bernadette hayburn, psy.d. coatesville … appropriate assessments (e.g. , phq not mmpi) saves time...
TRANSCRIPT
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B E R N A D E T T E H A Y B U R N , P S Y . D .
C O A T E S V I L L E V A M C
P R I M A R Y C A R E P S Y C H O L O G I S T
H E A L T H B E H A V I O R C O O R D I N A T O R
B a s e d o n s l i d e s d e v e l o p e d b y M a r g a r e t D u n d o n , P h . D . , C h r i s t o p h e r H u n t e r , P h . D .
a n d K a t h e r i n e D o l l a r , P h . D . f r o m t h e
D e p a r t m e n t o f V e t e r a n s A f f a i r s ’ C e n t e r f o r I n t e g r a t e d H e a l t h c a r e .
Primary Care Mental Health Integration
Objectives
Describe the rationale for integrating Behavioral Health into a Primary Care setting.
Identify three differences between the Primary Care-Mental Health Integration Model and Traditional Mental Health Care.
Identify the 5 A’s: An Evidence-Based Assessment and Intervention Model within the PC-MHI context.
List at least three clinical interventions utilized within PC-MHI.
Healthcare Realities
Up to 70% of PC medical appts have psychosocial component Psychiatric disorders – full spectrum Behavioral issues (IBS, tension headaches, insomnia, nonspecific
pains, vague somatic systems- most pts view as medical Unhealthy lifestyles (smoking, diet, etc..) Life stressors
› 80% of psychotropics are prescribed by non-psychiatric medical providers. (Hunter et al, 2009) .
Behavioral health problems compromise treatment of physical health problems (Nash et al., 2012).
Distressed patients use twice the healthcare services(McDaniel & deGruy, 2014)
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Primary Care Realities
“For primary care physicians…there is too much to do- too many patients, too many demands, too much information flowing through, too little time to do a good job.”
Average US (Non-VA) panel: 2300 patients. “To do chronic and preventive care would take 18 hours/day to do it right”NEJM, Perspective Roundtable 11-19-08.
Chronic diseases
Multiple comorbidities (associated with poorer
disease self-management & higher costs)
(Fisher & Dickinson, 2014)
Typical PC Clinic Day: VA Survey
14-16 appointments, with 30 min.
Clinical reminders: 4-10/pt., for 5-15 min
Health problems: 3-8 active, 1-2 complex
Admin Task: 100 view alerts per day (2 hours work), e-mails, phone calls, orders, scripts, notes, etc.
The result:
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What to Do???
“The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.” – Plato
Traditional practice (in both medicine and mental health) assumes the mind and body function independently.
In reality, they are interconnected and healthcare need to be as well. Emotional factors affect physical health.
Medical illnesses can lead to psychological distress. Psychological distress corresponds with morbidity and mortality risk. Effective treatment of many medical conditions includes a major
behavioral component.(Gatchel & Oordt, 2008)
Mind-Body Connection:Meet Lance
Integrated Care
• A form of care in which behavioral heath and primary care providers interact in a systematic manner to meet the behavioral and health needs of their patients.
-Dr. Christopher Hunter
• Unifies care for physical and mental concerns”
AHRQ 2008 Butler et al.
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Population-Based Integrated Care
• Serves a higher % of the population: a little service for a lot of pts vs. traditional MH
• Emphasizes early identification/prevention
• De-emphasizes MH Dx
• Provides triage and tx in stepped care fashion
• Supports, rather than replaces specialty mental health care
• (Nash et al., 2012)
Models of Integrated Care
Coordinated CarePCPs and BHPs work in separate systems and facilities, delivering separate care and exchange information as needed.
Co-location/Co-located ServiceBHP works in a space that is in close proximity to (or embedded in) a primary care clinic. PCPs may refer BHPs pts but BHPs and PCPs deliver separate care.
Collaborative Care/Collaboration (Integrated)PCPs and BHPs work together in a shared system for the purpose of developing treatment plans, providing clinical services and coordinating care to meet the physical and behavioral health needs of patients.
PC-MHI in the VA
2007: PC-MHI Initiative was launched
2008: Uniform MH Services Handbook requires that VAMCs provide a blended program:
1.) Integrated co-located collaborative care
2.) Care management
2010: VA PC was transformed into PACT Development of a stepped model of care
Shift to tending proactively to needs of a cohort of PC pts rather than a referred caseload of pts presenting for psychological care
(Kearney et al., 2014).
