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Primary Care and Behavioral Primary Care and Behavioral Health Integration within the Free Health Integration within the Free

Clinic Setting: Developing a Clinic Setting: Developing a PCBH Model of Care PCBH Model of Care

Alysia Hoover-ThompsonAlysia Hoover-Thompson

ahoover7@radford.eduahoover7@radford.edu

Radford UniversityRadford University

Presented at the Mental Health RoundtablePresented at the Mental Health Roundtable

Virginia Health Care Foundation, Richmond, VAVirginia Health Care Foundation, Richmond, VA

August 16, 2011August 16, 2011

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Radford University Psy.D. ProgramRadford University Psy.D. Program

First cohort began providing services to First cohort began providing services to community in 2008 as part of training programcommunity in 2008 as part of training program

Students provide mental health services to local Students provide mental health services to local community organizationscommunity organizations

Many of these organizations are not-for-profitMany of these organizations are not-for-profit Program emphasesProgram emphases

Rural practiceRural practice Cultural diversityCultural diversity Social justiceSocial justice Evidence-based practiceEvidence-based practice

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Free Clinics Free Clinics

““Free clinics are volunteer-based, safety-Free clinics are volunteer-based, safety-net health care organizations that provide net health care organizations that provide a range of medical, dental, pharmacy, a range of medical, dental, pharmacy, and/or behavioral health services to and/or behavioral health services to economically disadvantaged individuals economically disadvantaged individuals who are predominately uninsured” who are predominately uninsured”

(National Association of Free Clinics, 2008)(National Association of Free Clinics, 2008)

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Free Clinic of the New River ValleyFree Clinic of the New River Valley

On siteOn site MedicalMedical DentalDental PharmacyPharmacy Dermatology clinicDermatology clinic

Who Qualifies?Who Qualifies? Adults without health insuranceAdults without health insurance ““Low income” based on 2010 Federal Poverty Low income” based on 2010 Federal Poverty

GuidelinesGuidelines Mental Health Association of the New River ValleyMental Health Association of the New River Valley

Provides pro-bono counseling services to MHA clients Provides pro-bono counseling services to MHA clients at an office located in the Free Clinic at an office located in the Free Clinic

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Why Integrated Care?Why Integrated Care?

Up to 70% of visits to primary care offices are Up to 70% of visits to primary care offices are related to behavioral health needs related to behavioral health needs

Many common medical problems that are Many common medical problems that are treated by PCP involve health and behavioral treated by PCP involve health and behavioral habits that influence symptoms (Hunter, Goodie, habits that influence symptoms (Hunter, Goodie, Oordt, & Dobmeyer, 2009) Oordt, & Dobmeyer, 2009)

In 2008, the American Psychological Association In 2008, the American Psychological Association launched the Primary Care Initiativelaunched the Primary Care Initiative

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Developing an Integrated Developing an Integrated PCBH SitePCBH Site

Psy.D. Program Director approached by Free Psy.D. Program Director approached by Free Clinic DirectorClinic Director Program students had previous experience providing Program students had previous experience providing

traditional mental health services at site through traditional mental health services at site through Mental Health AssociationMental Health Association

Joshua Bradley was the first Psy.D. student from Joshua Bradley was the first Psy.D. student from Radford to complete a practicum thereRadford to complete a practicum there Developed forms and documents for integrationDeveloped forms and documents for integration Developed comprehensive 360 degree evaluation Developed comprehensive 360 degree evaluation

procedure to assess integration into the system and procedure to assess integration into the system and performanceperformance

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Integrating PCBH Services into an Integrating PCBH Services into an Established SystemEstablished System

Emphasize that you are there to support Emphasize that you are there to support existing servicesexisting services

Try to accept as many referrals as Try to accept as many referrals as possible in order to show usefulnesspossible in order to show usefulness

Get to know all people in the clinicGet to know all people in the clinic Explain what you doExplain what you do

Have a prepared explanation and examplesHave a prepared explanation and examples Create a handoutCreate a handout

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Systemic Contextual Systemic Contextual ConsiderationsConsiderations

