Integrated Behavioral Care: Clinical Systems

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Integrated Behavioral Care Clinical Systems

• Parinda Khatri, Ph.D.
• Director of Integrated Care
• Cherokee Health Systems

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References

• Blount, A. Integrated Primary Care The future of
  medical mental health collaboration. 1998.
  W.W. Norten Company New York.
• Cummings, N.A., ODonohue, W., Hayes, S.C., and
  Follette, V. Integrated Behavioral Healthcare
  Positioning mental health practi8ce with
  medical/surgical practice. 2001. Academic
  Press San Diego.
• Robinson, P. (1998) Behavioral Health Services in
  Primary Care A new perspective for treating
  depression. Clinical Psychology Science and
  Practice, 5(1), 77-93.
• McCarthy, R. (1998) Behavioral health Dont
  ignore, integrate. Business Health, August.
• Strosahl, K. (1996) Confessions of a behavior
  therapist in primary care The odyssey and the
  ecstasy. Cognitive and Behavioral Practice, 3,
  1-28.
• Strosahl, K. (1996). Primary Mental Healthcare
  New model for integrated services. Behavioral
  Healthcare Tomorrow, October.
•  

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Randomized clinical trials indicate that
integrated psychosocial interventions in primary
care are effective in treating psychiatric
disorders Blount, A. Integrated Primary Care
The future of medical and mental health
collaboration. WW Norten New York. 1998.
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Clinical Structure of Integrated Care

• Behavioral health consultation
• Consultative case management
• Integrated specialty consultation
• Collaboration and integration

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While we need to be able to think differently to
act differently, we also need to be able to act
differently to think differently.Alexander
Blount, Ed.D. Introduction to Integrated Primary
Care (1998) In Integrated Primary Care The
future of medical and mental health
collaboration, Blount, A. (Ed.) W.W. Norten New
York, p. 17.
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Role of Behavioral Health Consultant

• Management of psychosocial aspects of chronic and
  acute diseases
• Application of behavioral principles to address
  lifestyle and health risk issues
• Consultation and co-management in the treatment
  of mental disorders and psychosocial issues

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Skills for Behavioral Consultant

• The ability to understand the biological
  components of health, illness, and disease and
  interaction between biology and behavior
• An understanding of how cognition, emotion,
  motivation can influence health
• An understanding of how social and cultural
  factors affect health problems, access to health
  care, and adhering to treatment regimens
• Knowledge of how to assess cognitive, affective,
  behavior, social, and psychological reactions for
  all common conditions seen in primary care
• APA Primary Care Psychology Curriculum
  Interdivisional Task Force

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The Biobehavioral Continuum

• A treatment framework for conceptualizing
  relative influence of psychosocial and
  physiological factors in disease.

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Psychosocial Influence on Disease

• Cardiovascular Disease Risk
• Cancer Disease Progression
• Pulmonary Diseases Physiological Sensitivity
• GI Disorders Different Interventions
• Neurological/Endodrine conditions Exacerebated
  disability and suffering
• Rheumatological Disorders Multiple levels of
  psychological influence
• End Stage Renal Disease Disease or depression?
• Somatization The difficult patient
• Blount, A. Integrated Primary Care The future
  of medical mental health collaboration. 1998.
  W.W. Norten Company New York.

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Important Skills for ALL Providers

• Learning to speak to each other and the patient
• Working as team members
• Solution-focused interviewing
• Utilizing Brief Interventions

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When to consult?

• As early as possible
• Problem involves psychosocial factors (e.g.
  cancer)
• Symptoms are unexplained by medical findings
• Family issues
• Adherence
• Emotional/Relational problem
• Assessment/Treatment conflict
• Development/Life transition

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Behavioral Health Consultants in Primary Care

• Consultation with the primary care team
• Brief consultation with primary care patients
  (1-3 contacts)
• Programmatic treatment (4-7 contacts)
• Psychoeducational groups
• Triage
• Consultation with medical specialists
• Educational Services
• Robinson, P. Behavioral Health Services in
  Primary Care A new perspective on treatment
  depression. Clinical Psychology Science and
  Practice Vol 5, No. 1, 1998.

