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T

Integration
o
l
k
i
t
First steps to integrating mental health, physical
health and addiction services for Oregon
Medicaid clients
March 11, 2009
Contents
What is integration?......................................................................................... 1
About this guide........................................................................................ 1
Who will benefit from integration?............................................................. 1
Sharing client information................................................................................ 2
Who can share client information?............................................................ 2
Accepted information sharing under SB 163 (2007)............................ 3
Screening client needs.................................................................................... 4
Screening and assessment tools.............................................................. 4
Screening, Brief Intervention, and Referral to Treatment (SBIRT)....... 4
Mental health and substance abuse screening instruments................ 5
Procedure codes........................................................................................... 11
Health and Behavior Assessment and Intervention Codes......................11
Assessment codes............................................................................. 12
Intervention codes.............................................................................. 12
Claim submission............................................................................... 13
Documentation requirements ............................................................ 13
Screening, Brief Intervention, Referral and Treatment (SBIRT) codes... 14
Screening and brief intervention codes.............................................. 14
Claim submission............................................................................... 14
Documentation requirements............................................................. 14
Appendix....................................................................................................... 15
Sharing client information........................................................................ 16
Sample SB 163 (2007) acknowledgement form................................. 16
Summary of state and federal privacy laws....................................... 16
Systems of Care...................................................................................... 18
Four Quadrant Clinical Integration Model.......................................... 18
Pathway of Care Model...................................................................... 22
Assessment and Intervention Codes ..................................................... 23
HSC line placement effective January 1, 2009.................................. 23
Limitations of coverage...................................................................... 24
What is integration?
At a minimum, integration means physical, mental health and addictions providers share information
about their common clients. For purposes of this guide, addictions and mental health includes
behavioral health care. Integration efforts will move up the spectrum to involve client screening
practices, care coordination, and co-location of physical and mental health providers. Ultimately,
administrative and financial functions will be aligned to support clinical integration.
For first steps, DHS will focus on reducing administrative, regulatory and communication barriers to
make integration more feasible and less complicated for Oregon Health Plan (OHP) providers and
participating managed care organizations (MCOs). Managed care organizations include:
zz Fully Capitated Health Plans
zz Mental Health Organizations - County-based as well as other fully capitated Mental Health
Plans.
zz Physician Care Organization
zz Chemical Dependency Organization
zz Dental Care Organizations
For the purposes of this guide, all of the above organizations will be represented by the term Managed
Care Organizations (MCOs). In administrative rules, the term “Prepaid Health Plan” is used to denote
all of these managed care organizations.

About this guide


This toolkit represents the work of a team of stakeholders and DHS staff to address at least a few
barriers to the many integration projects already underway. It provides information that clarifies only
a limited number of issues related to how providers and MCOs can move toward integration in the
following areas:
zz Sharing client information
zz Screening client needs
zz Using Health and Behavior Assessment and Intervention Codes
zz Establishing billing guidelines
This Toolkit only provides guidelines and is not intended as the final authority or regulation. DHS
will continue to research and provide more information as integration efforts continue. For more more
information, go to the DHS Behavioral Health and Primary Care Integration Web site at
www.oregon.gov/DHS/ph/hsp/integration.shtml.

Who will benefit from integration?


DHS recommends implementing integration efforts for all persons who need some combination of
behavioral health and primary care assessment and treatment, regardless of the care setting in which
they enter the system. Populations come from all ages and cultural groups, and include:
zz Persons with depression, anxiety disorders or other mood disorders, substance use disorders,
or psychosis.
zz Persons with special residential and support needs.

3/11/09 Integration Toolkit 1


zz Persons in urban, rural, frontier, and mixed service areas.
zz Persons with chronic disease, such as heart disease, diabetes, hypertension, or obesity.
zz Children with conditions such as childhood onset schizophrenia.

Sharing client information


Existing state and federal privacy laws describe when health care providers must obtain client
authorization to release health care information, and when it is not required.
zz Authorization is permission by an individual or his/her personal representative(s) for the
release or use of information.
zz It gives the provider permission to obtain and use information from third parties for specified
purposes, or to disclose information to a third party specified by the individual.
With proper and signed Release of Information consent forms, providers can share information as
specified in those consent forms.
Senate Bill 163 (2007), now codified as Oregon Revised Statutes (ORS) 192.527 and 192.528,
permits some health information about OHP clients to be shared wtihout client authorization, as long
as there is client acknowledgement of the provisions of ORS 192.527 and 192.528.
zz Acknowledgement means that
information has been provided and
Minimal data set allowed by SB 163 (2007)
received. It only has to be signed once
(no time limit). • Client name;
• Medicaid ID number;
zz DHS obtains client acknowledgement • Performing provider number;
using the OHP 7210 (OHP • Hospital provider name;
Application); however, DHS is • Attending physician;
currently unable to track these • Diagnosis;
acknowledgements centrally. • Date(s) of service;
zz Once this acknowledgement is • Procedure code;
• Revenue code;
obtained, a minimal data set of
• Quantity of units of service provided; or
information can be shared when • Medication prescription and monitoring.
providing behavioral or physical health
care services to OHP clients.

