Transcript Integrated Behavioral Health What Are You Doing? How Does

Primary Care Behavioral Health:
Ascending toward the PCMH
Patricia J Robinson,
PhD
[email protected]
October 5, 2010
Louisiana Public Health
Institute
0
Mountainview
Consulting
Group
Winner of the 2009 APA
Practice Innovation Award
INTEGRATED
BEHAVIORAL HEALTH
What Are You Doing?
How Does It Work?
What Else Could You Do?
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Integration
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Addition
Mixing
Combination
Amalgamation
Assimilation
Merger
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Objectives
1. Introduce the Primary Care Behavioral Health
(PCBH) Model
2. Support you in describing your current
approach to Integrated Behavioral Health
3. Describe the benefits of the PCBH model
4. Assist you in evaluating the level of integration
and the effectiveness of your clinic’s approach
to integration
5. Assist you with planning targets to improve the
benefits derived from your clinic’s integration of
behavioral health services
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Goals of Primary Care?
1. Optimize the health of a population
2. “Equitize” (or minimize disparities across
population sub-groups)
The evidence also shows that primary care (in contrast
to specialty care) is associated with a more
equitable distribution of health in populations, a
finding that holds in studies within and across
nations.
Starfield, Shi, & Macinko (2005). Contribution of primary care
to health systems and health. Milbank Q., 83(3):457-502.
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Who Provides Primary Care?
MD, DO, NP, PA, Nurses, Medical
Assistants, Pharmacists, Behavioral
Health Consultants! (and BHC Assistants)
Where are PC services delivered?
• Family Medicine Clinics
• Internal Medicine Clinics
• Pediatrics & Women’s Health Clinics
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What is Primary Care?
Core Attributes:
– Contact (first)
– Comprehensive
– Continuous
– Co-ordinated
Starfield, B. (1992). Primary Care, Concept, Evaluation
and Policy, NY: NY: Oxford University Press Inc.
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First Contact
• Accessible
• Common, diverse and less well defined
problems
– stomach pain” – What is it?
• viral illness, alcohol-related, GERD, ulcer, anxiety
or depression-related, GI bleed, increased intracranial pressure, stomach cancer, pneumonia
pyloric stenosis
“
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Comprehensive
• Prevention
– Vaccination, wellness, well-child visits, routine screening labs
• Acute care
– Laceration, IPV, suicidal or homicidal ideation
• Chronic care
– Diabetes, depression, hypertension, obesity
• End of Life Care
– Symptom management, advance directives, grief
• Pregnancy and Deliveries
– prenatal care, peri and post-partum depression, family coaching
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Continuous
• Contextual care over time (individual
psychological strengths and weakness, family
and social, community), for generations!
• Both new and old problems
Coordinated
• Translate complexity of the healthcare system
(health literacy, cultural factors)
• Facilitate the patient getting what they need
• Coordinating multiple specialists for multiple comorbidities (patient-centered)
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The Integration Movement
“Co-located”
On-site Specialty
MH
“Collaborative
Care”
Single Population
Focus
Impact model
“PCBH”
PC Behavioral
Health Services
Brief
Interventions
Pathways
Primary Text: Robinson, P. J. & Reiter, & J. T. (2007) Behavioral
Consultation and Primary Care: A Guide to Integrating Services,
Springer
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PCBH Model FIRST CONTACT
Behavioral Health Consultant (BHC)
• Full-time provider of primary care behavioral
health services
• Most visits on same-day patients seek care
(increasing penetration from 3% to 15%
annually)
• Supports PCP decision making
• Functional rather than diagnostic focus (It’s
about quality of life!)
• Teaches practical skills to patients (and PCPs).
• Builds on PCP interventions
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PCBH Model COMPREHENSIVE
Behavioral Health Consultant (BHC)
• Prevention
– Available for coaching same-day visits related to adult
wellness & well-child visits, teaches open-access classes
on healthy weight, healthy lifestyle, parenting classes, sleep
hygiene
• Acute care
– Screens for IPV, suicidal or homicidal ideation, develops
plans, child abuse, sexual assault, elder abuse
• Chronic care
– Provides an array of services, including brief visits, classes,
group medical visits, workshops, registry and T/C visits for
patients with diabetes, depression, ADHD, chronic pain—in
a multi-disciplinary way
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PCBH Model COMPREHENSIVE
Behavioral Health Consultant (BHC)
• End of Life Care
– Provides support in developing advance directives,
problem-solving regarding other end-of-life concerns,
assists with grief, provides multi-disciplinary group-care
clinics for older adults
• Pregnancy and Deliveries
– Assists with screening for common psychosocial problems
during and after pregnancy, provides on-going support as
needed for patients with high-risk pregnancy, participates in
pregnancy group visits (“Centering” programs), available for
services to mother’s at risk for having an OW / obese child
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PCBH Model COMPREHENSIVE
Behavioral Health Consultant (BHC)
• Takes a patient education approach to health
behavior change (developing brief half-page
guides for high impact groups)
• Teaches PCPs basic behavioral health
intervention skills (and learns from them!)
• Improves PCP-patient working relationship
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PCBH Model CONTINUOUS
Behavioral Health Consultant (BHC)
• Provides care to couples and families
• Participates in community efforts to improve
health
• Intermittent care throughout the lifespan (without
opening and closing cases – no caseload!)
