Integrated Primary Care Behavioral Health Competency Training … · 2018-10-24 · Annual...

Integrated Primary Care Behavioral Health Competency Training in Two Large Medical Systems: Practical Lessons Learned• Lisa K. Kearney, Ph.D., ABPP, Associate Director for Education, VA Center for Integrated Healthcare• Gregory Beehler, Ph.D., Associate Director for Research, VA Center for Integrated Healthcare• Anne C. Dobmeyer, Ph.D., ABPP, Psychological Health Center of Excellence, Defense Health

Agency• Katherine Dollar, Ph.D., Associate Director for Implementation, VA Center for Integrated

Healthcare• Joseph Grasso, Ph.D., Education and Implementation Specialist, VA Center for Integrated

Healthcare• David Hunsinger, MD, MSHA, Medical Director, Binghamton VA Outpatient Clinic• Christopher Hunter, Ph.D., ABPP, DoD Program Manager for Behavioral Health in Primary Care• Andrew Pomerantz, M.D., National Director for Integrated Care, VA Central Office• Katharine Van Treese, LCSW, Supervisor, VISN 2 Behavioral Telehealth Center• Laura O. Wray, Ph.D., Executive Director, VA Center for Integrated Healthcare

Session # G6

CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Conference Resources

Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018

Slides and handouts are also available on the mobile app.

Learning ObjectivesAt the conclusion of this session, the participant will be able to:

• Discuss options for training their integrated primary care behavioral health (PCBH) workforce in the unique competencies required for primary care

• Identify common challenges in implementation of a systematic integrated PCBH training program and methods for overcoming these challenges

• Create an initial plan for local development of an integrated PCBH competency-based training program at their location

1. Hoge M.A., Morris J.A., Laraia M., Pomerantz A., & Farley, T. (2014). Core Competencies for Integrated Behavioral Health and Primary Care. Washington, DC: SAMHSA - HRSA Center for Integrated Health Solutions.

2. Hunter, C. L., Goodie, J. L., Dobmeyer A. C., & Dorrance, K. A. (2014). Tipping points in the Department of Defense’s experience with psychologists in primary care. American Psychologist, 69(4), 388-398.

3. McDaniel, S. H., Grus, C., Cubic, B., Hunter, C., Kearney, L. K.,. Schuman, C., … Johnson, S., B. (2014). Competencies for psychology practice in primary care. American Psychologist, 69 (4), 409-429

4. Milller, B.F., Gilchrist, E. C., Ross, K. M., Wong, S. L., Blount, A., & Peek, C. J. (2016) Core Competencies for Behavioral Health Providers Working in Primary Care. Prepared from the Colorado Consensus Conference.

5. Pomerantz, A. S., Kearney, L. K., Wray, L. O., Post, E. P., & McCarthy, J. F. (2014). Mental health services in the medical home in the Veterans Health Administration: Factors for successful integration. Psychological Services, 11 (3), 243-253.

Bibliography / Reference

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

“Medically Ready Force…Ready Medical Force”

Primary Care Behavioral Health Training and Outcomes in the Department of Defense


Acknowledgements

We would like to acknowledge the contributions of Justin Curry, Ph.D., and Melissa Kincaid, Ph.D., at the Psychological Health Center of Excellence, Defense Health Agency, for their contributions to DoD PCBH program monitoring and evaluation.

8


Internal Behavioral Health Consultants (IBHC): Who are They?

• Licensed social workers and psychologists (n=214)• Work in Army, Navy, and Air Force clinics around the world• Placed primarily in family health and internal medicine clinics• Hired locally (no central oversight)• Most with no prior integrated care experience

9


Training Program Overview

• Competency-based training approach• Designed to help IBHCs and clinics develop and demonstrate specific

primary care behavioral health (PCBH) competencies• Competencies assessed at two points in training cycle using the DoD Core

Competency Tool (CCT)1

1Adapted from the Air Force BHC Core Competency Tool (United States Air Force, 2002, Primary behavioral health care services practice manual. San Antonio, TX), with consultation from Mountain View Consulting Group.