Who can share client information?


All providers, whether FFS or managed care, must continue to make sure to obtain client
authorization for the specific disclosure of substance abuse records. Each disclosure requires specific
client authorization; and follow existing privacy laws. See Appendix for a summary of these laws.
How information can be shared under Senate Bill 163 (2007) as combined with other applicable
confidentiality laws is illustrated on the following page. See the Appendix for a sample
acknowledgement form.

2 Oregon Department of Human Services 3/11/09


Accepted information sharing under SB 163 (2007)

Minimal data set with client acknowledgement


FCHP
Medical information for behavioral health assessment MHO
PCO
Minimal data set with client acknowledgement

Behavioral Health Clinical information with client authorization Medical Providers


Providers Behavioral health information for medical treatment FCHP
MHO Clinical information with client authorization PCO

Behavioral Health Only with client authorization Medical Providers


Providers Substance abuse treatment records FCHP
MHO Only with cilent authorization PCO

3/11/09 Integration Toolkit 3


Screening client needs
Use of screening tools to assess client health care needs in the physical health, mental health, and
addiction services settings can help to ensure care is delivered in the right place and at the right time.
zz Screening tools are most useful when providers use them within a system of integrated care,
where providers have defined pathways to meeting identified client needs in a timely manner.
See the Appendix for some examples of integrated care models.
zz The specific assessment tools used may differ according to the specific health care setting, as
well as by age group. Assessment tools include interviews, observations, psychophysiological
monitoring, and health-oriented questionnaires.

Screening and assessment tools


The tools listed in this section are not intended to be a complete list. Instead, they are a compilation of
commonly-used tools to build on.
zz Each managed care entity should work with its provider network to ensure that they have a
workable list of screening tools for all ages and possible behavioral health issues.
zz The department will make as wide a range of tools possible available on the Integration Web
page at www.oregon.gov/DHS/ph/hsp/integration.shtml.
zz SBIRT is a structured process for delivering screening and brief interventions in primary care
settings with individuals who may be experiencing substance use issues. For this reason, and
because SBIRT is intended to intervene early before any substance use diagnosis has been
made, this practice is identified separately from the individual screening tools listed.

Screening, Brief Intervention, and Referral to Treatment (SBIRT)


The SBIRT Initiative targets those with nondependent substance use and provides effective strategies
for intervention prior to the need for more extensive or specialized treatment.
zz SBIRT is a comprehensive, integrated, public health approach to the delivery of early
intervention and treatment services for persons with substance use disorders, as well as those
who are at risk of developing these disorders. Primary care centers, hospital emergency rooms,
trauma centers, and other community settings provide opportunities for early intervention with
at-risk substance users before more severe consequences occur.
zz The Initiative involves implementation of a system within community and/or medical settings
that screens for and identifies individuals with or at-risk for substance use-related problems.
Screening determines the severity of substance use and identifies the appropriate level of
intervention.
zz The system provides for brief intervention or brief treatment within the community setting or
motivates and refers those identified as needing more extensive services than provided in the
community setting to a specialist setting for assessment, diagnosis, and appropriate treatment.
Research on SBIRT has demonstrated significant reductions in alcohol use and illicit drug use among
patients who received brief interventions in healthcare settings. Screening tools applied in the SBIRT
research include the AUDIT and the ASSIST described below. For more information about SBIRT,
go to http://sbirt.samhsa.gov. For information about SBIRT procedure codes and billing, see the
Procedure Codes section of this document.

4 Oregon Department of Human Services 3/11/09


Mental health and substance abuse screening instruments
The Oregon ABCD Screening Initiative and the Technical Assistance Partnership for Child and
Family Mental Health (TA Partnership) compiled the following list of assessments. For more
information, go to www.tapartnership.org.
Also see http://lib.adai.washington.edu/instruments/ for detailed descriptions of alcohol and drug
abuse screening tools.

Children
Target
Instrument Screens for population Web site
Ages and Stages Personal-social Ages 6–60 www.brookespublishing.com/
Questionnaires (self-regulation, months store/books/squires-asqse/
(Social Emotional) compliance, index.htm
(ASQ: SE) communication,
adaptive functioning,
autonomy, affect,
and interaction with
people)
Brief Infant- Toddler Socio-Emotional Ages 12–36 http://tinyurl.com/8yhkf
Social Emotional Issues months
Assessment
(BITSEA)
Child and Comprehensive 0-18 years, www.nctsnet.org/nctsn_assets/
Adolescent Needs mental health needs multiple pdfs/measure/CANS‑MH.pdf
and Strengths and strengths versions
(CANS)
Drug Use Screening Current status, Adults and www.dusi.com/
Inventory - Revised identifying areas in adolescents
(DUSI–R) need of prevention, >16 yrs.; youth
and evaluating change 10–16 yrs.
after a treatment
intervention.
Eyberg Child Behavioral Disorders Ages 2–16 http://tinyurl.com/cxrj3
Behavior Inventory (e.g., attention, years
(ECBI) conduct, oppositional-
defiant)
Pediatric Symptom Psychosocial Ages 4–16 http://psc.partners.org/psc_
Checklist (PSC) Dysfunction years detailed.htm
Reynold’s Depression Ages 8–12 www.hogg.utexas.edu/pages/
Depression Scale years IHCscreen.html
(RDS)

