Collaborative Family Healthcare Association 16 th Annual Conference

1. Session # A2c October 17, 2014 Integrating Behavioral Health Services into the Public Health Centers of Philadelphia: Discussing the Impact of Environment on Patient Satisfaction, Medication Adherence, and Treatment Outcome Lacondria Simmons, Psy.D., Licensed Clinical Psychologist/Behavioral Health Consultant, Drexel University College of Medicine Presented by Victor Lidz, Ph.D., Professor, Drexel University College of Medicine Philadelphia, PA Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • We 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: • List ways to make clinic environments more patient centered • Plan ways to use the Behavioral Health Consultant model in public infectious disease/HIV clinics • Identify the relationship between the clinic environment, patient experience, and treatment outcome among patients living with HIV/AIDS (PLWH/A) • Discuss modifying the traditional PCBH model to better address behavioral health needs of PLWH/A

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

5. Philadelphia Integrative Behavioral Health Initiative (PIBHI) • In the fall of 2011, Drexel University College of Medicine hired and trained 6 Behavioral Health Consultants (BHCs) to be placed at 6 HIV clinics in the city of Philadelphia • The project was supported by the AIDS Activities Coordinating Office of the Philadelphia Department of Public Health with grant funds from SAMHSA to provide resources for HIV/AIDS prevention and treatment services in the cities with the largest numbers of HIV+ individuals • This SAMHSA funded, Philadelphia Integrative Behavioral Health Initiative (PIBHI), represents the first time (to our knowledge) that BHC services have been made available in HIV clinics

6. PIBHI Objectives • PIBHI is based on the Primary Care Behavioral Health model in which Behavioral Health Consultants (BHCs) are integrated as full members of the HIV primary care team (4) • Goals of project include: • improved retention in care, • increased rates of viral suppression, • reduced mental health and substance abuse difficulties for patients • reduced HIV-related health disparities among participants (2) • Early results suggest improved retention in care, higher rates of adherence to ARVs, viral suppression, and greater access to services for underserved populations (2)

7. Philadelphia Ambulatory Health Centers (PHCs) • One of the six BHCs (Dr. Simmons) was placed at four city-operated ambulatory clinics to provide integrated BH services • Philadelphia PHCs are one of the few city operated facilities in the country that provide comprehensive care to residents, regardless of insurance status or ability to pay • Patient population is overrepresented by minorities and those living below the poverty line • At the end of 2012, Philadelphia had 11,571 persons living with HIV/AIDS • 753 were newly reported in 2012(3) • 30,000 cumulative cases since 1980

8. Addressing BH Needs at PHCs • There are 2 social workers available to address the psychosocial needs for the entire health center • Before BHC was placed, the majority of patients with behavioral health problems were referred to specialty mental health services • Many of our patients were initially treated at academic medical centers and then referred to PHCs when insurance benefits were canceled • subsequently, many patients worry that services received at PHCs are substandard

9. Challenges Faced by PLWH/A in Public Health Centers • Significant portion of our patients had or have a preexisting trauma diagnosis, superimposed with HIV/AIDS • Patients often present with a myriad of acute symptoms, including depression, anxiety, psychosis, and active substance use • Acute emotional stress, financial hardships (including no insurance), and limited social support (i.e., stigma related to disclosure of HIV status) can rapidly deplete patients’ coping capacity • Medication non-adherence is a frequent result and dangerous in HIV+ patients • Given the complex interaction of psychosocial stressors, these patients may require the BHC to modify the PC-BHC model of care

10. Increasing the amount of BHC contact • PC-BHC model suggests an average of 1-4 follow-up visits for majority of patients seen in PC (4) • This amount is often insufficient to create sustained behavioral change among newly diagnosed PLWH/A • Patients seem to benefit most when BHC “checks in” at each medical visit, even when no formal consult has been requested

11. Increasing Frequency of BHC Contacts • We suggest increasing frequency of contacts initially and gradually reducing over time • A “contact” might consist of a 5 minute engagement where BHC provides support, reminds patient about services available, or provides a formal intervention • For patients overwhelmed by feelings of shame and invalidation, briefer, more frequent contact, seems to be a “dose” that is manageable and helpful

12. Memorable patient quotes from our clinics • Stigma • “When I come here, I feel like everyone knows that I have HIV.” • Concerns about receiving subpar care • “Are city doctors really trained as well as real doctors?” • Long wait times, crowded, noisy environment • “This feels so chaotic. I’ll just miss my appointment and go to the ER.” [Staff: But, you may get a bill.] That’s OK, they can put it on my tab.”

