Primary care nurse practitioner management of adolescent behavioral health.

OBJECTIVES: To determine the personnel costs and revenue generated by embedding a behavioral health nurse practitioner (BHNP) in primary care clinics to evaluate and manage adolescent behavioral health needs. STUDY DESIGN: We estimated personnel costs and revenue from a quality improvement project undertaken at 4 clinic sites between August 1, 2016, and July 31, 2018, at a large multispecialty medical group in northern California. METHODS: Costs were estimated by identifying the actual hours spent by the BHNP and for medical assistant (MA) support and using Bureau of Labor Statistics national data on wages and benefits. Revenue was estimated by analyzing Current Procedural Terminology (CPT) codes for BHNP visits from the Epic electronic health record and corresponding relative value units (RVUs), based on 135% of 2018 nationally unadjusted Medicare rates. RESULTS: We estimate 2-year revenue of $144,449 and personnel costs (salary + benefits) of $90,431. The BHNP work totaled 1083 hours, and MA support totaled 312 hours. Using a nurse practitioner wage of $53.70/hour and an MA wage of $16.95/hour, total salary costs were $63,451; we then added benefits costs. Using the CPT codes assigned to the 768 encounters with 207 unique patients, we estimated generation of 1640 RVUs and total revenue of $144,449. CONCLUSIONS: This analysis found that personnel costs ($90,514) of a primary care-embedded BHNP are 63% of the potential revenue generated ($144,449). This analysis suggests that a primary care BHNP could be a cost-saving and patient-centered way to reduce the burden on primary care providers while meeting the growing needs of adolescents with behavioral health needs.

Primary care provider utilization and satisfaction with a health system navigation program for adolescents with behavioral health needs.

Approximately 49.5% of the adolescents report a mental health disorder; only about half of the children and adolescents with mental health disorders seek treatment from a mental health professional. Stigma and poor access to behavioral health providers are leading barriers to care. A large ambulatory health system implemented a BH navigation program to facilitate referrals from primary care physicians (PCPs), including pediatricians and family physicians, to BH providers. We studied PCP adoption of BH navigation services over a 4-year period, from July 2014 to June 2018. We retrieved operational data regarding service utilization, patient information from electronic health records and PCP information from administrative data, and surveyed PCPs for their appraisals of navigation services. Four thousand five hundred and fifty-five referrals were made for 3,912 patients from 290 PCPs (71% of PCPs in the health system). Depression (39%), anxiety (25%), and attention-deficit hyperactivity disorder (7%) were the most frequent reasons for referral. Referrals increased dramatically in the first half of the study period and decreased afterwards. Ninety-one percent of the PCPs agreed or strongly agreed that navigation enhanced their clinical care at 12-month survey. More than 90% of the PCPs rated the referral process, communication with navigation staff, and the overall experience as above average or excellent at 12 months. There was a decrease in these evaluation indicators after 2.5 years. The initial high referral volume reflects a need for BH navigation services. However, challenges remain to maintain positive PCP assessment in the face of such demand.

Enhancing Shared Decision Making Through Carefully Designed Interventions That Target Patient And Provider Behavior.

Patient-provider communication and shared decision making are essential for primary care delivery and are vital contributors to patient experience and health outcomes. To alleviate communication shortfalls, we designed a novel, multidimensional intervention aimed at nudging both patients and primary care providers to communicate more openly. The intervention was tested against an existing intervention, which focused mainly on changing patients' behaviors, in four primary care clinics involving 26 primary care providers and 300 patients. Study results suggest that compared to usual care, both the novel and existing interventions were associated with better patient reports of how well primary care providers engaged them in shared decision making. Future research should build on the work in this pilot to rigorously examine the comparative effectiveness and scalability of these interventions to improve shared decision making at the point of care.