VISN 2 Center for Integrated Healthcare (CIH)

Operations, Policies and Procedures

This section contains sample documents that provide administrative, operational, policy and supervisory primary care mental health integration program guidance. It includes sample service agreements, policy statements, and general program operational guidance. Administrators and individuals overseeing program development, implementation, and evaluation may find this section extremely helpful.

CCC Practice Management Tools

This section contains resources to support co-located collaborative care (CCC) clinicians practice management techniques congruent with providing mental/behavioral health services in PACT. For example, this section contains strategies and tools to structure appointments within a 30-minute timeframe using a 5As framework. It also includes sample provider scripts and note templates that can assist providers to successfully function within the primary care setting.

Patient Education Materials

This section contains informational handouts and self-management materials for patients. These include information about many of the patient problems that mental and behavioral health providers in PACT are like to encounter, e.g., problem drinking, anxiety, depression, etc. These materials are organized by specific content areas.

ADHD

ADHD Patient Information Sheet

Alcohol

Anger

Anxiety - Stress

Assertiveness

Assertive Communication

Cancer

Cardiac

Cardiac Health Fact Sheet

Chronic Fatigue Syndrome

Chronic Fatigue Syndrome

Cognitive Distortions

Communication Tips

Chronic Obstructive Pulmonary Disease (COPD)

COPD: Patient Information

Diabetes

Depression, Bereavement & Grief

Domestic Violence

Intimate Partner Violence: Patient Information

Erectile Dysfunction

Erectile Dysfunction: Patient Information

Gastrointestinal (GI) Problems

Irritable Bowel Syndrome: Patient Information

Hypertension

Hypertension: Patient Information

Military Sexual Trauma

Motivational Interviewing

OEF-OIF

Resources for OEF-OIF Veterans

Pain

Problem Solving

Problem Solving Worksheet for Patients

Posttraumatic Stress Disorder (PTSD)

Relaxation & Tools for Stress Management

Self Esteem

Self Esteem

Sleep Disorders

Stroke

Stroke Stats Handout for Patients

Tinnitus

Tinnitus Fact Sheet

Tobacco

Womens Health

Provider Education Materials

This section contains educational materials intended for mental/behavioral health providers working in PACT. It includes information about effective strategies for providing mental and behavioral health services in PACT, both co-located collaborative care (CCC) and care management (CM) services. Included here are is information about various mental/behavioral health and medical conditions and associated evidence-based treatments tailored for the primary care setting. These materials have been vetted by content experts from the related professional disciplines.

Foundations Training Manuals

Foundations for Integrated Care: Behavioral Health Solutions for Primary Care

Alcohol

Anxiety

Anxiety Monitoring Form

Arthritis

Asthma

Asthma Information Sheet for BHPs

Cancer

Cardiovascular

Cardiovascular Information Sheet for BHPs

COPD

Dementia

Dementia Information Sheet for BHPs

Depression

SSRI-SNRI Withdrawal Symptoms

Diabetes

Drug Abuse-Dependence

Endocrine

Gastrointestinal

Hypertension

Hypertension Information Sheet for BHPs

Lupus

Lupus Information Sheet for BHPs

Military Information

Military Facts for SW Information Sheet for BHPs

Military Sexual Trauma

Mobile Apps for Veterans and Providers

Mobile Apps for Veterans and Providers

Motivational Interviewing

Pain - Headaches

PTSD

Sexual Dysfunction

Erectile Dysfunction Information Sheet

Sleep Disorders

Stroke

Stroke Stats

Tinnitus

Tinnitus

Tobacco

Websites of Interest

Websites of Interest for PC-MHI Integration

Weight Management

Weight Management Information for BHPs

PCMHI Measures

Measurement-Based Care (MBC)

This section of the CIH website contains validated self-report measures for screening and assessing common mental and behavioral health concerns (e.g. depression, anxiety, PTSD, substance use) and are recommended for use in primary care/mental health integration (PCMHI) programs. These measures support implementation of Measurement-Based Care (MBC) as tools for assessing functioning and symptoms at initial visits and throughout the course of treatment as part of routine practice. We have also provided practical guidance for implementing measurement-based care in your PCMHI program.

