Primary Care
Clinicians:
How to Coordinate
Behavioral Health
Services for
PCC Plan Members
PCC Plan
600 Washington Street
Boston, MA 02111
Massachusetts Behavioral Health Partnership
100 High Street, 3rd floor
Boston, MA 02110
11/2011
Prepared by the
PCC Plan, MassHealth, and the
Massachusetts Behavioral Health Partnership
Primary Care Clinicians:
How to Coordinate
Behavioral Health Services
for PCC Plan Members
1
Primary Care Clinicians: How to Coordinate Behavioral
Health Services for PCC Plan Members
The Massachusetts Behavioral Health Partnership (MBHP)
manages the behavioral health benefit for all child and adult
Members enrolled in MassHealth’s Primary Care Clinician
(PCC) Plan. The PCC Plan has prepared this booklet to
assist you in your efforts to coordinate with the MBHPcontracted behavioral health care providers who are
providing services to your PCC Plan panel Members.
This booklet can help PCCs locate behavioral health
services for their PCC Plan Members. Additionally, it
highlights other services offered by MBHP that you may find
useful when managing the care of your PCC Plan Members
with behavioral health issues. If you have any comments or
questions about the information in this booklet, please call
Andrea Gewirtz, MBHP assistance vice president of Network
Operations, at (617) 350-1954.
Finding Behavioral Health Providers in the MBHP
Network for PCC Plan Members
For help in finding an MBHP-enrolled behavioral health
provider, PCCs may contact MBHP directly at
1-800-495-0086. You may also consult MBHP’s Behavioral
Health Regional Provider Reference Guides, which can be
found on MBHP’s web site, www.masspartnership.com, in
the “For PCCs” section under “BH Connection,” to identify
behavioral health providers to whom you can refer your PCC
Plan patients.
For PCCs who have more than 180 PCC Plan patients,
MBHP-employed Regional Network Managers (RNMs) are
available to you for information about care coordination or
referrals. The MBHP RNM collaborates with other MBHP
staff to assist in connecting PCCs to behavioral health
providers or MBHP care management programs.
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If a PCC entity has a behavioral health provider sited at the
PCC’s service location, but that behavioral health provider is
not part of the MBHP behavioral health provider network,
MBHP will review and consider requests for network
membership for such behavioral health providers. To pursue
network membership, a co-located behavioral health
provider should contact the MBHP Community Relations
Department to obtain a provider application by calling
1-800-495-0086 (press 1 for the English menu or 2 for the
Spanish menu, then 3, then 1 to skip prompts).
If you are a PCC who would like to contact a behavioral
health provider who may be interested in co-locating at your
service location, please consult the MBHP Behavioral Health
Regional Provider Reference Guides, which can be found on
MBHP’s web site, www.masspartnership.com, in the “For
PCCs” section under “BH Connection.” For additional help
in finding an MBHP-enrolled behavioral health provider with
whom you might be able to partner, contact the MBHP
Community Relations Department directly at 1-800-495-0086
(press 1 for the English menu or 2 for the Spanish menu,
then 3, then 1 to skip prompts).
MBHP considers requests for behavioral health provider
network membership from behavioral health providers who
are able to serve special populations, including populations
with specific cultural and linguistic needs and those who
offer clinical specialties. If you know of, or work with, a
behavioral health provider with these special skills who is not
enrolled in MBHP’s behavioral health provider network, you
can encourage that behavioral health provider to request
consideration for inclusion in the MBHP network by
contacting the MBHP Community Relations Department to
obtain a provider application by calling 1-800-495-0086
(press 1 for the English menu or 2 for the Spanish menu,
then 3, then 1 to skip prompts).
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Behavioral Health Care Management Services
MBHP offers a flexible, multi-level care management
program to meet the needs of PCC Plan Members. All care
management levels offer:
One point of contact into the behavioral health care
services system
Behavioral health crisis prevention planning
Integration of all MBHP-covered treatment services
with a Member’s natural and state agency supports
These levels of behavioral health care management are:
1. Targeted Outreach can provide help to a PCC Plan
Member to problem-solve obstacles in accessing
healthcare and/or community-based services, or
assist the Member to follow a treatment plan or a
medication routine. The Community Support Program
(CSP) providers offer many of the interventions used
in Targeted Outreach. PCCs may refer Members to
Targeted Outreach through the Assessment Unit
noted below, or PCCs may make a referral directly to
the appropriate regional CSP. Regional CSP
information can be found in the MBHP Regional
Provider Guides, which are posted in the “For PCCs”
section of the MBHP web site,
www.masspartnership.com, under “BH Connection.”
