PCBH

Foundations

Day 2: Getting

Your BHC Wings

Presented By: Patricia Robison, PhD

Mountainview Consulting Group

Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures

• Access to Care – “Be there when we need you”

• Accountability – “Take responsibility for us to receive the best possible health care”

• Comprehensive Whole Person Care – “Provide/help us get the health care and information we need”

• Continuity– “Be our partner over time in caring for us”

• Coordination and Integration – “Help us navigate the system to get the care we need safely and timely

manner”

• Person and Family Centered Care – “Recognize we are the most important part of the care team, and we our

responsible for our overall health and wellness”

Read more: http://primarycarehome.oregon.gov

PCPCH Model of Care

PCBH Foundations Training

1. Tuesday: Getting Your BHC WingsConsultation, Team, and Clinical Competencies

2. Wednesday: Tool Kit and Initial Visit Clinical Competencies

3. Thursday: Communication, Follow-up Visit, Group and Other InterventionsClinical, Team, Consultation, Documentation Practice Management Competencies

4. Friday: Administrative Procedures, Pathways, Meds, More Interventions, GraduationAdministrative and Clinical Competencies

Daily Routines

Schedule

– 10:30 Break

– 12-1 Lunch

– 2:30 Break

– 4:00 End (Friday at 3:00)

Afternoon: 2+ Participant presentations (Patient Ed

protocols or case example)

3:45 Daily Review Q & A (Tues-Thurs)

Getting the Lay of the Land

• Introduction to Primary Care

– Primary Care Terms

– Your New Colleagues

• Start Up Checklist

• Competency Self-Assessment Review, Discussion, Goal Setting

• Consultation Competencies

• Team Competencies: Influencing PCCs and RNs

• Influencing Patients

A Primer on Primary Care

The Mission:

Provision of integrated, accessible health care

services by clinicians who are accountable for

addressing a large majority of personal health care

needs, developing a sustained partnership with

patients and practicing in the context of family and

community.

Institute of Medicine

Four Functions of PC

Providing:

1. Accessible

2. Comprehensive

3. Longitudinal

4. Coordinated

care in the context of families and communities.

Starfield

National Academy of Sciences

Triple Aim

Centers for Medicare and Medicaid (CMS) adopted

his moniker; lots of effort to measure these 3 goals

Affordable Care Act

• A series of health insurance reforms

signed into law March, 2010

• 15 billion for prevention and public

health

• Guidance for care of ill (Community

Care Transition Programs)

• Address health disparities (millions

of uninsured to soon be insured)

Accountable Care Organizations (ACOs)

• Provider-led, strong PC base, collectively

accountable for quality and total per capita costs

across the full continuum of care for a population

of patients

– Payments link to quality improvements that reduce

overall costs

– Performance is reliably measured

Coordinated Care Organization CCOs)

• Network of different types of health care

providers (medical, addictions, MH, dental)

• Agreeing to work together to better serve the

health care needs of people in their community

• Provide both preventive and chronic care

management services

OHA Transformation Center

• Will support CCOs, and the adoption of the coordinated care model throughout the health care system, through technical assistance and learning collaboratives that foster peer-to-peer sharing of best practices among CCOs and other health plans and payers

http://transformationcenter.org/

Primary Care Clinicians (PCCs)

• Independently make decisions about all aspects of patient care

• Leader of the team

• Includes physicians, nurse practitioners, physician assistants, naturopathic physicians

• Most trained minimally in BH interventions

• Trained in medical model: Match symptoms to diagnosis and provide EBT

RNs, CNAs, Others

• RNs: Coordinate a variety of patient care activities; provide triage; provide chronic disease management services; provide chronic care services to MH patients

• CNAs/MAs: Involved throughout patient visit

• Support staff: Front desk, Ward Clerks, Appointment Line, Billing Specialists, Interpreters