At initial visits, self-report measures can be used to collect data to inform clinical decisions, including whether to follow a patient for brief follow-up in PCMHI or a refer to specialty care. The PCMHI provider can share this data with other PACT members involved in the patient’s care to succinctly inform about symptom severity. This information can also be shared and discussed with Veterans, as part of shared decision making and treatment planning. As the PCMHI provider continues to administer measures at follow-up visits, the provider and the healthcare team can then act to coordinate care and adjust the treatment plan as needed, based on the patient’s response to treatment. Adjustments to the intensity of the treatment can be made based on collaborative decision making that includes MBC data along with input from the Veteran and other PACT members.

Below are five brief measures that have been designated for use in PCMHI programs, along with important information about how to appropriately calculate and interpret scores. The final link provides a tool that combines the five most commonly used measures (i.e. PHQ-9, GAD-7, PCL-5, AUDIT-C, and BAM) in a single document for easier administration.

In addition to these specific measures, we have also included a summary document providing practical guidance describing how you can establish a foundation for use of Measurement-Based Care within your clinic.

Creating a Foundation for Measurement-Based Care

FAQ

Frequently Asked Questions (FAQ): Primary Care-Mental Health Integration

Business Operations

What is a stop code and what stop codes do we use in PCMHI for our clinics?

A: Stop Codes (formerly known as DSS Identifiers) are built into each clinic and identify workload for all outpatient encounters, inpatient appointments in outpatient clinics, and inpatient professional services. They are the single and critical designation by which VHA defines clinical work units for cost purposes. Stop Codes assist VA medical centers in defining workload to support patient care, resource allocation, performance measurement, quality management, and third party collections. They are a six-character descriptor composed of a primary stop code and a credit (secondary) stop code. Primary stop codes indicate the workgroup responsible for providing the specific set of clinic products while the Credit or secondary stop code further defines the primary workgroup, such as the type of services provided or the type of provider.

Additional information on Stop Codes can be found at VHA Directive 1731 Decision Support System Outpatient Identifiers.

To view stop codes to be used for PCMHI clinics, click here.

Further guidance and examples for stop code usage in PC-MHI programs are available here: PCMHI Stop Code Guidance.

What CPT codes should I use in PCMHI?

A: Mental health encounters provided by PC-MHI staff working within the discipline-specific Patient Aligned Care Team (PACT) are expected to be brief and problem focused. In some situations, longer visits are necessary.

To view a list of CPT codes for use in PCMHI, click here.

Please reference the PCMHI Workload QuickGuide in the Mental Health Business Operations SharePoint for the most updated guidance.

Can I code for team conference when I do curbside consultations with PCP providers in PACT?

A: No, unfortunately there are not CPT codes for brief curbside consultations with other providers in PACT. The team conference codes have very specific requirements for utilization and will rarely be used by PCMHI providers. These requirements are outlined below.

The 2013 American Medical Association (AMA) CPT Manual included three (3) new Team Conference codes for documenting team meetings with a minimum of three qualified health care professionals from different disciplines meeting for a minimum of 30 minutes. Two team meeting codes (99367, 99368) are available without the Veteran or collateral present, and one code (99366) is available for non-prescriber led team meetings with the Veteran. For Outpatient/Inpatient Team Conferences with Prescriber present and patient/ family present, the prescriber can create an encounter using the appropriate E&M code for the setting (99201-99215, 99241-99245, 99324-99337, 99341-99350) in conjunction with the appropriate Prolonged Service code (99354 or 99356) reflecting face-to-face patient contact beyond 30 minutes. Following the first hour of prolonged services, each additional 30 minutes of direct face-to-face patient contact may be reported by the respective CPT code (99355, 99357).

