You are NOT fired! Optimizing the PCBH

model for difficult patient encounters

Arissa Walberg, PhD, Behavioral Health Consultant/Faculty, Community Health of Central Washington

Bridget Beachy, PsyD, Director of Behavioral Health, Community Health of Central Washington

Stacy Ogbeide, PsyD, Assistant Professor/Clinical, UT Health Sciences San Antonio

Ragina Lancaster, DO, Faculty Physician, Community Health of Central Washington

Ramin Poursani, MD, Chief of Clinical Operations, UT Health San Antonio

Session # B4

CFHA 20th Annual Conference October 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 Objectives At the conclusion of this session, the participant will be able to:

1. Explain the negative outcomes of difficult patient

encounters.

2. Identify systemic strategies of the PCBH model for

difficult patient encounters.

3. Employ specific skills for PCP-BHC collaboration

to mitigate negative effects of these encounters.

Learning Assessment

A learning assessment is required for CE

credit.

A question and answer period will be

conducted at the end of this presentation.

A little context…

UT Health Sciences Center, San Antonio

Community Health of Central Washington

Difficult Patient Encounters

15% of Primary Care

Outcomes

Decreased patient and provider satisfaction

Increased burnout

Poorer health

Jackson & Kay, 2013

Hardavella et al. (2017)

• Frequent no-shows or

tardiness

• Medically unexplained,

complex, high-utilization

• Non-Adherence

• Inappropriate behavior

Jackson & Kay (2013)

Strategies

Frequent no-shows/tardy

Strategies

BHC accessibility/flexibility

BHC assesses cause

Case: 36yo, female, SSRI follow-up

15mins late, visit necessary to get refills

Outcome

○ BHC visit: Assessed medication efficacy, side effects

Contextual interview BH intervention for grief

○ PCP visit – 3mins

○ Patient: got refill plus behavioral intervention

Medically unexplained, complex,

high-utilization

Rosa is a 57-year-old woman living in San Antonio with two grown sons. She

retired after 18 years as an instructional aide in the public schools.

Rosa has Type 2 diabetes as well as coronary artery disease. She has

difficulty managing her condition, and as a result she has had both her legs

amputated and also suffers from diabetic gastroparesis, which makes it hard

for her to process food. Her lack of mobility makes it hard for her to access

the nutritious food she needs, which makes it that much more difficult for her

to control her blood sugar.

Camden (a), n.d.

Case example – “Rosa” (Cont’d)

Rosa reports suffering from both depression and anxiety, and her children do not offer much social support. When we met Rosa she did not have a good relationship with a primary care doctor, despite her many health conditions.

Over the past year, Rosa was frequently admitted to the hospital for nausea, vomiting, abdominal pain, diabetes, and depression/anxiety. She’d like to better manage her health, but feels unable to address her own needs in any significant way (ambivalent).

Camden (a), n.d.

Manning &

Gagnon, 2017

Complex patient

definition Patients with complex

care needs, with a combination of multiple chronic conditions, mental health issues, medication-related problems, and social vulnerability.

Martello et al.,

2014

What impacts complexity?

System Barriers

The healthcare system is designed to work for the average

patient, and like many large systems, it struggles to help

the outliers – the small number of patients with complex,

hard-to-manage needs and chronic conditions.

Camden (a), n.d.

What impacts complexity?

95% of variation in chronic disease outcomes is estimated

to be related to patient lifestyle and health behaviors

(Tuerk et al., 2008)

Self-management: to be successful, requires mastery

of transferable skills and strategies for goal-setting,

positive self-reinforcement, self-monitoring, problem-

solving, decision-making, and resource identification.

Also self-efficacy

Don’t forget:“ACES”?

Adverse Childhood Experiences Emotional abuse

Physical abuse

Parent substance abuse

Parent incarceration

Sexual abuse

Parent separation or divorce

Mother treated violently

Household mental illness

Physical neglect

Emotional neglect

http://www.cdc.gov/violenceprevention/acestudy/about.html

What can you do to help?