PCBH Impact: PCPs

• All PCPs reported

– Satisfaction with the PCBH program

– Improved job satisfaction

– Better able to address behavioral

problems

– Recommend the service for other sites

Your Digs

Location

Pros and Cons of options

Ways to work with limitations

Equipment

Start Up Checklist

• Week 1: Be Visible & Get the Lay of the Land

� Set-up voicemail, email, portal account, pager

and/or text plan

� Have your number added to roster

� Post list of staff and PCC contact numbers at your

work station

� Meet with BHC mentor & senior leadership

� Clarify billing plan

Start Up Checklist

• Week 1: Be Visible & Get the Lay of the Land

� Shadow every willing PCC for part of the day &

survey PCCs re: problems they most desire help with

� Obtain list of clinic meetings and determine which

to attend; attend huddles & clinical team meetings

� Form a PCBH steering committee

� Refine BHC program manual and move toward

ratification

� Visit or call important social service organization you

may use

Start Up Checklist

• Week 2: Begin Patient Care and Continue

Service Planning

� Meet with scheduling staff to discuss BHC

appointments; develop initial visit template

� Practice role introduction

� Learn EMR and / or dictation service

� Clarify CNA support to BHC

� Talk with interpreters about BHC services

� Prepare patient education handouts, outcome and

screening tools

Start Up Checklist

• Week 2: Begin Patient Care and Continue Service

Planning

� Review clinic risk management policies & procedures

� Shadow an experienced BHC

� Distribute handout to staff (intro self and service)

� Speak at a provider’s meeting

� Talk with referral manager and visit affiliated MH

service (if available)

� Walk through clinic hourly

� See patients!

Start Up Checklist

• Week 3 & Beyond: Expand and Be Guided by

Outcomes

� Preview schedules with PCCs (or by self) to identify

possible same-day patients

� Administer Referral Barriers Questionnaire and use

results to increase referrals

� Develop needed or requested materials

� Start classes or groups

Start Up Checklist

• Week 3 & Beyond: Expand and Be Guided by

Outcomes

� Start pathway development project

� Schedule standing time in provider / staff meetings

� Problem solve processes for evaluating program

� Spend another day with experienced BHC with plan

of observing class or pathway activity

BHC Competencies

• Review Self Assessments

• Q & A

• Clarification by modeling

• Set learning targets for week; 3 / domain

• Discuss with partner (will work together

again on Friday)

Consultation Competencies

• Differences between a psychotherapist and a

consultant, beginning with referral

• Role of consultant

• Expectation of referring PCC

Population-Based Care

1. A community perspective

2. A clinical epidemiology perspective (population-

based data)

3. Evidence-based practice

4. Emphasis on effective outcomes

5. Emphasis on primary prevention

From wellness to illness; optimal aging

Your Primary Customer Is . . .

1. Very busy

2. Stands to gain a great

deal from your

services

3. May not know this

How can you best

influence him / her?

Influencing PCCs

• Share evidence (1/2 page handouts)

• Shadowing (see Shadowing sheet)

• Scrub schedule

• Request of the day at huddles

• Exam room posters

• Routine orientation of new PCCs, RNs, CNAs

• Short presentations at meetings

Influencing PCCs

• The Evidence

– Improved job satisfaction

– Improved ability to serve patient with BH needs

– Improvement in ability to ser patients with substance

abuse needs

– Increase in rate of using behavioral intervention and

decrease in prescribing

PCCs: Use of a Relapse Prevention Plan

Are you facing difficult problems and

having trouble finding solutions?

� Reach out; talk to your PCM or Nurse today

� Coaching on problem solving is available in primary care

� You may be able to see the Behavioral Health Consultant (BHC) today

Practice

Find a Launch partner:

Pretend that you have 5 minutes to present evidence

about the PCBH model at a staff meeting. Select your

slides (okay to use some from yesterday, along with

some from today)

1. Make a 5-minute presentation to your partner (who

is a PCC at the meeting)

2. Switch roles

Dimension PCBH Spec. MH

1. Model of Care Population-based Client-based

2. PC Receivers PCP, then patient Client, then others

3. Key Goals PCP efficiency Intensive services

Small changeLess time for prevention

Prevent morbidity, high risk

Achieves med. cost offset

You Might Mention Some of These Points

Dimension PCBH Spec. MH

4. Therapy model Part of PC TeamSpecialized &

separate

5. Care manager PCP Therapist

6. Dominant modality

Consultation Specialty TX

7. Access to care Same day, every day Variable

8. Cost / episode Potentially lessHighly variable,

related to pt condition

You Might Mention Some of These Points

Practice

With your Launch partner:

Pretend that you have 3-5 minutes to talk about the

differences between the PCBH model and specialty MH

services at a staff meeting. Select the slides you will use.

