Behavioral health operational resources toolkit

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Behavioral health operational resources toolkit

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Behavioral health operational resources toolkit


Operational resources task force

Bryan A. Dovichi, MA,




, MD


Chamberlain, MSW

Sheri Gibson, PhD

Allison Ilem, PhD, BCBA

Katherine Jones

Brenda King,





Mary Beth Tubbs, BSN, MS


Behavioral health workgroupMaureen Nash, M.D. Chair

Terry Anderson

Ashton Andrews



Elisabeth BroderickRachel BroudyJessica BurtKelly CervenkaAuria ChamberlainLynda DavisNicole DesabraisMichael DiBiaseBryan DovichiAlicia EnglishPamela FenstemacherMartha FrostCurran GaughanSheri GibsonIrena GinsburgMelyssa HarmonCarrie Hays McElroyAllison IlemKatherine JonesLinda KasparianKendra KerrBrenda KingBill KirkpatrickLorelei LandauIan LaRoseHeather Laughland

Victor Lee







Mary Maxine Mello

Holly Onsager







Luz Ramos-Bonner





Rebecca Riley

Mary Ann Roberts



Adria Smith

Kristin Springfield

Joe Stanley

Laurie Strom

Carmarthen Swift

Misty Taylor-Paladino

Mary Beth Tubbs







Theresa Wright



Purpose Statement

Development Process


Behavioral Health – definition

Integration of Behavioral Health and Primary CareLevels of IntegrationBehavioral Health ProvidersBehavioral Health Services

Rationale for Integrating Behavioral Health and Primary Care

The Need for Behavioral Health in PACE

Behavioral Health in PACE: Recommendations for Best Practices

Referrals, Inclusion Criteria, and Confidentiality

Assessment and Care Planning

Clinical Interview

Mental Status Examination

Cognitive Screening

Mood Functioning Measures

Substance Abuse Measures

Other Measures

Treatment and Interventions

Risk Assessment and Crisis Intervention


Individual Psychotherapy

Motivational Interviewing

Group Psychotherapy

Substance Abuse Treatment

Psychiatric Pharmacotherapy

Psychiatric Admissions

Special Considerations


Severe Mental Illness

Elder Abuse

Collaborating with Community-Based Behavioral Health Services

Outcomes and Measurement-Based Care

Closing Statement



Assessment Forms and Policy and Process Examples



Purpose statement

It was not until recently that Program of All-inclusive Care for the Elderly (PACE) organizations began to recognize the need for Behavioral Health Services and add to their traditional model of care by including various professionals specializing in the discipline. The purpose of this toolkit is to

provide a resource and a guide of best practices for PACE organizations looking to achieve a greater level of behavioral health integration

. The National PACE Association (NPA) Behavioral Health Operational Resources Toolkit is

not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of an organization’s resources

. Every PACE organization will differ in its level of integration and implementation of new practices will be successful only if attempted within one’s reasonable ability to do so. These recommendations for best practice should be considered guidelines only. Adherence to them will not ensure a successful outcome of implementing Behavioral Health Services, nor should it be interpreted as including all proper methods of care or excluding of other acceptable methods of care aimed at successful treatment outcomes of PACE participants.


Development process

The NPA Behavioral Health Workgroup was formed in December 2015. Upon formation of the group, the work began by surveying PACE organizations regarding their use of Behavioral Health Services. Based on a thematic analysis of the results, the workgroup was broken down into three taskforces: Education, Operational Resources, and Outcomes. The Operational Resources Taskforce held its first meeting by conference call on June 8, 2016, during which time a work plan and working agenda were developed. It was also during this initial meeting that a call for forms was communicated to taskforce members in order to solicit policies, procedures, and assessment tools being used at members’ respective PACE organizations. Subsequent monthly meetings were held via conference call (with the exception of November 2016). Each meeting involved members discussing items according to its work plan. The taskforce began by developing and/or selecting definitions for Behavioral Health and levels of integration, providers, and services provided by the discipline. The task force then shifted its focus to developing recommended best practices for the following areas: (1) Referrals and Inclusion Criteria; (2) Assessment and Care Planning; (3) Treatment and Interventions; (4) Special Considerations; and (5) Outcomes and Measurement-Based Care. Time outside of the monthly conference calls included review of the solicited forms and supporting empirical literature and writing, reviewing, and editing this toolkit.