Names and FacesNames and Faces Virginia College of Osteopathic Medicine Virginia College of Osteopathic Medicine

residentsresidents On site physicianOn site physician Nurse practitioners Nurse practitioners NursesNurses Front office staffFront office staff VolunteersVolunteers

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Patient Contextual ConsiderationsPatient Contextual Considerations

Given the low-income client base, there may be relevant Given the low-income client base, there may be relevant considerations related to intervention optionsconsiderations related to intervention options

Clients may lack financial resources to make significant changes Clients may lack financial resources to make significant changes to their diet or join a gymto their diet or join a gym

Transportation may be a problemTransportation may be a problem High frequency of significant financial and environmental High frequency of significant financial and environmental

stressorsstressors Literacy rates may be lowerLiteracy rates may be lower Other contextual factors will undoubtedly become apparent as Other contextual factors will undoubtedly become apparent as

the BHC becomes more familiar with the client basethe BHC becomes more familiar with the client base This speaks to the importance of being aware of cultural This speaks to the importance of being aware of cultural

and contextual factors when working within an integrated and contextual factors when working within an integrated care systemcare system

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Primary Care EnvironmentPrimary Care Environment

Fast pacedFast paced Adjust clinical note takingAdjust clinical note taking

Space limitationsSpace limitations At least 7 different roomsAt least 7 different rooms Move from room to room frequentlyMove from room to room frequently

Finding medical chartsFinding medical charts Several places they can beSeveral places they can be

New facesNew faces Remembering names Remembering names

Patient ReferralsPatient Referrals

Self-ReferredSelf-Referred Request to see Mental Health Counselor at Request to see Mental Health Counselor at

appointment with physician/NPappointment with physician/NP Physician/NP ReferredPhysician/NP Referred

Request for BH evaluation/interventionRequest for BH evaluation/intervention Warm Hand-offWarm Hand-off

Occurs in exam room Occurs in exam room

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Additional ActivitiesAdditional Activities

Consultation with medical staff Consultation with medical staff Example: Patient is in abusive relationship and Example: Patient is in abusive relationship and

medical resident asks about treatment options. BHC medical resident asks about treatment options. BHC explains options such as Women’s Resource Center, explains options such as Women’s Resource Center, Mental Health Association, etc… Medical resident Mental Health Association, etc… Medical resident presents options to patientpresents options to patient

Presentations to clinic staffPresentations to clinic staff Safety in medical settingsSafety in medical settings Behaviors that increase appointment/treatment Behaviors that increase appointment/treatment

adherence adherence Case managementCase management

The First YearThe First Year

201 Total Contacts201 Total Contacts 21 warm hand-offs21 warm hand-offs 54 referrals54 referrals 126 follow-up appointments126 follow-up appointments

111 Cancellations/No Shows111 Cancellations/No Shows Primary ComplaintsPrimary Complaints

Depression (64), Anxiety (44), Depression (64), Anxiety (44),

Diet/Exercise (38), Relationship problems (32)Diet/Exercise (38), Relationship problems (32)

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The Second YearThe Second Year

Two students and two days/weekTwo students and two days/week Mondays, Wednesdays and Fridays at the Mondays, Wednesdays and Fridays at the

Free Clinic in ChristiansburgFree Clinic in Christiansburg Wednesdays at Giles satellite officeWednesdays at Giles satellite office

Want to increase warm hand-offsWant to increase warm hand-offs Will increase number of patients seen Will increase number of patients seen

Utilize 360 evaluationUtilize 360 evaluation

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Adjusting to EnvironmentAdjusting to Environment

““Client” versus “patient”Client” versus “patient” Transportable officeTransportable office Medical terminologyMedical terminology Brief encounters (as short as 5 minutes)Brief encounters (as short as 5 minutes) Case managementCase management Educator/Presenter Educator/Presenter In-house mental health representativeIn-house mental health representative

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ConclusionConclusion

Different paradigm Different paradigm Multiple treatment setting considerationsMultiple treatment setting considerations Need to be flexible Need to be flexible Fit into systemFit into system Requires more directness and behavioral Requires more directness and behavioral

focus because of time limitationsfocus because of time limitations