2. Care Coordination can provide a Member with
behavioral health needs support, which can help the
Member when he or she is discharged from a
behavioral health stay in the hospital and returns to
the community. MBHP care managers can
coordinate behavioral health treatment with primary
care services as well as any other appropriate
supports.
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3. Intensive Clinical Management can provide help to a
high-risk Member who is facing the most challenging
of mental health and substance abuse issues.
Whether the Member is a child, adolescent, adult, a
pregnant woman with alcohol and substance abuse
problems, or a person receiving state agency
interventions, the care manager can offer the Member
individualized help and obtain the necessary
behavioral health treatment services. Through
Intensive Clinical Management (ICM), intensive
clinical managers collaborate with PCCs, behavioral
health providers, and the Member’s family and/or
support system to help the Member manage
behavioral health issues and to integrate behavioral
health and medical care.
To make a referral for care management services, contact
the MBHP Assessment Unit at 1-800-495-0086 (press 1 for
the English menu or 2 for the Spanish menu, then press 2,
then Ext. 455633). You can also access the MBHP web site
at www.masspartnership.com.
Behavioral Health Individual Care Plan (ICP) Reports
Mailing to PCCs
Written individual care plans (ICPs) are developed by
intensive clinical managers for Members enrolled in the
Intensive Clinical Management (ICM) care management
level. The ICPs provide one document outlining the
Member’s contact information and behavioral health care
service needs, including short-term and long-term care
services and, as applicable, those medical services the
Member may require.
The ICP Report for each ICM-enrolled Member is mailed to
that Member’s PCC. Through the ICP Report, the PCC can
learn about the mental health and substance abuse
treatment interventions being received by their PCC Plan
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panel Member. The ICP Report, when mailed to the PCC,
will include a postcard for the PCC to sign and return,
acknowledging that the PCC has received the ICP Report.
Communication between Behavioral Health Providers
and PCCs
MBHP encourages its contracted behavioral health providers
treating PCC Plan-enrolled Members to be available for
consultation to families and other healthcare providers, such
as PCCs. PCCs should feel comfortable in directly
contacting behavioral health providers providing services to
the PCC’s enrolled Members to discuss a PCC Plan
Member, as long as the Member’s consent has been
obtained.
In an effort to support and facilitate communication between
PCCs and behavioral health providers, we suggest that
PCCs review “The Two-Way Behavioral Health and Primary
Care Clinician/Provider Communication Document,” which
has been developed for use by both behavioral health and
primary care providers when communicating about the
treatment of a Member they have in common. The
document includes key components of communication from
the perspectives of both behavioral health and primary care
providers or PCCs. Providers may find that using this form
simplifies their efforts to communicate with each other
concerning a particular patient’s treatment plan.
The Two-Way Behavioral Health and Primary Care
Clinician/Provider Communication Document can be
downloaded from MBHP’s web site at
www.masspartnership.com/pcc. (Click “Support Materials”
in the left navigation bar and scroll down the page to click on
the link to download the Two-Way Communication form.)
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PCC Plan Integration Forums
MBHP’s PCC Plan Performance Improvement Management
Services (PIMS) annually makes available forums for PCCs
and behavioral health providers, on topics of interest to both
types of providers. These integrated forums provide
behavioral health providers and PCCs training on managing
behavioral health in the primary care setting and on
facilitating the coordination of medical and behavioral health
care. Forums are free to PCC Plan PCCs and include free
CMEs and CEUs. For more information about these forums,
go to MBHP’s web site at www.masspartnership.com, or call
the PCC Hotline at 1-800-495-0086 (press 1 for the English
menu or 2 for the Spanish menu, then press 3 and then 4 to
skip prompts).
Med/Psych Rounds
Each month, a team of MBHP and MassHealth medical and
behavioral health staff meets to address Members identified
as needing complex care planning that involves both
behavioral health and medical care. The Med/Psych
Rounds Team considers the cases from a multidisciplinary
perspective and makes recommendations that support an
integrated approach to care.