Behavioral Health – definition

Behavioral Health Services offer assistance not just with diagnosable mental illnesses, but also when habits, behaviors, stress, worry, or emotional concerns about physical or other life problems are interfering with a person’s daily life and/or overall health. This is achieved by performing a variety of mental health activities within a primary care setting.

Integration of Behavioral Health and Primary Care

“Integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems often occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served.”





Primary (Traditional)



Social Workers

Licensed Professional CounselorsLicensed Marriage and Family TherapistsSecondary (Supportive)Primary Care MDs, NPs, and PAsRecreational Therapists/Activities CoordinatorsPhysical Therapists/Occupational TherapistsChaplainBehavior AnalystsBehavioral Health Providers



Behavioral Health Services



Rationale for Integrating Behavioral Health and Primary Care

1. The burden of mental disorders is great.

2. Mental and physical health problems are interwoven.

3. The treatment gap for mental disorders is enormous.

4. Primary care settings for mental health services enhance access.5. Delivering mental health services in primary care settings reduces stigma and discrimination.6. Treating common mental disorders in primary care settings is cost-effective.7. The majority of people with mental disorders treated in collaborative primary care have good outcomes.(WHO, 2008)



The Need for Behavioral Health in PACE

59. 7% of participants diagnosed with at least 1 psychiatric disorder with a higher rate of mental illness in the younger age group (53-64: 77.6%) versus the older age groups (65-74: 68.1%; 75+: 53.8%). (PACE Data Analysis Center Report, 2014)

77% of organizations have no formal behavioral health programming in place.

Common themes include: (1) Inadequate programing to serve high levels of need; (2) Fragmented communication with external behavioral health providers; (3) Unique challenges associated with specific populations and diagnoses; (4) Need for staff education on specific topics; and (5) Need for development of policies and procedures.


Behavioral health in pace:Recommendations for Best practices

At the greatest level of integration, Behavioral Health Services in a PACE organization ideally should aim to serve as an essential department integrated within the Interdisciplinary Team (IDT) with a focus on addressing the behavioral, cognitive, and emotional well-being of participants.

Implementation should focus on several key areas:

Integrated Primary Care Behavioral Health

Trauma-Informed Care

Culturally Competent CarePreventative CareData and Information Driven Care


Behavioral health in pace:Recommendations for Best practices

Referrals, Inclusion Criteria, and Confidentiality

Identify participant’s BH needs pre- and post-enrollment (when available, consider inclusion of BH in the pre-enrollment process).

Presenting Issues

Methods of referring (EHR vs. paper form)

Referral SourcesConfidentialityCoordinationLimitsDocumentation; types of notes


Behavioral health in pace:Recommendations for Best practices

Assessment and Care Planning

Clinical Interview

Mental Status Examination

Cognitive Screening

Mood Functioning MeasuresSubstance Abuse MeasuresOther Measures


Behavioral health in pace:Recommendations for Best practices

Treatment and Interventions

Risk Assessment and Crisis Intervention

Psychoeducation (with participants, caregivers, and staff)

Individual Psychotherapy

Motivational InterviewingGroup PsychotherapySubstance Abuse TreatmentPsychiatric PharmacotherapyPsychiatric Admissions


Special Considerations


PACE organizations without behavioral health integration have been successful at caring for its participants with dementia for a long time; however, behavioral health may be looked at as a way to help amplify and expand on existing programming.

Day Center Programming

Monitoring and Tracking

Medication Utilization


Special Considerations

Severe Mental Illness

Due to the growing number of participants suffering from severe mental illness (e.g., schizophrenia; bipolar disorder), it is important for organizations to develop programming to ensure proper care and treatment for these individuals. There are several areas that often provide difficulties which programs can proactively develop programming to provide effective and quality care:

Medication Management

Day Center Programming

Living Environment and Safety


Special considerations

Elder Abuse

There are various forms of elder abuse that PACE professionals should be aware of, including physical abuse, sexual abuse, psychological abuse, neglect, financial exploitation, and abandonment. Abuse occurs in the context of a trusted relationship, and may involve the targeting of older adults specifically because of their age and/or disability status. Another issue that PACE organizations may encounter is that of self-neglect.

Who is considered a vulnerable adult?

