Psychiatric Collaborative Care

Psychiatric Collaborative Care

OVERVIEW

This document outlines supporting evidence and specifics of the THRIVEE Psychiatric Collaborative Care (CoCM) offering. THRIVEE leverages its advanced technology to enable providers to effectively manage Medicare beneficiaries with behavioral health issues at the primary care level. Related to the Institute of Healthcare Improvement Triple Aim, THRIVEE CoCM delivers improvements in:

Experience of care: Patients keep their PCP receiving the care they need for behavioral and mental health

Quality: Better outcomes for patients with mental and/or behavioral health conditions

Cost: Improved margin and significant revenue opportunity to fund a Behavioral Health Manager (Registered Nurse) and reduced total cost of care

EVIDENCE BASE

Collaborative care, and specifically CoCM, was developed by researchers at the University of Washington AIMS Center. Collaborative care places the patient at the center of the care delivery experience with a care manager who ensures consistent communication, care coordination, and follow-up. The research foundation for CoCM has been proven in the United States in a variety of clinical settings and even internationally. A 2012 meta-analysis of 79 studies demonstrated improved short- and long-term clinical outcomes when comparing collaborative care to usual primary care for patients with depression and anxiety. CoCM doubles depression treatment response rates compared to usual care. This strong research foundation was adopted by Centers for Medicare and Medicaid Services for Medicare Part B in 2017 and added for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) as of 2018.

THRIVEE COLLABORATIVE CARE MODEL

THRIVEE enables primary care providers to deliver CoCM via a technology solution providing access to a psychiatric consultant (a board-certified psychiatry physician or nurse practitioner) for weekly caseload review. CoCM augments typical primary care with behavioral health treatment and inter-specialty consultation with the THRIVEE Psychiatric Consultant. Eligible Medicare beneficiaries include any mental, behavioral health, or psychiatric condition that is being treated by the billing provider (Primary Care Provider), that, in their clinical judgement, warrants collaborative care. This includes, but is not limited to, anxiety, depression, and substance use disorders.

Table 1. Care Team Roles


Primary Care Provider

Behavioral Health Manager

THRIVEE Psychiatric Consultant

  • Billing provider
  • Initial assessment and enrollment consent
  • Follow-up visits
  • Treatments including psychotherapy and pharmacotherapy
  • Typical panel of 20-30 Medicare beneficiaries
  • Typically, a Registered Nurse
  • Formal education or training in behavioral health with oversight by billing provider
  • Health coach
  • Care team communication
  • Uses patient registry for weekly caseload review
  • Coordinates care for up to 150 patients
  • A medical professional trained in psychiatry and qualified to prescribe the full range of medications (physician or nurse practitioner)
  • Weekly Caseload review with PCP and BHM

The care pathway is generally represented as:

Figure 1. CoCM Care Pathway.

Initiating visit: Initiating visits include an Evaluation and Management (E/M) encounter, Annual Wellness Visit (AWV) or Initial Preventive Physical Examination (IPPE), the billing provider (Primary Care Provider) determines a patient is eligible for and will benefit. During the initiating visit or within one year, the billing provider determines a patient is eligible for and will benefit from CoCM. Verbal consent should be documented in the patient record and the patient informed that standard deductible, copay, and/or coinsurance applies.

Treatment plan: Approximately 30 minutes of care planning time in the initial month and 26 minutes in subsequent months is reserved for the billing provider to make an individualized treatment plan. This treatment plan includes pharmacotherapy and psychotherapy incorporating monthly administration validated rating scales such as the Patient Health Questionnaire 9-item (PHQ-9) for depression and the Generalized Anxiety Disorder 7-item (GAD-7).

Registry: Medicare requires the use of a registry for patient entry and tracking of follow-up and progress. THRIVEE provides the registry with automatically populated fields as part of the platform technology at no cost.

Weekly caseload review: The THRIVEE Psychiatric Consultant reviews the caseload and provides expert input on the pharmacotherapy and psychotherapy aspects of the treatment plan status. The THRIVEE Psychiatric consultant makes adjustment recommendations using the populated registry in the platform with the Behavioral Health Manager during a weekly scheduled videoconference. Caseload review time for the Psychiatric consultant is projected as 13 minutes in the initial month and 7 minutes in subsequent months representing approximately 2 minutes of caseload review time per week. The additional time in the initial month is projected for an approximately 5-minute initial patient briefing.

Collaboration and care coordination: The THRIVEE platform enables a continuous relationship with the patient with secure messaging, file exchange, assignment and completion of PHQ-9 and GAD-7, and virtual video visits.

TECHNOLOGY

THRIVEE has extended its core virtual care platform with additional functionality to support CoCM (Figure 2). The core platform is used for maintaining the patient relationship via secure messaging and assignment and completion of PHQ-9 and GAD-7. The focal point of the CoCM offering is how THRIVEE technology enables registry review with the Psychiatric Consultant. The CoCM Registry workflow is designed to ensure an effective and time-sensitive focus of each patient during the weekly caseload review between the Behavioral Health Manager and the Psychiatric Consultant. The current patient (John Smith) is displayed with the next patients in review (Jane Davis and Mike Jones) in a muted display. Visual cues of flags (safety risk used as the example) and duration of patient record review. Clicking “Complete Review” during an individual patient focus will move to the next patient record in queue. Key characteristics such as diagnosis, date of diagnosis, treatment medications, date of last follow-up, and date of next scheduled follow-up are displayed. The most recent PHQ-9 and GAD-7 results are displayed and graphically trended. Review notes are displayed along with speech-to-text transcription of the caseload review discussion to reduce the need for typing notes.

Figure 2. THRIVEE CoCM Registry Screenshot

CoCM ADVANTAGE

THRIVEE CoCM in particular, and CoCM in general is a better care model to manage patients with behavioral health issues at the primary care level. Compared to Behavioral Health Integration (BHI) and Chronic Care Management (CCM), CoCM has a better Behavioral Health Manager to patient ratio, better outcomes for behavioral health, and increased revenue. Specifically, with regards to revenue, Medicare billing codes are 70-minutes for the initial month and 60 minutes for subsequent months with an additional 30-minute add-on code when necessary. By Contrast, BHI and CCM are 20-minute billing codes with no monthly add-on code.



CoCM

Psychiatric Collaborative Care

BHI

Behavioral Health Integration

CCM

Chronic Care Management

Panel Size

150 patients

200-300 patients

200-300 patients

Best For

Intervention (psychotherapy)

Medication (pharmacotherapy)

Intensive follow-up

Intervention (psychotherapy)

Continuity of care

Managing chronic disease

Evidence Base

2012 meta-analysis

79 studies

Improved outcomes for depression & anxiety, adherence, & satisfaction

2017 systematic review 46 studies Success driven by collaboration and communication. Financial sustainability concerns

2018 systematic review

157 studies

Self-management support effective yet wide variation influenced by organizational factors & provider capacity

Increased Revenue

99492 Psych CoCM $161.28 (Initial month, 70 min)

99493 Psych CoCM $128.88 (Subsequent month, 60 min)

99484 General BHI $48.60 (20 min)

99484 CCM $42.84 (20 min)


Rates are cited as 2018 Medicare Physician Fee Schedule Part B non-facility and non-geographically adjusted

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