Integrated Care and Health Behavior Change

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Integrated Care andHealth Behavior Change
TEXAS ASSOCIATION OF COMMUNITY HEALTH CENTERS,
INC21st ANNUAL CONFERENCE Corpus Christi, Texas
October 22-26, 2004
Paul F. Cook, Ph.D.

• Director of Research Development

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Todays Presentation

• Chronic Care and Health Behavior
• Why Dont People Do Whats Good for Them?
• Changing Health Behavior
• Self-Management of Chronic Illness
• What Can Providers Do?
• Mental Health in Primary Care
• Integrated Care
• The Behavioral Care Professional (BCP)
• Extending Behavior-Change Expertise
• Funding Integrated Care

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BehaviorMatters
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Health Behavior

• 7 of 10 deaths in the U.S. are preventable
• U.S. Surgeon Generals Office, 2001
• Most diseases disabilities linked to behaviors
• World Health Organization Report, 2002
• Healthy People 2010 Objectives
• Physical Activity Injury and violence
• Overweight and Obesity Immunization
• Tobacco Use Substance Use
• Responsible Sexual Behavior
• (Access to Health Care) (Mental Health)

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Behavior in Chronic Illness (40 of care for ages
22-55)

• Asthma
• Smoking Environmental Factors
• Medication Stress
• Diabetes
• Diet Self-Monitoring
• Exercise Medication
• Cardiovascular Disease
• Diet Self-Monitoring
• Exercise Medication

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The Chronic Care Model Health Disparities
Collaborative (HDC)
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But Our Patients are Not Informed and
Activated

• 50 of medications abandoned by 12 mos.
• Exercise has even lower adherence
• Diet changes are hard to sustain
• Self-monitoring is often insufficient
• Patients find lifestyle change difficult
• Continued smoking, alcohol, drug use

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An Old Problem

• Drugs dont work if people dont take them.
• C. Everett Koop, 1987
• Keep watch also on the fault of patients, which
  often makes them lie about taking of things
  prescribed.
• Hippocrates, circa 200 BCE

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The Paradox

• People behave in ways counter to their own best
  interests
• Labels (noncompliant) increase resistance
• Confronting denial increases resistance
• Appeals to fear increase resistance
• Increased knowledge behavior change

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A Model of Health Behavior
standard medical practice
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Why Dont People Change?
(Why Dont Continents Move?)
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Why Behavioral Health?

• Health psychology theories that explain health
  behavior
• Assessment variables that predict future
  behavior
• Research-based methods to help people change
  their behavior

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Medication Nonadherence Reasons Given by
Patients
Survey by Upjohn Company (1985)
Survey by AARP (1982)
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Health Psychology

• Theory of planned behavior Beliefs
• Self-regulatory model Emotions
• Behavioral theories Habits and actions
• Social support / Self-determination
  Relationships with others
• Transtheoretical model Motivations

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Health Beliefs
Health Belief Model,Theory of Planned Behavior

• Predictors Health-related beliefs
• Expectancy, valence, self-efficacy, subjective
  norm
• Intentions mediate between beliefs and behavior
• Perceived benefits vs. costs predict change
• Cognitive Dissonance predicts change
• Interventions
• Becks cognitive therapy

Beliefs Intentions Behavior
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Emotional Reactions
Self-Regulatory Model

• Predictors Dual-process theory
• Knowledge beliefs
• Emotional reactions
• Interventions
• Stages of acceptance
• Emotion-focused coping
• Social support

Emotions
Beliefs
Attitudes Behavior
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Habits and Actions
Behaviorism
Stimulus

• Predictors Analysis of behavior
• Behavioral repertoire
• Current reinforcement schedule
• Interventions
• Shaping / modeling
• Stimulus control (cues reminders)
• Contingency control (behavior modification)

Organism
Response
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Social Processes
Systems Theory

• Predictors Social cognitive variables
• Health-related locus of control, reactance
  potential
• Level of support
• Interventions
• Caregiver counseling
• Developing intrinsic motivation
• System-focused interventions

Doctors
Family
Patient
Friends
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Motivational Factors
Transtheoretical Model

• Predictors Stage model
• Stage of readiness
• Pros vs. cons of change
• Interventions
• Motivational interviewing
• Self-monitoring
• Problem-solving to remove perceived barriers

