Primary Care and Mental Health Integration: The Behavioral Health Laboratory

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Primary Care and Mental Health Integration The
Behavioral Health Laboratory

• VISN 4 MIRECC
• University of Pennsylvania

Johanna Klaus, PhD BHL Director, Philadelphia VAMC
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MH/PC Integrated / Collaborative Care A Model
Alcohol Care Management
Anxiety Care Management
Antipsychotic Management
Weights Management (Move Program)
Psychotherapy (Brief)
Consultation
Backbone EMR tracking and decision support
Depression Care Management
Smoking Cessation
Pain management
Referral care management
Dementia Care Management
Sleep Management
Bipolar Care Management
BHL Components
Mostly MH care focused
Other Primary Care based interventions
Primary and specialty MH care focused
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BHL Program Key Elements

• Deliver on-time on-target behavioral health
  care management
• A partnership with PC
• Patient centered care incorporating convenience
  and preference
• The program stresses self- management
• Emphasizes open access
• Time limited but open we dont create a forever
  caseload
• Ever changing

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Not

• A replacement for specialty care
• A stand alone treatment program

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Behavioral Health Laboratory

• A telephone based clinical management program
  focused on
• Identification screening, pharmacy based,
  direct to consumer, etc
• Assessment Reports to patient and provider
• Care Management / Counseling
• Triage Specialty care, care management,
  watchful waiting
• Management / Tracking

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BHL Clinical Process
Patient Identification Screening / Clinical
Assessment / Casefinding
Patient Education and Promote Self-Care
BHL Initial Assessment
Provider Recommendations
Schedule MH/SA Care
Monitor Response (Depression Monitoring)
No treatment Refusal of care
Watchful waiting Brief Interventions
Care Manage as Appropriate
Referral Management
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Behavioral Health Laboratory

• A telephone based clinical management program
  focused on
• Identification screening, pharmacy based,
  direct to consumer, etc
• Assessment Reports to patient and provider
• Care Management / Counseling
• Triage Specialty care, care management,
  watchful waiting
• Management / Tracking

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The patient must be assessed for suicide risk for
all positive scores The option to refer to the
behavioral health lab is still available Urgent
care documentation is present
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Pharmacy Based Case-finding

• Query of CPRS for new antidepressants
• 68 written by Primary Care Clinicians
• Completion of initial core assessment within 1
  week.
• Follow-up assessments at 2, 6, and 9 weeks

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Behavioral Health Laboratory

• A telephone based clinical management program
  focused on
• Identification screening, pharmacy based,
  direct to consumer, etc
• Assessment Reports to patient and provider
• Care Management / Counseling
• Triage Specialty care, care management,
  watchful waiting
• Management / Tracking

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Core Assessment

• Demographics
• Current care (MH and PC)
• Financial status
• Social support
• Blessed Orientation-Memory-Concentration (gt55
  yrs)
• Mini International Neuropsychiatric Interview
• PHQ-9
• PTSD Checklist (PCL)
• Past/Current Antidepressant medications
• 5-item Paykel scale for suicidal ideation
• Alcohol use (7 day follow-back)
• Illicit substance use
• Depression history
• Work Life questionnaire
• SF-12

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Behavioral Health Laboratory

• A telephone based clinical management program
  focused on
• Identification screening, pharmacy based,
  direct to consumer, etc
• Assessment Reports to patient and provider
• Care Management / Counseling
• Triage Specialty care, care management,
  watchful waiting
• Management / Tracking

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BHL Modules/Components

• Initial Triage Assessment comprehensive
• Watchful waiting
• 8 weekly calls
• Depression Monitoring
• 2, 6, 9 Weeks phone calls
• Adherence, Depressive symptoms, Side effects
• Alcohol Misuse Monitoring
• Follow-up at 3 months (phone call)
• Behavioral Health Specialist Modules each to
  last up to 6 months of treatment (phone or in
  person models)
• Depression disease management
• Brief Alcohol Intervention
• Referral Management

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Watchful Waiting Module

• A focus on subsyndromal or minor depression
• 8 Weeks of prospective monitoring by telephone
  using the PHQ-9
• Engagement with the care management program is
  based on the persistence of symptoms and/or
  patient choice
• 62 WW is sufficient and no further treatment is
  required (Ross et al, 2008)

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Depression Monitoring Module

• Contacts at 2, 6, and 9 weeks
• PHQ9, adherence, side effects
• 26 report non-adherence to treatment in first
  couple of months
• 12 report significant side effects
• 22 managed (dose change or med change) in first
  couple of months
• 53 symptom remission
• Guideline care (EPRP standard) 54 Center-wide
  (20 in 04)

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Depression and Anxiety Care Management

• Care Management is algorithm driven care
  delivered by a Behavioral Health Specialist as an
  adjunct to primary care.
• Depression
• Panic Disorder
• Generalized Anxiety disorder

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Alcohol Care Management

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

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Depression and Alcohol Care Management
85 receive at least one counseling session
Oslin, et. al. 2003
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Referral Management ModuleSpecialty Care
Engagement
Attended 1st Appointment
Motivational Session 70
Control Group 32
p lt .001
Zanjani et al, 2008
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Behavioral Health Laboratory

• A telephone based clinical management program
  focused on
• Identification screening, pharmacy based,
  direct to consumer, etc
• Assessment Reports to patient and provider
• Care Management / Counseling
• Triage Specialty care, care management,
  watchful waiting
• Management / Tracking

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BHL Software

• Initial assessment and structured follow-ups
• Built in algorithms for treatment decisions can
  be modified
• Generation of reports, letters, patient education
• Patient tracking
• Generate workload, call schedule, and module
  reports
• Export for analysis

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BHL Software Patient Search
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BHL Software Patient History
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BHL Software Page from Core Interview
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BHL Software Summary Page
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VISN 4 Hub and Spoke Model
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Early Lessons Changing Culture

• Educational meetings for PC and MH staff
• PC provider as customer along with veteran
• Win over patient by patient
• Be visible ? staff meetings, in clinic,
  flyers/e-mails
• Be a resource
• Adapt and evolve
• Flexibility, patience, and persistence

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BHL In Summary

• Increase identification of patients needing MH
  services and rates of positive screens (Oslin et
  al, 2006)
• Increase engagement in specialty care (Zanjani et
  al, 2008)
• Improve outcomes for depression and alcohol
  misuse (Oslin et al, 2003)
• Facilitate care for new cases of depression
• The triage and tracking mechanisms allow for
  seamless referral and the ability to reduce
  waiting times, prioritize care, and provide
  administrative support for monitoring.

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Whats next?

• Constantly evolving
• Regular software and manual updates
• Additional modules
• Pain
• Next trainings (in Philadelphia)
• March 17th-20th and April 7-10th (currently full)
  
• June 9th-12th (contact Jennifer Rego)
• Continuing weekly conference call
• Tuesday 2 pm EST 1-800-767-1750 31307
• 2nd and 4th Tuesday devoted to care manager
  topics

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Resources

• http//www.va.gov/visn4mirecc/BHL/index.htm
• Sharepoint site almost completed! (send an
  e-mail)
• Johanna Klaus 215 823-5899
• Erin Ingram 215 823-5800 x2895