Transcript Behavioral Health Consultation

Behavioral Health Consultation
ONE CENTER’S JOURNEY INTO PRIMARY
CARE MENTAL HEALTH
KIRSTEN GING, PSY.D
JACARANDA PALMATEER, PSY.D
CHRIS WERA, CPA
SCOTT CYPERS, PH.D
I NTRODUCTION
 DU – ~ 11,500 Students (Spring 2011)
 ~5,250 Undergraduate
 ~4,600 Traditional Graduates
 ~1,650 Non-Traditional Students
 ~1000 International Students
 Health and Counseling Center (2010-11 Academic)
 ~12,659 Primary Care Medical Visits
 ~2,800 Nurse Visits
 ~6,000 Mental Health Visits
O RGANIZATION
Executive Director
(Medical Director)
1 FTE
Medical Services
10 FTE
Counseling Services
4 FTE Senior Staff
5 FTE Interns/Trainees
BHC
1 FTE
Health Promotion
1 FTE
2 FTE Interns/Students
Admin. Support
Team
7 FTE
W HY
 Suicide Prevention:
 In 2007, there were 34,598 documented suicides in the United
States, the 11th highest cause of death (CDC Annual Report)
 Over 4000 in the 15-24 age range die by suicide each year
 Suicide is the second leading cause of death in college students
 Only 20% of suicide victims had contact with a mental health
provider in the month prior to their suicide compared to 45%
had contact with a medical provider (Luoma et al, 2002)
 Only 15% of college aged people have seen a mental health
provider in the last month, and only 24% in the past year; 77%
of people who commit suicide have seen a medical provider in
the last year (Luoma et al, 2002)
W HY
 Access and early intervention issues:
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Access issues are said to be the most significant reason why someone
seeks a medical versus mental health appointment for psychological
issues (Pomerantz, et al, 2004)
The window of opportunity of effective treatment may be missed if
treatment is delayed
Only 1/3 of people with diagnosable mental health disorders EVER
meet with a mental health professional (Gunn & Blount, 2009)
Approximately 32% of undiagnosed adults with mental health issues
report that they would first seek assistance from a primary care
medical professional; only 4% stated that they would seek treatment
with a psychologist (National Mental Health Association, 2000)
Decreased wait time for specialty care: in one VA study, wait time for
a mental health appointment decreased from 3-6 weeks to 19
minutes (Pomerantz, et al, 2004)
W HY
 Integration:
 The HCC has shared office space for around 8 years and has
been functionally integrated for approximately 6 years
 Increased collaboration between mental health and medical
staff
 Improved crisis support for medical appointments
 Improved understanding of treatment options and approaches
 Multidisciplinary meetings and increased collaborative care
with complicated cases
WHAT IS A BEHAVIORAL HEALTH CONSULTANT
 Mental health provider
 Housed with the PC providers
 Performs short-term, solution-focused interventions
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Current, primary stress and trigger?
Patient’s reaction?
Patient’s resources (individual, familial, social)?
Coping strategies ?
Intervention
Referral (longer-term counseling or hospitalization)?
I MPLEMENTATION
1st
Stage
2nd
• Brainstorming
• Selection of screening tool(s)
• “How do we ____?”
Stage
3rd
• Training
• Roll out
• Graduate Students Trainees
Stage
4th
• Re-evaluation of process
• Added substance
use/abuse screening
Stage
• Trying to make it permanent
• Future areas of development
F IRST S TAGE
 Brainstorming
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Identify the vision/goals
Development
Roadblocks and hiccups
 Selection of screening tool(s)
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
PHQ-9
Supplemental suicide screen
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How/when would it be administered
Interrupt patient visit/cumbersome
Would students be offended/honest
 “How do we . . .?”
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Administer the screen(s)
Address self-harm/suicidal ideation
Offer versus require consultations for high risk patients
Handle coverage issues
Patient Health Questionnaire – 9
(PHQ-9)
•
10-question survey
• Computer administration/scoring
• Scoring guidelines for severity of depression and
functional impairment
• Identifies self-harm/suicidal ideation risk
•
(KROENKE AND SPITZER, 2001)
S ECOND S TAGE : T RAINING
 Met as a full staff (medical, counseling, administration)
 Discussed how to use the PHQ-9 and scoring
 Established “cut-off” scores (ranges) for referral
 Discussed process for patients with self-harm/suicidal ideation risk
 Suggested ways to refer and the “warm handoff”
 Walked through the process from beginning to end
A Sample “Script” For How To Refer
“I noticed your answers on the survey, and it seems like you are having a
hard time. I have a colleague that can come, spend some time with you
and help you figure some things out. Would you be willing to meet with
her right now?”