1. Make a 3-5-minute presentation to your partner

(who is a PCC at the meeting)

2. Switch roles

Practice

• Review PCC and RN Competencies from Day 1

– What could you teach?

– What do you need help with?

• Discussion

• Small Group Practice

Influencing Patients

• The Evidence

– 90% said visit length “just about right”

– 76% were satisfied with ability to get appt

– 83% felt BHC understood their problems

– 89% said it was helpful to meet with BHC

– 65% said physical health improved

– 72% said mental health improved

Children: PSC Total Scores

*62% Hispanic, 40% Spanish-speaking

RURAL HC System

Adults with Chronic Disease: Duke Scores

*62% Hispanic, 40% Spanish-speaking

RURAL HC System

Adults with Major Depression:

Use of Coping Skills

CC

UC

Adults with Minor Depression:

Use of Coping Skills

CC

UC

EXAMPLE: STEP-UP PATHWAY

Evidence for PCBH Impact on Linkage

• BHC use of a “referral

management”module

increases engagement

twofold over typical

reminder mechanisms

such as automated

telephone remindfers

(Zanjani, 2008)

• Recent RCT: PCB with

module vs without

Influencing Patients

• Adapting ESTs for Primary Care

– See book chapter (USB)

• Framing the Problem for Change

– May see only 1 X; normalizing, de-pathologizing; strength context; framed as problem to solve; acceptance; bigger picture; will pass; trajectory questions, etc.

• Commonly Taught Skills

– See booklets, Living Life Well, Using Medications Successfully

Team Competencies

Is this true for you?

Understands and operates comfortably within primary care

culture

Shows awareness of team roles

When away from station, leaves information as to location and

time of return

Readily provides unscheduled services when needed

Is available for on-demand consultations

Wrap-Up

• Participant presentations

• Daily review

PCBH

Foundations

Day 3:

Tool Kit and

Initial Visit

Presented By: Patricia Robison, PhD

Mountainview Consulting Group

The PBCH Tool Kit

• The PCBH Manual (Tab 1)

– Vision and Mission

– Guidelines, Goals and Objectives

– Roles and Responsibilities of the PCBH team

– Training Program Overview

– Clinical Activities

• Brief Intervention Services, Pathways, Excluded Services

• Practice Support Tools

Primary Care

Behavioral Health

Toolkit

Provided as part of Primary Care Behavioral Health (PCBH) Introduction and Foundations

training provided by Mountainview Consulting Group through the Patient-Centered Primary

Care Institute

October 2013

A public-private partnership transforming primary care

www.pcpci.org

Mountainview

Consulting Group

The PBCH Tool Kit

• The PCBH Manual (continued)

– Clinical Activities

• Practice Support Tools

– Scripts for RNs, PCCs, clinical guides for BHCs

• Outcome Assessment Tools and Screeners

• Clinical Policies and Procedures

– Patient access, Informed consent, clinical assessment standards

• Quality Assurance of Charting and Documentation

• Providing Feedback to PCC

• Medication Consultations, Psychiatric Consults

The PBCH Tool Kit

• The PCBH Manual (continued)

– Administrative Procedures (BHC appointment

template, revenue/billing, performance measures

including staffing guidelines and productivity

standards)

– Core Competencies

The PBCH Tool Kit

• The PCBH Manual Appendices

– Performance Measures (A – Tab 2)

– Core Competency Tools (B – Tab 3)

