Behavioral Health Integration

This affinity group includes @Vista @Open_Door @NEMS @Afsheen_AXIS. Please feel free to share your group’s progress and updates below!

Hi @Vista @Open_Door @NEMS @Afsheen_AXIS! We have our 1st affinity group meeting happening on May 3rd at 10-11 am PST. Here’s the login information for the call:
Join: Launch Meeting - Zoom
1-Click Audio: 4086380968,4155614444#
Call-In: 408-638-0968 ID: 4155614444

I’ve emailed a suggested agenda to you all in your calendar invite, but I’d love for each of you to introduce yourself, your team, project and one thing you’d like to get out of our first call together!

Hello Affinity Group Folks! Here are the list of questions that we (Open Door) submitted. Just wanted to share in case anyone had feedback or were challenged with similar issues. Thanks!

  • Writing letters for students re: stress, financial aid, etc. Also, emotional support animals, court mandated patients, etc. – specifically around when they ask our BHCs to write a letter on their behalf

  • Templates, charting, documentation challenges – specifically around billing/coding (audit) requirements vs. clinical focus/understanding of what needs to be in the chart

  • Challenges around billing/coding folks communication w/BHC’s – speaking different languages

  • Getting all BHCs (and Medical Providers) onboard with the IBH model – training, implementation, tracking, outcomes, sustainability, leadership, team building, standardization, etc.

  • Safety planning for patients & Behavior contracts

  • Plus safety for BHCs!

  • Patients with workman’s comp needs (BH related)

  • Where & how are WHO’s documented in EPIC?

  • Standardization needed for tracking?

  • Crisis visit documentation

  • Groups and group curriculums - which ones are we utilizing now and what curriculum are we using for each?

  • Tracking tool (EBP) for patient self-management to track mood, reaction to meds, etc. - is there such a thing?

  • BHCs providing services to coworkers family members (in a rural low-access setting)

  • List item

BH Leadership style, structure, position-types, etc.

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Thanks @hscaglione for jumping into the conversation already and sharing your questions! We can keep revisiting this and seeing where there is synergy amongst other teams.

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Hi everyone! @Open_Door @Afsheen_AXIS @NEMS @Vista,

It was great to talk with you all last Friday! The notes from our meeting today are attached, a poll for our next meeting date and the next steps I captured are as follows:

  • @Linda_OpenDoorCHC and Amit or @Afsheen_AXIS - Connect to join Axis’ OCHIN/EPIC call.
  • Diana - Loop Lori Raney in during the next affinity group call
  • @Afsheen_AXIS - Check in with Chief of BH about the algorithm for who BH providers see.
  • Diana - Follow up with @Carolyn_CCI_Coach re: depression groups at Clinica and what that looks like (@Open_Door had asked about this).
  • @Open_Door - Ask the larger PHLN group if anyone is running depression groups at their clinic.

Thank you everyone! Let’s start leveraging this forum with any questions or insights you’d like to share! @gbetancourt is up next for facilitating the next call.

PHLN Affinity Group Meeting - 5.3.19.docx (10.3 KB)

  • Schedule next Affinity Group meeting in July
  • Schedule next Affinity Group meeting in August

0 voters

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Hi everyone!

I sent out a calendar invite a week ago for the next BH Affinity Group meeting on Wednesday, July 3rd at 11am-12pm. From the last call, we noticed that there were many questions related to the intricacies of this work so we’ve invited Dr. Lori Raney to join the next call.

From our last meeting, I’m suggesting the following agenda for the next call:

  1. Round Robin – Updates from each team & challenges/questions that are top of mind.
  2. Group Discussion: Stratification between PHQ scores and levels of care for patients
    3.What to do with patients whose PHQ aren’t changing over time?
    4.Sharing workflows for different levels of care.
  3. Next steps & meeting logistics

Are there other topics folks would like to prioritize for the next call? Would it be helpful to maybe share your current logic/workflow for levels of care? Another FYI, I’ll be on PTO, but @tammy_cci will be facilitating the next call :slight_smile:

@Vista @Open_Door @NEMS @Afsheen_AXIS

Hi Everyone,
This looks like a good list of topics. How about adding Care coordination with County Mental Health.

Thanks, Linda

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Thanks for your input!

@Linda_OpenDoorCHC @Open_Door @Vista @NEMS @Afsheen_AXIS We also discussed sharing some workflows for different levels of care. Can you post your workflows here by June 14?

Hi Team,
We are having a really challenging issue that I’d love some help with. Has anyone else gone through the new Medicare audit? We are having a lot of challenges dealing with the template/documentation requirements for BH charting. Even if you have not gone through the audit, we would love some advice about how to help coding/billing folks and BHCs work together.