3/11/09 Integration Toolkit 5


Children
Target
Instrument Screens for population Web site
Temperament and Behavioral Disorders Ages 11–71 www.brookespublishing.com/
Atypical Behavior months store/books/bagnato-tabs/index.
Rating Scale (TABS) htm

Adolescents
Target
Instrument Screens for population Web site
Beck Depression Biological, Medical, Adolescents www.hogg.utexas.edu/pages/
Inventory Substance Abuse and Adults IHCscreen.html
Fastscreen for Issues
Medical Clients For information on studies of
effectiveness, view: http://asm.
sagepub.com/cgi/reprint/9/2/164
Child and Comprehensive 0-18 years, www.nctsnet.org/nctsn_assets/
Adolescent Needs mental health needs multiple pdfs/measure/CANS‑MH.pdf
and Strengths and strengths versions
(CANS)
Columbia Depression Ages 11–18 www.teenscreen.org/cms/
Depression Scale years content/views/49/78
(CDS)
Columbia Health Suicide Ages 11–18 www.teenscreen.org/cms/
Screen (CHS) years content/views/49/78
Computerized Lifestyle strengths, Adults and www.mhs.com/
Lifestyle concerns, and risks adolescents
Assessment (CLA)
CRAFFT Substance Abuse Ages 14–18 http://ebn.bmjjournals.com/cgi/
years content/full/6/1/23

For more information, email


info@crafft.org
Diagnostic General Mental Health Ages 9–18 www.teenscreen.org/cms/
Predictive Scales Disorders years content/views/49/78
(DPS)
Drug Use Screening Current status, Adults and www.dusi.com/
Inventory - Revised identifying areas in adolescents
(DUSI–R) need of prevention, >16 yrs.;
and evaluating change youth 10–16
after a treatment yrs.
intervention.

6 Oregon Department of Human Services 3/11/09


Adolescents
Target
Instrument Screens for population Web site
Eyberg Child Behavioral Disorders Ages 2–16 http://tinyurl.com/cxrj3
Behavior Inventory (e.g., attention, years
(ECBI) conduct, oppositional-
defiant)
Global Appraisal of Substance abuse Adults and www.chestnut.org/LI/gain/GAIN_
Individual Needs- disorders adolescents SS/index.html
Short Screen (GAIN-
SS)
Michigan Alcoholism Lifetime alcohol- Adults and http://adai.washington.edu/
Screening Test related problems and adolescents instruments/pdf/Michigan_
(MAST) alcoholism Alcoholism_Screening_
Test_156.pdf
Mood Disorder Bipolar disorder Adults and http://ajp.psychiatryonline.org/
Questionnaire adolescents cgi/reprint/157/11/1873
(MDQ)
Personal Experience Substance Abuse Ages 12–18 http://tinyurl.com/d8qom
Screening years
Questionnaire
(PESQ)
Reynold’s Depression Ages 13–18 www.hogg.utexas.edu/pages/
Depression Scale years IHCscreen.html
(RDS)
Substance Abuse Individuals who have Adults and http://pubs.niaaa.nih.gov/
Subtle Screening a high probability of adolescents publications/sassi.pdf
Inventory (SASSI) having a substance
use disorder

Adults
Target
Instrument Screens for population Web site
Addiction Severity Recent and lifetime Adults www.tresearch.org/resources/
Index (ASI) problem areas in instruments/ASI_5th_Ed.pdf
substance abusing
patients
Addiction Admission Alcohol/drug abuse Adults http://pearsonassessments.com/
Scale (AAS) problems clinical/substance.htm

3/11/09 Integration Toolkit 7


Adults
Target
Instrument Screens for population Web site
Addiction Potential Personality factors Adults http://pearsonassessments.com/
Scale (APS) underlying the clinical/substance.htm
development of
addictive disorders.
Alcohol, Smoking Psychoactive Adults www.who.int/substance_abuse/
and Substance substance use and activities/en/ASSIST%20
Involvement related problems V.3-%20Guidelines%20for%20
Screening Test among primary care use%20in%20primary%20care_
(ASSIST) patients. TEST.pdf
Alcohol Use Hazardous or harmful Adults http://whqlibdoc.who.int/hq/2001/
Disorders alcohol consumption WHO_MSD_MSB_01.6a.pdf
Identification Test
(AUDIT)
Beck Depression Biological, Medical, Adolescents www.hogg.utexas.edu/pages/
Inventory Substance Abuse and Adults IHCscreen.html
Fastscreen for Issues
Medical Clients For information on studies of
effectiveness, view: http://asm.
sagepub.com/cgi/reprint/9/2/164
Computerized Lifestyle strengths, Adults and www.mhs.com/
Lifestyle concerns, and risks adolescents
Assessment (CLA)
Drug Use Screening Current status, Adults and www.dusi.com/
Inventory - Revised identifying areas in adolescents
(DUSI–R) need of prevention, >16 yrs.;
and evaluating youth 10–16
change after a yrs.
treatment intervention.
Five Shot Heavy alcohol Adults http://adai.washington.edu/
Questionnaire drinking in its early instruments/pdf/Five_Shot_
phase Questionnaire_121.pdf
Global Appraisal of Substance abuse Adults and www.chestnut.org/LI/gain/GAIN_
Individual Needs- disorders adolescents SS/index.html
Short Screen
(GAIN-SS)
GAD-7 Generalized anxiety Adults
disorder
MacAndrew Traits and Adults www.pearsonassessments.com/
Alcoholism Scale characteristics index.htm
(MAC) frequently associated
with substance abuse

