Integrating Behavioral Health Services with Primary Care. Objectives & Goals

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illness and co-morbid health conditions in a fragmented health care system. Define Integrative care and discuss the benefits of collaborative care models.

1 Integrating Behavioral Health Services with Primary Care Brenda J. Johnston, DNP, PMHNP-BC, PMHCNS-BC This presenter has no conflict of interest to disclose Objectives & Goals Objectives Discuss the difficulties encountered providing care for patients with mental illness and co-morbid health conditions in a fragmented health care system. Define Integrative care and discuss the benefits of collaborative care models. Describe integrative practice solutions for incorporating behavioral health services into the primary care setting. Goals Improve Access Improve communication Facilitate shared-decision making Mentor Improved patient satisfaction Track outcome measures Scope of the Problem Persons with mental illnesses die years earlier than the general population Fragmented care contributes to poor mental health outcomes Colton, C. W. & Manderscheid, R.W. (2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease. Johnston 1

Comorbidity 25 % of US Adults have Mental Disorders 58 % US Adults have a medical condition 68% of adults

health disorder Goodell, S., Druss, B. G., & Walker, E. R., (2011).

2 Comorbidity 25 % of US Adults have Mental Disorders 58 % US Adults have a medical condition 68% of adults with mental illness have at least one medical condition 29 % of adults with medical conditions have a mental health disorder Goodell, S., Druss, B. G., & Walker, E. R., (2011). Mental disorders and medical co morbidity: Research synthesis report No. 21. Robert Wood Johnson Foundation. Retrieved from Primary Care is the De Facto Mental Health System Wang P et al., Twelve Month Use of Mental Health Services in the United States, Arch Gen Psychiatry, 62, June 2005 Johnston 2

The Gateway 75% of patients with depression see PCPs and 80% of antidepressants are prescribed by PCPs PCPs have limited psychiatric training and experience and most do not routinely screen for

, Knowles, S., Coventry, P. A., & Rowland, N. (2011). Counseling for mental health and psychosocial problems in primary care. In The Cochrane Collaboration & P. Bower (Eds.), Mitchell, A. J., Vaze, A.

3 The Gateway 75% of patients with depression see PCPs and 80% of antidepressants are prescribed by PCPs PCPs have limited psychiatric training and experience and most do not routinely screen for mental illnesses Depression goes undetected in >50% of primary care patients and is often undertreated Only 20-40% of patients improve substantially in 6 months without specialty assistance Bower, P., Knowles, S., Coventry, P. A., & Rowland, N. (2011). Counseling for mental health and psychosocial problems in primary care. In The Cochrane Collaboration & P. Bower (Eds.), Mitchell, A. J., Vaze, A., & Rao, S. (2009). Clinical diagnosis of depression in primary care: a meta-analysis. The Lancet, 374(9690), doi: /s (09) The Free Medical Clinic (FMC) Opened in 1986 Medical home for nearly 1300 patients. The mission is to provide the gift of health to those in need. The FMC is dedicated to the belief that everyone should have access to health care services. The Free Medical Clinic The clinics unduplicated visits totaled 11,500 in Limited behavioral health (BH) services one night per month began in 2004, BH services comprise 7% of the total patient visits to the FMC. Johnston 3

Important Considerations There is an identified need to improve existing mental health care for established FMC patients The FMC is not a mental health facility It is a medical home for 1300

4 Important Considerations There is an identified need to improve existing mental health care for established FMC patients The FMC is not a mental health facility It is a medical home for 1300 individuals, and many patients have co-morbid psychiatric illnesses There are no plans to expand services that include patients with mental illness as their primary diagnosis The program evaluation of existing BH services will be used only as a guide for making suggested revisions to current services Top 4 Diagnosis at the FMC Series Hyperlipidemia Hypertension Diabetes Depression and Anxiety Series1 Program Evaluation Equipment & Personnel Structure 4 hour/mo. BH service. No room for growth 3 mo. wait list for referrals No EHR, No BH guidelines available for PCPs Patient Care Actions Process No established pt. Flow. PCPs express discomfort with BH treatments Limited screening & F/U No case management & limited counseling Treatment Results Outcome Outcome measures not routinely checked: Medication adherence Treatment progress Psychiatric medications filled Donabedian, A. (2005). Evaluating the Quality of Medical Care. The Milbank Quarterly, 83(4), doi: /j x Johnston 4

Patient Satisfaction Surveys 0.9 0.8 0.7 100% desired BM 0.6 0.5 0.4 0.3 0.2 GREAT 0.

