1. Eric Poolman, MD, MBA Rebekah Schiefer, MSW, CSWA Jenae Ulrich, MA Behavioral Health Integration in a Rural Setting: A Case Study

2. Behavioral Health Integration The need for behavioral health services in rural communities The approach to providing integrated behavioral health services at OHSU Family Medicine in Scappoose Common barriers to providing behavioral health services in rural communities

3. Behavioral Health Integration The need for behavioral health services in rural communities The approach to providing integrated behavioral health services at OHSU Family Medicine in Scappoose Common barriers to providing behavioral health services in rural communities

4. The Need in Rural Communities Rural residents have higher rates of Both mental health and medical problems Untreated mental health issues Barriers to care Suicide Rural residents are less likely to engage referrals outside clinic Greater stigma is placed on mental health issues by rural residents Large percentage of the population is elderly Alford (2011), Badger, Ackerson, Buttell & Rand (1997), Chipp et al. (2011), Correll, Cantrell, & Dalton (2011), Hartley, Britain, & Sulzbacher (2002), Meadows, Valleley, Haack, Thorson, & Evans (2011), and Oakley, Moore, Burford, Fahrenwald, & Woodward (2005)

5. Rural Health Care Providers Badger, Ackerson, Buttell & Rand (1997) Chipp et al. (2011), Correll, Cantrell, & Dalton (2011), Hartley, Britain, & Sulzbacher (2002), and Meadows, Valleley, Haack, Thorson, & Evans (2011) Rural areas have fewer mental health specialists resulting in reliance on PCP for mental health care PCPs have larger patient loads Higher burn-out rates

6. Behavioral Health Integration The need for behavioral health services in rural communities The approach to providing integrated behavioral health services at OHSU Family Medicine in Scappoose Common barriers to providing behavioral health services in rural communities

7. Barriers of Distance

8. Barriers of Time

9. Barriers of Money

10. Oregon Health Science University Family Medicine at Scappoose PCP Providers Physicians: 5 PA-C’s: 5 FNP: 1 BH Providers Psychiatrist: 1 day monthly Social Worker: 1FTE Clinical Psychology Students: 0.8 FTE Support staff: 47

11. Oregon Health Science University Family Medicine at Scappoose Learners Family Medicine residents rotate through for procedure clinic and maternity care Second and third year medical students First and second year Physician Assistant students First and second year Nurse Practitioner students

12. Clinic Population Approximately 8,500 patients 2,500 monthly patient visits 12% each month are new patients 25-30% are covered by Medicaid Approximately15% covered by Medicare Primarily serve patients who live in Columbia County Some patients commuting from more rural counties

13. Scappoose and Columbia County US Census Bureau Statistics 2011 Population of 49,402 93.6% white, non-Hispanic 4.4% speak language other than English at home Primary industry is wood products, paper manufacturing, construction and horticulture About 88% of residents over age 25 have high school diploma About 16% of residents over age 25 have a Bachelor’s or higher About 50% of county workforce commutes out of county for work Median household income $55,199 10.3% of persons living below the poverty line

14. Healthcare Indicators County Health Rankings and Roadmaps Approximately 20% of adults 18-64 are without health insurance Chronic Disease: Ranked 21 out of 33 counties in the state for overall health, morbidity, and mortality Columbia County has two primary care clinics, one urgent care and no hospital. One adult psychiatrist and one child psychiatrist for the entire county

15. Behavioral Health Team Psychiatrist Social Worker PsyD Candidates

16. Behavioral Health Team Psychiatrist Complex case consult Monthly management of psychiatrically complex patients Participates in monthly behavioral health rounds Social Worker PsyD Candidates

17. Behavioral Health Team Psychiatrist Social Worker Title: Behavioral Health Consultant (BHC) Warm Hand-offs Individual therapy Consultation Crisis management Behavioral contracts Care coordination PsyD Candidates

18. Behavioral Health Team Psychiatrist Social Worker PsyD Candidates Title: Master’s Level Behaviorist (MLB) Individual therapy Assessment for diagnosis and treatment planning Consultation Warm hand-offs

19. Value of Behavioral Health Integration Warm hand-offs during moments in crisis Less loss-to-follow-up Joint planning for (and debriefing about) management of complex patients Pairing counseling sessions with primary care visits Evaluation for more complex diagnostic questions without referral to Portland Management for those who would not make it to Portland Management for those who would not go to ‘Mental Health’ Enhanced learning for practitioners and staff

20. Enablers of Behavioral Health Integration Departmental support Use of PsyD students as inexpensive providers Coordination with County Mental Health regarding psychiatrist working in our clinic Rolling out billing for some services … and hope that with Accountable Care Organization, proactive use of Behavioral Health will reduce costs and improve clinic’s net reimbursement

21. Behavioral Health Integration The need for behavioral health services in rural communities The approach to providing integrated behavioral health services at OHSU Family Medicine in Scappoose Common barriers to providing behavioral health services in rural communities

22. Common Barriers to Care in Rural Communities Transportation Confidentiality Beliefs about providers Income and insurance Undertreated depression or mental health issue Overburdened providers Health Literacy Chipp et al. (2011), Correll, Cantrell, & Dalton (2011), Meadows, Valleley, Haack, Thorson, & Evans (2011), and Oakley, Moore, Burford, Fahrenwald, & Woodward (2005)

23. Dilemmas in Rural Health Settings Overlapping relationships Conflicting roles Altered therapeutic boundaries Multidisciplinary team issues Limited options for primary care Limited resources for consultation Greater stress experienced by rural health providers (Roberts, Battaglia, & Epstein, 1999)

24. Limited Options for Primary Care I started DHS investigation of mother biting her child. Child is temporarily removed from home; later returned. Mother switches to a different provider in our clinic. I see the mother again for an urgent visit.

