Transcript Slide 1

in+care Campaign
Webinar
January 10, 2013
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Ground Rules for Webinar Participation
• Actively participate and write your questions into the
chat area during the presentation(s)
• Do not put us on hold
• Mute your line if you are not speaking (press *6, to
unmute your line press #6)
• Slides and other resources are available on our website
at incareCampaign.org
• All webinars are being recorded
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Agenda
• Welcome & Introductions, 5min
• Data Review and Discussion of Retention Strategies
Collected Through the Campaign, 15min
• Integrative Medicine: Mental Health & Retention, 25min
• Virginia Commonwealth University Process Map, 5min
• Q & A Session, 5min
• Updates & Reminders, 5min
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Improvement
Strategies Exercise
Michael Hager, MPH MA
NQC Manager
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in+care Campaign National Raw Data Snapshot
Dec 2011 –
Dec 2012
Data
12/11
02/12
04/12
06/12
08/12
10/12
12/12
12/11
02/12
04/12
06/12
08/12
10/12
12/12
Average
Average
Average
Average
Average
Average
Average
Sites
Sites
Sites
Sites
Sites
Sites
Sites
(Patients)
(Patients)
(Patients)
(Patients)
(Patients)
(Patients)
(Patients)
as of 1/8/2013
Measure 1:
Gap Measure
Measure 2:
Visit
Frequency
Measure
Measure 3:
New Patient
Measure
Measure 4:
Viral
Suppression
Measure
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16.26%
209
(126,953)
16.11%
(132,199)
203
14.67%
(132,006)
209
15.00%
(118,969)
188
14.12%
(114,994)
177
15.64%
(116,396)
170
14.70%
(92,505)
145
63.09%
(85,176)
155
65.79%
(90,025)
155
62.33%
(103,954)
176
63.80%
(93,779)
167
65.64%
(94,723)
163
64.70%
(94,627)
155
64.29%
(78,176)
133
56.71%
(7,792)
195
58.41%
(8,957)
193
58.57%
(8,566)
198
59.67%
(7,369)
182
59.63%
(7,277)
174
56.68%
(7,625)
167
57.42%
(6,938)
141
69.56%
(149,699)
195
70.47%
(158,624)
201
71.89%
(143,363)
187
72.15%
(136,059)
174
71.90%
(136,648)
166
72.21%
(106,551)
142
69.80%
200
(137,564)
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Improvement Strategies Discussion
Take Home Points – Participant Submissions
• As a medical program, consistently review patient mental health status.
Conducting formal screenings annually will ensure quality assessment
• Utilize community networks, planning council groups, etc to drill into data for
explanations/predictors why patients are at risk for dropping out of care.
Have primary care and mental health groups meet together ocassionally
• Contractual requirement that retention is a focus of all funded services
• Colocation of services / Sharing Space / Multi-Service Center model
• Cross-training of medical and behavioral health providers on issues related to
patient retention in HIV care and mental health care
• Interdisciplinary team meetings to discuss common threads/concerns
• Medical providers keep special database for mental health patients for tracking
• Create PCMH teams based on competency/skill in working with various pops
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Submit Improvement Updates!
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Integrative Medicine: Mental
Health and Retention
“Agenda: Kevin Moore of AIDS Care Group in Philadelphia will
present on the connection between mental health and retention. He
will focus on miscommunication between medical and behavioral
providers that leave patients in vulnerable situations. He will also
describe opportunities for building mental health into HIV Patient
Centered Medical Homes.”
- in+care Campaign Webinar Newsletter
(Dual) Problem Statement
• Many people living with HIV suffer from mental
illness and addictions, which impair their ability to
participate in medical care.
• Mental health and substance abuse services are
separate care systems with poor care coordination
with HIV services.
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Solution: Integrative Medicine
Retention in HIV services is increased
• co-locate mental health and substance abuse
services at an AIDS Service Organization (ASO)
• embed a psychotherapist as part of your primary
care team
• the therapist’s desired outcomes to include
retention, medication adherence, and HIV health
literacy
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Patient Centered Medical Home
A model of integrative medicine which attempts to provide
all needed services in one location or one coordinated
network.
Endorsed by the American Academy of Family Physicians (AAFP), American
Academy of Pediatrics (AAP), American College of Physicians (ACP), and the
American Osteopathic Association (AOA).
Resources on integrative medical models:
Patient Centered Primary Care Collaborative: www.pcpcc.net
Collaborative Care Research Network: www.aafp.org/nm/ccm
Collaborative Family Healthcare Association: www.CFHA.net
National Council for Community Behavioral Health:
www.thenationalcouncil.org
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Psychotherapist as teammate in
patient-centered medical home
• Embedded members of HIV primary care team
• Expanded role for psychotherapist: consult on
diagnosis, provide health education information,
explain treatment options, and provide an array of
behavioral medicine interventions
• Mental health treatment offered ranges from brief,
aperiodic interventions to long-term psychotherapy
• Generalist orientation
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Mental health care is primary care
• 84% of the time, the 14 most common physical
complaints have no identifiable organic etiology
(Kroenke & Mangelsdorf, 1989)
• 80% of people with a behavioral health disorder will
visit a primary care provider at least one time in a
calendar year (Narrow et al., 1993).
