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Integrating Mental Health into Primary Care:

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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

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Title: Integrating Mental Health into Primary Care:


1
Integrating Mental Health into Primary Care 
The BHL Model
  • VISN4-Healthcare Network
  • Department of Veterans Affairs

2
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
    2006)
  • Nearly half of all antidepressants, sedatives,
    and hypnotics were prescribed by a primary care
    provider (20 of all antipsychotics)
    (cdc.gov/nchs/data/series/sr_13/sr13_157.pdf)

3
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
4
How is Care Provided?
  • Key Facts
  • Depressive disorders are common
  • (10-15 prevalence)
  • Less than 50 of patients have treatment
    initiated
  • Less than 50 are adequately treated
  • Rates of follow-up to new treatments (HEDIS) 20

5
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.
6
The BHL Program
7
So Whats the BHL Program?
  • A clinical program providing prevention and
    treatment services designed around the following
    principals
  • An emphasis on use of structure assessments and
    algorithms
  • 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
    stakeholders
  • A population based approach to care
  • A focus on self- management and collaborative
    decision making
  • A focus on open access

8
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

9
Step 1
  • Identification and triage
  • Primary care screening
  • Primary care assessment
  • Self-referral
  • Outreach
  • Prescribing
  • Driving principal we take anyone you are
    concerned about.

10
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!

11
Impressions from Initial Assessment
  • Enormous range of psychopathology
  • Greatly appreciated by patients
  • Phone vs face to face access or provider
    comfort
  • Greatly appreciated by primary care providers
  • A great tool for research recruitment

12
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
13
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)
14
Referral Management
  • Brief workbook based intervention designed to
    enhance engagement in specialty MH/SA services
  • Focus
  • Enhancing motivation
  • Addressing practical issues
  • Preparing the patient

15
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)
16
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

17
Disease Management Percent of Patients Achieving
Remission
18
Change in Depressive Symptomatology over the
Course of Monitoring (n140)
19
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

20
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

21
Alcohol Care Management
  • BHS meets with patient for 16 sessions over 6
    months
  • Collaborates with PCP to
  • Increase motivation to abstain
  • Be supportive and optimistic
  • Naltrexone
  • Encourage AA attendance
  • Provide education (health risks and detrimental
    outcomes)

22
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

23
Preliminary Outcomes
  • ACM
  • 90 (55/61) had at least 1 face to face visit
  • mean visits 10.2 (range 0-28)

24
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
    risks
  • Limited research on problem solving therapy and
    other brief focused interventions

25
Close Monitoring
  • 8 Weeks of prospective monitoring by telephone
    using the PHQ-9
  • Patient choice for treatment engagement is also
    allowed
  • Those with persistent symptoms or who choose are
    enrolled in depression disease management

26
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

27
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

28
Panel management
29
Patient History
30
Summary of Interview
31
Patient and chart documents
32
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
    management
  •  
  • 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

33
Conclusions
  • 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
    presentations.
  • A Brief alcohol intervention Works!
  • For patients without alcohol dependence
  • Alcohol Care Management Very Promising!
  • For patients with alcohol dependence

34
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

35
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