Methods: NP students experienced a co-located level 3 integrative collaborative care model (CoCM) while completing clinical hours at the Nurse Managed Primary Care Center (NMPCC). This CoCM was implemented by leasing in-office space to a Behavioral Health (BH) provider two days per week, seven hours per day. Electronic health records (EHR), billing systems, and third party payor contracts were separate.
The primary care measurements implemented included routine screening and evaluation of depression and anxiety (Gerrity, 2016; Raney, Lasky, & Scott, 2017). Depression and anxiety symptomology were screened using the Patient Health Questionnaire-2 (PHQ-2) and the Generalized Anxiety Disorder-2 (GAD-2) (Kroenke, Spitzer & Williams, 2001; Spitzer, Kroenke, Williams, Löwe, 2006). The combined use of these tools is known as the PHQ-4 (Löwe et al., 2009). If patients scored >3 on the PHQ-2, then the Patient Health Questionnaire-9 (PHQ-9) was administered and followed by treatment and/or referral as indicated (Kroenke, Spitzer, & Janet Williams, 2003). If patients scored >3 on the GAD-2, then the Generalized Anxiety Disorder-7 (GAD-7) was administered and followed by treatment and/or referral as indicated (Spitzer et al., 2006). Patients referred for BH services scheduled follow-up appointments with the front office staff at the conclusion of the primary care visit.
Results: Routine depression and anxiety screenings were a positive primary care practice initiative that increased provider detection of and referral for patient behavioral health needs. As a result, primary care NPs practiced to the full scope of their practice, confidently and efficiently. Independent billing for services for primary care versus BH services resulted in missed opportunities for higher CoCM reimbursement levels. Lack of corresponding third party agreements further inhibited seamless integrated care. Fragmented patient services persisted as a result of this informal, level 2, communication structure coupled with separate EHRs and billing structures.
Conclusion: Multiple pragmatic requirements were addressed, such as technologies to support implementation and evaluation of integrated care, billing for third party reimbursement, and formal provider and staff training sessions regarding communication and planned work-flow. Evaluation methods were identified to support Quality Assurance interventions and sustainability. Many lessons were learned during the NMPCC CoCM implementation. Team engagement was a critical concept that should have been assessed before and during this application. Selecting and utilizing a readiness assessment tool is recommended to measure team engagement and identify potential obstacles before launching a CoCM. Continuous quality assurance measures are essential to maintaining and sustaining this model overtime.