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Integrated Models of Care: Examples from HBPC and Cardiology

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.

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Integrated Models of Care: Examples from HBPC and Cardiology

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  1. Integrated Models of Care:Examples from HBPC and Cardiology Steven Lovett, Ph.D.

  2. 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.

  3. Program Descriptions – cont. • Cardiac Transplant Clinic • Serves vets who are candidates for, or, • have had a heart transplant. • Regional program. • Patients followed for life.

  4. Integration: Treatment Goals • Assist medical providers in reaching program’s treatment goals. • Identify undiagnosed psychological problems.

  5. Integration: Treatment Setting • Fast paced clinics. • Reduced privacy. • Specific accomplishments for each visit. • Relatively infrequent visits.

  6. Psychological Services Provided • Triage for psychological issues. • Adherence issues: • Knowledge • Skills • Resources • Motivation

  7. Psychological Services Provided – cont. • Health behaviors. • Somatic issues: • Sleep disturbance • Pain • Psychological distress: • Depression / anxiety • Stress

  8. Psychological Services Provided – cont. • Cognitive screening / capacity assessment. • Caregiver / Family issues. • End of life issues. • Provider consultation.

  9. Therapeutic Modalities • Single session intervention. • Phone follow-up. • Referrals / case management. • Individual therapy, as needed & feasible.

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