13. The relationship between environment, experience, and treatment outcome • Avoidant coping style • An environment perceived as invalidating can elicit and exacerbate shame related to HIV status • The environment then becomes another aspect of the disease that the patient is unwilling or unable to confront • To the extent that patients avoid coming to medical appointments to avoid the feelings elicited at the clinic, treatment outcome can be impacted

14. Consequences of Avoidant Coping • Difficulty accepting chronic conditions and managing psychosocial stressors is associated with poor disease management and lower quality of life (5). • Avoidant behaviors may provide temporary reduction in anxiety, but negatively reinforce ineffective strategies • Patients who are “lost” to care or “loosely engaged” in care may not benefit from BHC services to address these issues

15. Does Patient Experience REALLY Matter? • Treatment Adherence • 4,997 or 18% of PLWH/A in Philadelphia EMA were out of care in 2012 (3) • Feeling good about one’s health and having positive expectations about the care received, may impact patient satisfaction (1) • Satisfied patients are more likely to adhere to treatment recommendations (1) • Poor treatment adherence results in poor viral suppression and increases risk of developing drug resistance and HIV transmission to others

16. Fiduciary Consequences of Negative Patient Experience • Untreated medical and behavioral health conditions due to missed appointments and treatment non-adherence may contribute to higher utilization of ER and specialty MH care at higher costs (4) • Many patients prefer the anonymity of the ER over the sense of vulnerability and exposure perceived at the health center • Patients with lapsed care often require more intensive services upon return to the clinic (i.e., multiple referrals to address medical problems, PC team spending longer time managing patient’s needs), placing additional burden on resources

17. How we addressed clinic culture and patient experience • Be aware that patient perception of the clinic may extend to the PC team • Routinely inquire about patient experience • Especially relevant for new patients • Note patient behavior regarding medical care, not just verbal responses, to prevent overlooking needs of passive or acquiescent patients • “Experience” can also include activities where patient is not physically in HC (i.e., telephone encounters, attempts to reach staff)

18. Addressing PHC culture and Patient Experience • Added meaningful patient-centered initiatives • Expanded patients’ access to BHC by providing cell number • Patients call BHC when they arrive and BHC can see the patient while he or she is waiting to see PCP • Allows BHC to mitigate wait time fatigue, provide a positive interpersonal experience, act as a buffer between patient and front desk staff, as well as addressing behavioral health and medical engagement concerns

19. Addressing Culture and Patient Experience at PHCs • Introduce wellness and mind/body concept to both patients and staff • Both patients and staff may be unaware of how the environment impacts behavior • Increase patients’ engagement by offering choices when possible • Point out and facilitate discussion about negative ideologies and/or practices within PC team

20. A team-based approach • By using an interdisciplinary team to address our patients’ biopsychosocial needs, we often see significant reduction in emotional stress and increased engagement in care • This subsequently raises the team’s morale as inability to help patients can increase demoralization amongst providers • Integrated care should be the norm, not the exception

21. Summary of Lessons Learned from the PIBHI • May need to increase number of BHC contacts to address acuity of symptoms and to create sufficient behavioral change • The clinic environment has a significant impact on patient experience, adherence, and treatment outcomes • An integrated team approach provides a safety net that mitigates psychosocial stressors faced by PLWH/A

22. Questions/Comments

23. References • (1)Bleich, S.N., Ozaltin, E., & Murray, C. JL., (2009). How does satisfaction with the healthcare system relate to patient experience? World Health Bulletin, 87, 271-278. Retrieved July 9, 2014 from http://www.who.int/bulletin/volumes/87/4/07-050401/en/ • (2) Emerson, E., Brady, K., Lehrman, S., Nassau, T., & Terrell, C. (2014, May). Early results from the Philadelphia integrative behavioral health initiative: Improved retention in care. Poster Session Presented at AIDS Conference. • (3) Integrated epidemiologic profile for HIV/AIDS prevention and care planning, Philadelphia eligible metropolitan area. Retrieved July 9, 2014, from,http://www.hivphilly.org/Documents/Epi%20Profile/EpiProfile2014ws.pdfand AIDS Activities Coordinating Office Surveillance Report, Philadelphia Department of Public Health. Retrieved August 9, 2014 from: http://www.phila.gov/health/pdfs/2012SurveillanceReportFinal.pdf • (4) Robinson, P.J & Reiter, J.T. (2007).In Behavioral consultation and primary care: A guide to integrating services. An overview of primary care behavioral health consultation (pp. 3-16). New York, NY: Springer. • (5) Fisher, L., & Dickinson, W.P. (2014). New collaborations for providing effective care for adults with chronic health conditions. American Psychologist, 69, 355-363.

24. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!