5 Patient Satisfaction Surveys % desired BM GREAT 0.1 GOOD 0 EASE OF GETTING CARE Ability to get in to be seen Hours center is open Convenience of centerʹs location Prompt return on calls WAITING Time in waiting room Time in exam room Waiting for tests to be performed Waiting for test results STAFF PROVIDER Listens to you Takes enough time with you Explains what you want to know Gives you good advice and NURSES AND MEDICAL Friendly and helpful to you Answers you questions ALL OTHERS Friendly and helpful to you Answers you questions PAYMENT What you pay Expanation of charges Collection of payment/money FACILITY Neat and clean building Ease of finding where to go Comfort and safety while waiting Privacy OKAY FAIR POOR 42 % of patients cancel or no show (n = 17) Able to use behavioral activation techniques with patients as an adjunct to other treatments Able to provide optional evidence-based, brief structured psychotherapy Able to establish quick rapports to a wide range of individuals Ability to make patients feel that they are being listened to and supported Can bill utilizing therapy codes A Pilot CCM Piloted CCM at the FMC each Thursday from 9am-1pm beginning August 2013 through April 2014 Staff to include RN Care Manger and PMHNP Implement elements to determine feasibility and effectiveness Track outcome measures o Patient and provider satisfaction o Psychiatric vital signs o Number of patient visits o BH hospital admissions o Benefits of collaboration o Impact on BH monthly clinic Johnston 5

6 What is a PMHNP? MSN or DNP prepared Three separate, comprehensive graduate-level courses in: Advanced physiology/pathophysiology Advanced health assessment Advanced pharmacology Content in: Health promotion and/or maintenance Differential diagnosis and disease management, including the use and prescription of pharmacologic and non-pharmacologic interventions Clinical training in at least two psychotherapeutic treatment modalities. PMHNP-BC Credentialed through ANCC and licensed through the BON Full prescriptive authority Collaborative practice agreement with physician Solutions Collaborative Care Models promote evidenced-based practices and significantly improve treatment outcomes; o Improved coordination of care o Shared treatment plans o Eliminating communication barriers o Facilitates patient-centered care o Emphasis is on evidenced-based practices with established methods of tracking patient outcomes o Prevents duplicative services o Cost effective (RWJF, 2011; Buxton, Chandler-Altendorf, & Puente, 2012; Grogan-Kaylor, 2012; Pomerantz et al., 2010; Grella & Stein, 2006) Collaborative Care Models Coordinated Co located Collaborative Fully Integrated Johnston 6

Collaborative Care Model (CCM) Comprehensive screening and assessment Shared development and communication of care plans Care coordination and management Increased

Washington, D.C.SAMHSA HRSA Center for Integrated Health Solutions.

7 Collaborative Care Model (CCM) Comprehensive screening and assessment Shared development and communication of care plans Care coordination and management Increased patient-provider collaboration Heath, B., Wise Romero, P., & Reynolds. K. (2013). Review and Proposed Standard Framework for Levels of Integrated. Healthcare. Washington, D.C.SAMHSA HRSA Center for Integrated Health Solutions. Start in the Waiting Room Comprehensive Screening and Assessment Utilize screening tools to identify mental health symptoms and monitor treatment progress o Generalized Anxiety Disorder Questionnaire (GAD 7). o Patient Depression Questionnaire (PHQ 9) o Mood Disorder Questionnaire Johnston 7

8 Simplified questionnaire developed to help in the diagnosis of Generalized Anxiety Disorder, or GAD. 7 item questionnaire Score of 10 or more on the GAD-7 represented a reasonable cut point for identifying cases of GAD Cut points of 5, 10, and 15 may be interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7. PHQ 9 Patient completed, brief assessment tool with a diagnostic validity established in studies involving 8 primary care and 7 obstetrical clinics. PHQ scores 10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represents mild, moderate, moderately severe and severe depression 20-%20Questions.pdf Johnston 8

9 Mood Disorder Questionnaire Brief, self-report questionnaire Not as sensitive for bipolar II disorder Good sensitivity and specificity Can correctly identify 7 of 10 patients with bipolar disorder. The MDQ can provide primary care physicians with a quick and easy way to identify patients most likely to have bipolar disorder. Johnston 9

Shared Decision Making Involves both provider and patient working together to balance clinician s experience and expertise with patient preferences, values and experiences

211/sdm/print_video/sdm_print_and_video/general_issue_brief_508.pdf Pre evaluation Questionnaire How am I doing?