Clinical team conferences/case management can be captured as separate workload when the AMA criteria is met utilizing a Team Conference Clinic and Stop Code 673. The team conference codes include a time component and allow reporting only for conferences lasting 30 minutes or more. Team conference services of less than 30 minutes are not reported. Team conferences by physicians that involve both face-to-face and non-face-to-face time are reported using the appropriate E/M code. Team conference codes are not reported separately if reported using E/M codes.

Name

Stop

Code

Primary, Secondary or Either

Definition

Clinical Team Conference

673

S

Records a formal medical/clinical team conference for the formulation of an integrated plan of care without the presence of the patient or collateral. There must be face-to-face participation by a minimum of three qualified health care professionals from different specialties or disciplines each of whom is providing direct care to the Veteran. The participants must be actively involved in the development, revision, coordination, and provision of health care services needed by the Veteran. Participants shall have performed face-to-face evaluations or treatments for the Veteran independently of any team conference within the previous 60 days. The result of the conference is the integration of new information into the medical treatment plan and/or modification of medical therapy provided to the Veteran. Team conference services of less than 30 minutes are not reported.

When documenting a team conference with the Veteran present and face-to-face participation by three or more qualified health care professionals from different specialties or disciplines, the provider with the highest level of credentials should be listed as the Primary Provider. All other participants should be listed as Secondary Providers. If there are multiple providers with the same level of credential, the team can decide on whom to list as Primary Provider. Time spent discussing the patient must be documented as the patient must be discussed for at least 30 minutes to be a codeable event. All providers listed on the encounter will receive the workload credit. Each provider must enter documentation of their involvement in the team conference, either by addendum to the "parent" note or as a separate note linked to the one appointment.
Utilization of the Team Conference Codes requires that all reporting participants have performed face-to-face evaluations or treatment with the patient, independent of any team conference, within the previous 60 days.

What stop codes and CPT codes do we use for e-consults in PCMHI?

A: Stop codes for e-consults should be set up using 534 as the primary stop and 697 as the secondary stop. An additional CHAR4 code is also needed. E-Consult clinics need to be classified using a DSS CHAR4 code, which is assigned during clinic set up by your DSS site team. Below are the approved alpha codes to be utilized by mental health providers. Clinics must be set up utilizing the appropriate alpha code to assure EConsult workload is accurately captured.

National Four Character Code	Clinician
CLSZ	Psychologist, Social Worker, Licensed Professional Counselor, Licensed Marriage and Family Therapist
ECOP	Clinical Pharmacist
CNSZ	Physicians, Psychiatrists and providers not identified in another category
APSZ	Nurse Practitioner and Clinical Nurse Specialist
PASZ	Physicians Assistants
RESZ	Resident/Fellow

I do a lot of work that is not captured in CPT codes. Is there any guidance on how to have my productivity target reset to be appropriate for my work in PCMHI?

A: Not all important patient-specific work meets the VHA definition of a clinical Encounter or meets the established criteria for CPT coding. For example, some work, such as a Team Conferences without 3 different professions present, does not meet the definition necessary for CPT coding, but is still vital patient-specific work. To account for this critical clinical work, facilities can develop individualized wRVU targets, complete position-specific time-studies, and establish local workload expectations based upon the unique features of that position. There have been some national presentations providing guidance on setting individual provider productivity targets in general as well as specifically setting targets for PCMHI providers, which will likely be assistance to you in speaking with your supervisor about the need for setting an individualized target based on the specific context of working in PCMHI.

What do the numerator and denominator stand for in PACT 15?

A: PACT 15 is the percentage of primary care patients engaged in PCMHI. According to the Electronic Technical Manual,

Numerator: The total number of assigned primary care patients seen in primary care mental health integration (PCMHI) during the past 12 months for required divisions.

Denominator: The total number of assigned primary care patients (Team Assignments) at required divisions

To view the full definition from the technical manual, click here.

I need to create functional statements and performance plans for our PCMHI providers. Are there any examples available?

A: Yes, there are several examples on the CIH website here.

What dashboard tools are available to help care managers easily identify new patients on antidepressants that may be candidates for care management?

