1. Real-world Models of Integrated Behavioral Health Care Within Texas Primary Care Settings

2. Presentation Overview To present 3 models of collaborative care occurring within the UTHSCSA Family Medicine Residency Program: 1)Advanced Primary Care (APC) team– Inez Cruz, PhD, LMSW, University of Texas Health Science Center San Antonio 2)“Nosotros” – Carolina Schlenker, MD, MPH, University of Texas Health Science Center San Antonio 3)Primary Care Behavioral Health (PCBH) Consultation Model – Stacy Ogbeide, PsyD, MS, University of Texas Health Science Center San Antonio

3. Objectives At the end of this workshop, participants will be able to: Understand the differences between the Primary Care Behavioral Health (PCBH) consultation model and specialty mental health care; Identify at least one (1) essential component of the role of a “promotor/CHW” in primary care; and Identify at least one (1) goal of the Advanced Primary Care team.

4. What is “Behavioral Health”? Behavioral Health is an umbrella term for care that addresses any behavioral problems impacting health, including mental health and substance abuse conditions, stress-linked physical symptoms, patient activation and health behaviors. The job of all kinds of care settings, and done by clinicians and health coaches of various disciplines or training. Source: Peek, C. J., National Integration Academy Council. (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. In Agency for Healthcare Research and Quality (Ed.), AHRQ Publication No.13-IP001-EF.

5. Behavioral Health Presence In PC 84% of the time, the 14 most common physical complaints have no identifiable organic etiology 1 80% of individuals with a behavioral health disorder will visit primary care at least 1 time in a calendar year 2 50% of all behavioral health disorders are treated in primary care 3 20-40% of primary care patients have behavioral health needs 4 48% of the appointments for all psychotropic agents are with a non-psychiatric primary care provider 5 Sources: 1 Kroenke & Mangelsdorf, Am J Med. 1989;86:262-266. 2 Narrow et al., Arch Gen Psychiatry. 1993;50:5-107. 3 Kessler et al., NEJM. 2006;353:2515-23. 4 Martin et al., Lancet. 2007; 370:859-877. 5 Pincus et al., JAMA. 1998;279:526-531.

6. Collaborative Care involves behavioral health working with primary care Integrated Care involves behavioral health working within and as a part of primary care. 1 Co-Located Hybrid Integrated Model Fully Integrated Model 6 1 Collins, Hewson, Munger, & Wade (2010). Evolving Models of Behavioral Health Integration in Primary Care. Milbank Memorial Fund Publication. Integrated & Collaborative Care Models

7. Integrated Models Doherty, McDaniel, & Baird, 1996

8. Program Overview The University of Texas Health Science Center at San Antonio Family Medicine Residency (FMR) founded in 1972 Focuses on comprehensive family- oriented care for an underserved population. ACGME Accredited 13-13-13 program (starting with 15 interns in July 2016) Serves Bexar county residents (University Health System)

9. Situating our Programs: The Clinic Patient Mix by Arrived Appointments CategoryVisits % of Total Blue Cross4221.2% CareLink13,55940.1% Grant1100.3% HMO/PPO1,0883.2% HMO/PPO Exchange2,2216.6% Medicaid7,69822.8% Medicare6,91420.5% Self-Pay6672.0% UHS1,1283.3% Total33,807100.0% ArrivedUniqueYTD Visits PatientsMRN'sper Patient 33,9959,6503.52 Total DM Patients Active DM Patients Active & InactiveSince 2014 7,6423,187

10. THE ADVANCED PRIMARY CARE TEAM INEZ CRUZ, PHD, LMSW

11. The Mortar to our Clinic Complex Residency Clinics= similar & unique problems Ground work towards a PCMH model – Increased accessibility – Coordinates care towards achieving continuity – Team based for collaborative care – Advocates for cost efficiency – Focusing on Patient’s Values and Preferences – Cultural Competence APC primarily focuses on patients with Diabetes Program provides Patient Centered Care

