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Welcome to Welcome to Integrated Behavioral Health in Primary Care SettingsIntegrated Behavioral Health in Primary Care SettingsPresented by Peter Van Houten MD, Medical DirectorPresented by Peter Van Houten MD, Medical DirectorMichael Johnson PhD, LCSW, Behavioral Health DirectorMichael Johnson PhD, LCSW, Behavioral Health Director

The presentation will begin shortly.This webinar will be recorded and used for future presentations.

Funds for this webinar were provided by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) with the American Recovery

and Reinvestment Act (ARRA) funding for the Retention and Evaluation Activities (REA) Initiative.

This webinar is offered by San Francisco Community Clinic Consortium and the California Statewide AHEC program in partnership with the Office of Statewide Health Planning and

Development (OSHPD), designated as the California Primary Care Office (PCO).

WELCOME EVERYONE!Thank you for joining us today

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Peter Van Houten MD, Medical DirectorMichael Johnson PhD, LCSW, Behavioral

Health Director

Sierra Family Medical ClinicNevada City, CA(530) 292-3478

www.sierraclinic.org

YOUR PRESENTERSYOUR PRESENTERS

PeterPeter MichaelMichael

WHAT IS INTEGRATED CARE?WHAT IS INTEGRATED CARE?

The systemic coordination of physical and behavioral care.

It allows patients to feel that for almost any problem, they have come to the right place.

It creates a holistic and seamless approach as opposed to a fragmented system with obstacles and barriers to care.

WHAT IS INTEGRATED CARE?WHAT IS INTEGRATED CARE?

A model of the “medical home”Represents a “partnership” approach

to primary care Represents a shared learning

approach for all involved IBHP: “Integrated Behavioral Health

Project” is an excellent resource (www.ibhp.org)

Sierra Family Medical ClinicSierra Family Medical Clinic

It’s very rural

WHY INTEGRATE BEHAVIORAL HEALTH AND PRIMARY WHY INTEGRATE BEHAVIORAL HEALTH AND PRIMARY CARE?CARE?Surgeon General’s “Report on Mental

Health” (1999) – acknowledged the role of primary care in the provision of mental health carePresident’s “New Freedom Commission

on Mental Health” (2003) promoted integration

Secretary’s “National Advisory Committee on Rural and Human Services” (2004) called for integration

WHY INTEGRATE BEHAVIORAL HEALTH AND PRIMARY WHY INTEGRATE BEHAVIORAL HEALTH AND PRIMARY CARE?CARE?

“Institute of Medicine” (2005) called for integration

The “Health Resources Services Administration” (HRSA) designated the integration of behavioral health as a desired service to be provided by Federally Qualified Health Centers (FQHC’s) (2004 and 2006)

BOTH EXPERIENCE AND RESEARCH ILLUSTRATEBOTH EXPERIENCE AND RESEARCH ILLUSTRATEApproximately 70% of all visits in

primary care involve psychosocial factors. (Gater, et al, 1991)

Primary care providers are the de facto mental health and addiction disorder providers for over 70% of the population. (Kessler, et al, 1994)

Close to 80% of patients with depression go to their primary care physician first.

BOTH EXPERIENCE AND RESEARCH ILLUSTRATEBOTH EXPERIENCE AND RESEARCH ILLUSTRATEAn increasing number of primary care

providers have become experienced and skilled in the use of psychotropics

67% of psychoactive agents are prescribed by PCP

80% of antidepressants are prescribed by PCP

92% of all elderly patients receive mental health care from their PCP (Kirk Strosahl, Mountain view Consulting, 2003)

BOTH EXPERIENCE AND RESEARCH ILLUSTRATEBOTH EXPERIENCE AND RESEARCH ILLUSTRATE

Emotional disorders are factors in poor health, compliance, and levels of health care literacy.

Examples are many: DM (Stress, Depression), Respiratory (Anxiety), Cardio (Anxiety, Depression), CA (Depression, Anxiety), Kidney Disorders (OBS, Depression), Hepatic (OBS, Depression)

BOTH EXPERIENCE AND RESEARCH ILLUSTRATEBOTH EXPERIENCE AND RESEARCH ILLUSTRATE

Primary care has become the first line of treatment for mental disorders.

Integrated settings reduce the stigma of seeking mental health care.

A review of the expected changes in DSM show a shift to the Behavioral/Comorbid physical aspects of diagnosis.

BOTH EXPERIENCE AND RESEARCH ILLUSTRATEBOTH EXPERIENCE AND RESEARCH ILLUSTRATEMortality averages, for both SMI and SPMI

patients are 25 years earlier than the general population.

60% of premature death in schizophrenic individuals is due to cardiovascular, pulmonary and infectious disease.

Psychosocial distress corresponds with morbidity and mortality risk.

The medical community is becoming more accepting of integrated care.

BOTH EXPERIENCE AND RESEARCH ILLUSTRATE BOTH EXPERIENCE AND RESEARCH ILLUSTRATE Depending upon the county: ¼ to ¾ of

previous community mental health clients in California are now seen in primary care where their service needs are addressed.

Contracts and MOU examples are in IBHP data.

In a few frontier counties this figure is much higher (Integrated Tele-Psychiatry and Tele-Behavioral Health fill the gap)

WHERE DOES IBH “FIT” INTO THE SYSTEM OF WHERE DOES IBH “FIT” INTO THE SYSTEM OF CARE ?CARE ?

