Integrating Mental Health into Primary Care: - PowerPoint PPT Presentation


PPT – Integrating Mental Health into Primary Care: PowerPoint presentation | free to download - id: 624a96-OGJkM


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Integrating Mental Health into Primary Care:


Integrating Mental Health into Primary Care: The BHL Model VISN4-Healthcare Network Department of Veterans Affairs Thank You David Oslin, MD Johanna Klaus, PhD Elena ... – PowerPoint PPT presentation

Number of Views:356
Avg rating:3.0/5.0
Slides: 36
Provided by: VHA62


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Integrating Mental Health into Primary Care:

Integrating Mental Health into Primary Care 
The BHL Model
  • VISN4-Healthcare Network
  • Department of Veterans Affairs

Where is Mental Health / Depression Care Delivered
  • Depression FY 2002 64 of all outpatient
    depression visits for elderly occur in primary
    care (only 25 by psychiatrists) (Harmon et al
  • Nearly half of all antidepressants, sedatives,
    and hypnotics were prescribed by a primary care
    provider (20 of all antipsychotics)

Alcohol Use Disorders
Grant BF et al. Arch Gen Psychiatry.
200461807-816. SAMHSA, Office of Applied
Studies. Substance Dependence, Abuse and
Treatment Tables 2003 IMS - MAT March 2006
How is Care Provided?
  • Key Facts
  • Depressive disorders are common
  • (10-15 prevalence)
  • Less than 50 of patients have treatment
  • Less than 50 are adequately treated
  • Rates of follow-up to new treatments (HEDIS) 20

The Patients Perspective
Integrated Care Referral Care Odds Ratio
Depression 75 52 2.86 2.26,3.61
Anxiety 71 56 1.93 0.69, 5.40
At-risk Drinking 61 34 3.09 2.07, 4.63
Overall 71 48 2.84 2.35, 3.43
Engagement at least one contact with the mental
health specialist.
The BHL Program
So Whats the BHL Program?
  • A clinical program providing prevention and
    treatment services designed around the following
  • An emphasis on use of structure assessments and
  • An emphasis on the use of care management modules
  • Patient centered care incorporating convenience
    and preference
  • A focus on both patients and providers as the
  • A population based approach to care
  • A focus on self- management and collaborative
    decision making
  • A focus on open access

What are the (potential) parts?
  • Specialty Care (usually PhDs and MDs)
  • Consultative
  • Brief therapies
  • Care Management (BHSs usually RNs, SW)
  • Depression, Alcohol,(abuse and dependence),
    Anxiety , Pain, Smoking Cessation, Referral
    Management (optimizing specialty care)
  • PTSD, Bipolar, Dementia
  • Prevention and Health promotion (mix RNs, SW,
    PhDs, counselors, etc)
  • Watchful Waiting for subsyndromal symptoms
  • Problem solving therapy
  • Caregiver and family support
  • MOVE for weight
  • Education
  • Adherence

Step 1
  • Identification and triage
  • Primary care screening
  • Primary care assessment
  • Self-referral
  • Outreach
  • Prescribing
  • Driving principal we take anyone you are
    concerned about.

Initial Assessment Module Philadelphia BHL data
from 1/2008 to 1/2010
  • 5626 referred
  • 79 had a complete assessment
  • PTSD (85)
  • Depression (81)
  • MH and SA problems (79)
  • Alcohol problems (76)
  • Drug problems (71)
  • Only 7 refuse!

Impressions from Initial Assessment
  • Enormous range of psychopathology
  • Greatly appreciated by patients
  • Phone vs face to face access or provider
  • Greatly appreciated by primary care providers
  • A great tool for research recruitment

Step 2 Treatment Options
Patient Identification Screening / Clinical
Assessment / Case-finding
Patient Education and Promote Self-Care
Initial Assessment
Initial triage / treatment plan
No treatment Refusal of care
Specialty Care
Care Management
Prevention / Health Promotion
Optimizing Specialty Care Referral Management
  • Different methods of case finding lead to
    different rates of complex patients.
  • 30-50 of patients may have psychosis, PTSD,
    Illicit drug use, Severe depression, bipolar
    disorder, suicidal ideation
  • Limited evidence for treating these patients in
    primary care
  • Problem Low rates of MH/SA treatment engagement
    (30 40)

Zanjani F, Oslin D (2005). Telephone Based
Referral-Care Management. Grant Supported by
Philadelphia Veterans Affairs Mental Illness
Research Education and Clinical Center (MIRECC)
Referral Management
  • Brief workbook based intervention designed to
    enhance engagement in specialty MH/SA services
  • Focus
  • Enhancing motivation
  • Addressing practical issues
  • Preparing the patient

