1. Integrated Primary Care: From Theory to the Exam Room
Kirk Strosahl Ph.D.
Central Washington Family Medicine
Mountainview Consulting Group Inc.

2. No MH or CD services sought
Provision of Behavioral Health Care
in the US: Setting of Services
Primary Care
Specialty
MH or CD
No MH or CD services sought
(80% have HC visit)
Large ECA studies
Half do not get help from MH: go to bartender; priest
80% have one or more medical visits
Most of the management opportunities for BH issues are in the PC setting (but we don’t know their outcomes - health care and health costs outcomes are significant; clinical outcomes for untreated are not so bad compared with people who get tx)

3. Why Integrate Primary Care and Behavioral Health Care?
Cost and utilization factors
50% of all MH care delivered by PCP
70% of community health patients have MH or CD disorders
92% of all elderly patients receive MH care from PCP
Top 10% of healthcare utilizers consume 33% of outpatient services & 50% of inpatient services
50% of high utilizers have MH or CD disorders
Distressed patients use 2X the health care yearly
Aging population: mostly
top 10T of healthcare utilizers consume 33% - half of these have BH disorder
What drives high utilization? Psychological distress (doesn’t have to be a disorder)
BPC push is to have access for medical care; how can we do this if we address the BH disorders

4. Why Integrate Behavioral Health and Primary Care?
Process of care factors
Only 25% of medical decision making based on disease severity
70% of all PC visits have psychosocial drivers
90% of most common complaints have no organic basis
67% of psychoactive agents prescribed by PCP
80% of antidepressants prescribed by PCP
Work pace hinders management of mild MH or CD problems; better with severe conditions
1/4 who make an appointment in MH show up
some of these request change of provider
Other 75%: relat factors, how demanding pt is, gender of doctor/patient, neuroticism;
women in NY got more histerectomies--why? They ask for them.
10 most common complaints in PC (headache, numbness, tingling, cold/;cough, flu, dizziness, skin condition, - Kurt Kroenke followed these people for 3 years) What do you mean by not organic (virus)
Psychiatry - prescribes a minority of psychotropic meds
work pace - makes it difficult for PCP to diagnosis minor BH problems
PCPs are good at dx of severe BH problems
Problem: PCP sees MH problem, but doesn’t see Substance Abuse in our system
Are PCPs trained in mental status? Yes, Do they do it? No

5. Why Integrate Primary Care and Behavioral Health?
Health outcome factors
Medical and functional impairments of MH & CD conditions on a par with major medical illnesses
Psychosocial distress corresponds with morbidity and mortality risk
MH outcomes in primary care patients only slightly better than spontaneous recovery
50-60% non-adherence to psychoactive medications within first 4 weeks
Only 1 in 4 patients referred to specialty MH or CD make the first appointment
Health outcome factors: Med. Outcomes Study: Ken Wells: Natural course of 5 medical conditions (diabetes, RA, CAD, etc) - included depression as a control: 2nd leading cause of disability days and functional disability was depression - 2nd only to major coronary artery disease: Funcitoning and well-being of
Fossies: Psychosocial distress correlated positively with mortality and morbidity
If you are not managing psychosocial distress, you are hleping them die young or get sicker
?Hidis? 2 indicators: what in chart
?Pact model; Assertive Community models - check data on these
1 in 4 are referred - but many don’t show up
?Survey at ghc: people calling MH / their preference for site of care

6. Benefits of Integrating Primary Care and Behavioral Health
Improved process of care
Improved recognition of MH and CD disorders (Katon et. al., 1990)
Improved PCP skills in medication prescription practices (Katon et. al., 1995)
Increased PCP use of behavioral interventions (Mynors-Wallace, et. al. 1998)
Increased PCP confidence in managing behavioral health issues (Robinson et. al., 2000)

7. Six Dimensions of Integration
Mission
Clinical Service
Physical
Operational
Information
Financial

8. Population-Based Care: The Mission of Primary Care
Based in public health & epidemiology
Focus on raising health of population
Emphasis on early identification & prevention
Designed to serve high percentage of population
Provide triage and clinical services in stepped care fashion
Uses “panel” instead of “clinical case” model
Balanced emphasis on who is and is not accessing service
Not based in a clinical case model - we were trained in this - MH & specialty med: don’t see people if they are not sick
PCP: a gatekeeper and a shepherd for a flock - 50% of work could be preventive; sxs in pc tend to be less severe & easier to tx
MH - 3% - a few people get a lot
PCP - most get a little; can effect a large part of the population
Why aren’t rates of dep going down? No emphasis on prevention, only TX
Case specific: see people for an episode of care or a consultation
Training model: is fee for service - Managed care hasn’t financialized hc, it’s always been a business

9. Population-Based Care: Parameters for Integration
Employs evidence based medicine model
Interventions based in research
Goal is to employ the most simple, effective, diagnosis-specific treatment
Practice guidelines used to support consistent decision making and process of care
Critical pathways designed to support best practices
Goal is to maximize initial response, reduce acuity, prevent relapse

10. Two Perspectives On Population-Based Care
Horizontal Integration
Population
Specialty Consultation
Integrated Programs
General
Behavioral
Health Consultation
Condition Specific
Depression Critical Pathway
Chronic Depression
Major Depressive Episode
Dysthymia & Minor Depression
Adjustment & stress reactions with depressive symptoms
Target: get 20% of pc patients to have a bh consult or plan
Traditional MH model: can’t manage the demand for 10% of the population - have to have a dif model to see 20%
BHC - sees 20% of panel in a year
Specialty consultation - chronic dep: 6-10 yr involvement of BH 4 x / year
(PCP says too and all support same functioning plan)
Integrated Programs: Depression
?Does this slide need more lines?