• 50% of all behavioral health disorders are currently
treated in primary care (Kesslet et al., 2006).
• 48% of the appointments for all psychotropic
medication are with a non-psychiatric primary care
provider (Pincus et al., 1998).
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Mental health care needs more primary care
• People with severe mental illness have diminished life
expectancy, e.g. schizophrenia 12-15 years less, due to
increased physical health problems (van Os & Kapur,
2009).
• People with major depression have increased risk for
nearly every physical health condition including heart
disease and diabetes (Lehman & Boyer, 2008).
• People with panic disorder need a medical rule out for
co-occurring physical disorders, which is typically
unavailable.
• Metabolic syndrome has become a major concern for
anyone taking anti-psychotic medication.
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Mental health care is not available enough in
underserved communities
• 57% of people with a behavioral health disorder do
not get behavioral health treatment (Kessler et al,
2005).
• 30-50% of referrals from primary care to outpatient
behavioral health do not attend an initial
appointment (Fisher & Ramson, 1997).
• Two-thirds of primary care physicians (N=6,660)
reported not being able to access outpatient
behavioral health for their patients (Hoge et al,
2006).
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Patient-centered medical homes have demonstrated
better clinical outcomes
• depression (Gilbody et al., 2006; Williams et al,
2007)
• panic disorder (Butler et al, 2008; Craven et al, 2006)
• tobacco, alcohol, diabetes, irritable bowel syndrome,
generalized anxiety disorder, chronic pain, primary
insomnia, and somatic complaints (Hunter et al,
2009).
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How can embedding a psychotherapist improve
retention in HIV medical care?
• Meeting unmet need
• Improving quality of medical care by properly
delegating behavioral health functions to
psychotherapists
• Truly coordinated care
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Since so much of HIV primary care is behavioral
in nature, why is treatment primarily biologically
based?
HIV primary care would provide more than primarily
biologically-based interventions if the primary care
team had the skills to provide behavioral medicine
interventions.
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If everyone acclaims integrative medicine, why is
so little of it in existence?
Integrative medicine is difficult and complex but can
be accomplished by a generalist, multidisciplinary team
with an evidence-based approach and strong practical
leadership.
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But how do I pay for a therapist?
The conventional sources of revenue:
1.
2.
3.
Fee-for-service reimbursement
Ryan White awards for psychosocial or substance
abuse services
Public and private grants for mental health services
And there is another way….
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My recommendation: create a graduate student
practicum placement
• Very low cost
• They desire real world training in a model that is the
future of healthcare
• Flexibility in how they practice
• More easily incorporated into a primary care team
than an established therapist
• Benefit from not knowing what isn’t conventionally
thought “possible”
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Graduate Student Cons
• May not have developed all the professional skills
for the variety of demanding clinical situations
• Need strong supervision from a licensed
professional who is competent in an HIV
population and/or has a health psychology
background
• Require professional development feedback and
mentoring from a senior person on-site
• Typically stay for 10 or 12 months and some clients
find this frequent change disruptive
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How to create a graduate student practicum
placement
1) contact the practicum coordinator at a local
graduate program who is interested in an HIV patientcentered medical home model (most will jump at the
opportunity) and learn their supervision and
programmatic requirements
2) hire a supervisor that meets the requirements and
understands the patient-centered medical home model
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Primer on psychotherapy training
• Psychology- Masters, Doctoral; Clinical, Counseling,
Neuropsychology (but not School, Organizational)
• Social Work- Masters; Applied, Micro (but not
Admin, Macro)
• Marriage and Family Therapy- Masters
• Pastoral Counseling- Masters
• Free-standing psychotherapy institutes
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How low is low cost?
• Typically first and second year graduate students will take a
good practicum site gratis for 2 days a week, i.e. up to 10
clients a week plus care coordination
• Most graduate programs will require one hour of individual
supervision from an approved, licensed supervisor per 2 days
of work. Supervision cost is generally somewhat less than an
hourly session rate: $80-$120 depending on area
• Estimate of a 12 month practicum:
50 weeks x $100= $5,000 annual cost + office space
• $5K annum to significantly expand type of service is within
the reach of every ASO in the country
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How to think about using graduate student
practicums
• Psychotherapy is listening, understanding, creating rapport,
and offering a helpful intervention
• Most people (but not all) who go to graduate school to learn
psychotherapy are already gifted in these skills and are
primarily only learning new interventions
• Unlike medical students who follow a training model of close
supervision, grad students learning psychotherapy are
successful working independently and clients will never
meet the supervisor
• I recommend calling the student a “therapist” in the
workplace and treat them like a part-time employee, i.e. they
are professionals responsible for the services they provide
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Tips for working with graduate students
• Ditch bad fits- two kinds of people apply to graduate school to
be a psychotherapist
• Collect mental health-medical release of information as a standard
practice so the client knows it is a team approach
• Client will need to receive written notification of intern status and
how to contact the licensed supervisor
• Identify on-site mentor
• If no in-house education program for new staff to learn about
HIV, use internet resources:
1. www.aids-ed.org
2. www.aids.gov
3. www.thebody.com
4. www.teach-online.org/description.html
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Retention Outcomes
• Define position to include retention in medical
care, medication adherence, and improved health
literacy
• Use your CQI process and your HRSA performance
measures to give feedback to the primary care team
including psychotherapist
• Consider targeting a list of lost-to-care or at-risk
patients and offering them therapy first before your
medical providers fill your therapist with referrals
(typically within one or two weeks)
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Interdisciplinary Collaboration- Part 1
Even ASO staff who have had training in behavioral
interventions, sometimes revert to a “medical model”
mindset where the medical provider tells the patient what
s/he needs to do for their health and they are expected to
do it or be judged “non-compliant.” Therapists take a
patient-centered approach needed to establish rapport
and be effective in psychotherapy. Sometimes, the
therapist has sensitive information, e.g. drug relapse, which
the patient chose not to share with other staff. Should the
therapist share this information?
