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Research ArticleOriginal Research

Start-Up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the Advancing Care Together (ACT) Program

Neal T. Wallace, Deborah J. Cohen, Rose Gunn, Arne Beck, Steve Melek, Donald Bechtold and Larry A. Green
The Journal of the American Board of Family Medicine September 2015, 28 (Supplement 1) S86-S97; DOI: https://doi.org/10.3122/jabfm.2015.S1.150052
Neal T. Wallace
From Portland State University, Portland OR, (NTW); Oregon Health & Science University, Portland, OR, (DJC, RG); Kaiser Permanente Colorado, Denver, CO (AB); Milliman, Denver, CO (SM); Jefferson Center for Mental Health, Lakewood, CO (DB); University Colorado, Denver, Denver, CO (LAG).
PhD
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Deborah J. Cohen
From Portland State University, Portland OR, (NTW); Oregon Health & Science University, Portland, OR, (DJC, RG); Kaiser Permanente Colorado, Denver, CO (AB); Milliman, Denver, CO (SM); Jefferson Center for Mental Health, Lakewood, CO (DB); University Colorado, Denver, Denver, CO (LAG).
PhD
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Rose Gunn
From Portland State University, Portland OR, (NTW); Oregon Health & Science University, Portland, OR, (DJC, RG); Kaiser Permanente Colorado, Denver, CO (AB); Milliman, Denver, CO (SM); Jefferson Center for Mental Health, Lakewood, CO (DB); University Colorado, Denver, Denver, CO (LAG).
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Arne Beck
From Portland State University, Portland OR, (NTW); Oregon Health & Science University, Portland, OR, (DJC, RG); Kaiser Permanente Colorado, Denver, CO (AB); Milliman, Denver, CO (SM); Jefferson Center for Mental Health, Lakewood, CO (DB); University Colorado, Denver, Denver, CO (LAG).
PhD
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Steve Melek
From Portland State University, Portland OR, (NTW); Oregon Health & Science University, Portland, OR, (DJC, RG); Kaiser Permanente Colorado, Denver, CO (AB); Milliman, Denver, CO (SM); Jefferson Center for Mental Health, Lakewood, CO (DB); University Colorado, Denver, Denver, CO (LAG).
MSA, FAAA
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Donald Bechtold
From Portland State University, Portland OR, (NTW); Oregon Health & Science University, Portland, OR, (DJC, RG); Kaiser Permanente Colorado, Denver, CO (AB); Milliman, Denver, CO (SM); Jefferson Center for Mental Health, Lakewood, CO (DB); University Colorado, Denver, Denver, CO (LAG).
MD
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Larry A. Green
From Portland State University, Portland OR, (NTW); Oregon Health & Science University, Portland, OR, (DJC, RG); Kaiser Permanente Colorado, Denver, CO (AB); Milliman, Denver, CO (SM); Jefferson Center for Mental Health, Lakewood, CO (DB); University Colorado, Denver, Denver, CO (LAG).
MD
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Article Figures & Data

Tables

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    Table 1. Definitions and Examples of Study Expense Types
    Expense TypeDefinitionExample
    Start-upExpenses specifically incurred in preparation for delivery of the interventionValue of staff time spent planning intervention, acquired assets (eg, HIT), or training new or existing staff
    Developmental start-upStart-up expenses incurred in establishing the foundation of the intervention and typically unrelated to the scale of implementationValue of staff time spent on intervention planning, negotiating intra- or inter-organizational agreements, creating intervention tools, or re-tooling HIT systems
    General start-upStart-up expenses incurred to initiate a developed intervention and typically related to the scale of implementationValue of staff time spent on intervention training or purchased assets (eg, computers, software, screening tools) needed to implement the intervention
    OngoingExpenses specifically incurred in delivering the interventionDirect and administrative staff time, assets, or supplies used to provide intervention
    EffortAny expense incurred in support of the ACT intervention, regardless of whether the expense emanated from new or existing resourcesValue of time spent on intervention by existing staff and staff newly hired to accomplish intervention. Use of existing facilities and supplies and newly acquired assets specific to the intervention
    IncrementalExpenses emanating only from new (additional) resources acquired to develop or implement the intervention.Value of time spent on intervention by staff newly hired to accomplish intervention or newly acquired assets specific to the intervention
    Direct staffExpenses incurred to compensate patient facing staff involved in the interventionValue of time spent by clinical or front desk staff that interact with patients in preparing for or providing intervention
    Administrative staffExpenses incurred to compensate staff supporting intervention without direct patient interaction.Value of time spent by practice management, clinical supervisors, HIT or other support staff in preparing for or providing intervention.
    Non-staff directNon-staff expenses for items that could be directly and entirely tied to the interventionComputers, software, license fees, supplies, or travel purchased specifically to accomplish intervention
    OverheadNon-staff expenses that could be attributed in part to the intervention, but are neither distinctly nor entirely associated with itPortions of rent, utilities or other pooled or general practice expenses that can be allocated or assigned to intervention activities
    • Abbreviation: HIT, health information technology.

