Screening for BH and PH Conditions. When in Process Flow to Screen & What Screening Tools to Use?

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1 Screening for BH and PH Conditions When in Process Flow to Screen & What Screening Tools to Use?

2 Screening Tool Checklist Research base demonstrating construct validity Free Easy to Train Staff on Use Sixth Grade Reading Level Short and Long Versions Face Validity Widely Adopted Able to be coded into EMR 5/19/ :30 AM

3 Screening Tools Behavioral Health Clinic What tools are you currently using for Physical Health Screening? What Physical Health Data do you Collect? Primary Care Clinic What tools are you currently using for Behavioral Health Screening?

4 Screening Workflow When, Where, Who? Where does the data go? How is the data turned into information and leveraged? How are staff trained? 5/19/ :30 AM

5 Solutions for Effective Transportation Supports

6 Significant Barriers to Healthcare Structural Availability Organization Transportation Financial Insurance coverage Reimbursement levels Public support Personal Acceptability Cultural Language Attitudes Education/Income Source: Institute of Medicine. Access to Health Care in America. National Academies of Science Press, /19/ :30 AM

7 Burden of Transportation The poorest fifth of Americans spend 42 percent of their annual household budget on the purchase, operation, and maintenance of automobiles, more than twice the national average. Source: Surface Transportation Policy Project, org/library/factsheets/poverty.asp.

8 Patient Navigators Older Asian and Hispanic youth who do what they ve always done for family and friends Educated and trained at local community colleges 1 year credit bearing certificate program Career ladder - transferable, forward-looking skills for non-clinical health worker members of an integrated, culturally-competent, patient-facing care delivery team (whew)

9 How we roll Clinician refers patient for appt./consult Software matches patient language/time needs, texts appropriate patient navigator (PN) PN meets patient, accompanies her to referral service, checks in, interprets/explains, checks out App records non-clinical activities. After checkout, clinical supervisor reviews before posting. Instant electronic payment. Source: Asian Americans for Community Involvement (

10 Transportation Resources ansportation

11 High Performing Interdisciplinary Teams

12 Team & Teamwork means something different to everyone

13 A Continuum of Healthcare Teams Multi-disciplinary Team = hierarchical, each role separate, some communication, parallel processes. Inter-disciplinary Team = interdependent, maintain distinct professional responsibilities & assignments, must make dramatic adjustments in their orientation to coworkers. Trans-disciplinary Team = shared decision making, every member can do everyone else's role if needed, one process, much communication. Source: Cooper et al. (2003). The Interdisciplinary team in the management of chronic condition: Has its time come? RWJF.

14 The Interdisciplinary Team: People with distinct disciplinary training working together for a common purpose, as they make different, complementary contributions to patient-focused care. Leathard, A., ed. (1994). Going Interprofessional: Working Together for Health & Welfare. Routledge, London.

15 Adaptive Reserve Borrill et al. (2000) found that teams with greater occupational diversity reported higher overall effectiveness and the innovations introduced by these teams were more radical and had significantly more impact both on the organization and on patient care. Borrill & Haynes (2000). Managers' lives. Stressed to kill. Journal of Health Service.10;110(5691):24-5.

16 2007 Cochrane Review of Shared Care Results from a few of the studies suggested that shared care may be more effective in certain patient groups. These include patients with depression and other serious chronic mental health illness and those with high levels of morbidity at baseline such as the elderly and people with moderate to severe congestive cardiac failure. Source: Effectiveness of shared care across the interface between primary and specialty care in chronic disease management (Review) 13 Copyright 2007 The Cochrane Collaboration., JohnWiley & Sons, Ltd

17 Health Outcomes Related to Interdisciplinary Teams A study involving >5,000 patients in 13 ICU s found significant patient mortality reductions in hospitals where interdisciplinary teams worked in close collaboration. Source: Sommers LS, Marton KI, Barbaccia JC et al. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med 2000;160:

18 Health Outcomes Related to Interdisciplinary Teams Interdisciplinary teamwork correlated to lower hospital readmission rates the greatest reductions in readmission rates occurred when physicians, nurses, and social workers were most satisfied with their professional relationships on the team. Source: Knaus WA, Draper EA, Wagner DP et al. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med 1986;104:

19 The Team as an Emerging Standard of Care The high-performing team is now widely recognized as an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system. Source: Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, & I. Von Kohorn. (2012). Core principles & values of effective teambased health care. Discussion Paper, Institute of Medicine, Washington, DC. P.5.