Our internal coding/billing staff are returning BH charts (sometimes 10/day!) and telling the BHCs how to chart according to the audit standards. BHCs are saying that is not appropriate clinical documentation and that the “rules” are always changing. It’s making for a really challenging work environment and leading to a lot of really frustrated and burned out BHCs.
Thanks for any help you all can provide!

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@Vista @NEMS @Afsheen_AXIS Any ideas on this issue with the new Medicare audit?

Hi Diana,

To respond to your inquiry from May 24, after touching base with our Chief of Behavioral Health, Dr. Penney, she had stated that for our workflow the provider requests a warm-handoff and the care coordinator enters the session. If the patient is interested and there are no urgent clinical issues, they will be scheduled for an initial intake with the BH provider, typically within the same week. The patient then completes the intake and is then matched with a therapist. If the patient doesn’t show up, we call them and attempt to reschedule.

There was also a follow up question revolving around how many visits or over what duration of time do our BH providers see their clients. This completely depends on the presenting problem. We do not limit sessions, so the determination is made by the clinician. This tends to lead to higher staff/patient satisfaction and decreased provider burnout. We are considering limiting to one year, but haven’t had the data in place to be able to track that as of yet.

Hope this helps,


So I personally coordinate our primary care audits and have not gone through the Medicare audit myself, but I will touch base with our BH/Billing team to see if they have dealt with anything similar or if they are familiar with the new process and can chime in.


Thank you so much Afsheen!!

Hi everyone @Afsheen_AXIS @Open_Door @Vista @NEMS

Thanks so much to those of you that were able to join today’s affinity group call! I really enjoyed hearing about what you’re working on. Thanks to Lori for joining us and sharing advice and to Tammy for facilitating!

You can find detailed/verbatim-ish notes here. Let me know if you have trouble accessing/viewing as they are on google drive.

In the conversation, Lori mentioned collaborative compacts as an example of an agreement between the health center and other community behavioral health entities. Attached here are examples of those.
CareCompactExamplePrimary Care - Behavioral Health Collaborative Compact.docx (769.6 KB)
Care compact - WFH-BCCS - 2017-04-24.pdf (148.5 KB)

Next steps:

  • @Linda_OpenDoorCHC, you will look into how your org is billing for tele-psychiatry and share with the group.
  • Tammy will work to get the next call scheduled two months from now and will invite Lori to join again.
  • If you have feedback on the format of the call or any specific challenges/topics you want to discuss next time, let us know!

Hi teams @Afsheen_AXIS @Open_Door @Vista @NEMS,
Let us know what topic areas you’d like to focus on for the September call! Post ideas here!

Open Door is interested in talking about
-introducing the BHI model to medical providers
-infrastructure needed to support BH providers
-target # of visits per day for BH providers
-remission metric details.
Thanks everyone,

NEMS is interested in discussing:

  • Climbing decline rate for adolescents given iPad behavioral health screenings with decline option

Thank you,

Thanks @bettynguyen!

Hi everyone @NEMS @Afsheen_AXIS @Open_Door @Vista @tammy_cci

Thanks to those of you that were able to join the Behavioral Health Integration affinity group call earlier this week. You can find the notes from the call here.

We decided on the call to not do another call before the in-person learning session in December. There will be specific time set aside for affinity groups to meet in person during the convening.

I’ve followed up with the teams that were going to share resources (NEMS - brochure; Axis - registry info). Below is information from Afsheen at Axis (thanks so much, Afsheen!):

The report that we use lives in Business Objects via OCHIN. If another clinic would like to access the report and cannot find our service area (SA180), I’d be happy to either drop a copy of the report into their folder or I can provide the SQL query that was built for the report, depending on your preference.

Additionally, I attached our cover sheet for the report and a sample of what columns are included, but removed any PHI. Currently in progress is that we plan to add columns to track progress on EMDR Treatment for patients included in this report to see how it impacts patients’ scores over time.

Depression Registry with PHQ-9 Scores (PHLN Grant Report).pdf (59.6 KB)

Additionally, Axis had requested that others on the call share any processes/strategies for helping patients that aren’t making progress. Comment below with anything you have to share!

Hi @Afsheen_AXIS,
@bettynguyen shared some thoughts around helping patients that are stuck:

In terms of follow-up with patients who are not improving, there are different workflows that the provider can follow:

  1. Discussion with the clinical supervisor during clinical supervision meetings
  2. Consultation with other behavioral health therapists on the team
  3. Consultation with the psychiatric consultant and the primary care provider