Integrating Mental Health into Primary Care: The BHL Model

1. Integrating Mental Health into Primary Care:  The BHL Model VISN4-Healthcare Network Department of Veterans Affairs

2. Where is Mental Health / Depression Care Delivered • Depression: FY 2002: 64% of all outpatient depression visits for elderly occur in primary care (only 25% by psychiatrists) (Harmon et al 2006) • Nearly half of all antidepressants, sedatives, and hypnotics were prescribed by a primary care provider (20% of all antipsychotics) (cdc.gov/nchs/data/series/sr_13/sr13_157.pdf)

3. Alcohol Use Disorders Grant BF et al. Arch Gen Psychiatry. 2004;61:807-816. SAMHSA, Office of Applied Studies. Substance Dependence, Abuse and Treatment Tables; 2003 IMS - MAT March 2006

4. How is Care Provided? • Key Facts: • Depressive disorders are common (10-15% prevalence) • Less than 50% of patients have treatment initiated • Less than 50% are adequately treated • Rates of follow-up to new treatments (HEDIS) ~20%

5. The Patient’s Perspective Engagement = at least one contact with the mental health specialist.

6. The BHL Program

7. So What’s the BHL Program? • A clinical program providing prevention and treatment services designed around the following principals: • An emphasis on use of structure assessments and algorithms • An emphasis on the use of care management modules • Patient centered care – incorporating convenience and preference • A focus on both patients and providers as the stakeholders • A population based approach to care • A focus on self- management and collaborative decision making • A focus on open access

8. What are the (potential) parts? • Specialty Care (usually PhDs and MDs) • Consultative • Brief therapies • Care Management (BHSs usually RNs, SW) • Depression, Alcohol,(abuse and dependence), Anxiety , Pain, Smoking Cessation, Referral Management (optimizing specialty care) • PTSD, Bipolar, Dementia • Prevention and Health promotion (mix RNs, SW, PhDs, counselors, etc) • Watchful Waiting for subsyndromal symptoms • Problem solving therapy • Caregiver and family support • MOVE for weight • Education • Adherence

9. Step 1 • Identification and triage • Primary care screening • Primary care assessment • Self-referral • Outreach • Prescribing • Driving principal – we take anyone you are concerned about.

10. Initial Assessment ModulePhiladelphia BHL data from 1/2008 to 1/2010 • 5626 referred • 79% had a complete assessment • PTSD (85%) • Depression (81%) • MH and SA problems (79%) • Alcohol problems (76%) • Drug problems (71%) • Only 7% refuse!

11. Impressions from Initial Assessment • Enormous range of psychopathology • Greatly appreciated by patients • Phone vs face to face – access or provider comfort • Greatly appreciated by primary care providers • A great tool for research recruitment

12. Step 2 – Treatment Options Patient Identification Screening / Clinical Assessment / Case-finding Patient Education and Promote Self-Care Initial Assessment Initial triage / treatment plan Specialty Care Care Management Prevention / Health Promotion No treatment & Refusal of care

13. Optimizing Specialty CareReferral Management • Different methods of case finding lead to different rates of complex patients. • 30-50% of patients may have psychosis, PTSD, Illicit drug use, Severe depression, bipolar disorder, suicidal ideation • Limited evidence for treating these patients in primary care • Problem: Low rates of MH/SA treatment engagement (30 – 40%) Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)

14. Referral Management • Brief workbook based intervention designed to enhance engagement in specialty MH/SA services • Focus • Enhancing motivation • Addressing practical issues • Preparing the patient

15. Referral Management Module p = .006 Zanjani F, Oslin D (2005). Telephone Based Referral-Care Management. Grant Supported by Philadelphia Veteran’s Affairs: Mental Illness Research Education and Clinical Center (MIRECC)

16. Care Management Modules • Care Management is algorithm driven care delivered by a Behavioral Health Specialist as an adjunct to primary care. • Depression • Panic Disorder • Generalized Anxiety disorder • Alcohol Dependence • Pain • ?PTSD

17. Disease Management Percent of Patients Achieving Remission

18. Change in Depressive Symptomatology over the Course of Monitoring (n=140)

19. First 12 weeks • Issues addressed early • 26% report non-adherence to treatment • 12% report significant side effects • 22% managed (dose change or med change) • 53% symptom remission

20. Alcohol Care Management • Two components • Non dependent • Brief alcohol intervention - Time-limited (20 minutes in 1-3 brief sessions) and targets alcohol misuse • Dependent • Pharmacotherapy • Referral management

21. Alcohol Care Management • BHS meets with patient for 16 sessions over 6 months • Collaborates with PCP to: • Increase motivation to abstain • Be supportive and optimistic • Naltrexone • Encourage AA attendance • Provide education (health risks and detrimental outcomes)

22. What patients said • “I’ll take the chance on getting the nurses help” • “I have no interest in going back to the ARU, I am not that sick” • “I could use a med to help with my cravings”

23. Preliminary Outcomes • ACM • 90% (55/61) had at least 1 face to face visit • mean #visits = 10.2 (range 0-28)

24. Prevention Services • Sub syndromal anxiety and affective disorders • Most common treatment is an SSRI but no evidence of efficacy • Psychotherapy is time consuming and not without risks • Limited research on problem solving therapy and other brief focused interventions

25. Close Monitoring • 8 Weeks of prospective monitoring by telephone using the PHQ-9 • Patient choice for treatment engagement is also allowed • Those with persistent symptoms or who choose are enrolled in depression disease management

26. Study Results • 223 Subjects randomly assigned to WW (130) or usual care (93) • In the WW arm • 81 (62%) no further treatment required • Improved MH outcomes • Improved Physical functioning

27. What are the keys to success? • A plan – including training, supervision, etc • BHL software to promote measurement based care and to provide decision support and tracking • Great staff

28. Panel management

29. Patient History

30. Summary of Interview

31. Patient and chart documents

32. Implementation Factors • Facility • Small clinics may be collocated and collaborative just by size • Location – more rural clinics manage more BH in primary care • Leadership – very important to resource management • Access to Specialty care – factors into how complex cases are managed • Staff – highly variable on all sides • Scope – the more limited typically the less useful or hard to use • Method of case finding – screening, clinical exam, self referral leads to very different case mixes and thus different program needs • Marketing and program description – what you are known for. • Resources and reimbursement

33. Conclusions • Depression and anxiety care management Works! • By telephone or face to face • Reduced mortality • Reduced symptoms • But not for complex patients • Close monitoring Works! • For subsyndromal depressive symptoms waiting and targeting care management is effective • Referral management Works! • For complex patients with affective illnesses, substance abuse or more other complex presentations. • A Brief alcohol intervention Works! • For patients without alcohol dependence • Alcohol Care Management Very Promising! • For patients with alcohol dependence

34. David Oslin, MD Johanna Klaus, PhD Elena Volfson, MD Steve Sayers, PhD Shahrzad Mavandadi, PhD Health Specialists Lisa Dragani, BSN, RN Suzanne DiFilippo, RN Trisha Stump, BSN, RN Shani Simmons-Wilson, BSN, RN Janet Sherry Cocozza, MA, RN, APN.C Coordinator Erin Ingram, BA Health Technicians – Megan Aiello, BS Lauren Witte, BA Victoria Farrow, BS Kelly Stracke, BA Natacha Jacques, MS Chris Cardillo, BS Henry Quattrone, BS Lindsey Reid, BA Brian Cox, BS a host of others Funders: NIH, VA, BCBS Thank You