A: Care Managers may wish to use the MDD43h and MDD47h drill down tool to offer engagement in Care Management for those newly prescribed an antidepressant appropriate follow-up. This offers a listing of each patient, who prescribed the medication, the type of medication prescribed and when it was initiated, when the patient last refilled the medication, the number of refills left, and upcoming mental health and primary care appointments, as well as additional helpful information.

Where can I find a listing of all the mental health data dashboards? I can’t seem to find everything.

A: Nearly all relevant dashboards for mental health and PCMHI are available through the Program Evaluation Center (PEC) portal. The portal is organized by the following subsections: Mental Health Balanced Scorecard (contains SAIL, Mental Health Management System, and Mental Health Information System), Satisfaction, Care Continuity, Access, Staffing and Productivity, Prescribing Safety, Clinical Outcomes, and Specialty Programs. The PCMHI Dashboard and PCMHI Same Day Access Dashboard are hyperlinked under the Specialty Programs tab of the PEC Portal.

How do I get workload credit for PCMHI face-to-face interventions that last less than 15 minutes of time?

A:Simply answered, you cannot. Brief interventions of less than 15 minutes, while invaluable for care in the primary care setting, are not able to be captured with our CPT codes. Utilization of CPT codes must follow CMS standards. In order to code a 90832 (psychotherapy face-to-face with patient and/or family member) there must be a minimum of 16 minutes face to face service. This CPT code is valued at 1.50 wRVU. Initial appointments for health and behavior interventions can be coded at 15 minute intervals for those being treated for a medical condition and being provided a health behavior intervention (e.g., 96150 – Initial Health and Behavioral Assessment each 15 minutes face-to-face with the patient, .5 wRVU). Regarding the use of 99211 by RNs, while RN's can utilize this code it must be a part of a larger episode of care with the E/M service provided. This is not intended for independent utilization in the provision of psychological services. For more information on this code please see: http://www.aafp.org/fpm/2004/0600/p32.html . Additionally, you may not code a 90832 or 96150 with the Modifier 52 for reduction of services. The Modifier 52 is used only for medical procedures, not psychiatric procedures (e.g., disruption of a surgery which cannot be completed). Stopping psychotherapy early or failing to reach the minimum time needed to bill is not a partial procedure. Use of the modifier 52 to code time less than appropriate for the Psychiatric Code is inappropriate.

As directed in our PCMHI coding guide, consultation with your local HIMS expert is recommended. Briefer interventions should still be documented in the record with use of the historical note which will not require entry of a CPT code.

Please note it is much better to work with local supervisors to create appropriate productivity targets that are individualized for work in PCMHI settings. This is what is needed to address the concern. We run the risk of fraudulent coding practices otherwise. There is a full presentation on setting appropriate productivity targets in PCMHI settings that was given in November 2016 which can be accessed here. Consider sharing it with your supervisor and having a discussion about the important interventions you are doing that can’t be captured with a CPT code but are of great value to the Veteran and the primary care team.

Do we need to schedule appointments in VistA for PCMHI care management follow-up appointments?

A:Yes, according to VHA Directives 1230 and 1231, planned appointments, whether by telephone, video, or face to face, require a scheduled appointment in the scheduling package. Initial appointments, if not completed same-day through warm hand-off, must have an administrative consult sent from Primary Care and also be connected with a scheduled appointment in the scheduling package.

Policy Requirements in PCMHI

Are mental health treatment coordinator assignments required in PCMHI?

A: Mental health treatment coordinator (MHTC) assignments are not required in PCMHI. From the 2012 memo on MHTC identification, there is an attachment which specifically excludes the PCMHI stop codes.

What types of treatment plans are required by Joint Commission for PCMHI?

A: The PACT is responsible for the overall treatment plan of the patients seen in PC-MHI programs and the programs are surveyed under the ambulatory care standards. Within that treatment plan, the MH problem is identified. The PC-MHI providers are responsible for that portion of the overall plan but this does not require the comprehensive plan usually seen in specialty settings. It is brief and addresses the problem at hand. This plan may then be incorporated into the PACT treatment plan. This information is taken from the embedded newsletter article below. Additional information is available in the 2014 memo and its Attachment A.

