE BHI Convening in San Diego, CA.

Attendee List

Presentation Slides

Participant Workbook

Measure Logic & PHQ-9

Slide Show

Access conference materials for the April 2023 Improvement Coaching Workshop in Los Angeles, CA:

• Participant Agenda
• Participant Workbook
• Attendee List
• Faculty Bios
• Day 1 Slides
• Day 2 Slides
• Day 1 Capstone Activity