8 Oregon Department of Human Services 3/11/09


Adults
Target
Instrument Screens for population Web site
Michigan Alcoholism Lifetime alcohol- Adults and http://adai.washington.edu/
Screening Test related problems and adolescents instruments/pdf/Michigan_
(MAST) alcoholism Alcoholism_Screening_Test_156.
pdf
Mood Disorder Bipolar disorder Adults and http://ajp.psychiatryonline.org/
Questionnaire adolescents cgi/reprint/157/11/1873
(MDQ)
Rapid Alcohol Alcohol dependence Adults www.arg.org/RAPS4-1.html
Problems Screen during the last year
(RAPS-4)
Self-Administered Alcoholism in general Adults
Alcoholism medical inpatient and
Screening Test outpatient settings.
(SAAST)
Substance Abuse Individuals who have Adults and http://pubs.niaaa.nih.gov/
Subtle Screening a high probability of adolescents publications/sassi.pdf
Inventory (SASSI) having a substance
use disorder
T–ACE Patients at risk for Pregnant http://pubs.niaaa.nih.gov/
drinking amounts women publications/arh28-2/78-79.htm
which may be
dangerous to the
fetus.
TWEAK Patients in need Adults http://adai.washington.edu/
of more thorough instruments/pdf/TWEAK_252.pdf
assessments of their
drinking patterns
and alcohol-related
problems

Older adults
Target
Instrument Screens for population Web site
PHQ-9 Depression, also Adults and http://impact-uw.org/tools/phq9.
being used for other adolescents html
diagnoses, including
ADHD

3/11/09 Integration Toolkit 9


In addition, the following tools are useful for screening for mental health and substance use disorders
in young adult and adult populations.

Target
Instrument Screens for population Web site
CAGE Alcohol/drug Adults http://pubs.niaaa.nih.gov/
screening tool publications/inscage.htm
Duke Health Profile Health issues in Adults http://healthmeasures.mc.duke.
adults in behavioral edu/
settings
Short-Term Risk of violence Adults all ages www.bcmhas.ca/Research/
Assessment of Risk Research_START.htm
and Treatability
(START)
PHQ-9 Depression, also Adults and http://impact-uw.org/tools/phq9.
being used for other adolescents html
diagnoses, including
ADHD
The Primary Care Early psychosis Late
Evaluation of detection adolescence/
Mental Disorders early adulthood
(PRIME-MD)

10 Oregon Department of Human Services 3/11/09


Procedure codes
The following codes, used for assessment, intervention, and screening, are billed to the physical
health plans (FCHPs or PCO) or Division of Medical Assistance Programs (DMAP).

Mental health providers do not contract with physical health plans. The following codes are capitated
to the physical health plans. It is up to the physical health plan to determine whether it will reimburse
a mental health provider who does not have a contract with the plan.
Where possible, the department encourages physical health plans to contract with mental health
providers to provide integrated services to clients.
zz Payment for services provided to plan members is a matter between the provider and the plan
authorizing the services, except as otherwise provided in OAR 410-141-0410 (OHP Primary
Care Managers).
zz If a physical health plan denies payment to a provider because arrangements were not made
with the physical health plan prior to providing the service, DMAP will not reimburse the
provider, except as outlined in OAR 410-141-0120 (OHP PHP Provision of Health Care
Services).
DHS will work with the managed care plans to ensure that the billing process for these codes is well-
understood. Each plan must still decide whom they cover and how to add behavioral health specialists
to their provider panels as needed.

Health and Behavior Assessment and Intervention Codes


The Health and Behavior Assessment and Intervention codes (96150 through 96154) allow certain
behavioral health specialists to work with a client upon referral from a medical professional who has
made the primary physical health diagnosis.
For the purposes of the Oregon Health Plan, a behavioral health specialist is a mental health
professional licensed for individual practice who by training and experience demonstrates
competencies matching the needs of the medical setting and the population to be served.

A new HSC guideline references the CMS guidelines that provide limitations of coverage, medical
necessity, indications of coverage, documentation requirements, and utilization guidelines for these
codes.
zz For CMS guidelines, go to www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=13492&lcd_
version=49.
zz For the current HSC guidelines, go to www.oregon.gov/OHPPR/HSC/current_prior.shtml.
zz Also refer to your Current Procedural Terminology (CPT) codebook for information on
appropriate use of these codes.