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Clinical Integration Strategies

• Accurate screening / assessment
• Appropriate prescribing of medications
• Clear clinical practice protocols
• Consistent use of behavioral interventions
• Consistent use of relapse prevention
  maintenance treatments
• Optimal use of education based interventions
• Availability of on-site behavioral health support

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Integrated Care at Work

• Behavioral health care is significant part of
  medical practice (e.g. Post-MI patient may be
  evaluated for depression and social isolation)
• Behavioral health care is coordinated (e.g. panic
  management skills are reinforced in medical
  visits)
• Behavioral health care is the responsibility of
  the primary care team (e.g. monitoring of
  depression)

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Behavioral Health and Medical Provider
Collaboration

• Curbside consultation
• Shared written documentation
• Shared treatment planning and monitering
• Reinforcement of treatment plan goals and
  strategies

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Provider and Patient Perspectives
Less More

• Traditional Model
• Courtesy report of involvement
• Referral call for info.
• MHP/PCP support visits

• Integration Model
• Meetings between providers and together with
  patients
• Collaborative assessment and treatment planning
• Unified team in delivery of services

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Levels of integrated care

• Level 1 Consultation and brief targeted
  interventions in medical setting
• Level 2 Time limited focused interventions in
  medical setting
• Level 3 Referral for longer term therapeutic
  interventions

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Behavioral Health Contribution in Primary Care

• Increase recognition of psychological symptoms
  and factors in health
• Apply Biopsychosocial model
• Design and implement behavioral health plans
• Improve medical treatment (e.g. patient adherence
  to medications)
• Brief assessment, treatment, and consultation

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Horizontal and Vertical Integration Strategies

• Horizontal Integration-- Education and training,
  consultation (in-vivo training), and shared
  co-management
• Vertical Integration Specialty consultation,
  critical treatment pathways

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Medical Provider Training

• Assessment and Treatment of Depression
• Assessment and Treatment of Anxiety
• Brief Depression Management Strategies
• Management of Panic Attacks
• Stages of Behavior Change
• Sleep
• Stress Management Strategies
• Managing the Suicidal Patient
• Assessment and Management of the Bipolar Patient
  in Primary Care
• Stump the Chump Sessions with Psychiatrist

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Clinical System Strategies for Integration

• Screening and Identification in Primary Care
  (e.g. Well Child Checks, Red Flag Questions)
• Systematic assessment, intervention, and
  follow-up management guidelines
• Evidence based management protocols for target
  groups (e.g. ADHD, Depression, Anxiety, CHD,
  Diabetes, etc.)

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Integrated Care in ActionPediatric Clinic

• BHCs share office with Pediatricians
• Consultation room in Pediatric Clinic
• BHCs involved in EVERY Well Child Exam
• Traditional Therapy on-site
• Child Psychiatry on-site

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Clinical Protocol Well Child Exam

• Level 1 Screening
• Ages 0-17 months use Infant Development Review
• Ages 18 months to five years use Child
  Development Review
• Ages six to twelve years use Pediatric Symptom
  Checklist
• Screen mothers of newborns for PPD
• Informal screen of 4-5 year olds for kindergarten
  readiness.
• Behavioral intake/DSM IV diagnosis if indicated
  as a result of reported symptomotology.

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Clinical Protocol Well Child Exam

• Levels I and II Psychoeducation
• Developmental tasks at each age
• 3-4 specific socio-emotional anticipatory
  guidance topics (handouts developed for ages
  0-5).
• Basic behavior management skills / single session
  interventions to address specific behavioral
  issues.
• Development promotion education based on age
• Helping parents address academic concerns
• Basic nutritional information (taken from Bright
  Futures handout given to parent) with education
  about importance of activity and limiting TV/VG
  time (as effort to work toward obesity
  prevention).

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Clinical Protocol Well Child Exam

• Levels II and III Management and Referral
• Tennessee Early Intervention Services (TEIS) for
  developmental delays.
• Traditional psychotherapy (do intake in peds and
  then transfer to a therapist)
• Time Limited intervention with a BHC for 1)
  emotional/ behavioral /parent training/ academic
  issue OR 2) A health status management /health
  behavior change issue.
• Appropriate community resources
• Behavioral health care / SA treatment for parent
  or family member
• School psychologists/psychoeducational evaluation

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Integrated Care in Action

• Treating Depression in Primary Care

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Depression in primary care

• Depression is most common mental disorder in
  primary care.
• Undetected depression in primary care is
  associated with negative outcomes (e.g. loss of
  functioning and well-being, adverse health,
  decreased productivity)
• Economic analyses indicate primary care is
  optimal setting for depression care

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Integrated Care models for Depression vs. Usual
Care

• Significant improvements on depression outcome
  measures
• Increased use of active coping strategies
• Significant improvement in medication adherence
• Increased adherence to relapse prevention plan at
  follow-ups
• Improved medical provider satisfaction

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Education of Medical Providers