11. Primary Behavioral Health: Primary Goals
Function as core primary care team member
Support PCP decision making.
Build on PCP interventions.
Teach PCP basic behavioral health intervention skills.
Implement patient education approach to health behavior change
Improve PCP-patient working relationship.
Monitor, with PCP, “at risk” patients.
2.5 million consumers; 19 medical centers - Implemented in Kaiser NC
In rural MH, hc team is PCP and Bh
PCP has good ideas about tx - just help PCP refine them to get better pt adherence to behavioral tx
Core beh health skills in PCP are effective self-management skills (Ed Wagner: father of depression collaborative: can’t teach MD, just show them what you do; do something that’s effective and have the client tell the MD about it)
If BHC is wrong a lot, they don’t get used. Can’t be sayig I have to see this client 12 times - need to have 60 minute interventions

12. Primary Behavioral Health: Primary Goals
Manage chronic patients with PCP in primary provider role
Simultaneous focus on health and behavioral health issues
Effective triage and placement of patients in need of specialty behavioral health
Make PBH services available to large percentage of eligible population (>20% annually)
Never take over a case; PCP is always the primary provider
You are not a specialist
Best outcome is resolution of mh problem in pc
If you have to refer to specialty mh, indicate number of sessions and request a prevention plan for patient at time of specialty
Primary care takes the people specialty rejects - borderlines
20% of pc patients get 1 bh visit per year

13. Primary Behavioral Health: Referral Structure
Patient referred by PCP only; self-referral reserved for extreme instances
Emphasis on “warm handoff” to capitalize on teachable moment
BH provider may be involved to “leverage” medical visits (i.e. depression follow-ups)
Standing orders to see certain types of patients (i.e., A1-C > 10)

14. Primary Behavioral Health: Session Structure
1-3 consult visits in typical case
15-30 minute visits to mimic primary care pace and promote visit volume
Chronic condition pathways may require additional protocol driven visits
Uses classes and group medical appointments to increase volume & depth of intervention
High risk, high need patients seen more often as part of team based mgmt plan

15. Primary Behavioral Health: Intervention Methods
1:1 visits designed to initiate and monitor behavior change plans
Uses patient education model (skill based, interactive educational material)
Consultant functions a technical resource to medical provider and patient
Emphasis on home-based practice to promote change
Conjoint visits permissible but typically rare

16. Primary Behavioral Health: Primary Information Products
Consultation report to PCP (usually brief, core assessment findings and recommendations)
Part of medical record (in progress notes)
“Curbside consultation”
Chronic condition protocols and forms (i.e., chronic pain)

17. Targets for Primary Care Practice Improvement
Accurate screening / assessment
Appropriate prescribing of medications
Clear clinical practice protocols
Consistent use of behavioral interventions
Consistent use of relapse prevention & maintenance treatments
Optimal use of education based interventions
Consistent, real time access to behavioral health consultation and specialty services

18. Global Program Requirements for PCP’s
Types of patients to refer (i.e. what do we mean by “behavioral health?”)
What to say to patients when referring (use scripts to minimize refusals)
How to integrate BHC feedback into a team based biopsychosocial care plan
How to co-manage patients with a BHC team member
Population management strategies for patients with mental/addictive disorders

19. Primary Behavioral Health Care Model: PCP Consultation Skills
Sell the patient on the service and the BHC
Use BHC to “leverage” time and services
Use “warm hand-off” referral as preferred strategy to maximize teachable moment
Form written/curbside request before visit
Give feedback to BHC quality and feasibility of recommendations
Consider brief regular meeting with BHC to review patients and management plans
Time PCP & BHC visits to maximize “spread”

20. Primary Behavioral Health Care Model: Knowledge Competencies
Familiarity with habit formation and self directed behavior change principles
Knowledge of motivational interviewing and value driven behavior change strategies
Familiarity with acceptance/mindfulness interventions
Understanding of evidence based psychosocial treatments (not just medicines)
Fluency with strengths based, solution focused and strategic change principles
Knowledge of behavioral medicine treatments for common medical issues (diabetes, chronic pain)
Fluency with health psychology and health behavior change principles (weight control, smoking cessation)

21. Primary Behavioral Health Care Model: Practice Competencies
Rapid identification and prioritization target problems
Limiting intervention targets
Selecting specific, concrete and positive behavior changes
Creating a “collaborative set” with the patient
Modeling problem solving and goal setting skills
Willingness to “shape” adaptive behavioral responses over time (not panicking or trying to be a hero)