Joseph H. Evans, PhD Munroe Meyer Institute University of Nebraska Medical Center
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Transcript of Joseph H. Evans, PhD Munroe Meyer Institute University of Nebraska Medical Center
Interdisciplinary Behavioral Interdisciplinary Behavioral Health Training in Health Training in
Primary Care Primary Care (A HRSA Allied Health (A HRSA Allied Health
Supported Grant)Supported Grant)Joseph H. Evans, PhD Joseph H. Evans, PhD
Munroe Meyer Institute Munroe Meyer Institute
University of Nebraska Medical University of Nebraska Medical CenterCenter
Omaha, NebraskaOmaha, Nebraska
Interdisciplinary Behavioral HealthInterdisciplinary Behavioral HealthTraining in Primary Care Training in Primary Care
• Behavioral Health Disciplinary Partners– MMI Psychology Department– Marriage & Family Therapy Program (Family
Medicine Department)– MMI Social Work Department
Counseling Programs (Statewide)
Rural Nebraska Mental Health Rural Nebraska Mental Health FactsFacts
• 88 of 93 counties are MH HPSAs• 74% of MH professionals practice in Omaha and
Lincoln• 38 counties have 0 or 1 MH professionals• Of 147 licensed psychiatrists, 113 are in Metro
areas and 15 are in State facilities• #s of NE MH professionals are lower than the
national average, per capita • Child-Adolescent therapists even fewer
One Solution: Integrated Behavioral One Solution: Integrated Behavioral Health in Primary Care Health in Primary Care
• Defined as – Provision of BH care within a primary health
care setting– Integration of behavioral and physical health
care services– Preventive and first line interventions for
common behavioral/mental health problems presenting in primary care offices
Interdisciplinary BH Training in Interdisciplinary BH Training in Primary Care GrantPrimary Care Grant
• Grant Program Objectives– Improve and Extend the BH Training Model – Provide “Learning through Service Delivery”
experiences in Underserved Areas– Evaluate Effectiveness of the Interdisciplinary
BH Training Model and Disseminate Results– Improve Recruitment, Placement and
Retention of BH professionals in Underserved Areas
Why Integrated BH Care?Why Integrated BH Care?
Physicians are “de facto” mental health providers.
– 60% of all care mental health visits occur in PC setting (Magill & Garrett, 1988)
– 25% pediatric PC visits include behavioral health concerns (Cooper, Valleley, Polaha, Begeny, Evans, in prep)
– Pediatricians rank behavior most common problem (over ear infections) (Arndorfer, Allen, & Aljazireh, 1999)
Interdisciplinary Community-Interdisciplinary Community-Oriented Behavioral Health Oriented Behavioral Health
TrainingTraining• Internship Training in community primary care
settings• Interdisciplinary Rotation in roles of physicians,
nurses, PTs, OTs, speech therapists, etc.• Community Rotation in rural or urban
underserved areas w/ docs, nurses, etc.• Participation in Interdisciplinary Clinics for
cerebral palsy, spina bifida, genetics, depression, neurobehavioral disorders, marital problems, etc.
