Okay, so welcome. We're going to be talking about real-world solutions to implementing and sustaining the collaborative care model. My name's Anna Ratzliff. I work at the University of Washington, and I co-direct the AIM Center, which is the Advancing Integrated Mental Health Solution Center, which does a lot of work around implementation of collaborative care. And I'm really excited, actually, to spend most of the time today hearing about people who are actually doing the work of trying to make sure we can pay for and implement this model out in the real world. So I think especially for those of you who are maybe thinking about doing that or in the middle of doing that or well into doing that yourselves, this would be a great opportunity to have an exchange around some of the challenges that come up and some of the solutions that are helpful around implementing collaborative care. So I would just like to take a little poll of the audience to get a sense of who's here. How many people have or are working in an implementation of collaborative care already? Okay, so a good number of our audience members. Okay. And how many of you are thinking about collaborative care? That's one of the reasons why you're here? Okay. So almost everybody has some relationship to this work, so that's great. And I hope that this is helpful today. We are going to be doing... I'm going to do a very high-level overview of just what I mean when I'm saying the collaborative care model, so we all are starting from the same place. And then we will have a great presentation around thinking about the payment and how that's worked in Michigan. And then we'll hear from Dr. Kateh around his implementation in Emory. And then we'll hear from Dr. Jen Thomas, who I really appreciate is a primary care provider. So here, especially if you guys are working on those partnerships, I think she has a great perspective on how you might partner. And she really leads her collaborative care effort at her hospital system in Illinois. So you guys are going to get a great range of kind of experiences from academic and payer all the way down to real world and sort of rural areas, really. I've seen your clinic that's in the cornfields. Okay, so I'm going to just start with a little bit of an introduction. Let me just make sure that it's clicked on here. There we go. So I have disclosures to make. I receive royalties to my department for a book I wrote on integrated care. Okay, so I always like to start whenever we start any conversation about the collaborative care model with the patients, because that is why we're doing all this important work. And this is data from 2005, which I think may be even worse right now. If you look at some of the data on the CDC, they have these amazing pulse surveys where every four weeks they're kind of saying, how many of you have a mental health disorder? How many of you are getting treatment for it? So if you haven't looked at those, they're really interesting. And a little scary is what I personally feel. So in reality, in most populations, about 60% of people who have a diagnosable mental health condition are not receiving any care or are engaged in self-management. Of those patients that are receiving care, a lot of that over, so about 20% of the total population, half of the patients getting treatment are actually receiving that care in a primary care setting. And only about 20% of patients are actually seeing a mental health specialist. About 11% of those seeing a psychiatrist. And these data have been repeated and look pretty similar across time. And I think what this means, and how I look at these data, is that if we think about how are we going to engage those patients that aren't getting any care at all, I think the entry point of primary care is a really important place to be thinking about how do we improve engagement and the quality of care delivered there. And hopefully if we can expand that, we're also going to be benefiting our specialty care system because we're expanding capacity overall. I think it's always important to talk about why we can't just refer people from primary care out in the community to mental health treatment. I think of both patient and provider factors. So from patient perspective, a lot of patients when they get a referral just don't go. And I think that's complicated. There's a lot of reasons that go into that. I think right now it's actually hard to get connected anywhere else, honestly. I don't know about you, but many of my patients will end up calling 10, 20, 30 people, leaving voice messages, trying to get in on their network and sometimes get ghosted by all of them. So I think it's actually really hard for patients. I think it's also hard sometimes logistically for patients to go to other places. So sometimes they don't stick, even if they do go. There are also really important provider factors for us to think about. These data that I present with this map is actually representing the level of need across counties in the United States. And essentially about 96% of the counties in the United States have some level of unmet need for prescribers. The darker the shading, the more unmet need there is in that county. And you can see that if you live in a rural area, it's like basically 100% unmet need in many counties. And I think that's an important thing to think about. Even if we... I run a residency program in addition to my collaborative care work, and we expanded by four psychiatrists in the last couple of years that we're training each year, that is never going to make up for 100% unmet need. And so I think we're actually always going to be struggling with having enough prescribers. So having ways to really leverage our scarce psychiatric resources across populations is a really important thing to be thinking about as we're trying to build out systems of care. So this is how I think about the continuum of care, that there really is probably a lot of patients that are going to be served in primary care or self-management on their own. But hopefully we can expand the number of patients that are actually receiving integrated care or mental health services in primary care settings. I think that if we can expand that green band, that we're hopefully creating more space for the patients who really need direct patient care. And there always will be patients that need that direct services, but that this might allow us to kind of get the patient to the right level of care to get them better while leveraging our resources really effectively. So this is the vision. And we'll talk a little bit about how we might continue to work to get there. I'd just like to give a little history about the collaborative care model and why I think that that's a really important part of this solution. The collaborative care model is an evidence-based model. I really think that there was the recognition that depression and anxiety and mental health disorders are a primary care problem. Really, you see that in the literature in the 80s and 90s, where you see sort of this large number of patients that are like, oh my gosh, there's depression in primary care. So those were kind of the foundation for what the work then happened in the 2000s, which was basically saying that there, you know, how can we address this? And during that time, there was a large number of randomized controlled trials really testing what, you know, what could organizing and delivering mental health care in a primary care setting look like to be effectively able to treat patients. And from those data, you really found that in all of these 80 studies, if you organize care using a few key principles, you probably can double the effectiveness for depression and anxiety treatment. I think right now, since the 2010s and kind of beyond, people are like, this is established. We know that this is a strategy to do this. And I think what you see now is a lot of research looking at expanding the populations of patients, making sure that this works for different populations of patients. And then also a lot of work around how do we implement this well? How do we actually get this started? And what do we need to continue to deliver that care well over time, our sustainability? So we'll be talking a tiny bit about that. And I think each of our presenters will be touching on those important topics. I just want to say, if you want to learn more about what the patient experience of collaborative care model is, I really encourage you to check out Daniel's story. He was one of my patients when I was delivering collaborative care in primary care settings. And he is generous with telling his story, he and his mom, about what collaborative care meant to him. And I think this is, you know, also when you're trying to share why you might want to do this with other people, the patient perspective is a really important piece to pull on. So I just wanted to make you aware of that video. So I'm going to talk a little bit about what the core elements of collaborative care are. And I'm going to use the largest randomized controlled trial to date of collaborative care to describe that. So I'll be describing the IMPACT study. This work was done by Dr. Juergen Unitzer, who is our chair of our department. So, you know, I'm speaking of his work. There were 1,801 patients enrolled in this trial. This was done in the early 2000s. And what this model really tested is usual care, which is you can do anything you want in primary care setting. You can refer out, you can prescribe medications. If you have a co-located therapist down the hall, you can go ahead and involve them. And they compare, that was usual care. So half the patients got that. And the other half of the patients got collaborative care. And what collaborative care in this trial was, was that the primary care provider and the patient were supported by two new team members. The first one was the behavioral health care manager, who is typically a social worker or a nurse or another licensed mental health provider. That person has two main responsibilities. One is care coordination, which includes regular gathering of measures. So for depression, for example, the PHQ-9. So both for screening and then for follow-up. Management of a population health registry. So this is the list of all the patients that have been identified as needing collaborative care. And that list is really important for driving engagement and focusing the work of the team on the patients who weren't improving. This person also helps offer the full range of treatment options to patients who are in primary care settings. So those behavioral health care managers are trained to be able to deliver brief evidence-based therapies for primary care settings, like problem-solving therapy, behavioral activation, motivational interviewing, and also support engagement in medications that are prescribed by the primary care provider. This team is also supported by a psychiatric consultant. In this role as a psychiatric consultant, you typically are not seeing the patients in person. What you're doing as a psychiatrist is actually meeting with that care manager for a week each, sorry, meeting for them for an hour each week. And you're actually reviewing that list of patients and providing consultation, mostly indirect consultation. So reviewing notes, talking to the care manager, and then writing a set of diagnostic information and treatment recommendations. So in this model, when you actually compare what happened in usual care to collaborative care, twice as many people improve when they receive collaborative care. And I always like to say, nothing that we were doing in the collaborative care trial was different than what was available. It's just that they organized it in a different way. I'm losing my voice. What they did is they really systematically measured whether or not the treatments were getting patients better. And when they weren't, they were changing those treatments. So I like to think of collaborative care as a way of organizing the things that you need to do to get patients better and making sure they happen consistently and well. And so that is really what I think collaborative care is. And when you do that, not only do you improve depression outcomes, there's often less physical pain, better functioning, higher quality of life. When you ask patients, how did you like getting treated this way, there's patient satisfaction. PCPs really like this once they get to work in the model, because they get a sense of having a partner to do this hard work. And in the original impact trial, they actually looked at return on investment. So they basically kept track of how much did it cost to deliver collaborative care, and then what were the health care spending for those patients over the next four years. And what they found is there was an upfront cost of about $500. But over the next four years, the patients that had received collaborative care had a savings of about $3,500. So this is a return on investment of a little over $6 for every dollar spent. Most of those savings were in physical health care costs. So most of the patients who had received collaborative care had less health care spend on physical health needs. And I think that makes sense, right? Because if you're not depressed, you're probably going to be better engaged in your care overall and probably be healthier. So that's really one of the things that collaborative care can deliver. I just want to touch briefly on health disparities for racial and ethnic populations. So we know that although there's a prevalence of mental health conditions that's equal in racial and ethnic