– Self Assessment Tools (C – Tab 4)

– Pathway Program Examples (D & E – Tabs 5 & 6)

– Practice Supports: Referral scripts, referral form,

interview note form, chart not example, intervention

quick guide, interventions for 7 common referrals,

PCBH Introduction (F – Tab 7)

The PBCH Tool Kit

• The PCBH Manual Appendices (continued)

– Assessment and Screeners: List, Outcome, As

Indicated (G – Tab 8)

– Patient Brochure Example (H – Tab 9)

– Quality Management Chart Tool (I – Tab 10)

– PCBH Model References (J – Tab 11)

Patient Education Protocols (Tab 12)

• ADHD

• Adherence Using Meds Successfully

• Alcohol & Low Risk Drinking

• Anxiety & Coping with Panic Attacks

• Anxiety

• Chronic Pain

• Depression – Postpartum

• Depression

• Exercise & Physical Activity

• Grief

• Headaches

• Hypertension

• Parenting Protocol

• Relationship Problems

• Relationship Sexual Problems

• Sleep & Insomnia

• Sleep Apnea

• Sleep Behavior Change & Diary

• Sleep Class Packet

• Stress

• Substance Misuse & Maintaining Behavior Change

• Weight Management

Content Quiz on Manual

• True / False

• Score as we discuss

• There are a lot of grey areas

The Initial Visit

• Clinical Competencies (this morning)

– Goals of initial visit

– Case conceptualization

– Receiving a referral

– Your introduction

– Completion of outcome tools

– Review of screeners

– Identifying a target problem

The Initial Visit

• Clinical Competencies (this morning)

– Problem severity rating

– Conducting a target problem analysis

– Case conceptualization during the visit

– Problem summary statement

– Offering options

Case Conceptualization:

What is Your Philosophy?

PCBH Philosophy Your Philosophy

Maladaptive behaviors are

learned and maintained by

various external and internal

factors

Many maladaptive behaviors occur

as a result of skill deficits

Direct behavior change is the most

powerful form of human learning

Write out your philosophy; discuss in groups of four.

Factors to Consider in Conceptualizing

• Distress level

• Life as a context for problem

• Impact of problem on functioning

• Antecedents / consequences

• Efforts to address problem, workability

• Values Connection

• Stance: Approach, Avoidance

Case Conceptualization

How do skills play into patient’s current

situation?

Has skill but

avoids action

Doesn’t have a

skillHas disability

Exposure

Instruction

(modeling,

guided

rehearsal)

Principles of

Reinforcement

Case Conceptualization

What have you learned about the patient?

Two

types of

patient

behavior

Too Much Not enough

PublicImpulsive,

numbing action

Lack of action

consistent

w/values

Private

Lost in thoughts,

emotions,

thoughts - high

struggle

Desire, passion,

belief in better

future

Intervention Target(s)?

Access and Receiving a Referral

• Access to BHC

– Discussion:

• How can patients access the BHC?

• How can the BHC reduce potential barriers?

• Receiving a Referral

– Clarifying Question or Target Problem

Goals of Initial Visit

• Assessment

– Can patient be served in PC?

• Target problem analysis

• Intervention

• Recommendation to Patient, PCC

Initial Consult; Follow-up As Needed

Introduction

5 minutes

Snapshot

5 minutes

Functional Analysis

5 – 10 minutes

Problem Summary/Behavior Change Plan

5 – 10 minutes

Charting/Feedback to PCP

5 minutes

Physician refers to BHC for specific

problem / question

Clinician review recommendations;

retains full responsibility for patient care

decisions

Patient implements behavior change

plan, returns for follow-up as needed

Clinical Practice Skills:

The 30-Minute Consult

Informed Consent

• When patients sign their consent to receive

primary care treatment, they are also

signing consent for PCBH services

• PCBH providers will provide a brief

description of PCBH services at the first

patient visit. This description will be

consistent with the PCBH brochure

– Read PCBH brochure

– Practice introduction and giving PCBH

brochure

The 30 Minute Consult:

Introduction

• Your profession & title

– psychologist/SW/other & Behavioral Health Consultant

• Explain BHC role

– Enhance usual care; consultant to PCC and patient, biopsychosocial care

• Structure of appointment

– 15 to get a snapshot of your life and look at the referral concern, then 5

minutes to offer suggestions to help you improve your quality of life and

make a follow-up plan

• Commonalities with PCM

– chart to medical record, same reporting requirements)

• Linkage back to PCC

DUKE & PSC PRACTICE

• See Duke

and PSC

• Model

• Practice

with partner

• Quick look

at screeners

in manual

appendix

Duke Health Profile (The DUKE) Copyright 1989, 1994 by Dept of Community & Family Medicine, Duke Univ Medical Center, Durham, NC. For a manual and for

permission to use, contact George R. Parkerson, Jr, MD, MP; (919) 634-3620, Ext 452; E-mail: parke001@mc.duke.edu.

Patient Sex: [ ] Female [ ] Male Date of Visit: _______________ Last 4: ________

INTERVIEWER: Give these instructions: “I’ll ask you some questions about your health and feelings. Please listen to each question

carefully and give me your best answer. You should answer the questions in your own way. There are not right or wrong

answers.”

Interviewer: Read each question verbatim and circle

response number.

Yes, describes me

exactly.

Somewhat

describes me.

No, doesn’t

describe me at all.

1. I like who I am. 2 1 0

2. I am not an easy person to get along with. 0 1 2

3. I am basically a healthy person. 2 1 0

4. I give up too easily. 0 1 2

5. I have difficulty concentrating. 0 1 2

6. I am happy with my family. 2 1 0

7. I am comfortable being around people. 2 1 0

“TODAY would you have any physical trouble or

difficulty:

None Some A Lot

8. Walking up a flight of stairs?” 2 1 0

9. Running the length of a football field?” 2 1 0

“DURING THE PAST WEEK, how much trouble have

you had with…”

None Some A Lot

10. Sleeping?” 2 1 0

11. Hurting or aching in any part of your body?” 2 1 0

12. Getting tired easily?” 2 1 0

13. Feeling depressed or sad?” 2 1 0

14. Nervousness?” 2 1 0

“DURING THE PAST WEEK, how often did you…” None Some A Lot

15. Socialize with other people (talk or visit with

friends or relatives)?” 0 1 2

16. Take part in social, religious, or recreational

activities (meetings, church, movies, sports, parties)?” 0 1 2

“DURING THE PAST WEEK, how often did you…” None Some A Lot

17. “Stay in your home, a nursing home, or hospital

because of sickness, injury, or other health problem?” 2 1 0

QUALITY OF LIFE SCORE: Physical Health ________ Mental Health ________ Social Health ________

Snapshot Questions

• Where do you live? How long? With whom?

How’s that going?

• Relationships with

spouse/partner/roommate/children?

• Relationship with friends?

• Work? What do you do? Do you like it? Attend

school? How’s that going?

Snapshot Questions

• What do you do for fun? Relaxation?

• Spiritual practice or community involvement?

• Health status (chronic disease, meds)

• Health risk / health protection behaviors?

(Excessive TV, video games, tobacco, drugs,

alcohol, exercise, sports, outside play, clubs)

Love, Work, Play – Interview Tool

Love Where do you live? With whom?

How long have you been there?

Are things okay at your home?

Do you have loving relationships with your family or friends?

Work Do you work? Study? If yes, what is your work?

Do you enjoy it? If no, are you looking for work?

If no, how do your support yourself?

Play What do you do for fun? For relaxation?

For connecting with people in your neighborhood or community?

Health Do you use tobacco products, alcohol, illegal drugs?

Do you exercise on a regular basis for your health?

Do you eat well? Sleep well?

Target Problem Analysis

• Not a diagnostic assessment

• Focus referral question/problem/concern

• Onset

• Triggers

• Duration, Intensity, Frequency

• Impact on functioning

• Coping Efforts

• Workability

The Three T Interview Questions

Time When did this start? How often does it happen? Does it happen at a particular time? What happens just before the problem? Immediately after the problem?

