1. Who Should I Refer? VA Primary Care/Behavioral Health Integration in Practice David Hunsinger, MD, MSHA Medical Director Binghamton VA Outpatient Clinic

2. O BJECTIVE Over the course of this presentation, participants will begin to consider the broad range of clinical situations in which involvement of a Behavioral Health provider can prove helpful.

3. K EY C HARACTERISTICS Co-located Collaborative Dedicated Behavioral Health (BH) Provider with schedule flexibility Warm Handoffs

4. B ENEFITS OF THE M ODEL Timely patient evaluation and assistance

5. T HERE ’ S NO TIME LIKE THE PRESENT ….

6. B ENEFITS OF THE M ODEL Timely patient evaluation and assistance A continuation of the Primary Care encounter Eliminates the potential for ‘no show’

7. B ENEFITS OF THE M ODEL Face to face introduction

9. B ENEFITS OF THE M ODEL Face to face introduction Lends legitimacy and credibility Reduces patient anxiety about the meeting More personal

10. B ENEFITS OF THE M ODEL Face to face introduction Lends legitimacy and credibility Reduces patient anxiety about the meeting More personal

11. B ENEFITS OF THE M ODEL Reinforces ‘whole person’ focus

12. Mind body connection by John Hersey

13. T IP #1 Referrals are not just for Urgent Problems

14. U RGENT P ROBLEMS Major depression Anxiety Grief reaction Adjustment reaction ‘crying in the office’

15. T IP #2 Consider scripting your warm hand-off intro

16. W ARM H AND -O FF “I work with someone whose job is to help patient’s in situations like this. If you have a few minutes, I’d like to introduce you.” “We have someone who is a great resource for these things. Let me introduce you and you can get his/her card if you want to talk to someone about it.”

17. W ARM H AND -O FF “One of the members of your healthcare team is _________. If you have a few minutes, I’d like to introduce you so he/she can tell you a little bit about what kind of help he/she can provide you.”

18. T IP #3 Refer all positive Clinical Reminder screens …….better yet, revise clinic flow to have these patients seen automatically

19. C LINICAL REMINDERS PHQ2/PHQ9 [depression] PTSD screen AUDIT-C [alcohol] ?TBI screen

20. T IP #4 Think P ATIENT NEEDS not D IAGNOSES

21. N EEDS NOT D IAGNOSES Establishing a healthy lifestyle Behavior change Tobacco and alcohol issues/concerns Relationship stress Job stress

22. Establishing a healthy lifestyle Exercise Healthy Diet Sleep hygiene

25. Exercise Cardiovascular conditioning affects many health conditions Promotes a sense of well-being Relieves stress/tension/anxiety

26. Healthy Diet Weight loss Disease specific concerns Patients considering MOVE Patients unable to participate in MOVE

28. Tobacco Use Individual coaching as an alternative to QuitSmart

29. Relationship issues Spouse/significant other Children Boss Co-workers

31. T IP #5 Healthcare is a team sport [especially in a PACT environment]

33. T EAM Talk to your PCMHI provider Ask for suggestions about referrals Invite him/her to huddles and team meeting where patients are discussed

34. T IP #6 Most people’s lives are impacted far more by psychological, psychosocial, and behavioral issues than by physical issues

35. C ONCLUSION So………… refer early refer often!

36. C ONCLUSION So………… warm hand-off early warm hand-off often!