Collaborative Family Healthcare Association 14 th Annual Conference

1. Transitioning from Co-Located to Integrated Care: The role of the Behavioral Health Consultant (BHC)in designing and developing behavioral healthcarein the Medical Home Session #D2a October 5, 2012 Laura M. Daniels, M.A. Doctoral Student in Clinical Health Psychology Department of Psychology East Carolina University Jennifer L. Hodgson, Ph.D. Professor Departments of Child Development & Family Relations and Family Medicine East Carolina University Dennis C. Russo, Ph.D., ABPP Head, Behavioral Medicine Program; Clinical Professor Departments of Family Medicine and Psychology, Brody School of Medicine, East Carolina University Kari B. Kirian, Ph.D. Clinical Instructor, Behavioral Medicine Program, Dept. of Family Medicine, Brody School of Medicine, East Carolina University Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Objectives • Identify procedures which provide necessary mission, institutional, and patient centered support to assist training programs in their initial transition from Co-Location to Integrated Care • Evaluate methods for identifying how best to serve the needs of patients within the Integrated Care Setting • Describe the development of a collaborating group of professionals with reference to the makeup of the Behavioral Science Team • Evaluate components essential for ensuring the sustainability of program’s educational and clinical services

4. Learning Assessment Guided discussion will address audience implementation of a Transition Plan during a problem solving and question/answer session at end of presentation.

5. Transitioning from Co-Located to Integrated Care: The role of the Behavioral Health Consultant (BHC) in designing and developing behavioral healthcare in the Medical Home

6. Phase 5: Operating a Sustainable Integrated Primary Care Program Phase 4: Beginning Integrated Care 2012-2013 Phase 1: Prepare for Integration 2008-2010 Phase 2: Formal Program Development 2010-2011 Phase 3: Building Center for Integrated Care 2011-2012 Timeline

7. Transitioning from Co-Located to Integrated Care: Phase I: Building the Basis for an Enduring Program

8. Phase 1: Reintegration(January 2008-January 2010) • Re-establishing the behavioral medicine service and curriculum for the Family Medicine Center and Residency Program.

9. Priorities • Build a team of clinicians • Hire a full time director of behavioral medicine • Pilot an integrated care model • Write grants to help offset start-up costs

10. Strategies for success • Build relationships; respect the culture and system as it is and not seeing it as broken but something that can be enhanced • Build a team of BM providers and strengthen the connection to psychiatry • Attend as many meetings as possible, BM needs to stay visible • Walk around and spend time in precepting rooms doing video reviews and just waiting for opportunities to educate and integrate • Reach out to colleagues for ideas

11. Outcome #1: Grant Support • Received an Access East grant for $25,000 to fund a part of my position until May 31, 2009. • Received an SBIRT grant for $280,000 which resulted in 3 years of funding for program implementation in the Family Medicine Center.

12. Who accessed our services? • 58% Physician Extenders • 26% Residents • 16% Faculty • * 1st 9 months of implementing the new service

13. When were we brought into the Integrated Care process? • 50 x Therapist BEFORE PCP • 130 x Therapist WITH/DURING PCP • 135 x Therapist AFTER PCP • 25 x Traditional Session (45 min - 1 hour)

14. Constellation of Encounters • 160 Individual Encounters • 15 Couple Encounters • 35 Family Encounters • 130 Larger System (with provider) Encounters

15. Length of Encounters • 17% @ 15 minutes • 32% @ 30 minutes • 19% @ 45 minutes • 23% @ 1 hour • 9% @ > 1 hour

16. 245 x Joining or Assessing 95 x Psychoeducation 78 x Brief Therapy 107 x Lengthy Therapy 66 x Assist with Treatment Plan 32 x Lifestyle Change Consultation 32 x Psychological or Relational Diagnosis Services Provided

17. Depression/Mood Disorders Suicidal/Homicidal Ideations Anxiety/Phobias Relational Issues Overweight Diabetes PTSD ADHD Chronic Pain/Illness Substance Abuse Assessment Domestic Violence Most Common Diagnoses/Symptoms Addressed(neither exhaustive nor in a particular order) End of Life Personality Disorders New Diagnosis Fertility/Infertility Bereavement Stress Reduction Lifestyle Change Challenges and Issues of Adherence Doctor/Pt relational issues

18. Lessons learned in this phase • Learned that we need models for helping behavioral health professionals to integrate as well. • Taking steps back to help others catch up is hard but important • Model must be fluid, flexible, and yet have a good infrastructure for fidelity and training purposes • Sustainability is important but complex in academic settings where students cannot be billed for their services.

19. Next Steps…. • Decrease the threshold for Behavioral Medicine involvement • Increase screening for psychosocial problems • Increase numbers of concurrent visits to facilitate cross discipline learning and extend more comprehensive care • Billing and Reimbursement

20. Transitioning from Co-Located to Integrated Care: Phase II: Formal Program Development

21. Understand Institutional Mission and Priorities What’s our Job? Developing Clinical Services Increase Visibility of Program Ensure Sufficient Manpower to get the Job Done Build Professional Visibility Develop New Funding Resources Designing a fully Functioning Program

22. Our Mission It’s Health….. Not Just Mental Health, Stupid.* * My apologies to Bill Clinton

23. Clinical Services The presence of an Integrated Behavioral Health Service greatly enhances our ability to care for our patients

24. Integrated Care The “Beeper” Brief Traditional Care Education and Teaching Events Being There Everywhere….. Right Away!

