Patricia J Robinson, PhD patti1510@msn October 5, 2010 Louisiana Public Health Institute

1. Primary Care Behavioral Health: Ascending toward the PCMH Patricia J Robinson, PhD patti1510@msn.com October 5, 2010 Louisiana Public Health Institute Mountainview Consulting Group Winner of the 2009 APA Practice Innovation Award

2. INTEGRATED BEHAVIORAL HEALTHWhat Are You Doing? How Does It Work?What Else Could You Do?

3. Integration • Addition • Mixing • Combination • Amalgamation • Assimilation • Merger

4. Objectives • Introduce the Primary Care Behavioral Health (PCBH) Model • Support you in describing your current approach to Integrated Behavioral Health • Describe the benefits of the PCBH model • Assist you in evaluating the level of integration and the effectiveness of your clinic’s approach to integration • Assist you with planning targets to improve the benefits derived from your clinic’s integration of behavioral health services

5. Goals of Primary Care? Optimize the health of a population “Equitize” (or minimize disparities across population sub-groups) The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in studies within and across nations. Starfield, Shi, & Macinko (2005). Contribution of primary care to health systems and health. Milbank Q., 83(3):457-502.

6. Who Provides Primary Care? MD, DO, NP, PA, Nurses, Medical Assistants, Pharmacists, Behavioral Health Consultants! (and BHC Assistants) Where are PC services delivered? • Family Medicine Clinics • Internal Medicine Clinics • Pediatrics & Women’s Health Clinics

7. What is Primary Care? Core Attributes: • Contact (first) • Comprehensive • Continuous • Co-ordinated Starfield, B. (1992). Primary Care, Concept, Evaluation and Policy, NY: NY: Oxford University Press Inc.

8. First Contact • Accessible • Common, diverse and less well defined problems • stomach pain” – What is it? • viral illness, alcohol-related, GERD, ulcer, anxiety or depression-related, GI bleed, increased intra-cranial pressure, stomach cancer, pneumonia pyloric stenosis “

9. Comprehensive • Prevention • Vaccination, wellness, well-child visits, routine screening labs • Acute care • Laceration, IPV, suicidal or homicidal ideation • Chronic care • Diabetes, depression, hypertension, obesity • End of Life Care • Symptom management, advance directives, grief • Pregnancy and Deliveries • prenatal care, peri and post-partum depression, family coaching

10. Continuous • Contextual care over time (individual psychological strengths and weakness, family and social, community), for generations! • Both new and old problems Coordinated • Translate complexity of the healthcare system (health literacy, cultural factors) • Facilitate the patient getting what they need • Coordinating multiple specialists for multiple co-morbidities (patient-centered)

11. The Integration Movement Primary Text: Robinson, P. J. & Reiter, & J. T. (2007) Behavioral Consultation and Primary Care: A Guide to Integrating Services, Springer

12. PCBH Model FIRST CONTACTBehavioral Health Consultant (BHC) • Full-time provider of primary care behavioral health services • Most visits on same-day patients seek care (increasing penetration from 3% to 15% annually) • Supports PCP decision making • Functional rather than diagnostic focus (It’s about quality of life!) • Teaches practical skills to patients (and PCPs). • Builds on PCP interventions

13. PCBH Model COMPREHENSIVEBehavioral Health Consultant (BHC) • Prevention • Available for coaching same-day visits related to adult wellness & well-child visits, teaches open-access classes on healthy weight, healthy lifestyle, parenting classes, sleep hygiene • Acute care • Screens for IPV, suicidal or homicidal ideation, develops plans, child abuse, sexual assault, elder abuse • Chronic care • Provides an array of services, including brief visits, classes, group medical visits, workshops, registry and T/C visits for patients with diabetes, depression, ADHD, chronic pain—in a multi-disciplinary way

14. PCBH Model COMPREHENSIVEBehavioral Health Consultant (BHC) • End of Life Care • Provides support in developing advance directives, problem-solving regarding other end-of-life concerns, assists with grief, provides multi-disciplinary group-care clinics for older adults • Pregnancy and Deliveries • Assists with screening for common psychosocial problems during and after pregnancy, provides on-going support as needed for patients with high-risk pregnancy, participates in pregnancy group visits (“Centering” programs), available for services to mother’s at risk for having an OW / obese child

15. PCBH Model COMPREHENSIVEBehavioral Health Consultant (BHC) • Takes a patient education approach to health behavior change (developing brief half-page guides for high impact groups) • Teaches PCPs basic behavioral health intervention skills (and learns from them!) • Improves PCP-patient working relationship

16. PCBH Model CONTINUOUSBehavioral Health Consultant (BHC) • Provides care to couples and families • Participates in community efforts to improve health • Intermittent care throughout the lifespan (without opening and closing cases – no caseload!)

