Title: The 15minute hour: Providing Therapy in a Primary Care Clinic
1The 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.
2Introduction
- 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
telecommunications
3Overview
- Compare traditional therapy to therapy in a
primary care setting. - Discuss collaborative process with primary care
physicians/clinicians. - Look at the models and stimulants behind this
mental health approach. - Look at the patient populations.
- SWOT discussion
4Traditional 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
catalyst? - Number of clients daily 5 in private practice
15 in integrated care setting
5Collaborative Process
- Mix of medical clinicians MDs, DOs, PAs, NPs,
and nurses - Equality in roles expertise must be owned and
expressed. - Social Work role knowing resources matters
- Speed is essential, but not always. Knowing when
to slow down.
6Why 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.
7Primary 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
provider - Surgeon General report says 15 of US adult
population use mental health services in any
given year - --www.mahec.net/ic
8Primary Care by Numbers
- 40-50 of people who get alcohol, drug or mental
health treatment get it from their primary care
physicians - 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
counterparts - 6-10 of patients in primary practice have major
depression - Nearly 70 of all health care visits have
primarily a psychosocial basis (Fries, et. Al
1993, Shapiro et al., 1985) - -- www.mahec.net
9Primary 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
USA - 90 of the 10 most common complaints in primary
care setting have no organic basis - -- www.mahec.net/ic
10Common 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.
11Hold-Up
12Levels 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
article.
13Level 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
agencies. - Handles adequately Cases with routine medical or
psychosocial problems that have little
biopsychosocial interplay and few management
difficulties. - Handles inadequately Cases that are refractory
to treatment or have significant biopsychosocial
interplay.
14Level 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.
15Level 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.
16Level 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
complications. - 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
family.
17Level 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.
18Pathology 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
environment.
19A Four-Quadrant Model for Defining Treatment
Needs
- 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.
20The Four-Quadrant Model
- QUADRANT I
- 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. - QUADRANT II
- High BH-low physical health complexity/risk,
served in a specialty BH system that coordinates
with the PCP. - Example Event-oriented depression, anxiety.
21The Four-Quadrant Model
- QUADRANT III
- 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
managers. - Example COPD.
- QUADRANT IV
- 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.
22 Justice
All of the other reindeer USED to laugh and call
him names.
23The 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.
24Best 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
hospital - 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
25Duke 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
health - intervention in integrated care. Clinical Update
Conference, Pinehurst, NC
26Primary 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
27Elements of Treatment
- Triage/screening
- Assessment brief intervention
- Consultation/recommendation
- Follow-up therapy/case management
- Referral/linkage to other community resources
- Ongoing support/medication management
28Triage
- Physician suspects mental health issue, pages
therapist. - 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.
29Assessment
- 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
30Behavioral Health Questionnaire (BHQ)
- One-page, two-sided brief assessment
questionnaire. - 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
31Consultation/Recommendation
- Consult with physician prior to triage
- Physician provides snapshot of concern or
confusion - Following triage, consult again with physician,
confirming suspicions, providing alternate DX or
understanding - Make firm recommendation for TX
- Requires understanding of medication
32Follow-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.
33Referral
- Patients may need access to other services
housing, Medicaid, food stamps, transportation,
etc. - Patients may need referral for specialized care
psychiatric evaluation, community support, SA
treatment, long-term therapeutic support.
34Ongoing 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
follow-up.
35Behavioral 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
eyesight. - What are the barriers for this person to being
able to manage this illness? - What will patient agree to do differently to
change behavior?
36Mental 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.
37Depression Study
- Buncombe Countys Health Center took part in a
study of treating depression in primary care in
2000-2004. - 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.
38What 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
39Interest 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
sense. - HMOs, etc., are more comfortable with
evidence-based/manualized approaches to
treatment. - 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.
40Interest 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
health
41Primary Care Populations
- Middle-class primary care. Family practice
medicine is the front line of medical care in the
U.S. - Indigent care. Public health. Medicaid/Medicare/un
insured. - SPMI (serious and persistent mental illness)
- Chronic physically ill chronic pain, diabetes
(I II), COPD, etc.
42BCHC 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.
43Public Health Population
- Largely indigent, some homeless, little money,
little education, disorganized, chaotic lives - Chronic, complex physical and mental
difficulties - Somatized illness
- Trauma, grief, depression, anxiety, DV
- Diabetes, COPD, substance abuse, Hep C
44Low-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
scheduling.
45Low-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.
46Public 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
47What is Treatment?
- Symptom relief the medical model v. the wellness
model - 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
grief.
48Barriers, 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
49Some 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
50Some Pluses
- High-quality care delivered in a convenient
manner - 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
money - -- adapted from presentation in 2006 by Susan
Mims, Buncombe County Medical Director
51 Worries
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
52Examples/Cases
- L.S./S.M. Bipolar-disordered/dually diagnosed
woman - 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
53SWOT Issues
- One-stop treatment v. does diversion actually
create system dependence? - Collaboration more likely to produce positive
outcome - Adequacy/accuracy of DX v. cost savings
- Adequacy of follow-up by both patient and
therapist - 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
54Truth
Just plain nuts!
55Implications for NCCA
- This is a training issue few institutions offer
any training in integrated care approaches to
therapy. - 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.
56A 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,
D.C. - Web sites
- http//www.integratedprimarycare.com/
- http//www.primarycareshrink.com
- http//www.mahec.net/ic/
- http//www.thenationalcouncil.org/
-
57A Few More Resources
- www.depression-primarycare.org The MacArther
Foundation - Institute for Healthcare Improvement (IHI)
www.ihi.org/collaboratives - RWJ Project Depression in Primary Care
www.wpic.pitt.edu/dppc - National Council for Community Behavioral
Heathcare www.nccbh.org/html/learn/primary.htm - Developmental Behavioral Pediatrics Online
www.dbpeds.org - http//cartesiansolutions.com ( Financial
information) - http//www.cfha.net
- http//www.parc.net.au
- http//www.shared-care.ca
- http//www.behavioral-health-integration.com/news.
php - http//www.shepscenter.unc.edu/index.html
- http//www.icarenc.org/
58The End
- Thanks for listening. For a free copy of this
presentation, please go to -
- http//www.commcure.com/ncca2008.ppt
- Please provide credit for any material you use.
For more information on this and other trainings,
workshops and consultations, please go to
www.commcure.com - or contact me at
- shsnow_at_mindspring.com
- 828-250-5254 (o)
- 828-689-3615 (h)
- 828-319-5066 (c)