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BHL Care Management
Algorithm-based care, implemented by telephone, that includes routine monitoring/assessment of patients focusing on
Psychoeducation: encourage self-management skills
Brief treatment
Medication Monitoring (antidepressants)
In consultation with the supervising clinician, provide relevant information to the PCP to allow collaboration for appropriate care decisions
(Post et al., 2010)
Can’t PC just Refer to Specialty MH Care?
Long delays often result in attrition and lost windows of opportunity for effective treatment
High No Show rates
Perceived stigma (going to MH building or service)
• Patient volume has increased, not feasible to refer everyone out, especially pts with mild-sub-clinical symptoms(Pomerantz, et. al, 2008)
BHP in PACT vs. Traditional MHDimension BHP in PACT Mental Health Specialty
Care
Location On site A different floor, bldg…
Population Most are healthy, mild to moderate symptoms
Most have MH diagnoses
Inter-provider Communication
Collaborative & on-going Consultations via PCP’s method of choice
Consult reportsFormal communications
Service Delivery Structure Brief appointmentsLimited number of appointments
50 - 90 minute psychotherapysessionsLonger treatment episodes
Approach Problem-focusedSolution orientedPatient centered
Varies by therapy Diagnosis-focused
Treatment Plan Leader PCP continues to be lead MHP is lead
Primary Focus Support the over-all health Focus on function
Cure or ameliorate mental health symptoms
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Does It Work????PC-MHI Evidence Base
Improved identification
Improved access
• Improvedengagement andadherence
Higherqualitycare
Betterclinicalandfunctionaloutcomes
Increasedpatient satisfaction(Dollard,2011;Pomerantz etal,2008)
CVAMC PC-MHIStaffing
Bernadette Hayburn, Psy.D.: 3 days per week
Justin Charles, Psy.D.: 1 day per week
Kelly Gerhardstein, Psy.D.: 1 day per week
Michael Gliatto, M.D.: ½ day per week
Doctoral-Level Psychology Intern: 16 hours week
Services
Consultation
Assessment
Individual Treatment
Group Classes: Pain, Depression, MOVE
Psychiatric Medication Consultation and Management (Dr. Gliatto)
Staff Education
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Mind Over Mood Outcome Data
Total # of sessions: 10Format: Weekly 60-minute group sessions of Cognitive-Behavioral Therapy
for Depression
Outcome Data: A. Changes in scores on BDI-II (2012-2014)
Pre Group Post-Group 26.8 (high-moderately depression) 12.9 (minimal depression)
B. Changes in scores on PHQ-9 (2014-2015)Pre Group Post Group
15. 5 (moderately-severe) 7.5 (mild)
Patients who completed the group demonstrated a significant reduction in depression as evidenced by a marked decline in their BDI-II & PHQ-9 scores over the course of treatment.
Performance Measures
PC-MHI Penetration (PACT 15) – The percent of assigned PC pts seen by a PC-MHI Provider.
Goal: 6 % CVAMC: 5.27 %
Ranked 4th of 10 in VISN 4.
PC-MHI CASE
53 year old SC veteran
Referred for depression and “stress” secondary to chronic knee pain and frustration with medical system
Pain negatively affected his work, relationships,
leisure activities, and sleep.
Primary concern was his irritability and angry outbursts towards wife and children.
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Treatment Interventions
Psychoeducation about Stress
Managing Stress Workbook
Relaxation Training
Mindfulness Exercises for noticing
angry thoughts and feelings
Assertiveness Training to improve
communication with wife
Treatment Summary
6 sessions/ 30 minute intervals
Self-Report Measures:Pre Post
PHQ-9 9 (high-mild dep) 5 (low-mild dep)GAD-7 17 (severe anxiety) 6 (mild anxiety)
“I feel much better.” Pt reported increased awareness of triggers for his anger
and felt better able to choose his response instead of reacting impulsively.
What Tools Do Behavioral Health Providers Need to Work Effectively in PC?
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Conceptual Shift
“We must move beyond the narrow conception of ourselves as mental health professionals and begin to see ourselves as comprehensive health professionals.”
Russ Newman
May 2005 APA Monitor
Behavioral Health Consultation: Domains of Competency
Domain 1: Clinical Practice
Domain 2: Practice Management
Domain 3: Consultation
Domain 4: Documentation
Domain 5: Teamwork
Domain 6: Administrative Skills
Robinson, P. & Reiter, J. (2007). Behavioral consultation and primary care: A
guide to integrating services. New York: Springer Science-Media.