3/11/09 Integration Toolkit 11


Assessment codes
Assessment codes 96150 and 96151 are used to identify the biopsychosocial factors important to the
prevention, treatment, or management of physical health problems (not mental health problems).
Upon referral by a physical health provider, the
behavioral health specialist should use these codes What are biopsychosocial factors?
when: These are non-physiological
zz The client has an underlying physical illness or factors that contribute to the client’s
injury, physiological functioning, such as:
• Psychological factors
zz The purpose of the assessment or reassessment • Psycho-physiological factors
is to diagnose or treat physical (not mental) • Behavioral factors
illness, and • Emotional factors
zz The assessment or reassessment does not • Cognitive factors
duplicate other provider assessments. • Social factors

In addition, the following criteria also apply.

Additional criteria for Initial Assessment (CPT Code 96150)


zz A biopsychosocial factor that may be significantly affecting the treatment, or medical
management of an illness or an injury.
zz The client is expected to have the capacity to understand or respond meaningfully to the
intervention.
zz The client’s attending physician documents that the client needs assessment to successfully
manage his/her physical illness to resolve barriers to the management of his/her physical
disease and activities of daily living.

Additional criteria for Reassessment (CPT Code 96151)


zz Question of a sufficient change in the client’s status warranting re-evaluation of his or her
capacity to understand or to respond meaningfully to the intervention.
zz The client’s attending physician documents the need for reassessment.

Intervention codes
Intervention codes 96152 through 96154 are used to bill for cognitive, behavioral, social, and/or
psychophysiological procedures designed to improve the biopsychosocial factors directly affecting the
client’s health, well-being, treatment, or management of specific physical health problems.

Upon referral by a physical health provider, the behavioral health specialist should use these codes
when the following criteria apply:

Individual Intervention (CPT Code 96152) or Group Intervention (CPT Code 96153)
zz Client has an underlying physical illness or injury.
zz The purpose of the intervention is not the treatment of mental illness.
zz The client is expected to have the capacity to understand or respond meaningfully to the
intervention.
zz The client requires intervention to address:

12 Oregon Department of Human Services 3/11/09


zz Non-compliance with the medical treatment plan, or
zz The biopsychosocial factors associated with physical illness, and
zz The specific intervention(s) and client outcome goal(s) have been clearly identified.

Family Intervention (CPT Code 96154)


zz The family representative directly participates in the care of the client.
zz Immediate family members (including siblings, children, grandchildren, grandparents,
parents, spouse)
zz Primary caregiver who provides care on a voluntary, uncompensated, regular, sustained
basis
zz Guardian, or health care proxy
zz The intervention is necessary to address biopsychosocial factors that affect compliance
with the plan of care, symptom management, health-promoting behaviors, behaviors which
place the client or others at risk for safety, health-related risk-taking behaviors, and overall
adjustment to medical illness.

Claim submission
When billing DMAP or the physical health plan for Health and Behavior Assessment Intervention
Codes, bill one unit for each 15 minutes of service (one hour equals four units of service).
zz ICD-9-CM diagnosis code(s) reflecting the physical condition(s) being treated must be
present on the claim.
zz HSC limits use of assessment codes for initial assessment to 4 units (1 hour) per quarter, and
use of assessment codes for reassessment to 4 units (1 hour) per quarter.
zz HSC limits use of intervention codes to 48 units (12 hours) per quarter.
zz Do not submit documentation with your claim; instead, make sure you have the appropriate
documentation on file and available upon request.

Documentation requirements 
According to CMS guidelines, the client’s medical record must support that the indications of
coverage have been met, and that services were reasonable and necessary. Medical records include
complete nursing home records, doctor’s orders, progress notes, office records, and nursing notes.

For the complete CMS guidelines, go to www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=13492&lcd_


version=49.

3/11/09 Integration Toolkit 13


Screening, Brief Intervention, Referral and Treatment (SBIRT) codes
SBIRT is a preventative service under the Oregon Health Plan. The SBIRT codes (99408 and 99409)
allow health care professionals to screen, provide brief interventions, and refer to specialty services
for Substance Use Disorders.

Screening and brief intervention codes


Screening and brief intervention codes for SBIRT include:
zz CPT Code 99408: Used to implement structured screening and brief intervention services for
alcohol and/or substance abuse lasting 15-30 minutes.
zz CPT Code 99409: Used to implement a structure screening and brief intervention services for
alcohol and/or substance abuse lasting more than 30 minutes.

Claim submission
When billing DMAP or the physical health plan, bill one unit per encounter.
zz Payment for services provided to plan members is a matter between the provider and the plan
authorizing the services. Contact the member’s health plan for limitations and guidelines.
zz Payment for services provided to fee-for-service (“open card”) clients, is billed directly to
DMAP. For questions regarding reimbursement, limitations or guidelines, contact Provider
Services at 800-366-6016.

Documentation requirements
The client’s medical record must support that the services were reasonable and necessary. Medical
records should include the screening tool results, notes regarding brief intervention and/or referral as
applicable.

14 Oregon Department of Human Services 3/11/09


Appendix
Sharing client information

Sample SB 163 (2007) acknowledgement form


The sample at right shows the information that must be provided to clients for their acknowlegement
before the listed information can be shared for treatment purposes as permitted by ORS 192.527 and
192.528. The acknowledgement form must be signed and dated by the client. Keep a copy of the
completed form on file.

