Psychological Practice in Primary Care or Other Medical Settings

Robert J. Ferguson, Ph.D.Eastern Maine Medical Center

& University of Maine

Maine Psychological Association, Fall Conference, November 2, 2012

Theoretical underpinnings

Where is behavioral care delivered?

Primary Care19%

Other (Clergy)12%

None49%

Specialist Behavioral

Health17%

Specialist Health Care3%

Patient Centered Care

• Huh?

Patient Centered Care

Contributing Factor to Healthcare Cost Inflation: Inefficiencies due to Mental Health “Carve Out”

• 50% of high utilizers psychologically distressed (Katon, et al., 1990)

• 1 month prevalence of disorders in high utilizers– Mood (dysphoric) 40.3%– GAD 21.8%– Somatization 20.2%– Panic Disorder 11.8%– ETOH Abuse 5.0%

Contributing Factor to Healthcare Cost Inflation: Inefficiencies due to Mental Health “Carve Out”

• High healthcare utilizers account for:– 29% of Primary Care Visits– 52% of all Specialty Visits– 40% of in-hospital days– 26% of all prescriptions

(Katon, et al., 1990)

Example: Panic Disorder

• Attributed Physical Causes for Panic Sx’s after ED discharge:– Heart Attack

45%– CVA, Allergy, Hyperthyroid 40%– Overall Medical Cause 85%

Lerner et al., 1995 (N = 46)

Example: Panic Disorder Common Medical Settings Sought by Patients with Panic Disorder

Why Integration?....…not just “mental health” but “health behavior.”

• 60% HMO visits made by individuals with no diagnosable disorder (Cummings & Follette, 1968).

• 12-25% of Healthcare use accounted for by objective morbidity (Berknovic, Telsky, & Reeder, 1981).

• Review of 1,000 GIM patient records over 3 years found less than 16% of cases had detectable pathology for chief bodily complaint (Kroenke & Mangelsdorff, 1989).

• “Health rests on daily behavioral routines”(Rotheram-Borus, 2012; Wesner, 2002)

• 5 habits lead to 70% of morbidity and mortality:– How much we eat– What we eat– Exercise– Smoking– Alcohol use

(de Vol & Bedrosian, 2007)

Delivering care for chronic illnesses resulting from these habits account for 75% of medical care costs(CDC, 2009)

Health Behavior and Mental Health

• Why this dichotomy?• More than psychiatric or substance abuse

comorbidity…• Know the contributions of behavior to health

Psychiatric comorbidity is not the only behavioral factor contributing to utilization inefficiencies...

• Adherence to post-AMI medication regimens 45% (Carney, et al., 1995) (Behavior Change)

• Diabetes self-management regimens adhered to at about 15-20 %

• 1997 prevalence…798,000 new cases annually • $ 2.1 Billion allotment by CBO for 5 year Medicare self-

management plan (Behavior change arm)- CDC, October, 1997

Crude and Age-Adjusted Percentage of Civilian, Noninstitutionalized Population with Diagnosed Diabetes, United States, 1980–2010----CDCFrom 1980 through 2010, the crude prevalence of diagnosed diabetes increased by 176% (from 2.5% to 6.9%). During this period, increases in the crude and age-adjusted prevalence of diagnosed diabetes were similar, indicating that most of the increase in prevalence was not because of changes in the population age structure.

