1. Initial Examination of Characteristics of High Utilizers of an Established Behavioral Health Consultation Service Meghan Fondow, PhD, Behavioral Health Consultant Elizabeth Zeidler Schreiter, PsyD, Behavioral Health Consultant Chantelle Thomas, PhD, Behavioral Health Consultant Ashley Grosshans, LCSW, Behavioral Health Consultant Access Community Health Centers Madison, WI Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session C1b October 17, 2014

2. Faculty Disclosure We have had any relevant financial relationships during the past 12 months. Consulting work for primarycareshrink.com

3. Learning Objectives At the conclusion of this session, the participant will be able to: Summarize the basic characteristics of patients of an established BHC service Describe characteristics of high utilizing patients of the BHC service Describe the program accommodations (i.e. consulting psychiatry, care management, health promotions, etc) and the function for a high utilizing patient population. Discuss the rationale for the implementation of augmentation services within the PCBH model.

4. Bibliography / Reference 1.Bryan, Corso, Corso, Morrow, Kanzler & Ray-Sannerud (2012). Severity of mental health impairment and trajectories of improvement in and integrated primary care clinic. Journal of Consulting and Clinical Psychology, 80(3): 396-403. 2.Miller, Brown Levey, Payne-Murphy, & Kwan (2014). Outlining the scope of beahvioral health practice in integrated primary care: dispelling the myth of the one-trick mental health pony. Families, Systems & Health, 32(3): 338-343 3.Miranda, J., Hohnmann A.A., Attikisso, C.A. (1994). Epidemiology of Mental Health Disorders in Primary Care. San Francisco, CA: Jossey-Bass. 4.Pirl, W.F., Beck, B.J., Safren, S. A., Kim, H (2001). A descriptive study of psychiatric consultations in a community primary care center. Primary Care Companion Journal of Clinical Psychiatry, 3, 190-194.

5. Bibliography / Reference continued 5.Ray-Sannerud, Dolan, Morrow, Corso, Kanzler, & Bryan (2012). Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic. Families, Systems & Health, 30(1): 60-71 6.Serrano, N and Monden, K. (2011). The effect of behavioral health consultation on the care of depression by primary care clinicians. Wisconsin Medical Journal, 110:3, 113-118. 7.Simon GE, Ormel J, Von Korff M, et al: Health care costs associated with depressive and anxiety disorders in primary care. Am erican J ournal of Psychiatry 1995; 152:352–357. 8.Zeidler Schreiter, EA, Pandhi, N, Fondow, M, et al (2013). Consulting psychiatry wintin an integrated primary care model. Journal of Healthcare for the Poor and Underserved, 24(4): 1522-1530.

6. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

7. PURPOSE The purpose of this talk is to examine characteristics of high utilizing patients of an established BHC service over a 6 year time span (2007-2013). Demographics Consulting psychiatry Care management Health Promotions clinic (AODA care). Medical Comorbidity subset

8. INTEGRATED CARE Integrated care is associated with improved patient outcomes (Ray-Sannerud et al 2012; Bryan et al 2012) Behavioral Health providers located within primary care are able to address a variety of patient concerns(Miller et al 2014).

9. PRIMARY CARE BEHAVIORAL HEALTH The Primary Care Behavioral Health (PCBH) model is designed to provide population based care from a generalist perspective. Good model adherence implies that 85-90% of patients are seen 4 times or less in a given year (Robinson & Reiter, 2007). To date, there has been little work examining the remaining 10-15% of patients, and particularly the high utilizers of such services.

