BEHAVIORAL HEALTH

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BEHAVIORAL HEALTH LAB
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Goals of the BHL

• Instill
• Hope

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How?

• Provide
• the right care
• at the right time
• at the right place
• With Empathy and Compassion

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Research to PracticeBehavioral Health Laboratory

• BHL is designed to provide clinical services to
  support providers in Primary Care and Behavioral
  Health
• It is intended to be analogous to Clinical
  Chemistry or Radiology Laboratories
• The BHL is an automated telephone assessment,
  triage, and monitoring service for patients
  identified by primary care providers as having
  depressive symptoms or at-risk drinking.
• The BHL conducts a brief telephone (20-30
  minutes) assessment generating a report for the
  PCP including diagnosis, severity, and general
  treatment recommendations.

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How it works at the PVAMC

• Mechanisms for requesting an assessment
• Screening
• Annually PCPs are required to screen for
  depression and at-risk alcohol use (2 question
  screen for depression 3 for at-risk alcohol
  use).
• For patients who screen positive, the clinician
  is responsible to assess the need for immediate
  care. However, a consult request is
  automatically generated.
• Referral
• A BHL assessment can be ordered with any
  frequency by primary care providers.
• Disease management
• A package of assessments related to a new episode
  of treatment
• The BHL receives a printed consult request.
• The BHL reports findings, provides
  interpretation, and recommendations.
• Where appropriate, BHL staff facilitate referral.

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What does the Service Provide?

• Assessment of major illnesses depression,
  anxiety, substance use
• Screening for other domains cognition, smoking,
  psychosis, mania
• Initial Treatment recommendations
• Patient engagement
• Monitoring of initial treatment for depression
  adherence, adverse effects, symptoms

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The BHL as a Platform of Care

• Watchful Waiting
• Referral Management
• Disease Management (e.g. depression, alcohol,
  suicide)
• Research

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A Platform for other activities

• Telephone disease management for problem drinking
  
• Supported by VA HSRD
• Developing watchful waiting strategies
• Supported by Robert Wood Johnson Foundation
• ExTENd Use of naltrexone in managing alcohol
  dependence
• Supported by NIAAA R01
• DIADS depression of Alzheimers disease
• Supported by NIMH R01
• Family caregiver Support
• Depression Treatment Monitoring
• PTSD
• Referral Management

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Roll out over several different settings
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Referrals
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5 Month Referral Success

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Characteristics of Patients
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Does the BHL change practice?

• 25 reduction in the number of patient not
  screened for depression
• 10 increase in the screen positive rate for
  depression
• Significant increase in the identification of
  patients with suicidal ideation
• Possible improvement in EPRP measures for
  depression

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Engagement in Care
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Barriers to service

• Skepticism regarding validity of assessments
• Skepticism regarding treatment
• Limited treatment choices anyway
• Low frequency of patient problems - 1 or 2
  patients/week
• Novelty
• Doesnt meet needs
• Interventions for mild behavior/disease may not
  be accepted
• ?
• ?

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Two Ways of thinking about screening and
treatment initiation
Outcome Monitoring
Treatment Z
Treatment Adjustments
Systematic Screening
Initial Assessment And Triage
Clinical Exam
Outcome Monitoring
Treatment Q
Treatment Adjustments
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BHL Flow
Annual Screening
Direct consult
New treatment for depression
Consult request
Full Assessment
Recommendations to PCP and Patient
Referral to BHC
Enroll in Depression monitoring
Referral to Specific Research
No Treatment Recommended
Brief Intervention
Watchful Waiting 8 weeks
Referral Management
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Starting a New Practice

• Identify a thought leader / Champion
• Define practice specific needs screening,
  referral, resources
• Define practice specific procedures
• Announce the availability of the service
• Face-to-face
• Email
• Letters / Brochures

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Other Initial Practices

• Business cards for patients
• Business cards for providers
• ELM interface
• Listing of providers
• Staff in practice / Screening of patients
• 877 number
• ?

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Ongoing or new stuff

• Pens
• Sticky pads
• Business size card for computer
• Monthly email reminders
• Clinic feedback
• Inservice by staff on MH topics
• Website
• ?

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Conclusions

• BHL is a flexible, evidence based program
• Fills gaps in the VHA system
• Provides valid information and documentation
• Acceptable to veterans
• Valued by provider
• Can function at low cost across diverse settings
• Useful for outreach
• Can provide coordination as well as assessment
• Disease Management
• Referral Management
• Valuable as a tool for improving system
  performance