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Integrated Behavioral Care: Clinical Systems


Depression is most common mental disorder in primary care. ... Economic analyses indicate primary care is optimal setting for depression care ... – PowerPoint PPT presentation

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Title: Integrated Behavioral Care: Clinical Systems

Integrated Behavioral Care Clinical Systems
  • Parinda Khatri, Ph.D.
  • Director of Integrated Care
  • Cherokee Health Systems

  • Blount, A. Integrated Primary Care The future of
    medical mental health collaboration. 1998.
    W.W. Norten Company New York.
  • Cummings, N.A., ODonohue, W., Hayes, S.C., and
    Follette, V. Integrated Behavioral Healthcare
    Positioning mental health practi8ce with
    medical/surgical practice. 2001. Academic
    Press San Diego.
  • Robinson, P. (1998) Behavioral Health Services in
    Primary Care A new perspective for treating
    depression. Clinical Psychology Science and
    Practice, 5(1), 77-93.
  • McCarthy, R. (1998) Behavioral health Dont
    ignore, integrate. Business Health, August.
  • Strosahl, K. (1996) Confessions of a behavior
    therapist in primary care The odyssey and the
    ecstasy. Cognitive and Behavioral Practice, 3,
  • Strosahl, K. (1996). Primary Mental Healthcare
    New model for integrated services. Behavioral
    Healthcare Tomorrow, October.

Randomized clinical trials indicate that
integrated psychosocial interventions in primary
care are effective in treating psychiatric
disorders Blount, A. Integrated Primary Care
The future of medical and mental health
collaboration. WW Norten New York. 1998.
Clinical Structure of Integrated Care
  • Behavioral health consultation
  • Consultative case management
  • Integrated specialty consultation
  • Collaboration and integration

While we need to be able to think differently to
act differently, we also need to be able to act
differently to think differently.Alexander
Blount, Ed.D. Introduction to Integrated Primary
Care (1998) In Integrated Primary Care The
future of medical and mental health
collaboration, Blount, A. (Ed.) W.W. Norten New
York, p. 17.
Role of Behavioral Health Consultant
  • Management of psychosocial aspects of chronic and
    acute diseases
  • Application of behavioral principles to address
    lifestyle and health risk issues
  • Consultation and co-management in the treatment
    of mental disorders and psychosocial issues

Skills for Behavioral Consultant
  • The ability to understand the biological
    components of health, illness, and disease and
    interaction between biology and behavior
  • An understanding of how cognition, emotion,
    motivation can influence health
  • An understanding of how social and cultural
    factors affect health problems, access to health
    care, and adhering to treatment regimens
  • Knowledge of how to assess cognitive, affective,
    behavior, social, and psychological reactions for
    all common conditions seen in primary care
  • APA Primary Care Psychology Curriculum
    Interdivisional Task Force

The Biobehavioral Continuum
  • A treatment framework for conceptualizing
    relative influence of psychosocial and
    physiological factors in disease.

Psychosocial Influence on Disease
  • Cardiovascular Disease Risk
  • Cancer Disease Progression
  • Pulmonary Diseases Physiological Sensitivity
  • GI Disorders Different Interventions
  • Neurological/Endodrine conditions Exacerebated
    disability and suffering
  • Rheumatological Disorders Multiple levels of
    psychological influence
  • End Stage Renal Disease Disease or depression?
  • Somatization The difficult patient
  • Blount, A. Integrated Primary Care The future
    of medical mental health collaboration. 1998.
    W.W. Norten Company New York.

Important Skills for ALL Providers
  • Learning to speak to each other and the patient
  • Working as team members
  • Solution-focused interviewing
  • Utilizing Brief Interventions

When to consult?
  • As early as possible
  • Problem involves psychosocial factors (e.g.
  • Symptoms are unexplained by medical findings
  • Family issues
  • Adherence
  • Emotional/Relational problem
  • Assessment/Treatment conflict
  • Development/Life transition

Behavioral Health Consultants in Primary Care
  • Consultation with the primary care team
  • Brief consultation with primary care patients
    (1-3 contacts)
  • Programmatic treatment (4-7 contacts)
  • Psychoeducational groups
  • Triage
  • Consultation with medical specialists
  • Educational Services
  • Robinson, P. Behavioral Health Services in
    Primary Care A new perspective on treatment
    depression. Clinical Psychology Science and
    Practice Vol 5, No. 1, 1998.

