10/14/2015

1

B E R N A D E T T E H A Y B U R N , P S Y . D .

C O A T E S V I L L E V A M C

P R I M A R Y C A R E P S Y C H O L O G I S T

H E A L T H B E H A V I O R C O O R D I N A T O R

B a s e d o n s l i d e s d e v e l o p e d b y M a r g a r e t D u n d o n , P h . D . , C h r i s t o p h e r H u n t e r , P h . D .

a n d K a t h e r i n e D o l l a r , P h . D . f r o m t h e

D e p a r t m e n t o f V e t e r a n s A f f a i r s ’ C e n t e r f o r I n t e g r a t e d H e a l t h c a r e .

Primary Care Mental Health Integration

Objectives

Describe the rationale for integrating Behavioral Health into a Primary Care setting.

Identify three differences between the Primary Care-Mental Health Integration Model and Traditional Mental Health Care.

Identify the 5 A’s: An Evidence-Based Assessment and Intervention Model within the PC-MHI context.

List at least three clinical interventions utilized within PC-MHI.

Healthcare Realities

Up to 70% of PC medical appts have psychosocial component Psychiatric disorders – full spectrum Behavioral issues (IBS, tension headaches, insomnia, nonspecific

pains, vague somatic systems- most pts view as medical Unhealthy lifestyles (smoking, diet, etc..) Life stressors

› 80% of psychotropics are prescribed by non-psychiatric medical providers. (Hunter et al, 2009) .

Behavioral health problems compromise treatment of physical health problems (Nash et al., 2012).

Distressed patients use twice the healthcare services(McDaniel & deGruy, 2014)

10/14/2015

2

Primary Care Realities

“For primary care physicians…there is too much to do- too many patients, too many demands, too much information flowing through, too little time to do a good job.”

Average US (Non-VA) panel: 2300 patients. “To do chronic and preventive care would take 18 hours/day to do it right”NEJM, Perspective Roundtable 11-19-08.

Chronic diseases

Multiple comorbidities (associated with poorer

disease self-management & higher costs)

(Fisher & Dickinson, 2014)

Typical PC Clinic Day: VA Survey

14-16 appointments, with 30 min.

Clinical reminders: 4-10/pt., for 5-15 min

Health problems: 3-8 active, 1-2 complex

Admin Task: 100 view alerts per day (2 hours work), e-mails, phone calls, orders, scripts, notes, etc.

The result:

10/14/2015

3

What to Do???

“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” – Plato

Traditional practice (in both medicine and mental health) assumes the mind and body function independently.

In reality, they are interconnected and healthcare need to be as well. Emotional factors affect physical health.

Medical illnesses can lead to psychological distress. Psychological distress corresponds with morbidity and mortality risk. Effective treatment of many medical conditions includes a major

behavioral component.(Gatchel & Oordt, 2008)

Mind-Body Connection:Meet Lance

Integrated Care

• A form of care in which behavioral heath and primary care providers interact in a systematic manner to meet the behavioral and health needs of their patients.

-Dr. Christopher Hunter

• Unifies care for physical and mental concerns”

AHRQ 2008 Butler et al.

10/14/2015

4

Population-Based Integrated Care

• Serves a higher % of the population: a little service for a lot of pts vs. traditional MH

• Emphasizes early identification/prevention

• De-emphasizes MH Dx

• Provides triage and tx in stepped care fashion

• Supports, rather than replaces specialty mental health care

• (Nash et al., 2012)

Models of Integrated Care

Coordinated CarePCPs and BHPs work in separate systems and facilities, delivering separate care and exchange information as needed.

Co-location/Co-located ServiceBHP works in a space that is in close proximity to (or embedded in) a primary care clinic. PCPs may refer BHPs pts but BHPs and PCPs deliver separate care.

Collaborative Care/Collaboration (Integrated)PCPs and BHPs work together in a shared system for the purpose of developing treatment plans, providing clinical services and coordinating care to meet the physical and behavioral health needs of patients.

PC-MHI in the VA

2007: PC-MHI Initiative was launched

2008: Uniform MH Services Handbook requires that VAMCs provide a blended program:

1.) Integrated co-located collaborative care

2.) Care management

2010: VA PC was transformed into PACT Development of a stepped model of care

Shift to tending proactively to needs of a cohort of PC pts rather than a referred caseload of pts presenting for psychological care

(Kearney et al., 2014).