Why Integrate ?Example: Chronic Pain

• Pain is the most common chief complaint presented to Primary Care

• 70 million PC visits due to pain (Lawrence & McLemore, 1981)

• Behavioral-Biomedical treatment of chronic pain reduces patient distress, decreases medical costs (Caudill, et al., 1991)

Models of Integration…• Coordinated

• pcp-screen treat, community resources used outside

• Co-Located• Behaviorist and PC located in same facility

• Integrated• Behaviorist and PC located in same facility, team approach with

stepped care

(Blount, 2003; Millbank report 2010)

What is Primary Behavioral Healthcare?- Distinctions In Direct Services

• Specialty MH– 50 Minute hour– # Sessions free to vary or

based on research validated methods

– formal intake assessment tx planning

– high intensity tx– visits not related to PCP – long term f/u encouraged

for most

• Primary Behavioral Healthcare– 15-30 minute hour– 1-3 visits in typical case– Informal: revolves

around PCP goals– low intensity; between

session interval longer– visits coordinated with

PCP– long term f/u rare;

reserved for “high risk”

What is Primary Behavioral Healthcare? – Distinctions

• Specialty MH– Deliver primary treatment

to resolve condition– Coordinate with PC

Physician “At arms length”– Teach patient core self-

management skills– Manage more serious

disorders over time as primary provider

• Primary Behavioral Healthcare– Support PCP decision making– Build on PCP interventions– Teach physician “core” MH

skills– Educate patient in self-

management skills – Improve pt.-PCP relationship– Monitor with PCP “At Risk

Patients”– Assist in Team Building

Our patientnot “your patient…”

How to Integrate?

1. Identify your skill set– Inventory what rapid assessment and

treatment offerings you have

2. Identify the practice and the liaison/leader/practitioner who is

like-minded

Stepped CareSpecialty Referral

Family or Individual Consultations, brief visits

Shared Medical Appointments, Workshops, Classes

Curbside Consultation/Conjoint Visit, Coaching PCP

Clinical Behavior: For PC Colleagues

• Again… “our patient” say these words…• Coach the smooth handoff, coach the

language of stating the problem clearly (the “referral question”)

• Know the staff, ask how you can make their job better, how they can contribute, praise when all is smooth, not just for extra effort…

• Introduction and quick rationale:– Hi, I am____ I am part of your primary care team– Our job is to help change behavior in practical

ways to help people be as healthy as they can be– no matter what the condition

– Dr. ___ indicated you are dealing with (headaches, anxiety, sleep problems, depression, hypertension…”

• Motivational Interviewing

PDQ Motivational Interviewing

• Summary/Reflection• Stating the Extreme• Reconciling Disparate Sides of the Conflict

• http://www.nova.edu/gsc/forms mi_rationale_techniques.pdf

Daily work

Daily Work: The schedule

• Primary care providers may typically work 55 hours per week

• The intent is to move a lot of people a little way, not a few a long way (specialty care)

• As such, patients are scheduled on 15 or 30 minute blocks in some settings, 20 min in others

• Behaviorists fit the PC schedule

Always coach the smooth handoff

Some handoff script tips:• “a recommended step is to meet with Dr./Ms./Mr.___

who is an expert in this problem and can help you manage this.”

• “they can help you change that health habit –and stick to it-- with practical methods…”

• “he/she has expertise to help you meet the challenge…boost emotional strength…”

• “he/she is a coach for health behavior change…”• AVOID: “you need to talk to someone…”

– “This is psychological, you need psych…”– “talking with ____ will help you resolve this…”– “you need mental health… this is a mental thing…”

Daily Work: Conjoint visits

• A brief meeting with the patient and PCP, usually in an exam room

• Intended to “break the ice” (begin to establish rapport and therapeutic alliance)

• Can happen unexpectedly, on a moment’s notice and rapidly. Be prepared.

• If you see distress, anger, resentment, simply state, “I understand, you don’t have to make any decision, but know I am here and the door is open…” “talk more with Dr. __ if you wish… call with questions….”

Daily Work: Tracking activity

• Why? To identify the needs of practice• What to track:• Track provider behavior:

– Frequency of…• How many times each provider “refers” per month• How many times each provider curbsides

• Track problems: Of patients- billing/diagnostic records, categorize

Daily Work: Tracking activity

• Outcomes Monitoring– Will depend on the preferences of the practice– Do you want to track program outcomes?– Do you want to track general health of the panel served?– This can be time consuming and expensive

• Will you use commercially available or public domain measures?