Behavioral health is a basic component of general health care

Seamless access to BH servicesThe BH Practioner is a member of the

primary care team

CONTINUUM OF INTEGRATIONCONTINUUM OF INTEGRATION

Model AttributesSeparate space &

model 1 – 1 referral

relationship Co-locationCollaborative careFully integrated

Traditional BH model

Some exchangeOn site, separate

teamShared casesPC team member

Desirability

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INTEGRATED BEHAVIORAL HEALTH MISSIONINTEGRATED BEHAVIORAL HEALTH MISSIONProvide access to behavioral health services

and improve the physical and emotional well-being of our patients.

Improve/manage the behavioral health of the population through the integration of behavioral health care services into the daily provision of primary care.

Use prevention and wellness strategies to prevent the onset of a mental disorder or prevent recurrence.

INTEGRATED BEHAVIORAL HEALTH MISSIONINTEGRATED BEHAVIORAL HEALTH MISSION

Simultaneous focus on health and behavioral health issues

Improve adherence and compliance and build upon primary care team interventions

Example: diabetes careSupport self management and health

care literacy

CSRHA Rural Champions 2009CSRHA Rural Champions 2009

HOW DOES IT WORK?HOW DOES IT WORK?Close proximity of the teamEncounters are vulnerable to interruption

and are typically 15-30 min in lengthA schedule is no longer a schedule and the

average patient load per day is 9-12 (goal is 10)

Treatment encompasses behavioral aspects of healthcare: chronic physical and mental illness, pain management, and substance abuse

HOW DOES IT WORK?HOW DOES IT WORK?Behavioral interventions support

medical interventions within the behaviorist's scope of practice.

Interventions reflect an understanding of the mind-body components of disease: DM, pulmonary, cardiac, endocrine, CA, orthopedic, pediatric, geriatric, physical and psychological trauma, organic disorders of the brain, pain management, care-giver stress, grief and loss, the loss of primary functioning associated with chronic illness, and all aspects of chemical dependency and recovery.

HOW DOES IT WORK?HOW DOES IT WORK?The clinician/behaviorist must

understand (within scope of practice) psychopharmacology and pharmacology associated with pain management.

Understand and apply all DSM disorders for all ages and make immediate and secondary Dx.

Make on-going risk assessments Crisis intervention

HOW DOES IT WORK?HOW DOES IT WORK?

Interventions include, but are not limited to: •CBT•DBT•Narrative•Imagery•Stress reduction•EMDR•Mind-body interventions•Psycho-education•Solution focused•Developmental•Acceptance•And most important, compassion.

HOW DOES IT WORK? “THE WARM HAND OFF”HOW DOES IT WORK? “THE WARM HAND OFF”

What is a “warm hand off”?Benefits from the PCP perspective.80% return rate as opposed to 40% from

a traditional “cold hand off”.Same-day visits and reimbursement.

THE “WARM HAND OFF”THE “WARM HAND OFF”Benefits from the BH perspectiveExam room behaviors: intense, open,

honest, more informationDescriptive and honest language with a

motivational perspective helps connect and avoid labels

Perspective and flexibility: return is the goal

THE “WARM HAND OFF”THE “WARM HAND OFF”Basic components:

Provider preps and introduces the patient to the concept and goals

Excuses self to get the behaviorist and leaves patient with a questionnaire (screen) if necessary.

Provider returns and introduces the behaviorist and reviews screens

Transparency and collaboration

THE “WARM HAND OFF”THE “WARM HAND OFF”Basic components: screens utilized

“Mini” general screen for depression, anxiety, alcohol use, social anxiety and panic disorders.

“PCQ9” for depression (score can be tracked)

“MDQ” for bipolar disorders“Epworth” sleep screenDrug and alcohol screens

THE “WARM HAND OFF”THE “WARM HAND OFF”Behaviorist and patient discuss screen

results, reason patient is here and the behavioral options available.

Language and descriptors are very important at this point. Try not to repeat what has been stated before.

Language examples.Provider returns to collaborate and all

discuss treatment plan.

EXAMPLES OF A “WARM HAND OFF”EXAMPLES OF A “WARM HAND OFF”We have produced a DVD that depicts a

dozen scenarios.www.youtube.com/user/sierrafamilymedical/f

eed

Examples include:Diabetes, Post MI, insomnia, smoking

cessation, obesity, depression, anxiety, bipolar, grief, chronic pain, and substance abuse.

LESSONS LEARNEDLESSONS LEARNEDAddress political/organizational issuesHave strategic visionLink with other community servicesAddress any philosophical resistanceTrain and mentor new providersFinancing strategies that will sustain

budget stabilityBusiness modelFunding sources

LESSONS LEARNEDLESSONS LEARNEDCreate administrative infrastructure

that includes IBH (examples)Identify and address training needsUse measurement and performance

indicatorsBe a key player in any county

integration/collaboration efforts

CONCLUSIONCONCLUSIONOther possibilities:

Dental referrals and our experienceTele-behavioral health hand offs and our

experienceMore than 2 providers and specialties in a

hand off

Sierra Family Medical Clinic15301 Tyler Foote Rd.

Nevada City, CA 95959 (530) 292-3478

www.sierraclinic.orgPeter Van Houten, MD pvanhout@earthlink.net

Michael Johnson, PhD, LCSWmjohnson@sierraclinic.orgWendy Barnhart, COO, CCOwbarnhart@sierraclinic.org