1. Patricia J Robinson, PhD patti1510@msn.com October 5, 2010 Louisiana Public Health Institute Primary Care Behavioral Health: Ascending toward the PCMH Mountainview Consulting Group 0

2. INTEGRATED BEHAVIORAL HEALTH What Are You Doing? How Does It Work? What Else Could You Do? 1

3. Integration Addition Mixing Combination Amalgamation Assimilation Merger 2

4. Objectives 1. Introduce the Primary Care Behavioral Health (PCBH) Model 2. Support you in describing your current approach to Integrated Behavioral Health 3. Describe the benefits of the PCBH model 4. Assist you in evaluating the level of integration and the effectiveness of your clinic’s approach to integration 5. Assist you with planning targets to improve the benefits derived from your clinic’s integration of behavioral health services 3

5. Goals of Primary Care? 1. Optimize the health of a population 2. “Equitize” (or minimize disparities across population sub-groups) The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in studies within and across nations. Starfield, Shi, & Macinko (2005). Contribution of primary care to health systems and health. Milbank Q., 83(3):457-502. 4

6. Who Provides Primary Care? MD, DO, NP, PA, Nurses, Medical Assistants, Pharmacists, Behavioral Health Consultants! (and BHC Assistants) Where are PC services delivered? Family Medicine Clinics Internal Medicine Clinics Pediatrics & Women’s Health Clinics 5

7. What is Primary Care? Core Attributes: –Contact (first) –Comprehensive –Continuous –Co-ordinated Starfield, B. (1992). Primary Care, Concept, Evaluation and Policy, NY: NY: Oxford University Press Inc. 6

8. First Contact Accessible Common, diverse and less well defined problems –stomach pain” – What is it? viral illness, alcohol-related, GERD, ulcer, anxiety or depression-related, GI bleed, increased intra- cranial pressure, stomach cancer, pneumonia pyloric stenosis “ 7

9. Comprehensive Prevention –Vaccination, wellness, well-child visits, routine screening labs Acute care – Laceration, IPV, suicidal or homicidal ideation Chronic care –Diabetes, depression, hypertension, obesity End of Life Care – Symptom management, advance directives, grief Pregnancy and Deliveries –prenatal care, peri and post-partum depression, family coaching 8

10. Continuous Contextual care over time (individual psychological strengths and weakness, family and social, community), for generations! Both new and old problems Coordinated Translate complexity of the healthcare system (health literacy, cultural factors) Facilitate the patient getting what they need Coordinating multiple specialists for multiple co- morbidities (patient-centered) 9

11. The Integration Movement “Co-located” On-site Specialty MH “Collaborative Care” Single Population Focus Impact model “PCBH” PC Behavioral Health Services Brief Interventions Pathways 10 Primary Text: Robinson, P. J. & Reiter, & J. T. (2007) Behavioral Consultation and Primary Care: A Guide to Integrating Services, Springer

12. 11 PCBH Model FIRST CONTACT Behavioral Health Consultant (BHC) Full-time provider of primary care behavioral health services Most visits on same-day patients seek care (increasing penetration from 3% to 15% annually) Supports PCP decision making Functional rather than diagnostic focus (It’s about quality of life!) Teaches practical skills to patients (and PCPs). Builds on PCP interventions

13. 12 PCBH Model COMPREHENSIVE Behavioral Health Consultant (BHC) Prevention –Available for coaching same-day visits related to adult wellness & well-child visits, teaches open-access classes on healthy weight, healthy lifestyle, parenting classes, sleep hygiene Acute care – Screens for IPV, suicidal or homicidal ideation, develops plans, child abuse, sexual assault, elder abuse Chronic care –Provides an array of services, including brief visits, classes, group medical visits, workshops, registry and T/C visits for patients with diabetes, depression, ADHD, chronic pain—in a multi-disciplinary way

14. 13 PCBH Model COMPREHENSIVE Behavioral Health Consultant (BHC) End of Life Care – Provides support in developing advance directives, problem-solving regarding other end-of-life concerns, assists with grief, provides multi-disciplinary group-care clinics for older adults Pregnancy and Deliveries –Assists with screening for common psychosocial problems during and after pregnancy, provides on-going support as needed for patients with high-risk pregnancy, participates in pregnancy group visits (“Centering” programs), available for services to mother’s at risk for having an OW / obese child

15. 14 PCBH Model COMPREHENSIVE Behavioral Health Consultant (BHC) Takes a patient education approach to health behavior change (developing brief half-page guides for high impact groups) Teaches PCPs basic behavioral health intervention skills (and learns from them!) Improves PCP-patient working relationship

16. 15 PCBH Model CONTINUOUS Behavioral Health Consultant (BHC) Provides care to couples and families Participates in community efforts to improve health Intermittent care throughout the lifespan (without opening and closing cases – no caseload!)

