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Primary Care and Behavioral Primary Care and Behavioral Health Integration within the Free Health Integration within the Free
Clinic Setting: Developing a Clinic Setting: Developing a PCBH Model of Care PCBH Model of Care
Alysia Hoover-ThompsonAlysia Hoover-Thompson
[email protected]@radford.edu
Radford UniversityRadford University
Presented at the Mental Health RoundtablePresented at the Mental Health Roundtable
Virginia Health Care Foundation, Richmond, VAVirginia Health Care Foundation, Richmond, VA
August 16, 2011August 16, 2011
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Radford University Psy.D. ProgramRadford University Psy.D. Program
First cohort began providing services to First cohort began providing services to community in 2008 as part of training programcommunity in 2008 as part of training program
Students provide mental health services to local Students provide mental health services to local community organizationscommunity organizations
Many of these organizations are not-for-profitMany of these organizations are not-for-profit Program emphasesProgram emphases
Rural practiceRural practice Cultural diversityCultural diversity Social justiceSocial justice Evidence-based practiceEvidence-based practice
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Free Clinics Free Clinics
““Free clinics are volunteer-based, safety-Free clinics are volunteer-based, safety-net health care organizations that provide net health care organizations that provide a range of medical, dental, pharmacy, a range of medical, dental, pharmacy, and/or behavioral health services to and/or behavioral health services to economically disadvantaged individuals economically disadvantaged individuals who are predominately uninsured” who are predominately uninsured”
(National Association of Free Clinics, 2008)(National Association of Free Clinics, 2008)
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Free Clinic of the New River ValleyFree Clinic of the New River Valley
On siteOn site MedicalMedical DentalDental PharmacyPharmacy Dermatology clinicDermatology clinic
Who Qualifies?Who Qualifies? Adults without health insuranceAdults without health insurance ““Low income” based on 2010 Federal Poverty Low income” based on 2010 Federal Poverty
GuidelinesGuidelines Mental Health Association of the New River ValleyMental Health Association of the New River Valley
Provides pro-bono counseling services to MHA clients Provides pro-bono counseling services to MHA clients at an office located in the Free Clinic at an office located in the Free Clinic
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Why Integrated Care?Why Integrated Care?
Up to 70% of visits to primary care offices are Up to 70% of visits to primary care offices are related to behavioral health needs related to behavioral health needs
Many common medical problems that are Many common medical problems that are treated by PCP involve health and behavioral treated by PCP involve health and behavioral habits that influence symptoms (Hunter, Goodie, habits that influence symptoms (Hunter, Goodie, Oordt, & Dobmeyer, 2009) Oordt, & Dobmeyer, 2009)
In 2008, the American Psychological Association In 2008, the American Psychological Association launched the Primary Care Initiativelaunched the Primary Care Initiative
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Developing an Integrated Developing an Integrated PCBH SitePCBH Site
Psy.D. Program Director approached by Free Psy.D. Program Director approached by Free Clinic DirectorClinic Director Program students had previous experience providing Program students had previous experience providing
traditional mental health services at site through traditional mental health services at site through Mental Health AssociationMental Health Association
Joshua Bradley was the first Psy.D. student from Joshua Bradley was the first Psy.D. student from Radford to complete a practicum thereRadford to complete a practicum there Developed forms and documents for integrationDeveloped forms and documents for integration Developed comprehensive 360 degree evaluation Developed comprehensive 360 degree evaluation
procedure to assess integration into the system and procedure to assess integration into the system and performanceperformance
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Integrating PCBH Services into an Integrating PCBH Services into an Established SystemEstablished System
Emphasize that you are there to support Emphasize that you are there to support existing servicesexisting services
Try to accept as many referrals as Try to accept as many referrals as possible in order to show usefulnesspossible in order to show usefulness
Get to know all people in the clinicGet to know all people in the clinic Explain what you doExplain what you do
Have a prepared explanation and examplesHave a prepared explanation and examples Create a handoutCreate a handout
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Systemic Contextual Systemic Contextual ConsiderationsConsiderations
