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Welcome to Integrated Behavioral Health in Primary Care Settings Presented by Peter Van Houten MD, Medical Director Michael Johnson PhD, LCSW, Behavioral Health Director

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Title: Welcome to Integrated Behavioral Health in Primary Care Settings Presented by Peter Van Houten MD, Medical Director Michael Johnson PhD, LCSW, Behavioral Health Director


1
Welcome to Integrated Behavioral Health in
Primary Care SettingsPresented by Peter Van
Houten MD, Medical 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).
2
WELCOME EVERYONE!Thank you for joining us today
3
Raising your hand to ask a question
4
Sending Notes
5
Muting your phone
6
INTEGRATED BEHAVIORAL HEALTH IN PRIMARY CARE
SETTINGS
  • Peter Van Houten MD, Medical Director
  • Michael Johnson PhD, LCSW, Behavioral Health
    Director
  • Sierra Family Medical Clinic
  • Nevada City, CA
  • (530) 292-3478
  • www.sierraclinic.org

7
YOUR PRESENTERS
Peter
Michael
8
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.

9
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)

10
Sierra Family Medical Clinic
  • Its very rural

11
WHY INTEGRATE BEHAVIORAL HEALTH AND PRIMARY CARE?
  • Surgeon Generals Report on Mental Health
    (1999) acknowledged the role of primary care in
    the provision of mental health care
  • Presidents New Freedom Commission on Mental
    Health (2003) promoted integration
  • Secretarys National Advisory Committee on Rural
    and Human Services (2004) called for integration

12
WHY INTEGRATE BEHAVIORAL HEALTH AND PRIMARY 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 (FQHCs) (2004
    and 2006)

13
BOTH EXPERIENCE AND RESEARCH ILLUSTRATE
  • Approximately 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.

14
BOTH EXPERIENCE AND RESEARCH ILLUSTRATE
  • An 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)

15
BOTH 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)

16
BOTH 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.

17
BOTH EXPERIENCE AND RESEARCH ILLUSTRATE
  • Mortality 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.

18
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)

19
WHERE DOES IBH FIT INTO THE SYSTEM OF CARE ?
  • Behavioral health is a basic component of general
    health care
  • Seamless access to BH services
  • The BH Practioner is a member of the primary care
    team

20
CONTINUUM OF INTEGRATION
  • Attributes
  • Model

Desirability
  • Traditional BH model
  • Some exchange
  • On site, separate team
  • Shared cases
  • PC team member
  • ---
  • Separate space model
  • 1 1 referral relationship
  • Co-location
  • Collaborative care
  • Fully integrated

21
INTEGRATED BEHAVIORAL HEALTH MISSION
  • Provide 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.

22
INTEGRATED BEHAVIORAL HEALTH MISSION
  • Simultaneous focus on health and behavioral
    health issues
  • Improve adherence and compliance and build upon
    primary care team interventions
  • Example diabetes care
  • Support self management and health care literacy

23
CSRHA Rural Champions 2009
24
HOW DOES IT WORK?
  • Close proximity of the team
  • Encounters are vulnerable to interruption and are
    typically 15-30 min in length
  • A 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

25
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.

26
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

27
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.

28
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.

29
THE WARM HAND OFF
  • Benefits from the BH perspective
  • Exam room behaviors intense, open, honest, more
    information
  • Descriptive and honest language with a
    motivational perspective helps connect and avoid
    labels
  • Perspective and flexibility return is the goal

30
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

31
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 screen
  • Drug and alcohol screens

32
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.

33
EXAMPLES OF A WARM HAND OFF
  • We have produced a DVD that depicts a dozen
    scenarios.
  • www.youtube.com/user/sierrafamilymedical/feed
  • Examples include
  • Diabetes, Post MI, insomnia, smoking cessation,
    obesity, depression, anxiety, bipolar, grief,
    chronic pain, and substance abuse.

34
LESSONS LEARNED
  • Address political/organizational issues
  • Have strategic vision
  • Link with other community services
  • Address any philosophical resistance
  • Train and mentor new providers
  • Financing strategies that will sustain budget
    stability
  • Business model
  • Funding sources

35
LESSONS LEARNED
  • Create administrative infrastructure that
    includes IBH (examples)
  • Identify and address training needs
  • Use measurement and performance indicators
  • Be a key player in any county integration/collabor
    ation efforts

36
CONCLUSION
  • Other possibilities
  • Dental referrals and our experience
  • Tele-behavioral health hand offs and our
    experience
  • More than 2 providers and specialties in a hand
    off

37
  • Sierra Family Medical Clinic
  • 15301 Tyler Foote Rd.
  • Nevada City, CA 95959
  • (530) 292-3478
  • www.sierraclinic.org
  • Peter Van Houten, MD
  • pvanhout_at_earthlink.net
  • Michael Johnson, PhD, LCSW
  • mjohnson_at_sierraclinic.org
  • Wendy Barnhart, COO, CCO
  • wbarnhart_at_sierraclinic.org
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