Integrating Mental Health into Primary Care: The BHL Model

Integrating Mental Health into Primary Care: The BHL Model

VISN4-Healthcare NetworkDepartment of Veterans Affairs

UPENN / VISN 4 MIRECC2

Where is Mental Health / Depression Care Delivered

Depression: FY 2002: 64% of all outpatient depression visits for elderly occur in primary care (only 25% by psychiatrists) (Harmon et al 2006)

Nearly half of all antidepressants, sedatives, and hypnotics were prescribed by a primary care provider (20% of all antipsychotics) (cdc.gov/nchs/data/series/sr_13/sr13_157.pdf)


Alcohol Use Disorders

02468

1012141618

Alcohol Abuse/Dependence

AlcoholDependence

SeekingTreatment

Grant BF et al. Arch Gen Psychiatry. 2004;61:807-816.SAMHSA, Office of Applied Studies. Substance Dependence, Abuse and Treatment Tables; 2003IMS - MAT March 2006


How is Care Provided?

Key Facts:• Depressive disorders are common

(10-15% prevalence)

• Less than 50% of patients have treatment initiated

• Less than 50% are adequately treated

• Rates of follow-up to new treatments (HEDIS) ~20%


The Patient’s Perspective

Integrated Care

Referral Care

Odds Ratio

Depression 75 % 52 % 2.86 [2.26,3.61]

Anxiety 71 % 56 % 1.93 [0.69, 5.40]

At-risk Drinking 61 % 34 % 3.09 [2.07, 4.63]

Overall 71 % 48 % 2.84 [2.35, 3.43]

Engagement = at least one contact with the mental health specialist.


The BHL Program


So What’s the BHL Program?

A clinical program providing prevention and treatment services designed around the following principals:

• An emphasis on use of structure assessments and algorithms

• An emphasis on the use of care management modules• Patient centered care – incorporating convenience and

preference• A focus on both patients and providers as the stakeholders• A population based approach to care• A focus on self- management and collaborative decision

making• A focus on open access


What are the (potential) parts?

Specialty Care (usually PhDs and MDs)• Consultative• Brief therapies

Care Management (BHSs usually RNs, SW)• Depression, Alcohol,(abuse and dependence), Anxiety , Pain, Smoking

Cessation, Referral Management (optimizing specialty care)• PTSD, Bipolar, Dementia

Prevention and Health promotion (mix RNs, SW, PhDs, counselors, etc)

• Watchful Waiting for subsyndromal symptoms• Problem solving therapy• Caregiver and family support• MOVE for weight • Education• Adherence


Step 1

1. Identification and triage • Primary care screening• Primary care assessment• Self-referral• Outreach• Prescribing

• Driving principal – we take anyone you are concerned about.


Initial Assessment ModulePhiladelphia BHL data from 1/2008 to 1/2010

• 5626 referred• 79% had a complete assessment

– PTSD (85%) – Depression (81%)– MH and SA problems (79%)– Alcohol problems (76%)– Drug problems (71%)

• Only 7% refuse!


Impressions from Initial Assessment

Enormous range of psychopathology

Greatly appreciated by patients

Phone vs face to face – access or provider comfort

Greatly appreciated by primary care providers

A great tool for research recruitment


Step 2 – Treatment OptionsPatient Identification

Screening / Clinical Assessment / Case-finding

Initial Assessment

Initial triage / treatment plan

No treatment &

Refusal of care

Patient Education

and Promote Self-Care

Specialty Care Care Management Prevention / Health Promotion


Optimizing Specialty CareReferral Management

• Different methods of case finding lead to different rates of complex patients.

30-50% of patients may have psychosis, PTSD, Illicit drug use, Severe depression, bipolar disorder, suicidal ideation

Limited evidence for treating these patients in primary care

• Problem: Low rates of MH/SA treatment engagement (30 – 40%)

Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)


Referral Management

Brief workbook based intervention designed to enhance engagement in specialty MH/SA services

Focus • Enhancing motivation• Addressing practical issues• Preparing the patient


Referral Management Module

Attended 1st

Appointment

Motivational Session 70%

Control Group 32%

Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)

p = .006p = .006


Care Management Modules

Care Management is algorithm driven care delivered by a Behavioral Health Specialist as an adjunct to primary care.