10


CCT v3.0

• 59 items comprising six dimensions− Clinical practice− Practice management− Consultation− Documentation− Administration− Team performance

• A subset of items must be demonstrated to remain in position

11


Sample CCT Items

• Conducts efficient warm handoffs

• Interventions are collaboratively developed with the patient

• Appointments are routinely kept to 30 minutes or less

• Keeps on schedule with consecutive appointments

• Appointments are spaced in a manner consistent with a population health model as well as individual patient needs

• Regularly engages in behaviors to increase IBHC utilization

• Clarifies/reinforces other aspects of the primary care treatment plan

• Provides same-day verbal feedback to PCCs for every appointment

12


Phases of Training

• Orientation

• Phase I (includes CCT evaluation)

• Phone mentoring

• Phase II site visit (includes CCT evaluation)

13


Orientation

• Three week distance learning; self-guided learning activities

• Learning activities:

− Live webinars

− Readings

− Online training (military cultural competency)

− Reviewing PCBH video demonstrations

− Shadowing primary care clinicians (PCCs)

− Meeting with key clinic personnel

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Phase I

• Five day centralized training at a DoD Simulation Center

• Learning activities:

− Didactics: PCBH model, conducting PCBH visits, working with patients at risk for suicide, depression assessment/intervention, ethics

− Hands-on training in electronic health record (EHR) IBHC template

− Two days of role play with patient actors; CCT feedback from trainer

• IBHCs must pass select CCT items to begin seeing patients

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Phone Mentoring

• Six individual phone mentoring appointments with IBHC trainer

• Assistance with translating classroom learning into clinical practice

• Feedback on clinical documentation

• Tailored recommendations for practice management

• Preparing for Phase II site visit

16


Phase II Site Visit

• Two day site visit from trainer

• Occurs three to four months after Phase I training

• IBHC observed providing patient care and consultation

• Trainer meets with primary care staff, supervisors, leaders

• Trainer provides on-the-spot training and rates with CCT

• Provides recommendations for IBHC and clinic leaders

17


Program Monitoring and Evaluation

• Wide range of key program metrics are assessed on a quarterly basis

• Data pulled centrally and compiled into quarterly monitoring reports by Performance and Analytics Branch, Psychological Health Center of Excellence

• Complementary dashboards visually highlight key monitoring metrics at the IBHC and clinic level

• Data presented here are from second quarter of FY20181

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1Psychological Health Center of Excellence (2018, June). Psychological Health Analytics Report: IBHC monitoring report for FY18Q02. Defense Health Agency: Falls Church, VA


Program Snapshot, FY18Q2

Unique patients seen and number of encounters seen by full-time IBHCs during monitoring period

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Adult Pediatric TotalUnique Patients 34,210

(91.6%)3,132 (8.4%)

37,342

Encounters 55,461 (92.1%)

4,730(7.9%)

60,191

Presenter

Presentation Notes

361 full-time IBHCs


IBHC Dashboard Example

20

Presenter

Presentation Notes

Example of a portion of a dashboard for one IBHC


IBHC Dashboard Example, cont’d

21

Presenter

Presentation Notes

Screenshot of a portion of a dashboard for one IBHC


IBHC Dashboard Example, cont’d

22

Presenter

Presentation Notes

Screenshot of a portion of a dashboard for one IBHC


Program Fidelity, FY18Q2

• IBHC encounters per patient • Patients by condition • Encounters with feedback to PCC• Administration of Behavioral Health Meaure-20 (BHM-20)1

• CPT codes used (proxy for length and type of appointment)• IBHC utilization (mean encounters per day worked)

1 Kopta, S. M., & Lowery, J. L. (2002). Psychometric evaluation of the Behavioral Health Questionnaire-20: A brief instrument for assessing global mental health and the three phases of psychotherapy outcome. Psychotherapy Research, 12(4), 413–426.

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Presenter

Presentation Notes

All of these are during the monitoring period



Encounters per patient with an IBHC during monitoring period

24

Encounters Patients Percent1 21,854 63.9%2 7,322 21.4%3 3,015 8.8%4 1,168 3.4%5 450 1.3%6 199 0.6%7 88 0.3%

8+ 114 0.3%

Presenter

Presentation Notes

Modal number of patient appointments with an IBHC during the monitoring period is one.



Patients treated by IBHCs for conditions of interest during monitoring period

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Condition Total PercentAnxiety 7,560 22.1%Adjustment 5,779 16.9%Sleep 4,271 12.5%Depression 2,660 7.8%Nicotine 849 2.5%Pain 790 2.3%Obesity 678 2.0%PTSD 574 1.7%Other conditions 9,448 27.6%

Presenter

Presentation Notes

Number of patients treated for conditions of interest indicated in any diagnostic position by IBHCs during the monitoring period. Patients may fall into more than one category.