Referral Management Module
Attended 1st Appointment
Motivational Session 70
Control Group 32
p .006
Zanjani F, Oslin D (2005). Telephone Based
Referral-Care Management. Grant Supported by
Philadelphia Veterans Affairs Mental Illness
Research Education and Clinical Center (MIRECC)
Care Management Modules
  • Care Management is algorithm driven care
    delivered by a Behavioral Health Specialist as an
    adjunct to primary care.
  • Depression
  • Panic Disorder
  • Generalized Anxiety disorder
  • Alcohol Dependence
  • Pain
  • ?PTSD

Disease Management Percent of Patients Achieving
Change in Depressive Symptomatology over the
Course of Monitoring (n140)
First 12 weeks
  • Issues addressed early
  • 26 report non-adherence to treatment
  • 12 report significant side effects
  • 22 managed (dose change or med change)
  • 53 symptom remission

Alcohol Care Management
  • Two components
  • Non dependent
  • Brief alcohol intervention - Time-limited (20
    minutes in 1-3 brief sessions) and targets
    alcohol misuse
  • Dependent
  • Pharmacotherapy
  • Referral management

Alcohol Care Management
  • BHS meets with patient for 16 sessions over 6
  • Collaborates with PCP to
  • Increase motivation to abstain
  • Be supportive and optimistic
  • Naltrexone
  • Encourage AA attendance
  • Provide education (health risks and detrimental

What patients said
  • Ill take the chance on getting the nurses help
  • I have no interest in going back to the ARU, I
    am not that sick
  • I could use a med to help with my cravings

Preliminary Outcomes
  • ACM
  • 90 (55/61) had at least 1 face to face visit
  • mean visits 10.2 (range 0-28)

Prevention Services
  • Sub syndromal anxiety and affective disorders
  • Most common treatment is an SSRI but no evidence
    of efficacy
  • Psychotherapy is time consuming and not without
  • Limited research on problem solving therapy and
    other brief focused interventions

Close Monitoring
  • 8 Weeks of prospective monitoring by telephone
    using the PHQ-9
  • Patient choice for treatment engagement is also
  • Those with persistent symptoms or who choose are
    enrolled in depression disease management

Study Results
  • 223 Subjects randomly assigned to WW (130) or
    usual care (93)
  • In the WW arm
  • 81 (62) no further treatment required
  • Improved MH outcomes
  • Improved Physical functioning

What are the keys to success?
  • A plan including training, supervision, etc
  • BHL software to promote measurement based care
    and to provide decision support and tracking
  • Great staff

Panel management
Patient History
Summary of Interview
Patient and chart documents
Implementation Factors
  • Facility
  • Small clinics may be collocated and
    collaborative just by size
  • Location more rural clinics manage more BH in
    primary care
  • Leadership very important to resource
  • Access to Specialty care factors into how
    complex cases are managed
  • Staff highly variable on all sides
  • Scope the more limited typically the less
    useful or hard to use
  • Method of case finding screening, clinical
    exam, self referral leads to very different case
    mixes and thus different program needs
  • Marketing and program description what you are
    known for.
  • Resources and reimbursement

  • Depression and anxiety care management Works!
  • By telephone or face to face
  • Reduced mortality
  • Reduced symptoms
  • But not for complex patients
  • Close monitoring Works!
  • For subsyndromal depressive symptoms waiting and
    targeting care management is effective
  • Referral management Works!
  • For complex patients with affective illnesses,
    substance abuse or more other complex
  • A Brief alcohol intervention Works!
  • For patients without alcohol dependence
  • Alcohol Care Management Very Promising!
  • For patients with alcohol dependence

Thank You
  • David Oslin, MD
  • Johanna Klaus, PhD
  • Elena Volfson, MD
  • Steve Sayers, PhD
  • Shahrzad Mavandadi, PhD
  • Health Specialists
  • Lisa Dragani, BSN, RN
  • Suzanne DiFilippo, RN
  • Trisha Stump, BSN, RN
  • Shani Simmons-Wilson, BSN, RN
  • Janet Sherry Cocozza, MA, RN, APN.C
  • Coordinator
  • Erin Ingram, BA
  • Health Technicians
  • Megan Aiello, BS
  • Lauren Witte, BA
  • Victoria Farrow, BS
  • Kelly Stracke, BA
  • Natacha Jacques, MS
  • Chris Cardillo, BS
  • Henry Quattrone, BS
  • Lindsey Reid, BA
  • Brian Cox, BS
  • a host of others
  • Funders NIH, VA, BCBS

(No Transcript)