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Interdisciplinary Collaboration- Part 2
• Follow mandatory reporting laws
• Talk to supervisor about how medically necessary the
information may be: who might be harmed? How could
it impact medical decision-making?
• As a general rule, share all information that isn’t
deemed to likely be detrimental to clients
• Some mismatches between staff and patient can be
minimized by withholding non-vital information,
though this is the exception to the rule and should only
be done with clear rationale and supervisor approval
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Interdisciplinary Collaboration- Part 3
• A therapist is not an enforcer to demand the patient
take a medically recommended course of action, e.g.
“get them to take their meds”
• A therapist has the time to listen and understand a
patient’s point of view
• Therapy is a separate service which allows for
education, in-depth motivational interviewing, and
other techniques to facilitate change such as
medication adherence and healthy living
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Misinformation between medical providers and
therapists
• The power differential, especially between a seasoned
infectious disease physician and a green graduate student
intern, can be very great.
• Medical providers should attempt to include the therapist as
a full member of their team, while the therapist should show
appropriate respect and follow the team leader.
• Misinformation occurs when teams members are not allowed
to disagree or voice different points of view.
• A diversity of opinions is what is gained by making a team
more multidisciplinary.
• What psychology and other disciplines add to medical
practice is precisely a different way of viewing behavior.
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My contact info
Kevin Moore, Psy.D.
Director of Integrative Medicine
AIDS Care Group
907 Chester Pike, Sharon Hill, PA, 19079
610-715-0127
[email protected]
All citations available upon request and I’m happy to have
follow up conversation or offer technical assistance.
Thank you!
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Mike Rollison, LCSW
Virginia Commonwealth
University
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Click Link below for full-size version
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Time for Questions
and Answers
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Announcements
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Upcoming Events
•
Next Meet-the-Author Webinar: M.Vyavaharkar – How Can We
Increase Initiation of and Retention in Care Among People Living
with HIV? January 30, 2013 at 2pm ET
•
Dual Partners in+care and Campaign Webinar: Working with
Individual Patients to Improve Retention
Date Pending – to be announced!
•
Campaign Webinar: Social Service Providers Have a Role in
Retention! Date Pending – to be announced!
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Upcoming Deadlines and Office Hours
•
Campaign Office Hours:
Mondays & Wednesdays 4-5pm ET
•
•
•
•
•
•
•
•
Monday, January 14 - Open Space, no set topic
Wednesday, January 16 - Hurdling Over Individual Barriers to Care
Monday, January 21 - Campaign Offices Closed, No Office Hours
Wednesday, January 23 - Building Infrastructure to Personalize Care
Monday, January 28 - Open Space, no set topic
Wednesday, January 30 - Open Space, no set topic
Monday, February 4 - Open Space, no set topic
Wednesday, February 6 - Aligning Care Services Under a Single Message
•
Data Collection Submission Deadline:
February 1, 2013
•
Improvement Update Submission Deadline:
January 15, 2013
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MedScape Retention in HIV Care Series
• Technical Working Group working on articles for a new
Medscape Today News Series.
• We recommend that you subscribe to HIV/AIDS MedPlus
to be informed of new and exciting articles in this series!
• Published Pieces:
•
•
•
•
•
•
•
Implementing QI in HIV Clinics to Improve Retention in Care
Monitoring Rates of Retention in HIV Care Across the State
How Health Departments Promote Retention in HIV Care
Improving Retention in HIV Care: Which Interventions Work?
Engaging in HIV Care: What We Learned from AIDS 2012
How Should We Measure Retention in HIV Care?
Retention In HIV Care: The Scope of the Problem
http://www.medscape.com/index/section_10285_0
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Partners in+care
• Partners in+care Private Facebook Group is live!
• Share tips, stories and strategies
• Join a community of PLWH and those who love them
• Email [email protected] for more details
• Partners in+care website is live!
• http://www.incarecampaign.net/index.cfm/77453
• Join our mailing list (a list-serv version of the FB Group)
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Campaign Headquarters:
National Quality Center (NQC)
90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730
[email protected]
incareCampaign.org
youtube.com/incareCampaign
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