Encounters with PCC feedback and BHM-20 administration

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Number of Encounters

Percent of Encounters

PCC Feedback 41,213 82.2%1

BHM-20 Administered

34,620 75.1%2

1 Excludes phone encounters2 Excludes phone and group encounters

Presenter

Presentation Notes

Goal is 100%



Current Procedural Terminology (CPT) codes used

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CPT Code Total Encounters

96127 Brief Behavioral Assessment 34,031 (35.7%)

96152 Health & Behavior Intervention, Individual 24,801 (26.0%)

96150 Health & Behavior Assessment, Individual 19,830 (20.8%)

96151 Health & Behavior Reassessment 4,259 (4.5%)

90832 Psychotherapy, 30 minutes 2,648 (2.8%)

98969 On-line Medical Evaluation 2,340 (2.5%)

96153 Health & Behavior Intervention, Group 1,888 (2.0%)

90834 Psychotherapy, 45 minutes 683 (0.7%)

Other Other 2,673 (2.8%)

Presenter

Presentation Notes

The CPT coding provides one window for understanding fidelity to PCBH model (e.g., brief visits, group interventions for pop health, etc.) and to DoD-specific guidance for coding. Highlight 90834 (0.7%) “Other” Category includes: 96160 Administration of Health Risk Assessment – 2,132 (2.2%) 90885 Other psychiatric service or procedures – 541 (0.6%)



Average utilization (mean IBHC encounters per day worked)

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Quarter Encounters PerDay

FY18Q2 5.45

Presenter

Presentation Notes

Includes all ages (pediatrics included); group encounters, and telephone encounters


Program Fidelity, FY17Q2-FY18Q2

IBHC utilization over past five quarters

29

4.47

5.06 5.135.37 5.45

1

2

3

4

5

6

FY17Q2 FY17Q3 FY17Q4 FY18Q1 FY18Q2

Mean IBHC Encounters Per Day Worked

Presenter

Presentation Notes

Changes coincide with specific training and implementation efforts to increase utilization Have increased by 1 encounter per day over the entire DoD in past year


Patient Outcomes, FY18Q2

• BHM-20 is primary patient outcome measure for program monitoring– Global Mental Health (GMH) score

• Comprised of all 20 items• Assesses a range of symptoms, functioning, well-being• Reliable change threshold is + 0.72

– Life Functioning (LF) scale• Comprised of four items• Assesses functioning in work/school, intimate relationships social

relationships, life enjoyment (recreation/leisure activities)• Reliable change threshold is + 0.87

• Other measures are included based on presenting problem

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Presenter

Presentation Notes

From FY18Q2 IBHC Monitoring Report: “The reliable change index is used to determine the number and proportion of patients with two or more administrations of a measure who demonstrated reliable deterioration, reliable improvement, or no (reliable) change. Reliable change is used to “determine whether the magnitude of change for a given [patient] is statistically reliable” (Jacobson & Truax, 1991, p. 12). This measure draws on the established psychometric properties of each scale in order to create a threshold for determining the degree or magnitude of change that must occur in order to classify that difference as clinically significant or reliable. “ Other measures could include GAD-7, PHQ-9, BMI, ISI, etc.



Acuity of patients (based on BHM-20 GMH score) with a first IBHC encounter in the monitoring period

31

25%

17%

8%11%

39%

Normal Mild Moderate Severe No data

Presenter

Presentation Notes

Note: Total number patients lower because it does not include any patients who had an IBHC appt in the prior quarter



Patients1 exhibiting reliable change2 in BHM-20 GMH and LF scales

1Includes only those patients with baseline scores outside the normal range2Outcome scores from the three months prior to the monitoring period also included in analyses

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BHM-20Scale

Mean Initial Score

Reliable Deterioration

No Change Reliable Improvement

GMH 2.26 127 (2.0%) 4,682 (74.6%) 1,470 (23.4%)

LF 1.72 195 (3.0%) 4,626 (70.3%) 1,763 (26.8%)

Presenter

Presentation Notes

Compared first to last BHM20 scores for patients who had a first IBHC appt in the prior or current monitoring period, and an IBHC appointment in the current monitoring period (to best capture the magnitude of change over time) We also did significance testing (paired sample t-tests): all BHM20 change scores were statistically significant at the <.001 level