10 Shared Decision Making Involves both provider and patient working together to balance clinician s experience and expertise with patient preferences, values and experiences Recommended for those patients with conditions, such as depression, for which more than one reasonable form of treatment exists. (Hostsetter & Klien, 2012). Pre evaluation Questionnaire How am I doing? o Sleep o Appetite o Mood o Medication adherence o Relationships o Stressors o Medication side-effects o How are you helping yourself? o What are your goals for the next two weeks? o What would like to talk about today? Johnston 10

community connections Maintains the flow Keeper of the charts

11 Care Management Scheduling Appointment adherence Medications Awareness of issues that impact treatment Facilitate community connections Maintains the flow Keeper of the charts The bridge between providers Care Coordination & Management Johnston 11

12 Collaboration Consolidated records Face to face connections Input regarding treatment needs/concerns Providers serve as an on-site resource When medical/psychiatric issues arise help is close by Can schedule back to back appointments to further enhance treatment adherence Must have Mental Health Resources The National Alliance for the Mentally Ill: Substance Abuse and Mental Health Services Administration: National Institute of Mental Health: Depression and Bipolar Support Alliance: %20Providers/Tools%20and%20Resources/Toolkits/bhtoolkit.pdf Must have Mental Health Resources American Psychiatric Association (2013).Diagnostic and Statistical Manual of Mental Health Disorders 5 th Edition Stephen Stahl (2011). The Prescriber s Guide: Stahl s Essential Psychopharmacology American Psychiatric Association (2006). Psychiatric Practice Guidelines Johnston 12

Results Improved access to mental health services Mentored 10 psychiatric nurse practitioner students from Shenandoah University Timely follow-up Only one patient hospitalized on the BH Unit during

13 Results Improved access to mental health services Mentored 10 psychiatric nurse practitioner students from Shenandoah University Timely follow-up Only one patient hospitalized on the BH Unit during the CCM pilot Patient received prompt f/u after the admission Results CCM Pilot 20% Better Show Rate Total Patients Total Patients New Patients Follow ups Cancelations No shows ineligible Total Visits Series Results Improved patient and provider satisfaction Improved communication with PCPs Decreased burden on volunteer BH staff Decreased waiting times for new patient mental health evaluations Adopted psychiatric practice guidelines Utilized screening tools for tracking psychiatric vital signs Disseminated findings to PCPs in local community Johnston 13

14 Results and Future Directions Improved patient and provider satisfaction o Documented through verbal feedback, patient attendance & treatment adherence Improved communication with PCPs o More progression towards integration is needed Decreased burden on volunteer BH staff o Clinic is completed at 8pm most nights Decreased waiting times for new patient mental health evaluations o Eliminated new patient waiting list Adopted psychiatric practice guidelines o BH providers need more education on medical treatment protocols Utilized screening tools for tracking psychiatric vital signs o Progression toward an electronic medical record is needed Disseminated findings to PCPs in local community Conclusions Regarding Integrated Care Better coordination of care Mind and body connection More likely to keep appointments where multiple issues are being addressed Greater comfort discussing mental health issues Established relationship with primary care provider Less stigma walking into primary care setting then mental health setting Policy Barriers o Physical health and Mental health funding streams o Difficulty of sharing information due to HIPAA regulations (progress notes) Organizational Barriers o Shortage of mental health professionals o Limited communication between medical and mental health providers o Lack of agreement between medical and mental health providers Johnston 14

Clinical Barriers o Traditional separation of mental health issues from general medical issues o Lack of awareness of mental health screening tools in the primary care setting o Physicians' limited

