Lessons learned from implementing an Integrated Behavioral Health model in the provision of services for people living with

HIV/AIDS in Puerto Rico Juan C. Ramos, PsyD

Primary Care Psychology Fellow University of Massachusetts Medical School

Nydia M. Cappas, PsyD Director of Clinical Health Psychology Program

Ponce School of Medicine Clinical Psychology Program

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #H5October 29, 20112:00 PM

Faculty Disclosure

We have no relevant financial relationships

to disclose

Need/Practice Gap & Supporting Resources

• This talk is based on the experiences and data collected through eleven years in the provision of integrated mental health services to people living with HIV/AIDS in Puerto Rico

Objectives• Learn about background of the Health Psychology Program (HPP) at

Ponce School of Medicine

• Share the experiences, administrative process and protocols involved in the successful implementation of an integrated behavioral health program in a variety of settings that serve people living with HIV/AIDS.

• Discuss the use of administrative and organizational strategies used for the implementation of an integrated behavioral health program taking into consideration the particularities of diverse clinical and community settings.

Expected Outcomes

As stated in the objectives we hope at the end of this presentation participants will:

• Understand the background and functioning of the HPP at Ponce School of Medicine

• Recognize the administrative mechanisms used to implement the program in a variety of settings that serve people living with HIV/AIDS

Health Psychology Program (HPP) at Ponce School of Medicine

• Created in 2000 – Ryan White Part A funds– 4 clinics in Ponce, PR

• 2006-2008 – Interruption of services

• 2008 Re-integration– Ryan White Part A funds– Integrated behavioral health

model– 6 clinics in Ponce, PR

• 2010 Expansion of program– Ryan White Part B funds– PR Departments of Health– 7 immunology clinics

Where in the world is Puerto Rico?

- Population: 3.7 million- Island size: 100 x 35 miles- Territory of the US

Living with a diagnosis of HIV infection: 18,828

Living with an AIDS diagnosis: 10,453

CDC, 2009

Transmission category:

PR EU

Injection Drug Use 48.7% 25.6%

Heterosexual contact 26.3% 18.3%

Male to Male contact 16.5% 47.3%

CDC, 2009

Puerto Rican Health Reform

• 1994– Health care reform– government-run program– provides medical and healthcare services to indigent and

impoverished citizens of PR– include specialty mental health services.

• Health Psychology Program (HPP)– Chronic disease

• Better access to behavioral health care• Behavioral health interventions focused on adherence to medical

treatment– Optimal antiretrovital adherence: 95%

Health Psychology Program Goals

• Improve access and delivery of behavioral health services to people living with HIV/AIDS in Puerto Rico– Integrated care model

• Patient care• Administrative & organizational changes

• Reduce stigma associated to behavioral health needs and HIV/AIDS related stigma

• Improve the patient physical health– Adherence– Immunology status– Reduction in viral load

Health Psychology Progam

Clinical services

Didactic / research Public policy

Ryan White Part A Ryan White Part B

6 clinics 7 immunology clinics

2 Interns 2 students 6 Clinicians 2 students

Services Provided by the Health Psychology Program

RW A RW B TotalInitial interview 108 1,259 1,376Individual therapy 507 597 1104Case discussion 753 752 1505Adherence evaluation

137 862 999

Couple therapy 17 39 56Family therapy 6 64 70

July 2010 to June 2011

Other services provided by the HPP

• Dual interviews • Risk counseling• Staff Consults• Workshops • Standard screening (standing order)

Screening tools• Patient Health Questionnaire – 9 (PHQ-9) Spanish

version– Depression screening tool

• Generalized Anxiety Disorder-7 (GAD-7) Spanish version– Anxiety screening tool

• CAGE-AID Spanish version– Screening for alcohol and drug problems

• Immunologic status• Adherence registry• Semi-structured guide to explore biopsychosocial

factors associated with HIV/AIDS

Most common reasons for referral

• HIV/AIDS related Stigma • Challenges adhering to treatment• Depressive symptoms or mood changes

associated to the HIV/AIDS diagnosis• New diagnosis of HIV/AIDS• Behaviors associated to opportunistic

infections

LESSONSAdministrative and Clinical

Lessons:Be prepared to analyze and listen

Analyze• The culture of the clinics• The clinic relations with the

patients• The flow of patient services• Beliefs about sharing

information (including records)

• The existing level of integration – Between the clinic personnel

Listen to

• Past experiences with mental health providers– Through referrals or

collocation– Duration of contracts or

services

• Difficulties most commonly confronted with patients

Lessons:Assessment of Clinic Needs and Expectations

• Assessment of Needs and Level of Integration (ANLI)- Instrument designed to evaluate the clinic needs and expectations of the clinics

- before implementing behavioral health services

• The information was shared with the behavioral health provider assigned to the clinic before they start

Lessons:Share clinical, administrative and organizational information with behavioral health provider (BHP)

• Basic training in administrative functioning and organizational structure to BHP– Increase the awareness of the immunology clinics culture and

dynamics– Behavioral health clinicians more flexible and knowledgeable

• Sharing and discussion of the immunology clinics needs and expectation (results of ANLI)– Facilitate adaptation– Increase in chance of suggesting changes relevant to the clinics

• Behavioral health meetings – Sharing of ideas and strategies used in the clinics to improve the

patient care

Lesson:Integration of Behavioral Health Services Requires Flexibility• Clinic diversity:

– The patient demographics, administration, protocols and needs are diverse

– The engagement with the clinic personnel, patients and administration is essential

– Demonstrate how changes and suggestions are in their best interests

• Flexibility needed to adapt to changes, requirements and needs of:– Funding Agency– Clinics Protocols– Administrative personnel– Population served

Lessons:Training to Behavioral Health Provider

• Training is constant, supervision available– Individual and group case discussions– Supervisory Phone calls– Including progress notes

• Include tips for the adaptation to practical things like:– Office space- Or lack of it– What to do if there are no patients

• Must include an in depth understanding of the condition including– Physiology– Medication effects– Stigma– Adherence

• Historic development of the clinics

Lessons:Adaptation of Clinical Interventions

• Setting and patients needs • Collaborative work with medical providers,

nursing, social work and case management• Screening tools adapted to the clinics setting

and patients needs

Other Challenges

• Funding• Integration of Students• Training of new staff• Standardization of Processes without rigidity• Expand services to other chronic conditions

Q&A

Questions?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!