populations, they are often less likely to receive access to mental health care services and more likely to receive lower quality of care and have worse mental health outcomes. And I think collaborative care also has an important role in trying to address disparity. So if you actually look at the subpopulations of patients that were treated in the IMPACT trial, what you see is that the black patients had actually equal to or even more improvement than the white patients that were enrolled in that trial. And that was a similar outcome for the Latinx population that was seen in this trial. At the University of Washington in the AIM Center, we have supported an implementation project that was in clinic systems that served large American Indian and Alaska Native populations. And what we found is very similar to the IMPACT trial. There was no control because this was an implementation, but we saw outcomes in our Alaska Native and American Indian populations that were equal to or a little bit better than the white patients that were served by collaborative care. And so I just wanted to make sure you're aware that there are these data as well around what collaborative care might be able to offer. So we now have a strong evidence base for collaborative care. That's why we're talking about implementing it. It now has been shown to work in a lot of different populations and conditions. The bipolar disorder I've moved over to evidence-based established because those data have come out recently from John Fortney, who's a colleague in my department. They had a large trial called the SPIRT trial that really showed you can use collaborative care to deliver treatment for bipolar disorder in rural populations. So I do think it's, you know, we are ever expanding the list of conditions that this might be helpful for. I'm going to just touch, you know, one slide on implementation and one on sustainability because that's what we're going to really spend the rest of the time talking about. I will say we've been thinking a lot about implementation. I had the opportunity to partner with the American Psychiatric Association to really train people, specifically psychiatrists in the collaborative care model. And we trained over 3,500 psychiatrists in that four years that we had that grant. The training materials from that are still available for free on the APA web, you know, integrated care site. So if you haven't ever seen that training, you can still do it and it's available there for you. And I think that really excitingly in the last five years, we've also seen Medicare start to acknowledge the value of collaborative care with actually creating CPT codes to pay for this. These codes are a little different than your typical fee-for-service codes because they really are meant to pay for the work of the team over a month. So they're billed once a month. And we're going to hear a lot more about them, so I'm not going to spend a lot of time on them. I just wanted to make sure that you were aware that there are now new payment mechanisms. And that's a really important thing, I think, for sustainability because we saw that without a funding source to pay for working in a different way, it's really hard to sustain collaborative care. Okay, so that is a whirlwind tour of what collaborative care is and a little bit about implementation and sustainability. I really wanted to spend the bulk of our time today hearing from our presentations from practice. So we'll start with Dr. William Beecroft, who will speak about Michigan and the implementation of the codes. We'll then go to Brandon Conteh and Jennifer Thomas. We are actually going to, if there's time, each person has about 20 minutes and they'll try to answer a few questions during their presentation. But please write them down if you have them because we will have about 15 minutes at the end of the three presentations to have more of a discussion and answer additional questions then. I'm William Beecroft and thank you for your time this morning. It's afternoon almost in my time zone. And we'll go for a little bit of a whirlwind tour on how to be able to make this sustainable in a insurance plan. But my practice was in the real world as a consultation liaison psychiatrist in a relatively small community hospital up in Lansing, Michigan. And I did this for, I did the psychiatric work for this for 35 years of my practice every morning on rounds working with my colleagues. So that's where I come from. I think you know this, the issue, you know, we've got a significant psychiatric need in this, in this country. 57% of adults don't get the psychiatric care that they need. 26 million individuals experience a mental health condition at any one point in time, essentially all the time. Quarter of adults with mental illness reported that they're not able to receive treatment that that they need. And the biggest crisis that we've got right now by the American Association of Child and Adolescent Psychiatrists identified it is the suicide crisis in kids. Now we have also a suicide crisis in adults too, but this one has been truly identified. And what this looks like in in the graph over here on the right side of the screen is that the areas in the states that have highest level of psychiatric care capabilities and then lower levels, but even in the highest level states, we still have 50% of kids that aren't getting care that they truly need. So how do we move forward with this? How do we get something that can be helpful? Well as psychiatrists, we know there's not enough of us. We can't do this alone. We have to partner with our primary care colleagues and really engage them. And at this point, I'll get to this in a minute, but I think they're at the place that they're willing to do this with us to be able to help their patients get better. And remember, collaborative care is a medical fee schedule issue. Psychiatry is involved, but it's not a psychiatric primary treatment. It's an intervention from the primary care space. So looking at something that's population-based, doing screening for everybody, PHQ-9s, GAD-7s, and be able to treat the target. We've heard this from Dr. Nasrella over and over and over again the last 15 years, but we really do need to engage in doing this as a system. We do this for diabetes. What do they follow? Follow A1C. And you got to get your A1C below seven. And if you don't get it below seven, you don't get your value-based reimbursement as a primary care doctor. Same thing here, working on the PHQ-9 and GAD-7. Measurement-guided, evidence-based. There's over 90 different studies that show that collaborative care is an effective treatment idea. And as psychiatrists, we were always trained to be able to work in teams. The primary care specialists, colleagues, they've not been trained to do that. So they need our help to be able to learn how to work effectively in a team and work to the best of our abilities. The new components of this are the asterisk identified areas. The psychiatric consultant, you're not seeing the patient directly. You're being able to be presented the cases. And it's a different world to be thinking about this as a psychiatric consultant. In the training, the APA's put together. Thank you very much for the assistant on that. It really identifies this, but it's very fast-paced once you get going and getting this team more effective. Many times in our training, we learn to be able to kind of synthesize the whole case and understand this in depth. That's not what you're doing here. Person has a PHQ-9 of 16. They were started on Prozac six weeks ago. No improvement, PHQ-9 is now 17 or 18. They had a little smattering of some CBT, but only two or three sessions. What do you do, doc? You answer, keep the Prozac the same, probably optimize the dose, get them into CBT a little bit more aggressively. Do they have another component of their disorder, such as a borderline disorder that may need a different psychotherapy, such as DBT in addition to the CBT? Move on to the next case. That's how quickly this happens. And with that, the advantage is, is that we can leverage the resource of the psychiatrist substantially. I've talked with people around the country that have been doing this. Again, I did it for years. I capitated, or capped at about probably 600 to 700 patients that I could see face-to-face in my practice. In this model, I believe firmly that you can see between 2,000 and 2,500 cases that you'd have psychiatric influence on. Not direct care, influence on those cases. So it's a really substantial way of being able to influence more care. What's the business case for this? We've already heard about the impact study. I won't go into much detail beyond this. But what you're looking at is being able to make the case, if you're a psychiatrist working in a plan, insurance plan, be that public or private, working in a hospital system, working in a ACO, working in a capitated group, this is the document that you really need to go back to. You need to have them look at their patients that they have penalized, and look at the total overall medical and surgical spend, and the overall spend for those individuals. You'll find that the behavioral health spend is fairly low, but the behavioral health cases that are seen that have also a medical surgical comorbidity, those people cost you twice or three times. And in one case, there's a combination of COPD, hypertension, diabetes, and depression, which will cost roughly four to six times, depending on which study, but Milliman pegs it at between four and five times the overall medical spend. The medical spend is in ER use, ICU use, hospital use, all kinds of other things that we don't cost that much. The medical surgical side costs a whole lot more. So that's where you really have to make the case in your own organization to look at their own data, and then they'll be able to see the value of this and move on going forward. We had some early adopters back in 2012, there was some grant funding that was going around that was very effective for people to kind of get interested in this. And we had about 25 different provider organizations in Michigan that did this on their own. So they were really looking at how to be able to ensure that co-care claims would be processed by as a medical service, not a behavioral health service. In many insurance plans, they carve out the behavioral health component, the MBHOs, the Magellans, other companies in this kind of business of doing that. And they carve out all of the behavioral health diagnoses, the F0000 to 0999. And so if a primary care doctor was to treat depression, it wouldn't pay. So you have to be able to get the configuration correct in those systems to be able to pay in the primary care setting for these codes. Looking at getting the problems with the codes that CMS has outlined corrected in the insurance plan. The way CMS has it organized, you can only do two hours of co-care a month. Many of these cases are so complex that you can spend at least four or five hours on the first session with them, being able to get the social determinants of health, be able to get financial resources for co-pays for their medications, their psychotherapies, these sorts of things. So we did that. We changed the, because we have a Medicare Advantage plan, Medicare Advantage in 17 mandated this, or Medicare did, and then we put it into our commercial plans. So we can be able to do that as a plan. As an individual practitioner, you can't. So they have to work with the plans to be able to make that happen. But we took off the limitation on the 9-4 code, if you know what I'm talking about. And that's the one that's the half hour additional add-on code. And we've not seen any abusive use of it. So in that sense, people use it appropriately to be able to get the care that's needed for those individuals. And it does drift down after about four to six months to about two hours a month. But you have to get it right to begin with. We had to teach our companies that purchase our insurance and we also had to teach our membership how to be able to access these services. We partnered as far as our training partners with a large Michigan university and also a Michigan-based clinical systems improvement organization. That was able to hit geographically east side and the west side of Michigan and then all the way up to the upper peninsula for the training of our practices. And we had some practice transformation funds that we've put aside over the years in the plant, and this is Blue Cross Blue Shield of Michigan, to be able to pay for these kinds of services that are transformative for practice. And we decided to use those, the senior administration did. So what we have is a two-day training course with CME accreditation. We pay for the practices to close. The whole team needs to come. The physicians in the team don't need to be there more than a half day, but the rest of the team is seen. If they stay the full 24 hours, they get 24 hours of CME. We have a incentive for the provider organizations. We have about 40 organizations in Michigan that they're usually associated with. They may not be, they may be independents, but we have encouraged them to be able to help their practices to be able to do these kinds of services. And this is really transformational for a practice to do. With that, we have, it's not just the two days. We go on for a full year with ongoing webinars, discussion groups, site visits, being able to do case review shadowing and consultations. And I won't spend much time on the testimonials, but the patients love it. That's the testimonial. And the providers, you