Behavioral Health Assessment and Psychological Testing in Primary Care: Meeting the Population's Needs

1. Behavioral Health Assessment and Psychological Testing in Primary Care: Meeting the Need of the Population When Other Systems Fall Flat Jonathan Muther, PhD, Director of Behavioral Health & Psychology Training Ava Drennen, PhD, Psychology Postdoctoral Fellow Salud Family Health Centers Ft Lupton, Colorado Session # D7b CFHA 18th Annual Conference October 13-15, 2016  Charlotte, NC U.S.A.

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Better understand the difference between BH assessment and psychological testing, as well as strategies for implementing both in primary care • Identify specific measures that can be utilized to address the most common reasons for testing referral in primary care • Develop strategies for implementing psychological testing in primary care, including approaches to workflow and personnel

4. Bibliography / Reference • American Psychological Association (2012-08-15). APA Dictionary of Clinical Psychology (APA Reference Books) (Kindle Locations 64968-64974 & 70560-70563). American Psychological Association. Kindle Edition.  • American Psychological Association (2015). Competencies for Psychology Practice in Primary Care. Retrieved from • http://www.apa.org/ed/resources/competencies-practice.pdf • American Psychological Association Practice Organization (2014). Distinguishing between screening and assessment for mental and behavioral health problems. Retrieved online from • http://www.apapracticecentral.org/reimbursement/billing/assessmentscreening.aspx, 7/16/16. • Auxier, A., Farley, T., Seifert, K. (2011). Establishing an integrated care practice in a community health center. Professional Psychology: Research and Practice, 42(5), 391. • Fowler, N. R., Morrow, L., Chiappetta, L., Snitz, B., Huber, K., Rodriguez, E., & Saxton, J. (2015). Cognitive testing in older primary care patients: A cluster-randomized trial. Alzheimer’s & Dementia, 1(3), 349-357. • Lin, J. S., O’Connor, E., Rosoom, R. C., Perdue, L. A., Burda, B. U., Thompson, M., & Eckstrom, E. (2013). Screening for cognitive impairment in older adults: AN evidence update for the US preventive services task force. Agency for Healthcare Research and Quality (US), Report Number 14-05198-EF-1. • Davis, M. M., Balasubramanian, B. A., Cifuentes, M., Hall, J., Gunn, R., Fernald, D., … & Cohen, D. J. (2015). Clinician staffing, scheduling, and engagement strategies among primary care practices delivering integrated care. The Journal of the American Board of Family Medicine, 28(Supplement 1), S32-S40. • Cordell, C. B., Borson, S., Boustani, M., Chodosh, J., Reuben, D., Verghese, J., … & Medicare Detection of Cognitive Impairment Workgroup (2013). Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s & Dementia, 9(2), 141-150.

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Behavioral Health OverviewSalud Family Health Centers • Federally Qualified Health Center: BH in 11 of our 12 clinics • Integrated Model of Care • ≠ Co-located, consultative model • = Behavioral Health Provider; shared responsibility; team-based care • Triple Aim Oriented • Scientist – Practitioner • Empirically-supported interventions; Generalist clinicians treating broad spectrum • Measuring outcomes; Evaluating team-based model of care • Cultural Competence & Awareness of Health Disparities • Bilingual BHP’s, awareness of barriers to treatment, reducing stigma

7. Catchment Area and Clinics Our Mission: To provide a quality, integrated health care home to the communities we serve

8. BH Services We Provide

9. Behavioral Health Assessment Behavioral Health Screening Psychological Testing • American Psychological Association Practice Organization (2014). Distinguishing between screening and assessment for mental and behavioral health problems,http://www.apapracticecentral.org/reimbursement/billing/assessmentscreening.aspx. Retrieved, 7/16/16. • Any clinical information gathering • Early identification need for further evaluation • Brief and narrow in scope • Common in IPC, part of a routine clinical visit • Critical for population health management • Screening tools, can monitor progress & outcomes • Can be administered by support staff • Comparable to medical counterparts, i.e., reliability & validity • Psychological & Neuropsychological testing • Rare in IPC • Provides more complete clinical picture • Assesses functioning across multiple domains diagnosis & tx planning • Integrates multiple tests, interviews, bx observations, records review, collateral information, review of EHR • Specific training required

10. BH Screening Screen for Life Stressors & Outcome Rating Scale Follow up Measures • Outcome Rating Scale (ORS) Baseline functioning/distress Dep PHQ-9 Anx GAD-7 SA DAST etoh AUDIT PCL Depressed mood Anhedonia Nervous/tense, Worry Marijuana, Illicit drugs & Rx misuse etoh abuse per episode etoh abuse per week Trauma (PC-PTSD) Domestic violence

11. Testing Instruments ABAS (Adaptive Behavior) BASC (Spanish also) TOMM TONI-IV BHI-2/BBHI-2 (Health Inventory) MMPI-2 (Spanish also) Rorschach TAT WAIS-IV, EIWA-III (Spanish) WISC-V, WISC-IV (Spanish ) WJ-III, Woodock-Munoz III (Spanish) Conners’ CPT RBANS (Spanish also) DRS-2 WMS-IV

12. Common referrals • A 20 y/o bilingual, male, recently graduated from H.S., needing services due to cognitive deficit and limited adaptive functioning • Little to no follow up services now that he is out of the “system” • Wait list for Community Centered Boards can be 10-13 years • A 65 y/o Spanish speaking-woman with symptoms of dementia/cognitive decline • Limited family support, no collateral report • An 8 y/o bilingual male referred for “ADHD” • School has not done any testing • OR, school has done specific assessment of reading or math • Spanish-speaking parent does not know what an IEP is • Spanish-speaking older adult seeking exemption from citizenship test (N-648)

13. Who are our testing patients? • Age (n=282) • Unknown 12 • Known 270 • Age of Known Pts (=270) • Range = 2-83 • Mean = 34.93 • SD = 21.45 Gender (n=282) M 142 (50.35%) F 130 (46.01%) Trans 1 (<1%) Unk1 3.19% Language (n=282) Eng 198 (70.21%) Span 50 (17.73%) Bil 22 (7.80%) Other/ 12 4.26% Unk Payor Source (n=282) Medicaid 156 55.32% None/Clinic/CICP 44 15.60% Unk 42 14.89% Medicare 19 6.74% Private 14 4.96% CHP+ 7 2.48%

14. Administration • Psych Credentials (n=282) *Not used in write-up below • Extern 48 17.02% • Intern 24 8.51% • Postdoc/Unlicdr 146 51.77% • Lic psych 32 11.35% • Unk/TBD/Not assign 32 11.35%

15. Timeline • Timeline of Referrals • Unknown or prior to June 2010 21 7.45% • 2010 3 1.06% • 2011 10 3.55% • 2012 37 13.12% • 2013 51 18.09% • 2014 36 12.77% • 2015 60 21.28% • 2016 (Thru JULY) 64 22.70% (Not even full year).

16. Takeaways • Inform the PCP of what can be done • Be equipped to manage the demand • Have a workforce – i.e., Psychology Trainees • Train clinicians & staff on differing roles of clinicians • Provide Psychoeducation to patients/families • Timely follow through – don’t let them fall through the cracks • Track the referrals • Coordinate with payers, e.g., Prior authorization

17. Questions??? Thank you!!! Jonathan Muther, PhD Director of Behavioral Health & Psychology Training Salud Family Health Centers jmuther@saludclinic.org 303.820.4725

18. Session Evaluation Please complete and return the evaluation form before leaving this session. Thank you!