Integrated Behavioral Health Integrated Behavioral Health Care with Underserved Pts: The Care with Underserved Pts: The VCU PC Psychology ProgramVCU PC Psychology Program

Benjamin Lord, M.S.Benjamin Lord, M.S.Virginia Commonwealth Virginia Commonwealth

UniversityUniversity

Our ProgramOur Program

Virginia Commonwealth University includes Virginia Commonwealth University includes PhDs in both Clinical and Counseling PhDs in both Clinical and Counseling psychologypsychologyThe Clinical Psychology Program includes The Clinical Psychology Program includes specialty tracks in specialty tracks in Child PsychologyChild Psychology and in and in Behavioral MedicineBehavioral MedicineAll PhD students do practicum training in the All PhD students do practicum training in the community after their first year in the programcommunity after their first year in the program– Community Mental Health ClinicsCommunity Mental Health Clinics– University Counseling ServicesUniversity Counseling Services– Primary Care Psychology at VCU Medical CenterPrimary Care Psychology at VCU Medical Center

VCU Primary Care Psych: A HxVCU Primary Care Psych: A HxClinic was started in 2008 Clinic was started in 2008 Place psychology PhD students in the Place psychology PhD students in the Primary Care clinic at VCU Medical Primary Care clinic at VCU Medical CenterCenter– Work with MD residentsWork with MD residents– Work with underserved, indigent patientsWork with underserved, indigent patients

““Coping with Chronic Disease Clinic”Coping with Chronic Disease Clinic”Began with 3-4 students performing Began with 3-4 students performing consultations and advertising services consultations and advertising services several days per weekseveral days per weekCURRENTLY:CURRENTLY:– 16 PC Psych students at any given time16 PC Psych students at any given time– Expansion to Pediatric Primary CareExpansion to Pediatric Primary Care– 3 PhD LCP Supervisors 3 PhD LCP Supervisors – Psychiatry LiasonPsychiatry Liason– 3 Official clinic days with scheduled visits3 Official clinic days with scheduled visits– Consultation services 5 days per weekConsultation services 5 days per week– Monthly didactic training for MD residentsMonthly didactic training for MD residents– Team-Based LearningTeam-Based Learning– Provided approximately 950 sessions to Provided approximately 950 sessions to

190 individual patients 190 individual patients

Dr. Bruce RybarczykDr. Bruce RybarczykDirector of Clinical TrainingDirector of Clinical TrainingFounder of VCU PC PsychologyFounder of VCU PC Psychology

The Four NeedsThe Four NeedsTraining PhD students in psychology to Training PhD students in psychology to develop or work in future integrated care develop or work in future integrated care settings settings

Improving access to mental and Improving access to mental and behavioral health services for the behavioral health services for the underservedunderserved

Train medical residents to use mental and Train medical residents to use mental and behavioral health servicesbehavioral health services

Research the integrated care model to Research the integrated care model to show when and how it worksshow when and how it works

Our Training Model: Our Training Model: Learn one, Learn one, See one, Do one, Teach oneSee one, Do one, Teach one

Developing Competency in Developing Competency in Integrated CareIntegrated Care

When and Where Does Training When and Where Does Training Happen?Happen?

Training OpportunitiesTraining Opportunities– Counseling Skills Counseling Skills

CourseCourse– Behavioral Health and Behavioral Health and

Health Psych CoursesHealth Psych Courses– PC Psychology CoursePC Psychology Course– Group SupervisionGroup Supervision– On-site peer and faculty On-site peer and faculty

supervisionsupervision– ShadowingShadowing– ““On the Job” TrainingOn the Job” Training– Workshops/Team-Workshops/Team-

Based LearningBased Learning

Trajectory of a PC Trajectory of a PC Psych StudentPsych Student11stst year year– Counseling skills courseCounseling skills course– Attend “Group Sup”Attend “Group Sup”– Shadow 2Shadow 2ndnd semester semester

22ndnd year year– Begin seeing patients Begin seeing patients

solosolo

33rdrd year+ year+– Consultation and Consultation and

leadershipleadership

Mental and Behavioral Health Mental and Behavioral Health ServicesServices

Assessment, Treatment, and Assessment, Treatment, and ReferralReferral

Who are we serving?Who are we serving?Over 50% minorityOver 50% minorityOver 20% rural, low Over 20% rural, low incomeincome80+ %ile on SRRS-R80+ %ile on SRRS-RBehavioral Health Behavioral Health Problem areasProblem areas: : Insomnia, Chronic Pain, Insomnia, Chronic Pain, Smoking Cessation, Smoking Cessation, managing diabetesmanaging diabetesMental Health Problem Mental Health Problem AreasAreas: Depression, : Depression, AnxietyAnxietyAvg: 4-5 sessionsAvg: 4-5 sessions

VCU Medical Center, where PC Psychology operates

Referral Methods:

Traditional: Pt. is scheduled for an initial session by PCP

Same-Day Consultation: PC Psychologist is requested to participate in pt’s PCP appointment

Services We ProvideServices We Provide

Mental HealthMental Health– DepressionDepression– AnxietyAnxiety– Panic DisorderPanic Disorder– SomatizationSomatization– Adjustment Adjustment – Risk AssessmentRisk Assessment– Brief Cognitive Brief Cognitive