know, I go to these regional in Michigan primary care provider conferences. And the docs are always coming up to me and saying, you know, hey, 74% of us are burned out. 85% of us are burned out. We don't love medicine anymore. We wanna be a carpenter. And after a year in this, I've had doctors that have gonna be retired, keep on going with it. They love it. They, after a year or so, they start saying, I love being a doctor again. And as a society, we can't afford to let these doctors go. It costs about $2 million for our society to be able to bring a primary care doctor to practice. So we have to be able to work with our colleagues to be able to make that happen. I'll speed it up a little bit here because I know I'm running slow back on time. But you look at our timeline, we've done this very, very quickly and being able to move forward with this. We've removed the barriers, did all that configuration internally, be able to do all that training, setting it up, the curriculum development, and being able to move forward. And we've also used the AEM Center to be a really helpful consultant in this whole development. And this is what we have now, two years later. This 180 is an old number of six weeks ago. We're at about 200 practices now. We have a adolescent pilot, and I'll get into that in a minute, which we've had our pediatricians have asked us to develop a separate module, which we took six months to be able to put together a curriculum, trained up that. It's an add-on module to the base co-care program. And we have roughly 600 individual practitioners. And last year, we paid out to 800 practitioners that they actually treated patients with these codes and with this service. Now, if you look at how collaborative care works, you don't get the full benefit of this until year three. So we're in year one and a half to two. So that's where we get the 800 that there's been some in here. But this represents about 4,500 individual patients that have been given treatment through this model. The adolescent model is a little bit different because you have this sidebar over here. And with adolescents, there's, I get it, if I can get it, if I can show you there. The community-based services, therapy, working with a therapist, looking at the health coaches, the community health workers in the community, being able to coordinate with schools, parents, being able to look at coaches, other entities that this child becomes involved in is what the behavioral health care manager is doing as far as their work. It's substantial, it's hard, and the number of patients that they can manage consequently is a lot less. You're looking at between 30 and 60 patients that they can manage, whereas in adult practice, you can usually be tuned between 60 and 80 patients and being able to have your caseload. Cases that are really good, that are probably not good candidates would be ones that are unable or unwilling to communicate with you, with the behavioral health care manager, their primary care doctor. No buy-in from the guardian or parent, that's just not gonna work. You're not gonna get anywhere in those cases. Significant developmental disability, uncontrolled bipolar disorder, psychosis or delusional disorder when it's unstable. Now, this model can take care of people that have schizophrenia, bipolar illness, severe personality disorders when they're stable and when they've kind of gotten back into a maintenance phase, and they can identify quickly when they're going out of that maintenance phase, and that's the trick here, because you can catch them before they severely decompensate and get them to that secondary or tertiary level of care that they need early. A partial hospital program versus an inpatient, an IOP or a more intensive outpatient, or change their meds, that sort of thing. An uncontrolled OCD where people are really severely ill to the point that, I don't know if you were in the OCD lecture earlier this morning, but where the point they've already burned through the first two tiers, and they're moving to needing really significant interventions of residential treatment or even psychosurgery. Those patients probably are not best to be handled in this, in the acute phase, but once they're stable, again, they can be very well managed in this circumstance. So challenges, the code configuration is something that needs to be done by the individual plans, public or private plans. We're encouraging even CMS to review this in a variety of different places, so that that would be very helpful just to recognize how much time it does take. Reimbursement, the Medicare reimbursement is too low. You have to put a margin into this for the primary care doctor practice to be able to make some margin. It's not, you don't do this for free or losing money at it. Now, practices that are capitated and have a defined number of people that they have a economic benefit from, they see the benefit again because they're gonna be saving money on the med-surg side. So that's the key to make there. The issue of cost sharing, it's different with different plans, different ways of being able to do it, but we had a 55% dropout in our first co-pay that got dropped to that patient. So, you know, penny wise and pound foolish. You're saving $240 a year to lose money 750 to 1500 or so. So you have to make that economic argument to the plan. The current practitioner burnout, sometimes they just are so far burned out that they are unwilling and can't see the benefit of doing the extra work to be able to change their practices in this way. And the case manager and the psychiatric consultants to having adequate skills is really important. We really find that having a MSW is really the best to be able to put in that position. That doesn't mean that LPCs and LMFTs couldn't be doing this or a BSW. The reason for that is just the underlying training with LMSWs, they get some smattering of the medical component and you're doing an awful lot of medical work. You have to know that 70% of people with diabetes have depression. You know, pain, you know, six months of chronic pain, you're gonna have depression. Those kinds of things, med side effects, interactions, that's really helpful for your partner. As a psychiatrist, your partner is the behavioral health care manager and the PCP. But to have that understanding so you don't have to teach that right from the get go. Can be done, you can still teach it. And with that, I'll take questions or we can move on to the next. We can probably take a question or two if anybody has them. Sure. I may have mentioned it but I kind of missed, what entity does the training of the practices? Is that the state, is it an MCO, is it a separate company in terms of really getting this started with a given practice? So I didn't understand completely of it but I understand that what's the training? Yeah, what entity does the training? In other words, what organization? Is it a private company, is it managed care, is it the state? A couple different ways and I think you'll hear about some of those ways today. What we did as a insurance plan, we decided it was in our fiduciary best interest for the people in the state of Michigan to go ahead and just pick it up, put the training program together, engage in this case a large Midwestern university and this other think tank group to be able to be our training vendors to do the work for us. But we did it, we paid for it. And some people could say, are you crazy? You're thinking, why are you doing this? Because Medicare is gonna, Medicaid is gonna benefit from it. All the other insurance competitors in the state are gonna benefit from it. Well, yeah, they will. But so will the people of Michigan. And that's what we really did, is just that so will the people of Michigan and we just paid for it. I think we can take one more question and then somebody at the mic. Just considering the burnout factor among primary, the burnout factor among primary care physicians, how do you get their buy-in? You're asking them to take care of mental health issues in their practice. How to get their buy-in? Absolutely. And this is a question, it's a boundaries, it's a siloing that we've always had in medicine for a number of years. Took a lot of education. I was trained in internal medicine before I went into psychiatry. So I have a little bit of credibility in the community. I've been in Michigan all my career. Have a little credibility in the community. And being able to do that with looking at the benefits from that with the other providers that have done it already. And some of that's because of the capitated plans that we have. We have a large number of groups that are capitated. They saw the economic benefit. They are primary care and surgical ACOs. So bringing in the psychiatry was their request. And now other primary cares have seen that, seen the benefit of it, and they're starting to get the word out that this is really helpful. So it takes a lot of work. It's not just turning on a light switch. Thank you, and I'll be available for questions. Hi, Dr. Bickoff. Did you say you would take one more question? Is it a quick question? Yes. So I think I'm one of the collaborative care site consultants at Cherry Health. And the primary care physicians have really enjoyed the collaborative care model. And one of the challenges was the extensive training that they have to do. But now they can actually do a shorter one, I think, that's like a one hour, so that we can get more of them to buy in. But it's definitely reduced their burnout. At first, I thought it would be difficult because as a psychiatrist, I don't actually see the patient. I have a nurse, not a social worker, who's the collaborative care manager. But it's really working out really well. The challenge is just the documentation part because those templates aren't quite there yet, but. Yeah, that's an issue. But it does reduce a lot of burnout for both ends, yes. All right, so I'm Brandon Kitay. I'm the Director of Behavioral Health Integration for Emory Healthcare. And today I'm gonna be talking about how do we think about approaching collaborative care implementation in an academic health system. And when I say academic health system, you can think about that as your large, heterogeneous, very unwieldy, bureaucratic health system. So how do we think about approaching this? Here are my disclosures. As you can tell, I'm also a clinical trialist. I'm an interventional psychiatrist. So I really live at two ends of the spectrum, treating patients from a whole population base, and then really treating patients in a very highly specialized manner. The only disclosure I really have is I have received some honoraria working with Utsuka Pharmaceuticals on their PsyQ National Forum, in which actually we talked a lot about collaborative care and integrated behavioral health integration. And so the learning objectives for today, so from the perspective of a large, heterogeneous health system, my hope is that in the next 20 minutes, you guys will be able to recognize that collaborative care is one of many integrated mental health solutions amongst the landscape of integrated behavioral health options out there. I want you to be able to appraise the pros and cons of the collaborative care model for addressing barriers to mental health access, especially as you think about your health systems from which you're coming from. And I also want you to be able to conceptualize an approach to scalable change that may be adapted to your specific systems of delivery. So we're really gonna look at what steps do you take at the very early implementation stage when you're thinking about planning this process. And so a question for everybody in the audience, thinking back to where you're coming from in your practice environment, why should you implement collaborative care? Dr. Beecroft just gave us a great overview of why we should from the third-party payer perspective, and Dr. Ratzlaff gave us the abundance of evidence that supports collaborative care as a model, but why should you implement collaborative care in your health system? And really, we can also take this up a little bit, but why integrate mental health care at all? And so when I was getting recruited to Emory into the position that what eventually became this director of behavioral health integration, I asked that very same question. And this is the sentiments that I received. So we know we should integrate care. We've been thinking about it for years. It quote-unquote just makes sense, right? But it never really got off the ground. Primary care seems to want it, whatever it is referring to, but some sort of integration. We had a consultant drop by. That's always a major red flag. If you ever hear that somebody's invited a consultant to drop by, you know that there's a problem. And we're about to hire two social workers. So these are all good and kind of scary things for someone coming into a role, right? A couple of things that I want to highlight here is that there seems to be some sort of investment and initial buy-in from the health system. People want this. There seems to be some stakeholder engagement from the psychiatry side and from primary care. And there seems to be some willingness of an initial investment, right? We have money to hire two social workers. What we're hiring them to do was unclear to me. And really what I came to discover and what I really felt when I first arrived at Emory was that collaborative care or integrated care was a solution in search of a problem. And so really what you need to think about is why integrate care for your institution? And this is not a trivial