12. Position/ emphasis# of StaffTotal for Position RN Nurse Care Managers4 Diabetes 2 Hypertension1 Hepatitis C1 Licensed Vocational Nurse1 Transitions of Care1 Medical Assistants3 Diabetes3 Community Health Workers16 Community Based13 Clinic Based3 Psychology Interns2 TOTAL26 APC Staff

13. Patient Centered Services Offered Services for Patients with Uncontrolled Diabetes  Diabetes health education group visits  Diabetes support group visits  Group exercise and nutrition classes  In-home community health worker services  In-clinic community health worker consultations  Nurse care management services  Insulin education classes  Chronic care management services (desktop medicine directed by provider)  Mental health counseling  Pillboxes and education to increase adherence

14. Patient Centered Services Offered Transitions of Care (TOC) Services  Review preventable ED/hospitalizations/readmissions  TOC Individual/Group follow-up Community Based Services  Classes on the Nosotros Model (to improve health)  Classes on the Nuestra Mesa Model (to improve nutrition)  Direct access to Medical Assistants for o Scheduling/cancelling/rescheduling appointments o Referrals to SW, MAP, Pharmacotherapy, APC services o Same day appointments o Miscellaneous services as they appear

15. Patient Centered Services Offered Hepatitis C Vaccination targeted at baby boomers PharmD (services for patients with low health literacy) Medication protocols for Chronic Disease Management of Diabetes, Hypertension, and elevated LDL

16. APC Outcomes Improved continuity of care for all patients with diabetes  Goal: Lower the number of people with an A1c >9 o Patient navigators, Promotores – 900 patients served o Community based classes – 36 total provided o Reduce ER and hospitalizations– 20% reduction  Goal: Increase the number of people with an LDL <100 o Nurse Care Managers –67% of uncontrolled population served o Group Visits –400 uncontrolled patients served o QI: Desktop Medicine Project – initiate 1,200 new doctor visits o Plan Do Study Act (PDSA) cycles – provide 72 improvement cycles

19. PROMOTORES/COMMUNITY HEALTH WORKERS Work from the heart The life in me respects and cares for the life in you Our hearts connect our lives When you suffer I suffer When you smile I smile Your dignity is my dignity We travel this life together We are a Nosotros (us)

21. COMPREHENSIVE MANAGEABLE true good What I want Why I want it What I do What I get A HEALTH PERSPECTIVE SALUTOGENESIS (Antonovsky)

22. Striving for meaning… experience of illness health care coverage? HEALTH CARE INSTITUTION WHAT HAPPENS TO HEALTH? MONETIZATION science- based protocol disease measuring tool indicators health professionals PROMOTORES What does it mean to you? What is your story?

23. HEART DISCONNECTION $ SCARCITY $ Incomprehensible life events Unmanageable life events

24. Tunneling $ SCARCITY $ Uninformed Distrustful Stressed Sick… PURCHASING

25. SCARCITY What we want to happen What were able to do REDIRECTING ATTENTION, BUILDING TRUST

26. PROMOTORES PERIODS OF CARE

27. HEALTH CARE INSTITUTION MONETIZATION science- based protocol indicators Health professionals STORY UTOPIAN CARING COMMUNITY

28. THE PRIMARY CARE BEHAVIORAL HEALTH CONSULTATION (PCBH) MODEL STACY OGBEIDE, PSYD, MS

29. Before we get started...... What is the “PCBH” model?

30. Important Terms PCP = Primary Care Provider Retains ultimate responsibility for patient care BHC = Behavioral Health Consultant Member of the primary care team

31. The Primary Care Behavioral Health (PCBH) Model Behavioral Health Consultant (BHC) within the primary care setting Brief Interventions & Pathway Services – One-on-One – Screening – Classes or workshops – Group visits

