An Integrated Primary Care Behavioral Health Clinic at a University Health Service

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An Integrated Primary Care Behavioral Health
Clinic at a University Health Service

• Cheryl A. Flynn, M.D., M.S., M.A.
• Kelly S. DeMartini, M.S.
• Jennifer S. Funderburk, Ph.D.

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Cast of Characters
No conflicts of interest to disclose
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Objectives

• Define integrated healthcare
• Discuss benefits of IBHC in a university health
  service
• Describe Syracuse Universitys pilot IBHC program
• Describe initial results of pilot semester

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What is Integrated Behavioral Healthcare?
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Health Integration
From http//cnx.org/content/m13589/latest/
Health care Integrated
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What is Integrated Behavioral Healthcare?

• A cooperative method of caring for patients
  involving a partnership between primary care
  providers (PCPs) and behavioral health providers
  (BHPs) working within primary care.
• a way to bring the skills and expertise for
  addressing behavioral health needs to a setting
  in which the patients who can benefit from those
  services are already getting care. (Hunter et
  al)

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Specialty Care vs. Integrated
Care

• 50 minute, exploratory appointments
• Course of treatment 8-10 to unlimited
  sessions
• Delayed access through referral process
• Mental Hlth Provider functions independently from
  PCP
• High-intensity treatments for low volume of
  patients
• More gradual improvement

• Brief (15-30 min.), problem- focused appointments
• Course of treatment 1-4 sessions
• Immediate access through warm hand-offs from PCPs
• Behavorial Hlth Provider collaborates with PCP
• Low-intensity treatments for high volume of
  patients
• Rapid improvement

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Goals of IBHC

• Establishment of a collaborative,
  multidisciplinary team that focuses on patients
  health
• Encourage all providers to view health from a
  more multidimensional perspective
• Normalizes the need for behavioral health
• Improved outcomes for patients!

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Models of IBHC
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Primary Mental Health Care Model

• BHP as member of the primary care team
• BHP appts similar to PCP visits
• 15-30min duration
• 1-3 visits for given problem
• Focused assessment and treatment plan
• BHPs notes in same medical record
• PCP maintains role as provider in charge for pts
  care BHP role as consultant

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BHP role in 1o care mental hlth model

• BHP modifies involvement depending on need of PCP
• Behavioral health consultation
• Specialty consultation
• Integrated consultation

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BHPs focus as part of 1o care team

• Targeting the behavioral issues inherent in
  medical illnesses
• Addressing the psychological symptoms associated
  with medical illnesses
• Increased identification of psychological
  problems
• Focusing on non-specific factors related to
  improved medical outcomes

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Why Consider IBHC?

• Additional service/expanded care
• Identify serious mental illness earlier and
  connect to specialty services
• Identify mild/subclinical disease and treat with
  behavioral and medical interventions on-site
• Address acute situational distress that does not
  require specialty care
• Address behaviors (e.g., alcohol misuse,
  insomnia, risky sex, smoking) that negatively
  impact health

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Why Consider IBHC?...
because it works!

• Improves access and increases the number of
  patients who can receive care (Pomerantz, Corson,
  Detzer, 2009)
• Can reduce medical costs, improve patient and
  provider satisfaction, and enhance clinical
  outcomes (Blount, 2003)
• Patients receiving IBHC have more anxiety- and
  depression-free days, and show greater
  improvement on disability measures at 3 and 6
  months (Roy-Byrne Katon, Cowley, Russo, 2001)

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Why Consider IBHC in College Health?

• Increasing rates of mental health conditions in
  college population
• Also increasing complexity of MH problems
• More students typically use health services than
  specialty mental health services on campus
• Medical setting as treatment site for MH issues
• Greater potl for screening and prevention
• Barriers to seeking specialty mental health

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Integrated Primary Care Behavioral Health Clinic
at Syracuse University

• Collaboration among
• Health Services
• Doctoral Clinical Psychology Program
• Psychological Services Center
• Counseling Center

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SUs Student Health Center

• Population
• 20,000 undergrad and grad students
• Patient visits
• 150-200/day 15-30 min appt
• Urgent care gt primary care model no formal
  assigned PCP
• EMR begun 1 year prior
• Providers
• NPsgtgtMDs,
• limited background in mental health issues

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History of mental health services at SUHS