• Consultation
• Assessment and diagnoses
• Evidence based interventions
• Review of critical treatment pathways
• Brief interventions within medical visit
• Improving self-management of depression

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Clinical Protocol

• Screening and Identification with Red Flag
  Questions
• Follow-up with Patient Health Questionnaire
  (PHQ)-Depression
• Team Assessment of biological, psychological, and
  social factors
• Develop Initial Treatment Plan
• Begin Depression Management Interventions
• Monitoring
• Psychiatric Consultation if necessary
• Referral to Traditional Psychotherapy if
  necessary

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Interventions for Depression in Primary Care

• Pharmacotherapy
• Behavioral Activation
• Cognitive-Behavioral Therapy
• Exercise
• Interpersonal Therapy
• Systems Therapy
• Solution-focused Therapy

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Cognitive/Behavioral and Pharmacological Treatment

• Psychoeducation for patients and medical
  providers
• Coordination and collaboration between behavioral
  and medical providers
• Brief Treatment

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Brief Cognitive-Behavioral Intervention for
Depression

• Behavioral Activation
• Cognitive-Restructuring
• Problem-Solving Skills
• Coping Skills

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Improved clinical outcomes appear to be dependent
on continued on-site presence of behavioral
health staff
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Consultation alone is NOT enough
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Case Example I Gina

• Visit 1-Integrated Care visit
• -Assessment and Diagnoses Panic Disorder with
  Agoraphobia
• Psychoeducation about Panic attacks (verbal and
  written)
• Cognitive-Behavioral techniques (e.g. abdominal
  breathing, behavioral changes, cognitive
  restructuring)

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Case Example Gina cont.

• Consultation with Medical Provider-rule out
  cardiac
• Medical Visit-for allergies, but psychological
  intervention reinforced
• Visit 2- Reviewed progress and strategies,
  problem-solved
• Consultation with Medical Provider
• Visit 3- Significant improvement, maintenance and
  relapse prevention
• Consultation with Medical Provider
• 6 week follow-up scheduled

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Case Example Melinda

• 26 year old married Caucasian female
• Clinical Depression, Recurrent
• PHQ19 after 3 weeks Paxil 20mg
• Visit 1- Integrated Care
• Assessment and Diagnoses
• Psychoeducation
• Depression Management strategies (behavioral
  activation, exercise, coping skills)

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Case Example Melinda cont.

• Consultation with Medical Provider
• Phone Follow-up Check-in
• Visit 2- Review progress, problem-solve on
  strategies and coping skills
• Consultation with Medical Provider
• Visit 3-PHQ2, Significant improvement,
  maintenance, relapse prevention strategies
• Consultation with Medical Provider

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Case Example Sally

• 45 married Caucasian female
• Visit 1-Integrated Care visit
• Assessment and Diagnoses Dyspaernia and PTSD
• Psychoeducation
• Discuss treatment options

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Case Example Sally

• Consultation with Medical Provider
• Visit 2 Behavioral techniques, referral to
  longer term counseling
• Consultation with Medical Provider
• Visit 3-Integrated Care-follow-up
• Consultation with Medical Provider

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Case Example Tom

• 55 yo married male, Diabetic referred for
  noncompliance to dietary/monitoring regimen
• Visit 1-identified pt. Depressed and out of
  control. Behavioral activation to increase
  self-efficacy, develop daily diabetes
  self-management plan
• Consultation with PCP/nurses
• Medical visit-reinforce behavioral
  activation/self-efficacy, reviews progress in
  self-management plan
• Follow-up phone call
• Visit 2-Review progress/monitoring

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Case Example Pam

• 57 yo married female, Mammogram refusal
• Integrated care visit 1 Assessment Grief and
  Intervention (Grief work/coping skills)
• Follow-up Visit 2 Problem-solving and Coping
  skills
• Follow-up Visit 3

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Case Example Mindy

• 10 year old female
• Medical visit-school referred for ADHD
• Visit 1-Integrated Care Assessment
• Consultation with Medical Provider
• Talk to school teacher/psychologist
• Visit 2-Family session
• Talk to school psychologist
• Visit 3 Integrated care/Follow-up

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Case Example Jeff

• 35 yo married male, chronic headaches
• Integrated Visit 1 Assessment and Identification
  of Behavioral factors (patient homework)
• Consultation with provider Care plan (e.g. meds,
  diet change, behavioral strategies)
• Visit 2 Muscle Relaxation training, management
  of emotional and behavioral triggers
• Medical Visit Care plan reinforced
• Visit 3 Review and refine maintenance strategies