Clinical Integration Strategies
  • Accurate screening / assessment
  • Appropriate prescribing of medications
  • Clear clinical practice protocols
  • Consistent use of behavioral interventions
  • Consistent use of relapse prevention
    maintenance treatments
  • Optimal use of education based interventions
  • Availability of on-site behavioral health support

Integrated Care at Work
  • Behavioral health care is significant part of
    medical practice (e.g. Post-MI patient may be
    evaluated for depression and social isolation)
  • Behavioral health care is coordinated (e.g. panic
    management skills are reinforced in medical
  • Behavioral health care is the responsibility of
    the primary care team (e.g. monitoring of

Behavioral Health and Medical Provider
  • Curbside consultation
  • Shared written documentation
  • Shared treatment planning and monitering
  • Reinforcement of treatment plan goals and

Provider and Patient Perspectives
Less More
  • Traditional Model
  • Courtesy report of involvement
  • Referral call for info.
  • MHP/PCP support visits
  • Integration Model
  • Meetings between providers and together with
  • Collaborative assessment and treatment planning
  • Unified team in delivery of services

Levels of integrated care
  • Level 1 Consultation and brief targeted
    interventions in medical setting
  • Level 2 Time limited focused interventions in
    medical setting
  • Level 3 Referral for longer term therapeutic

Behavioral Health Contribution in Primary Care
  • Increase recognition of psychological symptoms
    and factors in health
  • Apply Biopsychosocial model
  • Design and implement behavioral health plans
  • Improve medical treatment (e.g. patient adherence
    to medications)
  • Brief assessment, treatment, and consultation

Horizontal and Vertical Integration Strategies
  • Horizontal Integration-- Education and training,
    consultation (in-vivo training), and shared
  • Vertical Integration Specialty consultation,
    critical treatment pathways

Medical Provider Training
  • Assessment and Treatment of Depression
  • Assessment and Treatment of Anxiety
  • Brief Depression Management Strategies
  • Management of Panic Attacks
  • Stages of Behavior Change
  • Sleep
  • Stress Management Strategies
  • Managing the Suicidal Patient
  • Assessment and Management of the Bipolar Patient
    in Primary Care
  • Stump the Chump Sessions with Psychiatrist

Clinical System Strategies for Integration
  • Screening and Identification in Primary Care
    (e.g. Well Child Checks, Red Flag Questions)
  • Systematic assessment, intervention, and
    follow-up management guidelines
  • Evidence based management protocols for target
    groups (e.g. ADHD, Depression, Anxiety, CHD,
    Diabetes, etc.)

Integrated Care in ActionPediatric Clinic
  • BHCs share office with Pediatricians
  • Consultation room in Pediatric Clinic
  • BHCs involved in EVERY Well Child Exam
  • Traditional Therapy on-site
  • Child Psychiatry on-site

Clinical Protocol Well Child Exam
  • Level 1 Screening
  • Ages 0-17 months use Infant Development Review
  • Ages 18 months to five years use Child
    Development Review
  • Ages six to twelve years use Pediatric Symptom
  • Screen mothers of newborns for PPD
  • Informal screen of 4-5 year olds for kindergarten
  • Behavioral intake/DSM IV diagnosis if indicated
    as a result of reported symptomotology.

Clinical Protocol Well Child Exam
  • Levels I and II Psychoeducation
  • Developmental tasks at each age
  • 3-4 specific socio-emotional anticipatory
    guidance topics (handouts developed for ages
  • Basic behavior management skills / single session
    interventions to address specific behavioral
  • Development promotion education based on age
  • Helping parents address academic concerns
  • Basic nutritional information (taken from Bright
    Futures handout given to parent) with education
    about importance of activity and limiting TV/VG
    time (as effort to work toward obesity

Clinical Protocol Well Child Exam
  • Levels II and III Management and Referral
  • Tennessee Early Intervention Services (TEIS) for
    developmental delays.
  • Traditional psychotherapy (do intake in peds and
    then transfer to a therapist)
  • Time Limited intervention with a BHC for 1)
    emotional/ behavioral /parent training/ academic
    issue OR 2) A health status management /health
    behavior change issue.
  • Appropriate community resources
  • Behavioral health care / SA treatment for parent
    or family member
  • School psychologists/psychoeducational evaluation

Integrated Care in Action
  • Treating Depression in Primary Care

Depression in primary care
  • Depression is most common mental disorder in
    primary care.
  • Undetected depression in primary care is
    associated with negative outcomes (e.g. loss of
    functioning and well-being, adverse health,
    decreased productivity)
  • Economic analyses indicate primary care is
    optimal setting for depression care

Integrated Care models for Depression vs. Usual
  • Significant improvements on depression outcome
  • Increased use of active coping strategies
  • Significant improvement in medication adherence
  • Increased adherence to relapse prevention plan at
  • Improved medical provider satisfaction