Summary of state and federal privacy laws


This summary is a brief outline. It should not be treated as a complete description of all applicable
privacy and confidentiality laws potentially applicable in individual cases. If more than one law could
apply to the health information, the law that is the most protective of the client’s privacy applies.
HIPAA and state The HIPAA Privacy Rules allow covered entities to exchange protected
privacy law health information (PHI) for treatment purposes without the individual’s
authorization under the following circumstances, among others:
• A covered entity may disclose protected health information for its own
treatment, payment, or health care operations.
• A covered entity may disclose protected health information for
treatment activities of a health care provider.

45 CFR § 164.506(c) (1) & (2). See also ORS 192.520(2) & (3).
Uses and disclosures Federal and state law permits the use and disclosure of information about
for purposes of recipients of medical assistance for purposes related to the administration
medical assistance of the medical assistance program.

See 42 CFR 431 Subpart F; 42 CFR 457.1110; ORS 410.150, 411.320,


and 412.074.
ORS 179.505 - ORS 179.505 limits use and disclosure of records about clients of publicly
Disclosure of written funded treatment for mental health conditions, developmental disabilities,
accounts by health public health, and substance abuse.
care services provider
Because ORS 179.505(6) does not expressly permit disclosure for
treatment purposes to MCOs, it is more protective of client privacy than
HIPAA or other state laws. Consequently, MCOs are required to obtain
client authorization for these treatment records that HIPAA might not have
required.
Other federal law Substance abuse treatment records are also confidential under federal law
at 42 CFR Part 2. Disclosure of these records for treatment purposes to
coordinate care requires the client to sign an authorization form.

This federal regulation remains unchanged by ORS 192.527 and 192.528.

16 Oregon Department of Human Services 3/11/09


Notice of Information Sharing Practices
For physical and behavioral health integration

Health care provider: Have this document completed and signed by the individual receiving
integrated services. Provide one copy to the individual; keep one copy on file.

Oregon Revised Statute (ORS) 192.527 allows the Oregon Department of Human
Services (DHS) and OHP Managed Care Plans to share the following protected health
information with other OHP Managed Care Plans for the purpose of treatment activities
when the OHP Managed Care Plan is providing behavioral or physical health services to
you:
„ Your name and Medicaid recipient number
„ The name of your hospital provider or attending physician
„ Your performing provider’s Medicaid number
„ Your diagnosis

Along with the following information about services provided to you:


„ Dates of service
„ The quantity of units of service provided
„ Procedure and revenue codes
„ Information about medication prescription and monitoring

Patient Acknowledgement of Information Sharing Practices

I, (print your name) ___________________________________________________,


have received and read the information about sharing my protected health information as
it pertains to ORS 192.527.

I understand that my signature on this document allows DHS and OHP Managed Care
Plans to share information as described above, as required by ORS 192.528. I also
understand that my signature on this document does not affect my OHP benefits in any
way.

Signed: ________________________________________ Date: _____________

Integration Acknowledgement Form Revised 1/16/09


Systems of Care

Four Quadrant Clinical Integration Model


The Four Quadrant Clinical Integration Model, used with permission of the National Council
for Community Behavioral Healthcare (NCCBH), is a client-centered care delivery model for
determining what part of the delivery system can provide the most appropriate care.

This model is a framework that provides guidance to determine which setting can provide the most
appropriate care, and who provides the medical home (main point of care) for the client— The
behavioral health (BH) provider or the primary care provider (PCP).

18 Oregon Department of Human Services 3/11/09


Descriptions of the Four Quadrants
Quadrant I The Population:
Low to moderate behavioral health (BH) and low to moderate physical health (PH)
complexity/risk.

The Model:
Person Centered Healthcare Home: a primary care team that includes a behavioral
health consultant/care manager, psychiatric consultant, screening for behavioral
health concerns, and stepped care.

The Providers:
The primary care provider assures the full-scope healthcare home and uses
standard behavioral health screening tools and practice guidelines to serve
individuals in the primary care practice.
• Use of standardized behavioral health tools by the primary care provider and
a tracking/registry system focuses referrals of a subset of the population to the
primary care based behavioral health consultant/care manager.
• The primary care provider prescribes psychotropic medications using treatment
algorithms. Psychiatric consultation is structured to support both the primary
care provider and the behavioral health consultant/care manager, with a focus
on treatment planning for individuals who are not showing improvement.

The role of the primary care based behavioral health consultant is to provide
consultation to the primary care provider as well as to provide behavioral health
triage and assessment, brief treatment services to the individual, referral to
community and educational resources, medication and symptom tracking, self
management supports, and relapse planning.
• Behavioral health clinical and support services may include individual or group
services, cognitive behavioral therapy, psycho-education, brief substance
abuse intervention, and limited case management.
• The behavioral health consultant should be competent in both mental health
and substance abuse assessment and service planning. The behavioral health
consultant is connected to the specialty behavioral health system, and able to
effectively support stepped care to specialty behavioral health services.
• In smaller primary care practices, the behavioral health consultant provides
behavioral health services, including interventions focused on assisting
individuals with management of their behavioral health and health issues,
as well as care management tracking. In larger primary care practices, the
behavioral health consultant may be supported by a paraprofessional who is
delegated some of the care management tracking activities.
Quadrant II The Population:
Moderate to high behavioral health and low to moderate physical health
complexity/risk.