10/14/2015

5

BHL Care Management

Algorithm-based care, implemented by telephone, that includes routine monitoring/assessment of patients focusing on

Psychoeducation: encourage self-management skills

Brief treatment

Medication Monitoring (antidepressants)

In consultation with the supervising clinician, provide relevant information to the PCP to allow collaboration for appropriate care decisions

(Post et al., 2010)

Can’t PC just Refer to Specialty MH Care?

Long delays often result in attrition and lost windows of opportunity for effective treatment

High No Show rates

Perceived stigma (going to MH building or service)

• Patient volume has increased, not feasible to refer everyone out, especially pts with mild-sub-clinical symptoms(Pomerantz, et. al, 2008)

BHP in PACT vs. Traditional MHDimension BHP in PACT Mental Health Specialty

Care

Location On site A different floor, bldg…

Population Most are healthy, mild to moderate symptoms

Most have MH diagnoses

Inter-provider Communication

Collaborative & on-going Consultations via PCP’s method of choice

Consult reportsFormal communications

Service Delivery Structure Brief appointmentsLimited number of appointments

50 - 90 minute psychotherapysessionsLonger treatment episodes

Approach Problem-focusedSolution orientedPatient centered

Varies by therapy Diagnosis-focused

Treatment Plan Leader PCP continues to be lead MHP is lead

Primary Focus Support the over-all health Focus on function

Cure or ameliorate mental health symptoms

10/14/2015

6

Does It Work????PC-MHI Evidence Base

Improved identification

Improved access

• Improvedengagement andadherence

Higherqualitycare

Betterclinicalandfunctionaloutcomes

Increasedpatient satisfaction(Dollard,2011;Pomerantz etal,2008)

CVAMC PC-MHIStaffing

Bernadette Hayburn, Psy.D.: 3 days per week

Justin Charles, Psy.D.: 1 day per week

Kelly Gerhardstein, Psy.D.: 1 day per week

Michael Gliatto, M.D.: ½ day per week

Doctoral-Level Psychology Intern: 16 hours week

Services

Consultation

Assessment

Individual Treatment

Group Classes: Pain, Depression, MOVE

Psychiatric Medication Consultation and Management (Dr. Gliatto)

Staff Education

10/14/2015

7

Mind Over Mood Outcome Data

Total # of sessions: 10Format: Weekly 60-minute group sessions of Cognitive-Behavioral Therapy

for Depression

Outcome Data: A. Changes in scores on BDI-II (2012-2014)

Pre Group Post-Group 26.8 (high-moderately depression) 12.9 (minimal depression)

B. Changes in scores on PHQ-9 (2014-2015)Pre Group Post Group

15. 5 (moderately-severe) 7.5 (mild)

Patients who completed the group demonstrated a significant reduction in depression as evidenced by a marked decline in their BDI-II & PHQ-9 scores over the course of treatment.

Performance Measures

PC-MHI Penetration (PACT 15) – The percent of assigned PC pts seen by a PC-MHI Provider.

Goal: 6 % CVAMC: 5.27 %

Ranked 4th of 10 in VISN 4.

PC-MHI CASE

53 year old SC veteran

Referred for depression and “stress” secondary to chronic knee pain and frustration with medical system

Pain negatively affected his work, relationships,

leisure activities, and sleep.

Primary concern was his irritability and angry outbursts towards wife and children.

10/14/2015

8

Treatment Interventions

Psychoeducation about Stress

Managing Stress Workbook

Relaxation Training

Mindfulness Exercises for noticing

angry thoughts and feelings

Assertiveness Training to improve

communication with wife

Treatment Summary

6 sessions/ 30 minute intervals

Self-Report Measures:Pre Post

PHQ-9 9 (high-mild dep) 5 (low-mild dep)GAD-7 17 (severe anxiety) 6 (mild anxiety)

“I feel much better.” Pt reported increased awareness of triggers for his anger

and felt better able to choose his response instead of reacting impulsively.

What Tools Do Behavioral Health Providers Need to Work Effectively in PC?

10/14/2015

9

Conceptual Shift

“We must move beyond the narrow conception of ourselves as mental health professionals and begin to see ourselves as comprehensive health professionals.”

Russ Newman

May 2005 APA Monitor

Behavioral Health Consultation: Domains of Competency

Domain 1: Clinical Practice

Domain 2: Practice Management

Domain 3: Consultation

Domain 4: Documentation

Domain 5: Teamwork

Domain 6: Administrative Skills

Robinson, P. & Reiter, J. (2007). Behavioral consultation and primary care: A

guide to integrating services. New York: Springer Science-Media.