15 Clinical Barriers o Traditional separation of mental health issues from general medical issues o Lack of awareness of mental health screening tools in the primary care setting o Physicians' limited training in psychiatric disorders and their treatment Financial Barriers o Lack of insurance parity for psychiatric disorders o Medicaid's low payment rates o Billing restrictions Sustaining the CCM Funding Issues o o o The clinic does not meet criteria as a federally qualified health center The Medicaid issue in Virginia Funding cuts from major contributors Solutions o o The local university has agreed to continue the pilot because it is consistent with community outreach goals and is a valuable clinical site Serves as a model to encourage local PCPs to consider developing CCMs o o o Key Points CCMs are an effective way to provide patient-centered care. Interpretation of the model can vary depending on the practice size and setting. Challenges to developing and sustaining CCMs can best be addressed by engaging key stakeholders and utilizing creative funding strategies. References Bower, P., Knowles, S., Coventry, P. A., & Rowland, N. (2011). Counseling for mental health and psychosocial problems in primary care. In The Cochrane Collaboration & P. Bower (Eds.), Cochrane Database of Systematic Reviews. Chi Chester, UK: John Wiley & Sons, Ltd. Retrieved from Buxton, J. A., Chandler-Altendorf, A., & Puente, A. E. (2012). A novel collaborative practice model for treatment of mental illness in indigent and uninsured patients. American Journal of Health-system Pharmacy. 69(12), doi: /ajhp Colton, C. W. & Manderscheid, R.W. (2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease. Retrieved from Donabedian, A. (2005). Evaluating the Quality of Medical Care. The Milbank Quarterly, 83(4), doi: /j x Goodell, S., Druss, B. G., & Walker, E. R., (2011). Mental disorders and medical co-morbidity: Research synthesis report No. 21. Robert Wood Johnson Foundation. Retrieved from Grella, C. E., & Stein, J. A. (2006). Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders. Psychiatric Services, 57(7), doi: /appi.ps Johnston 15

16 References Grogan-Kaylor, A. (2012). Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-analysis. American Journal of Psychiatry, 169(8), 790. doi: /appi.ajp Heath, B., Wise Romero, P., & Reynolds. K. (2013). Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, D.C.SAMHSA-HRSA Center for Integrated Health Solutions. Hostetter, M., & Klein, S. (2012) Quality Matters: Helping Patients Make Better Treatment Choices with Decision Aids, The Commonwealth Fund. Retrieved March 12, 2013 from November/In-Focus.aspx Keyes, C. L. M., & Simoes, E. J. (2012). To flourish or not: positive mental health and allcause mortality. American Journal of Public Health, 102(11), doi: /ajph Loeb, D. F., Bayliss, E. A., Binswanger, I. A., Candrian, C., & degruy, F. V. (2012). Primary Care Physician Perceptions on Caring for Complex Patients with Medical and Mental Illness. Journal of General Internal Medicine, 27(8), doi: /s National Alliance on Mental Illness (NAMI). (2010). Virginia Statistics. Retrieved from usepreview=yes/ References Pomerantz, A. S., Shiner, B., Watts, B. V., Detzer, M. J., Kutter, C., Street, B., & Scott, D. (2010). The White River model of co-located collaborative care: A platform for mental and behavioral health care in the medical home. Families, Systems, & Health, 28(2), doi: /a Sieber, W. J., Miller, B. F., Kessler, R. S., Patterson, J. E., Kallenberg, G. A., Edwards, T. M., & Lister, Z. D. (2012). Establishing the Collaborative Care Research Network (CCRN): A description of initial participating sites. Families, Systems, & Health, 30(3), doi: /a Srivastava, R. (2007). The healthcare professional s guide to clinical cultural competence. Toronto: Mosby Elsevier. Substance Abuse and Mental Health Services Administration (SAMHSA). (2010). Results from the 2009 National Survey on Drug Use and Health: Mental Health Findings, Office of Applied Studies, NSDUH Series H-39, HHS Publication No. SMA Retrieved from Substance Abuse and Mental Health Services Administration (SAMHSA). (2013). SAMSHA HRSA Center for Integrated Health Solutions: Screening Tools. Retrieved from United States Health and Human Services Association. (2013) Patient Satisfaction Survey. Retrieved from nsurvey.html References Unutzer, J., Harben, H., Schoenbaum, M., & Druss, B., The collaborative care model: An approach for integrating physical and mental health care in Medicaid health homes. Health Home Information Resource Center. Retrieved from Assistance/Health-Homes-Technical-Assistance/Downloads/HH-IRC-Collaborative-5-13.pdf Verité Healthcare Consulting, (2010). Community health needs assessment: Valley Health. Retrieved from VH%20CHNA%20Report%20Section%201%20(August%202%202010).pdf Wang, P. (2006). Changing Profiles of Service Sectors Used for Mental Health Care in the United States. American Journal of Psychiatry, 163(7), doi: /appi.ajp World Health Organization (WHO). (2009). Mental health poverty and development. Retrieved from Zaccagnini, M., & White, K. W. (2014). The doctor of nursing practice essentials: a new model for advanced practice nursing. (2nd ed.). Burlington, MA: Jones & Bartlett Learning. Zimmerman, M., Young, D., Chelminski, I., & Dalrymple, K. (2010). How can you improve quality without measuring outcome? Getting from here to there. Primary Psychiatry, Retrieved from Image from slide 20 found in Clipart Johnston 16

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