Trigger What do you think is causing the problem? Is there anything or anyone that seems to set it off?

Trajectory What’s this problem been like over time? Have there

been times when it was less of a concern? More of a

concern? What have you tried in the past?

Workability How have the things you’ve tried worked in the short run? In the long run or in the sense of being consistent with what really matters to you?

Potential Issues & Useful Questions

• Potential clinical issues that may require further attention from PCC:

– Medication related issues

– ETOH or drug use

– Domestic violence, child abuse

• Often useful:

– What does a typical day look like?

– What does a typical weekend day look like?

An Important Transition from Target Problem Focus

to Behavior Change / Brief Intervention Focus

Problem Summary

• Express empathy / engage the patient

– “This sounds very difficult and I can see that you’ve

tried…”

• Strategic Reframe: Simplify and reduce the

magnitude of the problem

– “So, you’ve been feeling a lot of stress since loosing your

job and it appears to be affecting your ability to relax and

to sleep at night.”

Problem Summary

• Help patient generate new strategies

– “If a miracle happened…”

• Create a do-able framework for change

– “Let’s take it one step at a time. I think the first step could

be x or y; what makes sense to you?”

• Offer options

The Initial Visit

• Clinical Competencies (after lunch)

– Educational and Skill Building Interventions

– Community Linkage

– Behavioral health prescription pads

– Confidence rating

– Planning follow-up

– Helpfulness rating

Behavior Change Basics

• Focus on function, not cure

– “My job is to help you and your doctor improve your overall

quality of life; often one or two small changes in our daily

routine can make a big difference over time.”

• Process Check

– “So at this point you are interested in…?”

• Assess patient values related to problem

– “In terms of what you think is really important in life--your

core values--why does this change seem important at this

time?”

Behavior Change Plan

• Look for patient strengths to use in plan

• Emphasize idea of small positives

• Use external supports to promote success

• Frame plan as an “experiment” & collect data

• Assess patient confidence in plan

• Does patient lack a pre-requisite skill?

• Provide a written copy of plan (RX pad or PCBH

brochure)

BHOP RX Pad Example

Susie Smith, Behavioral Health Consultant

Your Clinic Phone: 123-456-7890

Plan Week 1

Sun Mon Tues Wed Thur Fri Sat

1.

Week 2

Sun Mon Tues Wed Thur Fri Sat

2.

Your notes about behavior change experiment:

Please return: ____________ For Visit With: ____________

BHOP RX Pad Example

Susie Smith, Behavioral Health Consultant

Your Clinic Phone: 123-456-7890

Plan:

The Bulls-Eye PlanA Team-Based Behavior Change Intervention

Action Steps

1.

2.

3.

Value

Statement Love, Work, Play

Practice

• Forming a Plan

• Using RX Pad

• Asking Confidence

Question

• Planning Follow-Up

• Asking Helpfulness

Question

• Timed Practice Initial

Visit

• Participant

presentations

• Daily review

PCBH

Foundations

Day 4: Charting,

Communication,

Follow Up,

Groups and Other

Interventions

Presented By: Patricia Robison, PhD

Mountainview Consulting Group

Communications

• Non-verbals

• How to interrupt when you need to

• Brief, focused, specific

• Giving Feedback

– Same day and face-to-face if possible (close the loop)

– Problem, your impression, recommendation to

patient and to PCC, your follow-up plan

BHC Charting

• Chart note includes:

1. Referring PCC, referral question

2. Patient given standard information about PCBH

3. Pertinent history, functional analysis data

4. Results of any self-report measures administered

5. Risk evaluation results, as indicated

6. Clinical impression / Referral response

7. Recommendations for PCC (& given to PCC)

8. Recommendations for patient; BHC f/u plan

Demonstration

• Initial visit role play (your

choice)

• Watch and . . .