question, right? Because collaborative care, again, is one of many integrated potential behavioral health solutions out there, right? And collaborative care, while it is robust, and we'll talk about that in a second, there are many other options that may be better suited to your health system, that may be better suited to the resources you have available on hand, and may be better suited to the patient population for which you're looking to treat. So let's attempt to figure out what problem is integrated care attempting to solve. So this is the first question, step one, that I took when I got to Emory. And fortunately, I had a little bit of a running head start. There was a physician provider survey, a primary care provider survey, kind of feeling out primary care about how did they feel about mental health treatment with respect to their patients in primary care. And most of the questions really indicate that most primary care providers in the health system strongly agreed that mental health treatment was important for their patients, they wanted access for their patients to not only medication management, but psychotherapy, and to a certain degree, they felt already pretty comfortable with managing some degree of things. So that's good, right? Another indication that we have stakeholder buy-in from primary care. But what really stood out to me is the very last item where universally all primary care providers disagreed. The question was, it is easy to refer patients to Emory or other providers for mental health concerns. And the punchline to this is it is nearly impossible to refer a patient to Emory Adult Outpatient Services or other providers in the community for mental health concerns. So I'm hearing a problem of access. And it's not just access the way we traditionally think about it. So we kind of have the theme here, right? There's an access problem. And three months later, and lots of data analyses later, I really wanted to understand the scope of this problem. How bad is the access problem? Because that's also going to dictate what solution are we going to try to figure out, right? We need to start from a data-driven perspective. So I asked the question, how difficult is it to access a psychiatrist at Emory Healthcare? So just to give you an idea, Emory University, large academic medical school, we sit on top of several health systems in the state of Georgia, right? The VA, we have Grady Memorial Hospital, which is probably world-renowned, a big state-funded hospital. But Emory Healthcare as an entity is sort of the business arm that we also fund. So Emory Healthcare, again, is a large heterogeneous network with many clinics distributed throughout Northwest Georgia, even in some areas of Southern Georgia. We take patients internally, right, for referrals to the Brain Health Center, which is where our adult outpatient program resides. We are one floor of one very nice office park in North Druid Hills, Georgia. But we also accept referrals from the entire state for patients that don't have any care established at Emory. So for example, if you have all of your primary care at a local primary care provider's office, you can still also try to come in and see us as an outpatient. And just to give you an idea about our staffing and our resourcing, the adult outpatient program, we have 7.6 FTE dedicated to clinical care from academic psychiatrists at Brain Health, okay? So seven and a half full-time clinical FTE dedicated to doing this. Now in fiscal year 2021, turns out we have 72 primary care clinics distributed throughout the state of Georgia. This does not include specialty clinics. This does not include the fact that Emory Healthcare serves at least four major hospital systems which is Decatur Hospital, Columbus. We have several other hospital systems there that we can accept referrals. And we had 20,000 new calls to the call center for psychiatric services alone, okay? And each of these primary care clinics can be as small as about 2,000 patients, unique primary care patients. And some of the larger clinics have upwards of 15,000 primary care patients, unique primary care patients. So look at that ratio, right? From internal to external. Of the patients that came through, internal referrals and new patient calls that somehow made it filtered through the really challenging process of getting to our intake call line for psych services, we had 7,700 new patient appointment requests. We only booked 2,500 patient appointments. At its best, this is a 33% conversion rate to see some patient at Emory Healthcare, okay? Probably the problem is significantly worse because I have no idea what happened to the other 13,000 other patients that called in for a new patient appointment at Emory Healthcare. So now we're talking about the scope of the problem, okay? Hiring two social workers, what is that gonna do? So now we understand how big the problem is. We're getting some themes here, right? Access, scalability is gonna be important. And what did this look like on the primary care side of things, right? So I looked at the top 10 billed diagnosis that our primary care providers were billing through that same fiscal year. And not surprising, the ICD codes linked to those patient appointments, anxiety and a mood disorder, depression, were always amongst the top 10. So this is an average of all clinics. Some clinics, it was even number two or three on the list, okay, indicating that primary care is doing a lot of psychiatry. So much so that 5% of all of our primary care encounters were primarily billed based on an ICD-F code, which is a psychiatry code. And we all know that primary care does not really get reimbursed for F codes, for linking F codes to CPT codes. And here's a breakdown. So the majority of them for non-substance use disorders, mood and anxiety, which is what you would expect from this patient population, but there was also a lot of substance use treatment going on in primary care as well. And so if we were to model this, right, the current model of the one-to-one referral just does not work at Emory Healthcare. This teal box represents our psychiatry clinic. We have our psychiatrists. And what you can also tell is that we don't have a great distribution of expertise, meaning that when I first got to Emory and I opened up my patient panel, I received patients who had never seen a psychiatrist before or a therapist before. And I have received patients who have seen multiple psychiatrists or therapists or didn't like their therapist or were on TRD amongst the most TRD patients that I have ever seen. But because we were so backed up, it also turns out that primary care was seeing an equal distribution of these really difficult-to-treat patients. And it's not that my primary care colleagues are not nuanced or sophisticated, because they are. They're doing a lot of really good psychiatric work, but they're really treating patients that probably should be seen by specialists. And we are not providing them a service or a meaningful way to redistribute how our patients are seen at Emory Healthcare. So now that I understand this problem, it was time for me to really develop what our mission was. And so Emory Integrated Behavioral Health, I developed what our true north is. And this is really sort of the high-level philosophy of what Integrated Behavioral Health is scheming to do at Emory. And this is also gonna be what we use to drive and think about every solution that we look to develop for Emory Healthcare. So the mission statement is, we want to expand access to timely mental health resources at the appropriate level of care. So it's not that primary care can't do psychiatry or shouldn't see really difficult patients, but we also wanna support them so that we can see patients at the appropriate level of care and also send them back to the appropriate level of care once stabilized. So for example, we can create an ecosystem where I don't need to have an ever-expanding caseload of patients where once I stabilize them, I have a relationship with primary care, I can send a patient back so I can receive new patients who need me. And this is also a great salve for psychiatry burnout. It's a great way for us to review our caseloads and purge our caseloads of patients who are stable and see new patients who need us at the Brain Health Center. And we're talking about access, it's not just direct access for patients. It's also provider access, helping us develop more expertise and access for our providers, our PCPs, in the terms of education and consultation. And it's also, again, providing perhaps even a stepped care approach towards managing our patients so that I don't receive someone with mild depression or mild anxiety who's never received any first-line therapy before. So with that mission, we also have our vision. This is a very lofty vision, but I think it's important to think big, especially when I'm thinking about large, scalable change. So my vision is seamless entry, transition, and egress for mental health resources from anywhere within the health system. Again, that's sort of a patient delighter when we think about that, right? Patients would love that notion of being able to seamlessly enter or egress from treatment at any point in care. And have any provider at Emory Healthcare know the status of their treatment with respect to their mental health disorder. These are the values of the program, which I won't belabor, but obviously we want respect for the needs of our patients and our colleagues, right? Really important when we do integrated care. Inter-departmental professionalism, which is something that's always challenging when we're dealing with access crises. We want excellence in how we execute any solution we go through. Diversity is critically important from staff, but also to the solutions that we can provide to our patients, because we know that there's not gonna be a one-size-fits-all solution for these problems. And practical innovation. I don't wanna develop the Ferrari of solutions that will only solve the problem for a very small patient population. This is a numbers game. I wanna be working at a very high level. And these are the two north pillars and my strategic priorities for the program. Patient experience comes number one, because we wanna destigmatize mental health treatment, right? I wanna have a great introduction for patients to mental health treatment, and make it feel like it's not such a high barrier for them to overcome. We want quality that is evidence-based and also informed by our measurement-based care, right? Sustainability. So important. We need to implement physically viable programs with optimized workflows, because what I wanna develop are legacy programs that will outlast me when I leave, or if I leave Emory, right? And that really involves having a very good fiscal model and a way that we can sustain this that is not totally dependent on grants, or totally dependent on paying tax to the other departments to help support this program. We wanna be as cost-neutral as possible in order to make sure that this program has legs and is sustainable. We wanna think about growth and expansion very strategically. So thinking about where we go and why we're going to certain markets. And research and education, mostly because I'm an academic, but also if you really think about the data analytics that we have. My colleagues at the Rollins Public Health Center, they're doing my epidemiology, they're salivating. I'm sitting on top of a gold mine of data, right? With respect to integrated behavioral health. And this is also an opportunity for me as a clinical trialist. I now know where every patient with depression is in my health system, presumably. And I can draw them into research, into clinical trials. So the synergy with respect to this kind of work is critically important. So with this vision and True North statement in mind, how well does collaborative care satisfy my mission? And this is where you can start thinking about collaborative care as that solution. It's evidence-based, right? Cadillac of care delivery models. We know that. It's effective, it's timely, it's based on treatment in your own backyard is how I sell it to primary care providers. You have a mental health specialist who lives in the clinic, right? You're gonna have access to a psychiatric consultant every week. We're gonna talk about your patients, right? It's amazing. And again, there's synergy here, right? Better mental health outcomes, actually better medical outcomes, which we know hopefully cost savings. It's scalable, right? One clinic can have about 100 collaborative care patients that are potential collaborative care patients, right? And that's data-driven. I know that X percentage of my patients are being treated in primary care with a mental health diagnosis. You can do the math, right? When you're developing your pro forma or thinking about what's the volume gonna be in your particular clinic. We have one care manager hired per clinic, although that can change based on the clinic size. But again, we're operating about one care manager for about 7,000 to 10,000 primary care patients. And 0.1 FTE of a psychiatrist to X number of clinics. Okay, that's how we're thinking about the percent effort. And there's a sustainability model, which Dr. Beecroft mentioned, right? There's a CPT code. We can bill for these services. Work RVUs are generated. I negotiated with my health system that the work RVUs we generate since the PCPs are the billing providers, they get some of those work RVUs. So they're getting value-based care, and they're also getting, this is going into their bonus