Strategies

Value-Driven

Interventions

Improving the patient’s

engagement in

behaviors or activities

that are consistent with

their identified values

Robinson, Gould, &

Strosahl, 2011

Strategies

Motivational Interviewing

A conversational technique that engages

a patient’s motivation to change based on

his or her own needs and wants rather

than a provider’s goals.

Camden (a), n.d.

Strategies

Trauma-Informed Care

A framework for care that realizes the

prevalence of trauma in a population,

recognizes the presence of trauma

symptoms in an individual, acknowledges

the role that trauma has played in a

patient’s life, and seeks to avoid re-

traumatization.

Camden (a), n.d.

Strategies Accompaniment

The principle that care coordinators

should be active but short-term

participants in health care provider visits

and other interactions, with the goal of

helping develop the patient’s capacity for

self-advocacy and independent navigation

of complex systems.

Camden (a), n.d.

Strategies Harm Reduction

A set of practical strategies and ideas

aimed at reducing negative

consequences of various human

behaviors, legal and illegal, especially

those associated with drug use.

Camden (a), n.d.

Strategies: The Contextual Interview

Love – Work – Play Living situation

Relationship status & sex

Family

Friends

Spiritual life

Work

Income

Fun/hobbies

Health Risk & Behaviors Tobacco

Caffeine

Alcohol

Marijuana

Street drugs

Diet

Exercise

Sleep

Bauman, Beachy, & Ogbeide (2018)

Case

Myra is a 67 y/o female who has morbid obesity, diabetes, chronic pain, chronic open sores, depression and anxiety. She routinely meets w/her PCP in order to get on more medication to treat all these symptoms. It is clear from the PCP’s perspective that if she would start making lifestyle changes and working through her depression and anxiety, that she wouldn’t have to be so reliant on medications. Visit after visit, it is the same story, with worsening outcomes for the patient’s health and a demanding attitude by the patient. The PCP was frustrated, and finally (after several failed attempts previously) gets her to start meeting with the BHC. BHC + PCP visits on the same day for several months and then moved to alternating

months.

Addressed the current and past grief as well as past trauma

Myra’s “hard” exterior and demanding approach, reduced drastically.

The PCP felt supported and understood where the Myra was coming from.

Myra felt her independence was more supported.

“Inappropriate” behaviors

BHC + PCP co-visit If past communication has been difficult (to mediate)

In cases where a contract has been broken (for support, helping to set clear, behavioral expectations, etc.)

BHC acts a “witness” for PCP and/or patient Strength in numbers to decrease aggressive or threatening

behaviors

Help limit “he said – she said”

BHC helps understand the function of a patient’s “inappropriate” - including escalating or threatening behavior Discovering the “motive” or “need” via assessing the context

Case Chad is a 52yo white male who has significant anxiety and irritability that were treated

with Xanax in the distant past. He feels the anxiety is caused by his thyroid medication

and is seeking prescription for Xanax. He is generally distrustful of medical system and

feels he receives poor care. Dr. S has been assigned to maximize continuity. Dr. S does

not feel Chad is an appropriate candidate for Xanax given impulsivity and poor insight.

Chad refuses all other medications. An intermediate benzo was prescribed as a trial. A

few days later, Chad visits the pharmacy to request fill on the medication stating he

never received a prescription and yelling at the pharmacist. Dr. S believes the

prescription was handed to the patient and is concerned about misuse. A refill is

provided but patient refuses to take as it is not Xanax. Comes to next visit with intent of

Firing Dr. S and finding new physician.

