Integrating Primary Care & Behavioral Health: … Primary... · Certificate Program in Primary Care...

Certificate Program in Primary Care Behavioral Health© The Center for Integrated Primary Care

Integrating Primary Care & Behavioral Health:

Programs and Cultures

Alexander Blount, EdD Director, Center for Integrated Primary Care University of Massachusetts Medical School

1


c. Center for Integrated Primary Care 2

Learning Goals �  Par4cipants will be able to:

�  Ar4culate the reason for special training to do behavioral health care in primary care se?ngs.

�  List three models of behavioral health delivery in primary care.

�  Explain the general role of Behavioral Health Consultant.


3 3

The Current Transformation in Healthcare is “evidence-based”

�  Evidence of the impact of primary care on cost and quality of medical care.

�  Evidence of the role of behavioral health needs in driving up the cost of medical care, far beyond what is spent on behavioral health treatment.

�  Evidence of the impact of treatable behavioral health needs on the productivity of America’s workforce, above and beyond the cost of medical care.


What makes some medical care Primary Care?

�  First Contact – When you need to “go to the doctor”, it is who you see.

�  Continuous – Or “longitudinal”. Know you in context. Can tell when one person says “I’m not feeling so good” that it’s an emergency and when another says “I’m dying” it is time for a brief soothing chat.

�  Comprehensive – For any concern “You have come to the right place.”

�  Coordinating – “And if we don’t have it, we’ll help you find it.”

�  Care for the “undifferentiated” patient – “You don’t have to know what is wrong before you come to us.” Specialists see pre-defined patients & problems whereas most problems come in combinations. “The sicker you are, the sicker you are.”

4


5


6


7 Certificate Program in Primary Care Behavioral Health The Center for Integrated Primary Care


9

�  The vast majority of people (+/- 80%) will not accept (act on) a referral to specialty MH offered by a PCP. It is care in primary care or none.

Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system Arch Gen Psychiatry. 1993 Feb;50(2):85-94.

Primary Care is the only setting for a population approach to behavioral health


10

Primary Care is full of behavioral health needs, many unrecognized.

�  Mental Health �  Substance Abuse �  Health Behavior Change �  “Ambiguous” Illnesses �  Chronic Illness Behavioral Needs �  “Unfamiliar” Cultural Expressions of

Problems �  Discovered and undiscovered trauma hx �  Serious mental illness, in and outside of MH

tx


11

Behavioral Health Needs Assessment in Primary Care

PHQ-3000 Merillac 500 �  Major Depression = 10% 24% �  Panic Disorder = 6% 16% �  Other Anxiety Disorders = 7% 21% �  Alcohol Abuse = 7% 17% �  Any Mental Health Dx = 28% 52%


12

Prevalence of Behavioral Health Problems in Primary Care

Unhealthy Behaviors

�  Smoking = 20% �  Obesity = 30% �  Sedentary lifestyle = 50% �  Non-adherence = 20 - 50%


13

Culture Impacts Depression Culturally Syntonic Approaches

Signs of Depression found Cross-Culturally

�  Appetite changes �  Sleep changes �  Psychomotor agitation or

retardation �  Decreased energy �  Decreased libido �  Diminished ability to think or

concentrate

Signs of Depression found in “Western” Cultures

�  Self-deprecation �  Hopelessness �  Guilt �  Suicidality Pfeiffer, W. (1968). The symptomatology of depression

viewed transculturally. Transcultural Psychiatry Research Review 5: 121-123.


Relationship of Depression to Diabetic Symptoms

0 1 2 3 4 5 6

Cold hands and feet

Numb hands and feet

Pain in hands and feet

Polyuria

Excessive hunger

Abnormal thrist

Shakiness

Blurred vision

Feeling faint

Daytime sleepiness

Diabetic with Complications Odds RatioDiabetic and Depressed Odds Ratio

Ludman et al, Gen Hosp Psychiat 26:430-436, 2004.


15

10 most common complaints in adult primary care 15% x organic pathology found

(Kroenke & Mangelsdorff, 1989)

chest pain back pain

fatigue shortness of breath

dizziness insomnia

headache abdominal pain

swelling numbness


16 16

CBT in the Exam Room


17

Categories of Relationship between Collaborating Medical and Behavioral Health Services

❏ Coordinated = Behavioral services by referral at separate location with formalized information exchange.

❏ Co-Located = By referral at medical care location

❏ Integrated = Part of the “medical” treatment at medical care location

Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems & Health: 21, 121-134.


18

Coordinated Care �  Coordinated care elements:

•  Appointment arrival notification •  Clinical information exchange protocols •  Coordinated treatment planning and/or problem solving

for complex patients or as needed �  Expect communication to go both ways.

•  MH clinicians are healthcare professionals who should be knowledgeable about the patient’s health issues.

�  Ask about the person’s health behavior goals and consider them in treatment planning.


19

Coordination Plus - Specialty Mental Health as a consultant to Primary Care.

�  Massachusetts Child Psychiatry Access Program

�  For adults, in NC Medicaid pays for the time of the PCP and the psychiatrist, as patient visit rates, for consultation about a patient, whether the psychiatrist has met the patient or not.

�  When behavioral health clinicians are working in primary care, the referrals to specialty care for patients needing longer term work is more likely to be successful.


