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The 15minute hour: Providing Therapy in a Primary Care Clinic


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Title: The 15minute hour: Providing Therapy in a Primary Care Clinic

The 15-minute hour Providing Therapy in a
Primary Care Clinic
  • North Carolina Counseling Association Conference
  • February 22, 2008
  • Stephen Snow, PhD, LPC
  • Buncombe County Health Center
  • RHA Health Services, Inc.
  • Asheville, N.C.

  • MA, Counseling, UNC Charlotte, 2003
  • PhD, Counseling, UNC Charlotte, 2005
  • Private practice, 2003-present (specialties
    Family Violence and complex trauma in children
    and adults)
  • Integrated Care therapist, Buncombe County Health
    Center Primary Care Clinic, July 2007-present
  • Previous careers journalism and

  • Compare traditional therapy to therapy in a
    primary care setting.
  • Discuss collaborative process with primary care
  • Look at the models and stimulants behind this
    mental health approach.
  • Look at the patient populations.
  • SWOT discussion

Traditional Therapy v. Primary Care
  • Time comparison slow v. fast
  • Assessment processes quick, definitive
  • Consultative model know what you think
  • Brief modalities intervention as band-aid or
  • Number of clients daily 5 in private practice
    15 in integrated care setting

Collaborative Process
  • Mix of medical clinicians MDs, DOs, PAs, NPs,
    and nurses
  • Equality in roles expertise must be owned and
  • Social Work role knowing resources matters
  • Speed is essential, but not always. Knowing when
    to slow down.

Why Link Primary Care and Mental Health Care?
  • Primary care is where many people get their
    mental health treatment.
  • Ease of connection to therapists raises
    likelihood of treatment.
  • Costs are reduced.
  • Following patients provides greater likelihood of
    maintaining medical/emotional regimens.

Primary Care by Numbers
  • Surgeon General Report says that 20 of the U.S.
    population has a mental health diagnosis
  • National rate of depression is 16
  • 80 of clients prefer to get their behavioral
    health services from their regular medical
  • Surgeon General report says 15 of US adult
    population use mental health services in any
    given year

Primary Care by Numbers
  • 40-50 of people who get alcohol, drug or mental
    health treatment get it from their primary care
  • Study (Simon, 1992) suggests that, on average,
    primary care patients with even mild levels of
    depression use two times more health care
    services annually than their non-depressed
  • 6-10 of patients in primary practice have major
  • Nearly 70 of all health care visits have
    primarily a psychosocial basis (Fries, et. Al
    1993, Shapiro et al., 1985)
  • --

Primary Care by Numbers
  • 50 of mental health care is delivered solely by
    primary care physicians
  • 67 of all psychopharmacological drugs are
    prescribed by primary care physicians
  • Total economic cost of depression has been
    estimated at more than 83 billion/year in the
  • 90 of the 10 most common complaints in primary
    care setting have no organic basis
  • --

Common Problems
  • The 10 most common problems brought to adult
    primary care are
  • back pain
  • shortness of breath
  • Insomnia
  • abdominal pain
  • numbness
  • chest pain
  • fatigue
  • Dizziness
  • Headache
  • Swelling
  • Kroenke, K. Mangelsdorff, A. D. (1989).
    Common symptoms in ambulatory care
  • Incidence, evaluation, therapy and outcome.
    American Journal of Medicine, 86, 262-266.


Levels of Integrated Care
  • Doherty, McDaniel and Baird (1995) describe five
    levels of integrated care, originally published
    in Family Systems Medicine (13, 283-298). The
    journal is now named Family, Systems and Health
    The Journal of Collaborative Family Health Care.
    The following five slides are adapted from this

Level I Minimal Collaboration
  • Description Mental health and other health care
    professionals work in separate facilities, have
    separate systems, rarely communicate about cases.
  • Where practiced Most private practices and
  • Handles adequately Cases with routine medical or
    psychosocial problems that have little
    biopsychosocial interplay and few management
  • Handles inadequately Cases that are refractory
    to treatment or have significant biopsychosocial

Level II Collaboration at a Distance
  • Description Providers have separate systems at
    separate sites, but some communication about
    shared patients, mostly by phone and letters and
    driven by specific issues. Mental health and
    other health professionals see each other as
    resources, but operate in their own worlds, have
    little shared responsibility and little
    understanding of each other's cultures. There is
    little sharing of power and responsibility.
  • Where practiced Settings where there are active
    referral linkages across facilities.
  • Handles adequately Cases with moderate
    biopsychosocial interplay, for example, a patient
    with diabetes and depression where the management
    of both problems proceeds reasonably well.
  • Handles inadequately Cases with significant
    biopsychosocial interplay, especially when the
    medical or mental health management is not
    satisfactory to one of the parties.

