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1. Welcome to Integrated Behavioral Health in Primary Care SettingsPresented by Peter Van Houten MD, Medical DirectorMichael Johnson PhD, LCSW, Behavioral Health Director The presentation will begin shortly. This webinar will be recorded and used for future presentations. Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) with the American Recovery and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative. This webinar is offered by San Francisco Community Clinic Consortium and the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and Development (OSHPD), designated as the California Primary Care Office (PCO).

2. WELCOME EVERYONE!Thank you for joining us today

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6. INTEGRATED BEHAVIORAL HEALTH IN PRIMARY CARE SETTINGS Peter Van Houten MD, Medical Director Michael Johnson PhD, LCSW, Behavioral Health Director Sierra Family Medical Clinic Nevada City, CA (530) 292-3478 www.sierraclinic.org

7. YOUR PRESENTERS Peter Michael

8. WHAT IS INTEGRATED CARE? • The systemic coordination of physical and behavioral care. • It allows patients to feel that for almost any problem, they have come to the right place. • It creates a holistic and seamless approach as opposed to a fragmented system with obstacles and barriers to care.

9. WHAT IS INTEGRATED CARE? • A model of the “medical home” • Represents a “partnership” approach to primary care • Represents a shared learning approach for all involved • IBHP: “Integrated Behavioral Health Project” is an excellent resource (www.ibhp.org)

10. Sierra Family Medical Clinic It’s very rural

11. WHY INTEGRATE BEHAVIORAL HEALTH AND PRIMARY CARE? • Surgeon General’s “Report on Mental Health” (1999) – acknowledged the role of primary care in the provision of mental health care • President’s “New Freedom Commission on Mental Health” (2003) promoted integration • Secretary’s “National Advisory Committee on Rural and Human Services” (2004) called for integration

12. WHY INTEGRATE BEHAVIORAL HEALTH AND PRIMARY CARE? • “Institute of Medicine” (2005) called for integration • The “Health Resources Services Administration” (HRSA) designated the integration of behavioral health as a desired service to be provided by Federally Qualified Health Centers (FQHC’s) (2004 and 2006)

13. BOTH EXPERIENCE AND RESEARCH ILLUSTRATE • Approximately 70% of all visits in primary care involve psychosocial factors. (Gater, et al, 1991) • Primary care providers are the de facto mental health and addiction disorder providers for over 70% of the population.(Kessler, et al, 1994) • Close to 80% of patients with depression go to their primary care physician first.

14. BOTH EXPERIENCE AND RESEARCH ILLUSTRATE • An increasing number of primary care providers have become experienced and skilled in the use of psychotropics • 67% of psychoactive agents are prescribed by PCP • 80% of antidepressants are prescribed by PCP • 92% of all elderly patients receive mental health care from their PCP (Kirk Strosahl, Mountain view Consulting, 2003)

15. BOTH EXPERIENCE AND RESEARCH ILLUSTRATE • Emotional disorders are factors in poor health, compliance, and levels of health care literacy. • Examples are many: DM (Stress, Depression), Respiratory (Anxiety), Cardio (Anxiety, Depression), CA (Depression, Anxiety), Kidney Disorders (OBS, Depression), Hepatic (OBS, Depression)

16. BOTH EXPERIENCE AND RESEARCH ILLUSTRATE • Primary care has become the first line of treatment for mental disorders. • Integrated settings reduce the stigma of seeking mental health care. • A review of the expected changes in DSM show a shift to the Behavioral/Comorbid physical aspects of diagnosis.

17. BOTH EXPERIENCE AND RESEARCH ILLUSTRATE • Mortality averages, for both SMI and SPMI patients are 25 years earlier than the general population. • 60% of premature death in schizophrenic individuals is due to cardiovascular, pulmonary and infectious disease. • Psychosocial distress corresponds with morbidity and mortality risk. • The medical community is becoming more accepting of integrated care.

18. BOTH EXPERIENCE AND RESEARCH ILLUSTRATE • Depending upon the county: ¼ to ¾ of previous community mental health clients in California are now seen in primary care where their service needs are addressed. • Contracts and MOU examples are in IBHP data. • In a few frontier counties this figure is much higher (Integrated Tele-Psychiatry and Tele-Behavioral Health fill the gap)

19. WHERE DOES IBH “FIT” INTO THE SYSTEM OF CARE ? • Behavioral health is a basic component of general health care • Seamless access to BH services • The BH Practioner is a member of the primary care team

20. CONTINUUM OF INTEGRATION Model Attributes Desirability • --- • + • ++ • +++ • ++++ • Separate space & model • 1 – 1 referral relationship • Co-location • Collaborative care • Fully integrated • Traditional BH model • Some exchange • On site, separate team • Shared cases • PC team member

21. INTEGRATED BEHAVIORAL HEALTH MISSION • Provide access to behavioral health services and improve the physical and emotional well-being of our patients. • Improve/manage the behavioral health of the population through the integration of behavioral health care services into the daily provision of primary care. • Use prevention and wellness strategies to prevent the onset of a mental disorder or prevent recurrence.