17. 16 PCBH Model COORDINATED Behavioral Health Consultant (BHC) Assists with translation of health care to fit with patient cultural beliefs (for example, perspective on health, cause of illness, solutions) Provides assistance to patients with health literacy limitations) to optimize health care experience Provides motivational interviewing, exploring benefits, problem solving barriers to specialty MH/SA services (increases engagement 2 fold) (Anajani, 2008)

18. 17 PCBH Model VISIT STRUCTURE Behavioral Health Consultant (BHC) 1:1 consult focused on specific problem/question identified by PCP and pt 15-30 minute length (mimics primary care pace and accommodates increased service request volume) High risk, high need patients seen more often as part of team based management plan 1-4 visits is typical after referral Uses classes and group medical appointments to increase patient volume, depth of interventions, and shift burden from PCP / RN

19. 18 PCBH Model INTERVENTIONS Behavioral Health Consultant (BHC) Provides 1:1 visits designed to initiate and monitor behavior change plans Uses evidence-based CBT interventions adapted for PC (for example behavioral activation, adherence coaching, problem solving, MI, relaxation training, behavior modification, acceptance and mindfulness interventions) Uses patient education model (skill building, targeted change) Emphasis on home-based practice Charting is brief, plan-focused, and to medical chart & FB to PCP is same-day

20. Worksheet #1 Reference: What are the differences between Specialty Mental Health and the PCBH Model? FactorSpecialty Mental HealthPCBH Model BH Provider RoleIndependent Provider, identity as specialist Consultant, identity as member of PC team BH Provider Functions Case Focus: Stabilization, Case Management, Medication Management, Personality Restoration (20+), Resolve Unconscious Conflicts Population-based care Focus: Brief episodic care throughout the life time Group services, episodic and on-going Relationship to PC Referral ResourceTeam member AccessPatient or PCP Referral, most commonly scheduled for in- depth intake and assignment to CM / psychiatrist PCP Referral, often on same day as medical visit, 15-30 minute visits focused on single concern, skill-training focus, most patients come for 1-4 F-Us 19

21. Worksheet #1 Reference: What are the differences between Specialty Mental Health and the PCBH Model? FactorYour Clinic Similarities to PCBH Model Your Clinic Differences from PCBH Model BH Provider Role BH Provider Functions Relationship to PC Access 20

22. Benefits of the PCBH Model Decreases stigma Improves access (Brauer, 2009) Improves rates of patient use of effective life skills (Robinson, 1999) Improves rates of patient adherence to medications (Katon, 1996) Improves clinical outcomes (Katon, 1995, 1996; Robinson, 1996; & many others) and functioning Better value (Von Korff, 1998), supports PCP & BH productivity 21

23. Benefits of the PCBH Model Better patient satisfaction (Robinson, 1996 & many others) Better provider satisfaction (Robinson, 1996), including BHCs Improved adoption of CBT practices by PCPs (Robinson, 1998) Supports PCP recruitment and retention; a buffer to burn-out 22

24. How Can You Evaluate Your BH Integration Efforts? 1. Model fidelity measures? (more on the what are you doing part of the presentation) –# same-day to scheduled visits –# new to follow-up visits –# of pathway visits (consistent with populations served?) 2. Patient access to BH services –Steady increase, time to next appointment 23

25. How Can You Evaluate Your PCBH Program Efforts? 3. PCP and BHC productivity –Visits / day scheduled, completed 4. Patient clinical outcomes –Duke Health Profile,\ –Pediatric Symptom Checklist 17 (Parent, Youth versions) 5. Patient, PCP, RN, and BHC satisfaction 24

26. How’s Your Program Performing? QuestionData AvailableData Suggest Model fidelity? Patient access? PCP Productivity? BHC Productivity? Patient Clinical Outcomes? PCP & RN Satisfaction? BHC Satisfaction? 25

27. What Methods Could You Use to Move Your Program toward a PCBH model? 1. Workflow changes –BHC template change to enhance PCP and patient access –Exam room posters to help patients self- identify –PCP use of a referral checklist –Change charting and feedback practices 26

28. What Methods Could You Use to Move Your Program toward a PCBH model? 2. Clinical services: –Greater use of evidence-based behavior change interventions for PC –Start of group and class visits, workshops –Use of a Quality of Life or psychosocial measure at all BH visits –Development of pathway services to enhance care to high impact patient groups 27

29. How Can You Evaluate Your PCBH Program Efforts? 3. Initiate a performance review plan –Develop a manual for your program mission, roles and responsibilities, clinical services, training, performance review, practice support tools 4. Use data about your program to support provider practice, address system issues, and improve the impact of your program... 28

30. The PCBH Checklist Does our program...Yes / No 1. Include a full-time BHP? 2. 5+ same-day visits with the BHP everyday? 3. Offer the PCP a checklist to use to refer to the BHP? 4. Require the BHP to see patients in 15-30 minute visits? 5. Advise the BHP to take a functional approach and measure QOL? 6. Support the BHP in completing 10 visits / day? 7. Guide the BHP to chart SOAP notes in the medical record? 8. Advise the BHP to give same-day FB to PCPs / RNs? 9. Include classes, groups, & workshops delivered by the BHP? 10. Have a pathway that describes what the BHP does with a high impact group (e.g., screens, provides monthly class)? 29

31. Choose to do something new and possibly better For your patients! Thanks for your time. 30