17. PCBH Model COORDINATEDBehavioral Health Consultant (BHC) • Assists with translation of health care to fit with patient cultural beliefs (for example, perspective on health, cause of illness, solutions) • Provides assistance to patients with health literacy limitations) to optimize health care experience • Provides motivational interviewing, exploring benefits, problem solving barriers to specialty MH/SA services (increases engagement 2 fold) (Anajani, 2008)

18. PCBH Model VISIT STRUCTUREBehavioral Health Consultant (BHC) • 1:1 consult focused on specific problem/question identified by PCP and pt • 15-30 minute length (mimics primary care pace and accommodates increased service request volume) • High risk, high need patients seen more often as part of team based management plan • 1-4 visits is typical after referral • Uses classes and group medical appointments to increase patient volume, depth of interventions, and shift burden from PCP / RN

19. PCBH Model INTERVENTIONSBehavioral Health Consultant (BHC) • Provides 1:1 visits designed to initiate and monitor behavior change plans • Uses evidence-based CBT interventions adapted for PC (for example behavioral activation, adherence coaching, problem solving, MI, relaxation training, behavior modification, acceptance and mindfulness interventions) • Uses patient education model (skill building, targeted change) • Emphasis on home-based practice • Charting is brief, plan-focused, and to medical chart & FB to PCP is same-day

20. Worksheet #1 Reference: What are the differences between Specialty Mental Health and the PCBH Model?

21. Worksheet #1 Reference: What are the differences between Specialty Mental Health and the PCBH Model?

22. Benefits of the PCBH Model • Decreases stigma • Improves access (Brauer, 2009) • Improves rates of patient use of effective life skills (Robinson, 1999) • Improves rates of patient adherence to medications (Katon, 1996) • Improves clinical outcomes (Katon, 1995, 1996; Robinson, 1996; & many others) and functioning • Better value (Von Korff, 1998), supports PCP & BH productivity

23. Benefits of the PCBH Model • Better patient satisfaction (Robinson, 1996 & many others) • Better provider satisfaction (Robinson, 1996), including BHCs • Improved adoption of CBT practices by PCPs (Robinson, 1998) • Supports PCP recruitment and retention; a buffer to burn-out

24. How Can You Evaluate Your BH Integration Efforts? • Model fidelity measures? (more on the what are you doing part of the presentation) • # same-day to scheduled visits • # new to follow-up visits • # of pathway visits (consistent with populations served?) • Patient access to BH services • Steady increase, time to next appointment

25. How Can You Evaluate Your PCBH Program Efforts? • PCP and BHC productivity • Visits / day scheduled, completed • Patient clinical outcomes • Duke Health Profile,\ • Pediatric Symptom Checklist 17 (Parent, Youth versions) • Patient, PCP, RN, and BHC satisfaction

26. How’s Your Program Performing?

27. What Methods Could You Use to Move Your Program toward a PCBH model? • Workflow changes • BHC template change to enhance PCP and patient access • Exam room posters to help patients self-identify • PCP use of a referral checklist • Change charting and feedback practices

28. What Methods Could You Use to Move Your Program toward a PCBH model? • Clinical services: • Greater use of evidence-based behavior change interventions for PC • Start of group and class visits, workshops • Use of a Quality of Life or psychosocial measure at all BH visits • Development of pathway services to enhance care to high impact patient groups

29. How Can You Evaluate Your PCBH Program Efforts? • Initiate a performance review plan • Develop a manual for your program • mission, roles and responsibilities, clinical services, training, performance review, practice support tools • Use data about your program to support provider practice, address system issues, and improve the impact of your program . . .

30. The PCBH Checklist

31. Choose to do something new and possibly better For your patients! Thanks for your time.