structure, right? So they're getting extra money, right, for participating in referring patients. They're incentivized to do so. Now here's the question. Why should we not do collaborative care, okay? Because the question is, is it scalable enough for my institution, okay? If I only have 7.5 FTE of adult outpatient psychiatrists, right, how am I gonna staff all of these clinics? Is it reasonable for me to consider or think that I'm gonna hire one care manager for 75 primary care clinics distributed throughout the state of Georgia? Probably not. And so do you have sufficient resourcing in order to do this, and at what scale, okay? So what are my current and potential resources moving forward is really the question you need to ask yourself when you're thinking about how big you're gonna go with this and where you're gonna go. And also, is sustainability feasible? So yes, there's a billing code, but are the reimbursements enough to staff the consultation time for the psychiatrist? So I receive a fee, consultation fee, that's part of my salary. Is it enough to pay for the salary and benefits of the person you're bringing in to be the care manager, right? Is it enough to offset the bonus structure that you're also aligning to the work argues if you're gonna go that route with your primary care providers? And the billing model is hard. You have to calculate and keep an accounting of how many minutes you spend per month per patient so that you can bill every month for these patients. That is not an easy thing to operationalize or develop a workflow around. So your care managers have to be really well organized, and there's a lot of administrative time that's built into this that has nothing to do with clinical care. So really important. Pair mix and volume is important depending on where you practice. In Georgia, Georgia Medicaid does not cover these codes, meaning that me going into a pair mix that has a very large Georgia Medicaid population is gonna be very difficult for me to get that to that cost neutrality. Now, it doesn't mean that I shouldn't do it, but if I'm thinking about where I'm gonna go strategically, I have to think about the blend of pair mix as I go through and deploy this. And what are the volumes gonna look like? It doesn't make sense for me to hire one care manager for a small clinic or one care manager for a 20,000 patient population. You wanna make sure that your care managers are gonna be able to sustain a consistent volume to make this billing model work. And also, turnover in this role, not surprisingly, can be pretty high if you don't support them well with good workflows and make sure that they're well supported in the volumes that they're seeing. And the big thing that you need to think about is how much or how close is your system or your clinics to considering change? Are they really ready for change? You're asking them to implement population-based screening if it's not. I have my clinics now are doing PHQ-9s, GAD-7s, and a modified assist for opioid use disorder at every encounter. My MAs were not happy when I proposed this to them, but we're doing it. It's measurement-informed care, so it's not one and done. We need measurement at least once per month, and that takes time out of the day, okay? And we're building a business within a business, which can always be really, really challenging. You need to have good mechanisms for effective communication. Is everybody on the same electronic medical record? Is there a clear way that how you're gonna communicate recommendations to your primary care colleagues? And are the PCPs primed for engagement? Because if you make a Med-Rec and the PCPs are still thinking that this model is the one-to-one, I'm gonna refer my patient to you, but you're just in my clinic, it's not gonna work because collaborative care is not that. The PCP is the team leader, and when you're selling this model and when you're describing this model to the PCPs, you have to make sure that they understand that. I am not seeing your patient as the site consultant. We are giving you access to me and my expertise. We're giving you a therapist in the clinic, but you need to manage the meds and you need to be in charge of this patient's care. When they understand that and all of the benefits that it can afford, most of the time, they're on board. So what does the roadmap look like at Emory? Well, we've decided to go ahead with collaborative care because I do believe, one, it's the gold standard, and it really ticks a lot of the boxes in terms of what it can afford with access, right? Great patient access to care coordination and therapy, great access to PCPs and therapists to a psychiatric consultant, great access for influencing physical and mental health outcomes, and there is a sustainability model. But I've acknowledged it's not gonna be sufficient for the entire health system. Other things, which we won't talk too much about today, but just to give you an idea, is I've developed an interprofessional e-consult program where clinics that do not have access to collaborative care can phone a friend. By the way, there's a billing model for that, and so we've operationalized a billing model for that. So there's a way for other providers in the health system to get access to the psychiatric consultants. Five, 10 minutes, write an email. It's essentially formalizing the curbside consultation process and getting billing for it. And then the other thing that we're really working hard to do is to find a role for digital therapeutics. There are plenty of apps out there that can really serve as a great entree point for patients before they need to get to this care, right? They can do CBT or care journeys through their smartphone. They integrate with a medical record so we can proactively track these cases and how patients are doing. There's incentivization models involved in this, and so we're really looking to see how we can leverage information technology, passive data monitoring, in order to really develop a nice blend of operational resources for our patients. That also includes collaborative care as our prime one priority. And so the hope is to take this referral model, and again, as I sort of alluded to earlier, reshuffle the deck, right? We want patients treated in primary care at the appropriate level. Patients who get referred into collaborative care are gonna be in that moderate to maybe severe range, waiting for a transition of care, working to get patients into see psychiatrists in consultation or through longitudinal care to get them stabilized, and send them back to primary care, all right? So who are your stakeholders? You're ready to implement collaborative care. It's time to get this thing going. We're gonna go with collaborative care. Well, obviously, everybody in the model is a stakeholder. You gotta get good primary care provider leads, so what I've done is I go into every primary care clinic, and I find a PCP champion. It might be the medical director of that clinic, or it might be someone who's just very psychiatric and psychologically minded, and they're the ones who are gonna drive this process forward and help sell it to their colleagues. You gotta get psychiatrists excited about doing this work, which is actually pretty easy to do because it really changes your day, and it's kind of nice to be able to affect the whole patient population, and also, again, to develop relationships with primary care providers. Again, there's synergy there, and care managers. So here, we're bringing the care managers in, so they're important stakeholders, but it's really important to understand what their values are and what their desire is in joining your institution or your group to do this kind of work because it's very different than traditional outpatient models, and it's very different than pure case management. But the one stakeholder that I didn't mention, and that's probably most important, is your hospital administration is critically important, and in fact, they are the most important stakeholder that I have. Patient financial services or utilization management teams, I have had to energize them, and they are so excited to try these codes and get them out and to actually help make this sustainable. They have been the most important people on board. They're the money people, and they're helping me make sure that the budget makes sense. They're also the people that are gonna help you acquire data to do this work, understand how your clinics operate so that when you implement or wanna change workflows in primary care of which you are an outsider, they're gonna help you do that. They're gonna help you develop that pro forma to understand how are you gonna make this sustainable, when can you reasonably expect to maybe have a return on investment, so to speak. And they're also gonna help you navigate IT needs, which are not trivial with this model of care. Documentation is a little bit difficult. Tracking, and from a utilization management perspective, when your billing team goes to see when you drop a code, did you do everything that you were supposed to do over the course of the month? You gotta make sure everything is in the chart and ready to go. And so, I'm gonna end here. Here are some factors to consider when we are trying to implement or do strategic site selection. So like, where do we go? I'm happy to share this slide deck with anybody. And then the other thing I want to show you is, at the very end, sorry. Here are some helpful resources. Please feel free to send me an email whenever, if you have any questions. There is a fantastic Facebook group called Collaborative Care Psychiatry. It has about 300 members, 350 members. They have office hours. It's people from across the country who are doing this work in different care settings. Really great. And I would also highly recommend people go to the AHRQ Integration Academy. It has a lot of resources in thinking about implementation at the very early stages. All right, well, hi everybody. Thank you so much for having me today to talk about my experience with the collaborative care model. So I am that person from the other tribe, so I'm a primary care provider. Anybody else in my tribe here today doing primary care work? Yeah, all right. So most of you are in psychiatry, maybe. Okay, no, but I just wanted to share what this looks like where I am. So I'm Jen Thomas, I'm a family medicine trained physician in Illinois. I'm our current medical director of integrated behavioral health, and just wanted to share what this looks like in the real world. No disclosures. I'm not important enough to have any financial relationships. So this is Morris Hospital. So we are very proud of our agricultural heritage in Morris. Healthcare and agriculture are two top employers in our county. We have a corn festival every September, it's fabulous. The bottom right corner is my clinic there in Braidwood, Illinois. Fun fact, that building used to be a funeral home. The new funeral home is next door, so it gets interesting when people confuse, oh, I'm here for a visitation. Nope, next door. But yeah, so our health system bought that building a while ago, and the staff has fun with that chatter about ghosts and why not, so that's where I spend my time. So this is my health system. So we're a rural community-based center. So we're an 89-bed hospital, so relatively small. We're a non-profit. We have 37 primary care providers, 25 outpatient locations. So Morris is kind of a medium-sized town, and a lot of tiny little rural communities feed into the Morris Hospital system. So we serve a fairly big geographical region. So what does collaborative care look at in my neck of the woods at Morris Hospital? So we launched our first collaborative care patient in February 2019, and since then, we've grown the program to eight primary care sites. And this was in the midst of the pandemic, mind you, so it was a big lift, and we're still working on fine-tuning it every day. But we've served 870 unique patients and over 7,700 patient encounters. So we've certainly given it a try, and we're trying to figure out what works and how to make it better. So at this point, you're probably wondering, why is a FP doc at the APA meeting? I certainly had that question when Ana asked me to do this talk, too. But when I think of that, it's like, well, what do I have to offer you guys in this conversation? If this is a rural-world conversation about how to do this in the wild, where you don't have a controlled trial, and maybe you're just kind of doing this in a community-based setting, that I can speak to. I can talk to you about what a wild, feral program is in integrative behavioral health. That phrase, herding cats, comes to mind. I think Brandon uses the air traffic controller analogy, because it's a lot of moving parts. It's people in different guilds working together. But it's certainly needed. Someone asked a question earlier about how do you get buy-in from the PCP? You get buy-in because we're already doing a lot of that work. We get tasked with behavioral stuff all day, every day. And that was even prior to the pandemic. Since then, it's just more prevalent, and the crisis is so much more severe. I would say, talking to your PCP colleagues, talk to them about, hey, we can work together, and I can help you. And we can come at this problem of access from a different angle. And it's a really fun thing to do. And in talking about this, too, when I think back, like, all right, what did, Anna does a residency, what did my residency do to prepare me for the behavioral health stuff I'm gonna ask to be doing every day in work? Man, we had to do OB, so