Community-BasedCommunity-Based Training in Integrated Behavioral Training in Integrated Behavioral
Health in Primary Care Health in Primary Care Mission
• Provision of Behavioral Health Training & Services in Underserved Rural and Urban Areas
• Attraction, Recruitment, Training, Placement and Retention of Behavioral Health Providers
• Training for Physicians and other Health Care Professionals in Underserved Community Settings
• Evaluation of Effectiveness
Integration of Behavioral Integration of Behavioral Health into Primary Care Health into Primary Care
PracticePractice
• Advantages for Physicians:– Physicians have a “ready” referral source– Doctors can triage most “needy” patients– Coordinated care is possible– Patients are seen “in” the practice– 15-20% more practice productivity
Columbus Community Hospital Columbus Community Hospital PediatricsPediatrics
Integration of Behavioral Integration of Behavioral Health into Primary Care Health into Primary Care
PracticePractice• Advantages for Patients:
– Comfort in receiving MH care in your doctor’s office– Reduced stigmatization– Coordinated physical and mental health care– Reduced usage of inappropriate medical visits – Travel for rural patients/families is reduced
Integration of Behavioral Integration of Behavioral Health into Primary Care Health into Primary Care
PracticePractice• Advantages to MH Practitioners:
– Consistent referral stream– Coordination of psychotropic medication and
therapy approaches– Reduced/shared practice overhead– Physician availability for consultations
regarding medical conditions affecting behavior
Hastings Behavioral Health Hastings Behavioral Health ClinicClinic
Barriers to an Integrated Barriers to an Integrated Primary Care ModelPrimary Care Model
• Few MH training programs with interdisciplinary primary care focus
• MH training programs not located in university medical centers
• Scarcity of MH professionals interested in rural practice• Lack of available incentives for rural MH practice• “Carve out” MH insurance programs• “Start-up” costs can be prohibitive
The UNMC/MMI Integrated The UNMC/MMI Integrated Behavioral Health ModelBehavioral Health Model
• Rural Locations (1997-2004):– Columbus (1997-present)– Hastings (1999-present)– Fremont (1999-2002)– Plattsmouth (2000-present)– Nebraska City (2004-present)– Valley (2003-present)– Kearney (2004-present)– Chadron/Crawford/Gordon (2004-present)
The UNMC Integrated The UNMC Integrated Behavioral Health Model(cont’d)Behavioral Health Model(cont’d)• New Outreach Behavioral Health Clinics
(introduced in 2005-06)– Crete (2005-present)– Lincoln (2005-present)– Creighton University Pediatrics (2005-present)
The MMI Integrated Behavioral The MMI Integrated Behavioral Health ModelHealth Model
• Urban Locations (cont’d):– One World CHC (w/ FM) 2000-pres– Eagle Run (w/FM) 2002-present– Charles Drew CHC 2002-2005– Papillion 2001-present – SONA Clinic (w/FM) 1998-present– Summit Plaza (w/FM) 1996-present– Lincoln Complete Childrens’ Care (2005)– Council Bluffs (IA) Cogley clinic (2002)
Behavioral Health ClinicsBehavioral Health Clinics
Nebraska City Behavioral Health ClinicEst. 2004 at Physicians Clinic
Kearney Behavioral Health Clinic
Est. 2004 at Kearney Clinic, P.C.
Chadron Behavioral Health ClinicEst. 2004 at Chadron HealthGordon Behavioral Health ClinicEst. 2004 at Gordon Clinic
The MMI Integrated Behavioral The MMI Integrated Behavioral Health ModelHealth Model
• Components:– Co-location in the primary practice– Frequent contacts re: referrals with physicians and
nurses– Cross-training sessions with the practice and the
community– Relationships with community schools, courts,
agencies, other providers– Provision of dx assessment info and clinical data for
physicians (e.g., ADHD diagnostic protocols)
The MMI Integrated Behavioral The MMI Integrated Behavioral Health ModelHealth Model
• Administrative Issues:– MH services are “value added” to the primary care
practice– Licensing, credentialing, paneling, pre-authorizations,
billing, collections -independent from rural office @ 1st
– Space and staff imposition minimal– Goal is to establish the “importance” of available MH
services to physicians and their practices
Rural Impact - 2002Rural Impact - 2002
BHC Outreach Patient VisitsBHC Outreach Patient Visits
0
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6000
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1999-00
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2004-05
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Visits
MMI Behavioral Health Outreach MMI Behavioral Health Outreach Clinics - OutcomesClinics - Outcomes
Training and Retaining Providers• 54% trainees work in rural area after
graduation• 11 of 13 current rural outreach clinics
directed/staffed by graduate of this training program - 9 at Ph.D. level
• Monthly meetings via teleconferencing to improve communication, decrease isolation, increase retention.