Level III Basic Collaboration On-Site
  • Description Mental health and other
    professionals have separate systems but share a
    facility. They communicate regularly about
    patients, mostly by phone or letters.
    Occasionally meet face to face because of
    proximity. They appreciate each other's roles,
    and may have a sense of being part of a larger,
    though ill-defined team, but do not share a
    common language or much understanding of each
    other's worlds. Physicians have much more power
    over case management decisions than other
    professionals, who may resent this.
  • Where practiced HMO settings and rehabilitation
    centers where collaboration is aided by
    proximity, but where there is no systemic
    approach to collaboration and where
    misunderstandings are common. Also medical
    clinics that employ therapists but engage
    primarily in referral-oriented collaboration
    rather than systematic mutual consultation and
    team building.
  • Handles adequately Cases with moderate
    biopsychosocial interplay that require occasional
    face-to-face interactions between providers to
    coordinate complex treatment plans.
  • Handles inadequately Cases with significant
    biopsychosocial interplay, especially with
    ongoing and challenging management problems.

Level IV Close Collaboration in a Partly
Integrated System
  • Description Mental health and other health care
    professionals share sites and have some common
    systems, such as scheduling or charting. There
    are regular face-to-face interactions about
    patients, consultation, coordinated treatment
    plans for difficult cases, and a basic
    understanding and appreciation for each other's
    roles and cultures. There is a shared allegiance
    to a biopsychosocial/systems paradigm. The
    pragmatics are still sometimes difficult,
    team-building happens only occasionally, and
    there may be operational problems such as co-pays
    for mental health but not for medical services.
    There are likely to be unresolved but manageable
    tensions over medical physicians' greater power
    and influence on the collaborative team.
  • Where practiced Some HMOs, rehabilitation
    centers, and hospice centers that have worked
    systematically at team building. Also some family
    practice training programs.
  • Handles adequately Cases with significant
    biopsychosocial interplay and management
  • Handles inadequately Complex cases with
    multiple providers and multiple larger systems,
    especially when there is the potential for
    tension and conflicting agendas among providers
    or triangulation on the part of the patient or

Level V Close Collaboration in a Fully
Integrated System
  • Description Mental health and other health care
    professionals share sites, vision, and systems in
    a seamless web of services. Providers and
    patients have the same expectation of a team
    offering prevention and treatment. All
    professionals are committed to a
    biopsychosocial/systems paradigm and have an
    in-depth understanding of each other's roles and
    cultures. Regular collaborative meetings are
    held to discuss both patient and collaboration
    issues. There are conscious efforts to balance
    power and influence among the professionals
    according to their roles and expertise.
  • Where practiced Some hospice centers and other
    special training and clinical settings.
  • Handles adequately The most difficult and
    complex biopsychosocial cases with challenging
    management problems.
  • Handles inadequately Cases where the resources
    of the health care team are insufficient or where
    breakdowns occur in the collaboration with larger
    service systems.

Pathology v. Wellness
  • There is a tension in any of the models between a
    psychopathological approach and a wellness
    approach. Even within the BPS framework, the
    primary accent often is on a medical model. It
    sometimes can be challenging to find acceptance
    for non-medically driven treatments in a medical

A Four-Quadrant Model for Defining Treatment
  • This treatment definition approach is described
    in Minkoff, K. (2002). Dual diagnosis an
    integrated model for the treatment of people with
    co-occurring psychiatric and substance disorders
    in managed care systems. Presented to National
    Council for Community Behavioral Healthcare
    conference, March 2002.