26

Domain 1: Clinical Practice

Define role accurately

Identify problems rapidly

Limit problem definition

Focus on functional outcomes

o Less focus on diagnosis

o Targeted interventions

27

10/14/2015

10

Measurement-Based Care

Use appropriate assessments (e.g. , PHQ not MMPI)

Saves time and guides clinical interview

Facilitates systematic application of stepped-care (What is the next tx step based upon pt’s symptoms?)

Helps monitor outcome

Helps patients become more knowledgeable about their disorder and progress, which is key to self-management

Domain 2: Practice Management

Effective brief visits Recommend 20-30 minutes Focus on functioning Specific skills Should include charting and contact with PCP Limited number of sessions

Same day access Warm hand-off

Use an intermittent visit strategy

29

Domain 3: Consultation

30

• Focus on and respond to referral question• Tailor recommendations • Conduct effective curbside consultations

• Use same language as PCP• “Hallway”• Less than 5 minutes: 1-2 ideal

• Follow-up assertively

10/14/2015

11

Domain 4: Documentation Skills

31

Use same chart Use same format as PCP Brief, clear, concise Templates when possible Numbers when possible (e.g. PHQ 9 score) Include brief impression and plan Include suggestions for PCP

Domain 5: Teamwork32

• Be a team player, ideally a leader• Unscheduled services• Learn PCP culture • Be flexible • Be available• Build rapport with team

Domain 6: Administrative Skills

33

Understand relevant polices and procedures

Market services

Referral tips for PCPs

Review and refine linkages whenever possible

Ensure proper coding (stop codes)

Outcome Monitoring

Support management in recruitment

10/14/2015

12

What Exactly Do You Do????

Hamlett-Berry, 2010

The 5 A’s: An Evidence-Based Assessment &

Intervention Model

ArrangeSpecify plans for

follow-up (visits, phone calls,

mail reminders)

AssistProvide information, teach

skills, problem solve barriers to reach goals

AdviseSpecific, personalized, options for tx, how sx

can be decreased, functioning, quality of life/health improved

AgreeCollaboratively select goals based on patient interest and

motivation to change

AssessRisk Factors, Behaviors, Symptoms,

Attitudes, Preferences

Personal Action Plan1. List goals in behavioral terms2. List strategies to change health behaviors3. Specify follow-up plan4. Share plan with practice team

5A’s-Assess, Advise, Agree, Assist, Arrange

Diagram adapted from: Glasgow, R. E & Nutting, P. A. (2004). Diabetes. In Handbook of Primary Care Psychology. Ed., Hass, L. J. (pp. 299-311)

1. Introduction of behavioral health consultation service (1-2 minutes

2. Identifying Clarifying consultation problem (10-60 seconds) Assess

3. Conducting functional analysis of the problem (12-15 minutes)

4. Summarizing your understanding of the problem (1-2 minutes)

5. Listing out possible change plan options (selling it) (1-2 minutes) AdviseAgree

6. Starting a behavioral change plan (5-10 minutes) Assist Arrange

Phases of a 30-Minute Appointment

10/14/2015

13

ASSESSFunctional Assessment

Biopsychosocial Model

• -Physical

• -Behavioral

• -Cognitive

• -Emotional

• -Environmental factors

Initial Interview

CIH\Initial Interview Note _handout2pcmh_initial_interview_outline508_20140922-123111462.pdf

ADVISE

• Give clear, specific & personalized change advice

• What changes will be involved and how they might be beneficial

10/14/2015

14

AGREE

Collaboratively select goals based on patient’s interest in & willingness to change behavior

Find common ground & define behavior change goals & methods

Shared decision making = -Greater sense of personal control-Choices based on realistic expectations-Change matches patient values

ASSIST

Develop a specific tailored action plan

Plan should: 1. Help identify, address and overcome barriers 2. Develop self-management skills 3. Develop confidence to successfully change

ARRANGE

• Specific plans for subsequent contacts

• Individual, Group, Self-Management

• Other providers/adjunctive treatment

• Video clip

10/14/2015

15

PC-MHI INTERVENTIONS

Relaxation Training

Deep Breathing

Cue-controlled relaxation

Progressive muscle relaxation

Visual imagery

Goal Setting

Are the goals well defined in behavioral terms? (S.M.A.R.T)

Realistic/achievable

Within realm of control/influence

Break into sub-goals

Personally important

Whose goals are they anyway ?