Co-Located Behavioral Health

Advantages

�  Access greatly improved �  Improved patient & provider

satisfaction �  Cost effective �  Improved clinical outcomes

Challenges

�  Referrals don’t show �  Case-loads fill up �  Slow PCP learning curve �  Communication still difficult

20

Behavioral health in the same space with primary care Involvement by referral Separate behavioral health and medical treatment plans


21

Integrated Primary Care: The IMPACT Treatment Model

http://uwaims.org/about.html

�  Stepped protocol in primary care using antidepressant medications and/or 6-8 sessions of psychotherapy (PST-PC)

. Treat to target �  Collaborative care model includes:

•  Care manager: Depression Clinical Specialist •  Patient education •  Symptom and Side effect tracking •  Brief, structured psychotherapy: PST-PC

•  Consultation / weekly supervision meetings with •  Primary care physician •  Team psychiatrist


22

Substantial Improvement in Depression (≥50% Drop on SCL-20 Depression Score from Baseline)

Response (³50% drop on SCL-20 depression score from baseline)

0

10

20

30

40

50

60

3 6 12

month

perc

ent

Usual care Intervention

P<.0001

P<.0001

P<.0001

Unützer et al, JAMA 2002; 288:2836-2845.


23

Integrated Primary Care: Behavioral Health Consultant

�  Management of psychosocial aspects of chronic and acute diseases

�  Application of behavioral

principles to address lifestyle

and health risk issues

�  Consultation and co-management in the treatment of mental disorders and psychosocial issues


24

Models of Integrated Behavioral Health

- Expanded care management – IMPACT/Diamond - Behavioral Health Consultant model

IMPACT: BHC:

Disease based Program based Research heritage Clinical heritage

Patient outcome evidence Cost and satisfaction evidence Care manager (SW or Psychologist) Behavioral Health Consultant

The models are beginning to converge

Care manager does other behavioral BHC does some care mngment

health and chronic illness added and Case Managers added Array of services beyond disease prgms Beginning disease prgms


25

Fully Integrated Primary Care The System



“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress related physical symptoms, and ineffective patterns of health care utilization.” Peek CJ and the National Integration Academy Council. Executive Summary - Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-1-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013.

http://integrationacademy.ahrq.gov

What makes “Integration?” A consensus on terms:


27

Comprehensive Primary Care Payment (CPCP)

•  Risk-adjusted capitated payment for primary care services

•  3 Tiers of payment: •  1 - PCMH, 2 - PCBH, 3 - SP MH

Quality Improvement Payment

•  Annual incentive for quality performance, based on primary care performance

Payment transformation is coming, eg. Mass.

Shared savings payment

•  Primary care providers share in savings on non primary care spend, including hospital and specialist services

A

B

C


28

The workforce is not ready!

�  Mental health and substance abuse professionals want to do specialty care in the generalist environment of Primary Care.

�  Mental health case managers have little experience in working on issues of health.

�  Medical care managers are mostly nurses and struggle if they have to deal continuously with depressed patients.

�  Physicians, nurses and many MH professionals are used to giving advice and teaching, not to “activating” people and trying to help them reach their goals.

�  Hardly anyone’s training prepares them to think of the behavioral factors of chronic illness or the chronic illness factors in depression and anxiety.


29

Why Primary Care behavioral health is difficult for clinicians trained only in specialty mental health

�  Treat somewhat different population than in Specialty Mental Health services. •  Less disturbed and less diagnostically clear •  Won’t accept “mental health” definition of the problems

they bring •  Broader array of needs.

• BHC must understand medical conditions and practice behavioral medicine and substance abuse care in addition to mental health

�  Status as ancillary provider �  Different routines of time, confidentiality and

instrumentality


30

Generalist Behavioral Health Clinician PCBH is much more than poor SpMH

•  Care Management •  Brief Therapy

•  Cognitive-behavioral •  Solution-focused

•  Behavioral Medicine •  Relaxation/biofeedback/hypnosis •  Health behavior change

•  Family Therapy •  Substance Abuse Counseling •  Child Assessment and Parent Training •  Psychotropic medication input •  Groups and Patient Education •  Community Outreach •  Organizational transformation agent


31

Provider Skill Set and Fit (Discipline is not a good guide to fit)

�  It takes training, or experienced support to get the orientation necessary to learn on the job.

�  Good at making relationships with all of the roles in primary care. (New behavioral health clinicians are inconvenient to everyone.)

�  They must do well in ambiguous situations, dive in rather than wait for an invitation.

�  Because the job integrates the separated worlds the disciplines train people for, ideas about what discipline is needed are often wrong.


32

Integrated Care Requires New Ideas About “Disciplines”

�  Depression care managers – MSWs, nurses, psychologists, NPs

and PAs �  BHC’s – Masters and doctoral clinicians �  Care Managers/Coordinators in the PCMH need both behavioral

health skills and medical knowledge. •  Medically trained people must be “behaviorally enhanced” •  Behaviorally trained people must be “medically enhanced”

�  Paraprofessional counselors – community health workers, promotoras, (“peer” tradition from MH adapted to PC)

�  Modular skill sets vs. disciplines


33

Who trains the Workforce for Integration?

Center for Integrated Primary Care – •  Certificate Program in Primary Care Behavioral Health

• Web Workshops – 36 hours •  Certificate Program in Integrated Care Management

• Web Teaching – 20 hours •  Certificate of Intensive Training in Motivational Interviewing

• Web Teaching – 20 hours, Live practice and coaching http://Umassmed.edu/CIPC/

�  Other Certificate Programs: •  AIMS Center, University of Washington – Training program aimed at psychiatrists and care managers. •  Farleigh Dickinson University

�  Arizona State University offers a doctorate in Primary Care Behavioral Health •  Must already have a license to practice.

Certificate Program in Primary Care Behavioral Health© The Center for Integrated Primary Care 35

Let’s keep in contact

Center for Integrated Primary Care

http://UMassMed.edu/CIPC

[email protected]

Integrating Primary Care & Behavioral Health: … Primary... · Certificate Program in Primary Care...

Documents

Transcript of Integrating Primary Care & Behavioral Health: … Primary... · Certificate Program in Primary Care...