I'm an FP doc. We delivered 50 babies in the three years of residency. I've not delivered one kid since I left training. But you better believe, I get asked about depression and anxiety and trauma and substance use every single day. So if we can come together and work as a team, that really could be something cool. And I was you. So I was in a sitting in a conference in January 2018. I had never heard of the collaborative care model. And I kinda had that, like, whoa, this is cool, this triangle, this could make a difference where I work. If I had a care manager helping me clarify diagnosis, and if I had a psychiatrist I could ping and say, hey, doc, is this the right med? I'm kind of at my limit of comfort of what I can do for my patient. That would be cool. That could get the job done. So that's my why. And this is why that model speaks to me. So how does the team work together? Well, it's a team of different providers from different guilds or clinical backgrounds. And they're coming together to address the behavioral health needs in the primary care setting. And that's where most people enter healthcare, right? You know, we've all got our primary care doc, and whether we have a sore throat or a sore knee, or our back hurts, or we're depressed, we might start off with our PCP. And where I work, that's a lot of people that are even gonna be in different guilds, too. So nurse practitioners and PAs in the rural parts of this country, not everyone even sees a primary care physician. It might be an NP or PA colleague. So even more need for us to work together and have some shared leverage, that scarce resource of the psychiatrist. So it's an ensemble, people working together, using their talents in new ways. And so with that in mind, time for a cheesy analogy. In honor of our host city, I wanted to kind of make an analogy that building a collaborative care team is kind of like a jazz band. So what does that mean? Well, the different people on your, sorry. Ah, tech. The different people on your care team. Oops, I don't know, am I getting this mess? There we go. Okay, so your care team is like a jazz band. So think about it. You know, you've got an FP doc, and you've got a behavioral health care manager and a psychiatrist, and you all have different skills, and you're coming together for a common goal. So you have to play together, even though you're from different instrumental backgrounds. So, let's see if I can get this one to work better this time. All right, so there's me in primary care. And I'm like, all right, I can do some depression. Maybe I know something about meds, but it would be really cool if I could add somebody else into this. So maybe I join forces with the psychiatrist. And then maybe we can add the care manager. And now together, ooh, that would be something cool, right? The sound or the song we could create would be something new because all our voices are together. We could have the coolest song in the world, but if that patient's not involved, right, it's gonna be out of tune, and they're gonna be like, nope, not playing that song. So don't forget that patient is part of your band, if you will. So, what does this look like in the real world? So, achieve great things. Two things needed, a plan and not quite enough time. I don't know about you guys, but I'm totally feeling that lately is the, these things are cool. You know, you go to the meetings, and you're like, this is so cool. How do we get the time to do this, right? So in my role, I have six hours a week as admin time, and it's not nearly enough. But thankfully, I'm a geek for collaborative care, so I, you know, spend nights and weekends kind of pulling our programs together, and we kind of make it work. But, you know, I think it's important for us to, as we move forward, give it its due, and be like, hey, you know, if these programs are gonna get off the ground, we have to give people time to grow them in leadership. So, we've all been at these talks. We're like, all right, you know, there's these step-by-step instructions, and it's not that simple. How many of you were doing collaborative care already? Show our hands. Okay, so is it as easy as step one, two, three, four, five? No, not at all, not at all, right? It's complex. It's people working together with different agendas and different backgrounds, and it can be so challenging to get everybody on the same page. So, with that being said, it's not as simple as a step one, two, three, but if we lay the foundation, and again, this framework comes from the AEM Center. AEM Center was kind of my, you know, Bible, if you will, of like, how do we do this? You know, we straight up cold called them in 2018, and gracefully, they actually called us back, and they're like, well, tell us about what you're doing. You want to try collaborative care? All right, what's going on in Morris, Illinois? I'm still shocked they called us back, you know, because who are we? We're in the middle of the cornfields out there, but they were awesome. They're like, well, tell us where you're at, what you're trying to do, and we said, all right, we need to do some, you know, implementation work, and it just so happened, we have a perinatal depression study, and they said you can get free training and coaching, and we jumped on the MindEye study back in 2018, and from there, we really felt really fortunate that AEM Center gave us that great expertise. It's kind of surreal for me to be up here with Ana. I remember seeing the Daniel story video at that conference in 2018. I showed it to my sister, and I was like, isn't this cool? I want to do something like that, you know? So you just never know where those things are going to inspire you in your day-to-day work. So all right, so if you take a music lesson, if that's the analogy, what does that mean? So you all have to understand the model. You have to get your PCPs, or you as the psychiatrist, to do some of those AEM Center implementation modules, and really know what you mean by collaborative care, and then it's so important to identify your champions. So that's your super fan. That's me, that's the big collaborative care geek that's like, yeah, this is cool, we want to do it, and get out there and talk to their colleagues, and really talk about the model, and that great pitch that you want to write. So when you're talking about this to other folks, whether it's your administrators, or your medical assistant, or somebody that's just, you know, in the community, maybe the patient, it's important to speak from the heart, like develop your why, right? Take a page out of the Paul Sinek books of, hey, this is why we do what we do. It's not just about finance, it's not about cost savings, it's helping the patient in front of us get the care they need when they need it. So a pitch, you might want to do a roadshow of some slides, you can go talk to your administrators, you can shoot, I made appointments and went over to our behavioral health alliance, to our nursing executives. I mean, we did the Daniel's story video for anybody and everybody in Granite County. But getting the word out, because if you don't know that model's there, and I didn't a couple years ago, I don't know what it could be. So just spreading that, disseminating that knowledge of what we could do if we, you know, worked under the collaborative care model. So step two, what could we do? Get the band together. So this is where you guys, as potential clinicians that might want to try this model, need to find people to join your band, so to speak. So network within your health system. Do you guys hang out with a lot of other FPs? I mean, in residency, your friends might be your fellow coworkers, right? Maybe you all play trombone and you all do psychiatry, and that's cool, and you can get together and do some really cool music. But maybe if you step outside that comfort zone and go to a department meeting and introduce yourself to an internist or a pediatrician and talk about these creative ways to solve behavioral health problems, you might find that you can develop a team with somebody that's not in your guild or not in your area of specialty. And you might find it's actually really fun and rewarding to make those new friends, those new connections. Professional groups. So the APA has Job Central, and there's a collaborative care community that they're working on now to connect providers, so psychiatrists that might say, hey, I could devote four or eight hours or a few hours of my week to maybe doing this type of work. You could certainly consider, too, if you want to partner with a telehealth provider. That's what we do at Morris Hospital. So we didn't have the option of partnering with our local private psychiatry group. They didn't really want to do integration with us. So my psychiatrist that I consult with is located in Virginia, so she jumps on the Zoom and we do our thing with the care manager every week. And it was more important to find the person and the personality that she really believed in the model and liked working in an interprofessional team, and it just really clicked. So I think when you're going out and looking for those people for the band, think about folks that have those shared values and beliefs, and you might find that it's a better fit. The CFHA Collaborative Care Work Group is another really awesome thing. I think Patty kicked that off or is in charge of that. CFHA, Collaborative Family Healthcare Association, is another awesome influence that taught me pretty much everything I know about integrated behavioral health, in addition to the AIMS Center. So please check them out if you have not. All right, so step three, you got to build your clinical skills or you got to go practice, right? Because we need to know what we're talking about if we're going to say, all right, let's do this collaborative care thing. So learning about the team roles, you really need to think about it top down from a workflow standpoint, that if your medical assistant, the one that we said, hey, guess what? We're going to give a PHQ-9 to every single patient once a year, and they roll their eyes and it gets another form, like, why do we have to do this? Go back to the why. Well, for me as the clinician, this helps me take better care of my patient. It helps them feel like they can talk to us about behavioral health concerns. And having them know the why too and identify their own why. Why are you in healthcare? What drew you to being in the helping profession? It just kind of solidifies that group mindset of this is why we're doing what we're doing. And then spelling it out in a workflow, step by step, because we need to kind of know, left hand needs to know what the right hand is doing. Okay, so launching your care. That's where you have to kind of book the gig and start playing. So you have to give it a shot. And see what works. Educating your patients on the model. My nurse always says, you should just tattoo that triangle of the collaborative care model right here on your forehead, because you do all this all the time. I'm like, yeah, that's right. But we have to kind of tell them what we're talking about here and get their buy in as well. Figuring out how to use and maintain a registry. The AEM Center has been our partner with that because we're part of a couple of their research studies. So we get to use their wonderful technology to keep track of our patients. But it's some degree of practice transformation. And if you happen to be the change agent, the psychiatrist going to your health system and saying, hey, PCPs, let's do this. There's gonna be a lot of questions of like, well, is this gonna slow me down? Because PCPs are every 15 minutes and they're productivity, RVU driven. So you really gotta dig in and do that work with helping make sure that the workflows are as quick and efficient as possible for the PCPs to really make those transformations. And then step five, nurture your care. Talk about lessons learned. So take it on the road, go on tour. So monitoring your implementation process and your clinical outcomes. I'm at a very small health system. So we, I think, are small enough that we got to give this a shot. Looking at the data is certainly a next chapter for us. And jumping on some of the real world implementation studies like CHAMP with the AEM Center. They've helped teach us how to do that type of thing because, again, we're community based. We're not academia, but it's been a really rewarding learning process. And then sharing lessons learned. So coming to presentations like this and talking to other people and reading up on integrated behavioral health. You gotta spread the word. Another tip I would have is a really good manager that understands everybody's team role well because your leadership just sets the tone for the entire team. Billing coding, I will say in the real world, out in the wild, that's a challenge for us. We have a very small billing coding department. We're nowhere near sophisticated enough to do what we wanna do, which is get it down to the claim level and have those conversations like Brandon and Bill talked about with the payers and negotiating those rates. I'm a clinician. I see people for primary care all day. I don't know how to do that. But partnering with somebody who does maybe would be a way to do that. So these are things just to kind of think through when you're building that team. And don't forget about revenue for screening. So you can screen, you can code for behavioral health screens. PCPs should be doing that. If universal screening for depression is something that we're gonna do as part of collateral care, then we