PCMHI Treatment Plans and Joint Comission

What are the requirements for Primary Care-Mental Health Integration?

A: VHA Uniform Mental Health Services Handbook (1160.01) outlines that facilities must have embedded primary care-mental health integration providers (Co-located Collaborative Care [CCC]) and have PCMHI care management at all required primary care clinics (i.e., medical centers, very large CBOCs, and large CBOCs – clinics serving more than 5,000 patients per year).

How is PCMHI Care Management different than PCMHI Co-Located Collaborative Care?

A: PCMHI care management, along with co-located collaborative care, is to be available at VA medical centers, very large CBOCs, and large CBOCs must have integrated mental health services that operate in their primary care clinics. The PCMHI care management component can be based on the Behavioral Health Laboratory (BHL), the Translating Initiatives for Depression into Effective Solutions (TIDES) model, or other evidence-based strategies approved by the Office of Mental Health Services. It must include:
(a) Monitoring adherence to treatment, treatment outcomes, and medication side effects;
(b) Decision support; (c) Patient education and activation; and
(d) Assistance in referral to specialty mental health care programs, when needed.

I know we are supposed to have a service agreement for Primary Care and PCMHI. Where can I find an example?

A: There is an example available on the CIH website here along with its appendix. This presentation may also be of assistance to you as you work on developing one of your own.

Same Day Access in PCMHI

Are the expectations for Same Day access only met through the Primary Care-Mental Health Integration clinic?

A: Same day appointments can be completed in any appropriate Primary Care, specialty care, and mental health clinic, such as PCMHI, General Mental Health, Substance Use, etc. If PCMHI care management is to be utilized for same day access, the primary care provider must complete the initial evaluation screening to meet the in-person requirement.

Are PCMHI Care Managers able to complete the same day screening evaluation?

A: In order to fulfill the requirements of the November 25, 2014 Memo and current guidance, referrals from the PC to PCMHI should be conducted by CCC or PC providers. If referred directly to CM, PC must complete the initial screening evaluation.

How are Open Access PCMHI clinics structured?

A: Facilities can implement the PCMHI warm-hand off model that they believe works best for their facility, providers, and Veterans. Options include:

Full Open Access: providers have completely open grids. Patients are seen on a first come, first serve basis. This model is often effective where this is more than one PCMHI provider available to cover the clinic.
Alternating scheduled and unscheduled 30-minue appointments: Same day access is managed by alternating scheduled and unscheduled appointment slots. This is a model that may work well for sites with only one provider who is skilled in providing 30-minute appointments and can maintain fidelity to the PCMHI model.
Access based upon clinic flow: PCMHI clinicians have clinic open appointment slots during peak clinic times allowing for a warm hand-off with the PCPs. Utilization of vitual providers during peak clinic times can be utilized to expand provider availability during times of increased need.
Open Access Pager: for facilities with multiple providers, a provider can be assigned an open access schedule (e.g., ½ day rotation) allowing for unscheduled appointments and walk-ins. Typically, providers share a single pager, so that PACT members have a single number to call for an immediate warm hand-off.
PCMHI Care Management: Some clinics have created same-day access to PCMHI care management services by providing either open/advanced access to the initial PCMHI care management baseline assessment in person within the PACT setting. In this model, it is critical that the PCP completes the required initial screening evaluation necessary for mental health referrals.

How is success in PCMHI same day access measured?

A: Success has clinical and administrative implications. Warm hand-offs are critical for patient engagement. The frequency of warm hand-offs is reflected in the metric PCMHI5, which is defined as the frequency of same-day PCMHI appointments which follow a PCP appointment. A facility's local performance on same day access to mental health within PCMHI by reviewing PCMHI5 data available here. Additionally, a new PCMHI5 dashboard is available to provide real-time updates on success (PC-MHI Same Day Access Dashboard).

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