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ChangingHealth Behavior
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Chronic Care Model

• Health Care Organization supports and
  incentivizes quality improvement 
• Community Resources and Policies for coordination
  with community groups
• Decision Support evidence-based guidelines are
  embedded into practice. Specialist expertise is
  integrated into primary care
• Delivery System Design defines roles and
  delegates tasks
• Clinical Information Systems use a registry
  to track and provide information

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Self-Management Support in the Chronic Care
Model

• Patient has an active and central role
• Assess self-management knowledge, skills,
  confidence, supports, and barriers
• Effective behavior change interventions
• Ongoing support with peers or professionals
• Care planning and problem solving

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Effective Behavior Change Adherence
Meta-Analysis

• Average effect size d .74 (or r .35)
• Results are reliable not due to chance
• Range of ESs from d -.22 to d 2.98
• Smallest Home visit nursing program (negative
  result)
• Largest CBT with treatment-resistant
  steelworkers
• Significant heterogeneity of ESs

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Effective Self-Management

• Self-monitoring/engagement n 12 d 1.09
• Cognitive-behavioral counseling n 20 d 0.97
• Family counseling n 4 d 0.79
• Assertiveness training n 2 d 0.78
• Reminders and support n 14 d 0.59
• Rewards n 2 d 0.44

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Case Example
Haynes, et al. (1976)

• 38 hypertensive Canadian steelworkers, all
  previously noncompliant
• Intervention method
• asked to chart BP and pill-taking
• helped to link pill-taking to daily routines
• met biweekly with program coordinator for
  reinforcement and problem-solving
• Results 80 more compliant (vs. 39 in
  control group)

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Case Example
Maisiak, Austin, Heck (1996)

• 405 patients with rheumatoid and osteoarthritis,
  multiple recruitment methods
• Intervention method
• telephone counseling by psychologist
• multimodal assertiveness, CBT, motivational
• feedback to treating physician
• Results 57 improved (vs. 38 in
  control group)

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Case Example
Katzelnick, et al. (2000)

• 407 depressed outpatients receiving antidepressa
  nts from their PCP
• Intervention method
• ongoing telephonic outreach and counseling
• routine feedback to physicians (included
  education)
• also offered Pfizers RHYTHMS program patient
  education / disease management
• Results 69 filled 3 Rxs (vs. 19 in
  control group)

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Common Threads

• Active Listening
• Building Rapport
• Attention / Mindfulness
• Cognitive Dissonance
• Collaborative Empiricism
• Social Facilitation
• Engagement and Choice

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What Can Providers Do?
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The HDCs Recommendations

• The 5 As Approach
• Assesspatient knowledge skills
• Adviseeducate the patient
• Agreeset goals together
• Assistproblem solve around barriers
• Arrangefollow up on goals

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The HDCs Findings (2003)

• few providers or staff had formal training
  in self-management except for using
  goal-setting
• inconsistency in the approach to
  self- management education between nurses and
  physicians
• documentation of self-management is not
  consistent

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Why is Change so Hard?

• Everyone is ambivalent
• Talking to the wrong stage of change
• Precontemplation
• Contemplation
• Action
• Maintenance
• Language traps I wish I wanted to change
• No one can make anyone change

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What Can Practitioners Do?

• Listen More Effectively
• Open-Ended Questions
• Restate or Summarize Content
• Reflect Emotions or Intentions
• Mirror Intensity
• Affirm Current Efforts
• Respect the Ambivalence
• Choose Goals that Gain Leverage
• Postpone the Need to Intervene

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What About Teaching?

• The Medical Model
• Tell Ask Tell
• Assumes the Person is Rational (but no one is)
• Motivational Approach
• Elicit Provide Elicit
• Assumes the Person has Information Already
• Assumes the Person Reacts to Information

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Avoiding the Traps

• Medical Training Leads to the Traps
• Expert Trap
• Question-Answer Trap
• Labeling Trap
• Premature Focus Trap
• Taking Sides Trap
• Story of the Ships Plumber much of the work
  is in knowing where to begin

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Why is Change so Easy?
Secrets of the Behavior-Change Professionals

