Transcript Slide 1

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Learning Objectives
 To provide an overview of racial/ethnic behavioral health
disparities
 To provide an overview of integrated behavioral health
services in a primary care setting.
 To provide an overview of one model of integrationCommuniCare Health Centers.
 To define roles of integrated team members.
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Health Disparities vs. Health Care
Disparities
 Health Disparities
 Health status of ethnic
populations
 Diabetes
 Cardiovascular disease
 HIV/AIDS
 Mental health and
behavioral health
disorders
 Health Care Disparities
 Access to care
 Lack of interpreters
 Un- and underinsured
populations
 Under-diagnosis of
diseases
 Lower referral rates
A Supplement to Mental Health: A Report of the Surgeon General,
Department of Health and Human Services, 1999
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Executive Summary
 Themes of Report
 Mental health and mental illness require the broad focus of
public health approach.
 Mental disorders are disabling conditions.
 Mental health and mental illness are points on a
continuum.
 Mind and body are inseparable.
 Stigma is a major obstacle preventing people from getting
help.
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Executive Summary
 Message from Surgeon General
 Mental health is fundamental to health.
 Mental illnesses are real health conditions.
 The efficacy of mental health treatment is well
documented.
 A range of treatments exists for most mental disorders.
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Purpose of the Supplement
Report
 To understand better the nature and extent of mental
health disparities;
 To present the evidence on the need for mental health
services and the provision of services to meet those
needs, and
 To document promising directions toward the elimination
of mental health disparities and the promotion of mental
health.
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Striking Disparities in Mental
Health Care
 Racial and ethnic minorities:
 have less access to and availability of mental health
services.
 Are less likely to receive needed mental health services.
 In treatment often receive a poorer quality of mental
health care.
 Are underrepresented in mental health research.
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Main Messages From Report
 Culture Matters
 Personal Health Recommendation
 Seek Help
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Prevalence of Mental Disorders
Among Hispanics
 Lower rates of depression in Hispanics than for non-
Hispanics (in particular in Mexican and Cuban
Americans)
 Higher rates of Major Depression in Whites than
Blacks than Hispanics
 Higher rates of Dysthymia in Whites than Blacks than
Hispanics
Vega, Alegria, Latino Mental Health and Treatment in US, 2001; Riolo, et al, Am J Pub
Health, 2005; Kessler, et al, Arch Gen Psychiatry, 2005
Mental Disorders in Hispanic May Go
Undetected in Primary Care Settings
 Primary Care providers identified only 21% of Hispanic
patient with depression.
 Elderly Medicare recipients who were Hispanic had a .72
odds ratio for diagnosed depression compared with
Caucasian patients.
Borowsky, et al, J Gen Intern Med, 2000; Schmaling, et al, J Health Care Poor Underserved, 2005
Health Factors That May Affect
Patient’s Mental Health
 Obesity
 Regular leisure time exercise
 Diabetes
 Tobacco use
 Alcohol use
 Illicit drug use
 Prescription drug abuse
CDC, National Health Interview Survey, 2005; SAMHSA, National Survey on Drug Use and Health, 2005
Rationale for Integration of
Physical and Behavioral Health
 Most patient seek help for behavioral health problems in
primary care.
 Behavioral health problems often go undetected or
untreated in primary care.
 Patients with medical disorders like diabetes have higher
rates of behavioral health problems.
 Treating behavioral health problems in primary care
presents opportunity for early intervention and
prevention of more disabling conditions.
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Why Do Patient Seek BH Services In
Primary Care Settings?
 Patient may be un or under insured.
 Patient’s insurance may not cover BH services.
 Limited access to public MH services.
 Lack of availability of MH services, especially in rural
areas.
 Cultural beliefs and attitudes.
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Conceptualizing Care Across
Integrated Systems
 The four quadrant system of care conceptualizes
frameworks for designing integrated programs.
 The four quadrant model is built on the type of care
people need and where that care is best delivered
depends on severity of needs.
 The systems of care model recognizes that patient are
likely to interact with many systems of care.
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Low -Behavioral Health Risk -High
The Four Quadrant Clinical
Integration Model
Low -Physical Health Risk-High
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Definition of Integrated Behavioral
Health
 Defined as the systematic coordination of physical and
behavioral health services.
 Collaborative care adopted by the Wagner’s chronic care
model.
 Integrated services will provide the best results.
 Integrated services are patient center.
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Collaborative Care’s Key
Ingredients
 Care management- Patient education & empowerment,
ongoing monitoring, co-management.
 Evidence based treatment.
 Expert consultation for patients who are not improving.
 Outcome tracking.
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Overview of Chronic Care Model
 Health Care Organization and Leadership
 Linkage to Community Resources
 Support of Patient Self-Management
 Coordinated Delivery System Design
 Clinical Decision Support
 Clinical Information Systems
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CommuniCare Health Centers
Our Mission
CommuniCare Health Centers has been serving the
community since 1972. Our mission is "to provide
comprehensive, affordable, quality health care while
responding to the changing needs of the community
and respecting the dignity, values and culture of the
individual."
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About Us
• CommuniCare Health Centers offer comprehensive primary health
care services in Bexar and Hays counties. Our services include:
• Medical
•
•
•
Family Medicine
Pediatrics
Women’s Health
• Dental
• Behavioral Health
• Pharmacy & Laboratory
We pride ourselves for being a one-stop service facility for all of your