The Model:
Person Centered Healthcare Home: primary care capacity in a behavioral health
setting, including medical nurse practitioner/primary care physician, wellness
programming, screening for health status concerns, and stepped care to a full-
scope healthcare home. Access to the array of specialty behavioral health services
designed to support recovery.

3/11/09 Integration Toolkit 19


Quadrant II The Providers:
(continued) The primary care physician assures the full-scope healthcare home either through
practicing on site or supervision of the nurse practitioner, consultation with
behavioral health provider and stepped care.

Psychiatric consultation with the primary care provider may be an element in


these complex behavioral health situations, but it is more likely that psychotropic
medication management will be handled by the specialty behavioral health
prescriber, in collaboration with the primary care physician.

Standard health screening (e.g., glucose, lipids, blood pressure, weight/BMI) and
preventive services will be provided. Wellness programs (e.g., nutrition, smoking
cessation, physical activities) are available as primary as well as secondary
preventive interventions, incorporating recovery principles and peer leadership and
support.
Quadrant III The Population:
Low to moderate behavioral health and moderate to high physical health
complexity/risk.

The Model:
Person Centered Healthcare Home: a primary care team that includes a
behavioral health consultant/care manager, psychiatric consultant, screening for
behavioral health concerns, stepped care, and access to specialty medical/surgical
consultation and care management.

The Providers:
In addition to the services described in Quadrant I, the primary care provider
collaborates with medical/surgical specialty providers and care managers (e.g.,
diabetes, asthma) to manage the physical health concerns of the individual.
• Specialty healthcare and care management programs could also integrate
behavioral health screening and the behavioral health consultant/care manager
into a wide array of self management and rehabilitation programs, building
on research findings regarding the frequency and impact of depression in
cardiovascular or diabetes populations.
• Depending on the setting, the behavioral health consultant may also (in
addition to the services described in Quadrant I) provide health education and
behavioral supports regarding lifestyle and chronic health conditions found in
the general public (diabetes, asthma) or conditions found in at-risk populations
(Hepatitis C, HIV).
• These population-based services, as articulated by Dyer, would include:
patient education, activity planning, prompting, skill assessment, skill building,
and mutual support.41 In addition to these services, the behavioral health
consultant might serve as a physician extender, supporting efficient use of
physician time by problem solving with individuals trying to manage either acute
or chronic health concerns or related medication adherence issues.

20 Oregon Department of Human Services 3/11/09


Quadrant IV The Population:
Moderate to high behavioral health and moderate to high physical health
complexity/risk.

The Model:
Person Centered Healthcare Home: primary care capacity in a behavioral health
setting, including medical nurse practitioner/primary care physician, nurse care
manager, wellness programming, screening/tracking for health status concerns,
and stepped care to a full-scope healthcare home. Access to the array of specialty
behavioral health services designed to support recovery and access to specialty
medical/surgical consultation and care management.

The Providers:
In addition to the services described in Quadrant II, the primary care physician
collaborates with medical/surgical specialty providers and external care managers
to manage the physical health concerns of the individual.
• In some settings, behavioral health consultant/care manager services may also
be integrated with specialty provider teams (for example, Kaiser has behavioral
health consultants in OB/GYN programs, working with substance abusing
pregnant women). Nurse care management is added, along with focused
goal setting and self management planning, to the standard health screening/
registry tracking (e.g., glucose, lipids, blood pressure, weight/BMI). Wellness
programs (e.g., diabetes groups) are available as secondary and tertiary
preventive interventions, incorporating recovery principles and peer leadership
and support.
• The organization of collaborative care for this population will frequently be
person-specific, developed by the team of care providers in collaboration with
the individual. With the expansion of Medicaid disease management programs,
there may be coordination with external care managers in addition to multiple
healthcare providers—this may be the role of the nurse care manager or the
specialty behavioral health clinician/case manager as the team defines specific
roles and responsibilities.
• The nurse care manager, behavioral health clinician/case manager, and
external care manager should assure they are not duplicating tasks, but
working together to support the needs of the individual. A specific protocol
should be adopted that defines the methods and frequency of communication
among all providers/team members.

3/11/09 Integration Toolkit 21


Pathway of Care Model
There are multiple pathways of care (also known as
integrated care pathways or clinical pathways) that can
be used to address the needs of individuals.
Health care organizations should consider what their
current pathways of care look like and how resources
might be redistributed and incentives created to enable
more clients to be accommodated by the service delivery
design.
The model on this page, used with permission of Peter
Davidson, shows the important similarities and linkages
between the behavioral and primary care systems.
It also demonstrates the basic steps in treating illness,
whether it is behavioral or medical.

Pre-treatment or treatment readiness


An effective pre-treatment phase is critical to a client’s
readiness for treatment. This includes:
zz Access: Community supports that, through
information gathering and triaging, allow clients
entry into the medical or behavioral health care
setting; and
zz Face-to-face consult in the clinical setting.

