1. FROM CO-LOCATED TO MORE- INTEGRATED Claudia W. Allen, PhD, JD Theodore Siedlecki, Jr., PhD Rebekah Compton, DNP, FNP-BC USING THE PCMH APPLICATION AND TEAM-BASED CARE TO BETTER INTEGRATE BEHAVIORAL HEALTH INTO A PCC University of Virginia Department of Family Medicine

2. OBJECTIVE How did we get here? What are we doing now? Where are we going?

3. WHAT ARE THE ISSUES? Where patients seek behavioral health care Size of need Physical separation Access concerns Difficulty collecting cost outcomes data

4. WHAT DID WE FIND ?  Review of our patients with more than 1 ED visit in the past year revealed that the majority of those patients went to the ED …  with behavioral health issues, NOT the diabetes, CHF, or COPD that we were thinking!  Patients are told to follow-up with their PCP

5. OUR CONCERNS  Clinic set-up  Acute needs  Bi-directional relationships: diabetes and depression

6. WE STARTED HERE A few consults a week Preceptor Beh Med Clinic

7. VIDEO ONE

8. HOW COULD WE DO BETTER?

9. OUR JOURNEY  Interest in becoming a PCMH  Regular meetings started with clinical leadership (but forgot about our Mental Health team!!)  NCQA PCMH 2008 guidelines  Next step – 2011 guidelines  More Mental Health discussed  We need to talk with our Behavioral specialist!  Time goes by….

10. JOURNEY CONTINUES… Behavioral specialist reaches out to the PCMH leadership team about desire to be involved (aren’t we lucky!) Behavioralists attend team meetings. Benefit is noted!! These folks can do more than just see our patients for counseling!

11. All-Staff Training on Motivational Interviewing Non-Pharmacological Pain Treatment Plan Behavioralists in Team Meetings Brief Behavior Change Intervention In place: warm handoff, safety screening, crisis support Brief Relaxation Intervention

12. PROVIDER UTILIZATION SURVEY SPRING 2013

13. THREE CHALLENGES ACCESSIBLE We tried to make what we could offer more… UNDERSTANDABLE TEACHABLE

14. ACCESSIBLE TO PROVIDERS, PATIENTS AND STAFF 1.Behavioralists in precept room. 2.Increased graduate student behavioralists from 2-3. 3.PCC team meetings. 4.EMR. 5.Expanded beyond traditional psychotherapy…

15. UNDERSTANDABLE ?

16. UNDERSTANDABLE Poster- size menu in precept room

17. UNDERSTANDABLE… NOT JUST TO PROVIDERS, BUT TO NURSING, SUPPORT STAFF, AND FRONT DESK STAFF ALL STAFF TRAINING The Spirit of Motivational Interviewing

18. POWTOON

19. TEACHABLE Semi-manualized, scripted, brief interventions in ready-to-go notebooks. Behavior Change Individualized Pain Treatment Plan Brief Relaxation Collab. Care ASQ/MCHAT

20. NOW WE ARE HERE ABOUT 10 CONSULTS A WEEK (COMPARED TO 3) Preceptor Beh Med Clinic

21. Video 2

22. WHY IS THIS IMPORTANT ? NCQA PCMH (2011) standards: Additional focus on preventative and chronic care needs Emphasis on whole person care/self-management Incorporates behaviors that may affect health Focus on care management Supports team-based care

23. 2011 AND 2014 NCQA PCMH GUIDELINES Emphasis on behavioral health care continues Element 2D: self-management, self-efficacy, and behavior change Element 3C: Screening needs (Developmental and depression) Element 4C: Assess medication adherence barriers

24. WHERE ARE WE GOING? 2014 NCQA guidelines encourage even more focus on mental health care and support Element 1A: alternative encounters Element 2B: behavioral health Element 3E: mh or substance use Element 4A: Care mgmt. Element 4B: goals Element 4E: self-care

25. IMPACT OF SETTING GOALS ON HEALTH OUTCOMES Kiesler and Bandura promoted use of action plans (goals) Setting an action plan and raising the confidence of completion associated with patients reaching their goals Let patients set the goal Behavioral counseling can help in achieving the goal

26. Enhanced patient care Improved communication Support for busy providers Team involvement on quality improvement Medication adherence Lifestyle changes Parental support

27. THERE ARE SO MANY BENEFITS TO INTEGRATIVE CARE!! Great patient care Support for providers Team members benefit More opportunities…

28. CHALLENGES  Time  Access  Billing  Engaging providers and staff

29. QUESTIONS AND COMMENTS?

30. REFERENCES Butler, M. Kane, R.L., McAlpin, D., Kathol, R.G., Fu, S.S., Hagedorn, H., et al (2008). Integration of mental health/sustance abuse and primary care (No. 173). Rockville, Maryland: Agency for Health Research and Quality. Cummings, M., Cummings, J., & Johnson, J. (1997). Behavioral health in primary care. Madison: Pyschosocial Press. Hooper, L. (2014). Mental health services in primary care: Implications for clinical mental health counselors and other mental health providers. Journal of Mental Health Counseling, 36(2), 95-98. Kessler, R., & Stafford, D. (2008). Primary care is the defacto mental health system. In R. Kessler & D. Stafford (Eds.). Collaborative medicine case studies: Evidence in practice. New York: Springer. Kessler, R., Stafford, D., & Messier, R. (2009). The problem of integrating behavioral health in the medical home and the questions it leads to. Journal of Clinical Psychology in Medical Settings, DOI: 10.1007/s10880-009-9146- y. Lorig, K., Laurent, D., Plant, K. Krishnan, E., & Ritter, P. (2014). The components of action planning and their associations with behavior and health outcomes. Chronic Illness, 10(1), 50-59. Madia, J. & Bolt, B. (2014). Behavioral treatment of obesity in patients encountered in primary care settings: A systematic review. Journal of the American Medical Association. Retrieved on 11/10/14 from http://www.dailyrx.com/behavioral-therapy-primary-care-settings-may-increase-weight-loss-obese-patients NCQA (2014). PCMH 2011- PCMH 2014 Crosswalk. National Committee for Quality Assurance. Retrieved on Oct. 16, 2014 from http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH201 4Crosswalk.aspxwww.ncqa.org/Programs/Recognition/Practices/ Vogel, M., Malcore, S., Illes, RA, & Kirkpatrick, H. (2014). Integrated primary care: Why you should care and how to get started. Journal of Mental Health Counseling, 36(2), 130-144.

31. PROVIDER UTILIZATION SURVEY Spring 2013 Spring 2014

32. PROVIDER UTILIZATION SURVEY Spring 2013 Spring 2014