Primary Care Mental Health Integration

Transcription

1 Primary Care Mental Health Integration BERNADETTE HAYBURN, PSY.D. COATESVILLE VAMC PRIMARY CARE PSYCHOLOGIST HEALTH BEHAVIOR COORDINATOR Based on slides developed by Margaret Dundon, Ph.D., Christopher Hunter, Ph.D. and Katherine Dollar, Ph.D. from the Department of Veterans Affairs Center for Integrated Healthcare. Objectives Describe the rationale for integrating Behavioral Health into a Primary Care setting. Identify three differences between the Primary Care-Mental Health Integration Model and Traditional Mental Health Care. Identify the 5 A s: An Evidence-Based Assessment and Intervention Model within the PC-MHI context. List at least three clinical interventions utilized within PC- MHI. Healthcare Realities Up to 70% of PC medical appts have psychosocial component Psychiatric disorders full spectrum Behavioral issues (IBS, tension headaches, insomnia, nonspecific pains, vague somatic systems- most pts view as medical Unhealthy lifestyles (smoking, diet, etc..) Life stressors 80% of psychotropics are prescribed by non-psychiatric medical providers. (Hunter et al, 2009). Behavioral health problems compromise treatment of physical health problems (Nash et al., 2012). Distressed patients use twice the healthcare services (McDaniel & degruy, 2014) 1

2 Primary Care Realities For primary care physicians there is too much to do- too many patients, too many demands, too much information flowing through, too little time to do a good job. Average US (Non-VA) panel: 2300 patients. To do chronic and preventive care would take 18 hours/day to do it right NEJM, Perspective Roundtable Chronic diseases Multiple comorbidities (associated with poorer disease self-management & higher costs) (Fisher & Dickinson, 2014) Typical PC Clinic Day: VA Survey appointments, with 30 min. Clinical reminders: 4-10/pt., for 5-15 min Health problems: 3-8 active, 1-2 complex Admin Task: 100 view alerts per day (2 hours work), s, phone calls, orders, scripts, notes, etc. The result: 2

3 What to Do??? The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated. Plato Traditional practice (in both medicine and mental health) assumes the mind and body function independently. In reality, they are interconnected and healthcare need to be as well. Emotional factors affect physical health. Medical illnesses can lead to psychological distress. Psychological distress corresponds with morbidity and mortality risk. Effective treatment of many medical conditions includes a major behavioral component. (Gatchel & Oordt, 2008) Mind-Body Connection: Meet Lance Integrated Care A form of care in which behavioral heath and primary care providers interact in a systematic manner to meet the behavioral and health needs of their patients. -Dr. Christopher Hunter Unifies care for physical and mental concerns AHRQ 2008 Butler et al. 3

4 Population-Based Integrated Care Serves a higher % of the population: a little service for a lot of pts vs. traditional MH Emphasizes early identification/prevention De-emphasizes MH Dx Provides triage and tx in stepped care fashion Supports, rather than replaces specialty mental health care (Nash et al., 2012) Models of Integrated Care Coordinated Care PCPs and BHPs work in separate systems and facilities, delivering separate care and exchange information as needed. Co-location/Co-located Service BHP works in a space that is in close proximity to (or embedded in) a primary care clinic. PCPs may refer BHPs pts but BHPs and PCPs deliver separate care. Collaborative Care/Collaboration (Integrated) PCPs and BHPs work together in a shared system for the purpose of developing treatment plans, providing clinical services and coordinating care to meet the physical and behavioral health needs of patients. PC-MHI in the VA 2007: PC-MHI Initiative was launched 2008: Uniform MH Services Handbook requires that VAMCs provide a blended program: 1.) Integrated co-located collaborative care 2.) Care management 2010: VA PC was transformed into PACT Development of a stepped model of care Shift to tending proactively to needs of a cohort of PC pts rather than a referred caseload of pts presenting for psychological care (Kearney et al., 2014). 4

