Behavioral Health in Primary Care: The Role of the BHC in the Navy’s Medical Homeport Program

1. Behavioral Health in Primary Care: The Role of the BHC in the Navy’s Medical Homeport Program Joe Holshoe PMHNP-BC Commander, United States Public Health Service Behavioral Health Consultant, Primary Care Clinic Naval Health Center New England Newport, RI

3. Naval Health Center New England

5. Naval Station Newport • Training Command • NWC • USWC • PCO/SWOS • Senior Leadership • JAG • ODC • OCS • NAPS

6. NHCNE Background • NHCNE: 9,000 enrollees; 432 Staff • Clinics: • Primary Care • Pediatrics • Immunizations • Behavioral health • Deployment health • Physical Therapy • Pharmacy • Dermatology • ENT • Ophthalmology • Surgery • Orthodontics • Radiology • Lab • Wellness • Occupational health Primary Care Clinic: • 7 full-time providers • 4 part-time providers • 2 Pediatricians • 1 PharmD • 2 Dieticians • 2 Case Managers

7. Why Have a BHC in Primary Care? • 70-80% of all psychotropic medications prescribed by Primary Care • Majority of psychiatric illnesses diagnosed in primary care • Integrated care improves collaboration between providers and enhances satisfaction with overall care • Access to Behavioral Care is problematic – 66 % of PCP report poor access to MH care • Integrated care provides care that is better matched for level of need. • 15 min PCC appointments limits PCM’s ability to explore and address behavioral health issues

8. Patient Centered Medical Home Model • Behavioral Health Consultant (IBHC) within PCC • BHCs and PCPs share patient information • Brings a team-based management approach • Helps team improve BH assessment and intervention • Focused on full range of BH and health behavior change.

9. Re-Engineering Health Care Integration Programs (REHIP)P)

11. Who is the BHC? • Psychologist • Social Worker • Psych NP Care facilitator • RN

12. BHC Goal • Integrate Behavioral Health Care into Primary Care • Improve access to BH care • Improve patient outcomes • Universal screening for depression & anxiety

13. Basic Structure • NOT psychiatry practice within the PCC! • Internal Behavioral Health Consultant (IBHC) • External Behavioral Health Consultant (EBHC) • Real-time BH expertise in PCC • BHC is a consultant to PCM • PCM retains control over the case • Charting is blend of MH & PCC • Schedule • Appointments on the hour (30 min appt) • Every half hour is open

14. Basic Components • Short Consultations (30 minutes) • Brief Interventions (no more than 3-5 sessions) • Problem-focused (as determined by PCM) • Can code for symptoms vs. diagnosis • No “Do Not Disturb” Signs • Same-day & scheduled appointments

15. Take-Away • The IBHC provides consultative assessment & guidance to the patient and the PCM but does not assume responsibility for the patient’s psychiatric care! • The IBHC is not a consult to psychiatry! • Scheduled & Same-Day Appointments-every day! • BHC does not prescribe or order labs

16. Real-Time Team-Based Care • Warm hand-offs • Co-visits • Curbside consultation • Liaison between BH Clinic and PCC • Broadening treatment perspectives • Staff education

17. Exclusionary Criteria (or, what we don’t / won’t do) • Fitness for Duty evaluations • Specialty Evaluations (sniper, submarine, SEAL, etc.) • Competency & Sanity Boards • Medical Boards • Order labs, tests, Rx • Provide “Standard” Psychiatric Care in the Primary Care Setting

18. Phases of a 30-Minute Appointment • Introduction of behavioral health consultation service (1-2 minutes) • Identifying/Clarifying consultation problem (10-60 seconds) Assess • Conducting functional analysis of the problem (12-15 minutes) • Summarizing your understanding of the problem (1-2 minutes) • Listing out possible change plan options (selling it) (1-2 minutes) AdviseAgree •  6. Starting a behavioral change plan (5-10 minutes) Assist Arrange 6/12/2012