should be billing for it. Strong templates. So one thing a PCP might ask you, if they're like, all right, say I do this, what about informed consent? What if I get sued? So you're gonna have to have those conversations with them about informed consent can be a template built into your EMR. The PCP can go over the core components of collaborative care. And a verbal consent is acceptable. So for me, this was a huge time saver. This was what am I like, how am I gonna fit this into a busy primary care visit if I'm having to think about consenting someone for collaborative care? But you can do it with a verbal. So some of those dot phrases can save you a world of time. And that's where the rubber meets the road with your PCP colleagues. They wanna talk about efficiencies. And it can be done. You just gotta be very mindful with it. And then templates. So an EMR with a good template, it saves you a lot of time. If you got that repetitive thing that you always do with charting, this is just an example of what we do in eClinicalWorks is our EMR. It's not epic. It's not the gold standard of EMRs, but we make it work. So yeah, I think investing time in that just helps everybody feel like the documentation burden isn't so high. So I'm probably going long on time. Am I over time? Okay, good. All right, so just in wrapping up, I wanted to share a fun, and Anna, do I do this computer? Just because we're in New Orleans and jazz is not your cheesy music theme for this. I wanted to show a fun video about jazz. And I think it really just speaks to the whole concept of working together as a team in the collaborative care model. So I hope you like it. How long is it? It's just two minutes. Okay, let's do it. Oops, sorry, your mic, my touch screen. But jazz is like love. It's something we recognize when we encounter it. It's very hard to define. It's fun to hear. It's complex. It's creative. It's fun to listen to. It's fun to play. It's complex. It's creative. It's inspiring. It's basically a life force. Well, it's always moving forward. It isn't music of the past. It's music of today. It's music of the future. Jazz came out of the African American community experience, and much of that is based on the black church. Call and response is a active component of praise and worship. The leader speaks, and then the audience responds. The person who's taking a solo makes a musical statement. Someone might respond to that statement. So it becomes a actual conversation that's going on. It's a conversation. One of the hallmarks of jazz is improvisation. And so you're responding to lots of things, ideas that you have in your head, things that you know, things that are coming at you in a millisecond. You really want to lose yourself in the music, and you don't know what's coming out of you. But the only thing that's coming out of you is what's inside of you. Jazz expresses core American values, freedom, risk-taking, cultural diversity, innovation, creative collaboration, and democracy. When you see me coming, baby, raise your window up high. In a democracy, everybody gets a vote. In a good jazz band, everybody gets a voice. All right, so thanks for humoring me there. I just thought that was a beautiful illustration of the music being part of it. So yeah, thank you guys. It was such a pleasure. So whether you go home and do collaborative care or join a jazz band or do both, just do it with gusto and let us know how it's going. Thank you so much. Thank you. So we have time for a couple of questions. I am just gonna throw up a slide that has a bunch of resources on it. I also have paper copies if anybody wants the list of resources. And I just want to thank all of our speakers for coming and sharing their stories. I think it's so helpful to hear the real world stories of collaborative care. So we'll take the questions. Take it away. Sure, this might be for Brandon, I'm not sure. But the role of med school, maybe university in implementing this, I get the impression that at Emory you guys supply the psychiatry consultants. What about the care managers? What about training of the staff? Are there turnkey operations? Do you guys offer this? Does the university have a role in a given state or a given area of kind of getting this going implementation-wise? Hello? Can you hear me? Okay. So I think just to restate the question, so I think you're asking, so what's the role of the School of Medicine in terms of training, especially from the care manager position? Is that my understanding? Yeah, and the practice implementation. Because those are just two parties in the jazz band, so to speak. But how do you get everything implemented, the workflows, the forms, the templates, all that IT stuff? So this is gonna really depend on how your academic health system is organized and its relationships with the different clinical entities. So for example, Grady Memorial Hospital already actually does have collaborative care and they've been doing it for quite some time. They're not billing for those services. And again, they're sort of a state-run hospital system. They've got their own primary care setting. So that's all been done in-house. For Emory Healthcare, yes, I am a faculty member of the School of Medicine, but all of the resourcing for this has come from the Emory Healthcare System proper, which is the health system. So me as an academic and as a director, so I've negotiated a way that I'm getting the School of Medicine to fund a portion of my salary, I'm getting Emory Healthcare from the primary care department to fund my time as the site consultant for the clinical effort there, and in terms of the care managers, they are financially funded and supported from the health system. So they are actually health system employees, not School of Medicine employees. Now, that could change depending on who I hire for that position. So for example, I was working pretty hard to try to get a psychologist, a clinical psychologist, to join the collaborative care effort at one point, and that was gonna be a faculty appointment plus a clinical position. So there's a lot of different creative ways you can do that, but you do need to have a good understanding of where the funding streams are coming from and how that's gonna be supported from the dean's tax, from the School of Medicine versus the health system. Because this is such a clinical care effort, it's coming from the health system and they've made it a concerted effort, and actually, the care managers are primary care department employees, not psychiatry. But I've made sure to create connections so that those mental health providers don't feel like they're on an island of primary care without feeling supported by the Department of Psychiatry and Psychology itself. In terms of the training, that's been me, essentially, as the director, but also with a lot of help and assistance from the AIM Center. And part of this was also becoming a clinical trial site for the CHAMP trial, which we didn't really talk about, but it's another clinical trial looking at collaborative care, implementation for opioid use disorder. So there was a lot of, again, synergy there. We got training, but what I will say is now that I have some veteran care managers with me, they are now gonna be training and onboarding the new care managers that come through in collaboration with some of the online AIM Center resources. So that's the great thing about the scalability of this is if you get a good core team, they can take that show on the road and start training other people in the system. And there are a lot of people that are really excited about this, so we're now expanding into palliative medicine and the CHAMP is gonna pilot integrated behavioral health and they're repurposing some of their social workers to do this. We're doing some corporate health, mental health related stuff. So kind of the sky's the limit. Thanks, I guess a related follow up. I spoke to the program, Medicaid program manager in Washington State about their rollout of integrated care to the private sector. I think they got a grant or an appropriation for about $20 million to spread over maybe 10 or 20 organizations to implement this. I wonder if you have any thoughts on the cost and the timeline for implementation of a given practice or a rollout like this. In other words, I think you mentioned Brandon that this is expensive. The rates sometimes aren't sufficient. Is that because the rate per consult is not sufficient or when you're rolling the implementation cost to it, it's not sufficient. So if you roll out a implementation package or grant to go with it, are then the rates enough? So two part question, it's rolling it out with seed money, an implementation package and whether or not the rates are sufficient in and of themselves once you get implemented. I'll add a little bit to that maybe. There are two costs I think around collaborative care. One is the implementation costs. I think it takes real time to do this and typically a timeline of six to 18 months I think to bring a clinic online and somebody needs to pay for the time for someone to really invest in doing all the work around the workflow changes and things like that. I recently got asked to try to come up with some estimates. There's not a lot of great data out there but I would estimate that that cost is somewhere in the neighborhood of probably $100,000 per clinic. I mean, it could be lower than that but when you add up all the time of everybody on the team plus the time it takes for everybody to get up to efficiency and a full caseload, that's real time and real money that needs to be accounted for from somewhere. So I think it is worth doing that. I mean, I think that could be cheaper if you can get some contributions but it is real money and it does take real time. I think the reimbursement rates and I think you spoke to this, Dr. Beecroft, so I don't know if you wanna add to that. You have to run a really efficient and pretty full caseload to cover the cost of the psychiatric consultant and the care manager once you're up to speed. And so I do think that for that piece, we are seeing that the Medicare reimbursement is probably right on the edge of being able to do that, probably not quite enough in most cases. And so depending on the cost of your people and your cost of your institution, which is one of the reasons why the APA is advocating for higher reimbursement value for those codes. Private insurers generally pay more, so. Private insurers pay very well. So that's why I sort of belabor the point that payer mix is important. Again, depending on the entity you're thinking of doing this in. And so making sure the blended reimbursement that you're gonna get is sufficient is really important. And so what we've done is we had a projected model of the volume of patients that we thought we would need to see, all the costs for the staff members and my cost for my time. And then over the past year, what we've actually done is looked at really what are we getting reimbursed and redeveloped a model to figure out what our thresholds are per clinic. And so with our blended rates at most of our clinics, the care managers need to bill at least 65 cases per month. Again, throwing that out there. But the caseloads are actually much larger than that. They're about 100 to 120 active patients on your caseload, just because you may not be getting to every patient every month. But that seems to be where it would be looking at a large clinic where let's say a third of your patients are Medicare, very small percentage of Medicaid, mostly commercial insurance. Take a couple quick questions. And if anyone needs to go, we can call. Maybe we could just give some appreciation to our wonderful panel. And please feel free to leave if you need to go. But we are also, I'm happy to stay and I know a few other people are if you would like to ask some questions. Yes. Thank you so much for a great talk. So I have a couple of questions, but I think they'll all be pretty quick. First for the adolescent pilot that you're doing currently, what age range is included and are the psychiatric consultants all CAP trained? The adolescent pilot goes down to, we've had a lot of argument back and forth, but we initially started at 12. And we're planning on pushing it to 10. But for the first year here for the trainings, we're gonna see how it does with 12 and how we go from there. And yes, usually in Michigan, we have a dearth of child psychiatry. So it's that are willing to do this work. So it's a little bit difficult to do that. So you have to kind of take who's available, but we want people that have clearly a very strong interest in child and has been doing that either being boarded in child or have had a number of years experience doing that. A lot of general psychiatrists do children's work up to a certain age. And we would like to have just those. Great, thank you. And then this is something, I just finished an FMP residency and something I didn't think about is who takes the liability in these cases. So is it the primary care doctor? Is that kind of just a very trusting relationship when the psychiatrist doesn't actually see the patient? Well, there's a troubling problem with that, that the malpractice insurance goes up when you do collaborative care as a psychiatrist. Now, why they do that, I have no idea, except they're looking at vicarious liability as a consultant. But why wouldn't you have that already covered in your role as a psychiatrist? Did you do consultations, curbside consults all the time anyway? So it's very curious to me that that is there. What I've heard is it's pushed it up between 800 and $1,200 