Implementing Cognitive Behavioral Therapy (CBT) Skills Group Medical Visits within Primary Care

Dr. Bill Bullock, Dr. Erin Burrell, Dr. Joanna Cheek, and Christine Tomori

The problem: Meet Mary Mary is one of the 29% of people* struggling with the most common chronic

condition in Victoria: depression and/or anxiety.

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*VIHA, 2013

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Mary is feeling…

Afraid. Ashamed.

Overwhelmed. Uncertain.

Demoralized. Hopeless.

Stuck.

And all alone.

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But Mary has many barriers to getting help…

42% of people no longer socialize with

someone with a mental health

problem.

55% wouldn’t marry someone with a

mental health problem.

50% wouldn’t tell friends or colleagues

about family member with a mental

health problem.*

*Canadian Medical Association. (2008). Eighth Annual

National Report Card on Health Care.

STIGMA

It’s a sign of weakness to be

depressed and anxious.

I should just get over it.

No one else understands

this.

I don’t want people to know

I’m struggling.

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Mary is courageous and finally

asks her family doctor for help.

*Canadian Mental Health Association, 2012

80% of people with

mental health issues in

Canada receive care

exclusively within the

primary care system.*

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And alone.

• Psychiatrist wait list

• Rejected: “not sick enough”

• Private services $$$

• GP has too little expertise,

confidence, & time for self-

management strategies

Is no one going to help

me with this patient in

need?

I can’t do this all alone.

She needs more support

than I can give in the

office!

But eventually he, too, feels stuck.

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Her relationships and family members are affected.

Mary and her family suffer.

Mary goes off work.

Society suffers.

She stops exercising, eats poorly and her mental &

physical health deteriorates.

The healthcare system pays the bill.

Our Aim: To create accessible and effective self-management services for patients with mild/moderate mental health problems within primary care. So patients and doctors feel less stuck and alone when managing mental health

problems.

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Our Design

Cognitive Behavioural Therapy (CBT) Skills Group Medical Visits

• Combine CBT & Acceptance-based strategies

• Adult patients suffering with mild-moderate anxiety or depression

• Groups of 15 patients led by family physicians/psychiatrists

• 90 min groups for 8 consecutive wks

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Strategies for Change:

1. Developing content

2. Enhancing family physicians’ skills

3. Establishing referral centre

4. Delivering group medical visits o Part 1: psychiatrists and family physicians co-

facilitating patient groups

o Part 2: family physicians facilitating their own patient groups

5. Evaluation

6. Sustainability and spread

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Developing content

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Referral Centre hosted by the Victoria Division of Family Practice

• 480+ referrals

• 103 referring family physicians

0

20

40

60

80

100

120

Aug Sep Oct Nov Dec Jan Feb

# o

f refe

rrals

Month

Enhancing family physicians’ skills

Delivering the MH Service

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Seven groups completed (Oct - Dec 2015)

• 91 patients; 72 completed (6/8 sessions)

Eleven groups in progress (Jan – Mar 2016)

• 166 patients being served

• 3 groups solo-facilitated by family physician

Two “Booster” groups planned (Feb – Mar 2016)

• 30 patients

Seventeen CBT and four “booster” groups planned (April – June 2016)

• 315 patients

91

257

602

Mary participates in a CBT Skills Group

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Self-Management Skills Tool Box

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Effects of Change: Patients

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“Learning in the

group helped me

remember and

assimilate the skills.”

“I feel this course

would be valuable

for a lot of

people”.

“A doctor tells you to take a

pill to feel better but this

same person is telling you to

practice skills gives

credibility”

“The peer support was

truly invaluable. Knowing

others with shared

experiences helped.”

“I know I’m not alone”.

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Effect Size:

CBT N=63 Waitlist Control N=140

PHQ-9 0.9 “Large effect”

GAD-7 1.2 “Very large effect”

WASA 0.7 “Moderate effect”

Effect on Participating GPs:

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“One of the

greatest learning

experiences of

my life”

“This is going to

help me with so

much of my

clinical work

with patients”

“This is protective

against physician

burn-out”

“The group has changed the way I

relate to myself—personally and

professionally”.

GMVs are a cost-effective model for the system

GROUP MEDICAL VISITS (GMV)

Fee Code Average # of

patients/group

Practice Type Cost/per person Cost of 1.5

hours/per

person

Cost of 6

sessions/ per

person

Cost of 8

sessions/ per

person

G78773 13 Psych $ 16.71 $ 50.13 $ 300.78 $ 401.04

P13773 13 GP $ 8.74 $ 26.22 $ 157.32 $ 209.76

INDIVIDUAL VISITS

Fee Code Average age of

patients/group

Practice Type Cost of 1.5

hours/ per

person

Cost for 6

sessions/ per

person

Cost of 8

sessions/ per

person

00630/00632 n/a Psych $ 261.24 $ 1,567.44 $ 2,089.92

00120 43 GP $ 52.76 $ 316.56 $ 422.08

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$209.76 is equivalent to 4 GP 20 min visits

Plus huge savings with prevention of disability, downstream health

care spending & ripple effects in communities.

Learning & Challenges

• Steep facilitator learning curve

• Enhancing family physicians’ skills

• Administrative & MOA functions

• Appropriate space & times to run GMVs

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Sustainability and Spread

Crucial factors of sustainability

• Retention & expansion of physician champions

• GMV fee codes stable & adequate

• Victoria Division of Family Practice

• Island Health partnership

• On-going program adaptation

Opportunities for spread

• New physicians within the same community

• New physicians in other communities

• Modified CBT Skills Groups for other patient populations

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Questions?

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