32. Scope of Integrated Behavioral Health Practice Patients with mental health/ substance abuse conditions / risks Depression/Anxiety/PTSD/ADHD, other Substance Abuse/Dependence Patients with stress-linked or unexplained physical symptoms. Headache, insomnia, pain, fatigue, dizziness, numbness, “don’t feel well”, frequent visits for no apparent medical cause Patients with unmanaged behavioral risk factors in chronic illnesses Diabetes / High BP /Obesity / Heart Disease Asthma / Childhood Chronic Illness Other Persons with any complex social/ medical situation that interferes with standard care Functional impairment, diagnostic uncertainty Multiple interacting conditions Distress, distraction, difficulty engaging care Lack of social safety & support Disorganized care or patient-clinician relationships Language / Culture / Insurance barriers Clients with mental health/ substance abuse conditions receiving care in intensive mental health / substance abuse settings Basic primary care / chronic illness management Timely preventive care Health behaviors

33. Why be brief? Primary care = fast-paced Lots of patients “On-Demand” services Population health focus (think vertical versus horizontal) Problem-focused

34. What do you do? Example interventions: – Sx/mood management Patient Education Building Awareness/Options for bx change Problem Solving/Goal Setting Motivational Interviewing – Behavioral Activation – Relapse Prevention Skills – Behavioral Medicine (e.g., self-mgmt for diabetes, sleep hygiene, asthma mgmt, chronic pain mgmt)

35. How does this work? Clinical service delivery altered(e.g., cold consult, joint consult, warm-hand off). EHR - allowed for BHC to create a same-day encounter with a patient as well as create a note that can be viewed by the entire treatment team, as well as a note that can have additional signers Where does the BHC see patients? Where do they chart? “Bumpability” is key

36. Impact? Outcome data (effectiveness): – PHQ-9 (depression) scores – GAD-7 (anxiety) scores – quality of life scores (Quality of Life Enjoyment and Satisfaction Questionnaire – SF) – Body Mass Index (BMI) – Blood pressure. “RE-AIM” program evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) – Behavioral health consultation penetration rates (i.e., reach of the intervention) is also being tracked – Preliminary data will be available after the first year of implementation. 36

37. Implementation Challenges: The Implementation Dip Michael Fullan, The Six Secrets of Change

38. Leadership in comprehensive integrated care “Successful integration is really hard.” Complexity Leadership Theory – Administrative: build the vision, acquire resources, and “get out of the way” – Adaptive: engaging in interactive processes for adaptive changes – Enabling: territory between administrative and adaptive levels; accesses resources for adaptive problem solving (protects flexibility) (deGruy, 2015)

39. Summary How does all of this fit together? Team Based Care! Examples?

40. Questions? Comments?

41. Contact Information Inez Cruz, PhD, LMSW: cruzi@uthscsa.edu cruzi@uthscsa.edu Carolina Schlenker, MD, MPH: schlenker@uthscsa.edu schlenker@uthscsa.edu Stacy Ogbeide, PsyD, MS: stacy.ogbeide@gmail.com stacy.ogbeide@gmail.com 41

42. References deGruy, F. (2015). Integrated care: Tools, maps, and leadership. Journal of the American Board of Family Medicine, 28, S107-S110. doi: 10.3122/jabfm.2015.S1.150106 Mauer, B. J., & Druss, B. G. (2010). Mind and body reunited: Improving care at the behavioral and primary healthcare interface. Journal of Behavioral Health Services & Research, 37(4), 529-542. Miller, B. F., Brown-Levey, S. M., Payne-Murphy, J. C., & Kwan, B. M. (2014). Outlining the scope of behavioral health practice in integrated primary care: Dispelling the myth of the one-trick mental health pony. Families, Systems, & Health. Advance online publication. http://dx.doi.org/10.1037/fsh0000070 Robinson, P. J., & Strosahl, K. D. (2009). Behavioral health consultation and primary care: Lesson learned. Journal of Clinical Psychology in Medical Settings, 16, 58-71. doi: 10.1007/s10880-009-9145-z Vogel, M. E., Malcore, S. A., Illes, R. C., & Kirkpatrick, H. A. (2014). Integrated primary care: Why you should care and how to get started. Journal of Mental Health Counseling, 36(2), 130-144.