Lessons Learned

• Identify and operationalize core competencies for your system; plan how you will measure them

• Establish minimum requirement for use of standardized measures with all patients− Essential for program monitoring− Aids IBHC in providing measurement-based care

• Build data-mining capability within EHR − Include desired fidelity and outcome metrics − Ensure workflow and structure of EHR allows for ease of documenting

key data

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Lessons Learned, cont’d

• If limited ability to hire BH providers experienced in integrated care, provide training to develop (and demonstrate) core competencies

• Regardless of experience level, provide some degree of initial training and skills verification, as well as process for ongoing performance monitoring

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Q & A

35

36

Integrated Primary Care Competency Based Training in the

Department of Veterans Affairs

VETERANS HEALTH ADMINISTRATION 37

With appreciation to our VHA PCMHI Competencies Training Development

Workgroup and Program Evaluation Partners

• Jessica Ackermann• Peggy Arnott• Joel Baskin• Greg Beehler• Peggy Bramlet• Katherine Dollar• Pat Dumas• Brad Felker• Wade Goldstein• Joe Grasso• David Hunsinger

• Karey Johnson• Elyse Kaplan• Lisa Kearney• Johanna Klaus• Andy Pomerantz• Elizabeth Scheu• Beret Skroch• Katharine Vantreese• Tanya Workman• Laura Wray• Erin Zerth

Presenter

Presentation Notes

Kathy: A workgroup of national and field subject matter experts in IPC was formed to create a three phase curriculum:

VETERANS HEALTH ADMINISTRATION

Need for Specific Integrated Primary Care Training• Most mental health providers lack skills necessary to succeed in

Integrated Primary Care (IPC, Serrano et al., 2018).

• Hiring and placing mental health providers without IPC training in PC settings is insufficient.– Function as independent practitioners– Provide general or specialty mental health services

• IPC requires mental health providers to work differently.– fast-paced– team-based care settings

• Necessitates the development of new skills to promote successful collaboration and same-day access to services (Dollar et al., 2018).

38

Presenter

Presentation Notes

DAVE HUNSINGER? Most mental health providers do not have background or specific training to practice in integrated settings (Serrano et al., 2018). Simply hiring and placing mental health providers with no specific background in PC into these settings may lead to the development of traditional MH settings in primary care, rather than truly integrated care practice. Integrated primary care requires adjustment of mental health providers to work in fast-paced, team-based care settings requiring the development of new skills to promote successful collaboration and same-day access to services, a hallmark of integrated care models (Dollar et al., 2018). Dollar, K. M., Kearney, L. K., Pomerantz, A. S., & Wray, L. O. (2018). Achieving same-day access in integrated primary care. Families, Systems, & Health, 36(1), 32-44. doi:10.1037/fsh0000327 Serrano, N., Cos, T. A., Daub, S., & Levkovich, N. (2017). Using standardized patients as a means of training and evaluating behavioral health consultants in primary care. Families, Systems, & Health, 35(2), 174-183. doi:10.1037/fsh0000272


Need for Specific IPC Training• Most Primary Care providers are not familiar with IPC.

– Interaction skills must be learned– Mechanisms for educating PCPs on services and their benefits– IPC requires modification of work flows

• Large deficits existed with Primary Care Mental Health Integration (PCMHI) – Same day access to PCMHI was routinely only occurring 1/3 of the time– PCMHI reach was not at desired levels

• Surveys and site visits revealed significant variability in implementation across sites. – Standardization of training offers a common knowledge base for

implementation39

Presenter

Presentation Notes

DAVE HUNSINGER? Most mental health providers do not have background or specific training to practice in integrated settings (Serrano et al., 2018). Simply hiring and placing mental health providers with no specific background in PC into these settings may lead to the development of traditional MH settings in primary care, rather than truly integrated care practice. Integrated primary care requires adjustment of mental health providers to work in fast-paced, team-based care settings requiring the development of new skills to promote successful collaboration and same-day access to services, a hallmark of integrated care models (Dollar et al., 2018). Dollar, K. M., Kearney, L. K., Pomerantz, A. S., & Wray, L. O. (2018). Achieving same-day access in integrated primary care. Families, Systems, & Health, 36(1), 32-44. doi:10.1037/fsh0000327 Serrano, N., Cos, T. A., Daub, S., & Levkovich, N. (2017). Using standardized patients as a means of training and evaluating behavioral health consultants in primary care. Families, Systems, & Health, 35(2), 174-183. doi:10.1037/fsh0000272


