BEHAVIORAL HEALTH

LAB

MIRECC – VISN 4ACSIR

Goals of the BHL

InstillHope

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How?

Provide» the right care » at the right time » at the right place

With Empathy and Compassion

MIRECC – VISN 4ACSIR

Research to Practice:Behavioral Health Laboratory

BHL is designed to provide clinical services to support providers in Primary Care and Behavioral Health

It is intended to be analogous to Clinical Chemistry or Radiology Laboratories

The BHL is an automated telephone assessment, triage, and monitoring service for patients identified by primary care providers as having depressive symptoms or at-risk drinking.

The BHL conducts a brief telephone (20-30 minutes) assessment generating a report for the PCP including diagnosis, severity, and general treatment recommendations.

MIRECC – VISN 4ACSIR

How it works at the PVAMC

Mechanisms for requesting an assessment» Screening

• Annually – PCPs are required to screen for depression and at-risk alcohol use (2 question screen for depression – 3 for at-risk alcohol use).

• For patients who screen positive, the clinician is responsible to assess the need for immediate care. However, a consult request is automatically generated.

» Referral• A BHL assessment can be ordered with any frequency by primary care providers.

» Disease management• A package of assessments related to a new episode of treatment

The BHL receives a printed consult request.

The BHL reports findings, provides interpretation, and recommendations.

Where appropriate, BHL staff facilitate referral.

MIRECC – VISN 4ACSIR

What does the Service Provide?

Assessment of major illnesses – depression, anxiety, substance use

Screening for other domains – cognition, smoking, psychosis, mania

Initial Treatment recommendationsPatient engagementMonitoring of initial treatment for depression –

adherence, adverse effects, symptoms

MIRECC – VISN 4ACSIR

The BHL as a Platform of Care

Watchful Waiting

Referral Management

Disease Management (e.g. depression, alcohol, suicide)

Research

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A Platform for other activities

Telephone disease management for problem drinking » Supported by VA HSR&D

Developing watchful waiting strategies» Supported by Robert Wood Johnson Foundation

ExTENd – Use of naltrexone in managing alcohol dependence » Supported by NIAAA – R01

DIADS – depression of Alzheimer’s disease » Supported by NIMH R01

Family caregiver Support

Depression Treatment Monitoring

PTSD

Referral Management

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Roll out over several different settings

PVAMC CBOCs Coatesville Ralston Family Practice

2 years 1.5 years 1 year 4 months 1 week

~2000 ~ 1000 ~20 ~5 1

Systematic Screening

Systematic Screening

Systematic Screening

No Screening No Screening

ELM ELM ELM ELM ELM

VA VA VA Penn Penn

4 clinics 3 clinics 4 clinics 1 clinic 1 clinic

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Referrals

0

50

100

150

200

250

300

Aug Oct Dec Feb Apr June Aug Oct Dec Feb

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5 Month Referral Success

Total Referred for

Depression

Referred for

Alcohol

Referred for Depression & Alcohol

p value

Sample size N=605 N=472 N=75 N=58

Percentage of total cases 100.0 78.0 12.4 9.6

Completed Interviews (% within category)

74.0 75.2 64.0 77.6 0.263

Age >65 (% ) 20.8 23.3 16.0 6.9 0.008

Gender (% male) 95.0 95.6 93.3 100 0.161

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Characteristics of PatientsReferred for Depression

Referred forAlcohol

Depression & Alcohol

p value

N=355 N=48 N=45

Age (% > 65) 21.4 14.6 8.9 .091

Race (% White) 45.9 27.1 26.7 .004

MDD 45.0 25.6 55.8 .014

Alcohol dependence 7.1 39.6 51.1 .000

Anxiety disorder (Panic or PTSD) 21.5 6.3 31.1 .010

Psychosis 13.6 10.4 26.7 .044

Mania 7.9 2.1 17.8 .020

High Risk Suicide 14.5 11.6 20.9 .439

In MH/SA care (last 12 months) 27.3 14.6 22.2 .379

On antidepressant 38.1 23.3 23.3 .036

MIRECC – VISN 4ACSIR

Does the BHL change practice?

25% reduction in the number of patient not screened for depression

10% increase in the screen positive rate for depression

Significant increase in the identification of patients with suicidal ideation

Possible improvement in EPRP measures for depression

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Engagement in Care

Overall Required an appointment

Requested an

appointment

p value

Patients needing an appointment (% of total # of assessments)

N=254(44.3%)

N=200(35.0%)

N=54(9.3%)

Patients refusing appointment 12.5%

Proportion seen in MH/SA care within 3 months of the BHL assessment

N=119(55.0%)

N=92 (52.6%)

N=27(50.0%)

0.741

Proportion seen in primary care within 3 months of BHL assessment

N=117(51.1%)

N=87(49.7%)

N=30(55.6%)

0.453

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Barriers to service

Skepticism regarding validity of assessments Skepticism regarding treatment Limited treatment choices anyway Low frequency of patient problems - 1 or 2

patients/week Novelty Doesn’t meet needs Interventions for mild behavior/disease may not be

accepted ? ?

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Two Ways of thinking about screening and treatment initiation

Systematic Screening

Clinical Exam

Initial AssessmentAnd Triage

Treatment Z

OutcomeMonitoring

TreatmentAdjustments

Treatment Q

OutcomeMonitoring

TreatmentAdjustments

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BHL FlowAnnual Screening Direct consult New treatment for depression

Consult request

Full Assessment

Referral to BHC

Recommendations to PCP and Patient

Enroll in Depression monitoring

Referral to Specific Research

No Treatment Recommended

Brief Intervention

Watchful Waiting – 8 weeks

Referral Management

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Starting a New Practice

Identify a thought leader / Champion» Define practice specific needs – screening,

referral, resourcesDefine practice specific proceduresAnnounce the availability of the service

» Face-to-face» Email» Letters / Brochures

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Other Initial Practices

Business cards for patientsBusiness cards for providersELM interfaceListing of providersStaff in practice / Screening of patients877 number?

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Ongoing or new stuff

PensSticky padsBusiness size card for computerMonthly email remindersClinic feedbackInservice by staff on MH topicsWebsite?

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Conclusions

BHL is a flexible, evidence based program» Fills gaps in the VHA system» Provides valid information and documentation

• Acceptable to veterans• Valued by provider

» Can function at low cost across diverse settings» Useful for outreach» Can provide coordination as well as assessment

• Disease Management• Referral Management

» Valuable as a tool for improving system performance