BHC + PCP co-visit

○ Established plan ahead of time, talked through main points

○ Explained purpose of co-visit to Chad: BHC as mediator and witness

○ Chad did not fire Dr. S, did not receive Xanax, has resumed medical care w/Dr. S

Role-Play John is frustrated he’s been called for an opioid pill count at the request of his

PCP. He tells the nurse how upset he is that Dr. Smith “doesn’t trust him,” nor

does he feel like “she ever listens” to him. He begrudgingly agrees to the pill

count, which shows he’s off by a handful of pills. At the next visit, Dr. Smith asks

him about the situation. He gets louder than usual stating how he is tired of

being treated like “an addict.” John explains that he had to take his wife to the

hospital several hours away, which caused him to be traveling for longer than

expected, so he took a few extra pills. Dr. Smith had also tapered down these

medications when he started care with her due him being over the recommended

limit of MEUs. John feels targeted. Dr. Smith feels disrespected. Dr. Smith cites

how she’s given him several chances to be in compliance with the pain contract.

She’s fed up and John is requesting another PCP or he threatens to leave the

clinic. John shows up for his appointment w/Dr. Smith and Dr. Smith pages BHC.

Groups of 3: 1) Patient; 2) PCP; 3) BHC

References Bauman, D., Beachy, B. & Ogbeide, S. A. (2018). Stepped care and behavioral approaches for

diabetes management in integrated primary care. In W. O’Donahue & A. Maragakis (Eds), Principle-based stepped care and brief psychotherapy for integrated care settings. New York, NY: Springer Science, Business Media, LLC.

Bridges, A. J., Gregus, S. J., Rodriguez, J. H., Andrews, A. I., Villalobos, B. T., Pastrana, F. A., & Cavell, T. A. (2015). Diagnoses, intervention strategies, and rates of functional improvement in integrated behavioral health care patients. Journal Of Consulting And Clinical Psychology, 83(3), 590-601.

Camden Coalition of Healthcare Providers(a) (n.d.) Healthcare hotspotting. Retrieved from https://hotspotting.camdenhealth.org/

Camden Coalition of Healthcare Providers(b) (n.d.) Introduction: What is hotspotting? Retrieved from http://healthcarehotspotting.com/wp/introduction/

Center for Integrated Health Solutions Trauma Informed Care (CIHS TIC; 2013). It’s just good medicine: Trauma-informed primary care. SAMHSA/HRSA Webinar. Retrieved from www.Integration.samhsa.gov

Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm: Institute for Futures Studies.

Hardavella, G., Aamli-Gaagnat, A., Frille, A., Saad, N., Niculescu, A., & Powell, P. (2017). Top tips to deal with challenging situations: doctor–patient interactions. Breathe, 13(2), 129–135.

Jackson, J. L., & Kay, C. (2013). Heartsink Hotel, or “Oh No, Look Who’s on My Schedule this Afternoon!” Journal of General Internal Medicine, 28(11), 1385–1386.

References Martello, C., Bessière, G., Bigras, M., et al. (2014). What Do We Mean When We Say "This

Patient is Complex"? . NAPCRG Annual Conference (North American Primary Care Research 22 Group). New York.

Miller, W. & Rollnick, S. (2012) Motivational interviewing (3rd ed.). New York: Guilford.

O’Donohue, W.T., Byrd, M.R., Henderson, D. A., & Cummings, N. A., (Eds.). (2005). Behavioral integrative care: Treatments that work in the primary care setting. New York: Routledge.

Reiter, J., Dobmeyer, A., & Hunter, C. (2018). The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition. Journal of Clinical Psychology in Medical Settings. Published online: 26 February 2018. https://doi.org/10.1007/s10880-017-9531-x

Robinson, P., Gould, D., & Strosahl, K. (2011). Real behavior change in primary care: Improving patient outcomes and increasing job satisfaction. Oakland, CA: New Harbinger Publications

Robinson, P., & Reiter, J. (2016). Behavioral consultation and primary care: A guide to integrating services (2nd Ed.). New York: Springer.

Tuerk, P. W., Mueller, M., & Egede, L. E. (2008). Estimating physician effects on glycemic control in the treatment of diabetes: Methods, effects sizes, and implications for treatment policy. Diabetes Care, 31, 869-873.

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