K.C. Lomonaco, Psy.D ., Psychologist, Denver Health Medical Center

1. Session # C2b October 16, 2015 Envisioning the Integration of Behavioral Health in a Women’s Care Clinic: A tour of the process a year in K.C. Lomonaco, Psy.D., Psychologist, Denver Health Medical Center Alison Lieberman, Psy.D., Psychologist, Denver Health Medical Center Collaborative Family Healthcare Association 17th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Faculty Disclosure The presenters of this session: Have NOT had any relevant financial relationships during the past 12 months.

3. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

4. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Define the steps necessary for implementing integrated behavioral health in women’s care. • Describe the role of integrated behavioral health in women’s care clinics. • Discuss why integrated behavioral health is a perfect fit for women’s care clinics.

5. References • World Health Organization (2001). World Health Report, 2001. Mental Health: New Understanding, New Hope. • Poleshuck, E.L. & Woods, J. (2014). Psychologists Partnering with Obstetricians and Gynecologists: Meeting the Need for Patient-Centered Models of Women’s Health Care Delivery. American Psychologist, Vol. 69, No. 4: 344-354. DOI: 10.1037/aoo36044 • Freed, R.D., Chan, P.T., DingmanBoger, K, & Tompson, M.C. (2012). Enhancing Meternal Depression Recognition in Health Care Settings: A Review of Strategies to Improve Detection, Reduce Barrieres, and Reach Mothers in Need. Families, Systems, & Health, Vol. 30, No. 1: 1-18. • Baker-Ericzén, M.J., et.al. (2012). A Collaborative Care Telemedicine Intervention to Overcome Treatment Barriers for Latina Women with Depression During the Perinatal Period. Families, Systems, & Health, Vol 30, No.1, 224-240. • Chin, J.L., Yee, B.W.K., Banks, M.E. (2014). Women’s Health and Behavioral Health Issues in Health Care Reform. Journal of Social Work in Disability and Rehabilitation, 13:122-138.

6. References: • Katon, W.J., et.al. (2010). Collaborative Care for Patients with Depression and Chronic Illness. The New England Journal of Medicine; 363:2611-20. • Funderbunk, J.S. et.al. (2010). The Description and Evaluation of the Implementation of an Integrated Healthcare Model. Families, Systems, and Health; Vol 28, No.2: 146-160. • Jarrett, E.M., Yee, B.W.K., & Banks, M.E. (2007). Benefits of Comprehensive Health Care for Improving Health Outcomes in Women. Professional Psychology: Research and Practice; Col 38, No.3; 305-13. • Baker-Ericzén,M.J., Mueggenborg, M.G., Hartigan, P., Howard, N., Wilke, T. (2008). Partnership for Women’s Health: A New-Age Collaborative Program for Addressing Maternal Depression in the Postpartum Period. Families, Systems, and Health: Vol. 26, No 1., 30-43. • Adams, Susan M. On The Scene: Integration of Mental Health Services within Ob/Gyn Private Practice: A Collaborative Model. Nursing • Selix, N.W. and Goyal D., (2015). Postpartum Depression Among Working Women: A Call for Practice and Policy Change. The Journal of Nurse Practioners, Vol 11 (9), 897-902.

7. Integrated Care at Denver Health • Population of Denver Health • Growth and change of the program • Women’s Care Clinic at Denver Health

8. Why is integrated care needed in women’s care? • Referrals to specialty mental health • Limitations of specialty care • Women’s Care IS primary care for many women. The WHO recommended (2001) that mental health care be moved in to primary care/into the community • Allows for early screening and treatment for pregnancy related mood/anxiety disorders • 3300 deliveries per year-about 16% of women with previously diagnosed comorbid mental health disorders • 1:7 women have chronic pelvic pain during reproductive years • Aging population growing with increase in urogynecological problems (admittedly more local competition in this area) • Women are the healthcare decision-makers for their households

9. Barriers to specialty behavioral health • Why women’s care patients are reluctant to seek behavioral health treatment • Demystifying the role of behavioral health in integrated care • Keys to the successful warm handoff in establishing therapeutic alliance • Improving access, reducing stigma and decreasing barriers to care

10. Logic Model

11. Starting from Scratch • Seeking out institutional support • “Shark tank” – WIPHC at Denver Health • Budget expansion/Grant funding • Have a clinic champion • Allocation of time, space, and resources • Clinician training and focus – OB vs. Gyn

12. Respect for Cultural Diversity • Maternal depression can have various meanings across communities • May affect how women (and fathers) perceive and report symptoms • Varying opinions about the meanings and cause of sadness across cultures • Traditional healing practices are often part of the intervention • Religious communities can support or increase shame and guilt (Dennis & Chung-Lee, 2006).

13. Screening • While it is feasible to conduct perinatal depression screenings in primary care settings and OB/GYN clinics, only a small percentage of women are estimated to be screened for depression during pregnancy or in their first year postpartum. ACOG recommendations. • Marcus et al. found that 20% of pregnant women in obstetric clinics had elevated depressive symptom scores, but only 13.8% of these received any formal treatment for depression. • Screening for mood/anxiety/trauma in women with chronic health conditions

14. Benefits of integration • Improved access to comprehensive care • Unique interactions from multiple disciplines and providers elicit different perspectives • Mutual support around challenging patients and team approach to care, reduces provider burnout • Collaboration/communication to improve patient outcomes • Improved screening protocols

15. Implementation • Four days per week in the women’s care clinic • Divide and conquer-taking all comers • Utilizing areas of expertise/interest • Provide in-service, training for staff • Marketing

16. Advertise Psychology available for: *weight management *smoking cessation *treatment adherence *diagnostic clarification/treatment planning/referrals *GynOnc/end-of-life issues *sleep hygiene *substance use/abuse *crisis intervention/psychosis or acute issues *risk assessment *couples and family issues *mood disorders *chronic disease/chronic pain management *anxiety disorders *resources for housing, OP therapies, substance *grief and loss, fetal demise *triage for psychiatric appointments/consults *perinatal mood and anxiety *transitions to parenting or parenting concerns *postpartum issues *chronic pelvic pain *fertility issues *issues of psychosis *suicidality *health behavior change

17. What we do • Collaboration takes multiple forms (curbside, integrated visits, behavioral health visits) • Screenings/Assessment (psychosocial, cognitive, health behaviors, functional) • Interventions (short term vs. long term, couples/family, cultural sensitivity, evidence based) • Additional functions (referrals, case management, etc)

18. Data Numbers: 900+ billable visits (Aug 2014 - July 2015) Population: Complicated GYN/OB and multiple psychosocial issues/concerns. Provider satisfaction: 90+% say the presence of BH in WCC has improved their satisfaction within their own practice Provider utilization frequency Provider rating of BHC assessment and interventions

19. Qualitative Data • Availability of resources to mentally ill patients who are in clinic but not planning to see a psychologist. • The warm hand off and immediate assessment and ability to provide more extensive counseling than can be done in the MD visit. • On a daily basis, there is a patient in need of BH services. It is a significant improvement to quality patient care, to be able to offer this to patients, the very same day, while they are already present in the clinic. • Having a backup when we have a patient that needs more time and expertise on a behavior health related issue • Being confident that patients actually get adequate attention for mental health needs that I am not able to provide in limited schedules

20. Lessons learned one year in • Infinite need-opening the floodgates • Challenges to the short term model • Challenges in management after pregnancy • High no show rates/low availability • Individual provider variables • Culture of Medicine vs. Psychology • Social work and psychiatric support • Expansion to outside clinics

21. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!