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    Table 2. Characteristics and Descriptions of Advancing Care Together (ACT) Innovations
    IDPatient Screening TypeDirect Staff FTENew Hires for InterventionLarge-Asset Investment (IT/Space Build-Out)
    19Systematic<20NoYes/yes
    Description: CMHC developed a new integrated care clinic; this included building a new facility and bringing on a primary care team. Systematic screening is accomplished via a Web tablet at check-in. The practice developed a Health Tracker that extracts selected information from two separate behavioral health and medical EHRs to provide information about patients' behavioral and physical health needs at the point of care.
    16Systematic20 to 50NoNo/no
    Description: A research team is working with an FQHC with an onsite behavioral health provider and patient navigators to develop a screening tool that assesses patients' behavioral health needs and treatment preferences. Clinic and research staff implemented this tool with the goal of establish consistent screening and referral of patients to their preferred treatment.
    18Clinician discretion>50YesNo/yes
    Description: This was a partnership between a FQHC system, a substance abuse treatment center and a CMHC. The CMHC was the site of the intervention. A team that included a physician's assistant, medical assist, care coordinator, and substance abuse counselor moved among three CMHCs to make primary care and substance use services available to patients at each site.
    14Clinician discretion20 to 50NoNo/no
    Description: This system colocated behavioral health providers in primary care clinics to provide patients with solution-focused interventions and to facilitate referral to other organizational resources (eg, long-term therapy, case management). Behavioral health providers also provided some consultations to medical clinicians upon request.
    9Systematic<20YesNo/no
    Description: Privately owned primary care practice partnered with a CMHC to hire, train, and supervise a colocated behavioral health provider. Practice also expanded its health coach services. Practice systematically screened patients at check-in using paper based tool with follow-up screening administered by Medical Assistant during intake, as needed. Patients connected with behavioral health provider or health coach, as needed.
    7Systematic>50YesYes/no
    Description: Privately owned primary care practice automated behavioral health screening by implementing web-tablets at check-in. The practice worked with information technology partners to develop coding necessary to integrate data into their EHR, and hired and colocated a psychologist to address patients' needs. They continue to expand their behavioral health staff.
    12Clinician discretion<20NoNo/no
    Description: FQHC increased screening and behavioral health services for newly identified pregnant women by adding a psychology fellow who screened patients, offered brief therapy, and followed up with patients as needed. All eligible patients received a followup screen at 6 weeks postpartum.
    4Systematic20 to 50YesNo/no
    Description: A postdoctoral psychology training program partnered with an FQHC serving seniors to implement an enhanced, computerized cognitive and psychological screening. The team implemented and tracked clinical use of the screening, provided a summary report to clinicians, and followup treatment to patients as requested
    10Systematic<20YesNo/no
    Description: Solo, privately owned primary care practice partnered with CMHC to embed a behavioral health provider into the practice. The practice systematic screened patients at check-in and intake. Behavioral health provider delivered therapy to patients most with poorly controlled chronic diseases, and most in need of services.
    13Clinician discretion20 to 50NoNo/no
    Description: Privately owned family practice collaborated with a privately owned behavioral health center to integrate care. A behavioral health provider was colocated in the primary care practice. The behavioral health center expanded services into the family practice by delivering trainings on integration, colocating a behavioral health provider to increase consultations and warm handoffs, and implementing systematic screening.
    • CMHC, community mental health center; EHR, electronic health record; FTE, full-time equivalent; IT, information technology.

