Date: 10 Oct 01 To:BHT Washington D.C.

1. Integrating Behavioral Health Providers into Primary Care in the USAF: The Behavioral Health Optimization Project I n t e g r i t y - S e r v i c e - E x c e l l e n c e Col (sel) G. Wayne Talcott, Ph.D., USAF Capt Christine R. Russ, Ph.D., USAF Capt Anne Dobmeyer, Ph.D., USAF Date: 10 Oct 01 To:BHT Washington D.C. 1

2. Goal: Maintain viability of AF Medical Service (AFMS) Two priority areas identified by AFMS council 1. Primary Care Optimization (PCO) 2. Re-Capture care from private sector Re-engineering healthcare-delivery system From a reactive sickness-based To a proactive prevention-based system Background: AFMS Initiatives

3. Quality of care Individual Medical Readiness Mammography, paps, immunizations, prenatal care Customer service Satisfaction Access Best value Efficient use of MTF resources Appropriate recapture of downtown work PCO Priority Areas

4. Population health Framework to achieve desired goals Population-based health care Improving the overall health of a defined population through needs assessment, proactive delivery of preventive services, condition management, and outcome measurements Population Health

5. Disease Free Subclinical Disease Clinical Disease A B C ReducedPerformance Diseased Healthy Health Continuum

6. Traditional Health Care ReducedPerformance Diseased Healthy Disease Treatment Acute Illness Treatment

7. Stay healthier longer! ReducedPerformance Diseased Healthy The REAL Objective

8. Why Target ALL Enrollees with BHOP Common risk factors are present in a large proportion of the population Most enrollees visit Primary Care at least annually Up to 80% of PC visits are related to behavioral health needs/concerns Stigma of Mental Health Target Population

9. Targets of traditional behavioral health care: Alleviate the severity of disease Increase function and quality of life Current behavioral health delivery system: Limited access to care (especially for non-active duty) Limited collaboration with medical care providers Minimal prevention focus Mismatch between patient’s needs and readily available services How Does Behavioral Health Fit In Now?

10. Targets for optimized behavioral health care: Modify behavioral risk factors – reduce disease incidence Reduce the prevalence of disease Prolong the individual’s healthy life Improve functioning and health-related quality of life Delay the onset of disability Optimized behavioral health delivery system: Increased access to care for all beneficiaries Improved collaboration with medical care providers Primarily a prevention focus – early intervention Services match identified needs better How Should Behavioral Health Fit In?

11. Deliver the right care by the right provider at the right time Behavioral health providers need to be directly accessible Ability to recognize and intervene early in condition lifecycle Consultative Model chosen for integration in primary care Population health framework Expansion of primary care services Rationale for Integration

12. BHC is part of PC healthcare team Patient’s seen at PCM’s request BHC is a consultant; PCM responsible for overall care No written informed consent; no separate record Same day feedback to PCM Brief assessment and intervention -- focused on patient’s functioning Briefer appointments; Limited number of visits AF BHC Model: Key Elements

13. Rationale for BHOP • 1997-98, Behavioral Health Optimization Trial • Two BH providers placed in primary care at Tinker AFB • “Proof of concept” for integrated care in USAF • Numerous lessons learned including • Need to train BH providers • Need to establish a standardized delivery of care • Led to Behavioral Health Optimization Project (BHOP)

14. Purpose/Specific Aims: Define a model for the delivery of primary behavioral health care Build infrastructure Develop, conduct, and evaluate the training to integrate behavioral health providers into primary care settings Pilot implementation and expansion Evaluation Behavioral Health Optimization Project

15. Phase I: Development (Completed Dec ’00) Contract with external consultant Site selection: WHMC, WPAFB, AAFB Working group Develop practice and training manuals that detail consultative model of care Legal review and endorsement of model Project Description

16. Phase II: Deliver Training and Pilot Implementation (Completed Aug ’01) Train 7 BHCs at 3 psychology residency sites to deliver integrated care and train others Revise manuals as indicated with help from working group members and BHCs Identify and train providers at 10 additional AF Military Treatment Facilities Project Description

17. Phase III: Evaluation and Next Steps BHC workload Diagnoses of patients seen and services delivered (CPT Procedure and E&M Codes) Person-Centered Outcomes Satisfaction ratings (PCMs, Patients) Clinical outcomes (Pre-Post SF-36 Scores) - underway Project Description

18. Comprehensive BHC Services Manual Establishes clear guidelines for primary behavioral health care and clinical tools Integrated care at 3 pilot locations (8 clinics) Primary care rotations for psychology residents Trained providers currently integrating at 10 additional sites Analysis of preliminary outcomes – underway Training being established at social work residencies Current Status

19. Anonymous survey given to all patients seen by BHC for approximately one month 76 respondents Anonymous surveys to 76 providers in BHC staffed clinics 65 respondents (86% response rate overall) Surveys mailed directly from respondents Satisfaction Surveys

20. Patients and providers in Primary Care (PC) vs. Internal Medicine (IM) clinics may differ Analyzed results separately by clinic type No intention to compare between PC and IM clinics Satisfaction Surveys