S ECOND S TAGE : R OLL O UT
 Started with only two providers
 Trouble-shooting
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What happens if scores get “missed”
Moved my notes to mental health in EHR
Decided not to use supplemental survey for SI
Random answering
International students/translation difficulties
 Gradually added in the rest of the providers
 Interviewed and selected two Graduate Student
Trainees (GSTs)
T HIRD S TAGE
 Re-evaluation
 Statistical analysis
 Weren’t seeing the high scores we anticipated
 Use a different screening instrument?
 Added substance use/abuse screening
 Added four questions that were incorporated into the survey
 Problems encountered:
Scoring
 Pushback

F OURTH S TAGE
 Trying to make it permanent
 Ideas for future development
 How can we make it more robust
 Biofeedback
 Translate into different languages
 Continue screening for substance use/abuse
I NTERVENTIONS
 Motivational interviewing
 Behavioral activation
 Cognitive-Behavioral Therapy
 “Third-wave”
 How can we “suffer better?”
 Coping strategies
 Psycho-education
C ULTURAL C ONSIDERATIONS
 International students: ~1000
 Translation of PHQ-9
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Common for international students to misinterpret questions
Guess at what the question asked
High scores
 However, the BHC reached international students
who might not otherwise come in
C ASE P RESENTATION
•
“Jane” is a 27-year-old female graduate student
• Presented for a women’s annual exam
• PHQ-9 score: 13
1.
2.
3.
4.
5.
“More than half the days”
Little interest/pleasure
Feeling down, depressed, or hopeless
Having little energy
Feeling bad about yourself
Troubles concentrating
“Several days”
1. Troubles falling asleep
2. Poor appetite
3. Feeling fidgety and restless
C ASE P RESENTATION
Referral information:
 Had been “stressed out” since beginning graduate school
 Experienced low libido
Additional information:
 Spent almost all of her time focusing on school
 Felt like she was neglecting her relationships
 About to graduate and worried about post-graduation plans
 Described herself as “high strung, perfectionistic, and always
anxious”
Case Presentation
First Meeting:
 Collaboratively established what to target
 Self-care and behavioral activation (BA)
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Boyfriend:
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Rewarding experiences:
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talk without distractions
go for a walk holding hands
sensate focus
Museums
cooking/baking
bike riding
Diet and exercise:
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
eat healthier
yoga
 Made specific goals (how often, how long)
C ASE P RESENTATION
First Meeting:
 Collaboratively
established what to
target
 BA and self-care
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Second Meeting:
 Reviewed what helped
 Discussed tendency to ruminate
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Cognitive distortions
Rules vs consequences
Mindfulness/grounding/breathing
Boyfriend
Rewarding experiences
Diet and exercise
 Made specific goals
(how often, how
long)
Third Meeting:
 Reviewed what helped
 Discussed new stressors
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Fears of post-graduation plans
On-going family issues
 Explored benefits of therapy for
deeper issues
Handouts:
* Anxiety
* Panic Attacks
* Depression
* Sleep hygiene
* Nutrition
* Fatigue
* Cognitive distortions
* Counseling FAQs
* Diaphragmatic breathing
* Reduced risk drinking
M EDICAL P ROVIDER : H ER
 Advantages:
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Same day, same time
Avoids future scheduling
issues
Helps to identify somatizing
Reduces, “Oh, by the way
…”
Reduces chances of missing
mental health issues
Handles patients in acute
crisis
PERSPECTIVE
 Drawbacks:
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Irritation with repeated
surveying
Scores can be more
indicative of medical illness
vs mental health
Difficult for international
students which leads to
inaccurate information
Haven’t used survey as a
measure of treatment, just
screening
O VERALL S CORE A NALYSIS
Winter Quarter:
Fall Quarter:
N=1752
1
2
3
4