To refer a Member for discussion at Med/Pysch rounds,
contact Terri Joiner at (617) 790-4098.
Buprenorphine Treatment Guidelines
EOHHS, MBHP, the PCC Plan, and the MassHealthcontracted managed care organizations have collaborated
with clinicians to develop guidelines to support physicians
who are trained and certified to provide buprenorphine
treatment in the outpatient setting.
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Buprenorhphine treatment guidelines for trained and certified
PCCs may be found at
http://www.mass.gov/eohhs/docs/masshealth/pharmacy/sub
oxone-letter.pdf.
Publications
Four times each year, the PCC Plan produces the Primary
Care Clinician (PCC) Plan Quarterly newsletter for PCC and
behavioral health providers. This publication
disseminates information about PCC Plan
and MassHealth medical and administrative
policies, relevant medical and behavioral
clinical health issues, and updates. Twice
yearly, a Member-focused newsletter,
Health Highlights, is
produced and mailed to
PCC Plan Members. This
newsletter informs PCC Plan Members
about health-related topics to promote
wellness, educates them about common
medical and behavioral health conditions,
offers administrative reminders, and
provides general updates.
PCCs can obtain additional copies of these publications by
calling the PCC Hotline at 1-800-495-0086 (press 1 for the
English menu or 2 for the Spanish menu, then press 3, then
4 to skip prompts).
Primary Care Clinician (PCC) Plan Health Education
Materials Catalog
Twice yearly, the PCC Plan produces the Health Education
Materials Catalog for all PCCs. PCCs can order through the
catalog a variety of free materials that support quality
improvement activities related to primary care quality
measures established by the PCC Plan. Many of the
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materials have been designed by MassHealth and MBHP
staff to address the unique needs of PCC Plan Members.
The catalog contains a section with
materials selected to assist PCCs in
screening children under the age of
21 for behavioral health needs in
conjunction with Early and Periodic
Screening, Diagnosis, and
Treatment/Preventive Pediatric
Healthcare Screening and Diagnosis
(EPSDT/PPHSD) well-child care
visits. Other materials are designed
to help PCCs manage the behavioral
health needs of their patients in the
primary care setting.
The catalog is available for downloading, and materials can
be ordered online through the MBHP web site at
www.masspartnership.com by clicking on “Support
Materials” under the “For PCCs” section. Alternatively,
materials can be ordered by contacting the PCC Hotline at 1800-495-0086 (press 1 for the English menu or 2 for the
Spanish menu, then press 3, then 4 to skip prompts).
For Youth
The Massachusetts Child Psychiatry Access Project
The Massachusetts Child
Psychiatry Access Project
(MCPAP) provides child
psychiatry consultative services
to PCCs. These consultative services are available for all
youth in Massachusetts regardless of insurance status.
MCPAP also assists PCCs with access to behavioral health
services for youth.
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PCCs who care for children and adolescents and are
enrolled with MCPAP may access consultative services by
contacting the appropriate regional MCPAP team. PCCs
who would like to enroll in MCPAP may also call one of the
MCPAP regional teams listed below to sign up. For
additional information, contact Irene Tanzman at the
Massachusetts Behavioral Health Partnership, at
(617) 350-1990, by e-mailing her at
[email protected], or by visiting
www.mcpap.com.
MCPAP Regional Teams
Western Region
Baystate Medical Center
(413) 794-3342
Central Region
UMass Medical Center
(508) 334-3240
Northeast Region
North Shore Medical Center
(888) 627-2767
Boston/Metro Region I
Mass. General Hospital
(617) 724-8282
Boston/Metro Region II
NEMC/Children’s
(617) 636-5723
Southeast Region
McLean-Brockton
(508) 894-8484
Resources for Screening for Behavioral Health Needs by
Primary Care Providers
MassHealth now mandates that primary care providers use
an age-appropriate, standardized behavioral health
screening tool when completing the behavioral health
component of the Early Periodic Screening, Diagnosis, and
Treatment (EPSDT)/Preventive Pediatric Healthcare
Screening and Diagnosis (PPHSD) well-child care visit. The
tool must be selected from the list of MassHealth-approved
tools.
MBHP has developed toolkits for assisting PCCs with
implementing behavioral health screening activities. They
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are available in the “For PCCs” section under “Support
Materials” on MBHP’s web site: www.masspartnership.com.