EvaluationsEvaluations

Behavioral HealthBehavioral Health– Pain management Pain management – Behavioral Behavioral

Treatment of Treatment of InsomniaInsomnia

– Smoking CessationSmoking Cessation– Medication adherenceMedication adherence– Diabetes managementDiabetes management– Diet/Weight lossDiet/Weight loss– Coping with chronic Coping with chronic

diseasediseaseInterventions are brief, problem-focused, and generally based on cognitive-behavioral principles

Assessment ToolsAssessment ToolsSRRS-RSRRS-R– Life Stressors Life Stressors

PHQ-9PHQ-9– DepressionDepression

GAD-7GAD-7– AnxietyAnxiety

ISIISI– InsomniaInsomnia

MPQ-SFMPQ-SF– PainPain

Behavioral MeasuresBehavioral Measures– Cigarettes smokes per Cigarettes smokes per

weekweek– WeightWeight– A1CA1C

The QPDThe QPDQuick Psychodiagnostic Quick Psychodiagnostic assessment tool for primary careassessment tool for primary careSelf-administered on portable tabletSelf-administered on portable tabletScreens for:Screens for:

QPD Tablet: An easy screening tool for use by both PC Psychology and medical residents

Training with Medical Training with Medical ProvidersProviders

Enhancing Integration with Enhancing Integration with Residents and StaffResidents and Staff

Three Major ProjectsThree Major ProjectsTeam-Based LearningTeam-Based Learning– Large training activitiesLarge training activities– Focus on one topic (adherence, pain, depression)Focus on one topic (adherence, pain, depression)– Troubleshoot in teams (MDs, Pharmacists, Troubleshoot in teams (MDs, Pharmacists,

psychologists, pastoral counselors)psychologists, pastoral counselors)

The “Clinic Minute”The “Clinic Minute”– 5min didactic presentations5min didactic presentations– Developed based on requests by attendings and Developed based on requests by attendings and

medical residentsmedical residents– Interpersonal skills; Adult ADHD; Chronic PainInterpersonal skills; Adult ADHD; Chronic Pain

Mandatory ShadowingMandatory Shadowing– 22ndnd year residents do rotations where they sit in on PC year residents do rotations where they sit in on PC

Psychology sessions and participate in brief didactic Psychology sessions and participate in brief didactic presentationspresentations

Researching our modelResearching our model

Some Preliminary DataSome Preliminary Data

Current Research ProjectsCurrent Research Projects

Success with Team-Based LearningSuccess with Team-Based Learning– Evaluate outcomes of our TBLs in terms of the Evaluate outcomes of our TBLs in terms of the

educational goals and attitudes toward working in a educational goals and attitudes toward working in a teamteam

Success with ResidentsSuccess with Residents– Surveyed residents attitudes toward PC Psychology, Surveyed residents attitudes toward PC Psychology,

the amount of contact with PC Psych, and their the amount of contact with PC Psych, and their attitudes toward integrationattitudes toward integration

Success with PatientsSuccess with Patients– Currently analyzing data on outcomes from our Currently analyzing data on outcomes from our

screening and assessment measuresscreening and assessment measures– Also conducted patient satisfaction research w/ Also conducted patient satisfaction research w/

sample of 20 patientssample of 20 patients

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Value Efficiency PhysiciansRole

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Psychology

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Figure 1. Mean percentage of maximum possible subscale score by profession for TBL 1: Adherence

TBL DATA

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Value Efficiency PhysiciansRole

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Psychology

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Figure 2. Mean percentage of maximum possible subscale score by profession for TBL 2: Depression

TBL DATA

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Value Efficiency PhysiciansRole

TBL 1:Adherence

TBL 2:Depression

Figure 3. Mean percentage of maximum possible subscale score by TBL session (excluding chaplain participants who did not attend both sessions)**Difference in Value was significant p<.01

TBL DATA

Resident SurveyResident SurveyN = 58 medical residentsN = 58 medical residents

Referral rates: 58% referred btw 1 and 7 Referral rates: 58% referred btw 1 and 7 patients in 30 dayspatients in 30 days

75% satisfied or very satisfied with PC 75% satisfied or very satisfied with PC PsycholPsychol

Satisfaction QuestionMean rating

Q1 My clinician seemed warm supportive and concerned 3.8

Q2 My clinicain seemed trustworthy 3.8

Q3 My clinician treated me with respect 3.7

Q4 My clinician did a good job of listening 3.7

Q5 I was able to express my feelings during the visit 3.7

Q6 I talked about the problems that are bothering me 3.7

Q7 The approach my provider used made sense 3.7

Q8 I learned some new ways to deal with my problems 3.7

Q9 I believe the visit was helpful to me 3.8

Q10 Overall, I was satisfied with today's visit 3.7

Q11I plan to do what I told the clinician I would do before I come to the clinic for my next visit 3.7

Q12 I intend to use what I learned in today's visit 3.7

Q13 At times, my provider didn't seem to understand how I felt 3.8

Q14 At times, I felt uncomfortable during the visit 0.8

Q15 I didn't always agree with my clinician 0.5

Q16 Number of visits with PC Psychology 5.2

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PHQ-9 ScoresPHQ-9 Scores

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2 sessions3 sessions4 sessions5 sessions6 sessions

GAD ScoresGAD Scores

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pretx posttx

2 sessions3 sessions4 sessions5 sessions6 sessions