20 Five Components of Effective Interdisciplinary Teams: 1. Defining appropriate team goals. 2. Clear role expectations for team members. 3. A flexible decision-making process. 4. The establishment of open communication patterns. 5. The ability of the team to treat itself. Source: Leipzig, Hyer et al. (2002). Attitudes Toward Working on Interdisciplinary Healthcare Teams: A Comparison by Discipline J Am Geriatr Soc 50:

21 Terms Teams Must be able to Operationalize Concepts that are not Yet Well Operationalized Team based care Care Coordination/Care Navigation Patient Centered Care/Medical Home Population Health Management Treat to Target Bundled/Episode of Care

22 Defining appropriate team goals Develop a team dashboard that includes measurable, and meaningful/relevant goals. The goals must relate to tx plan, staff work plan & broader organizational goals. Tie the goals to a quality improvement/pdsa process. Incorporate discussion of the goals/measures into every meeting.

23 Clear role expectations for team members The more complex the task the clearer roles must be. All team members have their own opinions of what their role is and what their team member s role is If suspected or seen role ambiguity & conflict should be discussed right away. Routinely, clearly state who owns or is responsible for a task to help foster this thinking.

24 Staff Competencies 1. Interpersonal Communication 2. Collaboration & Teamwork 3. Screening & Assessment 4. Care Planning & Care Coordination 5. Intervention 6. Cultural Competence & Adaptation 7. Systems Oriented Practice 8. Practice Based Learning & Quality Improvement 9. Informatics

26 A flexible decision-making process A team is a problem-solving, decision-making mechanism. This is not to imply that an entire group must always make all decisions as a group. The issue is one of relevance and appropriateness; who has the relevant information and who will have to implement the decision.

27 A flexible decision-making process cont. Similarly, when a group faces a conflict it can choose to (a) ignore it, (b) smooth over it, (c) allow one person to force a decision, (d) create a compromise, or (e) confront all the realities of the conflict (facts & feelings) and attempt to develop an innovative solution. The choices individual team members and the team as a whole make will significantly influence how the team functions.

28 The establishment of open communication patterns Create avenues for communication (e.g., logs, regular team meetings, use of common language, etc.). Maintain regular contact with agency leadership. Understand how culture & training drives language and communication styles. Maintain regular one-on-one supervision.

29 What Staff Care About/ Want from a Leader Practical Questions What do you want me to keep doing? (standardization) What do you want me to stop doing? (waste) What do you want me to do differently? (CQI) Personal Questions Is my job fulfilling my passion/life vision? Is my job fulfilling my career goals?

30 The ability of the team to treat itself Include a Team self-audit process that is tied to the team s dashboard. Encourage questioning & the voicing of alternative views. Declare team breakthroughs & team breakdowns when necessary. Encourage necessary acts of leadership.

31 Team Norms Norms take on particular potency because they influence all of the other areas previously discussed. Groups develop norms governing leadership, influence, communication patterns, decisionmaking, conflict resolution, and the like. Inherently, norms are not good or bad. The issue is one of appropriateness Does a particular norm help or hinder a group's ability to work?