10. ACCESS COMMUNITY HEALTH CENTERS Basic Demographics FQHC Clinic mission Clinic growth 2007-2013: About 10,000 patients served in 2007 Over 26,000 patients served in 2013

11. ACCESS PATIENT DEMOGRAPHICS 2013

12. ADDITIONAL DEMOGRAPHICS FOR ACCESS PATIENTS 2013 Patients seen by BHC % non-English Speaking23% Gender58% Women, 42% men Age (mean, range)30 (0 to 94)

13. BHC TEAM DESCRIPTION Team consists of 5 psychologists, 3 clinical social workers, 8 trainees (masters level practicum through post-doctoral fellows) Primary Care Behavioral Health model (Robinson & Reiter 2007) Additional programs for: Consulting Psychiatry Care Management AODA Care – Health Promotions Clinic

14. ALL BHC PATIENTS 2007-2013

15. ADDITIONAL DEMOGRAPHICS FOR ALL BHC PATIENTS Patients seen by BHC % Spanish Speaking24% Gender60% Women, 40% men Age (mean, range)33 years (0 to 94)

16. BEHAVIORAL HEALTH CONSULTATION Sample included = 8772 unique patients seen by BHC team at least once 2007-2013 Over 36,000 visits for BHC 2007-2013 NMeanMinMax 20076782.46115 200810442.60119 200916252.61123 201026552.50129 201130832.55131 201228542.39125 201325412.42129

17. MODEL FIDELITY 1 Visit2-3 Visits3-4 Visits5 or More 200745%33%13%9% 200848%32%10% 200951%27%12%10% 201051%29%10% 201150%30%10% 201251%31%10%8% 201353%30%8%9%

18. HIGH UTILIZERS DEFINED Not explored in BHC context Definition = top 5% of patients seen by year 8 or more visits in a year N for high utilizers = 250 unique patients

19. DISTRIBUTIONS FOR RACE <8 Visits> 8 Visits (High Utilizers) American Indian or Alaskan Native 10%5% Asian2%1% Black or African American 25%31% Native Hawaiian or Other Pacific Islander 0.5%0% Patient Declined or Unknown 18%9% White45%54%

20. DISTRIBUTION FOR ETHNICITY AND LANGUAGE < 8 Visits> 8 Visits (High Utilizers) Hispanic/Latino31%13% Not Hispanic/Latino64%82% Patient Declines or Unknown 6%5% Language Spoken< 8 Visits> 8 Visits (High Utilizers) English53%54% Spanish25%8% Other or Unknown22%38%

21. GENDER AND AGE For non- high utilizers, 78% were adults, compared to 92% of high utilizers Breakdown for Gender was the same, about 60% of patients seen were women for both high utilizers and non-high utilizers

22. DIAGNOSTIC CATEGORIES Diagnoses were categorized into 11 categories to facilitate analyses: ADHD Anxiety Adjustment AODA Behavioral Health Bipolar Disorders Depression PTSD and/or trauma history Psychosis Personality Other Average Number of Categories: 1.9 Range: 1 to 8

23. DIAGNOSTIC CATEGORIES There was a significant association between diagnostic categories and high utilizer status

24. NEED FOR INCREASED PSYCHIATRIC SUPPORT IN PRIMARY CARE Research has shown that in the current treatment model (clinics that do not have integrated care and refer patients elsewhere for mental health treatment) less than one-third of referrals are actually completed (Miranda et. al., 1994). Primary care physicians (PCPs) prescribe approximately 60% to 70% of the psychotropic medications prescribed in the United States (Pirl et. al., 2001).

25. NEED FOR INTEGRATION Depressive and anxiety disorders in medical patients have been associated with increased utilization of medical services leading to increased cost, significant functional impairment, and sub- optimal adherence rates in patients with chronic medical issues (Simon et. al., 1995). Many of these patients can be successfully managed within a primary care environment with assistance from BHC and access to consulting psychiatry (Serrano & Monden, 2011)

26. ROLE OF CONSULTING PSYCHIATRY Explanation of consulting psychiatry service Population based care Modalities Chart review Face to face Verbal recommendations Education (formal and informal) Primary Care Physician ALWAYS retains prescribing authority (Zeidler Schreiter et. al, 2013)

27. RESIDENCY TRAINING Allows residents exposure to community psychiatry Broadens resident’s exposure to more severe and persistent mental illness in the context of complex medical issues and limited resources Able to see wide variety of patients Working in collaboration with primary care providers and BHC Prepares resident to work within a medical home Learn to recognize and diagnose psychiatric and/or behavioral conditions common in primary care settings

