Primary Care and Behavioral Health Integration within the Free Clinic Setting: Developing a PCBH Model of Care

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Primary Care and Behavioral Health
Integration within the Free Clinic Setting
Developing a PCBH Model of Care

• Alysia Hoover-Thompson
• ahoover7_at_radford.edu
• Radford University
• Presented at the Mental Health Roundtable
• Virginia Health Care Foundation, Richmond, VA
• August 16, 2011

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Radford University Psy.D. Program

• First cohort began providing services to
  community in 2008 as part of training program
• Students provide mental health services to local
  community organizations
• Many of these organizations are not-for-profit
• Program emphases
• Rural practice
• Cultural diversity
• Social justice
• Evidence-based practice

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Free Clinics

• Free clinics are volunteer-based, safety-net
  health care organizations that provide a range of
  medical, dental, pharmacy, and/or behavioral
  health services to economically disadvantaged
  individuals who are predominately uninsured
• (National Association of Free Clinics, 2008)

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Free Clinic of the New River Valley

• On site
• Medical
• Dental
• Pharmacy
• Dermatology clinic
• Who Qualifies?
• Adults without health insurance
• Low income based on 2010 Federal Poverty
  Guidelines
• Mental Health Association of the New River Valley
• Provides pro-bono counseling services to MHA
  clients at an office located in the Free Clinic

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Why Integrated Care?

• Up to 70 of visits to primary care offices are
  related to behavioral health needs
• Many common medical problems that are treated by
  PCP involve health and behavioral habits that
  influence symptoms (Hunter, Goodie, Oordt,
  Dobmeyer, 2009)
• In 2008, the American Psychological Association
  launched the Primary Care Initiative

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Developing an Integrated PCBH Site

• Psy.D. Program Director approached by Free Clinic
  Director
• Program students had previous experience
  providing traditional mental health services at
  site through Mental Health Association
• Joshua Bradley was the first Psy.D. student from
  Radford to complete a practicum there
• Developed forms and documents for integration
• Developed comprehensive 360 degree evaluation
  procedure to assess integration into the system
  and performance

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Integrating PCBH Services into an Established
System

• Emphasize that you are there to support existing
  services
• Try to accept as many referrals as possible in
  order to show usefulness
• Get to know all people in the clinic
• Explain what you do
• Have a prepared explanation and examples
• Create a handout

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Systemic Contextual Considerations

• Names and Faces
• Virginia College of Osteopathic Medicine
  residents
• On site physician
• Nurse practitioners
• Nurses
• Front office staff
• Volunteers

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Patient Contextual Considerations

• Given the low-income client base, there may be
  relevant considerations related to intervention
  options
• Clients may lack financial resources to make
  significant changes to their diet or join a gym
• Transportation may be a problem
• High frequency of significant financial and
  environmental stressors
• Literacy rates may be lower
• Other contextual factors will undoubtedly become
  apparent as the BHC becomes more familiar with
  the client base
• This speaks to the importance of being aware of
  cultural and contextual factors when working
  within an integrated care system

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Primary Care Environment

• Fast paced
• Adjust clinical note taking
• Space limitations
• At least 7 different rooms
• Move from room to room frequently
• Finding medical charts
• Several places they can be
• New faces
• Remembering names

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Patient Referrals

• Self-Referred
• Request to see Mental Health Counselor at
  appointment with physician/NP
• Physician/NP Referred
• Request for BH evaluation/intervention
• Warm Hand-off
• Occurs in exam room

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Additional Activities

• Consultation with medical staff
• Example Patient is in abusive relationship and
  medical resident asks about treatment options.
  BHC explains options such as Womens Resource
  Center, Mental Health Association, etc Medical
  resident presents options to patient
• Presentations to clinic staff
• Safety in medical settings
• Behaviors that increase appointment/treatment
  adherence
• Case management

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The First Year

• 201 Total Contacts
• 21 warm hand-offs
• 54 referrals
• 126 follow-up appointments
• 111 Cancellations/No Shows
• Primary Complaints
• Depression (64), Anxiety (44),
• Diet/Exercise (38), Relationship problems (32)

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The Second Year

• Two students and two days/week
• Mondays, Wednesdays and Fridays at the Free
  Clinic in Christiansburg
• Wednesdays at Giles satellite office
• Want to increase warm hand-offs
• Will increase number of patients seen
• Utilize 360 evaluation

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Adjusting to Environment

• Client versus patient
• Transportable office
• Medical terminology
• Brief encounters (as short as 5 minutes)
• Case management
• Educator/Presenter
• In-house mental health representative

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Conclusion

• Different paradigm
• Multiple treatment setting considerations
• Need to be flexible
• Fit into system
• Requires more directness and behavioral focus
  because of time limitations