1. Memphis VAMC Robert Baldwin, Ph.D. Charissa Camp, Ph.D. November 1, 2012 Presentation for TPA Convention 2012

2. Dr. Oslin and Philadelphia VA “Best Practice” Evidence and Readings Handout

3. Memphis Main Hospital Campus Co-Located Collaborative Care and Care Management Staff Copper Behavioral Health (PC-MHI Psychologist Dr. Robert Baldwin) Blue Behavioral Health (PC-MHI Psychologist Dr. Charissa Camp) Louisville Call Center BHL Care Management Staff Program Director (Psychologist Dr. Beth Scheu) 2 RNs 1 Supervisory Health Technician 12 Health Technicians

4. Veteran Centered Primary Care Patient Aligned Care Team Veteran PCP RN Clinical Associate Clerical Associate Auxiliary PACT Members Psychologist BHL Nutritionist Social Worker

5. Psychologist = CCC CCC = Co-located collaborative care BHL = CM BHL = Behavioral Health Lab CM = Care Management PC-MHI = CCC + CM PC-MHI = Primary Care Mental Health Integration

6. Disease Management (Brief Counseling) Depression Monitoring (BHL) Watchful Waiting (BHL) Referral Management (to MH, SA, PCT, SMI, other) SMI Management No Tx—Refusal of services/Not in need of services

7. Patient Identification By screening or clinical assessment in PCC BHL Core Assessment Referral Management to MH, SA, PCT, &/or SMI services Review Results + Triage (by PC-MHI Psychologist) Disease Management and/or Medical Consultation No Treatment Indicated Refusal of Services BHL Watchful Waiting or Depression Monitoring ** Initial PC-MHI Psychologist Contact ** when possible

8. Warm-Handoff When pt is identified by PCP or self-identifies as having an urgent MH issue PCC staff contacts Psychologist (individual teams have different methods of communication) Pt is seen same-day, generally within 30 min or less due to protected schedule Initial contact note is completed and initial triage made CORE is scheduled to start parallel care management services (CORE if appropriate)

9. Structured Interview completed by HTs Screening assessment -Depression- Anxiety and Panic -Trauma - Mania -Psychosis- Substance Abuse -Cognitive Impairment Report summary generated for CPRS Reviewed and disposition made by the appropriate PC-MHI Psychologist, depending upon clinic— Copper or Blue

10. Initial Referral Primary Care Staff refer to PC-MHI Psychologist via route agreed upon by that clinic (consults, additional signers, whatever) Referral for BHL support PC-MHI Psychologist sends basic info to a sharepoint to enroll Veteran in BHL for Core Assessment Same day Assessment/Evaluation If emergency or positive clinical reminders Triage and Referral Determine the recommended and Veteran directed level of care – refer as indicated (back to BHL or to specialty MH services) Brief Therapy Typically 1-6, 30 min visits Goal directed/action oriented/MI or SMI management Referral Management Motivational interviewing is utilized to assist Veteran in referral process to specialty care such as MHC, PTSD, CDC, SMI programs

11. Health Technicians (HTs) in Louisville Conduct the BHL phone services (structured interviews at intervals determined by protocol and/or clinical recommendation) PC-MHI Psychologists (also the CCC provider in the Veteran’s Primary Care Clinic Reviews all collected data and drafts of CORE reports edits them in CPRS with a disposition Communicates with PC medical providers via CPRS or in person about dispositions and status of Veteran’s mental health issues

12. Brief Therapy (1-6 sessions) Cognitive Behavioral Solution Focused Motivational Interviewing Use of Action Plans Often concurrent with Depression Monitoring when the patent is placed on an Antidepressant by their PCP Lose the couch and (maybe) the do not disturb sign

13. PCP prescribed new Antidepressant per MH-PC service agreement Significant changes in their Antidepressant Phone calls at week 2, 6, 9, by Health Techs to administer follow-up screeners PHQ-9, Sub Abuse If PCP is not comfortable prescribing necessary medication, patient is placed in Referral Management to psychiatry

14. HT will alert psychologist that contact has been completed Psychologist will review report, make edits, make treatment adjustments, and place the report in CPRS If trend is static or depressive symptoms increase, psychologist contacts Veteran for phone contact/assessment or have their Prescribing Provider consultant look at case and make recommendations for PCP or PCP may refer to psychiatrist Final Depression Monitoring report, paste into CPRS with determination Often the psychologist will contact the Veteran to confirm determination is consistent with pt needs/desires Closing summary note is completed if appropriate

15. Mild cases of mental health symptoms Patients not willing/able to engage in treatment 8 weekly phone calls: Health Techs will call to complete follow-up screening PHQ-9, Sub Abuse If conditions worsen, can be referred for disease management or referral management

16. HT will alert psychologist of the completion of this contact (often with encrypted email as well) Psychologist logs into BHL software to review trend in PHQ-9 scores and substance abuse report If trend is static or depressive symptoms/SA increases, psychologist contacts Veteran for phone contact/assessment Final WW will elicit a BHL software report; access and edit similar to Core and paste into CPRS with determination Often the psychologist will contact the Veteran to confirm determination is consistent with pt needs/desires Closing summary note is completed if appropriate

17. Facilitate transition between Primary Care and Specialty Mental Health Services Offer interim appts/contacts as needed VA system consults to specialty services as indicated If high risk, psychologist will follow-up by phone or in person during interim and coordinate with Suicide Prevention Team as needed

18. May or may not have CORE Monthly supportive meetings for persons with serious mental illness that are not appropriate for other categories

19. (a) Referral from PACT to PC-MHI Psychologist (b) CORE/Initial meeting with psychologist (c) Review of CORE and determine disposition(s) (6 possible) (d) Follow procedure for disposition(s) selected (e) Close As with PCP, Veteran/patient may be seen again in future as primary care psychology need arises.