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Domain 1: Clinical Practice
Define role accurately
Identify problems rapidly
Limit problem definition
Focus on functional outcomes
o Less focus on diagnosis
o Targeted interventions
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Measurement-Based Care
Use appropriate assessments (e.g. , PHQ not MMPI)
Saves time and guides clinical interview
Facilitates systematic application of stepped-care (What is the next tx step based upon pt’s symptoms?)
Helps monitor outcome
Helps patients become more knowledgeable about their disorder and progress, which is key to self-management
Domain 2: Practice Management
Effective brief visits Recommend 20-30 minutes Focus on functioning Specific skills Should include charting and contact with PCP Limited number of sessions
Same day access Warm hand-off
Use an intermittent visit strategy
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Domain 3: Consultation
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• Focus on and respond to referral question• Tailor recommendations • Conduct effective curbside consultations
• Use same language as PCP• “Hallway”• Less than 5 minutes: 1-2 ideal
• Follow-up assertively
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Domain 4: Documentation Skills
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Use same chart Use same format as PCP Brief, clear, concise Templates when possible Numbers when possible (e.g. PHQ 9 score) Include brief impression and plan Include suggestions for PCP
Domain 5: Teamwork32
• Be a team player, ideally a leader• Unscheduled services• Learn PCP culture • Be flexible • Be available• Build rapport with team
Domain 6: Administrative Skills
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Understand relevant polices and procedures
Market services
Referral tips for PCPs
Review and refine linkages whenever possible
Ensure proper coding (stop codes)
Outcome Monitoring
Support management in recruitment
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What Exactly Do You Do????
Hamlett-Berry, 2010
The 5 A’s: An Evidence-Based Assessment &
Intervention Model
ArrangeSpecify plans for
follow-up (visits, phone calls,
mail reminders)
AssistProvide information, teach
skills, problem solve barriers to reach goals
AdviseSpecific, personalized, options for tx, how sx
can be decreased, functioning, quality of life/health improved
AgreeCollaboratively select goals based on patient interest and
motivation to change
AssessRisk Factors, Behaviors, Symptoms,
Attitudes, Preferences
Personal Action Plan1. List goals in behavioral terms2. List strategies to change health behaviors3. Specify follow-up plan4. Share plan with practice team
5A’s-Assess, Advise, Agree, Assist, Arrange
Diagram adapted from: Glasgow, R. E & Nutting, P. A. (2004). Diabetes. In Handbook of Primary Care Psychology. Ed., Hass, L. J. (pp. 299-311)
1. Introduction of behavioral health consultation service (1-2 minutes
2. Identifying Clarifying consultation problem (10-60 seconds) Assess
3. Conducting functional analysis of the problem (12-15 minutes)
4. Summarizing your understanding of the problem (1-2 minutes)
5. Listing out possible change plan options (selling it) (1-2 minutes) AdviseAgree
6. Starting a behavioral change plan (5-10 minutes) Assist Arrange
Phases of a 30-Minute Appointment
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ASSESSFunctional Assessment
Biopsychosocial Model
• -Physical
• -Behavioral
• -Cognitive
• -Emotional
• -Environmental factors
Initial Interview
CIH\Initial Interview Note _handout2pcmh_initial_interview_outline508_20140922-123111462.pdf
ADVISE
• Give clear, specific & personalized change advice
• What changes will be involved and how they might be beneficial
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AGREE
Collaboratively select goals based on patient’s interest in & willingness to change behavior
Find common ground & define behavior change goals & methods
Shared decision making = -Greater sense of personal control-Choices based on realistic expectations-Change matches patient values
ASSIST
Develop a specific tailored action plan
Plan should: 1. Help identify, address and overcome barriers 2. Develop self-management skills 3. Develop confidence to successfully change
ARRANGE
• Specific plans for subsequent contacts
• Individual, Group, Self-Management
• Other providers/adjunctive treatment
• Video clip
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PC-MHI INTERVENTIONS
Relaxation Training
Deep Breathing
Cue-controlled relaxation
Progressive muscle relaxation
Visual imagery
Goal Setting
Are the goals well defined in behavioral terms? (S.M.A.R.T)
Realistic/achievable
Within realm of control/influence
Break into sub-goals
Personally important
Whose goals are they anyway ?
