1. Lessons learned from implementing an Integrated Behavioral Health model in the provision of services for people living with HIV/AIDS in Puerto Rico Juan C. Ramos, PsyD Primary Care Psychology Fellow University of Massachusetts Medical School Nydia M. Cappas, PsyD Director of Clinical Health Psychology Program Ponce School of Medicine Clinical Psychology Program Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session #H5 October 29, 2011 2:00 PM

2. Faculty Disclosure We have no relevant financial relationships to disclose Need/Practice Gap & Supporting Resources This talk is based on the experiences and data collected through eleven years in the provision of integrated mental health services to people living with HIV/AIDS in Puerto Rico

3. Objectives Learn about background of the Health Psychology Program (HPP) at Ponce School of Medicine Share the experiences, administrative process and protocols involved in the successful implementation of an integrated behavioral health program in a variety of settings that serve people living with HIV/AIDS. Discuss the use of administrative and organizational strategies used for the implementation of an integrated behavioral health program taking into consideration the particularities of diverse clinical and community settings.

4. Expected Outcomes As stated in the objectives we hope at the end of this presentation participants will: Understand the background and functioning of the HPP at Ponce School of Medicine Recognize the administrative mechanisms used to implement the program in a variety of settings that serve people living with HIV/AIDS

5. Health Psychology Program (HPP) at Ponce School of Medicine Created in 2000 – Ryan White Part A funds – 4 clinics in Ponce, PR 2006-2008 – Interruption of services 2008 Re-integration – Ryan White Part A funds – Integrated behavioral health model – 6 clinics in Ponce, PR 2010 Expansion of program – Ryan White Part B funds – PR Departments of Health – 7 immunology clinics Start Ponce 2000 Interrupti on of services 2006 Re- integratio n using the Integrate d Care Model 2008 Expansio n to island wide services 2010

6. Where in the world is Puerto Rico? - Population: 3.7 million - Island size: 100 x 35 miles - Territory of the US

7. Living with a diagnosis of HIV infection: 18,828 Living with an AIDS diagnosis: 10,453 CDC, 2009 Transmission category: PREU Injection Drug Use48.7%25.6% Heterosexual contact26.3%18.3% Male to Male contact16.5%47.3% CDC, 2009

8. Puerto Rican Health Reform 1994 – Health care reform – government-run program – provides medical and healthcare services to indigent and impoverished citizens of PR – include specialty mental health services. Health Psychology Program (HPP) – Chronic disease Better access to behavioral health care Behavioral health interventions focused on adherence to medical treatment – Optimal antiretrovital adherence: 95%

9. Health Psychology Program Goals Improve access and delivery of behavioral health services to people living with HIV/AIDS in Puerto Rico – Integrated care model Patient care Administrative & organizational changes Reduce stigma associated to behavioral health needs and HIV/AIDS related stigma Improve the patient physical health – Adherence – Immunology status – Reduction in viral load

10. Health Psychology Progam Clinical services Didactic / researchPublic policy Ryan White Part A Ryan White Part B 6 clinics7 immunology clinics 2 Interns2 students6 Clinicians2 students

11. Services Provided by the Health Psychology Program RW ARW BTotal Initial interview1081,2591,376 Individual therapy5075971104 Case discussion7537521505 Adherence evaluation 137862999 Couple therapy173956 Family therapy66470 July 2010 to June 2011

12. Other services provided by the HPP Dual interviews Risk counseling Staff Consults Workshops Standard screening (standing order)

13. Screening tools Patient Health Questionnaire – 9 (PHQ-9) Spanish version – Depression screening tool Generalized Anxiety Disorder-7 (GAD-7) Spanish version – Anxiety screening tool CAGE-AID Spanish version – Screening for alcohol and drug problems Immunologic status Adherence registry Semi-structured guide to explore biopsychosocial factors associated with HIV/AIDS

14. Most common reasons for referral HIV/AIDS related Stigma Challenges adhering to treatment Depressive symptoms or mood changes associated to the HIV/AIDS diagnosis New diagnosis of HIV/AIDS Behaviors associated to opportunistic infections

15. LESSONS Administrative and Clinical

16. Lessons: Be prepared to analyze and listen Analyze The culture of the clinics The clinic relations with the patients The flow of patient services Beliefs about sharing information (including records) The existing level of integration – Between the clinic personnel Listen to Past experiences with mental health providers – Through referrals or collocation – Duration of contracts or services Difficulties most commonly confronted with patients

17. Lessons: Assessment of Clinic Needs and Expectations Assessment of Needs and Level of Integration (ANLI) - Instrument designed to evaluate the clinic needs and expectations of the clinics - before implementing behavioral health services The information was shared with the behavioral health provider assigned to the clinic before they start

18. Lessons: Share clinical, administrative and organizational information with behavioral health provider (BHP) Basic training in administrative functioning and organizational structure to BHP – Increase the awareness of the immunology clinics culture and dynamics – Behavioral health clinicians more flexible and knowledgeable Sharing and discussion of the immunology clinics needs and expectation (results of ANLI) – Facilitate adaptation – Increase in chance of suggesting changes relevant to the clinics Behavioral health meetings – Sharing of ideas and strategies used in the clinics to improve the patient care

19. Lesson: Integration of Behavioral Health Services Requires Flexibility Clinic diversity: – The patient demographics, administration, protocols and needs are diverse – The engagement with the clinic personnel, patients and administration is essential – Demonstrate how changes and suggestions are in their best interests Flexibility needed to adapt to changes, requirements and needs of: – Funding Agency – Clinics Protocols – Administrative personnel – Population served

20. Lessons: Training to Behavioral Health Provider Training is constant, supervision available – Individual and group case discussions – Supervisory Phone calls – Including progress notes Include tips for the adaptation to practical things like: – Office space- Or lack of it – What to do if there are no patients Must include an in depth understanding of the condition including – Physiology – Medication effects – Stigma – Adherence Historic development of the clinics

21. Lessons: Adaptation of Clinical Interventions Setting and patients needs Collaborative work with medical providers, nursing, social work and case management Screening tools adapted to the clinics setting and patients needs

22. Other Challenges Funding Integration of Students Training of new staff Standardization of Processes without rigidity Expand services to other chronic conditions

23. Q&A Questions?

24. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!