– Time components of

interview and total time

– Chart note

– Use chart review tool to

evaluate note

– Give FB to PCC

Goals of Follow-Up Visit

• Re-assessment

– Improving, Stable, Deteriorating

• Experience with implementing plan

– Impact of Plan

• Development of new plan (or support of initial

plan)

• Teach additional skills; provide additional

information

Demonstration

• Follow-up visit role play

(your choice)

• Watch and . . .

– Time components of

interview and total time

– Chart note

– Use follow-up chart review

tool to evaluate note

– Give FB to PCC

Practice Management

• Staying on-time, using groups to deepen skill training

• Missed appointments– All missed appointments with the BHC will be

documented in the progress note section of the patient’s medical record

– Additionally, the BHC will attempt to telephone a patient who does not show for a scheduled follow-up visit and, if possible, provide services by phone when the patient is reached

– Charting ensures that the PCc knows that the patient did not follow through with a scheduled appointment or received BHC services by phone

Class Visits in Primary Care

• Goals

– Provide more skill training

– Better management of a

population (e.g., chronic

condition)

• Better use of resources

• Measure outcomes

• Improve outcomes (e.g., pt

& PCM satisfaction, pt

confidence in self-

management, pt’s rate of

behavior-value

consistency)

• Approaches

– The QOL or Life

Satisfaction Class (a

generic class)

– Open Access for high

impact pops (e.g., LEARN

adapted for PC)

– Group Medical Visits,

including Group Clinics

(standard care for a

specific group, e.g., older

adults, ADHD, chronic

pain) & DIGMA

Classes

• Generic

• Open Access

• Psycho-educational

• Continuity statements

• Usually 1 hour

• Use feasible assessment and chart

• Announce in Exam Room Posters

Groups

• Monthly

• On-going management

• On-going skill training

• Measurement of outcomes over time

• Often related to pathway

• May be drop-in or required

• May be lead by BHC / BA alone or co-led with PC Team members

Typical PC Group Agenda /Activities

Time Topic

5 minutes Assessments

5 minutes Introductions, Updates (continuity statement)

10 minutes Lecture

10 minutes Skill Training

10 minutes Discussion/Application of Skill & Individualized

Homework Plans

10 minutes Wrap-Up

30 minutes Charting (1 – 3 minutes, 10 patients)

Group or Individual Visits

PCBH Foundations

Day 5:

Administrative

Procedures,

Pathways, Meds,

Interventions &

Graduation

Presented By: Patricia Robison, PhD

Mountainview Consulting Group

Administrative Procedures

• BHC Productivity Standards

– 10 face to face / day

• PCCs will refer between two and eight patients

per day to the BHC

• BHCs will receive monthly feedback similar to that

provided to PCCs

– eg. encounters per clinic hour

Template

TimeActivity

Type

8:30 RT

9:00 RT

9:30 RT

10:00 RT

10:30 RT

11:00 RT

11:30 RT

TimeActivity

Type

1:30 RT

2:00 RT

2:30 RT

3:00 RT

3:30 RT

4:00 RT

4:30 RT

PCBH Pathway Services

• Targets a patient population that has high impact (by numbers or by way or presentation)

• Applies the evidence for the care of the targeted population

• Respectful of local resources

• Seeks to improve efficiencies

• Specifies outcomes used to evaluate processes and outcomes

WHAT PATHWAYS MIGHT BE USEFUL

IN YOUR CLINIC? WHY?

PCBH Pathways

• High Impact Population Surveys

• Forming a Pathway Committee

• Developing a Pilot

• Selecting Outcomes / Measures

• Revising and Expanding

Small Group Discussion

Pathway ideas and applying evidence-based interventions

Generate pathway target list and interventions for each

Report to larger group

Medication Consults

• Explore patient preference for treatment,

assess symptom severity and adherence

coaching

– See Adherence Using Medications Successfully

Patient Education HO

• Coaching involves exploring the patient’s

experience of beneficial and side effects;