25. Limited Options for Primary Care I see three generations of a family At different times, a member of each generation has a restraining order against, or court case against, another member Both grandmother and mother are in clinic at the same time and need to be ferried out separately

26. ‘Collateral Information’ Staff with prior relationships with patients and patient families: Staff are parents of the patient’s classmate Staff as prior romantic partners of patients Patients who were former staff Staff known by patients from less formal circumstances

27. Ethical Considerations across Disciplines Competence Boundaries of Competence vs. patient barriers Emergency Services Avoid Harm Multiple Relationships Community Interaction Church Grocery Restaurants Conflict of Interest 3 rd Party request for services Parent referral Employer referral Church referral Informed Consent Privacy and confidentiality Confidentiality in integrated system with EMR Confidentiality concerns in small town No regular office Minimizing intrusions on privacy Consultation vs. privacy – informed consent issue APA. (2012). Ethical principles of psychologists and code of conduct: Including 2010 amendments. Retrieved from http://www.apa.org/ethics/code/i ndex.aspx

28. Ethics in conflict across disciplines Tina is a patient of Dr. Miller. She has been a patient of his for about a year, but has been receiving her care from this family medicine clinic for six years. She occasionally has brought small gifts for her doctor on special occasions. These gifts have been accepted with thanks and no further discussion. For the past year, Tina has also been working with the clinic social worker on several of her behavioral health concerns. She struggles with dysregulated mood, several pain complaints, occasional suicidal ideation, insomnia and depression. She started seeing the clinic BHC after several bad experiences with community mental health, and she refuses to receive care there any longer.

29. Ethics in conflict across disciplines Tina has demonstrated progress over the past year, consistently attends her appointments and is committed to making changes to improve her health. To show her appreciation, Tina one day brings in a bag of treats for the BHC’s dog. Tina reacts poorly when asked to talk about the meaning behind the gift. Several months later, Tina comes to her appointment with a large box, full of several beautiful hand made bowls, made specifically for the BHC by Tina’s mother. She says she also has gifts for Dr. Miller and is excited to see his reaction. Two different sets of principles guide the BHC and Dr. Miller’s response to gift giving. One is open to receiving gifts, the other is not. Should they present a unified response?

30. Commonly asked questions with ethical considerations Can you see my son/daughter? Can I bring my partner in? What do you put in my note? What if we see each other outside of clinic? Do you talk to my doctor? Don’t tell them I smoke medical marijuana.

31. Discussion time and Questions

32. References Alford, N. B. (2011). Integrated care in rural settings. In G.M. Kapalka (Ed.), Pediatricians and pharmacologically trained psychologists (67-94). NC: Carriage House Psychological Associates. Badger, L., Ackerson, B., Buttel, F., & Rand, E. (1997). The case for integration of social work psychosocial services into rural primary care practice. The Journal of the National Association of Social Workers, 22 (1), 20-29. Chipp, C., Dewane, S., Brems, C., Johnson, M., Warner, T., & Roberts, L. (2011). “If only someone had told me…”: Lessons from rural providers. The Journal of Rural Health, 27, 122-130. doi: 10.1111/j.1748-0361.2010.00314.x Correll, J., Cantrell, P., & Dalton, W. (2011). Integration of behavioral health services in a primary care clinic serving rural Appalachia: reflections on a clinical experience. Families, Systems & Health: The Journal Of Collaborative Family Healthcare, 29(4), 291-302. doi:10.1037/a0026303 Hartley, D., Britain, C., & Sulzbacher, S. (2002). Behavioral health: setting the rural health research agenda. The Journal Of Rural Health: Official Journal Of The American Rural Health Association And The National Rural Health Care Association, 18 Suppl 242-255. Meadows, T., Valleley, R., Haack, M., Thorson, R., & Evans, J. (2011). Physician "costs" in providing behavioral health in primary care. Clinical Pediatrics, 50(5), 447-455. Oakley, C., Moore, D., Burford, D., Fahrenwald, R., & Woodward, K. (2005). The Montana model: integrated primary care and behavioral health in a family practice residency program. The Journal Of Rural Health: Official Journal Of The American Rural Health Association And The National Rural Health Care Association, 21 (4), 351-354. Roberts, L., Battaglia, J., Epstein, R. (1999). Frontier ethics: Mental health care needs and ethical dilemmas in rural communities. Psychiatric Services, 50(4), 497-503.