• Changes Made Already / Exceptions
• Change Talk
• Pros vs. Cons of Current Behavior / Pros vs. Cons
  of Change
• Intention to Change (or not)
• Psychotic Optimism What Else?
• Answer yes-but with both-and
• Restrain Change
• Problem-Solving Coping Techniques
• Change is the Only Constant

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Mental Health Medical Care
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Mental Health in Primary Care

• 35 of primary care patients have a diagnosable
  DSM mental disorder (vs. 20
  in the general population)
• Patients with mental health conditions have 2x as
  many PCP visits
• Depression is second only to hypertension as the
  most common diagnosis in primary care
• Depression and pain have a reciprocal
  relationship, and depression lowers immune
  functioning. Depressed patients are less likely
  to be adherent
• For 334 consecutive patients presenting to an
  urban ED with chest pain, 17.5 had panic
  disorder and 23.1 had depression. Both groups
  were 1.5x as likely to have additional ED
  visits in the past year

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Screening and Referral
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Treatment in Primary Care Antidepressant Example
Recurrence
Relapse
Euthymia
Relapse
IncreasedSeverity
Symptoms

Progression to disorder
Syndrome
Acute (6 to 12 wk)
Treatment phases
Continuation (4 to 9 mo)
Maintenance (?1 y)
Time
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Integrated CarePutting Behavior Change Into
Primary Care Practice
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Integrated Care Teams

• PCP owns the doctor-patient relationship
• Ancillary medical professionals include
• Nurses
• Lab technicians
• Pharmacist
• Behavioral care professional (BCP)
• Team meetings for collaboration training
• Team creates a medical home

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Benefits of Integrated Care

• Seamless for the Patient
• Immediate Access (no referral out)
• Reduces Stigma
• Improves Access for Mental Health Care
• Immediate Curbside Consultation
• Extends Behavior Change Expertise into the
  Primary Care Clinic

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Patients Seen by the BCP
Hallway Handoff
Screening For Issues
40 finished
20 finished
15-20 min. consult
initial session
10 referred to specialty MH/CD
Individual Follow-ups
Chronic Disease Programs
From N. Cummings, 2004
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Services Provided by BCPs CMS Health Behavior
Codes
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The BCPs Activities
16 of primary care patients will benefit from
a BCP consult

406 patients
Annual BCP Hours, 1 FTE
203 patients
30 pt hrs/wk
1015 patients

• Ideal ratio is 1 BCP per 6-8 PCPs
• Two BCPs needed (one always available)

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Group Appointments
(Kaiser Permanente model)

• Groups of 8-10 people
• Can have patients with multiple chronic diseases
  in a single group
• 30-minute presentation on a health topic
• 30-minute discussion and support group
• Followed or preceded by individual check-ups
  (10-15 min.) with a nurse or MD
• Leverages MDs time up to 300

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Funding Fee-for-Service
Annual FFS Revenue Generated by 1 FTE BCP
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Funding Capitation

• Melek (2001)
• Full Capitationphysicians have time freed up,
  and therefore can accept more capitated lives
  with the same number of physicians.
• Risk-sharing arrangementsproviders also
  receive revenue from risk pools based on
  decreased referrals to facilities and specialty
  care.
• A 20-practitioner group can increase revenue by
• more than 800,000 per year without adding
• any new physicians to the practice.

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Funding Grant Money

• Federal Grants
• ultimately, the source of funding for 70 of
  the patients seen at FQHCs
• pilot grants may be available to fund Integrated
  Care programs
• eventually, FQHCs are required to have a
  behavioral health practitioner on
  staffIntegrated Care may be a way to fund that
  mandated position
• Medical Cost Offsets
• eventually, Integrated Care programs may pay for
  themselves through reductions in the overall cost
  of health care
• the beneficiaries of the cost reductions (states,
  health plans) should be willing to pay for the
  service

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Centenes Support for Integrated Care

• Phase I Contract with Centers that Already Have
  Behavioral Providers
• psychotherapy as part of IMHS network
• add health behavior codes under new RFP proposal
• already in progress
• Phase II Grant to Test Integrated Care Program
• 1 center, 1.5 FTEs for 1 year to test Integrated
  Care
• Centene providing funding, training for staff
• target start date is 1/1/05
• Phase III Contract with new FQHCs
• interested centers should let us know

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