5
6
7
8
9
10
Total Score
Mean
0.36
0.32
0.73
0.84
0.43
0.23
0.35
0.12
0.03
0.39
3.79
SD
0.673
0.604
0.897
0.851
0.734
0.594
0.707
0.439
0.198
0.644
4.668
N=1916
Normal
N
N
Y
Y
M
N
N
N
N
N
N
1
2
3
4
5
6
7
8
9
10
Total Score
Mean
0.33
0.28
0.69
0.76
0.39
0.19
0.32
0.1
0.03
0.33
3.41
SD
0.651
0.59
0.859
0.799
0.668
0.518
0.672
0.367
0.214
0.564
4.273
Normal
N
N
Y
Y
N
N
N
N
N
N
N
O VERALL S CORE A NALYSIS
Quarter by Quarter 10-11
Spring Quarter:
N=1919
0.9
0.8
1
2
3
4
5
6
7
8
9
10
Total Score
Mean
0.364
0.28
0.69
0.76
0.39
0.20
0.33
0.10
0.03
0.33
3.43
SD
0.67
0.66
0.86
0.86
0.77
0.54
0.69
0.41
0.30
0.60
4.36
Normal
N
N
Y
Y
M
N
N
N
N
N
N
0.7
0.6
0.5
Fall 10
Winter 11
0.4
Spring 2011
0.3
0.2
0.1
0
1
2
3
4
5
6
7
8
9
10
O VERALL S CORE A NALYSIS
Fall Quarter:
Winter Quarter:
O VERALL S CORE A NALYSIS
Winter Quarter:
Fall Quarter:
PHQ-9 Score
Frequency
Valid
Percent
Cumulative
Percent
0
479
27.3
27.3
1
204
11.6
39.0
0
2
232
13.2
52.2
1
3
184
10.5
62.7
4
139
7.9
5
100
6
Valid
Percent
Cumulative
Percent
594
31.0
31.0
242
12.6
43.6
2
232
12.1
55.7
70.7
3
181
9.4
65.2
5.7
76.4
4
133
6.9
72.1
87
5.0
81.3
5
108
5.6
77.8
7
55
3.1
84.5
6
78
4.1
81.8
8
54
3.1
87.6
7
74
3.9
85.7
9
42
2.4
90.0
8
68
3.5
89.2
10
28
1.6
91.6
9
48
2.5
91.8
11
19
1.1
92.6
10
24
1.3
93.0
12
11
.6
93.3
11
30
1.6
94.6
13
23
1.3
94.6
14
10
.6
95.1
12
17
.9
95.5
15
17
1.0
96.1
13
18
.9
96.4
16
17
1.0
97.1
14
9
.5
96.9
17
12
.7
97.8
15
10
.5
97.4
18
6
.3
98.1
16
14
.7
98.1
19
7
.4
98.5
17
7
.4
98.5
20
6
.3
98.9
18
5
.3
98.7
21
2
.1
99.0
19
3
.2
98.9
22
3
.2
99.1
20
4
.2
99.1
23
3
.2
99.3
21
7
.4
99.5
24
4
.2
99.5
22
2
.1
99.6
25
2
.1
99.7
23
1
.1
99.6
26
2
.1
99.8
24
2
.1
99.7
27
1
.1
99.8
25
1
.1
99.8
28
2
.1
99.9
26
2
.1
99.9
30
1
.1
100.0
30
2
.1
100.0
Total
1752
100.0
Total
1916
100.0
PHQ-9 Score Frequency
 Non-Acute
Score
Summary
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Fall Quarter – 90%
Winter Quarter – 91.8%
Spring Quarter – 93.1%
 Intervention by PHQ-9 Score
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Fall Quarter – 10%
Winter Quarter – 8.2%
Spring Quarter – 6.9%
 Acute
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Fall Quarter – 1.5%
Winter Quarter – 1.1%
Spring Quarter – 1.1%
Total Visits to
Number of
BHC Visits
 Total Visits - Fall – Spring
Quarter

N=5587
 Actual BHC Visits
 N = 216
 3.87%
 Expected as much at 10%

About 6% that decline BHC Consult
 BHC Visit Initiation
 43% from PHQ-9 Score
 57% with scores 11 and below
C ONCLUSIONS & Q UESTIONS
1.
2.
3.
4.
5.
6.
7.
8.
Increased medical provider awareness about mental health
issues
Allowed PCPs to briefly address mental health issues
because they had someone who could follow up immediately
Provided students with instant access to a mental health
provider who could briefly intervene or facilitate referral
Established a more efficient system for handling crises on
the medical side
Aided in our suicide prevention efforts
Facilitated collaboration and integration of medical and
mental health issues, especially for complicated cases
Reached a larger number of international students
Improved the relationship between the medical and mental
health providers
R EFERENCES & R ESOURCES
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Gunn, W. B., & Blount, A. (2009). Primary care mental health: A new frontier for psychology.
Journal of Clinical Psychology, 65 (3), 235-252.
James, L. C., & O’Donohue, W. T. (2009). The Primary Care Toolkit: Practical Resources for the
Integrated Behavioral Care Provider. New York: Springer.
Hunter, C. L., Goodie, J. L., Ooordt, M. S., & Dobmeye, A. C. (2009) Integrated Behavioral Health in
Primary Care. Washington, D. C.: American Psychological Association.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). Validity of a brief depression severity measure.
Journal of General Internal Medicine, 16 (9), 606-613.
Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care
providers before suicide: A review of the evidence. The American Journal of Psychiatry, 159 (6), 909916.
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
(6), 546-551.
Robinson, P. J., & Reiter, J. T. (2007). Behavioral Consultation and Primary Care: A Guide to
Integrating Services. New York: Springer.