• No mental health care (eval or tx)
• Referral to CC /or off-campus
• 2004, new director, began medical MH care
• Lots of ADHD, increasing amt depression, anxiety
• Recruited staff internist NP to prescribe
  onsite
• 2008new provider at SUHS family med/family
  therapy
• Primary care mental health
• Another FNP also expanded medical role

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Evolution to IBHC at SU

• Proposal of IBHC onsite in SUHS
• New Health Psychology course director experienced
  in this area, began 2008
• SUHS as placement site, limited structure 08-09
• Spring 09 began developing pilot IBHC
• Engaged CC and PSC psychology dept in planning
• CC as main MH resource for students
• PSC as ongoing therapy resource, grad student
  therapists
• Psychology dept for interns, specialty assessment
  intervention tools
• Decision to incorporate screening into formal
  activity

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Roadblocks

• Resource issues
• No funding
• Limited time
• Structural changes
• 1 yr into EMR
• Loss of Director of SUHS
• Cultural issues
• Relative silos
• Medical team w/o orientation to MH care

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Half Full

• Course director passionate about IBHC
• Open-minded Assoc Medical Director
• Willingness of psychology grad students for
  new/expanded experience
• Change as an opportunity

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Sales pitch win-win all around

• Students
• Gain expanded services, easier access to care
• SUHS
• Additional providers, possibility to screen,
  training and support for BH/MH care
• Psychology Dept/PSC
• Clinical site for grad students, valuable
  training
• Pre-screening ADHD referrals
• CC
• Potl to off-load wait list/decr unnecessary
  referrals, expanded MH services, linkage w/ PSC

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SUHS Pilot Program IBHC
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Description of the Pilot Program

• WHO?
• Integrated BHPs were 3 advanced clinical
  psychology doctoral students
• 1 had IBHC experience 2 did not
• Offered workshop prior to fall semester IBHC 101
• Ongoing supervision by course director/licensed
  psychologist trained in IBHC

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Pilot Program

• WHEN?
• Provided service 20 hours a week
• WHERE?
• BHP office in medical clinic at SUHS
• BHP notes entered in EMR
• Written feedback in addition to verbal
  communication, warm hand-offs

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Pilot Program What?

• Brief assessments interventions
• Mental health sx
• Anxietygtgtdepression
• Unclear diagnosis
• Behavioral concerns
• Substance use
• Medication /or treatment compliance
• ADHD pre-screen

• Behavioral Hlth Screening
• No prior screening
• Areas chosen
• Tobacco use
• ETOH use
• Depression, suicide
• Sleep concerns
• Positive screens prompted referral to BHP

BHP services compliment other mental health
services on campus
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Why Screen These Areas?

• Prevalence
• Suicide 3 cause of death among 15-24y.o.
• Rates of depression gt10 on NCHA data
• Early intervention has benefit
• Brief alcohol interventions efficacious in
  reducing alcohol use with college students
• Addressing sleep problems improves functioning
• Recommended/evidence-based
• USPSTF supports screening for ETOH misuse and
  depression in young adults

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Pilot Program How?

• All BHP appts as referrals from PCP
• warm hand-offs from PCP appt
• Schedule if BHP not available
• BHP schedule own f/u
• Further explanation of assessment tools,
  interventions and screening tools

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IBHC at SUHSResults of Pilot Semester Fall 2009
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Steps in a BHP Visit

• Review Screening Results
• Conduct Assessment
• Begin Intervention

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Part 1 Screening Step 1 Administer and Review
Screening Results
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Behavioral Health Screening

• Only screened students with a provider visit
• Approx. 10 FTE providers (2 MDs, 8 NPs)
• Average PCP visits/day 116
• Total of 704 screens collected on 42 days
• Fall 09 - Screened only when BHP in clinic
• Inconsistent collection

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What Screening Tools?

• Depressed Mood/Suicidal Ideation
• Personal Health Questionnaire (PHQ9)
• Positive Moderate symptoms ( 10) or any
  thoughts of death/self-harm
• Alcohol misuse
• Alcohol Use Disorders Identification
  Test-Consumption (AUDIT-C)
• Positive Hazardous drinking level (scoring 8)

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What Screening Tools?

