Integrated Models of Care:Integrated Models of Care: Examples from HBPC and Examples from HBPC and

CardiologyCardiology

Steven Lovett, Ph.D.Steven Lovett, Ph.D.

Program DescriptionsProgram Descriptions

Home Based Primary Care (HBPC)Home Based Primary Care (HBPC)

– Primary care delivered in the home.Primary care delivered in the home.

– 3 teams with their own NPs, RN, SW, OT3 teams with their own NPs, RN, SW, OT

– Shared Medical Director, Pharmacist, Shared Medical Director, Pharmacist, Dietitian, Psychology.Dietitian, Psychology.

– Goal = return patients to clinic or avoid Goal = return patients to clinic or avoid institutionalization.institutionalization.

Program Descriptions – Program Descriptions – cont.cont.

Cardiac Transplant ClinicCardiac Transplant Clinic

– Serves vets who are candidates for, or,Serves vets who are candidates for, or,

– have had a heart transplant.have had a heart transplant.

– Regional program.Regional program.

– Patients followed for life.Patients followed for life.

Integration: Treatment Integration: Treatment GoalsGoals

Assist medical providers in Assist medical providers in reaching program’s treatment reaching program’s treatment goals.goals.

Identify undiagnosed Identify undiagnosed psychological problems.psychological problems.

Integration: Treatment Integration: Treatment SettingSetting

Fast paced clinics.Fast paced clinics.

Reduced privacy.Reduced privacy.

Specific accomplishments for Specific accomplishments for each visit.each visit.

Relatively infrequent visits.Relatively infrequent visits.

Psychological Services Psychological Services ProvidedProvided

Triage for psychological issues.Triage for psychological issues.

Adherence issues:Adherence issues:– KnowledgeKnowledge– SkillsSkills– ResourcesResources– MotivationMotivation

Psychological Services Psychological Services Provided – cont.Provided – cont.

Health behaviors.Health behaviors.

Somatic issues:Somatic issues:– Sleep disturbanceSleep disturbance– PainPain

Psychological distress:Psychological distress:– Depression / anxietyDepression / anxiety– StressStress

Psychological Services Psychological Services Provided – cont.Provided – cont.

Cognitive screening / capacity Cognitive screening / capacity assessment.assessment.

Caregiver / Family issues.Caregiver / Family issues.

End of life issues.End of life issues.

Provider consultation.Provider consultation.

Therapeutic ModalitiesTherapeutic Modalities

Single session intervention.Single session intervention.

Phone follow-up.Phone follow-up.

Referrals / case management.Referrals / case management.

Individual therapy, as needed & Individual therapy, as needed & feasible.feasible.