Brief Introduction to Integrating Behavioral Health into Primary Care

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Brief Introduction to Integrating Behavioral
Health into Primary Care
May 5, 2009 Alexander Blount, Ed.D Clinical
Professor of Family Medicine and
Psychiatry Department of Family Medicine and
Community Health University of Massachusetts
Medical School - Worcester
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Behavioral Health Needs Assessment in Primary
CareMental Health/Substance AbuseHealth
Behavior ChangeAmbiguous and Chronic
IllnessCulturally Syntonic Approaches
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Prevalence of MH/SAProblems in Primary Care

• PHQ-3000
  Merillac 500
• Major Depression 10 24
• Panic Disorder 6 16
• Other Anxiety Disorders 7 21
• Alcohol Abuse 7 17
• Any Mental Health Dx 28 52

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Ambiguous and Chronic Illness 10 most common
complaints in adult primary care. 15 x organic
pathology found(Kroenke Mangelsdorff, 1989)

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Chronic conditions that require behavioral health
component in standard of care protocols

• Asthma
• Diabetes
• CVD
• Irritable Bowel Syndrome
• Obesity
• Substance Abuse

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Culture Impacts Depression Culturally Syntonic
Approaches

• Signs of Depression found Cross-Culturally
• Appetite changes
• Sleep changes
• Psychomotor agitation or retardation
• Decreased energy
• Decreased libido
• Diminished ability to think or concentrate

• Signs of Depression found in Western Cultures
• Self-deprecation
• Hopelessness
• Guilt
• Suicidality
• Pfeiffer, W. (1968). The symptomatology of
  depression viewed transculturally. Transcultural
  Psychiatry Research Review 5 121-123.

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Correlates of Somatization in the United States

• lower socioeconomic class
• traditionally oriented ethnic groups
• blue collar workers
• rural living
• lower educational levels
• Katon, W., Kleinman, A. Rosen, G. (1982).
  Depression and somatization a review, Parts I
  II. American Journal of Medicine 72 127-135,
  241-247, page 131.

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Underserved and Minority Populations are
Particularly Affected

• racial and ethnic minorities are less inclined
  than whites to seek treatment from mental health
  specialists. Instead, studies indicate that
  minorities turn more often to primary care.
• Surgeon Generals Report on Mental Health, 1999.
  Supplement on Culture, Race and Ethnicity

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Categories of Relationship between Collaborating
Medical and Behavioral Health Services

•  
• Coordinated
• Co-Located
• Integrated

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Coordinated Behavioral services by
referral at separate locationCo-Located
By referral at medical care
locationIntegrated Part of the
medical treatment
at medical care
location
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Programs of Collaborative Care

• Coordinated
• Targeted
• Specified
• Massachusetts Child Psychiatry Access Project
• Plan-based care management

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CO-LOCATEDBHP working in primary care seeing
all referred. Advantages
ProblemsAccess
Referrals dont show Patient
Satisfaction Case-loads fill
up Provider SatisfactionCost EffectivenessClinic
al Outcome (in most studies)
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Making Co-Location Work

• BHP in health center - 7 sessions/wk.
• Patients attending first visit w. BHP when
  scheduled by physician w/o introduction
• 40
• Patients attending first visit w. BHP when
  scheduled after introduction by physician
• 76
• N80, p lt.01
• Apostoleris, N. Blount, A. In preparation.

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Length of treatment in specialty mental health
care vs. Co-Located Non-targeted Unspecified
behavioral health care

• Specialty mental health care 6.2 visits
• Co-Located behavioral hlth. care 3.2 visits
• Simpson, R. (1998). Developing a behavioral
  health system of care. In, Blount, A. (Ed.),
  Integrated Primary Care The Future of Medical
  and Mental Health Collaboration. NY WW Norton.