• Sleep problems
• Insomnia Severity Index (ISI)
• Positive Anyone who said they were interested in
  discussing sleep problems
• Smoking
• Positive Anyone who said they were interested in
  discussing smoking

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Results Screening Demographics
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Results Screening Demographics
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Screening Results - Smoking

• 16 (N 115) smoke at least some days
• Of those who smoke
• 96.5 smoke 1-9 cigarettes per day
• Only 7 (N 8) of participants who smoke were
  interested in talking to someone about quitting

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Screening Results Sleep

• 45 (N 314) reported being dissatisfied with
  their sleep to some extent
• 60 (N 420) reported that their sleep problems
  interested with their functioning at least
  somewhat
• 9 (N 61) were interested in talking to someone
  about their sleep

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Screening Results - Depression

• 11 (N 78) were positive on the PHQ9
• Of those who were positive
• 74.4 moderate sxs (scores 10-14)
• 15.4 moderate-severe sxs (scores 15-19)
• 10 severe sxs (scores 20-27)
• 3 (N 18) endorsed suicidal ideation

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Screening Results Alcohol Use

• 592 (84) drink alcohol
• 11 (N 77) scored positive (gt 8)
• Of those who drank
• Frequency of Use
• 43 drank 2-3x/week
• 6 drank 4 or more times per week
• Amount
• 40 consumed 3-4 drinks on days they consumed
  alcohol
• 28 drank at least 5-6 drinks
• 2 drank 10 or more drinks

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Screening Results Alcohol Use Binges

• Of those who reported any drinking
• 31 (N 186) reported 0 binge episodes
• 35 (N 205) reported lt monthly binge episodes
• 18 (N 109) reported 1x/month binges
• 15 (N 86) reported weekly binges
• 1 (N 6) reported almost daily or daily binge
  episodes

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Part 2 BHP Visits
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Behavioral Health Provider Visits

• Screening resulted in a total of 110 BHP visits
  for 83 students
• Patient visit frequency
• 61 had single visits
• 17 had two visits
• 5 had 3 visits

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Results Visit Demographics
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Results Visit Demographics
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Results Visit Demographics
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Results Visit Reason
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Part 2 BHP Visits Step 2 BHP Conducts
Assessment
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BHP Assessment Tools

• Clinical interview (approx 5-10 min)
• Additional symptom inventories or psychological
  questionnaires
• Beck Anxiety Inventory (BAI) (Beck, 1993)
• Insomnia Severity Index (ISI) (Bastien et al.,
  2001)
• Daily Drinking Questionnaire (DDQ)

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BHP Assessment Goals

• Diagnosis
• Determine whether patient meets criteria for a
  mental health diagnosis
• If yes, determine severity
• Determine patients priorities for tx
• Generate preliminary treatment plan based on dx
  results

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Part 2 BHP Visits Step 2 BHP Intervention
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General BHP Interventions

• Motivational Enhancement Interventions
• Motivation for entering treatment
• Motivation to initiate behavior change
• Relaxation Techniques
• Incorporated into treatment of depression,
  anxiety, chronic pain, IBS
• Stress-Management

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Diagnosis Specific BHP Interventions

• Sleep Hygiene/Stimulus Control Interventions for
  Sleep Problems
• Feedback- and Norms-based Harm Reduction
  Intervention for Alcohol
• Brief CBT for Anxiety and Depression

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Qualitative Feedback on IBHP

• Providers have heightened awareness of behavioral
  health issues
• Rely on BHPs as team members to collaboratively
  and efficiently care for students
• Allows for greater access to mental health
  services
• BHPs gaining training experience
• Improved collaborative efforts to care for
  students

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Case ExampleMedical Provider Viewpoint
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Case ExampleBehavioral Health Provider Viewpoint
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Conclusions

• Subjective Strengths of the Program
• Implementation of Screening helps to identify
  students in need of services---early intervention
• Gives students immediate access to mental health
  services
• Provides complementary service to on-campus
  specialty services
• Gives PCPs someone to rely on for additional help
  with behavioral health concerns

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Conclusions

• Obstacles or Areas of Improvement
• Implementing screening is difficult due to time
  pressures, lack of familiarity
• Takes time to develop skills of PCPs to discuss
  these issues
• Funding a more permanent service
• Coordinating services among on-campus specialty
  clinics to maximize experience for the student

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Contact Information

• Cheryl Flynn
• caflynn_at_syr.edu
• Kelly DeMartini
• klsmit03_at_syr.edu OR kdemartini05_at_gmail.com
• Jennifer Funderburk
• Jennifer.Funderburk_at_va.gov