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Explore examples of integrated care models in Home Based Primary Care (HBPC) and Cardiology Transplant Clinic. Learn about treatment goals, settings, and psychological services provided, including addressing adherence issues, health behaviors, somatic issues, and cognitive screening. Discover therapeutic modalities like single-session interventions, phone follow-up, referrals, and individual therapy.
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Integrated Models of Care:Examples from HBPC and Cardiology Steven Lovett, Ph.D.
Program Descriptions • Home Based Primary Care (HBPC) • Primary care delivered in the home. • 3 teams with their own NPs, RN, SW, OT • Shared Medical Director, Pharmacist, Dietitian, Psychology. • Goal = return patients to clinic or avoid institutionalization.
Program Descriptions – cont. • Cardiac Transplant Clinic • Serves vets who are candidates for, or, • have had a heart transplant. • Regional program. • Patients followed for life.
Integration: Treatment Goals • Assist medical providers in reaching program’s treatment goals. • Identify undiagnosed psychological problems.
Integration: Treatment Setting • Fast paced clinics. • Reduced privacy. • Specific accomplishments for each visit. • Relatively infrequent visits.
Psychological Services Provided • Triage for psychological issues. • Adherence issues: • Knowledge • Skills • Resources • Motivation
Psychological Services Provided – cont. • Health behaviors. • Somatic issues: • Sleep disturbance • Pain • Psychological distress: • Depression / anxiety • Stress
Psychological Services Provided – cont. • Cognitive screening / capacity assessment. • Caregiver / Family issues. • End of life issues. • Provider consultation.
Therapeutic Modalities • Single session intervention. • Phone follow-up. • Referrals / case management. • Individual therapy, as needed & feasible.