The Four-Quadrant Model
  • Low BH-low physical health complexity/risk,
    served in primary care with BH staff on site
    very low/low individuals served by the Primary
    Care Physician. BH staff serves those with
    slightly elevated health or BH risk.
  • Example A non-complicated ailment, such as the
    flu, with no emotional components.
  • High BH-low physical health complexity/risk,
    served in a specialty BH system that coordinates
    with the PCP.
  • Example Event-oriented depression, anxiety.

The Four-Quadrant Model
  • Low BH-high physical health complexity/risk,
    served in the primary care/medical specialty
    system with BH staff on site in primary or
    medical specialty care, coordinating with all
    medical care providers including disease
  • Example COPD.
  • High BH-high physical health complexity/risk,
    served in both specialty BH and primary
    care/medical systems in addition to BH case
    manager, there may be disease manager. The two
    work at a high level of coordination with all
    team members.
  • Example Uncontrolled diabetes and somatization
    in a person with an Axis II DX.


All of the other reindeer USED to laugh and call
him names.
The Five Interventions
  • According to a study by Lee Schwamm of Duke
    University (1995), when a patient comes to the ER
    with symptoms of a stroke, there are five basic
    interventions every physician has been trained to
    do. These are considered best practice for
    immediate stroke intervention that carry the
    greatest potential for saving a persons life in
    this particular medical crisis.

Best Practice for Stroke
  • Patient given aspirin upon arrival at hospital
  • Patient continues to take aspirin after leaving
    the hospital
  • Patient given beta blocker upon arrival at
  • Patient prescribed beta blocker when he leaves
    the hospital
  • Patient prescribed ACE inhibitor before leaving
    the hospital
  • -Munger, R. (2008). The power of BRIEF
    behavioral health intervention in integrated
    care. Clinical Update Conference, Pinehurst, NC

Duke University Study
  • About 40 of the time, almost half the time, the
    doctors in the ER did not do all five things.
  • The traditional assumption is that if doctors
    know what works, they will provide it.
  • They had neglectedin most cases, simply
    forgottenthe very simple treatments that can
    make the biggest difference in how patients feel
    or how long they live.
  • Focus on basics first go with what works.
  • Imagine the questions medical clinicians dont
    ask about mental health, for which they havent
    been trained.
  • -Munger, R. (2008). The power of BRIEF behavioral
  • intervention in integrated care. Clinical Update
    Conference, Pinehurst, NC

Primary Care Visit How it Works
  • When physician suspects mental health issue,
    therapist is paged.
  • Brief discussion precedes handoff to therapist.
  • Therapist is introduced as a part of the
    health-provision team.
  • Following initial contact, therapist consults
    with and recommends to physician.
  • Therapist follows patient and maintains contact
    with physician about progress.
  • Other models are variations on this approach

Elements of Treatment
  • Triage/screening
  • Assessment brief intervention
  • Consultation/recommendation
  • Follow-up therapy/case management
  • Referral/linkage to other community resources
  • Ongoing support/medication management

  • Physician suspects mental health issue, pages
  • Therapist interviews patient, combining
    supportive counseling as part of process
    motivational interviewing, as necessary.
  • Therapist does intervention, as necessary.
  • Recommendation to patient and to physician for
    next steps.

  • Assess for Suicidality/lethality (SI/HI)
  • Assess for specific conditions (depression,
    anxiety, trauma, SA, etc.)
  • Time varies, often lt10 minutes
  • Assess current medication
  • Assess likelihood of follow-through
  • Use of BHQ instrument

Behavioral Health Questionnaire (BHQ)
  • One-page, two-sided brief assessment
  • Depression questions
  • Nine weighted questions, including SI/HI
  • CAGE
  • Four-question Substance Abuse measure
  • Bipolar questions
  • Mania, irritability, problems because of periods
    of hyper-alertness
  • Anxiety questions
  • General immediate symptoms
  • Domestic/family violence questions
  • Still to be designed

  • Consult with physician prior to triage
  • Physician provides snapshot of concern or
  • Following triage, consult again with physician,
    confirming suspicions, providing alternate DX or
  • Make firm recommendation for TX
  • Requires understanding of medication

Follow-up Therapy
  • If the patient is amenable and there is time
    available, there can be a more immediate, brief
    intervention as part of the triage. This can take
    five to 90 minutes.
  • A follow-up appointment can be made for the next
    PC visit.
  • A follow-up appointment can be made with
    therapist, depending on availability, time,
    patient need, etc.
  • Telephone therapy also is a follow-up modality.

