Psychologists in Primary Care: Where We Are, Where We're Heading

1. Psychologists in Primary Care: Where We Are, Where We're Heading Robert E. McGrath Professor, Fairleigh Dickinson University Director, Integrated Care for the Underserved of Northeastern NJ

5. The Issues • Cultural reservations about MH services • Barriers to participating in consistent treatment • Lack of access/integration

6. The Future? • Pretty hazy right now

7. The Affordable Care Act • Medicare Accountable Care Organizations • Responsible for comprehensive care • Any savings over customary costs are divided between Medicare and ACO • Proportion of savings allotted to ACO depends on effectiveness meeting 34 quality measures

8. New Jersey ACOs

9. Medicaid • Oregon Coordinated Care Organizations • Had to meet at least 12 of 17 benchmarks • 2011-2014: • ED visits down 22% • admissions for patients with diabetes with short-term complication down 26.9% • admissions for patients with COPD or asthma down 60% • New Jersey Medicaid ACO Demonstration Project • Focused on urban centers • Recently initiated, no data yet

10. NJ Medicaid Demonstration ACOs

11. Results So Far • Perceived Benefits: • Uses free market economies • Emphasizes both cost savings and quality in outcomes • Emphasizes prevention/population health over fee for service • Puts decision-making in the hands of provider rather than third-party organizations • Reduces risk for the insurer

12. Mental Health Benchmarks • ACO mental health metrics • Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen • The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit • NJ mental health metrics • Screening for Clinical Depression and Follow Up Plan • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment • Anti-Depressant Medication Management • Oregon incentive benchmarks • Alcohol and drug misuse (SBIRT) • Depression screening and follow-up plan

13. The Inter-Related Problems • Lack of access to mental health services • Lack of practicality in the traditional specialty mental health model • The collaborative care model (IMPACT, DIAMOND) • Screen for depression • Focus on individuals with depression and somatic diagnoses • Overseen by a psychiatrist • Care by a social worker or APN • Little emphasis on anything but depression • Emphasis on medication over psychosocial services

14. The Better Solution? • Integrated care • Integration of mental health services into primary care services • Brief interventions for most, consistent with primary care • Coordinated transfer to longer-term services when warranted • Function as part of the primary care team (NOT mental health)

15. PROPER PACING: MANAGING AN INITIAL CONSULT1 2 Min INTRODUCTION: PSYCHOLOGIST’S ROLE, JOINT UNDERSTANDING OF REASONS FOR CONSULT 10-15 Min ASSESSMENT: PROBLEM DEFINITION, FOCUSING ON PRESENT SYMPTOMS AND FUNCTIONING INTERVENTION: SHARED-DECISION MAKING, TREATMENT PLAN DEVELOPMENT WRAP-UP: SUMMARY AND FOLLOW-UP PLAN 5-10 Min POST-CONSULT: FEEDBACK AND ADMINISTRATIVE TASKS 2-5 Min 5 Min

16. Common Interventions • Acceptance and commitment • Access social supports • Behavioral activation • Cognitive-behavioral treatment • Couples/family intervention • Imagery • Mindfulness meditation • Motivational interviewing • Negative thought management • Problem-solving • Psychoeducation • Relaxation training • Risk assessment • Safety plan • Supportive therapy • Symptom management • Watchful waiting (wait and see)

17. Becoming Part of the Team • Record Review/Screen • Curbside Consult • Warm Handoff • Brief Consultation/Feedback • Team Huddle

18. Record Review

19. What to look for in a record review • Problem list: MH and CDM issues, chronic pain, vague somatic concerns, many problems or high acuity • Visit record: No-shows, high # visits, ED visits, BHC visits • Referrals: High # of specialists involved in care, hx of MH care • Lab: Check labs related to chronic disease (HbA1C) • Review screenings from previous visits • Think about signs of barriers to optimal care (social determinants of health, family issues, ACES, etc)

20. Warm Hand-off

21. Do’s and Don’ts of “Warm Handoffs” DO DO NOT Assume patient wants care Assume referral source and patient share perspective “Dig deep” into issues Lengthen appointment beyond provider’s timeframe Automatically make a follow up appointment • Connect with patient • Reflect your understanding of reason for referral, cross reference with patient • Normalize ambivalence • Use empathic statements • Assess readiness to change & engage • Circle back with referral source on outcome of dialogue

22. The Crisis Warm Handoff • Clarify with the provider if they want to manage or want you to “take over” • Manage a crisis as you would in any other setting • Ensure there is feedback loop to other providers with outcome and planned follow up • Realize that in population health model you retain responsibility for patient care; you must see it through • Realize that in team based care there are other resources to help; • close follow up with PCP and other team members can be part of plan • Other team members may have information that will help you resolve immediate crisis situation

23. Brief Consultation

24. Brief Consultation Tips • Assess provider’s main agenda and concern for patient • Attend to provider/patient relationship and process of care issues • Ensure that you don’t criticize the provider’s work • Recognize there may have been a lot of effort and work put in by the provider to get to point of the referral • Ask permission to give advice; listen thoroughly first • Get feedback on any advice you offer • Work to contextualize the patient’s problem – may help to build empathy and reveal helpful interventions and supports

25. Team Huddles

26. Facilitating a Successful Huddle • Be prepared: ID patients who need intervention and think about approach before huddle • Listen for challenging patients, offer to help • Sometimes appropriate to help structure conversation • Ensure all team members have a voice • Overtly triage day’s plan by patient and provider need • Ensure biopsychosocial thinking underlies conversation • Respectful curiosity and leading with questions can avoid power struggles

27. The Opportunity • Greater diagnostic diversity • Greater cultural/ethnic diversity • Greater age diversity • Economically needier • More resistant to mental health/psychosocial services • An exciting challenge: finally achieving penetration

28. Integrated Care in NJ • Nicholson Foundation • Eric B. Chandler Health Center (New Brunswick) • Visiting Nurse Association of Central Jersey Community Health Center (Asbury Park) • AtlantiCare(Atlantic City) • Metropolitan Family Health Network (Jersey City) • Kennedy Family Health Services (Somerdale) • Hackensack Meridian Family Health Center (Neptune) • Henry J. Austin Health Center (Trenton) • CHEMED (Lakewood) • HRSA GPE • Integrated Care for the Underserved of Northeastern NJ • North Hudson Community Action Corporation

34. The Future? • Specialty mental health/integrated behavioral health • Cherokee Health System estimates: • 1 integrated BHC is needed for 3 PCPs • 1 specialty BHC is needed for 3 PCPs • Competencies