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INTEGRATEDBHC working in primary care as part
of a team delivering care through a single
treatment plan. - Care management for
depression- Behavioral Health Consultant
modelAdvantages
ProblemsAccess
Sometimes narrowly Patient Satisfaction
focused Provider Satisfaction
May not provide muchFits
protocols alt. to
individ. focus of Cost Effectiveness and
Offset medical approachClinical Outcome Outcome
Maintenance
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The IMPACT Treatment Model

• Collaborative care model includes
• Care manager Depression Clinical Specialist
• Patient education
• Symptom and Side effect tracking
• Brief, structured psychotherapy PST-PC
• Consultation / weekly supervision meetings with
• Primary care physician
• Team psychiatrist
• Stepped protocol in primary care using
  antidepressant medications and / or 6-8 sessions
  of psychotherapy (PST-PC)
• http//impact-uw.org/

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Summary of 1st 2nd Generation StudiesStephen
Bartels, MD, MS Dartmouth Medical School

• Multiple component interventions
• Lectures /or distributing guidelines do not
  change behavior nor outcomes
• Adding patient tracking with a care manager
  significantly improves outcomes
• Including a mental health specialist in an
  integrated treating or consulting role improves
  outcomes the most

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Advantages of Creating an Integrated Primary
Care Program by Starting with Care Management

• Quick start up
• Start up to model program in about 3 years in one
  instance
• Care management easiest for PCPs to understand
  and accept
• BHPs get used to a high volume brief intervention
  service
• Need to be able to broaden service incrementally

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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
• Model developed by Kirk Strosahl, PhD

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Physicians Love Having a BHC Around

• ANECDOTAL reports indicate
• Docs feel less isolated
• Bolder in can of worms situations
• Enjoy treating complex patients more
• Better job satisfaction
• Better provider retention
• TEACHES THE KIND OF TRUE TEAMWORK NEEDED FOR PCMH.

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Why Primary Care is difficult for BHCs trained in
specialty mental health

• Treat different population than in Specialty
  Mental Health services.
• Less disturbed and less diagnostically clear
• Wont accept mental health definition of the
  problems they bring
• BHP must understand medical conditions and do
  behavioral medicine in addition to mental health
• Return to functioning rather than work through
• Status as ancillary provider
• Different routines of time, instrumentality
  confidentiality

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Relationship with Specialty Mental Health

• Still important for longer term care
• Makes referrals to SMH more likely to be
  successful
• Specialty MH able to better target high need
  populations
• Consultation backup to PCP
• In some systems SMH has developed specialized
  teams to support generalist PCBH clinician

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Generalist Behavioral Health Clinician

• Care Management
• Brief Therapy
• Cognitive-behavioral
• Solution-focused
• Behavioral Medicine
• Relaxation/biofeedback/hypnosis
• Health behavior change
• Family Therapy
• Substance Abuse Counseling
• Child Development
• Psychotropic medication input
• Groups and Patient Education
• Community Outreach
• Organizational transformation agent

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In the future, manpower needs will be acute.

• Direct transfer, Specialty Mental Health
  clinician to PCBH clinician often fails
• Cant train enough PCBH in current system of
  graduate, internship and fellowship structure.
• Graduate schools just beginning to be a little
  more responsive
• Transition experience for trained SMH folks

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Certificate Program in Primary Care Behavioral
Health

• Designed to be the skills, tools and information
  a well-trained mental health professional needs
  to succeed as a primary care behavioral health
  clinician.
• Video-conference allows attendance all over the
  US and Canada (and now Australia)
• Six all-day workshops, one Friday per month for
  six months. Starts in Sept. and Jan.

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So, do we have a best model defined for the
future?

• Was the Model T the best model car?
• Experimentation at some point creates an
  innovation that fits the environment.
• Innovation reshapes the environment and creates
  the context for new innovation.
• There has to be some time for evolution of roles,
  routines and models.

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For further information

• Blount, A. (Ed.), Integrated Primary Care The
  Future of Medical and Mental Health
  Collaboration. W.W.Norton, 1998. Still the best
  introduction to the field.
• Robinson, P. Reiter, J., Behavioral Health
  Consultation and Primary Care A Guide to
  Integrating Services. Best handbook for
  practice.
• March 2009 issue of Clinical Psychology in
  Medical Settings.
• www.IntegratedPrimaryCare.com
• Alexander.Blount_at_umassmemorial.org