32 Team Value Systems Wilmot (1995) reported that nurses valued individualism, caring, autonomy, holism & patient well-being, while social workers internalized collectivity, liberty, equality & justice. Family practice and internal medicine medical students and residents were found to be least inclined to interdisciplinary practice while social workers were most inclined. Source: Wilmot (1995). Professional values & inter-professional dialogue. Journal of Inter-professional Care. 9(3):

33 Take Care of Your Team Transformation occurs, not at a steady & predictable pace, but in fits & starts. After the strenuous task of implementing a particular PCMH component, the practice had to simultaneously manage the ripple effects, maintain the change, & prepare for the next the work is daunting, exhausting & occurring in practices that already felt as if they were running as fast as they could. This type of transformative change, if done too fast, can damage practices and often result in staff burnout, turnover, & financial distress. Source: Nutting et al. (2010) Effect of Facilitation on Practice Outcomes in the National Demonstration Project Model of the Patient-Centered Medical Home Annals of Fam. Med., VOL. 8 (1)

34 Team Care Recognize teams are dynamic, emotion laden, and need constant attention and reassurance. Hardwire rewards into the work flows. Be careful to hire team members not positions. Get in the habit of monitoring and responding to changes in morale/trust.

35 Team Tools/Scales ATHCT Scale: Attitudes Toward Health Care Teams Scale Team Skills Scale (TSS): a self-assessment instrument Inter-professional Collaboration Scale (IPC): Team function from individual team members perspective specifically, effectiveness of communication, accommodation and appearance of isolation Primary Health Care Team Effectiveness Survey Scale for Leadership Assessment & Team Evaluation (SLATE),

36 Other Sources Bosch M, Faber MJ, Cruijsberg J, et al. Effectiveness of Patient Care Teams and the Role of Clinical Expertise and Coordination: A Literature Review. Med Care Res Rev :5S-34S. Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, & I. Von Kohorn. (2012). Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC. P.7. O Leary KJ, Wayne DB, Haviley C, Slade ME, Lee J, Williams MV. Improving Teamwork: Impact of Structured Interdisciplinary Rounds on a Medical Teaching Unit. J Gen Intern Med. 2010;25(8): Mudge A, Laracy S, Richter K, Denaro C. Controlled Trial of Multidisciplinary Care Teams for Acutely Ill Medical Inpatients: Enhanced Multidisciplinary Care. Intern Med J : Smith ST, Enderby S, Bessler RA. Teamwork in Leadership and Practice-Based Management. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS, eds. Principles and Practice of Hospital Medicine. 1 st ed. New York, NY: McGraw-Hill; 2012: Internet Citation: Essentials Instructional Module: TeamSTEPPS Long-Term Care Version. July Agency for Healthcare Research and Quality, Rockville, MD.

37 Primary Care Behavioral Health Ohio Integrated Health Learning Community Suzanne Daub, LCSW May 15, 2014

38 What is Behavioral Health Integration?

occurs when behavioral and primary care providers work

39 The Primary Care Behavioral Health (PCBH) Model At the simplest level, integrated behavioral and physical health care occurs when behavioral and primary care providers work together to address the physical and behavioral health needs of their patients.

40 A Standard Framework For Describing Integrated Health Services

41 Integrating Behavioral Health and Primary Care: Behavioral Health Consultation

PCBH and Role of Primary Care Provider Serves as team leader Screens for depression, anxiety and trauma Refers a broad range of patients to behavioral health Uses

42 PCBH and Role of Primary Care Provider Serves as team leader Screens for depression, anxiety and trauma Refers a broad range of patients to behavioral health Uses behavioral health consistently at certain types of visits (chronic pain, initial dx of diabetes, well child visits, etc.) Conducts medication evaluation, prescribing, and monitoring

PCBH and Role of Behavioral Health Work alongside primary care providers as Behavioral Health Consultants (BHCs) Immediately accessible for

record using a Subjective, Objective, Assessment, and Plan (SOAP) note format Reimbursement by encounter not by time No office, No

43 PCBH and Role of Behavioral Health Work alongside primary care providers as Behavioral Health Consultants (BHCs) Immediately accessible for both curbside and in-exam room consults, same-day visits (15 30 minute consults between 7 10/day) Shared records: chart in the medical record using a Subjective, Objective, Assessment, and Plan (SOAP) note format Reimbursement by encounter not by time No office, No caseload, No no shows Robinson, P.J. and Reiter, J.T. (2007). Behavioral Consultation and Primary Care (pp 1-16). N.Y.: Springer Science + Business Media.