SAMHSA Competencies

I. Interpersonal Communication

II. Collaboration & Teamwork

III. Screening & Assessment

IV. Care Planning & Care

CoordinationV. Intervention

VI. Cultural Competence &

Adaptation

VII. Systems Oriented Practice

VIII. Practice Based Learning & Quality

Improvement IX. Informatics

40

Presenter

Presentation Notes

Kathy

http://www.integration.samhsa.gov/workforce/interpersonal-communication

http://www.integration.samhsa.gov/workforce/collaboration-and-teamwork

http://www.integration.samhsa.gov/workforce/screening-and-assessment

http://www.integration.samhsa.gov/workforce/care-planning-care-coordination

http://www.integration.samhsa.gov/workforce/intervention

http://www.integration.samhsa.gov/workforce/cultural-competence-adaptation

http://www.integration.samhsa.gov/workforce/systems-oriented-practice

http://www.integration.samhsa.gov/workforce/practice-based-learning-and-quality-improvement

http://www.integration.samhsa.gov/workforce/informatics


National Competency Training Program

41

Phase I

Conducted virtuallyBaseline assessment of competency, review of written materials, and online trainings Must be completed to attend in-person Phase II training

Phase II2.5 day in-person training with on hands-on role playing and demonstration skillsAt conclusion of passing of competency assessment, participants receive certification in CCC and/or CM (trainers must complete both)

Phase IIIVirtual follow-up at 3/6 months with role play and survey assessmentOngoing fidelity reviewed through self-report measures and national data* Booster training provided until fidelity is obtained.

Note: CCC = Co-located Collaborative Care, CM = Care Management *Looks at fidelity across time at the provider and clinic levels (e.g., same day access, 30

minute appointments, penetration, return to clinic frequency, etc.)

Presenter

Presentation Notes

Kathy The proposed model includes three phrases of training (see Appendix A for detailed descriptions) with pre and post assessments of competency required for certification. Phase I: Conducted completely virtually Includes baseline assessment of competency, review of written materials, and online trainings Must be completed to attend in-person Phase II training Phase II: Includes a three day in-person training, focused primarily on hands-on role playing and demonstration of all CCC and CM skills At conclusion of passing of competency assessment, participants receive certification in CCC and CM Phase III: Involves virtual follow-up meetings at 3 and 6 months with a national subject matter Fidelity to the model will be reviewed through self-report measures and national administrative data Follow up meetings will also include sustained skills-based competency demonstrations. Those not demonstrating fidelity will be required to participate in remediation training until fidelity is obtained.


Decentralized Train the Trainer Model

Developers and SMEs

Step 1:

Regional Lead

Trainers (June 2017)

Step 2:

Facility Lead

Trainers(Sept. 2017)

Step 3:

All 1600+ Local

Clinicians

(Through Dec 2018)

42

Presenter

Presentation Notes

Kathy Decentralization of Training. Rather than training all 1500+ PCMHI providers nationally, a regional model will be implemented to include a train-the-trainer approach with a focus on certification in both co-located collaborative care (CCC) and care management (CM), reflecting the model of the DoD (Hunter et al., 2014). The national rollout would occur in a stepped process as follows. Step 1: Training of VISN Level Trainers An initial national training would involve a smaller group of 18 individuals (one per VISN) who would be selected by the VISN based on their expertise in PCMHI and requirement to assist with follow-up training at the VISN and local level for each facility in the VISN. VISN level trainers will obtain certification in both CCC and CM at completion of the Phase II training. Step 2: Training of One Facility Trainer at Each Health Care System by VISN and National Level Trainers The 18 VISN Level trainers will commit to assisting national experts with providing one training in their VISN, where at least 1 facility PCMHI provider would be present. Step 3: Training of Local PCMHI Providers: Each VISN trainer would assist each local facility trainer in conducting the Phase II training at each local facility in their VISN (or if preferred the VISN could conduct one training with all PCMHI providers present from each facility if travel is approved). VISN and facility level trainers would be provided additional virtual training in the skills necessary to train providers in this model. VISNs would be given 18 months to complete training for all PCMHI providers across all facilities. Additional implementation support through the Center for Integrated Healthcare will be available for sites requesting assistance.