per year when you tell the insurance company you're doing collaborative care consultations. Okay, good to know. So it could be both parties involved if there was anything that came up. The APA recommends that any psychiatrist involved in collaborative care get liability coverage to cover that site that you're providing consultation to because it is a formal treating relationship on the very lowest connection level. So it's more than a curbside consult. So that's why the recommendation is that you do that because it should be shared liability amongst the team members for each of their different roles. I will say, to date, no one has sued anyone for collaborative care, and I still would articulate the argument. I think most people will, and there's even some papers out there that talk about this, that the reality is that you're providing an evidence-based treatment when you're delivering collaborative care. And so it would be hard to make an argument that this didn't meet a reasonable standard of care as long as you were involved in a thoughtful, systematic way delivering the core components of collaborative care. Yeah, as a psychiatrist, I'm also very mindful of protecting my colleagues in so much as if there is something that I don't think is within their scope or I think that it would be too challenging or that I think would be best served by a psychiatric specialist, I will make sure that a referral gets placed and make very clear that sometimes we use collaborative care as a transition to get somebody into the appropriate level of care, which I think you would be very hard-pressed to be found liable in that particular circumstance, but understand that you are the prescribing provider, and anything that I say as a consultant is a recommendation, and it still is up to you to determine what your level of comfort is. And so again, some primary care doctors are very comfortable, some are not. This is definitely a learning opportunity for you to learn from a psychiatrist, but also what your colleague's level of practice is, so that's another advantage of this program. All the primary care providers seem to rise to the challenge, but we do have to be mindful of the fact that some patients would be better served by specialists. Yeah, collaborative care does not take care of all patients. Like, that's why all of us talked about it as part of an ecostructure or continuum of care, and I think, you know, I've had patients that refused to go to specialty care, and so then we very clearly documented, we've offered this, we continue to offer this, we would rather do this something than nothing, and I think those are really important, you know, ways to actually document that you're being intentional and thoughtful about the level of care you're trying to offer to patients. Thank you so much. Yeah. Awesome, thank you guys. I feel like I'm a fangirl. Like, AIMS is my most searched website. So I just wanna say, one is like a plea for networking. I work in a company where we're expanding collaborative care to geriatric clinics, so if you would like to connect, please, let's connect. My name is Jacqueline Posada. My second question on that topic is the flexibility of the scales that we collect. Like, I know that the APA has their specialty population toolkits, but when I look at all the studies about collaborative care in the geriatric population, they're still using the PHQ-9, and so, but my team wants to move to the geriatric depression scale. So I guess my larger question is like, we're using measurement-based care, how flexible can we be? Like, this evidence says one thing, but like, the practice suggests that maybe we should be using something else. You can really. Yeah, do you wanna speak to that? You can really kinda use what works for your practice. Okay, so don't worry about it. And again, the geriatrics depression scale is really quite good, but it is not as specific because it doesn't have the question about suicide. So in that, you know, you may wanna use both in that population. You might wanna have the caregiver in the waiting room be able to fill out with the individual, both of them while they're waiting to be able to come in. And that gives you actually more data. So there's nothing that says you can't add more or use what works for your clinic in that process. The main principles that I would think about for this are that there are screening measures, and then there are measures that are sensitive to change over time. You need to make sure whatever measure you're using is sensitive to change over time so that when you're doing those repeated measurements of it, it's actually informing your treatment decision-making, not all screeners are also validated for detecting change over time. So that's, you know, I think globally, when I'm thinking about how do I pick a measure, I use some measures for screening, and that's, you know, to identify patients, and I use measures. And the reason we use the PHQ-9 and the DAD-7 is that they have that validation for being sensitive to change over time. So that's the thing you should probably be looking at when you're picking measures. And then you should pick the measure that works for your practice and that they will do regularly because the most important thing is that you have that measure done at the time you're making the clinical decision about treatment because that's what in the evidence base we see is actually meaningful about measurement-based treatment to target. So it's not specific to specific measures, but you have to have something, it helps you have better information to do your treatment decision-making. Okay, that's super helpful. Thank you. Hi, thank you so much for that presentation. Also a fangirl. I'm a groupie of this jazz band right here. So my question was, is there anything unique to FQHCs that either makes it easier or harder to implement collaborative care in the system? Billing? Yeah. Okay. The FQHCs do not recognize the CPT codes, and they only recognize a G-code that I can't remember right off the top of my head. Possibly Dr. Ranscliff. Yeah, I can get the number. I mean, I don't wanna say it. It's a G-code, and that's all that they can do. And I've argued this that, well, if you have a mixed population of people that are in an FQHC, and also a private insured population, why can't that group use the CPT codes for the private insured and the G-code? They tell me that it's an issue of a regulation that they can't commingle funds through an FQHC. So it makes it very, very difficult. Thank you. I think it makes it difficult for them to fill the Medicare codes, because, and the other thing is they, unlike the CPT codes for general populations, which you only have to bill half the time plus a minute to be able to actually do that code for the FQHC codes, you actually have to have full 60 minutes of billing. They are also not eligible for encounter rates, which I think is the other problem, so that some FQH, so many of the FQHCs implement collaborative care, so use an alternative strategy, and they tend to bill for the psychotherapy component that the care manager delivers, and when you do that, many of them can find a sustainable, or close to sustainable model with that different structured approach to the billing. So you might consider a different approach. On the AEM Center website, we actually do have a fact sheet for FQHCs that goes into some of that detail, so you can find that under a financing section, so that might be a good place to look. Awesome, thank you. Yeah, and I'm gonna just show you guys where it is on the AEM Center while you're talking. Keep going. Next question. And I had a question about how you bill for the physician services, because the CPT codes, those are for the behavioral health care manager, or are there some for the physician billing too? It all goes through the primary care doctor, the medical lead. So the encounter that they would do, say they do a 99214 medical encounter. At the end of the month, they would then, because the behavioral health care manager is an employee of the PCP or medical lead, and the consulting relationship is a direct contractual relationship with the medical lead, this is not a psychiatric billing. They don't get billed for it separately. As a matter of fact, Medicare said you can't bill as a psychiatrist the collaborative care codes, period. So it all goes through the PCP. So they bill all of that, and they take the money, distribute it to where they're supposed to in their buckets. That's why you have to have a margin. You can't do this with them losing money on each of the components. They have to be able to have a margin, and that's what we did as a regressive analysis of how much does this cost, threw in a 20% uplift, and they not only make their base, but they make a 20% margin on these codes. It's also important to acknowledge that the PCPs can still bill for routine E&M visits. Yeah, their fee for service. If they see a patient in person, they do their regular billing for that. So this is actually above and beyond, and so you're getting, which we didn't really talk about, but patients are getting more contact points with the primary care team than they would normally, and you're getting opportunities to bill for services that may not even really involve the PCP seeing the patient face-to-face, which is the real opportunity for these billing codes. The way that we've arranged it at Emory is that the PCP is the billing provider, the care manager is the rendering provider. For what that's worth, it gives them some credit, and it's a way for us to track their efforts, and anytime anything happens that involves the care manager either reaching out to the patient, the PCP, or the site consultant, that gets lumped into the minutes per month. So that's kind of how everybody's time gets allocated. So then as a psychiatrist, I have a contract with the primary care, and we negotiate what they can afford or how we'll work that out, and then if, like for the example where the psychiatrist is not within the healthcare system, does that provider have to be on all the insurance panels of all of the patients, or how does that work? Yeah, so the advantage of the collaborative care model is actually typically they don't because that psychiatrist is not billing anything directly to any of those insurances. So even, for example, if you have a psychiatrist that isn't enrolled to accept Medicare, they can still serve in the psychiatric consultant role, and the team, since it's the primary care provider that actually bills the codes, can bill Medicare. So you do not, as the psychiatrist, have to be on all the insurance panels that would be billing. We do have sample contracts and job descriptions for psychiatric consultants on the AEM Center website if you're looking for models of what that might look like. This is really a follow-up to her question, but I think you may have partially answered it. The psychiatrist or the case manager, if the case manager, for example, is a social worker, they can do direct care if that is a requirement for the patient. Yes. That's outside of the collaborative care consultation and teamwork, and they can bill the appropriate CPT code for medication management if it's a one-to-one referral, or psychotherapy if that happens by the psychiatrist or the case manager if it's a social worker. Correct? That's correct. What we have found, though, just in practice, and this may be different than what AEMS and others have found, but in the practices that we have, the case manager needs to be a case manager. Full-time. And if you're gonna have them do therapy, they need to be a therapist either co-located in the clinic or outside the clinic. But if you try to mix that, then the patient gets very confused as to the boundary of, am I talking to the therapist or am I talking to the case manager now? And what we found is, just because of those boundary issues and the inefficiency of that, we make it clear that I'm your case manager. If you need psychotherapy, we will set you up with a therapist to work on those services. Just to be clear. Makes sense. For those boundary issues. Yeah, I mean, we have seen both. I mean, we have been around care managers that are skilled in delivering the evidence-based treatment, so they do a blend of care management and psychotherapy. So we have seen that model work. I think if you're doing more intensive psychotherapy, like for example, we often would refer out for more specialty psychotherapy. So if somebody needed, they have OCD or they have PTSD and they need evidence-based, more extensive treatment, that often would happen outside of collaborative care or be another referral. But teams can be configured lots of different ways. So I just wanna kind of leave that there's a lot of flexibility. The only other thing I wanted to say is for the codes, you can bill any direct services directly. You just can't double count them in it. So if you spend that time delivering psychotherapy and bill a psychotherapy code, then you can't count those minutes towards the collaborative care codes. But the rules for Medicare are explicit that you can bill both of those things for the same patient in the same month because they're complimentary services. Thank you. All right, thank you guys so much. Thank you. If people want the resources.

collaborative care model

integrated mental health care

primary care provider

behavioral health care manager

psychiatric consultant

depression treatment

anxiety treatment

rural areas

stakeholder buy-in

leadership support

healthcare provider training

payment mechanisms

video presentation

panel discussion