Outcome - Behavioral Health Outcome - Behavioral Health Trainees (2001-06)Trainees (2001-06)
• Psychology- U Nebraska at Lincoln- Mississippi State U- Syracuse U- Illinois State U- U Southern Mississippi- Xavier U- U Kansas- U Western Michigan
• Social Work – U Nebraska at Omaha
• Counseling– Wayne State College– U Nebr at Kearney– Chadron State College– Doane College
• Mar & Family Therapy– U Nebraska at Lincoln– BYU
Outcome-Physicians Use of Outcome-Physicians Use of Empirical Assessment Empirical Assessment
ProtocolsProtocolsMeasure % Present
Pre-Protocol(N=76)
% Present First Year After Training(N=28)
% Present ThirdYear After
Training(N=26)
CBCL/Parent BASC
1% 93% 93%
TRF/Teacher BASC
0% 88% 93%
CPRS-R:S 1% 93% 93%
CTRS-R:S 1% 93% 88%
Parent ADHD-IV 3% 88% 93%
Teacher ADHD-IV 1% 88% 93%
ECBI 3% 93% 88%
MMI Behavioral Health Outreach MMI Behavioral Health Outreach Clinics - OutcomesClinics - Outcomes
• 2005-06 Data– 3 Publications in Refereed Journals– 2 Journal Articles/Chapters in press– 10 Presentations at National/Regional Conferences– 3 Presentations at State Conferences– 5 Presentations to Physician Groups– 32 Community Presentations (Schools, Agencies,
Parent Groups, etc)– 11 Courses taught at Colleges/Universities (7 Rural)
Patients Seen at Rural BHC - Patients Seen at Rural BHC - Percent In and Out of TownPercent In and Out of Town
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HastingsColumbus Omaha CouncilBluffs
Valley Fremont
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Out of Town
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Fiscal Support for the MMI Fiscal Support for the MMI Integrated Behavioral Health ModelIntegrated Behavioral Health Model
• HRSA Allied Health Training grant (2001-2007)• HRSA Graduate Psychology Education grant
(2004-2007)• HRSA Quentin Burdick grant (1999-2002)• Americorps State Formula grant (2004-2007)• HRSA SEARCH grant (support from AHEC)• Clinical revenue support• University Faculty-time contributions
Integrated Behavioral Health Integrated Behavioral Health Necessities:Necessities:
• Interested Primary Care partner• Willingness to participate in an education
program for trainees• Space (docs’ days off)• Referrals available (Clinical experience is that 3
docs needed to support one MH professional)• Administrative supports that can eventually be
shifted to the practice
The UNMC/MMI Integrated The UNMC/MMI Integrated Behavioral Health ModelBehavioral Health Model
Adjunct Service:
The Pediatric Behavioral Telehealth Clinic– Initiated March, 2005– 60+ families served in 200+ visits to date– 6-10 visits provided weekly– From 20+ remote sites as far as 452 miles
from Omaha– Males and females ages 3 to 21 years
UNMC/MMI Rural Outreach Behavioral UNMC/MMI Rural Outreach Behavioral Health Care ProgramHealth Care Program
Fremont Pediatric
Partners**
Fremont Pediatric
Partners**
Kearney Pediatrics
Kearney Pediatrics
RequestedCrete Comm Hosp
RequestedCrete Comm Hosp
Requested LincolnLMEP
Requested LincolnLMEP
Requested Blair
Comm Hosp
Requested Blair
Comm Hosp
RequestedNorfolkPeds
RequestedNorfolkPeds
RequestedGrand Island Peds
RequestedGrand Island Peds
ChadronFam Med
Clinic
ChadronFam Med
Clinic
Nebraska City
FamilyMed
Nebraska City
FamilyMed
PlattsmouthNMC
Pediatrics
PlattsmouthNMC
Pediatrics
Columbus CCH
Pediatrics
Columbus CCH
Pediatrics
HastingsChild/Adol
Clinic**
HastingsChild/Adol
Clinic**
MMI Rural Beh HealthOutreachProgram
MMI Rural Beh HealthOutreachProgram
Integrated Behavioral Health Integrated Behavioral Health NecessitiesNecessities
• Dedicated faculty/preceptors willing to travel to rural sites
• Students/graduates interested in rural practice (preferably from rural towns/training programs)
• Fiscal support for faculty and trainees
• Revenue support for travel/billing/ required equipment and supplies
Contact InformationContact Information
Joe Evans, PhDDirector, Psychology Department at Munroe-Meyer Institute (MMI) and Professor, Dept of Pediatrics
University of Nebraska Medical Center
985450 Nebraska Medical Center
Omaha Nebraska 68198-5450
Phone: (402) 559-5758
E-mail: [email protected]
QUESTIONS ?QUESTIONS ?