Program Evaluation: Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework

43

Element Metrics Data Source

Reach Overall % of PCMHI staff who attend program, including demographics

% of those reaching initial certification% of those maintaining certification

Self-Report Surveys

Behavioral Demonstration

Effectiveness:(Including Fidelity)

Role play demonstrations Behavioral Demonstration

Adoption Penetration Rate (Facility Level) VA Administrative Databases

Implementation PPAQ-2 CCC & CM (Provider Level)Average Appointment Length (Provider & Facility Level)Average Return to Clinic Rate (Provider & Facility Level)

Self-Report SurveysVA Administrative Databases

Maintenance Items above at 3 AND 6 month follow-up Noted above

Presenter

Presentation Notes

GREG


Overview of Provider Participation• Massive, complex data collection process

– Survey data, admin data, demonstration data at baseline, 3, and 6 months– Staggered initiating of cohorts with individualized time frames for follow-up

• In first 6 months of rollout, 58 training cohorts initiated

• Target: 2,005 participants currently scheduled to be trained by Dec 31, 2018

• 1,207 participants trained to-date across 83 training cohorts• Based on educational background, training program participants

were largely similar to VA National PCMHI staff with 2 exceptions: – Psychologists were slightly over-represented in our program

• 44% v. 36% nationally– Physicians were slightly under represented in our program

• 10% v. 16% nationally 44

Presenter

Presentation Notes

GREG: WE COULD TRIM THIS DOWN TOO


Reach: Trainee Characteristics (Regional Trainer & Facility Leads)

Characteristic Regional Trainern = 19

Facility Leadn = 95

Current integrated care role n (%) n (%)PCBH-only 11 (57.9) 55 (57.9)Both PCBH and CM 6 (31.6) 39 (41.0)CM-only 2 (10.5) 1 (1.1)

Years in current integrated care role≤2 2 (10.5) 24 (25.3) 3-5 3 (15.8) 32 (33.6)>5 14 (73.7) 39 (41.0)

Educational BackgroundPsychologist (PhD/PsyD) 15 (78.9) 71 (74.7)MSW/LCSW (Masters-Level Provider) 2 (10.5) 15 (15.8)RN/APN 1 (5.3) 4 (4.2)Physician 1 (5.3) 2 (2.1)Other 0 3 (3.2) 45

Response rates: 73% Regional Trainers; 75% Facility Leads.

Presenter

Presentation Notes

Greg: THESE WOULD ACTUALLY BE CONSIDERED THE START OF RESULTS


Implementation - Regional Trainer Outcome Improvements in Co-Located Collaborative Care

46

Note: Repeated Measures ANOVA utilized for statistical analyses. Scores range from 1 to 5 (higher scores=higher fidelity) †Higher scores better (e.g., less prohibited behaviors utilized). Improvements (but non-significant) for clinical scopes and intervention, prohibited, and referral management and care continuity* Statistically significant.

4.25

4.3

4.35

4.4

4.45

4.5

4.55

4.6

4.65

Baseline 3 month 6 months

Practice and Session Management*

3.95

4

4.05

4.1

4.15

4.2

4.25

4.3

4.35

4.4

4.45


Consultation, Collaboration, & Interprofessional Communication*


Implementation Regional Trainer Outcome: Improvements in Care Management

47

Note: Repeated Measures ANOVA utilized for statistical analyses. Scores range from 1 to 5 (higher scores=higher fidelity) ). Improvements (but non-significant) for panel management.* Statistically significant.

4.3

4.35

4.4

4.45

4.5

4.55

4.6

4.65


Pt. Education, Self Management Support,

Psychological Intervention*

3.1

3.2

3.3

3.4

3.5

3.6

3.7


Supervision and Care Coordination*

3.7

3.8

3.9

4

4.1

4.2

4.3

4.4

4.5

Baseline 3 month 6months

Measurement Based Care and Protocol Adherence*


Implementation Facility Trainer Outcome:Co-Located Collaborative Care

Note: Repeated Measures ANOVA utilized for statistical analyses. Scores range from 1 to 5 (higher scores=higher fidelity) †Higher scores better (e.g., less prohibited behaviors utilized)* Statistically significant.

