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The American Journal of Accountable Care June 2018
Amazing Grace: A Free Clinic's Transformation to the Patient-Centered Medical Home Model
Jason Alexander, BS, PCMH CCE; Jordon Schagrin, MHCI, PCMH CCE; Scott Langdon, BA; Meghan Hufstader Gabriel, PhD; Kendall Cortelyou-Ward, PhD; Kourtney Nieves, PhD; Lauren Thawley, MSHSA; and Vincent Pereira, MHA, PCMH CCE
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Lessons Learned in Implementing Behavioral Screening and Intervention
Richard L. Brown, MD, MPH
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Lessons Learned in Implementing Behavioral Screening and Intervention

Richard L. Brown, MD, MPH
This article describes lessons learned over the past 10 years while helping several dozen primary care settings implement evidence-based, cost-saving behavioral screening and intervention.
ABSTRACT

Value-based reimbursement programs are creating strong incentives for primary care settings to deliver evidence-based behavioral screening and intervention (BSI). BSI for unhealthy drinking, depression, and smoking improves outcomes and generates substantial cost savings. Addressing other behavioral risks and disorders may also reduce costs. From experience helping dozens of primary care clinics implement BSI, the author makes several recommendations: expand the healthcare team, because BSI requires ample time; hire full-time bachelor’s-level health coaches selected for their personality attributes rather than prior training and experience; initially, deliver BSI for patients of one clinician, and optimize workflow, then serve patients of other clinicians; obtain buy-in from all clinicians and staff with strong support from healthcare organization and clinic leaders, data demonstrating patients’ need for BSI, initial success stories, and local data documenting effectiveness; train coaches rigorously in motivational interviewing, an empathic, respectful, patient-centered, evidence-based approach to promoting healthier behaviors; provide ongoing support for coaches after 2 to 3 weeks of initial training; have receptionists ask patients to complete screening forms in waiting areas, then have medical assistants review completed screens and summon coaches to see patients with positive screens; use a data-driven quality improvement program to refine the workflow, maximizing the proportions of patients screened and of patients with positive screens who see health coaches; and adapt electronic health records to support BSI. Administering BSI in this manner can help primary care clinics make substantial progress toward achieving the quadruple aim and thriving under value-based reimbursement.

The American Journal of Accountable Care. 2018;6(2):e9-e14
The Changing Playing Field of Value-Based Reimbursement

Under fee-for-service reimbursement, primary care clinicians in the United States have had little financial incentive to help reduce healthcare costs. Primary care practice leaders have understandably viewed the expenses of many recommended cost-saving measures as indefensible investments, as savings would accrue to payers or purchasers, not to the primary care practices.

Value-based reimbursement is creating a new playing field. Payers are increasing expectations and incentives for primary care clinicians to deliver cost-effective care. Under the Medicare Access and CHIP Reauthorization Act, Medicare will modify each practice’s reimbursement rates, starting in 2019, based on claims submitted throughout 2017. Whether primary care practices choose to participate in alternative payment models (APMs) or the Merit-based Incentive Payment System (MIPS), an increasing portion of their earnings will depend on quality metric performance and cost control.

Especially after commercial payers start to emulate Medicare and most payment is based on value, a Darwinian vicious-circle scenario will likely ensue. Better-performing and more highly compensated practices will invest more in innovation, improve their performance further, generate more profit, and entice clinicians and staff away from other practices with better working conditions and higher compensation while other practices will wither. Now is the time for primary care practices to start making bold changes if they aim to thrive under value-based reimbursement.

Behavioral Screening and Intervention

One recommended cost-saving practice not widely implemented by primary care practices in a robust, evidence-based manner is behavioral screening and intervention (BSI).1 The core components of BSI are smoking screening and cessation; alcohol screening, brief intervention, and referral to treatment; and depression screening and collaborative care. These services carry Grade A or B recommendations from the United States Preventive Services Task Force, are recommended by many other authorities, and generate ample net cost savings, as shown in Table 1.1 BSI can also include screening, intervention, and referral for drug use, intimate partner violence, diet, physical activity, and obesity—services that are recommended by many authorities but lack documentation of cost savings. BSI can be extended to address additional behaviors relevant to various chronic diseases, such as adherence to medication, dietary, and physical activity regimens.2

The author and colleagues have helped dozens of primary care practices implement BSI. From 2006 to 2011, with funding from the Substance Abuse and Mental Health Services Administration, they helped 33 clinical settings to conduct alcohol and drug screening for more than 100,000 patients; deliver more than 20,000 interventions; and garner high patient satisfaction. Six-month follow-up phone calls to hundreds of patients found average reductions of 20% in binge drinking and 15% in marijuana use.3 An analysis of Medicaid claims data also found average net 2-year cost savings of $782 per patient screened.4 In a small pilot project in which 3 of the 33 settings also implemented depression screening and collaborative care, depression symptom scores declined by 55% over 8 to 12 weeks.3 In other projects since then, the author and colleagues have helped other practices implement BSI with various combinations of behavioral focuses, including cardiovascular risk reduction for patients with hypertension, lipid disorders, and diabetes, as recommended by HHS’ Million Hearts Initiative.

BSI would help primary care practices that join APMs excel on 15 Medicare Shared Savings Program metrics, as shown in Table 2, and practices that choose MIPS increase scores in 3 of 4 areas: quality metrics, cost control, and practice improvement.

For practices that wish to implement BSI, this paper will report on lessons learned from helping dozens of primary care settings implement BSI since 2006.

Lesson 1. Plan for Robust Service Delivery and Expand the Healthcare Team

The robust services required for optimal behavioral outcomes and cost savings require ample patient contact time. Optimal smoking quit rates are obtained with motivational interviewing and at least 9 one-on-one support sessions.5,6 Collaborative care for depression involves contact with patients over several months.7 Although some patients with unhealthy drinking patterns respond to a single-­session brief intervention, follow-up contacts elicit greater and more sustained change.8

In planning for BSI estimate patient contact time requirements. Table 39-11 shows such calculations based on the prevalence of smoking, unhealthy drinking, and depression in the US adult population. Practice administrators can easily obtain population prevalence figures for their states.9,10 These figures should be regarded as conservative because behavioral risks and disorders are usually more prevalent in clinical populations than in general populations. As shown in Table 3, robust BSI for smoking, unhealthy drinking, and depression for an average panel of 2300 patients11 would require more than 900 total hours of patient contact time per year. This calculation makes clear that busy clinicians or other staff cannot deliver robust BSI. The healthcare team must be expanded to enable delivery of the high-quality services necessary to improve outcomes and reduce costs. The calculation suggests that practices must plan to add 1 health coach for every 2 full-time primary care clinicians. A higher health coach-to-clinician ratio would be needed if coaches address additional behavioral risks and disorders and chronic diseases.


 
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