5 BHL Care Management Algorithm-based care, implemented by telephone, that includes routine monitoring/assessment of patients focusing on Psychoeducation: encourage self-management skills Brief treatment Medication Monitoring (antidepressants) In consultation with the supervising clinician, provide relevant information to the PCP to allow collaboration for appropriate care decisions (Post et al., 2010) Can t PC just Refer to Specialty MH Care? Long delays often result in attrition and lost windows of opportunity for effective treatment High No Show rates Perceived stigma (going to MH building or service) Patient volume has increased, not feasible to refer everyone out, especially pts with mild-sub-clinical symptoms (Pomerantz, et. al, 2008) BHP in PACT vs. Traditional MH Dimension BHP in PACT Mental Health Specialty Care Location On site A different floor, bldg Population Inter-provider Communication Service Delivery Structure Most are healthy, mild to moderate symptoms Collaborative & on-going Consultations via PCP s method of choice Brief appointments Limited number of appointments Most have MH diagnoses Consult reports Formal communications minute psychotherapy sessions Longer treatment episodes Approach Problem-focused Solution oriented Patient centered Varies by therapy Diagnosis-focused Treatment Plan Leader PCP continues to be lead MHP is lead Primary Focus Support the over-all health Focus on function Cure or ameliorate mental health symptoms 5

6 Does It Work???? PC-MHI Evidence Base Improved identification Improved access Improved engagement and adherence Higher quality care Better clinical and functional outcomes Increased patient satisfaction (Dollard, 2011; Pomerantz et al, 2008) CVAMC PC-MHI Staffing Bernadette Hayburn, Psy.D.: 3 days per week Justin Charles, Psy.D.: 1 day per week Kelly Gerhardstein, Psy.D.: 1 day per week Michael Gliatto, M.D.: ½ day per week Doctoral-Level Psychology Intern: 16 hours week Services Consultation Assessment Individual Treatment Group Classes: Pain, Depression, MOVE Psychiatric Medication Consultation and Management (Dr. Gliatto) Staff Education 6

7 Mind Over Mood Outcome Data Total # of sessions: 10 Format: Weekly 60-minute group sessions of Cognitive-Behavioral Therapy for Depression Outcome Data: A. Changes in scores on BDI-II ( ) Pre Group Post-Group 26.8 (high-moderately depression) 12.9 (minimal depression) B. Changes in scores on PHQ-9 ( ) Pre Group Post Group (moderately-severe) 7.5 (mild) Patients who completed the group demonstrated a significant reduction in depression as evidenced by a marked decline in their BDI-II & PHQ-9 scores over the course of treatment. Performance Measures PC-MHI Penetration (PACT 15) The percent of assigned PC pts seen by a PC-MHI Provider. Goal: 6 % CVAMC: 5.27 % Ranked 4 th of 10 in VISN 4. PC-MHI CASE 53 year old SC veteran Referred for depression and stress secondary to chronic knee pain and frustration with medical system Pain negatively affected his work, relationships, leisure activities, and sleep. Primary concern was his irritability and angry outbursts towards wife and children. 7

8 Treatment Interventions Psychoeducation about Stress Managing Stress Workbook Relaxation Training Mindfulness Exercises for noticing angry thoughts and feelings Assertiveness Training to improve communication with wife Treatment Summary 6 sessions/ 30 minute intervals Self-Report Measures: Pre Post PHQ-9 9 (high-mild dep) 5 (low-mild dep) GAD-7 17 (severe anxiety) 6 (mild anxiety) I feel much better. Pt reported increased awareness of triggers for his anger and felt better able to choose his response instead of reacting impulsively. What Tools Do Behavioral Health Providers Need to Work Effectively in PC? 8

9 Conceptual Shift We must move beyond the narrow conception of ourselves as mental health professionals and begin to see ourselves as comprehensive health professionals. Russ Newman May 2005 APA Monitor Behavioral Health Consultation: Domains of Competency Domain 1: Clinical Practice Domain 2: Practice Management Domain 3: Consultation Domain 4: Documentation Domain 5: Teamwork Domain 6: Administrative Skills 26 Robinson, P. & Reiter, J. (2007). Behavioral consultation and primary care: A guide to integrating services. New York: Springer Science-Media. Domain 1: Clinical Practice Define role accurately 27 Identify problems rapidly Limit problem definition Focus on functional outcomes o Less focus on diagnosis o Targeted interventions 9

