Integrated Behavioral Health 101 for Nursing Care Transformation

1. Integrated Behavioral Health 101 for Nursing Care Transformation Collaborative of R.I. Nelly Burdette, Psy.D.5/5/15

2. Integrated Behavioral Health • Care from a practice team of primary care and behavioral health clinicians • working together with patients and families • using a systematic and cost-effective approach • to provide patient-centered care for a defined population. 3 • May address • mental health and substance abuse conditions, • health behaviors (including their contribution to chronic medical illnesses), • life stressors and crises, • stress-related physical symptoms, • ineffective patterns of health care utilization. 3

3. Why does it matter to me? • Impact • In New England, nearly 1 of every 5 adults has a mental health need.2, 4, 5 • Behavioral health drives 60-80% of all visits to the PCP, especially as chronic diseases increase 4,5 • Cost • Financial: Comorbid behavioral health conditions can cost 2-3 times more 2, 5 • Mortality: substantially shorter life expectancies than the average person 2, 5 • Substance Use • 20 million Americans with alcohol or illicit drug dependence do not receive treatment 6 • Rarely screened for within primary care, but when treated ED visits can be reduced with significant cost savings and health improvements. 6

4. Depression & Physical Health • Depression one of top 10 drivers of medical costs 2 • History of depression = 4x likely suffer heart attack and to die within six months of having a heart attack compared to those without history of depression/current depression 2 • Depression care management for Medicaid enrollees can reduce overall healthcare costs by $2,040 per year with impressive reductions in emergency department visits and hospital days. 2

5. Depression Cycle JAMA. 2012;308(9):909-918. doi:10.1001/2012.jama.10690

6. Diabetes and Depression • Diabetes is very common in primary care, and many patients with diabetes also suffer from depression. 5 • Type 2 Diabetes nearly doubles an individual’s risk of depression and depression is associated with poor glycemic control, increased risk of complications, functional disability and overall higher healthcare costs 2 • Patients receiving integrated care had significantlygreaterdecreases in hemoglobin A1c levels, depression scores, and LDL-cholesterol than patients receiving usual care. 5

8. What is a NCM’s role? • You are the care coordination face of integrated care • Perfectly positioned to be involved in depression care management • When a patient screens positive on a mental health screening (such as depression on PHQ9), it is critical that you be able to understand how care management can benefit • Not a one-size fits all approach.

9. NCM for Depression in Spain 1 • Initial nursing visit • Within one week of meeting with PCP • PHQ9 and antidepressant education • Follow-up nursing • Every 4 weeks until remission • medication management and adherence • Repeat PHQ9, psychoeducation, treatment planning • Phone or In-Person • NCM does not • Provide psychotherapy or make medication decisions

10. NCM for Depression in US • IMPACT • Depression Care Manager may be nurse • Educates, monitors and completes a relapse prevention plan • Supports antidepressant prescribed by PCP • Coaches patients in behavioral activation and pleasant events scheduling • Six-eight session course of Problem-Solving Treatment http://impact-uw.org/about/key.html

11. IMPACT Outcomes

12. Future Directions • Every nurse is a NCM • Every nurse has capacity and skill set to learn how to utilize integrated behavioral health interventions in primary care • Behavioral health and substance use triage • Antidepressant and referrals compliance • Psychoeducation and self-management goal planning

13. References Arogones, E., Lopez-Cortacans, G., Baida, W., Hernandez, J.M., Caballero, A., Labad, A. and INDI Research Group. (2008) Improving the role of nursing in the treatment of depression in primary care in Spain. Perspectives in Psychiatric Care, 44 (4), 248-258. Mauer, BJ and Jarvis, D. (2010). The Business Case for Bidirectional Integrated Care: Mental health and substance use services in primary care setting and primary care services in specialty mental health and substance use settings. MCPP Healthcare Consulting. Available at: http://www.mhsoac.ca.gov/meetings/docs/Meetings/2012/Mar/OAC_032212_Morning_BusCase.pdf Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013. Available at: http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf Strosahl, K. (2002). Identifying and capitalizing on the economic benefits of integrated primary behavioral health care. In Cummings, O’Donohoe & Ferguson (Eds.) The impact of medical cost offset on practice and research: Making it work for you. NV: Context Press. Tice, J.A., Ollendorf, D.A., Reed ,S.J. Shore, K.K., Weissberg, J. & Pearson, S.D. (2015). Integrating Behavioral Health into Primary Care: Draft Report. Institute for Clinical and Economic Review. Available at: http://cepac.icer-review.org/wp-content/uploads/2015/01/BHI-CEPAC-REPORT-FINAL-VERSION-FOR-POSTING-MARCH-231.pdf Urada, D., Teruya, C., Gelberg, L. & Rawson, R. (2014). Integration of substance use disorder services with primary care: health center surveys and qualitative interviews. Substance Abuse Treatment, Prevention and Policy, 9 (15). Available at: http://www.substanceabusepolicy.com/content/pdf/1747-597X-9-15.pdf

14. Questions Nelly Burdette, Psy.D. naburdette@providencechc.org Director, Integrated Behavioral Health, PCHC Integrated Behavioral Health Practice Facilitator, CTC MHI Faculty Advisor, HMS Center for Primary Care Faculty, Alpert Brown Medical School & University Of MA Medical School Center For Integrated Primary Care