  • Patients may need access to other services
    housing, Medicaid, food stamps, transportation,
  • Patients may need referral for specialized care
    psychiatric evaluation, community support, SA
    treatment, long-term therapeutic support.

Ongoing Support
  • Patients come to clinics for their primary
    medical care. An obvious time to reconnect and
    follow up.
  • Telephone support. Case management is an
    important part of follow-up.
  • Assisting with medication management and medical

Behavioral Health v. MH
  • Behavioral health is about changing behavior.
    Uncontrolled diabetes is an example. An HgA1c
    (long-term blood sugar measure) reading above 6
    is not good 13-14 could begin affecting
  • What are the barriers for this person to being
    able to manage this illness?
  • What will patient agree to do differently to
    change behavior?

Mental Health v. BH
  • Mental health issues in public health often are
    more complex. A woman comes in for treatment of
    anxiety and depression. During the interview, she
    reveals significant child sexual abuse, that her
    mother had schizophrenia and her father died two
    years ago and she has never addressed it. Simply
    addressing anxiety and depression is not enough
    for her.

Depression Study
  • Buncombe Countys Health Center took part in a
    study of treating depression in primary care in
  • 27 of patients screened positive for depression.
  • Results included improved patient compliance,
    reduced depression severity, improved general
    health, decreased disability, better functioning,
    enhanced satisfaction, lower overall costs.

What Were the Results?
Increase in Mental Functioning over Time
  • Decrease in
  • Depression
  • over time

Fewer missed work days in Past 3 Months for
Emotional Reasons
  • -- adapted from presentation in 2006 by Susan
    Mims, Buncombe County Medical Director

Interest inIntegrated Care
  • Insurance companies are looking for faster
    turn-around and lowered costs relating to all
    health care.
  • Since most physical problems have an emotional
    base or connection, connecting the two makes
  • HMOs, etc., are more comfortable with
    evidence-based/manualized approaches to
  • Divert treatment from higher-cost venues, such as
    ERs, in-patient care
  • Desire for greater accountability and also for
    more science-based or evidence-based treatments
    that have shorter and more predictable timelines.

Interest inIntegrated Care
  • Improved outcomes for behavioral change
  • Better continuity of care
  • Improved overall health because patients are
    being tracked and monitored
  • No wrong door for treatment
  • Reduced stigma for emotional distress
  • Mind-body synthesis in approaching care reflects
    more sophisticated understanding of medicine and

Primary Care Populations
  • Middle-class primary care. Family practice
    medicine is the front line of medical care in the
  • Indigent care. Public health. Medicaid/Medicare/un
  • SPMI (serious and persistent mental illness)
  • Chronic physically ill chronic pain, diabetes
    (I II), COPD, etc.

BCHC Asheville, N.C.
  • 36,000-40,000 patient visits annually
  • 12 medical clinicians
  • 2 integrated care clinicians
  • Safety net for indigent care in Buncombe County,
    plus all public health functions
  • Unusual for public health department to provide
    primary care in N.C.

Public Health Population
  • Largely indigent, some homeless, little money,
    little education, disorganized, chaotic lives
  • Chronic, complex physical and mental
  • Somatized illness
  • Trauma, grief, depression, anxiety, DV
  • Diabetes, COPD, substance abuse, Hep C

Low-Income Patients
  • Living in poverty is a health risk. The stresses
    of the lives of people in poverty take a greater
    toll on their bodies than is true for people with
    adequate financial resources.
  • Low-income and underserved populations are less
    likely than the general public to accept a mental
    health definition of their problem. If they do
    accept a referral for mental health services,
    they have much greater difficulty with travel and

Low-Income Patients
  • Garrison, et. al., (1992), in a study in
    Springfield, MA, found that while low income
    patients have higher levels of psychosocial
    needs, medical providers are less likely to
    address psychosocial needs in this population
    than in more affluent populations.
  • Lower institutional trust, clinicians lack of
    assertive treatment.
  • Physicians were more likely to try to deal with
    parents concerns if the payment type was
    anything except Medicaid and more likely to try
    to refer Medicaid patients to specialty mental
    health services.
  • Garrison, W., Bailey, E., Garb, J. Ecker, B.
    (1992). Interactions between parents and
    pediatric primary care physicians about
    children's mental health.  Hospital Community
    Psychiatry 43 489-493.