10 Measurement-Based Care Use appropriate assessments (e.g., PHQ not MMPI) Saves time and guides clinical interview Facilitates systematic application of steppedcare (What is the next tx step based upon pt s symptoms?) Helps monitor outcome Helps patients become more knowledgeable about their disorder and progress, which is key to self-management Domain 2: Practice Management Effective brief visits Recommend minutes Focus on functioning Specific skills Should include charting and contact with PCP Limited number of sessions Same day access Warm hand-off Use an intermittent visit strategy 29 Domain 3: Consultation Focus on and respond to referral question Tailor recommendations Conduct effective curbside consultations Use same language as PCP Hallway Less than 5 minutes: 1-2 ideal Follow-up assertively 30 10

11 Domain 4: Documentation Skills Use same chart Use same format as PCP Brief, clear, concise Templates when possible Numbers when possible (e.g. PHQ 9 score) Include brief impression and plan Include suggestions for PCP 31 Domain 5: Teamwork Be a team player, ideally a leader Unscheduled services Learn PCP culture Be flexible Be available Build rapport with team 32 Domain 6: Administrative Skills Understand relevant polices and procedures Market services Referral tips for PCPs Review and refine linkages whenever possible Ensure proper coding (stop codes) Outcome Monitoring Support management in recruitment 33 11

12 What Exactly Do You Do???? The 5 A s: An Evidence-Based Assessment & Intervention Model Hamlett-Berry, 2010 Arrange Specify plans for follow-up (visits, phone calls, mail reminders) 5A s-assess, Advise, Agree, Assist, Arrange Diagram adapted from: Glasgow, R. E & Nutting, P. A. (2004). Diabetes. In Handbook of Primary Care Psychology. Ed., Hass, L. J. (pp ) Assess Risk Factors, Behaviors, Symptoms, Attitudes, Preferences Personal Action Plan 1. List goals in behavioral terms 2. List strategies to change health behaviors 3. Specify follow-up plan 4. Share plan with practice team Advise Specific, personalized, options for tx, how sx can be decreased, functioning, quality of life/health improved Assist Provide information, teach skills, problem solve barriers to reach goals Agree Collaboratively select goals based on patient interest and motivation to change Phases of a 30-Minute Appointment 1. Introduction of behavioral health consultation service (1-2 minutes 2. Identifying Clarifying consultation problem (10-60 seconds) Assess 3. Conducting functional analysis of the problem (12-15 minutes) 4. Summarizing your understanding of the problem (1-2 minutes) 5. Listing out possible change plan options (selling it) (1-2 minutes) Advise Agree 6. Starting a behavioral change plan (5-10 minutes) Assist Arrange 12

13 ASSESS Functional Assessment Biopsychosocial Model -Physical -Behavioral -Cognitive -Emotional -Environmental factors Initial Interview CIH\Initial Interview Note _handout2pcmh_initial_interview_outline508_ pdf ADVISE Give clear, specific & personalized change advice What changes will be involved and how they might be beneficial 13

14 AGREE Collaboratively select goals based on patient s interest in & willingness to change behavior Find common ground & define behavior change goals & methods Shared decision making = -Greater sense of personal control -Choices based on realistic expectations -Change matches patient values ASSIST Develop a specific tailored action plan Plan should: 1. Help identify, address and overcome barriers 2. Develop self-management skills 3. Develop confidence to successfully change ARRANGE Specific plans for subsequent contacts Individual, Group, Self-Management Other providers/adjunctive treatment Video clip 14