Not sure whether to report? Consult. Who should report?Person-centered reporting. Reporting responsibility. Other Resources.


Special considerations

Collaborating with Community-Based Behavioral Health Services

As the majority of PACE organizations recently surveyed indicated that they have none or are in the very beginning stages of developing and implementing behavioral health programming, effective working relationships with community-based Behavioral Health Services, including counseling and psychiatry, are vital in serving the mental health needs of participants for these organizations.

Bringing Behavioral Health Care to the PACE Model When Integration is Limited


Outpatient PsychiatrySpecialty Care SettingsNon-clinical Resources


Treatment Outcomes/

Measurement-based Care

Participant Satisfaction



Hospital Re-admissionsAvoidable ED VisitsPsychiatric AdmissionsMedication UtilizationPlacementsGrowth/Market ShareStaff TrainingProvider Satisfaction

PACE Behavioral Health Services – Outcome Measures




Outcomes and measurement-based care

Frequently referred to as “measurement-based care” or “routine outcome measurement”.

Use of standardized tools or instruments to obtain objective data to monitor the impact of and inform decisions related to individual plans for care, treatment, or services.

Data may also used for organizational performance improvement efforts.

Demonstrates the value of services and increases the quality of care provided.


Closing Statement

The PACE model of care and its individual organizations historically have proven to be very effective at caring for older adults since its humble beginnings in 1971 at On


in San Francisco, California. It was inevitable that other populations would learn about and gravitate toward this all-inclusive approach to care.

Recently, we have come to see the average PACE participant not only become younger, but also present with more of a need for mental health services. Moreover, as community mental health organizations across the country have demonstrated difficulties in caring for the needs of their patients, it appears that the PACE model of care continues to increasingly grow as an attractive option for many of the individuals served by related agencies. Accordingly, the National PACE Association has recognized the need to adjust and add to its model of care to serve the growing aging population in America.

This toolkit seeks to serve as the first step in creating a new department within the existing model the PACE interdisciplinary team and also illustrate the need for PACE organizations to adapt their approach to providing the best care for all participants. As the population continues to evolve, it is the primary goal of the NPA Behavioral Health Workgroup Operational Resources Task Force to continue to provide PACE organizations with a resource to continue to learn, grow, and adapt. Looking to the future, it is recommended that PACE organizations approach the existing model of care with the belief that there is no health without behavioral health.



Behavioral Health Referral Paper Form

Clinical Interview Schedule

Mental Status Exam – Rapid Record Form

Montreal Cognitive Assessment (

MoCA) – Administration and Scoring InstructionsMontreal Cognitive Assessment (MoCA) – Version 7.1 Original Version Montreal Cognitive Assessment (MoCA) – Version 7.2 Alternate VersionMontreal Cognitive Assessment (MoCA) – BLIND – Administration and Scoring Instructions Montreal Cognitive Assessment (MoCA) – BLIND – Version 7.1 Original VersionMini-Mental State Examination (MMSE)The Saint Louis University Mental Status (SLUMS) ExaminationAid to Capacity Evaluation (ACE)Functional Assessment Staging (FAST)Global Deterioration Scale (GDS)Clinical Dementia Rating (CDR)Process flow example for Depression and Anxiety ScreeningPatient Health Questionnaire 9-item (PHQ-9)Geriatric Depression Scale (GDS)The Cornell Scale for Depression in DementiaGeneralized Anxiety Disorder 7-item (GAD-7)Geriatric Anxiety Scale (GAS)The Mood Disorder Questionnaire (MDQ)Alcohol Use Disorders Identification Test (AUDIT)Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)Current Opioid Misuse Measure (COMM)Participant Medication Agreement FormLife Events Checklist for DSM-5 (LEC-5)PTSD Checklist for DSM-5 (PCL-5)Clinician-Rated Dimensions of Psychosis Symptom SeverityAbnormal Involuntary Movement Scale (AIMS)Caregiver Burden Scale

Safety Plan

Psychotherapy Outcome Reporting

Treating Behavioral Disturbances and Intervention Grid

Behavior Logs for Tracking Behavioral Disturbance Associated with Dementia

Behavioral Care Plan


A special thank you to NPA Support staff

Teresa Belgin, (former) Member Services Manager

Shawn Bloom, President and CEO

Sam Kunjukunju, Director of Project Management





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