Managing Adult ADHD in Primary Care through Integrated Team-Based Care Armando Hernández, PhD Jacob Austin, PsyD Julie Vander Werff, PA-C Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # D October 16, 2015

Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

Learning Objectives At the conclusion of this session, the participant will be able to: Gain an understanding of the reason why developing a care pathway for Adult ADHD supports the Triple Aim Understand the steps involved in efficiently and proactively screening and evaluating the population that presents with concentration and attention difficulties Implement an Adult ADHD care pathway involving the collaboration between PCP, PCBH, and other Mental Health providers.

Armando Hernández, PhD Jacob Austin, PsyD Julie Vander Werff, PA-C Managing Adult ADHD in Primary Care through Integrated Team-Based Care CFHA 2015 Conference

Group Health Cooperative Dane County, Wisconsin Member owned cooperative & HMO Over 80,000 members Over 330,000 visits last year PCBH within Department of MH – Since 2012 – Four PC clinics Patient-Centered ● Quality-Driven ● Innovative ● Community Involved

PCBH – Key Reminders PCBH providers are part of your Care Team “Knock” us out of room for warm handoffs (preferred!) We work with chronic disease and positive health behaviors Follow-up visits may be provided by a different BHC Communication – Epic Message Board for our status and availability – Pool for coordination and Qs

“A primary objective of integrated primary care is to make seeing a behavioral service provider in the setting as seamless and routine as seeing a nurse or medical assistant.” (Strosahl, 1998 cited by Nash et al, 2012, p. 98)

Why Adult ADHD? Primary Care pressures Complex Dx – Performance – Mood & Anxiety – AODA High cost of stimulant medication Reduce utilization of Psychiatry

Paradigm Shift Slow down… Evaluation before Medication Team-effort/collaborative Not Guaranteed Limit setting “Coping” as pathway

Patient ADHD Packet Steps to evaluation process 1. Initial consultation 2. Complete ADHD Packet (attached) 3. Follow-up consultation* 4. Share Dx Impression 5. Discuss coping/treatment options * Additional evaluations may be recommended

Patient ADHD Packet Screeners PHQ-9 (Depression) & GAD-7 (Anxiety) Cross-Cutting Symptom Meas. (DSM-V) BAARS-IV: ADHD Self-Report: Current BAARS-IV: Other-Report: Childhood** ** Required if no evidence of childhood impairment provided (e.g., assessment, records, school reports)

Clinical Interview - ORS QUICK SCREEN O – Onset When did you first experience difficulties with concentration or attention? R - Rule-Out Are you currently struggling with any other problems, stressors, or life difficulties? S – Setting Which areas of your life do these difficulties impact or make worse?

Adult ADHD Quick Screen O – Onset 12+ years old R - Rule-Out “X” explains Sx S – Setting Single Setting

Clinical Interview 1.Hopes/goals for today/evaluation 2.Current difficulties & functional impairment 3.Self-care/wellness/coping activities 4.History (beginning, formal Dx, etc.) 5.Childhood Hx: academic, behavioral, & social; ACE 6.Work history 7.Other: MH, AODA, medical, meds

Diagnostic Impressions ADHD Continuum Need additional evaluation? Rx Flags (AODA, co-existing) Treatment recommendation –Medication –Coping skills –Group treatment

PCP Positive Feedback “ I think the program is great. Adult ADHD is difficult to diagnose the first time, so having PCBH really take the bulk of the investigative work on is really helpful, and way more thorough than I could be. Patients like being able to start the process right away.” Helpful ● Coordination of Care ● Diagnostic Assistance

Common Challenges ADHD vs. ACD (Attention & Concentration Difficulties) Time pressure: brief visits, immediate results Reliance on medication treatment Complex diagnostic picture AODA, addiction ….

Future Developments Promote use of ORS Quick Screen by PCP & RNs Continue to develop flow (Reception/Nursing provide packets) Expand to pediatric population Expand current group offering Consulting Psychiatry

Discussion What are your current CHALLENGES in meeting the needs of the Adult ADHD/ACD population? What MODIFICATIONS would you need to make in order to implement a similar Adult ADHD program. Share any creative or innovative SOLUTIONS you have implemented.

Case Discussion ADHD- he takes Vyvance since HS. He still feels it's helpful. He doesn't take it everyday if he doesn't have to go to work or school. Helps him stay focused and concentrate. And it brings down his hyperactivity. He does smoke marijuana. / Hx of anxiety, depression, and Rx Seroquel also noted.

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

“This experience - just knowing that PCBH is available with GHC is comforting. GHC is taking the time to treat and return patients back to a wholesome individual. Knowing the mind and body are one. This PCBH is going to benefit everyone who has the opportunity to be seen.” - - GHC Member