• Depression• Panic Disorder• Generalized Anxiety disorder• Alcohol Dependence• Pain• ?PTSD


Disease ManagementDisease Management Percent of Patients Achieving

Remission

0.0

10.0

20.0

30.0

40.0

50.0

4Months

8Months

12Months

18Months

24Months

% R

emit

ted

ControlIntervention


Change in Depressive Symptomatology over the Course of Monitoring (n=140)

4

5

6

7

8

9

10

11

Baseline 2 Weeks 6 Weeks 9 Weeks

Assessment

Me

an

PH

Q S

co

re


First 12 weeks

Issues addressed early• 26% report non-adherence to treatment• 12% report significant side effects

22% managed (dose change or med change)

53% symptom remission


Alcohol Care Management

Two components• Non dependent

Brief alcohol intervention - Time-limited (20 minutes in 1-3 brief sessions) and targets alcohol misuse

• DependentPharmacotherapyReferral management


Alcohol Care Management

BHS meets with patient for 16 sessions over 6 months

Collaborates with PCP to:• Increase motivation to abstain• Be supportive and optimistic• Naltrexone• Encourage AA attendance• Provide education (health risks and detrimental

outcomes)


What patients said

“I’ll take the chance on getting the nurses help”

“I have no interest in going back to the ARU, I am not that sick”

“I could use a med to help with my cravings”


Preliminary Outcomes

ACM• 90% (55/61) had at least 1 face to face visit

• mean #visits = 10.2 (range 0-28)


Prevention Services

Sub syndromal anxiety and affective disorders• Most common treatment is an SSRI but no

evidence of efficacy• Psychotherapy is time consuming and not without

risks• Limited research on problem solving therapy and

other brief focused interventions


Close Monitoring

8 Weeks of prospective monitoring by telephone using the PHQ-9

Patient choice for treatment engagement is also allowed

Those with persistent symptoms or who choose are enrolled in depression disease management


Study Results

223 Subjects randomly assigned to WW (130) or usual care (93)

In the WW arm• 81 (62%) no further treatment required• Improved MH outcomes• Improved Physical functioning


What are the keys to success?

A plan – including training, supervision, etc

BHL software to promote measurement based care and to provide decision support and tracking

Great staff


Panel management


Patient History


Summary of Interview


Patient and chart documents


Implementation Factors

Facility • Small clinics may be collocated and collaborative just by size• Location – more rural clinics manage more BH in primary care

Leadership – very important to resource management Access to Specialty care – factors into how complex cases are managed Staff – highly variable on all sides Scope – the more limited typically the less useful or hard to use Method of case finding – screening, clinical exam, self referral leads to very different

case mixes and thus different program needs Marketing and program description – what you are known for.

Resources and reimbursement


Conclusions Depression and anxiety care management Works!

• By telephone or face to face• Reduced mortality• Reduced symptoms• But not for complex patients

Close monitoring Works!• For subsyndromal depressive symptoms waiting and targeting

care management is effective Referral management Works!

• For complex patients with affective illnesses, substance abuse or more other complex presentations.

A Brief alcohol intervention Works!• For patients without alcohol dependence

Alcohol Care Management Very Promising!• For patients with alcohol dependence


Thank You

David Oslin, MDJohanna Klaus, PhDElena Volfson, MDSteve Sayers, PhDShahrzad Mavandadi, PhD

Health Specialists Lisa Dragani, BSN, RNSuzanne DiFilippo, RNTrisha Stump, BSN, RNShani Simmons-Wilson, BSN, RNJanet Sherry Cocozza, MA, RN, APN.C

Coordinator Erin Ingram, BA

Health Technicians –

Megan Aiello, BS

Lauren Witte, BA

Victoria Farrow, BS

Kelly Stracke, BA

Natacha Jacques, MS

Chris Cardillo, BS

Henry Quattrone, BS

Lindsey Reid, BA

Brian Cox, BS

a host of others

Funders: NIH, VA, BCBS

Integrating Mental Health into Primary Care: The BHL Model

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