Treatment
Active treatment in the clinical setting (medical or
behavioral).

Post-treatment or aftercare
This includes continutation treatment in the clinical setting, and recovery/maintenance assistance
through community supports.

22 Oregon Department of Human Services 3/11/09


Assessment and Intervention Codes

HSC line placement effective January 1, 2009

Addition of CPT codes 96150-96154


Lines Condition type
10-12, 26, 33, 35-36, 42, 46, 52, 61, 66, 76, 82, 87, Chronic disease
100, 109-110, 129, 135, 141, 150-152, 169, 174,
180, 183-184, 192, 194, 196, 200, 206, 211, 225,
233-234, 237-238, 250, 265-268, 274, 284, 301,
303, 305, 312, 325, 330, 336, 355, 359, 369-370,
373, 407, 416-417, 419-420, 427, 430, 433, 436,
438, 440, 442, 460, 463-465, 470, 481, 483, 497
65, 139, 236, 350, 365 Renal dialysis
15, 55-56, 120, 136, 148, 165, 191, 228, 246, 271, Chronic infections (TB, HIV, etc.)
289, 352, 384
102, 124-125, 145, 160, 167-168, 182, 197-198, Cancer
208-209, 219, 221-222, 229-230, 243, 249, 252,
272, 275-278, 286, 291, 309-311, 319, 337-339,
354, 453
63, 80, 203 Burns
1 Maternity care
79, 92, 103, 106, 111, 170, 253-256, 279, 313, 332 Organ transplant
84, 159, 397, 429 Spinal cord injury/abscess
101, 138, 186, 202, 273, 340 Injuries to the nervous system (concussion,
stroke, etc.)
8 Medical obesity
404 Reduction in self-directed care
147, 166, 287 Amputation of limb
6 Tobacco dependence
41, 68, 391 TAB/SAB related
Addition of CPT code 96154 only (Family assessment/intervention)
Lines Condition type
13-14, 16-18, 20-22, 25, 28-29, 34, 37, 39-40, 47, Newborn issues requiring parental training/
50, 53, 70, 74, 85, 94, 96, 98, 112, 114, 116, 123, assessment
142, 292, 374

3/11/09 Integration Toolkit 23


Limitations of coverage
This list is from the CMS guidelines for behavioral services on the CMS Web site at www.cms.hhs.
gov/mcd/viewlcd.asp?lcd_id=13492&lcd_version=49.
zz When the indications of coverage have not been met.
zz Health and behavioral intervention services are not considered reasonable and necessary to:
zz Update or educate the family about the client’s condition
zz Educate non-immediate family members, non-primary care-givers, non-guardians, the
non-health care proxy, and other members of the treatment team, e.g. health aides, nurses,
physical or occupational therapists, home health aides, personal care attendants and co-
workers about the client’s care plan.
zz Treatment-planning with staff
zz Mediate between family members or provide family psychotherapy
zz Educate diabetic clients and diabetic clients’ family members 2
zz Deliver Medical Nutrition Therapy 3
zz Maintain the client’s or family’s existing health and overall well-being
zz Provide personal, social, recreational, and general support services. These services may
be valuable adjuncts to care; however, they are not psychological interventions. Examples
of these services are:
zz Stress management for support staff
zz Replacement for expected nursing home staff functions
zz Recreational services, including dance, play, or art
zz Music appreciation and relaxation
zz Craft skill training
zz Cooking classes
zz Comfort care services
zz Individual social activities
zz Teaching social interaction skills
zz Socialization in a group setting
zz Retraining cognition due to dementia
zz General conversation
zz Services directed toward making a more dynamic personality
zz Consciousness raising
zz Vocational or religious advice
zz General educational activities
zz Tobacco withdrawal support
zz Caffeine withdrawal support
zz Visits for loneliness relief
zz Sensory stimulation
zz Games, including bingo games

24 Oregon Department of Human Services 3/11/09


zz Projects, including letter writing
zz Entertainment
zz Excursions, including shopping outings, even when used to reduce a
dysphoric state
zz Teaching grooming skills
zz Grooming services
zz Monitoring activities of daily living
zz Teaching the client simple self-care
zz Teaching the client to follow simple directives
zz Wheeling the client around the facility
zz Orienting the client to name, date, and place
zz Exercise programs, even when designed to reduce a dysphoric state
zz Memory enhancement training
zz Weight loss management
zz Case management services including but not limited to planning activities of
daily living, arranging care or excursions, or resolving insurance problems
zz Activities principally for diversion
zz Planning for milieu modifications
zz Contributions to client care plans
zz Maintenance of behavioral logs
zz Provision of support services, not requiring the skills of a Clinical Psychologist (CP)
(Specialty Code 68).
zz When a health and behavior assessment/intervention service is not rendered, e.g.:
zz Reviewing activity therapy reports
zz Supervising nursing and ancillary personnel
zz Leading or directing treatment teams
zz Only monitoring the behavioral effects of medications
zz Only providing medication recommendation

3/11/09 Integration Toolkit 25