    • View popup
    Table 3. Practice Start-Up Effort Expenditures
    Practice IDStart-Up Expense TypeDuration, moStaff ExpenseNon-Staff ExpenseTotal
    DirectAdminDirectOverhead
    19Total, $10413738,537129,25114,023185,949
    Developmental, %1079.420.662.426.351.4
    16Total, $111357401912222766874
    Developmental, %1188.849.036.823.753.7
    18Total, $1310,44036,56310,62515,40573,033
    Developmental, %130.024.60.03.413.0
    14Total, $16491431220914
    Developmental, %10.00.00.00.00.0
    9Total, $520,9802128945012,36044,918
    Developmental, %562.945.413.261.351.2
    7Total, $2416,60513,54231,10014,39975,645
    Developmental, %2498.964.62.983.550.3
    12Total, $2556416,096264538824,694
    Developmental, %215.431.75.727.525.2
    4Total, $157332610005282427
    Developmental, %112.50.00.020.07.3
    10Total, $5.546813820273364411,879
    Developmental, %5.530.123.90.027.321.0
    13Total, $6794038231618104714,428
    Developmental, %641.576.583.752.956.3
    OverallTotal, $7.9729311,90018,977590744,076
    Developmental, %7.954.531.644.742.042.4
    Highest Five (No. 19, 18, 9, 7, and 12)Total, $10.811,54521,37336,61411,31580,848
    Developmental, %10.858.529.745.342.242.6
    Lowest Five (No. 16, 14, 4, 10, and 13)Total, $4.93040242613394997304
    Developmental, %4.939.447.927.036.139.7
    • View popup
    Table 4. Practice Start-up Incremental Expenditures
    Practice IDStart-up Expense TypeDuration, moStaff ExpenseNon-Staff ExpenseTotal
    DirectAdminDirectOverhead
    19Total, $1000129,2510129,251
    Developmental, %0.00.062.40.062.4
    16Total, $1100122201222
    Developmental, %0.00.036.80.036.8
    18Total, $132160010,625012,785
    Developmental, %4.80.00.00.00.8
    14Total, $1001220122
    Developmental, %0.00.00.00.00.0
    9Total, $5156309450011,013
    Developmental, %71.40.013.20.021.5
    7Total, $24137957431,100040,810
    Developmental, %50.050.02.90.014.1
    12Total, $203274264505920
    Developmental, %0.051.15.70.030.8
    4Total, $13260100001326
    Developmental, %22.00.00.00.05.4
    10Total, $5.510840273303817
    Developmental, %0.00.00.00.00.0
    13Total, $600161801618
    Developmental, %0.00.083.70.083.7
    OverallTotal, $7.9527128518,977020,788
    Developmental, %25.850.344.70.044.5
    Highest Five (No. 19, 18, 9, 7, and 12)Total, $10.8772257036,614039,956
    Developmental, %33.450.345.30.045.4
    Lowest Five (No. 16, 14, 4, 10, and 13)Total, $4.928201,33901621
    Developmental, %5.10.027.00.023.2
    • View popup
    Table 5. Ongoing Monthly Practice Effort Expenses per Patient
    Practice IDPatient VolumeStaff, $Non-Staff, $Total
    DirectAdminDirectOverhead
    195169.892.616.634.6723.80
    16347.9310.280.121.2919.63
    1820031.4227.310.005.8064.54
    147947.1639.520.0036.66123.34
    926714.754.686.7820.4846.69
    710495.019.640.000.7115.36
    12831.1325.370.003.3629.86
    41304.380.000.0011.3715.75
    105416.603.100.035.1514.89
    139814.0817.400.0018.5650.04
    Practice Average29914.2413.991.3610.8040.39
    Highest Five (No. 18, 14, 9, 12, and 13)14521.7122.861.3616.9762.89
    Lowest Five (No. 19, 16, 7, 4, and 10)4546.765.121.364.6417.88
    • View popup
    Table 6. Ongoing Monthly Practice Incremental Expenses Per Patient
    Practice IDPatient VolumeStaff, $Non-Staff, $Total, $
    DirectAdminDirectOverhead
    195160.000.006.630.006.63
    16340.000.000.120.000.12
    182009.650.000.000.9510.60
    14790.000.000.000.000.00
    92674.700.006.784.9416.41
    710494.540.000.000.224.76
    12830.000.000.000.000.00
    41301.590.000.004.095.68
    105410.890.000.030.691.62
    13980.000.000.000.000.00
    Practice Average2992.140.001.361.094.58
    Highest Five (No. 19, 18, 9, 7, and 4)4323.370.002.692.138.19
    Lowest Five (No. 16, 14, 12, 10, and 13)1670.000.000.030.000.03
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The Journal of the American Board of Family     Medicine: 28 (Supplement 1)
The Journal of the American Board of Family Medicine
Vol. 28, Issue Supplement 1
September-October 2015
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Start-Up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the Advancing Care Together (ACT) Program
Neal T. Wallace, Deborah J. Cohen, Rose Gunn, Arne Beck, Steve Melek, Donald Bechtold, Larry A. Green
The Journal of the American Board of Family Medicine Sep 2015, 28 (Supplement 1) S86-S97; DOI: 10.3122/jabfm.2015.S1.150052

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Start-Up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the Advancing Care Together (ACT) Program
Neal T. Wallace, Deborah J. Cohen, Rose Gunn, Arne Beck, Steve Melek, Donald Bechtold, Larry A. Green
The Journal of the American Board of Family Medicine Sep 2015, 28 (Supplement 1) S86-S97; DOI: 10.3122/jabfm.2015.S1.150052
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