48

3.25

3.3

3.35

3.4

3.45

3.5

3.55

3.6

3.65

3.7


Clinical Scope and Interventions*

4.1

4.15

4.2

4.25

4.3

4.35

4.4

4.45

4.5


Practice and Session Management*


Implementation Facility Trainer Outcome: Co-Located Collaborative Care

Note: Repeated Measures ANOVA utilized for statistical analyses. Scores range from 1 to 5 (higher scores=higher fidelity) †Higher scores better (e.g., less prohibited behaviors utilized)* Statistically significant.

49

3.8

3.85

3.9

3.95

4

4.05

4.1

4.15

4.2

4.25


Prohibited†*

4.1

4.15

4.2

4.25

4.3

4.35

4.4

4.45


Referral Management and Care Continuity*

3.95

4

4.05

4.1

4.15

4.2

4.25

4.3

4.35


Consultation, Collaboration, & Interprofessional Communication*


Implementation Facility Trainer Outcome: Care Management

50

Note: Repeated Measures ANOVA utilized for statistical analyses. Scores range from 1 to 5 (higher scores=higher fidelity) * Statistically significant.

4.15

4.2

4.25

4.3

4.35

4.4


Patient Identification*

4.1

4.15

4.2

4.25

4.3

4.35

4.4

4.45


Pt. Education, Self Management Support, Psychological Intervention*


Implementation Facility Trainer Outcome: Care Management

51

Note: Repeated Measures ANOVA utilized for statistical analyses. Scores range from 1 to 5 (higher scores=higher fidelity). ). Improvements (but non-significant) for panel management* Statistically significant.

3.35

3.4

3.45

3.5

3.55

3.6

3.65


Supervision and Care Coordination*

3.75

3.8

3.85

3.9

3.95

4

4.05

4.1

4.15

4.2


Measurement Based care and Protocol Adherence*


But what about actual change in provider observed behavior and clinic behavior?

This is all self report….

52

PPAQ Self Report

Actual Clinic Administrative

Data

Standardized Case Role

Play

Regional Trainers Baseline: 92.3% Pass3-Month: 100% Pass6-Month: 100% Pass

Facility TrainersBaseline: 81.8% Pass3-Month: 93.4% Pass6-Month: 100% Pass


Implementation Trainer Outcomes: Administrative Data

Note: Repeated Measures ANOVA utilized for statistical analyses. Scores range from 1 to 5 (higher scores=higher fidelity) * Statistically significant.

53

40%

45%

50%

55%

60%

65%

70%


Regional Trainer30 Minute Ratio*

40%

45%

50%

55%

60%

65%

70%


Facility Trainer30 Minute Ratio*


Overarching Outcomes for Regional/Facility Trainers• Self reported improvement on PPAQ –

even stronger with facility leads• Greater fidelity with actual clinic

behavior of 30 minute appointments– Implications for improvements in

same- day access• Particularly notable findings given this

sample included those already demonstrating higher fidelity IPC practices.

• Next steps: changes in frontline IPC provider behavior! (SNEAK PEEK!)

54


Lessons Learned and Implications for Other Systems

55

• Process for trainer selection is critical.• Sustainable training models require significant oversight and

systems to support standardization (including data management systems)

• Prepare for trainer turnover.• Create mechanisms for continual feedback on the training itself, as

well as provider behavior and clinic changes.• Get leadership buy-in early. Report successes regularly. • Address interdisciplinary concerns with interprofessional

education. Create training for PC and MH teams together.

Presenter

Presentation Notes

Kate ? The process for selection of trainers is critical. Assess for effects of trainer fidelity. Sustainable training models require significant oversight and systems to support standardization for all new providers hired in your system. Importance of regular check-ins Standardized email reminders of tasks Initial training processes Level of attention to detail required for front line trainers Do not underestimate the critical need for data management systems for program evaluation and implementation. Prepare for trainer turnover. Create mechanisms for continual feedback on the training itself as well as provider behavior and clinic changes. Address interdisciplinary concerns with interprofessional education. Get leadership buy-in early. Report successes regularly. Very important for start up and for addressing “bumps in the road” If possible, require training for PC and MH teams together. Provide both individual and clinic focused training (e.g., panel management changes).