N:\My Documents\HPDP\0577 VANCP MyHealthChoicesV2 508 F screen.pdf
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Help track progress towards a goal
Use a calendar
Keep a tally
Chart on a graph
Self-Monitoring
Behavioral Activation
Difficult to feel depressed when engaged in activities that provide pleasure and accomplishment
•Re-establish routines
•Increase reinforcing experiences
•Overcome avoidance patterns
•Distraction from problems or unpleasant events
Pleasant Activities:
N:\My Documents\Mood Group\365 Pleasant Activities List (2).doc
Help to identify unhealthy thoughts
Use thought logs
Question thought process
“Cognitive Disputation”
Self-help books for highly motivated
“Mind Over Mood”
Greenberger and Padesky
Identifying and Disputing Negative Cognitions
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Motivational Interviewing
Examine readiness to change (Readiness Ruler)
Examine importance and confidence for change
Elicit pros and cons of change
Problem Solving Training
Define the problem
Brainstorm solutions
Critically evaluate each solution
Select and implement an option
Assess the outcome
Assertive Communication
Assess patterns of communication
Explain differences in passive, assertive, and aggressive communication
Help patient to learn how to speak assertively
Practice through role-play
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References
Dollar, K., M., Greenwood, S.,& Klaus, J. (2011). Introduction to PC-MHI Functions: CCC, CM, and howthey work together [PowerPoint slides]. Retrieved from Center for Integrated Healthcare Sharepointsite https://vaww.visn2.portal.va.gov/sites/natl/cih/default.aspx?RootFolder=%2fsites%2fnatl%2fcih%2fShared%20Documents%2fAugust%202011%20Co%2dlocated%20Collaborative%20Care%20Training%20Presentations%20%2d%20Charlotte%20NC%2fIntroduction%20to%20PC%2dMH%20Integration%20Functions&FolderCTID=&View=%7b3E2788C6%2d149B%2d4287%2d85D3%2dBB111FBFFF18%7d.
Dundon, M. & Hunter, C. (2009). Effective evidence-based assessments and interventions in 30-minutesor less: What every collaborative primary care mental health clinician should know [PowerPoint slides]. Retrieved from Center for Integrated Health Sharepoint site https://vaww.visn2.portal.va.gov/sites/natl/cih/Shared%20Documents/Forms/AllItems.aspx.
Fisher, L. & Dickinson, W. P. (2014). Psychology and primary care: New collaborations for providingeffective care for adults with chronic health conditions. American Psychologist, 69(4), 355-363.
Gatchel, R. J. & Oordt, M. S. (2008). Clinical health psychology and primary care: Practical advice andclinical guidance for successful collaboration. Washington, DC: American Psychological Association.
Glasgow, R. E., & Nutting, P.A. (2004). Diabetes. In L. Hass (Ed.), J. Handbook of Primary Care Psychology, (pp. 299-311) . New York: Oxford.
Hunter, C. L., Goodie, J. L, Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated behavioral health inprimary care: Step by step guidance for assessment and intervention. Washington, DC: American Psychological Association.
References (continued)
Kearney, L. K., Post, E. P., Pomerantz, A., & Zeiss, A. M., (2014). Applying the
interprofessional patient aligned care team in the Department of Veterans Affairs:
Transforming primary care. American Psychologist, 69(4), 399-408.
McDaniel, S. H., & deGruy, F. V., (2014). An introduction to primary care and psychology. American
Psychologist, 69(4), 325-331.
Nash, J. M., McKay, K. M., Vogel, M. E., & Masters, K. S. (2012). Functional roles and foundational
characteristics of psychologists in integrated primary care. Journal of Clinical Psychological Medical
Settings, 19, 93-104.
Pomerantz, A., Cole, B. H., Watts, B. V., & Weeks, W. B. (2008). Improving efficiency and access to
mental health care: combining integrated care and advanced access. General Hospital Psychiatry 30,
546-551.
Post, E. P. (2008). Veterans Health Administration primary-care-mental health integration initiative.
North Carolina Medical Journal, 69(1), 49-52.
Valenstein, M., Adler, D. A., Berlant, J., Dixon, L. B., Duilt, R. A., Goldman, B. … Sonis, W. A.
Implementing standardized assessments in clinical care: Now’s the time. Psychiatric Services:
60(10), 1372-1375.