Education of Medical Providers
  • Consultation
  • Assessment and diagnoses
  • Evidence based interventions
  • Review of critical treatment pathways
  • Brief interventions within medical visit
  • Improving self-management of depression

Clinical Protocol
  • Screening and Identification with Red Flag
  • Follow-up with Patient Health Questionnaire
  • Team Assessment of biological, psychological, and
    social factors
  • Develop Initial Treatment Plan
  • Begin Depression Management Interventions
  • Monitoring
  • Psychiatric Consultation if necessary
  • Referral to Traditional Psychotherapy if

Interventions for Depression in Primary Care
  • Pharmacotherapy
  • Behavioral Activation
  • Cognitive-Behavioral Therapy
  • Exercise
  • Interpersonal Therapy
  • Systems Therapy
  • Solution-focused Therapy

Cognitive/Behavioral and Pharmacological Treatment
  • Psychoeducation for patients and medical
  • Coordination and collaboration between behavioral
    and medical providers
  • Brief Treatment

Brief Cognitive-Behavioral Intervention for
  • Behavioral Activation
  • Cognitive-Restructuring
  • Problem-Solving Skills
  • Coping Skills

Improved clinical outcomes appear to be dependent
on continued on-site presence of behavioral
health staff
Consultation alone is NOT enough
Case Example I Gina
  • Visit 1-Integrated Care visit
  • -Assessment and Diagnoses Panic Disorder with
  • Psychoeducation about Panic attacks (verbal and
  • Cognitive-Behavioral techniques (e.g. abdominal
    breathing, behavioral changes, cognitive

Case Example Gina cont.
  • Consultation with Medical Provider-rule out
  • Medical Visit-for allergies, but psychological
    intervention reinforced
  • Visit 2- Reviewed progress and strategies,
  • Consultation with Medical Provider
  • Visit 3- Significant improvement, maintenance and
    relapse prevention
  • Consultation with Medical Provider
  • 6 week follow-up scheduled

Case Example Melinda
  • 26 year old married Caucasian female
  • Clinical Depression, Recurrent
  • PHQ19 after 3 weeks Paxil 20mg
  • Visit 1- Integrated Care
  • Assessment and Diagnoses
  • Psychoeducation
  • Depression Management strategies (behavioral
    activation, exercise, coping skills)

Case Example Melinda cont.
  • Consultation with Medical Provider
  • Phone Follow-up Check-in
  • Visit 2- Review progress, problem-solve on
    strategies and coping skills
  • Consultation with Medical Provider
  • Visit 3-PHQ2, Significant improvement,
    maintenance, relapse prevention strategies
  • Consultation with Medical Provider

Case Example Sally
  • 45 married Caucasian female
  • Visit 1-Integrated Care visit
  • Assessment and Diagnoses Dyspaernia and PTSD
  • Psychoeducation
  • Discuss treatment options

Case Example Sally
  • Consultation with Medical Provider
  • Visit 2 Behavioral techniques, referral to
    longer term counseling
  • Consultation with Medical Provider
  • Visit 3-Integrated Care-follow-up
  • Consultation with Medical Provider

Case Example Tom
  • 55 yo married male, Diabetic referred for
    noncompliance to dietary/monitoring regimen
  • Visit 1-identified pt. Depressed and out of
    control. Behavioral activation to increase
    self-efficacy, develop daily diabetes
    self-management plan
  • Consultation with PCP/nurses
  • Medical visit-reinforce behavioral
    activation/self-efficacy, reviews progress in
    self-management plan
  • Follow-up phone call
  • Visit 2-Review progress/monitoring

Case Example Pam
  • 57 yo married female, Mammogram refusal
  • Integrated care visit 1 Assessment Grief and
    Intervention (Grief work/coping skills)
  • Follow-up Visit 2 Problem-solving and Coping
  • Follow-up Visit 3

Case Example Mindy
  • 10 year old female
  • Medical visit-school referred for ADHD
  • Visit 1-Integrated Care Assessment
  • Consultation with Medical Provider
  • Talk to school teacher/psychologist
  • Visit 2-Family session
  • Talk to school psychologist
  • Visit 3 Integrated care/Follow-up

Case Example Jeff
  • 35 yo married male, chronic headaches
  • Integrated Visit 1 Assessment and Identification
    of Behavioral factors (patient homework)
  • Consultation with provider Care plan (e.g. meds,
    diet change, behavioral strategies)
  • Visit 2 Muscle Relaxation training, management
    of emotional and behavioral triggers
  • Medical Visit Care plan reinforced
  • Visit 3 Review and refine maintenance strategies