Team Training Key Components of Collaborative Collaborative Team Approach Patient PCP Manager New Roles Core Program Psychiatric Consultant Behavioral Health Clinicians Additional Clinic Resources Substance, Vocational Rehabilitation, CMHC, Community Resources Outside Resources 1
Collaborative In this module- -use of behavioral health measures -approaches to engaging patients with collaborative care -typical course of care management for depression -the principles of tracking symptoms over time proactively adjusting treatments -the principle of relapse prevention Collaborative s Identify s 2
Behavioral Health Measures as Vital Signs Behavioral health screeners are like monitoring blood pressure! Identify that there is a problem Need further assessment to underst the cause of the abnormality Help with ongoing monitoring to measure response to treatment PHQ 9: How to Score Adapted from Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16:606-13, 2001. 3 4 6 13 Understing the PHQ-9 Score Score Severity 0 4 No Depression 5 9 Mild Depression 10 14 Moderate Depression 15 Severe Depression 3
PHQ-9: How to Administer In-Person Facilitates assessment AND teaching about depression symptoms Can be administered orally for low literacy patients By phone Send a copy home that patient can use to follow along Self-administered In clinic or at home Advantages Objective assessment Creates common language Focuses on function Avoids potential stigma of diagnostic terms Helps identify patterns of improvement or worsening Diagnose, s 4
Initial Visit Overview Introduce treatment program Instill hope Assessment treatment plan formulation (can take up to 2 sessions) Education Start initial treatment plan Arrange follow-up contact In person or by phone In one week or earlier Document initial visit Discussing Diagnosis with Patient Don t argue about whether or not patient has specific diagnosis focus on symptoms symptom resolution Give hope! You don t have to feel this way This can be treated Educate patient about treatment in primary care Depression / anxiety medical conditions We have effective treatments Many Options for Depression Brief Behavioral Interventions for Primary Pleasant Event Scheduling / Behavioral Activation Problem-Solving Evidencebased Therapies Medication Primer for Primary Psychopharmacology for primary care Supporting medication therapy as a team Talking with patients about medication 5
Discussing Options Review all treatment options available Psychotherapeutic interventions Behavioral Activation, Problem-Solving, Cognitive-Behavioral, etc. Medications Discuss pros cons of each option Discussing Options The treatment that WORKS is the best one Person-centered care means selecting treatments based on client preference, not clinician preference Try to be unbiased when offering treatment options Be eclectic: One size fits few Medication therapy is not right for everyone Psychotherapy is not right for everyone; Different therapies Supporting whole person treatment is important This may include medication therapy You can support medication therapy within scope of practice Ask questions collect information Support patient being informed active about all aspects of treatment plan Follow-Up s 6
Measurements Over Time! http://www.jhartfound.org/sif/ 19 Follow-Up Contacts Weekly or every other week during acute treatment phase In person or by telephone to evaluate symptom severity (PHQ-9, GAD-7) treatment response Initial focus on Adherence to medications Side effects Follow-up on activation PST plans Later focus on Complete resolution of symptoms restoration of functioning Long-term treatment adherence Using the Telephone Under utilized tool Check up on adherence to medications Check in about side effects to medications Check in on behavioral activation Check in on symptoms after in remission Client-centered approach Convenient Pro-active 7
Typical Frequency of Management Contact Active : Initial 3-6 months until patient improved / stable Minimum 2 contacts per month Typical during first 3-6 months of treatment Mix of phone in-person works Monitoring: 1 contact per month After 50% decrease in PHQ / GAD (or similar) achieved Monitor for ~3 months to ensure patient stable Typical Duration of Management 6-10 Months (average) Best if determined by clinical outcomes, not preset 50%-70% of patients will need at least one change in treatment to improve Each change of Tx moves an additional ~20% of patients into response or remission If pre-determined, minimum 6 months with option to extend to 12 months if additional prescription change is wanted s s 8
Seek Consultation with Psychiatrist when Patient Is severely depressed (PHQ-9 score 20) Fails to respond to treatment Has side effects from medication Has complicating mental health diagnosis, such as personality disorder or substance abuse Is bipolar or psychotic Has current substance dependence Is suicidal or homicidal The above descriptions may require a referral to specialty mental health care. s Purpose of Relapse Prevention Helps patients identify: Their own symptoms of depression or anxiety Look at first few symptom measurements if cannot remember Intervene earlier if symptoms return What worked to get better Keep doing these things A plan if symptoms return 9
Maintenance & Relapse Prevention Patient in remission from acute episode Make a relapse prevention plan Follow the patient with monthly contacts Usually by telephone Individual OR in a maintenance group Bring patient back in for further evaluation if symptoms recur Collaborative Team Approach Patient PCP Manager New Roles Core Program Psychiatric Consultant Behavioral Health Clinicians Additional Clinic Resources Substance, Vocational Rehabilitation, CMHC, Community Resources Outside Resources 10