25. Create and Enhance Institutional Relationships Medical Family Therapy Program, Department of Child Development and Family Relations Doctoral Program in Clinical Health Psychology, Department of Psychology (APA Accredited) School of Social Work Don’t stop there! Develop relationships with other training sites and academic departments at other institutions Ensuring Sufficient Manpower Building Alliances

26. Focusing the Attention of the Department on Integrated Care

27. Growth of Patient Care

28. Focus on Integrated Care Team Education Video Precepting The Behavioral Science Base of Integrated Care Learners teaching Learners Identify Service Units Necessary Faculty Students The Billing, Scheduling, and Coding Team Do it at home. Develop it nationally. System Level Healthcare Change Integrated Care Stakeholders Group Get more Grant Funding Addressing Sustainability and Funding Issues

29. Health Resources and Services Administration Center for Integrated Care Delivery Funded by a grant from Health Resources and Services Administration to The Department of Family Medicine, Brody School of Medicine, East Carolina University • To establish a Center focusing on training strategies for integrated care management of behavioral issues in chronic disease • To build, test, and evaluate new curricula for medical students and residents on integrated care for concurrent depression/behavioral problems and chronic disease in primary care settings • To evaluate and improve care outcomes in underserved populations with chronic diseases and behavioral problems by establishing an integrated care management training program

30. Transitioning from Co-Located to Integrated Care: Phase III: Piloting Integrated Care

31. Phase III: Piloting Integrated Care • Environmental considerations • Training BHC Learners • Kick-off Conference • Integrated Care Pilot • Outcome Evaluation

32. Environmental considerations • Structural barriers • Bigger is not always better • Maintaining relationships • Creativity and openness to various forms of communication • Technical difficulties • Availability and flexibility

33. Training BHC Learners • Advanced students • Adjusting from the 50min to 15min sessions • On-call to the clinics • Skill building at medical setting • Increasing face-time and comfort with medical team • Supervision

34. Kick-off conference • Bringing in experts • Increasing clinic-wide awareness of integration • Establishing a supportive team atmosphere and patient-centeredness • Goal: Educate on benefits of integrated care and skill-training

35. Kick-off conference: BHC evolving role • BHC is a team leader with the PCP • Decreasing time and frequency in the therapy room • Increasing time in clinic • Engaging in brief consultations and interventions • Knowing team strengths

36. Integrated Care Pilot • Interdisciplinary input • Huddle Pilot • Screening Pilot • Screening at-risk Diabetes Patients Pilot • BM fully integrated for 2-4 shifts over 2 wk period

37. Personal Reflections • Facilitating Factors • Reviewing clinic schedule • Talking with providers prior to start of clinic • Flexible operations • Real-time supervision • PCP follow-up • Barriers & Opportunities for growth • Resistance to change • Communication lapses • Closed-door operations • Scheduling with specialties

38. What will the future bring?

39. Transitioning from Co-Located to Integrated Care: Phase IV: Defining, Detailing, Implementing

40. Defining • Behavioral medicine team • Meet as a team • Solidify our ideas for IPC • Operationally define … • How we want behavioral health to be utilized on the modules • What is feasible • Who, when, where, what, how?

41. Detailing • Meeting with key groups to educate, elicit concerns, and request input • Behavioral medicine learners • Nursing and CMAs • Residents • Preceptors • Manifest purpose vs. latent purpose • Impart information and answer questions • decrease anticipatory anxiety • Extending olive branch- their meeting, their turf • Increase ownership • Rapport, communication, and relationships

42. Implementing: the Grant has Prompted… • IC delivery in clinics • Residency curriculum changes • Evaluation of impact

43. IC Delivery • Pager service • Dietician/Nutrition • Pharmacotherapy • Behavioral health • Physical presence of BHC on the resident modules • 1-2 days/month  every day • Ongoing therapy clinic • 4-6 sessions Balance: being accepted and being utilized

44. Residency curriculum changes • BH presence and involvement during academic opportunities • Direct Observation • Interdisciplinary (MD + BH faculty), video precepting • Expanded teaching strategies • Medium: vignettes, case examples, role play, small group, discussion, etc. • Content: IC, evidence-based interventions, interpersonal communication

45. Evaluation of Impact • Direct observation evaluations • Utilization data for IC visits • Diabetes Interviews • PHQ 9, DDS, DES-SF, HRQOL • Biologic and psychologic outcomes • Patient and provider knowledge and satisfaction

46. Initial Outcomes Utilization Data

47. Mean = 46

48. When BHC Met with Patient

49. Time Spent with Patient

50. Who Initiated the Consult?