Psychiatrists in Integrated Care

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• Collaborative Care Model- APA online training• Controversy in the field over role of psychiatry in PCMHI

– Does it discourage PCP taking responsibility?– Adds ability to treat more complex conditions

• But training challenges– “you’re trying to turn us into psychologists”– “I need much more time”

• Solutions:– Get the right people– 5As are S.O.A.P. with different letters

Presenter

Presentation Notes

The process for selection of trainers is critical. Assess for effects of trainer fidelity. Sustainable training models require significant oversight and systems to support standardization for all new providers hired in your system. Importance of regular check-ins Standardized email reminders of tasks Initial training processes Level of attention to detail required for front line trainers Do not underestimate the critical need for data management systems for program evaluation and implementation. Prepare for trainer turnover. Create mechanisms for continual feedback on the training itself as well as provider behavior and clinic changes. Address interdisciplinary concerns with interprofessional education. Get leadership buy-in early. Report successes regularly. Very important for start up and for addressing “bumps in the road” If possible, require training for PC and MH teams together. Provide both individual and clinic focused training (e.g., panel management changes).


Questions/Discussion

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• What training tools might you wish to develop or apply in your own setting?

• What are actionable next steps you would like to take when you return to your clinic to improve fidelity of yourself or the team you oversee?

Presenter

Presentation Notes

Laura to Lead


Resources

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Fidelity Instrument• The Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ): Available

online - https://www.mirecc.va.gov/cih-visn2/PPAQ.aspTraining Tools for Core Elements• Primary Care Behavioral Health/Co-located Collaborative Care Functional Assessment

Training Tool (Based on 5As) - https://www.mirecc.va.gov/cih-visn2/Documents/Clinical/CCC_Functional_Assessment_Tool.pdf

• Primary Care Behavioral Health/Co-located Collaborative Care Follow-Up Appointment Training Tool (Based on 5As) - https://www.mirecc.va.gov/cih-visn2/Documents/Clinical/CCC_Follow_Up_Tool.pdf

• Collaborative Care Management/Care Management Initial and Follow-up Telephone Appointment Training Tools - https://www.mirecc.va.gov/cih-visn2/clinical_resources.asp

• Introductory Script for IPC Providers: https://www.mirecc.va.gov/cih-visn2/Documents/Clinical/BHP_Intro_Script.pdf

https://www.mirecc.va.gov/cih-visn2/PPAQ.asp

https://www.mirecc.va.gov/cih-visn2/Documents/Clinical/CCC_Functional_Assessment_Tool.pdf

https://www.mirecc.va.gov/cih-visn2/Documents/Clinical/CCC_Follow_Up_Tool.pdf

https://www.mirecc.va.gov/cih-visn2/clinical_resources.asp

https://www.mirecc.va.gov/cih-visn2/Documents/Clinical/BHP_Intro_Script.pdf


Resources

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Rating Tools

• VA’s Core Competency Tool – contact us – [email protected]• DoD IBHC Core Competency Tool v3.0 -contact us -

[email protected]• Behavioral Health Consultant Outcome Rating Scale (Serrano et

al., 2017) - Serrano, N., Cos, T. A., Daub, S., & Levkovich, N. (2017). Using standardized patients as a means of training and evaluating behavioral health consultants in primary care. Families, Systems, & Health, 35(2), 174-183. doi:10.1037/fsh0000272

mailto:[email protected]

mailto:[email protected]


Key Questions to Implement Trainingat Your Own Site

Step 1: Needs Assessment

• What are your training needs?

• Provider prior competency based training?

Step 2: Measures of

Success• Provider fidelity

measures (PPAQ?)• Clinic level outcomes

– Same Day access? Penetration rate?

• Competency Pass Rate?

• Tracking systems for program evaluation and data management

Step 3: Stakeholders

• PC/MH Leadership• Frontline staff• Support staff• Executive leadership

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Key Questions to Implement Training at Your Own Site

Step 4: Curriculum

Development

• Which model? CoCM? Behavioral Health?

• DoD? VA? Other?• APA Curriculum

available free• Consider prior

knowledge & expertise • Virtual training? In

person training? Combination?

• Regional train-the-trainer?

• Document storage and dissemination

Step 5: Pilot

• Identify initial “class”• Train trainers• Complete pre-

assessment• Complete prework• Gather 3 and 6 month

outcome data

Step 6: Implement

• How many sites?• Build Communities of

Practice• How to continue to

train trainers? • Re-evaluate and revise

curriculum

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Presenter

Presentation Notes

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