28. CONSULTING PSYCHIATRY TEAM MEETING

29. REFERRAL REASONS TO CONSULTING PSYCHIATRY  Main requests focused on diagnostic clarification, medication recommendations, management of psychiatric issues co-morbid with physical health issues, and guidance regarding needed lab monitoring.  Primary diagnoses seen include: Mood disorders, schizophrenia/psychotic disorders, PTSD/Anxiety disorders.  Many patients also had co-morbid substance abuse issues.

30. POPULATION SERVED Patient numbers as seen face-to-face by Consulting Psychiatry: 2014: 119 patients (Quarter 1 and 2) 2013: 208 patients 2012: 262 patients 2011: 241 patients 2010: 210 patients 2009: 170 patients 2008: 107 patients 2007: 34 patients Over 400 verbal or written consultations in 2013

31. CONSULTING PSYCHIATRY Consulting psychiatry was significantly associated with high utilizer status(Χ 2 (1,8772)=228.9, p<.000) High UtilizersNon-High Utilizers Consulting Psychiatry 26%4%

32. CARE MANAGEMENT A process of improving the management of patient care by identifying at-risk patient populations to provide support and any needed interventions between clinic visits with the goal of increased continuity and reduced lapses in patient care.

33. CARE MANAGEMENT AT ACCESS Adapted to fit the needs and patient population of Access Identified Populations: Depression, ADHD, and General Pediatrics Quarterly chart reviews to determine need for outreach between clinic visits When appropriate, phone call placed to patient to follow-up and provide intervention as warranted

34. CARE MANAGEMENT AT ACCESS 2013 METRICS Total Chart Reviews: Depression: 836 ADHD: 226 General Pediatrics: 696 Total Telephone Calls Made: Across All Lists: 713

35. CARE MANAGEMENT Care management was significantly associated with high utilizer status (Χ 2 (1,8772)=109.3, p<.000) High UtilizersNon-High Utilizers Care Management 49%21%

36. AODA CARE: DETERMINING NEED According to Substance Abuse and Mental Health Services Administration (2014): 8.9 million adults have co-occurring disorders Only 7.4 percent of individuals receive treatment for both conditions with 55.8 percent receiving no treatment at all Certain people with mental illness (males, low SES, increased medical illness) are at increased risk of abusing drugs and alcohol One-third of people with all mental illnesses and approximately one-half of people with severe mental illnesses experience substance abuse

37. HEALTH PROMOTIONS CLINIC Developed in 2012 Staffed by Randy Brown, MD, PhD Takes place in clinic on Tuesday morning Over the last 6 month period 159 patients seen over 19 clinics by MD (8 per clinic) No show rate of 28% 116 patient seen over 19 clinics by BHC (6 per clinic) Addiction Medicine Fellow started this year

38. HEALTH PROMOTIONS CLINIC STATISTICS Current 81 active patients 65% actively involved with BHC Written vs Verbal consults Ongoing vs One time consults Number of referrals in 2012: 38 referred, 27 seen Number of referrals in 2013: 34 referred, 29 seen Number of referrals in 2014: 10 referred, 8 seen

39. HEALTH PROMOTIONS CLINIC Health Promotions clinic was significantly associated with high utilizer status(Χ 2 (1,8772)=5.9, p<.015) High UtilizersNon-High Utilizers Health Promotions2%0.7%

40. DISCUSSION There are differences between high utilizers and non high utilizers that are suggestive of increased clinical severity and appropriate use of services The presence of extra services appears to be related to increased use of BHC services, and to reflect the ability of such programs to target those patients who most need the clinical care.

41. FUTURE DIRECTIONS Need to explore relationship between BHC high utilizer and medical high utilizer status Would be interesting to track reasons for high utilizer status beyond what we were able to look at here Access to mental health or AODA specialty services Willingness to participate in specialty care Other barriers to care

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