primary health care needs.
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Health Care Organization and
Leadership
 Leadership within organization and within the
department that supports this model is key.
 Organizational environment that systematically supports
and encourages chronic illness care.
 Results in successful quality improvement activities.
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Linkage to Community Partnerships
 Methodist Health Care Ministries
 Electronic Health Records- BH Module
 Center for Health Care Services
 Crisis Unit and Care Management
 University Health System
 Psychiatric ER and Adult Inpatient Unit
 Clarity Child Guidance Center
 Child Inpatient Unit
 United Way Referral Agencies
 Haven for Hope
 Independent School Districts
 Early Childhood Intervention
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Maslow’s Hierarchy of Needs
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Support Patient Self-Management
 Problem Focused Therapy
 Cognitive Behavioral Therapy
 Motivational Interviewing and Therapy
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Clinical Decision Support
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American Academy of Child and Adolescent Psychiatry
Treatment Guidelines
American Psychiatric Association Treatment Guidelines
Substance Abuse Mental Health Service Administration
Treatment Improvement Protocols
American Association of Family Physicians
US Department of Health and Human Services: Treating
Tobacco Use and Dependence Clinical Practice Guidelines
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Standard Screening Instruments
 Patient Health Questionnaire (PHQ)- 9
 Beck Depression & Anxiety Inventory (BDI & BAI)
 Mood Disorder Questionnaire (MDQ)
 Vanderbilt Attention Deficit Hyperactivity Disorder
(ADHD) Scale
 Edinburgh Post-Partum Depression Scale
 Fagerström Tobacco
 Michigan Alcohol Screening Test-Short form
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Clinical Information Systems
 Access to adequate database software.
 NexGen Health Information System
 Generate treatment plans and provide these to patients
at part of appointments.
 Handouts and messages to facilitate self-care.
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Roles of the Integrated Team
 Psychiatrist
 Social Workers
 Psychologist
 Psychiatric Nurse Practitioner
 Medical Assistant
 Mental Health Technician
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Interprofessional Behavioral Health
Staff
 Frank Bryant Clinic
 Dr Clarissa Aguilar, PhD
 Rulynne Ballinger, LCSW
 Tandra Rathey, PNP
 Barrio Family Health Center
 Thelma Rivera, LCSW
 Sandra Trevino, LCSW
 Christina Wei, PNP
 San Marcos Clinic
 Donna Murphree, LCSW
 Kyle Clinic
 Michele Purvin, LCSW
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Japan Proverb; Kenneth Hartley Blanchard.
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INTERPROFESSIONAL TEAMS
 More effective and efficient patient care.
 Patient benefit from receiving care from professions with
various areas of expertise.
 Team work provides coordination of all aspects of patient
care.
 Professional growth and job satisfaction.
 Enhances breadth of knowledge and appreciation for
skills and knowledge of other health professionals, above
and beyond their roles in team work.
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Patient Health Questionnaire-2
 Over the past 2 weeks, how often have you been
bothered by any of the following problems?
 Little interest or pleasure in doing things?*
 Feeling down, depressed or hopeless?*
*Responses are not all the time, several days, more than half
the days or nearly every day.
Kroenke, K, et al, Medical Care 2003.
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PATIENT FLOW WHEN BH STAFF IN PRIMARY CARE POD
Patient Vitalized by Medical Assistant
↓
↓
PHQ-2 Positive
PHQ-2 Negative
↓
↓
Patient seen by BH staff
PHQ-2 labeled and scanned into chart
↓
PHQ-9 completed and scored
↓
↓
Positive
Negative
↓
↓
Patient scheduled for
Provide information about BH Program
Intake appt
and anticipatory guidance
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Beck Scales
 Depression Inventory
 Anxiety Inventory
 Mean 29.4 (Severe)
 Mean 28.8 (Severe)
 Median 29
 Median 28
 Range 4-53
 Minimal 14 (13%)
 Mild 14 (13%)
 Moderate 24 (22%)
 Severe 56 (52%)
 Total 109
 Range 14-63
 Minimal 7 (6%)
 Mild 11 (10%)
 Moderate 28 (26%)
 Severe 63 (58%)
 Total 108
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Behavioral Health Initiatives
 Post Partum Depression
 ADHD Children
 Smoking Cessation Initiative
 Alcohol Abuse Intervention
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PEDIATRICS POST PARTUM DEPRESSION FLOW
CHART
Mother presents infant (patient) for first visit
↓
MA ask mother to complete PHQ-2 → Negative → No further action
↓
Positive → Mother Not CommuniCare patient → Depression Handout
↓
Mother CommuniCare patient
↓
Pediatrician to ask patient to complete
Edinburgh Post Partum Depression Scale → Negative* → Anticipatory guidance
↓
Positive*
↓
Refer to Behavioral Health for appointment
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Ms. Smith
Medications
Medications
 Promethazine 25 mg
 Cyclobenzaprine 10 mg
 Prednisone 20 mg
 Butalbital/apap/caf
 Hydroxychloroquine 200 mg
 Azithromycin 150 mg
 Meclizine 25 mg
 Citalopram 20 mg
 Naproxen 500 mg
 Proair
 Methotrexate 2.5 mg
 Propo-n/apap 100-650
 Folic acid 1 mg
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Future Plans
 Expand staffing to include:

Pharm D as consultant
 Expand Screening and Evaluation tools

Panic Disorders
 Enhance existing programs with BH needs



FUN Clinic
Smoking and Alcohol Abuse
Mother Infant Attachment Assessments
 Expanding Community Partnerships

Hospital Emergency Rooms
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Closing Thoughts
 The Integrated Model allows opportunities for Behavioral
and Physical Health Prevention and Health Promotion.
 The Integrated Model developed at our site is a hybrid of
many models to address our patient populations needs.
 Integrated Models are patient centered.
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Learning Objectives
 To provide an overview of racial/ethnic behavioral health
disparities
 To provide an overview of integrated behavioral health
services in a primary care setting.
 To provide an overview of one model of integrationCommuniCare Health Centers.
 To define roles of integrated team members.
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Questions
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