1 A Project of the Tides Center Initiative Overview and Evaluation Findings Gary Bess, PhD and Jim Myers, MSW Collaborative Family Healthcare Association October 23, 2009

2 About Us….  Launched in March 2006 as a project of to accelerate integration of behavioral health services into primary care settings (CCHs)  Sunsets in  Focus is on providers in California

3 Our goals …  Increase access to behavioral health services  Reduce stigma associated with seeking treatment  Improve treatment outcomes  Strengthen linkages between mental health and primary care by….

4 Our goals …  Identifying, studying and disseminating promising practices and models  Establishing a learning community  Sponsoring training opportunities  Designing a resource website (  Advocating for policy and system changes

5  Conducted developmental assessment of IBH practice levels in CCHCs  Selected seven primary care clinics and two clinic consortia to receive grants and serve as vanguard demonstration sites  Build IBH capacity  Study operations & mine data  Evaluate approaches  Identified policy and system barriers to integration Phase I

6 Data Collected

7 Patient Description (N = 5,000+)  Female %; Male – 29.1%  Nearly 90% either Hispanic/ Latino (40.8%) or White (48.6%); other ethnic/racial groups comprised no more than two percent of population.  Average age approximately 41 years; range from 18 to 94.  Average number of visits for either primary care or behavioral health (or both) during study period was 2.63.

8 First Clinic Visit and the “ Warm Hand-Off ”  One-third (33.3%) of patients tracked for the study* had the same date for their initial visit with the clinic AND entry into the clinic ’ s integrated behavioral health program (N=1162).  Greater than one-half of patients (52.5%) tracked for the study* were referred to the clinic ’ s integrated behavioral health program within six months of their initial visit to the clinic (N=1162). *Includes patients that were referred for behavioral health services in the 12 months prior to commencement of grant award AND those patients that were referred for behavioral health services after the commencement of the grant.`

9 Duke Health Profile  17 Item patient self report  6 Health measures—physical, mental, social, general, perceived, self-esteem  4 Dysfunction measures—anxiety, depression, pain, disability

10 Duke Findings During the Study Period…  Health scores increased (the desired clinical outcome) for each of the six health measures from baseline to most recent follow-up assessment. Statistically significant changes occurred in physical health, mental health, and general health.  Each health score at the time of the most recent assessment, however, was lower (p <.05) than the normative sample from which the Duke was developed.

11 Duke Findings During the Study Period…  Dysfunction scores decreased (the desired clinical outcome) in each of the four health measures from baseline to most recent follow-up. Statistically significant decreases occurred in anxiety and depression.  Each dysfunction score at the time of the most recent assessment, however, were significantly (statistically) was greater (p <.05) than the normative sample from which the Duke was developed.

12 PHQ-9  9 Item depression scale  The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV)

13 PHQ-9 During the study period…  The average depression score decreased (p <.05)(the desired clinical outcome) from baseline to most recent assessment follow-up.

14 Patient Satisfaction Survey High patient satisfaction in every dimension measured during study period.  Treatment and language of provided information  Comfortable at clinic  Treated the same as other patients  Staff consideration of person’s well-being  Patients are more likely to follow through with an outside referral for mental health services after engagement in the behavioral health program

15 Phase II

16  Launched in summer 2008  One-year grants ranged from $10,000 to $75,000 to 27 CCHCs and consortia  Funds support IBH continued development, and innovative projects that met grant objectives ♦ Special populations / provider education / new technologies  Continue advocacy for policy and system changes ♦ Reducing barriers that inhibit integration efforts ♦ Gaining support for the basic tenets of integrated care Phase II

17  Develop a Learning Community of providers through educational activities, trainings, and sharing of information on the IBHP website  Establish a “mentor”/ T.A. consultation component using Phase I grantees as “experts” to introduce best practices to new grantees Phase II Continued

18 Current Study

19 BASIS OF STUDY  A survey based upon Conceptualizing and Measuring Dimensions of Integration in Service Models Delivering Mental Health Care to Primary Care Patients by Miles, K., Linkins, K., et al.,[1][1]  Proposed a continuum of integration with respect to five dimensions [1][1]Miles, K., Linkins, K., Chen, H., Zubritsky, C., Kirchner, J., Coakley, E., Quijano, L., & Bartels, S.

20 Dimension of Integration 1.Physical Proximity – physical proximity of primary care providers and mental health counselors 2.Temporal Proximity (Timing) – the degree of delay or time separation between the delivery of primary care services and scheduling of mental health services

21 Dimensions of Integration 3.Communication – primary care and mental health clinicians share information about patient diagnosis and treatment 4.Mental Health Expertise and Services Available – the level of integrated with respect to mental health expertise, thus minimizing necessity of referrals

22 Dimensions of Integration 5.Institutional Stigma – where mental health care is provided in a setting not explicitly recognized as a mental health setting (e.g., primary care clinic), there may be less stigma associated with receiving services

23 Methodology  IBHP required grantees to complete the Dimensions of Integration Tool  Uploaded for Asynchronous Responses During Window of Three Weeks  Completed only by staffs involved in IBH services  86 BH staff and 195 PCPs