21. Patient Rating N=24 N=52

22. Patient Rating N=52 N=24

23. Patient Rating N=52 N=24

24. PCM Rating N=23 N=42

25. PCM Rating N=23 N=42

26. PCM Rating N=23 N=42

27. PCM Rating N=23 N=42

28. PCM Rating N=23 N=42

29. “Patient access is great - Gives better care to patients!” “BHC has bridged the gap between primary care and behavioral health” “Patients love being seen in the clinic and not going to behavioral health” “Having the BHC see patients with BH issues allows us to proceed with business as usual” “Too hard to get patients to go to mental health –BHCs provide a new way for patients to get BH care” Provider Comments

30. “More time for the BHC to be in clinic” “BHC needs his/her own space” “Set up classes for patients with newly diagnosed chronic diseases” “More specific recommendations on drugs/doses” Provider Comments

31. Patients Seen by BHC (N=868) Note: Data collection from 6 BHCs working part-time in PC over 6 months of project

32. Primary Diagnostic Category Note: These six categories account for over 70% of all patient diagnoses seen by BHCs

33. Competing priorities at the local level Delicate balance between standardization and flexibility Securing legal opinion on standard of care and informed consent Expect behavioral health staff to offer resistance Coding BHC patient visits Establishing a process of care Identification and prioritization of BHC patients Challenges

34. Advantages of an outside expert Need for frequent teleconferences and meetings Importance of selecting true “champions” Build in sustainability from outset Communicate a clear, consistent, and concise vision Evaluation Plan Quality Control Outcomes measurement Lessons Learned

35. Continue to disseminate clinical guidelines Develop official guidance (policies) Encourage local “self-assessments” and provide central support Continue outcome measurement and feedback Expand and lengthen training experience Expand pool of BHC mentors Expand pool of trained BHCs Develop, implement, and evaluate depression management guideline BHOP: Next Steps

36. Implementation of Behavioral Health Consultation at a USAF Primary Care Clinic Barriers (and Solutions) to Integration at the Clinic Level

37. Dualistic view of mind/body Stigma surrounding “mental health” Need for BHC to modify practice Need for medical providers to modify practice Barriers to Integration at the Clinic Level

38. Patients, healthcare providers, and mental health providers may over-emphasize divisions between “physical health” and “mental health” Needed shift towards conceptualizing overall health as an integrated whole Barrier #1:Dualistic view of mind/body

39. Strategies for addressing barrier: Co-located services Used a common language BHC participated in provider meetings Written educational materials emphasized relationship between behavioral health and physical health concerns Barrier #1:Dualistic view of mind/body

40. Providers were often unsuccessful in getting patients to keep appointments for specialty behavioral health services due to mental health stigma “I don’t want a mental health record” “I’m afraid this will impact my career” “I’m not crazy! This isn’t all in my head!” Barrier #2:Stigma of “mental health”

41. Strategies for addressing barrier: Co-located services No separate mental health record (just a primary care note) Decreased mental health “jargon” Verbal communications and written materials emphasized consultative role Message: BHC is part of routine health care Barrier #2:Stigma of “mental health”

42. BHC needed to change perspectives & methods Change length, interval, and number of appts (and still effectively help patients change) Emphasize brief, solution-focused and behavioral strategies focused on functional improvements Work as a consultant (not primary provider) Increase skill in medication issues Increase knowledge of medical problems Barrier #3:BHC Practice Modifications

43. Strategies for addressing barrier Initial week of training by expert BHC; ongoing phone consultation BHC email working group Targeted readings to increase knowledge Consultation with psychiatrist Created handouts and guided self-help materials; increased knowledge of resources Barrier #3:BHC Practice Modifications

44. PCM needed to change perspectives & methods Initial referral rate was low Early referrals tended to be limited to traditional “mental health issues” Early referrals were for more severe problems only Barrier #4:PCM Practice Modifications

45. Strategies for addressing barrier: Handouts & discussions about how to “sell” BHC services Information on types of problems BHC could help with Case presentations at provider meetings Monthly “ads” about specific referral issues Emphasizing BHC availability Timely and helpful feedback on patients PCM “word of mouth” increases BHC referrals Barrier #4:PCM Practice Modifications

46. BHC working group discussed “what works” and “what doesn’t” when starting up BHC services in a primary care clinic Strategies for overcoming these barriers to integration are being integrated into newest version of BHC Services Manual to assist future BHCs Barriers Can Be Opportunities

47. Clearly defined model of integrated care with comprehensive written guidance Effectively trained BHCs integrated into 18 clinics High satisfaction among customers (PCMs and Patients) Increased access in direct care system Conclusions

48. Population Health Support Division Website: http://www.afms.mil/phsd/ BHOP Project Manager Capt Tina Russ (210) 536-4322 Tina.russ@brooks.af.mil Sources for Additional Information

49. QUESTIONS All of the material and views presented here are solely those of the authors and do not represent the official or unofficial opinion or policies of the USAF, Department of Defense, or US Government.