Primary Care/Medical Home

​​​Primary Care is a front door for the full range of medical issues, including behavioral health issues. The patient-centered Medical Home is well positioned to screen for and detect many behavioral health conditions, and can be equipped to fulfill the treatment needs of those with mild to moderate behavioral health problems and to refer those with more severe issues to specialty care. Community Care of North Carolina (CCNC) is Cardinal Innovations' partner in ensuring primary care offices are equipped to manage the needs of many behavioral health patients.

Intended Populations

  • Those at increased risk of behavioral health diagnoses who may benefit from routine and targeted screenings for behavioral health problems.

  • Those with mild to moderate acute behavioral health issues willing to be treated in the primary care setting. Typically, those in Quadrants I and III (those with low behavioral health costs 4 Quadrant model) are appropriate for management in the primary care setting.

  • Those with moderate to severe behavioral health issues who are in recovery or who are stable in maintenance treatment and who are willing to be treated in the primary care setting, according to their preference and practitioner comfort.

Recommended Best Practices

  • Core Best Practices

  • Health Foster Care America Standards

  • Fostering Health NC Standards 

  • Screenings (with support and follow up):

    • Yearly depression screening is recommended for all adults with an evidence-based tool (e.g., PHQ-9 with IMPACT/collaborative care models; CCNC Depression Resources​. Support and follow up for those who screen positive includes:

      • Link to primary mental health treatment

      • Follow the PHQ-9 (or other tool) to monitor improvement (50 percent reduction in score by week 12 of antidepressant), monitoring every one to two weeks (by phone or in person) during the treatment phase, following yearly thereafter.

      • Add therapy or support as needed

    • Post-partum women should be screened for depression with the Edinburgh Scale at the following post-partum intervals: two weeks, one month, two months, and four months. This may occur at pediatrics practices.

    • Yearly screening for alcohol use disorders following the SBIRT model.

    • Use of Motivational Interviewing with patients who are difficult to engage in services or those having difficulty achieving their treatment adherence goals, especially those with substance abuse issues.
       
  • Basic Medication Management

  • Referral to appropriate supports and services

    • Natural Supports:  Maximizing the use of natural supports is vital to obtaining and sustaining recovery. Cardinal Innovations encourages primary care offices to contact us if help is needed to refer patients to appropriate community and natural resources.

    • Outpatient Therapy: Often behavioral health conditions will respond to therapy alone, or therapy added to medication management. Cardinal Innovations encourages primary care providers to refer patients to us to assist in connecting them to a community therapy provider.

    • Specialty Care: For those patients with moderate behavioral health conditions combined with complex social problems, and for those with severe (SMI) or serious and persistent (SPMI) behavioral health conditions, referral to specialty providers (psychiatric management with or without wrap around services) is the standard of care. Cardinal Innovations is available through our Access Center 24/7/365 to assist providers in connecting these consumers to the range of behavioral health services. (Contact Us)

    • For referral to crisis care please (Contact Us) 
       
  • Co-Location, Collaborative Care

    • Collaborative behavioral and physical health services are ideal but do face some financial sustainability challenges. Collaborative models vary widely and both CCNC and Cardinal Innovations are happy to assist primary care practices in selecting a model that will work for their specific needs. For those with multiple chronic conditions (physical and behavioral), a single care coordinator for ensuring seamless integration of care is recommended.
       
  • Patient/Caregiver Education

    • Psychoeducation about a patient's diagnosis, medications and other treatment options can be time consuming but is an important tool in achieving desired outcomes.

Desired Outcomes

  • Core Expected Outcomes

  • Increased detection of behavioral health conditions needing treatment in the primary care setting.

  • Prevention or minimization of disability from early detection of and intervention for behavioral health conditions​​

Management Approach

  • While Cardinal Innovations is not the payer of primary care services, we do fund the (b)(3) psychiatric consultation service, which reimburses psychiatrists for telephonic consultation to primary care providers and assists them in coordinating care based upon the recommendations of the consultant psychiatrist. We are currently working with this definition to try to adapt it to better match the needs of primary care physicians.

  • Cardinal Innovations reviews high risk/cost cases with CCNC care managers, based on monthly data gathering about patients who have preventable episodes of care, as detected by CCNC or Cardinal Innovations' data systems.

  • Cardinal Innovations provides care coordination for special population high risk/cost consumers (link to special populations section)

  • Cardinal Innovations assists in the education of primary care providers about screening, treatment and referral for behavioral health conditions.​