24 PCPs and BHS staff were asked to assess communication regarding the provision of behavioral healthcare using a scale of zero (0) to 20 0Very Low – PCP and BHS very rarely communicate beyond initial referral; includes little feedback about progress and almost no communication about missed appointments 5Low – PCP and BHS staff may communicate occasionally about diagnosis in rare selected cases; feedback is infrequent; communication about missed appointments is irregular and only in special circumstances 10Moderate – PCP and BHS staff sometimes communicate about diagnosis and occasionally about treatment, but not in most cases; may be some feedback about progress and missed appointments 15High – PCP and BHS staff often communicate about diagnosis and treatment choices; information is often shared about progress and outcomes; missed appointments are reported in most cases 20Very High – PCP and BHS staff almost always communicate about diagnosis; communication about treatment in most if not all cases; constant feedback about treatment and progress; missed appointments are almost always shared Communication

25 PCPs (M = 13.47) and BH staff (M = 13.64) assessed their communication as moderate Moderate: PCP and BHS staff sometimes communicate about diagnosis and occasionally about treatment, but not in most cases; may be some feedback about progress and missed appointments. Communication

26 PCPs and BHS staff were asked to assess the level of behavioral health expertise in their clinic utilizing a scale of zero (0) to 20: 0Very Low – No specialty BHS expertise within clinic; occasional pharmacological interventions may be provided; patients referred off-site for specialty BH care. 5Low – Very limited BHS expertise available in clinic; usually provide standard pharmacological interventions; patients with modestly complex problems almost always referred off-site 10Moderate – Some limited BHS expertise available in clinic; trained BHS counselor or psychiatrist consultation available by phone; some short-term counseling for routine BH issues provided by PCP; more complex usually referred off-site 15High – Trained BHS counselor or psychiatrist on site for face-to-face consultation; all pharmacological and many counseling services for BH issues are available in clinic setting; only complex problems or treatment resistance usually referred to specialty care 20Very High – Wide range of specialty BH expertise available in clinic setting; most basic services are provided by fully qualified BH clinicians; minimal need to use outside specialty expertise Behavioral Health Expertise Within Primary Care Setting

27 PCPs assessed behavioral health expertise as high – M = BH staff assessed behavioral health expertise as high to very high – M= Variance in mean scores was statistically significant (p <.005) Behavioral Health Expertise Within Primary Care Setting

28 PCPs and BHS staff were asked to assess temporal proximity regarding the provision of behavioral healthcare using a scale of zero (0) to 20: 0Very Low – Primary care referral and initial BH services are scheduled at distinctly different times, separated by on average by more than 21 days 5Low – Primary care referral and initial BH services are provided at different times, separated by an average of 15 to 21 days 10Moderate – Primary care referral and initial BH services are usually provided within an average of 8 to 10 days of each other 15High – Primary care referral and initial BH services are provided within 7 days, but not on the same day 20Very High – Primary care referral and initial BH services are provided during the same visit, on the same day Temporal Proximity of Primary and Behavioral Health Care

29 Temporal Proximity of Primary and Behavioral Health Care PCPs assessed Temporal Proximity as moderate – M = BH staff assessed Temporal Proximity as nearing high– M = Variance in mean scores was statistically significant (p <.001)

30 PCPs and BHS staff were asked to assess physical proximity regarding the provision of behavioral healthcare using a scale of zero (0) to 20: 0Very Low – Primary care and BH services are separated by more than four blocks 5Low – Primary care and BH services are located within four blocks but not within the same complex or campus 10Moderate – Primary care and BH services are in different buildings but within the same campus or complex 15High – Primary care and BH services are in the same building but in different practice areas 20Very High – Primary care services are co-located with BH services, in the same practice area Physical Proximity of Primary Care and Behavioral Health

31 Physical Proximity of Primary Care and Behavioral Health PCPs assessed physical proximity as moderate – M = BH staff assessed physical proximity as high – M= Variance in mean scores was statistically significant (p <.001)

32 PCPs and BH staff were asked to assess the level of institutional stigma in their clinic utilizing a scale of zero (0) to 20: 0Very High – BH services are referred to as a separate entity; staff makes no attempt to treat it as other than a program just for those in need of BH services 5High – May have a name that is indirectly related to BH service, but staff makes little attempt to avoid treating it as a separate program for those in need of BH services 10Moderate – Program has a distinct separate name not directly related to BH treatment; staff makes some efforts to avoid referring to it as a separate program 15Low – Minimal distinction is made between PC and BH settings; staff attempts to avoid treating it as a separate program 20Very Low – No distinction is made between PC and BH settings in name or setting; staff does not treat as a separate program Institutional Stigma

33 Institutional Stigma PCPs (M = 13.52) and BH staff (M = 13.77) assessed institutional stigma as moderate Moderate – Program has a distinct separate name not directly related to BH treatment; staff makes some efforts to avoid referring to it as a separate program

34 Overall Integration Score PCPs, M = and BH staff, M = A overall integration score of greater than equal to 75 suggests an integrated program Variance in mean scores was statistically significant (p <.005)

35 Thank you!!