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PCBH Model COORDINATED
Behavioral Health Consultant (BHC)
• Assists with translation of health care to fit with
patient cultural beliefs (for example, perspective
on health, cause of illness, solutions)
• Provides assistance to patients with health
literacy limitations) to optimize health care
experience
• Provides motivational interviewing, exploring
benefits, problem solving barriers to specialty
MH/SA services (increases engagement 2 fold)
(Anajani, 2008)
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PCBH Model VISIT STRUCTURE
Behavioral Health Consultant (BHC)
• 1:1 consult focused on specific problem/question
identified by PCP and pt
• 15-30 minute length (mimics primary care pace
and accommodates increased service request
volume)
• High risk, high need patients seen more often as
part of team based management plan
• 1-4 visits is typical after referral
• Uses classes and group medical appointments
to increase patient volume, depth of
interventions, and shift burden from PCP / RN
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PCBH Model INTERVENTIONS
Behavioral Health Consultant (BHC)
• Provides 1:1 visits designed to initiate and
monitor behavior change plans
• Uses evidence-based CBT interventions
adapted for PC (for example behavioral
activation, adherence coaching, problem solving,
MI, relaxation training, behavior modification,
acceptance and mindfulness interventions)
• Uses patient education model (skill building,
targeted change)
• Emphasis on home-based practice
• Charting is brief, plan-focused, and to medical
chart & FB to PCP is same-day
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Worksheet #1 Reference: What are the differences
between Specialty Mental Health and the PCBH Model?
Factor
Specialty Mental Health
PCBH Model
BH Provider Role
Independent Provider, identity
as specialist
Consultant, identity as
member of PC team
BH Provider
Functions
Case Focus: Stabilization,
Case Management, Medication
Management, Personality
Restoration (20+), Resolve
Unconscious Conflicts
Population-based care
Focus: Brief episodic care
throughout the life time
Group services, episodic
and on-going
Relationship to
PC
Referral Resource
Team member
Access
Patient or PCP Referral, most
commonly scheduled for indepth intake and assignment to
CM / psychiatrist
PCP Referral, often on
same day as medical visit,
15-30 minute visits
focused on single
concern, skill-training
focus, most patients come
for 1-4 F-Us
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Worksheet #1 Reference: What are the differences
between Specialty Mental Health and the PCBH Model?
Factor
Your Clinic Similarities
to PCBH Model
Your Clinic Differences
from PCBH Model
BH Provider
Role
BH Provider
Functions
Relationship to
PC
Access
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Benefits of the PCBH Model
• Decreases stigma
• Improves access (Brauer, 2009)
• Improves rates of patient use of effective life skills
(Robinson, 1999)
• Improves rates of patient adherence to medications
(Katon, 1996)
• Improves clinical outcomes (Katon, 1995, 1996;
Robinson, 1996; & many others) and functioning
• Better value (Von Korff, 1998), supports PCP & BH
productivity
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Benefits of the PCBH Model
• Better patient satisfaction (Robinson, 1996 & many
others)
• Better provider satisfaction (Robinson, 1996),
including BHCs
• Improved adoption of CBT practices by PCPs
(Robinson, 1998)
• Supports PCP recruitment and retention; a buffer to
burn-out
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How Can You Evaluate Your BH
Integration Efforts?
1. Model fidelity measures? (more on the
what are you doing part of the
presentation)
– # same-day to scheduled visits
– # new to follow-up visits
– # of pathway visits (consistent with
populations served?)
2. Patient access to BH services
– Steady increase, time to next appointment
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How Can You Evaluate Your
PCBH Program Efforts?
3. PCP and BHC productivity
– Visits / day scheduled, completed
4. Patient clinical outcomes
–
–
Duke Health Profile,\
Pediatric Symptom Checklist 17 (Parent, Youth
versions)
5. Patient, PCP, RN, and BHC
satisfaction
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How’s Your Program Performing?
Question
Data Available
Data Suggest
Model fidelity?
Patient access?
PCP Productivity?
BHC Productivity?
Patient Clinical
Outcomes?
PCP & RN
Satisfaction?
BHC Satisfaction?
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What Methods Could You Use to Move
Your Program toward a PCBH model?
1. Workflow changes
– BHC template change to enhance PCP and
patient access
– Exam room posters to help patients selfidentify
– PCP use of a referral checklist
– Change charting and feedback practices
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What Methods Could You Use to Move
Your Program toward a PCBH model?
2. Clinical services:
– Greater use of evidence-based behavior
change interventions for PC
– Start of group and class visits, workshops
– Use of a Quality of Life or psychosocial
measure at all BH visits
– Development of pathway services to
enhance care to high impact patient groups
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How Can You Evaluate Your
PCBH Program Efforts?
3. Initiate a performance review plan
– Develop a manual for your program
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mission, roles and responsibilities, clinical
services, training, performance review, practice
support tools
4. Use data about your program to
support provider practice, address
system issues, and improve the
impact of your program . . .
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The PCBH Checklist
Does our program . . .
Yes / No
1. Include a full-time BHP?
2. 5+ same-day visits with the BHP everyday?
3. Offer the PCP a checklist to use to refer to the BHP?
4. Require the BHP to see patients in 15-30 minute visits?
5. Advise the BHP to take a functional approach and measure
QOL?
6. Support the BHP in completing 10 visits / day?
7. Guide the BHP to chart SOAP notes in the medical record?
8. Advise the BHP to give same-day FB to PCPs / RNs?
9. Include classes, groups, & workshops delivered by the
BHP?
10. Have a pathway that describes what the BHP does with a
high impact group (e.g., screens, provides monthly class)?
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Choose to do something
new and possibly better
For your patients!
Thanks for your time.
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