22. INTEGRATED BEHAVIORAL HEALTH MISSION • Simultaneous focus on health and behavioral health issues • Improve adherence and compliance and build upon primary care team interventions • Example: diabetes care • Support self management and health care literacy

23. CSRHA Rural Champions 2009

24. HOW DOES IT WORK? • Close proximity of the team • Encounters are vulnerable to interruption and are typically 15-30 min in length • A schedule is no longer a schedule and the average patient load per day is 9-12 (goal is 10) • Treatment encompasses behavioral aspects of healthcare: chronic physical and mental illness, pain management, and substance abuse

25. HOW DOES IT WORK? • Behavioral interventions support medical interventions within the behaviorist's scope of practice. • Interventions reflect an understanding of the mind-body components of disease: DM, pulmonary, cardiac, endocrine, CA, orthopedic, pediatric, geriatric, physical and psychological trauma, organic disorders of the brain, pain management, care-giver stress, grief and loss, the loss of primary functioning associated with chronic illness, and all aspects of chemical dependency and recovery.

26. HOW DOES IT WORK? • The clinician/behaviorist must understand (within scope of practice) psychopharmacology and pharmacology associated with pain management. • Understand and apply all DSM disorders for all ages and make immediate and secondary Dx. • Make on-going risk assessments • Crisis intervention

27. HOW DOES IT WORK? Interventions include, but are not limited to: • CBT • DBT • Narrative • Imagery • Stress reduction • EMDR • Mind-body interventions • Psycho-education • Solution focused • Developmental • Acceptance • And most important, compassion.

28. HOW DOES IT WORK? “THE WARM HAND OFF” • What is a “warm hand off”? • Benefits from the PCP perspective. • 80% return rate as opposed to 40% from a traditional “cold hand off”. • Same-day visits and reimbursement.

29. THE “WARM HAND OFF” • Benefits from the BH perspective • Exam room behaviors: intense, open, honest, more information • Descriptive and honest language with a motivational perspective helps connect and avoid labels • Perspective and flexibility: return is the goal

30. THE “WARM HAND OFF” • Basic components: • Provider preps and introduces the patient to the concept and goals • Excuses self to get the behaviorist and leaves patient with a questionnaire (screen) if necessary. • Provider returns and introduces the behaviorist and reviews screens • Transparency and collaboration

31. THE “WARM HAND OFF” • Basic components: screens utilized • “Mini” general screen for depression, anxiety, alcohol use, social anxiety and panic disorders. • “PCQ9” for depression (score can be tracked) • “MDQ” for bipolar disorders • “Epworth” sleep screen • Drug and alcohol screens

32. THE “WARM HAND OFF” • Behaviorist and patient discuss screen results, reason patient is here and the behavioral options available. • Language and descriptors are very important at this point. Try not to repeat what has been stated before. • Language examples. • Provider returns to collaborate and all discuss treatment plan.

33. EXAMPLES OF A “WARM HAND OFF” • We have produced a DVD that depicts a dozen scenarios. • www.youtube.com/user/sierrafamilymedical/feed • Examples include: • Diabetes, Post MI, insomnia, smoking cessation, obesity, depression, anxiety, bipolar, grief, chronic pain, and substance abuse.

34. LESSONS LEARNED • Address political/organizational issues • Have strategic vision • Link with other community services • Address any philosophical resistance • Train and mentor new providers • Financing strategies that will sustain budget stability • Business model • Funding sources

35. LESSONS LEARNED • Create administrative infrastructure that includes IBH (examples) • Identify and address training needs • Use measurement and performance indicators • Be a key player in any county integration/collaboration efforts

36. CONCLUSION • Other possibilities: • Dental referrals and our experience • Tele-behavioral health hand offs and our experience • More than 2 providers and specialties in a hand off

37. Sierra Family Medical Clinic 15301 Tyler Foote Rd. Nevada City, CA 95959 (530) 292-3478 www.sierraclinic.org Peter Van Houten, MD pvanhout@earthlink.net Michael Johnson, PhD, LCSW mjohnson@sierraclinic.org Wendy Barnhart, COO, CCO wbarnhart@sierraclinic.org