• Usually a psychologist in charge: Is he or she being paid for the time it takes?

• Who will manage the data base? Enter the data? Analyze the data? Who will oversee data safety and monitoring plan?

Problems Seen In Collaborative Primary Care in GIM (‘97-99)

Anxiety Dis-orders

33%

Adjmt Dis/Anx13%

Mood Dis-orders

25%Insomnia

3%

IBS3%

Behavior Af-fecting Med Condition

4%

HTN2%

Pain 9%

Other8%

Daily Work: Tracking outcomes

• Public domain resources:– Patient Reported Outcomes Measurement

Information Systemwww.nihpromis.org/• Functional Assessment of Chronic Illness

Therapy (FACIT.org)www.facit.org/

Daily Work: Framing the behavioral health visit

1. Warm introduction 2. State purpose of the visit: evaluate the and

make a plan3. Indicate when the visit will end4. Give a 5 minute warning

Daily Work: The initial interview

• After the frame…• Rapid assessment

– Use the referral question and previous note of PCP to identify the problem

– Use reflection, summarization and Socratic questioning to validate the person’s experience

– Use the template of questions of specific problem (discussed later)

Daily Work: The initial interview

• After rapid assessment…• Set a specific, measurable goal

– (daily activity schedule, approach supervisor, ask friend for assistance, call specialty service)

– Establish a follow-up visit

More motivational interviewing methods

1) “Asking permission”– “do you mind if we talk about…?”– “so now that you are here, should we talk about ?”2) “Eliciting change talk”– “what would you like to see different about your

situation” or “what makes you think you need to change?

3) “Exploring importance/confidence”“- What would it take to move from – to --?”“- How would you life be different?”

Daily Work: Scheduling the follow-up

• Assure an appointment is made upon leaving• Set up the system to do this• It should be identical to any other PC appointment!• All staff must be aware of this system– good,

helpful, customer service with enthusiastic social skills

• “When is a convenient time to check in– a week would be good for behavioral momentum but what is preferred… ?” 10 days?”

Daily Work: Documentation and other unsettled challenges

• Privacy– Each institution is different in policies– Integrated care IS primary care ROI is for outside entities (e.g., if

seeing someone on one day in specialty MH, then release is needed at that facility)

– HIPAA (Health Insurance Portability and Accountability Act of 1996)

– http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html

– The act continuously changes and balances the tension between continuity of care and privacy of private health information(PHI)

Daily Work: Documentation and other unsettled challenges

• Documentation-- considerations that others have used– Assumption: notes on medical record– Keep them succinct– Avoid “states secrets”– Assure compliance with your compliance officer– Document:

• Time begin, end, date• Status of the patient– were they able to understand, participate?• What was the procedure• Diagnosis, assessment • Plan

THIS IS SUBJECT TO YOUR INSTITUTIONAL PRACTICE POLICY

What can be done in primary (integrated) care?

• Shared Medical Appointments (aka, “drop-in” “group..”)– Not group therapy– billed with a medical code– Alternative, addition to 1:1 medical appointment– Leverages physician and other provider time– Patients– more time with Dr.– Increases physician, patient, staff satisfaction– Not for everyone (40%??)– Requires set-up, buy-in with ALL staff

Headache

• Workshops: Penzien, et al. – See

http://www.apa.org/pubs/videos/4310731.aspx• See also Jonathan Borkum, Ph.D. “Chronic Headache: Biology, Psychology and Behavioral Treatment”

Medical Problems

• Chronic Non-malignant pain• Headache• Coping with and managing chronic illness• Adherence to medical regimens

– Anti coagulant clinics, e.g. Coumadin (warfarin)• Cancer Survivorship

– Medical checks, imaging, blood work, medical vulnerabilities (cardiac, metabolic, cognitive)

• Essential Hypertension

The Path Ahead