identifying barriers to adherence including

personal beliefs, problems remembering to

take the medication, cost of the

medication, etc.; and, developing specific

behavioral strategies to address barriers

• Regarding patient use of all medications,

not just psychotropic medicines

Prescribers and BHCs

• May assist PCC with consultations with

specialty prescribers, as requested

• May assist with linkage to specialty

prescriber services, as clinically indicated

• May assist with tele-specialty prescriber

services

Interventions for Common Problems

• Eating, Sleeping, Engaging in Social Activities, Engaging in Exercise

• Medical Problems: Basic Interventions – Addressing stigma

– Creating a values context

– Recognizing primacy of psychosocial stresses

– One step at a time

• Overweight / obesity; diabetes; hypertension; ADHD

• Substance Abuse

• PTSD

• Medication Issues

Interventions: Depression (or fatigue, insomnia, loss of interest)

� Demystify depression, focus on symptom of concern

� Ask about patient’s world view

� Use PHQ-9 to identify sx of concern to patient

� Explain the “lethargy cycle”

� Make behavioral activation plan, particularly social

activities

� Problem solving

� Relapse prevention plan

� Mindfulness training

� QOL Drop in Class

Interventions: Anxiety

• Teach relaxation / mindfulness / acceptance strategies

• Square breathing for panic

• CALM or diaphragmatic breathing

• Set up self-guided exposure (based on values)

Lunch

Participant Presentations

Alcohol / Drugs

• Community based reinforcement approach

• Harm reduction

• Use MI in assessment

• AA, Alanon

• Specialty care

Decisional Balance Sheet

ChangingNot

Changing

Costs of

Benefits of

Interventions:

Chronic Disease / Lifestyle

• Motivational Interviewing

– Decisional Balance Sheet

• Team-based support of specific goals

– Bulls-Eye or SMART goals

• Classes and workshops

• Internet-based with BHC phone call support

• Bibliotherapy

– The Diabetes Lifestyle Book by Gregg

Interventions: Sleep, Smoking

• Use Handouts

• Review Sleep Hygiene Guidelines

• Sleep diary

• Very common and high impact problem,

so offer monthly workshops

• See Patient Handouts for Smoking Class

packet of materials

Chronic Pain

• Bull’s Eye RX Pad

– to prevent, to intervene

• Educate regarding the chronic pain cycle

• Teach skills that address barriers to improved

QOL

– pacing, relaxation, defusion, mindfulness,

acceptance, committed action

Interventions: Relationship Problems

• Marital Dissatisfaction

– See Relationship Couples Handout

– Use Problem Solving

– Caring Bank Account

• Parenting Stress

– Parenting Protocol (play, positive and descriptive

praise, ignoring)

– Enuresis (The Good Kid Book)

– Overweight / obesity prevention

Parent/Child or Child Problems

• Parenting

– Explain proper use of rewards, Timeout, guidelines for play

– PC Parenting Protocol

– Triple P Parenting Program

• Sleep problems

• Enuresis

• Overweight / obesity prevention

• School problems

Other Common Interventions

• Self-monitoring

• Recommend pamphlet – One page vs. multiple page

• Suggest self-help book– Living with Children

(Patterson)

– I Can If I Want To (Lazarus)

– Living Life Well: New

Strategies for Hard Times

(Robinson)

– Just One Thing (Hanson)

• Refer to support /

educational classes

• Recommend App – Sleep, breathing

• Internet programs– Insomnia, UCANPOOP2, Mild

depression

Marketing PCBH Services

• Place posters and brochures in community locations

• Place posters and brochures in clinic waiting areas and exam rooms

• Talk with local CCO

• Talk with local hospital

• Talk with local CMHC

• Brief presentation to board, HC system leadership team

• And . . .

Are You Interested?

• Sustainability & BHCM (MENTOR) Training

• Manual

• BHCM Core Competency Tool

– Excellence in all basic core competencies (5 on 95%)

– Additional domain: Teaching (with evaluation by BHCs

mentor trains)

Closing

• PCBH FoundationsTraining Certificate

• Re-rate your Competency Levels on CC Tool

• THANK YOUR TRAINING PARTNERS!