44 Clinical Approach of Behavioral Health Consultant Problem-focused and functional-contextual approach to assessment and treatment of behavioral health disorders Use evidence-based instruments to develop treatment plans, monitor patient progress, and flexibly provide care to meet patient s changing needs: 1. Motivational Interviewing 2. Behavioral Activation 3. Acceptance and Commitment Therapy 4. Screening, Brief Intervention, and Referral to Treatment (SBIRT) Robinson, P.J. and Reiter, J.T. (2007). Behavioral Consultation and Primary Care (pp 1-16). N.Y.: Springer Science + Business Media.

45 Role of the Behavioral Health Consultant Address a variety of issues common to primary care: Affective concerns: depression; anxiety Response to physical illness; pain; substance use and abuse Health behavior change: obesity, smoking, sleep, medication adherence, self management of chronic conditions Engage in prevention activities Hunter, C.L., Goodie, J.L., Oordt, M.S., & Dobmeyer A.C., (2009), Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. Washington, DC: American Psychological Association

PCBH Collaborative Approach PCPs systematically screen and do warm hand-offs according to patient needs PCPs and BHCs regularly review each other s notes in the Electronic Medical Record Regularly

46 PCBH Collaborative Approach PCPs systematically screen and do warm hand-offs according to patient needs PCPs and BHCs regularly review each other s notes in the Electronic Medical Record Regularly consult about patient care and change or adjust treatments if patients do not meet treatment targets Co-monitor treatment response at each contact with valid outcome measures Patients who are not improving are identified and targeted for move to a higher level of care

47 Case Example Ms. T is a 73 year old African American woman. She is a retired teacher with chronic back pain, hypertension, and a history of multiple hospitalizations for coronary artery disease. She is depressed, has stopped going to church, misses her PCP appointments, and takes her HBP medications on her own terms.

To work in integrated care settings Basic understanding of primary care medical conditions Screening, rapid assessment and brief intervention Motivational interviewing, behavioral activation, self

48 To work in integrated care settings Basic understanding of primary care medical conditions Screening, rapid assessment and brief intervention Motivational interviewing, behavioral activation, self management Systems oriented practice including care planning and care coordination Primary care communication skills and interdisciplinary care Working knowledge of psychopharmacology Substance use/addiction treatment (Source: /Forthcoming/ Annapolis Coalition on Behavioral Health Workforce White Paper, Core Competencies for Integrated Behavioral Health and Primary Care )

49 Questions

50 Resources SAMHSA/HRSA Center for Integrated Health Solutions (CIHS) Field-based & Research-based Materials Council on Social Work Education (CSWE) Free Integrated Health Social Work Curriculums Integrated Care Resource Center (ICRC) Medicaid State Level Tech. Asst. for Integrated Health AHRQ Academy for Integrating Behavioral Health & Primary Care Great Research-based Resources Dear State Medicaid Letters/Centers for Medicaid & Medicare Services (CMS) Variety of IH Directives including: Health Home Core Quality Measures

51 Resources Clinical Social Work & Behavioral Medicine Certificate Program University of Michigan Certificate in Integrated Health University of Massachusetts Two Certificate Programs in Integrated Health Fairleigh Dickinson University Certificate in Integrated Primary Care Arizona State University Doctor of Behavioral Health

THE AFFORDABLE CARE ACT: OPPORTUNITIES FOR SOCIAL WORK PRACTICE IN INTEGRATED CARE SETTINGS. Suzanne Daub, LCSW April 22, 2014

THE AFFORDABLE CARE ACT: OPPORTUNITIES FOR SOCIAL WORK PRACTICE IN INTEGRATED CARE SETTINGS Suzanne Daub, LCSW April 22, 2014 Agenda Why integrate primary care and behavioral health? Define integrated