Public Health Population
  • Most common issues presented
  • Unresolved grief
  • Physical and sexual trauma in childhood
  • Anxiety/depression/panic
  • Bipolar disorder
  • Chronic pain
  • Axis II
  • Eating disorders
  • Somatized disorders

What is Treatment?
  • Symptom relief the medical model v. the wellness
  • Medicine often is less about cure than it is
    about symptom management. Medications can help
    with symptoms. SSRIs, mood stabilizers, etc.
  • Behavioral change v. insight-based change
  • Manualized care can more easily address behavior
    modification issues but is less useful when it
    comes to deeper, chronic distress. CBT can help
    with depression or managing anxiety, much less so
    with such issues as chronic trauma and unresolved

Barriers, Conflicts
  • Does integrated care foster dependence?
  • Is the MH infrastructure adequate to serve needs?
  • Relationship to clinicians
  • Chaotic patients often unable to maintain
    treatment regimens
  • Difficulty in tracking patients
  • Med-seeking patients pain, anxiety

Some Challenges
  • North Carolina mental health reform in chaos
  • Rising numbers of uninsured adds stress to system
  • Lack of therapy guidelines (evidence-based)
  • Legal barriers to communication among providers
  • Organizational and professional culture
    differences between PC and BH
  • Clinical and fiscal separation of physical and
    mental health care
  • -- adapted from presentation in 2006 by Susan
    Mims, Buncombe County Medical Director

Some Pluses
  • High-quality care delivered in a convenient
  • Screening identifies people who may not have
    otherwise sought services
  • Integrated care reduces stigma
  • Improved mental health improves physical health
  • Preventive and early-intervention care saves
  • -- adapted from presentation in 2006 by Susan
    Mims, Buncombe County Medical Director


Dear Santa, If you leave a new bike under the
tree, I will give you the antidote to the poison
I put in the milk. Timmy
  • L.S./S.M. Bipolar-disordered/dually diagnosed
  • J.H. Depressed man with chronic illnesses
    (depression, COPD, diabetes)
  • S.H. Woman with trauma, anxiety, depression and
    unresolved grief
  • P.B. Man with schizophrenia symptoms
  • J.B. Chronic back pain, depression, Hep C,
    med-seeking behavior

SWOT Issues
  • One-stop treatment v. does diversion actually
    create system dependence?
  • Collaboration more likely to produce positive
  • Adequacy/accuracy of DX v. cost savings
  • Adequacy of follow-up by both patient and
  • Availability/adequacy of resources in the
    community v. crisis in N.C. mental health
  • Short-term mentality for long-term problems can
    interfere with appropriate TX
  • Biopsychosocial/spiritual approach provides a
    more holistic approach to care


Just plain nuts!
Implications for NCCA
  • This is a training issue few institutions offer
    any training in integrated care approaches to
  • This is a potential internship/career path.
  • There is some downward pressure on this area
    professionally some people are saying that
    people with a bachelors degree can do the work
    with equal adequacy.
  • This is not going away, and will affect private
    practices, school-based work, agencies and health
    care clinics.

A Few Resources
  • Books
  • Blount, A. (1998). Integrated primary care The
    future of medical and mental health
    collaboration. Norton New York
  • Gatchel, R Oordt, M. (2003). Clinical health
    psychology and primary care Practical advice and
    clinical guidance for successful collaboration
    American Psychological Association Washington,
  • Web sites
  • http//
  • http//
  • http//
  • http//

A Few More Resources
  • The MacArther
  • Institute for Healthcare Improvement (IHI)
  • RWJ Project Depression in Primary Care
  • National Council for Community Behavioral
  • Developmental Behavioral Pediatrics Online
  • http// ( Financial
  • http//
  • http//
  • http//
  • http//
  • http//
  • http//

The End
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    workshops and consultations, please go to
  • or contact me at
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