Names and FacesNames and Faces Virginia College of Osteopathic Medicine Virginia College of Osteopathic Medicine
residentsresidents On site physicianOn site physician Nurse practitioners Nurse practitioners NursesNurses Front office staffFront office staff VolunteersVolunteers
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Patient Contextual ConsiderationsPatient Contextual Considerations
Given the low-income client base, there may be relevant Given the low-income client base, there may be relevant considerations related to intervention optionsconsiderations related to intervention options
Clients may lack financial resources to make significant changes Clients may lack financial resources to make significant changes to their diet or join a gymto their diet or join a gym
Transportation may be a problemTransportation may be a problem High frequency of significant financial and environmental High frequency of significant financial and environmental
stressorsstressors Literacy rates may be lowerLiteracy rates may be lower Other contextual factors will undoubtedly become apparent as Other contextual factors will undoubtedly become apparent as
the BHC becomes more familiar with the client basethe BHC becomes more familiar with the client base This speaks to the importance of being aware of cultural This speaks to the importance of being aware of cultural
and contextual factors when working within an integrated and contextual factors when working within an integrated care systemcare system
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Primary Care EnvironmentPrimary Care Environment
Fast pacedFast paced Adjust clinical note takingAdjust clinical note taking
Space limitationsSpace limitations At least 7 different roomsAt least 7 different rooms Move from room to room frequentlyMove from room to room frequently
Finding medical chartsFinding medical charts Several places they can beSeveral places they can be
New facesNew faces Remembering names Remembering names
Patient ReferralsPatient Referrals
Self-ReferredSelf-Referred Request to see Mental Health Counselor at Request to see Mental Health Counselor at
appointment with physician/NPappointment with physician/NP Physician/NP ReferredPhysician/NP Referred
Request for BH evaluation/interventionRequest for BH evaluation/intervention Warm Hand-offWarm Hand-off
Occurs in exam room Occurs in exam room
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Additional ActivitiesAdditional Activities
Consultation with medical staff Consultation with medical staff Example: Patient is in abusive relationship and Example: Patient is in abusive relationship and
medical resident asks about treatment options. BHC medical resident asks about treatment options. BHC explains options such as Women’s Resource Center, explains options such as Women’s Resource Center, Mental Health Association, etc… Medical resident Mental Health Association, etc… Medical resident presents options to patientpresents options to patient
Presentations to clinic staffPresentations to clinic staff Safety in medical settingsSafety in medical settings Behaviors that increase appointment/treatment Behaviors that increase appointment/treatment
adherence adherence Case managementCase management
The First YearThe First Year
201 Total Contacts201 Total Contacts 21 warm hand-offs21 warm hand-offs 54 referrals54 referrals 126 follow-up appointments126 follow-up appointments
111 Cancellations/No Shows111 Cancellations/No Shows Primary ComplaintsPrimary Complaints
Depression (64), Anxiety (44), Depression (64), Anxiety (44),
Diet/Exercise (38), Relationship problems (32)Diet/Exercise (38), Relationship problems (32)
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The Second YearThe Second Year
Two students and two days/weekTwo students and two days/week Mondays, Wednesdays and Fridays at the Mondays, Wednesdays and Fridays at the
Free Clinic in ChristiansburgFree Clinic in Christiansburg Wednesdays at Giles satellite officeWednesdays at Giles satellite office
Want to increase warm hand-offsWant to increase warm hand-offs Will increase number of patients seen Will increase number of patients seen
Utilize 360 evaluationUtilize 360 evaluation
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Adjusting to EnvironmentAdjusting to Environment
““Client” versus “patient”Client” versus “patient” Transportable officeTransportable office Medical terminologyMedical terminology Brief encounters (as short as 5 minutes)Brief encounters (as short as 5 minutes) Case managementCase management Educator/Presenter Educator/Presenter In-house mental health representativeIn-house mental health representative
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ConclusionConclusion
Different paradigm Different paradigm Multiple treatment setting considerationsMultiple treatment setting considerations Need to be flexible Need to be flexible Fit into systemFit into system Requires more directness and behavioral Requires more directness and behavioral
focus because of time limitationsfocus because of time limitations