15 PC-MHI INTERVENTIONS Relaxation Training Deep Breathing Cue-controlled relaxation Progressive muscle relaxation Visual imagery Goal Setting Are the goals well defined in behavioral terms? (S.M.A.R.T) Realistic/achievable Within realm of control/influence Break into sub-goals Personally important Whose goals are they anyway? N:\My Documents\HPDP\0577 VANCP MyHealthChoicesV2 508 F screen.pdf 15

16 Self-Monitoring Help track progress towards a goal Use a calendar Keep a tally Chart on a graph Behavioral Activation Difficult to feel depressed when engaged in activities that provide pleasure and accomplishment Re-establish routines Increase reinforcing experiences Overcome avoidance patterns Distraction from problems or unpleasant events Pleasant Activities: N:\My Documents\Mood Group\365 Pleasant Activities List (2).doc Identifying and Disputing Negative Cognitions Help to identify unhealthy thoughts Use thought logs Question thought process Cognitive Disputation Self-help books for highly motivated Mind Over Mood Greenberger and Padesky 16

17 Motivational Interviewing Examine readiness to change (Readiness Ruler) Examine importance and confidence for change Elicit pros and cons of change Problem Solving Training Define the problem Brainstorm solutions Critically evaluate each solution Select and implement an option Assess the outcome Assertive Communication Assess patterns of communication Explain differences in passive, assertive, and aggressive communication Help patient to learn how to speak assertively Practice through role-play 17

18 References Dollar, K., M., Greenwood, S.,& Klaus, J. (2011). Introduction to PC-MHI Functions: CCC, CM, and how they work together [PowerPoint slides]. Retrieved from Center for Integrated Healthcare Sharepoint site Shared%20Documents%2fAugust%202011%20Co%2dlocated%20Collaborative%20Care%20Training %20Presentations%20%2d%20Charlotte%20NC%2fIntroduction%20to%20PC%2dMH%20Integratio n%20functions&folderctid=&view=%7b3e2788c6%2d149b%2d4287%2d85d3%2dbb111fbfff18 %7d. Dundon, M. & Hunter, C. (2009). Effective evidence-based assessments and interventions in 30-minutes or less: What every collaborative primary care mental health clinician should know [PowerPoint slides]. Retrieved from Center for Integrated Health Sharepoint site Fisher, L. & Dickinson, W. P. (2014). Psychology and primary care: New collaborations for providing effective care for adults with chronic health conditions. American Psychologist, 69(4), Gatchel, R. J. & Oordt, M. S. (2008). Clinical health psychology and primary care: Practical advice and clinical guidance for successful collaboration. Washington, DC: American Psychological Association. Glasgow, R. E., & Nutting, P.A. (2004). Diabetes. In L. Hass (Ed.), J. Handbook of Primary Care Psychology, (pp ). New York: Oxford. Hunter, C. L., Goodie, J. L, Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated behavioral health in primary care: Step by step guidance for assessment and intervention. Washington, DC: American Psychological Association. References (continued) Kearney, L. K., Post, E. P., Pomerantz, A., & Zeiss, A. M., (2014). Applying the interprofessional patient aligned care team in the Department of Veterans Affairs: Transforming primary care. American Psychologist, 69(4), McDaniel, S. H., & degruy, F. V., (2014). An introduction to primary care and psychology. American Psychologist, 69(4), Nash, J. M., McKay, K. M., Vogel, M. E., & Masters, K. S. (2012). Functional roles and foundational characteristics of psychologists in integrated primary care. Journal of Clinical Psychological Medical Settings, 19, Pomerantz, A., Cole, B. H., Watts, B. V., & Weeks, W. B. (2008). Improving efficiency and access to mental health care: combining integrated care and advanced access. General Hospital Psychiatry 30, Post, E. P. (2008). Veterans Health Administration primary-care-mental health integration initiative. North Carolina Medical Journal, 69(1), Valenstein, M., Adler, D. A., Berlant, J., Dixon, L. B., Duilt, R. A., Goldman, B. Sonis, W. A. Implementing standardized assessments in clinical care: Now s the time. Psychiatric Services: 60(10),