19. Issues with the BHC Role • 30 minute time frame ineffective for “full” psych evaluation • Liability issues • Scope of care • Follow-ups? • Documentation concerns • Safety assessments? • Referral systems

20. Issues with the BHC Role (Cont’d) • High tolerance for “gray” • When to refer, when to treat/ not treat • Moral conundrums • A little care better than none? • Staff requests for care • Informal care

21. Issues with the BHC (Cont’d) • Templates / Scheduling • No MEPRS sub-code • Children

22. My Experience (So Far!) • Strong working relationship with PCMs and Psych providers • Serve as psychopharm expert • Fine tuning medications • Expanding understanding of patient’s issues with providers • Uncovering medication compliance issues • Past psych history • Uncovering diagnoses • Breaking patient barriers to Mental Health • Clinic sleep expert • Patient satisfaction!

23. Cases • Parasomnia: Sleep-eating! • Post-partum depression • Psychotic depressions • OCD • Anxiety • Grief • Depression • Adjustment • Sleep disorders

24. Notes Internal Behavioral Health Consultation Note Patient Referred: Referred from Dr. Smith for consultation for mood. Time: 1000-1030 Introduction: Patient is a 52 year old female, dependent spouse of USN/AD service member. Source of information was patient and is considered reliable. Role of Behavioral Health Consultant was explained and patient verbalized understanding and provided consent for care. CC: “I can’t sleep.” Objective: The patient presented as an alert, oriented and cooperative female dressed in civilian clothes. Eye contact was good. Speech was normal in rate, rhythm and volume. Mood was “ok” with broad-ranging affect. Cognition was grossly intact. Thought process was logical, linear and goal-directed without evidence of psychotic process. Thought content was consistent with themes delineated in referring HPI and devoid of suicidal and homicidal ideations. Insight and judgment were good. No evidence of psychomotor agitation or retardation.

25. HPI: Patient reports sleeping difficulties since returning from A-School in late August. Reports sleeping 3-4 hours/night with frequent awakenings and delay to sleep onset by 60-90 mins. Awakenings last from 1-2 mins to 30 mins and average 5-6/night. Patient reports feeling fatigued during day, with decreased appetite, and little interest in working out which was once one of his favorite activities. Patient frequently naps 1-2 hours after work. Reports decreased concentration at work and feeling like he is fogged during the day and making “wrong decisions” like driving his car when he is tired. Patient takes Ambien every night with minimal success but takes the medicine about 2-3 hours before trying to sleep. Has recently increased his exercise but still feels tired and has not seen an improvement in sleep. Notes fatigue when eating and decreased appetite with minimal weight loss. • Patient denies use of illicit drugs, tobacco, caffeine and ETOH: 1-2. • Assessment: Insomnia • R/O Mood disorder • Functional Assessment: Patient experiencing moderate impairment of functionality related to fatigue and mild anhedonia.

26. Plan: The results of this evaluation were discussed with the patient and patient concurred. • Patient was educated on sleep hygiene and factors promoting and diminishing sleep. Patient educated to not stay in bed longer than 15 mins if unable to sleep, and should get out of bed and engage in non-stimulating activity until sleepy and then return to bed; educated to avoid stimulating activities in PM including TV, computer, and cell phone; educated patient to move bed time back to time of usual sleep onset to increase sleep load; educated patient to take Ambien right before getting into bed and not any earlier to avoid amnesic effects before sleep onset; discussed eating light carbo snack before bedtime. Patient verbalized understanding. • Recommend to PCM to consider continuing Ambien 10mg at bedtime. • Recommend to PCM to consider for patient to begin Melatonin 3mg QHS to regulate circadian rhythms • If no improvement is seen in 2-3 weeks, recommend to PCM to consider Doxepin 10mg QHS for sleep maintenance. • Patient educated to report to clinic or call 911 if mood worsens or SIs/HIs develop. • Conferred with PCM on assessment and recommendations and PCM concurred. • Patient to F/U with IBHC in 2 weeks.

28. Questions