PCCs can obtain additional information about screening
children for behavioral health conditions and find the list of
approved screening tools by visiting the Children’s
Behavioral Health Initiative (CBHI) web
site:www.mass.gov/eohhs/gov/commissions-andinitiatives/cbhi/.
CBHI Services
Overview
As part of the Children’s Behavioral Health Initiative (CBHI),
several new behavioral health services are available to
support youth under the age of 21 who are enrolled in
MassHealth. It is important for primary care clinicians
(PCCs) caring for MassHealth-enrolled youth to be familiar
with this system of services.
PCCs may be asked to be part of a care planning
team.
PCCs may receive an Individual Care Plan (ICP) for a
youth they referred or who was referred by another
team member.
PCCs may decide to make referrals to the CBHI
services based on behavioral health screening in the
primary care office.
CBHI services are described starting on p. 12, but you can
also link to MBHP’s web site (www.masspartnership.com) to
learn more about these services and for providers of these
services. PCCs may refer youth directly to Intensive Care
Coordination (ICC), Mobile Crisis Intervention (MCI,) and InHome Therapy (IHT). Therapeutic Mentoring (TM), Family
Support and Training, (FS&T), and In-Home Behavioral
Services (IHBS) need referrals either from ICC, IHT, or an
outpatient provider as they are only available to facilitate the
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attainment of goals as identified in a Treatment Plan or ICP
developed by one of those aforementioned providers.
Additionally, CBHI educational materials for both families
and providers can be accessed from the EOHHS web
site,www.mass.gov/eohhs/gov/commissions-andinitiatives/cbhi/. The family brochure, “Worried About the
Way Your Child is Acting or Feeling?” is printed in five
regional editions with each version containing provider
information specific to a geographical region. The provider’s
companion guide to the family brochure, “Helping Families
Access MassHealth Behavioral Health Services for Children
and Youth under Age 21: A Briefing Guide for Working with
Children and Families,” is available in downloadable format
only.
Please note that the family brochure can be viewed, but it
was not intended to be downloadable from the CBHI web
page on the EOHHS site. PCCs will be able to obtain
region-specific copies from the PCC Plan Health Education
Materials Catalog. An online version and order form is
located at www.masspartnership.com/pcc. (Click “Support
Materials” in the left navigation bar.)
MOBILE CRISIS INTERVENTION (MCI) is the youth-serving
(under the age of 21) component of an emergency service
program (ESP) provider. MCI provides a short-term service
that is a mobile, on-site, face-to-face therapeutic response to
a youth experiencing a behavioral health crisis for the
purpose of identifying, assessing, treating, and stabilizing the
situation and reducing immediate risk of danger to the youth
or others consistent with the youth’s risk management/safety
plan, if any. This service is provided 24 hours a day, seven
days a week.
The service includes: a crisis assessment; development of a
risk management/safety plan, if the youth/family does not
already have one; up to 72 hours of crisis intervention and
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stabilization services, including: on-site, face-to-face,
therapeutic response, psychiatric consultation, and urgent
psychopharmacology intervention, as needed; and referrals
and linkages to all medically necessary behavioral health
services and supports, including access to appropriate
services along the behavioral health continuum of care.
For youth who are receiving Intensive Care Coordination
(ICC), Mobile Crisis Intervention staff coordinates with the
youth’s ICC care coordinator as well as with the youth’s
PCC, any other care management program, or other
behavioral health providers providing services to the youth
throughout the delivery of the service. PCCs may request
MCI services by calling your local emergency service
provider (ESP). ESP 1-800 numbers are available on the
MBHP web site (www.masspartnership.com).
IN-HOME THERAPY SERVICES (IHT) are delivered by one
or more members of a team consisting of professional and
paraprofessional staff, offering a combination of medically
necessary In-Home Therapy and Therapeutic Training and
Support. In-Home Therapy is a structured, consistent,
strength-based, therapeutic relationship between a licensed
clinician and the youth and family for the purpose of treating
the youth’s behavioral health needs, including improving the
family’s ability to provide effective support for the youth to
promote his/her healthy functioning within the family.