N:\My Documents\HPDP\0577 VANCP MyHealthChoicesV2 508 F screen.pdf

10/14/2015

16

Help track progress towards a goal

Use a calendar

Keep a tally

Chart on a graph

Self-Monitoring

Behavioral Activation

Difficult to feel depressed when engaged in activities that provide pleasure and accomplishment

•Re-establish routines

•Increase reinforcing experiences

•Overcome avoidance patterns

•Distraction from problems or unpleasant events

Pleasant Activities:

N:\My Documents\Mood Group\365 Pleasant Activities List (2).doc

Help to identify unhealthy thoughts

Use thought logs

Question thought process

“Cognitive Disputation”

Self-help books for highly motivated

“Mind Over Mood”

Greenberger and Padesky

Identifying and Disputing Negative Cognitions

10/14/2015

17

Motivational Interviewing

Examine readiness to change (Readiness Ruler)

Examine importance and confidence for change

Elicit pros and cons of change

Problem Solving Training

Define the problem

Brainstorm solutions

Critically evaluate each solution

Select and implement an option

Assess the outcome

Assertive Communication

Assess patterns of communication

Explain differences in passive, assertive, and aggressive communication

Help patient to learn how to speak assertively

Practice through role-play

10/14/2015

18

References

Dollar, K., M., Greenwood, S.,& Klaus, J. (2011). Introduction to PC-MHI Functions: CCC, CM, and howthey work together [PowerPoint slides]. Retrieved from Center for Integrated Healthcare Sharepointsite https://vaww.visn2.portal.va.gov/sites/natl/cih/default.aspx?RootFolder=%2fsites%2fnatl%2fcih%2fShared%20Documents%2fAugust%202011%20Co%2dlocated%20Collaborative%20Care%20Training%20Presentations%20%2d%20Charlotte%20NC%2fIntroduction%20to%20PC%2dMH%20Integration%20Functions&FolderCTID=&View=%7b3E2788C6%2d149B%2d4287%2d85D3%2dBB111FBFFF18%7d.

Dundon, M. & Hunter, C. (2009). Effective evidence-based assessments and interventions in 30-minutesor less: What every collaborative primary care mental health clinician should know [PowerPoint slides]. Retrieved from Center for Integrated Health Sharepoint site https://vaww.visn2.portal.va.gov/sites/natl/cih/Shared%20Documents/Forms/AllItems.aspx.

Fisher, L. & Dickinson, W. P. (2014). Psychology and primary care: New collaborations for providingeffective care for adults with chronic health conditions. American Psychologist, 69(4), 355-363.

Gatchel, R. J. & Oordt, M. S. (2008). Clinical health psychology and primary care: Practical advice andclinical guidance for successful collaboration. Washington, DC: American Psychological Association.

Glasgow, R. E., & Nutting, P.A. (2004). Diabetes. In L. Hass (Ed.), J. Handbook of Primary Care Psychology, (pp. 299-311) . New York: Oxford.

Hunter, C. L., Goodie, J. L, Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated behavioral health inprimary care: Step by step guidance for assessment and intervention. Washington, DC: American Psychological Association.

References (continued)

Kearney, L. K., Post, E. P., Pomerantz, A., & Zeiss, A. M., (2014). Applying the

interprofessional patient aligned care team in the Department of Veterans Affairs:

Transforming primary care. American Psychologist, 69(4), 399-408.

McDaniel, S. H., & deGruy, F. V., (2014). An introduction to primary care and psychology. American

Psychologist, 69(4), 325-331.

Nash, J. M., McKay, K. M., Vogel, M. E., & Masters, K. S. (2012). Functional roles and foundational

characteristics of psychologists in integrated primary care. Journal of Clinical Psychological Medical

Settings, 19, 93-104.

Pomerantz, A., Cole, B. H., Watts, B. V., & Weeks, W. B. (2008). Improving efficiency and access to

mental health care: combining integrated care and advanced access. General Hospital Psychiatry 30,

546-551.

Post, E. P. (2008). Veterans Health Administration primary-care-mental health integration initiative.

North Carolina Medical Journal, 69(1), 49-52.

Valenstein, M., Adler, D. A., Berlant, J., Dixon, L. B., Duilt, R. A., Goldman, B. … Sonis, W. A.

Implementing standardized assessments in clinical care: Now’s the time. Psychiatric Services:

60(10), 1372-1375.