Interventions are designed to enhance and improve the
family’s capacity to improve the youth’s functioning in the
home and community and may prevent the need for the
youth’s admission to an inpatient hospital, psychiatric
residential treatment facility, or other treatment setting. IHT
is an enhanced and expanded service that was previously
known as Family Stabilization Services (FST).
COMMUNITY SERVICE AGENCIES (CSAs): There are 32
Community Service Agencies across Massachusetts. These
organizations are charged with providing Intensive Care
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Coordination (ICC) and Family Support and Training (FS&T),
two services provided under the CBHI.
INTENSIVE CARE COORDINATION (ICC) uses the
Wraparound model to provide care coordination for youth
under the age of 21 with serious emotional disturbance
(SED). In ICC, a care coordinator facilitates the
development of a care planning team (CPT) by working with
the youth and family/caregiver to identify and bring together
a team of individuals that may include informal supports,
behavioral health providers, schools, state agency
personnel, primary care clinicians (PCCs), and others who
play a key role in the youth’s life, in order to develop an
Individual Care Plan (ICP) to address the needs identified by
the youth and family and support his/her goals.
The care planning team is an essential aspect of ICC, and
coordination with and participation of the PCC is important.
PCCs may be asked by a care coordinator, a
parent/caregiver, or both to be part of a care planning team
(CPT), and they should receive an ICP for a youth who is
their patient. PCCs are encouraged to call into a CPT
meeting since physically being present may be difficult.
FAMILY SUPPORT AND TRAINING (FS&T) provides a
structured, one-to-one, strength-based relationship between
a family partner and a parent/caregiver of a youth under the
age of 21. This service aims to resolve or ameliorate the
youth’s emotional and behavioral needs by improving the
capacity of the parent/caregiver to parent the youth. FS&T
aims to improve the youth’s functioning in the community or
support the youth’s return to the community via work with the
caregiver. Services may include education; assistance in
navigating the child-serving systems (DCF, education,
mental health, juvenile justice, etc.); fostering empowerment,
including linkages to peer/parent support and self-help
groups; assistance in identifying formal and community
resources (e.g., after-school programs, food assistance,
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summer camps, etc.); and support, coaching, and training for
the parent/caregiver.
IN-HOME BEHAVIORAL SERVICES addresses a youth’s
(under the age of 21) behaviors that interfere with successful
functioning in the community. Services are delivered by one
or more members of a team consisting of professional and
paraprofessional staff via a combination of Behavior
Management Therapy and Behavior Management
Monitoring.
– Behavior Management Therapy includes a functional
behavioral assessment (observing the youth’s behavior,
antecedents of behaviors, and identification of
motivators) and the development of a highly specific
behavior plan with interventions that are designed to
diminish, extinguish, or improve specific behaviors
related to the youth’s behavioral health condition(s).
Supervision and coordination of interventions, and
training other interveners to address specific behavioral
objectives or performance goals are provided.
– Behavior Management Monitoring includes
implementation of the behavior plan developed by the
Behavior Management Therapist as well as monitoring of
the youth’s behavior and reinforcing implementation of
the behavior plan by the caregiver(s). Also included is
progress reporting back to the Behavior Management
Therapist on implementation of the behavior plan and
progress toward behavioral objectives or performance
goals so that the behavior plan may be modified as
needed.
THERAPEUTIC MENTORING SERVICES (TM) are
provided to youth (under the age of 21) in any setting where
the youth resides, such as the home (including foster homes
and therapeutic foster homes), and in other community
settings such as school, child care centers, or respite
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settings. TM offers structured, one-to-one, strength-based
support services between a therapeutic mentor and a youth
for the purpose of addressing daily living, social, and
communication needs. Therapeutic Mentoring services
include supporting, coaching, and training the youth in ageappropriate behaviors, interpersonal communication,
problem-solving and conflict resolution, and relating
appropriately to other children and adolescents, as well as
adults, in recreational and social activities. TM promotes a
youth’s success in navigating various social contexts,
learning new skills, and making progress in the community.
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Primary Care
Clinicians:
How to Coordinate
Behavioral Health
Services for
PCC Plan Members
PCC Plan
600 Washington Street
Boston, MA 02111
Massachusetts Behavioral Health Partnership
100 High Street, 3rd floor
Boston, MA 02110
11/2011
Prepared by the
PCC Plan, MassHealth, and the
Massachusetts Behavioral Health Partnership